What is the management of antepartum hemorrhage (APH) at 35 weeks gestation in the labor room?

Management of Antepartum Hemorrhage at 35 Weeks Gestation

For bleeding at 35 weeks gestation in the labor room, immediately stabilize hemodynamics, avoid digital examination until placenta previa is excluded by ultrasound, and prepare for delivery as this gestational age favors expedited management over expectant observation. 1

Immediate Assessment and Stabilization

Initial Actions

• Establish large-bore IV access (two lines) and initiate aggressive fluid resuscitation with crystalloids, followed by blood products as needed 2
• Obtain baseline laboratory studies urgently: complete blood count, coagulation profile (PT, PTT, fibrinogen), type and crossmatch for at least 4-6 units of packed red blood cells 2
• Assess hemodynamic stability by checking vital signs, signs of hypovolemia (tachycardia, hypotension, altered mental status), and severity of active bleeding 2
• Maintain normothermia (>36°C) as hypothermia severely impairs clotting factor function 3, 2

Critical First Step

• Do NOT perform digital cervical examination until placenta previa, low-lying placenta, and vasa previa are excluded by ultrasound 1, 2
• This is an absolute contraindication that can precipitate catastrophic hemorrhage 1

Diagnostic Evaluation

Ultrasound Assessment

• Perform transabdominal ultrasound immediately as the primary diagnostic modality to evaluate placental location, assess for abruption, and confirm fetal well-being 1
• Add transvaginal ultrasound if needed for precise placental localization and cervical assessment—this has been proven safe and accurate even with suspected placenta previa 1
• Ultrasound identifies placenta previa (most common diagnosed cause, 1 in 200 pregnancies) but detects only 50% of abruption cases 1

Fetal Monitoring

• Initiate continuous fetal heart rate monitoring to assess fetal well-being and identify fetal tachycardia or compromise 4
• Monitor for signs of fetal distress including persistent tachycardia, late decelerations, or decreased variability 4

Management Based on Etiology

If Placenta Previa or Vasa Previa Identified

• Hospitalize immediately and plan for cesarean delivery 1
• Absolute avoidance of any digital examination 1
• Prepare operating room and surgical team for potential emergency cesarean 1

If Placental Abruption Suspected

• Assess severity based on clinical presentation (vaginal bleeding, abdominal pain, uterine tenderness, fetal distress) 1, 4
• Expedite delivery if maternal or fetal compromise present 1
• Monitor closely for development of coagulopathy (DIC) 3

If Bleeding Source Unclear

• Consider other etiologies: cervical causes, lower genital tract lacerations, bloody show from labor 1
• Perform careful visual inspection of lower genital tract when safe 5

Hemorrhage Management Protocol

If Bleeding Continues or Worsens

• Activate massive transfusion protocol if blood loss exceeds 1,500 mL or ongoing active hemorrhage 2, 5
• Transfuse blood products in 1:1:1 ratio (packed red blood cells: fresh frozen plasma: platelets) 2
• Administer tranexamic acid 1 gram IV over 10 minutes, then 1 gram over 8 hours if given within 3 hours of bleeding onset 2, 5
• Target fibrinogen >200 mg/dL with cryoprecipitate, platelets >50,000/mm³, INR <1.5 2

Uterotonic Agents (If Postpartum Component)

• Oxytocin infusion: 10-40 units in 1000 mL crystalloid at 125-200 mL/hour 2, 5
• Methylergonovine 0.2 mg IM if not hypertensive 2
• Carboprost 250 mcg IM every 15-90 minutes (maximum 8 doses; avoid if asthmatic) 2
• Misoprostol 800-1000 mcg rectally 2

Delivery Planning at 35 Weeks

Timing Considerations

• At 35 weeks gestation, delivery is generally favored over prolonged expectant management given adequate fetal maturity and maternal hemorrhage risk 3, 1
• Antenatal corticosteroids are NOT routinely indicated at 35 weeks as fetal lung maturity is adequate 4, 6
• Magnesium sulfate for neuroprotection is not indicated beyond 32 weeks 4

Mode of Delivery

• Cesarean delivery is mandatory for placenta previa or vasa previa 1
• Vaginal delivery may be attempted for abruption if maternal and fetal status stable and no other contraindications exist 1
• Emergency cesarean if fetal compromise or uncontrolled maternal hemorrhage 1

Surgical Intervention for Uncontrolled Bleeding

Indications for Operative Management

• Hemodynamic instability despite resuscitation 2
• Active ongoing hemorrhage not controlled by medical management 2
• Signs of hemoperitoneum or intra-abdominal bleeding 2, 7
• Clinical deterioration with falling hemoglobin 2

Surgical Options

• Immediate laparotomy for hemodynamically unstable patients—do not delay for imaging 2
• Uterine artery ligation, hypogastric artery ligation, or uterine compression sutures for persistent bleeding 3
• Hysterectomy if conservative measures fail 3, 5
• Pelvic packing may be used for stabilization with plan for reoperation in 24 hours 3

Interventional Radiology

• Uterine artery embolization may be considered for hemodynamically stable patients with persistent bleeding after initial surgical control 2, 5
• Requires CT angiography to identify feeding vessels 2
• Not appropriate for unstable patients 5

Postoperative/Postpartum Monitoring

Intensive Care

• Transfer to intensive care unit for hemodynamic monitoring for at least 24-48 hours 3, 2
• Serial hemoglobin/hematocrit checks every 4-6 hours initially 2
• Monitor for postpartum hemorrhage (occurs in 23.1% of complicated deliveries) 4
• Maintain low threshold for reoperation if suspected ongoing bleeding 3, 2

Infection Prevention

• Administer prophylactic antibiotics with manual uterine examination or surgical intervention 5
• Monitor for signs of chorioamnionitis or endometritis 4

Critical Pitfalls to Avoid

• Never perform digital examination before ultrasound excludes placenta previa or vasa previa—this can cause catastrophic hemorrhage 1, 2
• Do not delay surgical intervention in unstable patients while pursuing conservative measures or additional imaging 2
• Do not wait for laboratory results to initiate transfusion if patient is hemodynamically unstable—treat based on clinical presentation 3, 2
• Avoid hypothermia and acidosis as both severely impair coagulation 3
• Do not underestimate blood loss—visual estimation is notoriously inaccurate 5