What is the management of antepartum hemorrhage (APH) in a primigravida at 32 weeks gestation?

Management of Antepartum Hemorrhage in a Primigravida at 32 Weeks Gestation

Definition of Antepartum Hemorrhage (APH)

Antepartum hemorrhage is defined as any bleeding from or into the genital tract during pregnancy after the period of viability (20 weeks) until delivery of the fetus. APH complicates approximately 2-5% of pregnancies and is a significant cause of maternal and perinatal morbidity and mortality 1, 2.

Causes of Antepartum Hemorrhage

The main causes of APH include:

1. Placenta Previa (32-58% of cases) - Implantation of the placenta in the lower uterine segment, partially or completely covering the internal cervical os 3, 2

2. Placental Abruption (14-44% of cases) - Premature separation of a normally implanted placenta 3, 2

3. Placenta Accreta Spectrum (10% of cases) - Abnormal placental attachment to the myometrium 3

4. Vasa Previa - Fetal vessels running through the membranes over the cervical os

5. Local Causes - Cervical lesions, cervical polyps, cervical carcinoma, vaginal trauma

6. Undetermined/Unknown (24-30% of cases) 2

Management of APH in a Primigravida at 32 Weeks Gestation

Initial Assessment and Stabilization

1. Maternal Resuscitation:

   • Establish two large-bore IV access (16-18G)
   • Start fluid resuscitation with crystalloids
   • Send blood samples for complete blood count, coagulation profile, and cross-matching
   • Monitor vital signs continuously (pulse, blood pressure, respiratory rate, oxygen saturation)
   • Administer oxygen if signs of hypovolemia or fetal distress

2. Assessment of Bleeding Severity:

   • Quantify blood loss (mild, moderate, severe)
   • Assess for signs of hypovolemic shock
   • Check for vital sign derangement (associated with adverse outcomes) 4

3. Fetal Assessment:

   • Continuous electronic fetal monitoring
   • Ultrasound to assess fetal viability, presentation, and growth
   • Assess amniotic fluid volume

Diagnostic Approach

1. Ultrasound Examination:

   • Transabdominal and/or transvaginal ultrasound to determine placental location
   • Rule out placenta previa or placental abruption
   • Assess for placenta accreta spectrum if placenta previa is present

2. Speculum Examination:

   • Only after placenta previa has been excluded by ultrasound
   • Identify cervical or vaginal sources of bleeding

Specific Management Based on Diagnosis

1. Placenta Previa Management:

• Admit to hospital for observation and monitoring
• Administer antenatal corticosteroids for fetal lung maturity at 32 weeks
• Avoid digital vaginal examination to prevent massive hemorrhage
• Plan for delivery:
  • If stable with minimal bleeding: Consider expectant management until 36-37 weeks
  • If significant bleeding: Prepare for immediate cesarean delivery
  • Cesarean delivery is the mode of choice for complete placenta previa

2. Placental Abruption Management:

• Admit to hospital for close monitoring
• Administer antenatal corticosteroids for fetal lung maturity
• Monitor for signs of coagulopathy (DIC occurs in 10-20% of severe abruptions)
• Plan for delivery:
  • Severe abruption with fetal distress: Immediate delivery regardless of gestational age
  • Moderate abruption with stable maternal and fetal condition: Consider expectant management with close monitoring
  • Vaginal delivery may be attempted if maternal and fetal conditions are stable

3. Management of APH with Unknown Cause:

• Admit for observation and monitoring
• Administer antenatal corticosteroids for fetal lung maturity
• Monitor maternal and fetal condition closely
• Plan for delivery based on severity of bleeding and fetal/maternal status

Specific Considerations at 32 Weeks

1. Antenatal Corticosteroids:

   • Administer betamethasone (12 mg IM, 2 doses 24 hours apart) or dexamethasone (6 mg IM, 4 doses 12 hours apart) to enhance fetal lung maturity 5

2. Tocolysis:

   • Short-term tocolysis may be considered to allow for corticosteroid administration if there are signs of preterm labor
   • Contraindicated in severe abruption or maternal hemodynamic instability

3. Magnesium Sulfate for Neuroprotection:

   • Consider if delivery is anticipated before 32 weeks + 6 days 5

4. Antibiotics:

   • Consider if there are signs of infection or if expectant management is planned 5

Delivery Planning

The decision for timing and mode of delivery depends on:

1. Maternal condition:

   • Hemodynamic stability
   • Ongoing blood loss
   • Development of complications (DIC, shock)

2. Fetal condition:

   • Evidence of fetal distress
   • Gestational age
   • Estimated fetal weight

3. Cause of APH:

   • Placenta previa: Cesarean delivery (82-94% of APH cases require cesarean section) 3, 2
   • Abruption: Vaginal delivery may be attempted if conditions are favorable

Blood Transfusion Protocol

1. Prepare blood products (28% of APH cases require transfusion) 2

   • Packed red blood cells
   • Fresh frozen plasma
   • Platelets
   • Cryoprecipitate if needed

2. Implement massive transfusion protocol if severe hemorrhage occurs

   • Fixed ratio of blood products (1:1:1 ratio of PRBCs:FFP:platelets)
   • Monitor coagulation parameters

Postpartum Management

1. Close monitoring for postpartum hemorrhage (occurs in 40% of APH cases) 2
2. Active management of third stage of labor
3. Vigilance for development of DIC (4% of APH cases) 2
4. Consider thromboprophylaxis in the postpartum period

Maternal and Perinatal Outcomes

• Maternal mortality is reported at 2% in APH cases 2

• Perinatal mortality ranges from 18-30% 2, 4

• Common maternal complications include:

  • Postpartum hemorrhage (40%)
  • Blood transfusion requirement (28%)
  • DIC (4%)
  • Cesarean hysterectomy (4-17%) 3, 2

• Common fetal complications include:

  • Preterm birth
  • Low birth weight
  • Birth asphyxia
  • Intrauterine death (11.84%) 3

Conclusion

The management of antepartum hemorrhage in a primigravida at 32 weeks requires prompt assessment, stabilization, accurate diagnosis, and appropriate intervention based on maternal and fetal condition. Early recognition and management are crucial to improve outcomes, as APH remains a significant cause of maternal and perinatal morbidity and mortality.