What is the management of Antepartum Hemorrhage (APH)?

Management of Antepartum Hemorrhage (APH)

Antepartum hemorrhage requires immediate resuscitation, accurate diagnosis, and appropriate management based on the underlying cause, with placenta previa and placental abruption being the most common etiologies.

Definition and Epidemiology

• APH is defined as any vaginal bleeding from the genital tract after 20 weeks of gestation until delivery 1
• Complicates 2-5% of pregnancies globally 2
• Major causes include:
  • Placental abruption (44%)
  • Placenta previa (32%)
  • Undetermined causes (24%) 2

Initial Assessment and Resuscitation

1. Maternal Stabilization

   • Assess vital signs for signs of hypovolemia (tachycardia, hypotension)
   • Establish two large-bore IV access
   • Send blood samples for complete blood count, coagulation profile, and cross-matching
   • Administer oxygen if signs of maternal compromise
   • Position patient in left lateral position to prevent aortocaval compression

2. Fetal Assessment

   • Continuous electronic fetal monitoring
   • Ultrasound assessment for fetal viability, presentation, and estimated fetal weight

Diagnostic Approach

1. History

   • Timing, amount, and character of bleeding
   • Associated pain (suggests abruption)
   • Previous cesarean deliveries (increased risk of placenta previa/accreta)

2. Examination

   • Avoid digital vaginal examination until placenta previa is excluded
   • Assess uterine tone and tenderness
   • Monitor vital signs and bleeding amount

3. Investigations

   • Ultrasound (transabdominal and/or transvaginal) to determine placental location
   • Laboratory tests: CBC, coagulation profile, fibrinogen level
   • Maintain fibrinogen levels >200 mg/dL 3
   • Maintain platelet count >50,000/mm³ 3

Management Based on Etiology

1. Placenta Previa

• Conservative Management (if not actively bleeding and preterm):

  • Hospitalization or modified bed rest
  • Corticosteroids if <34 weeks for fetal lung maturity
  • Serial ultrasound monitoring
  • Avoid sexual intercourse and strenuous activity

• Delivery Indications:

  • Active bleeding not responding to conservative measures
  • Term gestation (37-38 weeks)
  • Evidence of fetal compromise
  • Mode of delivery: Cesarean section 2

2. Placental Abruption

• Management:

  • Continuous maternal and fetal monitoring
  • Blood product replacement as needed
  • Correction of coagulopathy if present

• Delivery Indications:

  • Severe abruption
  • Fetal distress
  • Term gestation
  • Mode of delivery: Vaginal delivery if stable and progressing; otherwise, cesarean section

3. Undetermined Cause

• Exclude other causes (cervical lesions, trauma)
• Management based on severity of bleeding, gestational age, and fetal status

Management of Complications

1. Maternal Complications

• Postpartum Hemorrhage (most common complication, 40% of APH cases) 2

  • Active management of third stage of labor
  • Uterotonic agents (oxytocin, ergot derivatives, prostaglandins) 3
  • Uterine massage
  • Bimanual compression if needed

• Disseminated Intravascular Coagulation (DIC)

  • Early hemostatic resuscitation with 1:1:1 ratio of red blood cells, fresh frozen plasma, and platelets 3
  • Do not delay transfusion waiting for laboratory results 3

• Severe Hemorrhage

  • Consider uterine tamponade with balloon or packing
  • Arterial embolization if available
  • Surgical interventions: arterial ligation, pelvic packing
  • Hysterectomy as last resort 3

2. Fetal Complications

• Preterm birth
• Low birth weight
• Fetal distress
• Intrauterine fetal death (occurs in 42.8% of APH cases) 4

Special Considerations for Delivery

1. Anesthesia

   • Regional anesthesia (epidural/spinal) preferred if hemodynamically stable
   • General anesthesia may be required for massive hemorrhage or maternal instability

2. Post-delivery Care

   • Maintain body temperature >36°C to support coagulation 3
   • Correct acidosis
   • Redose antibiotics if blood loss >1500 ml 3
   • Intensive monitoring for at least 24 hours

Prevention Strategies

• Regular antenatal care
• Early identification and management of risk factors
• Every obstetric unit should have a clear protocol for management of massive hemorrhage 1
• Regular drills and training for emergency management

Prognosis

• Maternal mortality: 2% (primarily from abruption) 4
• Perinatal mortality: 18% overall 2
• Increased risk of recurrence in subsequent pregnancies

APH remains a significant cause of maternal and perinatal morbidity and mortality, requiring prompt recognition and management to improve outcomes.