What is the management of antepartum hemorrhage (APH) at 37 weeks gestation?

Management of Antepartum Hemorrhage at 37 Weeks Gestation

Immediate delivery is recommended for women with antepartum hemorrhage at 37 weeks gestation due to increased maternal and fetal risks with expectant management. Antepartum hemorrhage (APH) at term requires prompt assessment and intervention to reduce maternal and perinatal morbidity and mortality.

Initial Assessment and Stabilization

• Maternal Assessment:

  • Evaluate vital signs (BP, pulse, respiratory rate) - vital sign derangement predicts adverse outcomes 1
  • Assess the amount and duration of bleeding - bleeding ≥12 hours before arrival is associated with worse outcomes 1
  • Establish IV access with two large-bore cannulas
  • Obtain blood samples for:
    • Complete blood count with platelets
    • Coagulation profile (PT, PTT, fibrinogen)
    • Blood type and cross-match (at least 2-4 units)
    • Renal and liver function tests

• Fetal Assessment:

  • Continuous electronic fetal monitoring
  • Ultrasound to determine placental location, fetal position, and estimated fetal weight

Diagnosis and Management Based on Cause

1. Placenta Previa

• If diagnosed with placenta previa:
  • Prepare for cesarean delivery
  • Consider internal iliac artery occlusion catheters for high-risk cases (e.g., suspected placenta accreta) 2
  • Arrange multidisciplinary team including gynecological oncologists, interventional radiologists, and anesthesiologists 2
  • Type and cross-match for at least 4 units of blood

2. Placental Abruption

• If diagnosed with placental abruption:
  • Proceed with immediate delivery (cesarean section if fetal distress or significant bleeding)
  • Monitor for disseminated intravascular coagulation (DIC)
  • Prepare for potential postpartum hemorrhage

3. APH of Unknown Origin

• Even with unknown origin, APH at 37 weeks warrants delivery rather than expectant management
• Mode of delivery depends on obstetric factors and maternal/fetal status

Mode of Delivery

• Cesarean Section (recommended in 82% of APH cases 3):

  • Mandatory for placenta previa
  • Indicated for significant abruption, fetal distress, or heavy bleeding
  • Consider for cases with suspected placenta accreta spectrum

• Vaginal Delivery:

  • May be attempted in minor abruption with reassuring fetal status
  • Not appropriate for placenta previa or heavy bleeding

Management of Hemorrhage

If severe hemorrhage occurs:

1. Resuscitation:

   • Keep the patient warm (temperature >36°C) as clotting factors function poorly below this temperature 4
   • Avoid acidosis 4
   • Implement massive transfusion protocol if blood loss exceeds 1500 mL 4

2. Blood Product Administration:

   • Transfuse packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio for acute hemorrhage 4
   • Consider point-of-care testing (thromboelastography or rotational thromboelastometry) if available 4

3. Interventional Procedures for uncontrolled bleeding:

   • Uterine artery embolization through interventional radiology 4
   • Pelvic pressure packing for temporary stabilization 4
   • Hypogastric artery ligation (though efficacy is unproven) 4

Postpartum Care

• Close hemodynamic monitoring for at least 24 hours after delivery 4
• Low threshold for reoperation if ongoing bleeding is suspected 4
• Monitor for common complications:
  • Postpartum hemorrhage (occurs in 40% of APH cases) 3
  • Need for blood transfusion (28% of cases) 3
  • DIC (4% of cases) 3

Special Considerations

• Hypertensive Disorders: If APH is accompanied by hypertension, treat severe hypertension (BP ≥160/110 mmHg) immediately with IV labetalol, IV hydralazine, or oral nifedipine 4, 5

• Magnesium Sulfate: Consider for women with preeclampsia features (loading dose 4-5g IV over 15-20 minutes, maintenance 1-2g/hour) 5

Prognosis

• APH at term is associated with significant maternal and perinatal risks:
  • Maternal mortality rate of approximately 2% 3
  • Perinatal mortality rate of approximately 18% 3
  • Common fetal complications include low birth weight and prematurity 3

Key Pitfalls to Avoid

1. Delaying delivery at 37 weeks with significant APH
2. Underestimating blood loss and delaying transfusion
3. Failing to prepare for potential massive hemorrhage
4. Not involving a multidisciplinary team for complex cases (e.g., suspected placenta accreta)
5. Inadequate postpartum monitoring (continue for at least 24 hours)

Remember that APH is a significant cause of maternal and fetal morbidity and mortality, and prompt, decisive management at 37 weeks gestation is essential for optimal outcomes.