What is the management of antepartum hemorrhage in a pregnant woman?

Antepartum Hemorrhage: Management Overview

For pregnant women presenting with antepartum hemorrhage (APH), immediate hemodynamic stabilization with large-bore IV access and aggressive fluid resuscitation takes absolute priority, followed by rapid diagnostic ultrasound to determine etiology and guide definitive management. 1

Immediate Stabilization and Assessment

Initial Resuscitation

• Establish two large-bore IV lines (16-18 gauge) immediately and begin aggressive crystalloid resuscitation, transitioning rapidly to blood products if bleeding is significant 1
• Obtain urgent laboratory studies including complete blood count, coagulation profile (PT, PTT, fibrinogen), and type and crossmatch for at least 4-6 units of packed red blood cells 1
• Maintain maternal temperature above 36°C, as hypothermia severely impairs clotting factor function and worsens coagulopathy 2, 1, 3
• Avoid acidosis, which similarly impairs coagulation 2, 4

Diagnostic Evaluation

• Perform transabdominal ultrasound immediately as the primary diagnostic tool 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 is safe even with suspected placenta previa 1
• Never perform digital vaginal examination until placenta previa has been definitively excluded 1

Etiology-Based Management

Placenta Previa

• Hospitalize immediately and plan for cesarean delivery 1
• Absolute avoidance of any digital examination to prevent catastrophic hemorrhage 1
• Coordinate multidisciplinary team including experienced obstetricians, anesthesiologists, and blood bank for delivery planning 2

Placental Abruption

• Assess severity based on clinical presentation: sudden severe abdominal pain, uterine tenderness, and hemodynamic status 3, 4
• Do not wait for CTG abnormalities to develop—significant placental separation has already occurred by the time fetal heart rate decelerations appear 3
• Activate emergency cesarean protocol immediately if maternal hemodynamic instability or fetal compromise is present, aiming for delivery within 30 minutes 3, 4
• Anticipate disseminated intravascular coagulation (DIC) in over 80% of severe abruption cases 4

Placenta Accreta Spectrum

• Delivery should occur at a tertiary care center with multidisciplinary team including maternal-fetal medicine, gynecologic oncology or pelvic surgery, interventional radiology, anesthesiology, and critical care 2
• Planned cesarean hysterectomy is often the definitive management to minimize maternal morbidity and mortality 2

Hemorrhage Management Protocol

Massive Transfusion Protocol

• Activate massive transfusion protocol if blood loss exceeds 1,500 mL or ongoing active hemorrhage is present 1
• Transfuse blood products in a 1:1:1 ratio (packed red blood cells: fresh frozen plasma: platelets) for hemostatic resuscitation 1, 4
• Avoid crystalloid-only resuscitation, as this causes dilutional coagulopathy and volume overload 4

Pharmacologic Interventions

• Administer tranexamic acid 1 gram IV over 10 minutes, then 1 gram over 8 hours if given within 3 hours of bleeding onset 1, 4
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2, 3
• Use slow IV oxytocin (<2 U/min) for postpartum hemorrhage prevention while avoiding systemic hypotension 4
• Avoid methylergonovine due to vasoconstrictive effects and risk of hypertension in hemodynamically unstable patients 4

Surgical Interventions for Uncontrolled Bleeding

Immediate Surgical Management

• Proceed directly to laparotomy for hemodynamically unstable patients without delay for imaging 1
• Consider uterine artery ligation, hypogastric artery ligation, or uterine compression sutures (B-Lynch) for persistent bleeding 2, 1
• Pelvic packing can be highly effective for patient stabilization when experiencing acute uncontrolled hemorrhage—may be left in place for 24 hours with open abdomen and ventilatory support 2
• Make the decision to proceed to hysterectomy expeditiously if conservative measures fail to control bleeding 2, 5

Interventional Radiology

• Hypogastric artery embolization may be useful for persistent hemorrhage when no single bleeding source can be identified surgically 2
• However, this is difficult to perform safely in unstable patients and requires available equipment and expertise 2

Postoperative and Postpartum Monitoring

Intensive Care Management

• Transfer to intensive care unit for hemodynamic monitoring for at least 24-48 hours following severe APH or massive transfusion 2, 1, 4
• Perform serial hemoglobin/hematocrit checks every 4-6 hours initially 1
• Monitor for ongoing coagulopathy, DIC, and postpartum hemorrhage 3, 4
• Have a low threshold for re-exploration if bleeding continues postoperatively 2, 4

Complications Surveillance

• Watch for renal failure, liver failure, infection, unrecognized ureteral/bladder/bowel injury, pulmonary edema, and Sheehan syndrome (postpartum pituitary necrosis) given the clinical scenario and potential for hypoperfusion 2

Critical Pitfalls to Avoid

• Never attempt oxytocin augmentation in suspected abruption—this increases uterine contractility and can worsen placental separation, leading to massive hemorrhage 3
• Do not underestimate blood loss—significant concealed hemorrhage can occur behind the placenta without proportionate external bleeding 3
• Avoid waiting for laboratory results before initiating treatment in hemodynamically unstable patients—treat based on clinical presentation 4
• Do not attempt vaginal delivery in placental abruption with hemodynamic instability, even if labor is progressing—this delays definitive management and risks catastrophic hemorrhage 3

Prognosis and Outcomes

APH complicates 2-5% of pregnancies and remains a leading cause of maternal morbidity and mortality worldwide 5, 6, 7. Adverse outcomes are associated with vital sign derangement, vaginal bleeding for ≥12 hours before arrival, gestational age <37 weeks, rural residence, primiparity, and amount of vaginal bleeding 6. The main fetal risks include preterm labor and its complications, with perinatal mortality significantly elevated in cases of APH 6, 7, 8. Even in optimal settings with multidisciplinary care, substantial maternal morbidity and occasionally mortality occur 2.