Antepartum hemorrhage (APH): anesthetic considerations

1. Immediate assessment and preparation

• Call for senior multidisciplinary help early: obstetrician, anesthetist, hematology/blood bank, neonatology, theater and labor-ward staff.
• Assess severity:
  • Amount and rate of visible bleeding, remembering that abruption can cause substantial concealed hemorrhage.
  • Maternal hemodynamics, mental status, urine output, abdominal pain/uterine tone.
  • Fetal status and urgency of delivery.
  • Cause suspected: painless bleeding suggests previa; painful, tender uterus suggests abruption; scarred uterus with pain, shock or fetal distress raises concern for rupture.
• Use left uterine displacement to reduce aortocaval compression.
• Establish two wide-bore peripheral IV cannulae. In anticipated major blood loss, add an arterial line and consider central access only if needed.
• Send and repeat: CBC, group and crossmatch, PT/INR, aPTT, fibrinogen, electrolytes, ionized calcium, and blood gas/lactate.
• Activate the local major obstetric hemorrhage / massive transfusion protocol early if bleeding is substantial.
• Warm the patient and all IV fluids/blood. Use rapid infuser and fluid warmer where available.
• Insert urinary catheter and monitor hourly output.

2. Resuscitation and blood-product strategy

• Do not delay blood-product replacement while waiting for laboratory results in severe ongoing bleeding.
• Avoid excessive crystalloid, which worsens dilutional coagulopathy.
• Replace red cells, plasma, platelets, and fibrinogen-containing product according to local major hemorrhage protocol and laboratory or viscoelastic testing where available.
• Monitor and correct:
  • Hypothermia
  • Acidosis
  • Hypocalcemia from citrate in transfused blood
  • Coagulopathy, particularly low fibrinogen in abruption/DIC
• Consider cell salvage for anticipated high blood loss, particularly placenta accreta spectrum, subject to local protocol.
• If the woman declines allogeneic blood, establish her documented wishes early and involve senior staff.

3. Choice of anesthetic technique

4. General anesthesia precautions

• Treat as a full-stomach obstetric emergency:
  • Preoxygenate thoroughly.
  • Rapid-sequence induction with cricoid pressure according to local practice.
  • Prepare for difficult airway and failed intubation.
• Anticipate marked hypotension after induction in hypovolemia. Resuscitate concurrently and use vasopressors judiciously.
• Use invasive arterial pressure monitoring when severe bleeding is present or expected.
• Ensure blood and a rapid infuser are in the operating room before incision if feasible.
• Communicate continuously with obstetrics about urgency, incision timing, uterotonics, possibility of hysterectomy, and need for damage-control surgery.

5. Condition-specific concerns

• Often painless, intermittent bleeding, but may become sudden and massive.
• An anterior placenta previa carries increased risk of severe hemorrhage at cesarean birth.
• Even after delivery, bleeding can persist because the lower uterine segment contracts poorly.
  Morgan and Mikhail’s Clinical Anesthesiology, 7e, p. 1639.

• May cause concealed bleeding, maternal shock disproportionate to vaginal blood loss, fetal compromise, and DIC.
• Check fibrinogen and coagulation urgently and serially.
• Severe abruption may require massive transfusion including coagulation factors and platelets.
  Morgan and Mikhail’s Clinical Anesthesiology, 7e, p. 1640.

• Requires immediate laparotomy, usually under GA, alongside aggressive volume and blood-product resuscitation.
  Morgan and Mikhail’s Clinical Anesthesiology, 7e, p. 1640.

• Plan delivery in a tertiary center with experienced obstetric, anesthesia, surgical, interventional-radiology, blood-bank, and neonatal teams.
• Prepare for cesarean hysterectomy and major hemorrhage: large-bore access, arterial line, rapid blood warming/infusion, and cell salvage where appropriate.
• The technique depends on surgical urgency, bleeding, anticipated duration, hemodynamics, and coagulation status. Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 3518.

6. Post-delivery care

• Continue surveillance for ongoing hemorrhage, uterine atony, coagulopathy, hypothermia, and electrolyte abnormalities.
• Transfer to HDU/ICU if massive transfusion, invasive ventilation, vasopressor support, hysterectomy, persistent coagulopathy, or major organ dysfunction.
• Document estimated/quantified blood loss, products given, coagulation course, and anesthetic events.
• Provide postoperative analgesia, thromboprophylaxis when hemostasis is secure, and psychological support/debriefing after a major obstetric emergency.

Exam-style key points

1. Resuscitate mother first and simultaneously prepare for delivery.
2. Obtain two large-bore IVs, blood tests including fibrinogen, crossmatched blood, warming, and urinary monitoring.
3. Suspect concealed hemorrhage and DIC in placental abruption.
4. Regional anesthesia only if stable and coagulation is normal.
5. GA is indicated for active massive bleeding, shock, coagulopathy, fetal/maternal compromise, uterine rupture, or immediate cesarean delivery.
6. Anticipate persistent bleeding after placenta previa and massive blood loss with placenta accreta spectrum.

Antepartum Hemorrhage (APH)

Definition

Classification

According to amount of blood loss

• Spotting: blood-stained mucus or minimal staining.
• Minor APH: bleeding less than 50 mL, which has settled.
• Major APH: bleeding 50-1000 mL without clinical shock.
• Massive APH: bleeding more than 1000 mL and/or associated with clinical signs of shock.

According to cause

1. Placental causes
   • Placenta previa
   • Placental abruption
   • Vasa previa
   • Placenta accreta spectrum
2. Local genital tract causes
   • Cervical ectropion
   • Cervical polyp
   • Cervicitis
   • Carcinoma cervix
   • Vaginal trauma or varicosities
3. Other causes
   • Uterine rupture
   • Bloody show in labor
   • Unexplained APH

Etiology and Risk Factors

1. Placenta previa

Risk factors

• Previous cesarean delivery
• Previous placenta previa
• Multiparity
• Advanced maternal age
• Multiple pregnancy
• Assisted reproductive techniques
• Smoking
• Previous uterine curettage or surgery
• Large placenta

Typical presentation

• Painless, bright-red vaginal bleeding
• Usually occurs in late second or third trimester
• Uterus is soft and non-tender
• Malpresentation or high, unengaged presenting part may be present
• Bleeding may stop spontaneously but can recur suddenly and severely

2. Placental abruption

Risk factors

• Hypertension and pre-eclampsia
• Previous abruption
• Abdominal trauma
• Smoking and cocaine use
• Premature rupture of membranes
• Polyhydramnios with sudden decompression
• Multiparity
• Short umbilical cord
• Thrombophilia

Clinical features

• Painful vaginal bleeding
• Sudden severe abdominal pain
• Uterine tenderness and increased tone, often described as a "woody hard" uterus
• Fetal distress or fetal death in severe cases
• Maternal shock may be greater than expected from visible vaginal loss because bleeding can be concealed behind the placenta
• Coagulopathy or disseminated intravascular coagulation (DIC) may occur

3. Vasa previa

Features

• Bleeding follows spontaneous or artificial rupture of membranes.
• Bleeding is fetal in origin.
• It is associated with rapid fetal bradycardia, severe fetal anemia, or fetal exsanguination.
• Immediate cesarean delivery is indicated if diagnosed intrapartum with fetal compromise.

4. Uterine rupture

Clinical Assessment

History

• Gestational age
• Amount, color, duration, and recurrence of bleeding
• Pain: painless in previa; painful in abruption
• Uterine contractions
• Passage of clots
• Reduced fetal movements
• Trauma or recent intercourse
• Previous cesarean section or uterine surgery
• Previous placenta previa or abruption
• Hypertension, pre-eclampsia, smoking, cocaine use
• Blood group and Rh status
• Use of anticoagulants or history of bleeding disorder

Examination

General examination

• Check airway, breathing, circulation, and mental state.
• Record pulse, blood pressure, respiratory rate, oxygen saturation, temperature.
• Look for pallor, sweating, peripheral vasoconstriction, and signs of shock.
• Assess urine output after catheterization in significant bleeding.

Abdominal examination

• Uterine size and tone
• Uterine tenderness
• Fetal lie and presentation
• Engagement of presenting part
• Frequency of contractions
• Fetal heart rate

Vaginal examination

• Do not perform a digital vaginal examination until placenta previa has been excluded by ultrasound.
• Digital examination may provoke catastrophic bleeding in placenta previa.
• A careful speculum examination may be used to identify local causes such as cervical ectropion, polyp, trauma, or cervical dilatation, when appropriate.

Investigations

Maternal investigations

• Complete blood count: hemoglobin, hematocrit, platelet count
• Blood group, Rh typing, antibody screen, and crossmatch
• Coagulation profile: PT/INR, aPTT, fibrinogen
• Renal function and electrolytes
• Liver function tests if pre-eclampsia is suspected
• Arterial or venous blood gas, lactate, and ionized calcium in major hemorrhage
• Kleihauer-Betke test or equivalent test in RhD-negative women to quantify fetomaternal hemorrhage and calculate additional anti-D immunoglobulin requirement

Fetal assessment

• Continuous cardiotocography if fetus is viable and monitoring is feasible
• Ultrasound for:
  • Placental location and placenta previa
  • Fetal growth, presentation, liquor volume, and fetal viability
  • Evidence of abruption, though a negative scan does not exclude it
• Doppler assessment if fetal anemia is suspected, especially in possible vasa previa or fetomaternal hemorrhage

Management

Principles

1. Communication and team activation
2. Maternal resuscitation
3. Monitoring and investigation
4. Arresting hemorrhage through delivery when indicated

A. Initial resuscitation

Airway and breathing

• Give high-flow oxygen by face mask, especially with major bleeding, shock, or fetal compromise.
• Position the woman with left lateral tilt or manual left uterine displacement.

Circulation

• Insert two 14-16 G wide-bore IV cannulae.
• Take blood samples at the time of cannulation.
• Begin warmed crystalloid cautiously while arranging blood.
• Crossmatch at least 4 units of packed red cells in major bleeding.
• Activate a major obstetric hemorrhage protocol when bleeding is severe or ongoing.
• Use a fluid warmer and blood warmer.
• Insert a Foley catheter to monitor hourly urine output.
• Monitor pulse, BP, oxygen saturation, temperature, ECG, and urine output.

Blood and coagulation support

• Packed red cells for oxygen-carrying capacity
• Fresh frozen plasma for clotting-factor replacement
• Platelets for thrombocytopenia
• Cryoprecipitate or fibrinogen concentrate for hypofibrinogenemia
• Correct hypothermia, acidosis, and hypocalcemia
• Use viscoelastic testing, such as thromboelastography, if locally available

B. Management of minor APH

• Admit or observe depending on gestation, recurrence, distance from hospital, and social circumstances.
• Perform ultrasound to identify placental location.
• Give anti-D immunoglobulin to unsensitized RhD-negative women.
• Counsel regarding recurrent bleeding and immediate return if bleeding, pain, contractions, or reduced fetal movements recur.
• Monitor fetal growth where APH is recurrent or unexplained because APH is associated with fetal growth restriction and preterm birth.
• Consider corticosteroids if preterm birth is likely.
• Consider magnesium sulfate for fetal neuroprotection when very preterm birth is anticipated, according to local policy.

C. Management of major or massive APH

• Immediate senior obstetric and anesthetic review
• Continuous fetal monitoring if viable
• Major hemorrhage protocol
• Blood products and correction of coagulopathy
• Preparation for operative delivery
• Neonatal team presence
• Delivery when bleeding is ongoing, maternal instability exists, fetal distress occurs, or gestation is sufficiently advanced and risks of continuation outweigh those of delivery

Cause-Specific Management

Placenta previa

Expectant management

• Bleeding is mild or has stopped
• Mother is stable
• Fetus is preterm and reassuring
• No labor or fetal compromise is present

• Hospital observation initially
• Corticosteroids if risk of preterm delivery
• Correction of anemia
• Avoidance of digital vaginal examination
• Counseling about recurrence and emergency access
• Planned cesarean birth for major previa

Delivery

• Major placenta previa
• Persistent or recurrent significant bleeding
• Maternal instability
• Fetal distress
• Labor with placenta previa
• Term pregnancy with placenta previa

Placental abruption

Conservative treatment

• Abruption is mild
• Mother is stable
• Fetus is alive and reassuring
• Pregnancy is preterm
• There is no progressive bleeding or coagulopathy

Delivery

• Maternal shock or continuing major hemorrhage
• Fetal compromise
• Severe abruption
• DIC or worsening coagulopathy
• Fetal death with maternal deterioration or inability to establish labor safely

• Vaginal birth may be preferred if fetal death has occurred and maternal condition permits, because it avoids surgical bleeding.
• Cesarean birth is required when fetal compromise exists and vaginal delivery is not imminent.

Vasa previa

• If diagnosed antenatally, plan cesarean delivery before labor or rupture of membranes.
• With bleeding after membrane rupture and fetal bradycardia, perform immediate cesarean delivery.
• Neonatal resuscitation and blood transfusion may be necessary.

Anesthetic Considerations in APH

Regional anesthesia

• Mother is hemodynamically stable
• Hemorrhage has settled or is limited
• Coagulation profile and platelet count are acceptable
• There is no urgent requirement for immediate delivery

General anesthesia

• Active massive hemorrhage
• Hemodynamic instability or shock
• Suspected DIC or severe coagulopathy
• Fetal distress requiring immediate delivery
• Uterine rupture
• Urgent cesarean delivery where neuraxial block would delay birth

Placenta accreta spectrum

• Massive hemorrhage
• Arterial line
• Large-bore IV access
• Rapid infuser and blood warmer
• Cell salvage where available
• Potential cesarean hysterectomy and ICU care

Maternal and Fetal Complications

Maternal complications

• Hypovolemic shock
• Severe anemia
• Disseminated intravascular coagulation
• Acute kidney injury
• Postpartum hemorrhage
• Emergency cesarean hysterectomy
• Blood transfusion complications
• Maternal death

Fetal and neonatal complications

• Fetal hypoxia and acidosis
• Fetal anemia
• Prematurity
• Fetal growth restriction
• Stillbirth
• Low Apgar score and neonatal intensive care admission
• Cerebral palsy risk related largely to prematurity

Prevention and Follow-Up

• Identify placenta previa and placenta accreta spectrum during antenatal ultrasound.
• Optimize maternal anemia with iron and nutritional treatment.
• Control hypertension.
• Counsel against smoking and cocaine use.
• Give anti-D immunoglobulin to eligible unsensitized RhD-negative women after APH.
• After major APH, provide debriefing, document events, and assess need for thromboprophylaxis once bleeding is controlled.
• Counsel regarding recurrence risk in future pregnancy, especially after abruption, placenta previa, uterine rupture, or accreta spectrum.

Conclusion