definition of APH, diagnosis, cause, classification, managment & anaesthetic considerations

1. ANAESTHESIA FOR
ANTEPARTUM HAEMORHHAGE
Dr. SHASHIKANT SHARMA
MD ANAESTHESIOLOGY & CRITICAL CARE
MEDICINE

2. ANTEPARTUMHAEMORHHAGE
• Vaginal bleeding after 24weeks and before the delivery of
the fetus.
• It complicates (3-4%) of all pregnancies.
• It is an obstetric emergency because it endanger the life of
both the mother and fetus.
• Hemorrhage remain the most frequent cause of maternal
deaths.
1. Mild= <50 mL loss of blood
2. Major= 50-1000mL loss
3. Massive=>1000mL loss
• Bleeding >1 occasion regarded as recurrent APH.
• Placenta previa and abruptio placenta are most common
causes of APH.

3. • Third trimester bleeding due to premature separation of a
normally sited placenta.
• Iincidence 0.5-2% of pregnancies.
• It could be of two types:
1. Revealed (Overt) and External Bleeding: there is
obvious external vaginal bleeding (2/3 of cases)
2. Concealed or Internal Bleeding: bleeding in the uterus
with no external bleeding. (1/3 of cases).
Placental Abruption:

4. A. MAJOR
1. Life-threatening to the mother, involves separation of more
than one-third of the placenta.
2. This is clinically obvious and may result in death of the fetus
B. MINOR
1. Premature separation of small areas of the placenta may
result in placental infarcts.
2. Several small abruptions may precede a large abruption.
Classification of Abruptionenta:

5. Risk factors
1. Direct trauma e.g. RTA and external cephalic version.
2. Multiparity:
3. Uterine overdistention (as in polyhydramnios and multiple
pregnancy).
4. Sudden decompression of the uterus e.g. after delivery of 1st twin
or release of polyhydramnios.
5. Hypertension
6. Smoking
7. Folic acid deficiency

6. Diagnosis
 This is based on the presence of Painful, late trimester
vaginal bleeding with a normal Fundal or Lateral uterine
wall placental implantation not over the lower Uterine
segment.
 USG can be helpful in some cases, demonstrating retro
placental clot and excluding placenta previa.
 Usually occurs near term and frequently during labor.

7. Clinical Presentation:
A. MAJOR
 Women present with abdominal pain and shock.
 The blood loss that is visible (revealed haemorrhage) is
often less than the degree of shock.
On examination:
1.The uterus is woody hard; due to a tonic contraction.
2.The fetal parts cannot be felt.
3.The fetus may be dead.

8. B. MINOR
Minor abruptions are often not diagnosed until after
delivery.
They may present with:
1. Mild abdominal pain associated with threatened
preterm labour.
2. UnexplainedAPH.
3. Tenderness over one area of the uterus only.
Clinical Presentation:

9. Placenta previa
 Implantation of the placenta in the lower uterine segment.
 Symptomatic placenta previa occurs when painless vaginal
bleeding develops through avulsion of the anchoring villi of an
abnormally implanted placenta as lower uterine segment
stretching occurs in the latter part of pregnancy.
 Bleeding from placenta previa account for about 30% of all
cases of APH.

10. 1. Multiple gestation.
2. Previous LACS scar.
3. Aadvanced maternal age
4. Multiparity
5. Previous history of placenta previa
6. Uterine structural anomaly (e.g. septate uterus).
7. Smoking
8. Fetal Cong. Anomaly or Malpresentation
Predisposing Factors

11. Diagnosis
 This is based on the presence of recurrent painless late-
trimester vaginal bleeding.
 The uterus non-tender and fetal heartis normal.
 An ultrasound scan will show the position of the placenta.
 Per-vaginal (PV) examination is contraindicated.
 PV exm can only be done as double as double setup
examination.

12. Grading of placenta previa
 Grade 1. (lateral placenta):
The placenta implanted in the lower uterine segment but not reach the internal os.
Grade 2. (marginal placenta):
The edge of the placenta reaches the internal os but not cover it.
Grade 3. (partial placenta previa):
The placenta partially covering the internal os.
Grade 4. (complete placenta previa):
The placenta completely cover the internal os completely.

13. ANAESTHETIC MANAGMENT
 Have a multidisciplinary planning and consider arranging for
use of blood salvage, placement of iliac balloon catheters,
arterial embolization or a combination of these in advance.
 Obtain a brief medical history and perform a clinical
assessment of the patient.
 Use fluid warmers and forced air warmer.
 Place bladder catheter to measure urine output.
 Place lower extremity compression devices to minimize
chance of thromboembolism.
 Designate a person for recording and tallying blood products
and blood loss.
 Obtain direct communication with blood bank and central
laboratory and request prioritization of workflow to your
location.

14.  During significant hemorrhage, transfuse products based on
clinical situation rather than waiting for laboratory results.
 Prepare for general anesthesia.
 Ensure vasopressors and uterotonics are immediately
available.
 Reserve ICU bed for postoperative care.
 Consider cryoprecipitate if fibrinogen < 100 mg/dL.
 Consider use of interventional radiology for arterial
embolization if patient is stable for transport.
 Consider other surgical options, including uterine balloon
tamponade, compression sutures, and hysterectomy.

15. ANAESTHESIA MANAGEMENT FOR ABRUPTIO
PLACENTAE
 Best anesthetic plan for abruptio placenta is general
anaesthesia, even in hemodynamiclly stable patients. This is
because of the high probability of PPH in patients of abruptio
placenta.
 Rapid sequence induction has to be done. The choice of
induction agent strongly depends on the hemodynamic
stability of the patient.
 Ketamine is the agent of choice in patients presenting with
shock. Etomidate is another good alternative.
 Volatile agent has to be added to prevent awareness with a

16. ANAESTHESIA MANAGEMENT FOR ABRUPTIO
PLACENTAE
The type of anesthesia in placenta previa largely
depends on hemodynamic stability of patient.
Spinal or epidural anesthesia may be considered in
stable patients provided the possibility of placenta
accreta has been ruled out.
General anesthesia is administered in unstable
patients.

17. Thank You