ANTEPARTUM HEMMORRHAGE - pregnancy complication

1. ANTEPARTUM HEMORRHAGE :
ANESTHETIC IMPLICATIONS
Dr.zikrullah mallick

2. CONTENTS
 Causes of APH
 Antenatal interventions
 Antepartum bleeding management (obstetric)
 Anesthetic considerations
 Intraoperative management
 Complications and monitoring
 Massive hemorrhage
 DIC
 Sheehan syndrome
 Summary

3. CLASSIFICATION
Bleeding after 20 weeks of pregnancy is APH.
A) Placental bleeding: placenta previa, placental
abruption, and vasa previa.
B) Extraplacental bleeding : cervical erosions, cervical
polyps, cervical carcinoma, uterine rupture and
trauma.

4. • PLACENTA PREVIA
• DEFINITION: Placenta situated wholly or partially in
lower uterine segment.
• INCIDENCE: 1:300
• TYPES: total, partial and marginal.
• SYMPTOMS: painless uterine bleeding.
First episode usually stops spontaneously.
• DIAGNOSIS: USG , transvaginal better than
transabdominal.

5. ASSOCIATION:
Elderly, assisted pregnancy, multiparity, prior
placenta previa , uterine scar.
COMPLICATIONS:
• antepartum, intrapartum and postpartum bleeding,
• abnormalities of placental adherence,
• preterm birth ,
• congenital malformations ,
• septicemia and
• thrombophlebitis.

6. • VASA PREVIA
• Velamentous insertion of umblical vessels.
• Fetal vessels traverse the fetal membranes and are
positioned over cervical os.
• Blood loss is fetal
• DIAGNOSIS: transvaginal USG colour doppler.
• If not diagnosed antenatally, emergency LSCS under
GA preferred because of urgency .
• If diagnosed, elective LSCS is planned after fetal lung
maturity.

7. • PLACENTAL ABRUPTION
• DEFINITION: Premature separation of normally
implanted placenta.
• INCIDENCE: 1:200
• TYPES: Total & Partial
Concealed or external bleeding
• SYMPTOMS: vaginal bleeding with uterine
tenderness +/- fetal demise.
• DIAGNOSIS: High suspicion, USG (not confirmatory as
placenta and fresh clots have similar appearance)

8. ASSOCIATIONS:
Gestational Hypertension, preeclampsia, Chronic
Hypertension
COMPLICATIONS:
• PPH
• Hemorrhagic shock
• DIC
• AKI
• Sheehan’s syndrome
• Fetal distress

9. • UTERINE RUPTURE
• Life threatening injury includes from scar dehiscence to
complete rupture.
• CLINICAL PRESENTATION: fetal bradycardia, uterine
contractions cessation, abdominal pain, vaginal bleed
and loss of station.
Nonreassuring FHR tracing is the most reliable clinical
sign.
• ASSOCIATIONS: trial of labour after LSCS, fetal
malposition, instrumental delivery, trauma, tumor etc.

10. ANTENATAL INTERVENTIONS
• Kleihauer test in rhesus D (RhD)-negative women to
quantify fetomaternal haemorrhage (FMH) to gauge
the dose of anti-D immunoglobulin (anti-D Ig)
required.
• Ultrasound for diagnosis of placenta praevia and to
establish fetal heart pulsation.
• Use of point-of-care tests for differentiating between
fetal and maternal blood.

11. • Single course of antenatal corticosteroids to women
at risk of preterm birth.
• Serial ultrasound for fetal growth.
• Use of continuous electronic fetal monitoring or
intermittent auscultation during labour.
• Administration of anti-D Ig to all non-sensitised RhD-
negative women.
• Avoidance of anticoagulant therapy in women with
APH

13. ANESTHETIC CONSIDERATIONS
• Double set up examination
• Neuraxial or general anesthesia
• Antiaspiration prophylaxis
• Preparation of patient and OT
• Hypovolemic shock
• Uterine atony and PPH
• Coagulopathy
• Sheehan syndrome

14. Double set up examination:
 Not a part of modern obstetrics.
 Per vaginal examination to locate placental site.
 Life threatening bleeding can occur.
 Medical personnel including anesthesiologist and
preparation for LSCS under GA with 2 units of cross
matched PRBC should be ready.

15. • Choice of anesthesia depends on LSCS indication, urgency
and maternal volume status.
• Many preferred continuous epidural .
• Other choices include spinal, combined spinal -epidural or
continuous spinal.
• Informed consent for conversion to GA at any time.
• Suspected placenta accreta ,GA preferred.

16. CONTRAINDICATIONS:
ABSOLUTE:
 Refusal
 Uncorrected hypovolemia or shock
 Infection at site of needle insertion
 Frank coagulopathies
 Mass lesions causing raised ICT
RELATIVE:
systemic infections, blood coagulation tests
abnormalities disorder or neurological diseases.

17. INTRAOPERATIVE MANAGEMENT
• Administer high flow oxygen.
• Antiaspiration prophylaxis.
• Attach standard monitors.
• If needed CVP or radial arterial line.
• Maintain left lateral position , difficult airway
equipments , suction and appropriate drugs.
• Two wide bore intravenous cannulae (at least 16 G)
should be sited.

18. • Bladder catheter to monitor urine output.
• Lower extremity compression devices to minimize
thromboembolism.
• Blood taken for urgent blood count, clotting studies,
cross-match and blood gas analysis.
• Fluids should be warmed,
• Newer rapid infusion devices are beneficial.

19. • The choice of fluid for initial resuscitation includes
crystalloid or colloid as well as blood.
• In significantly hemodynamically compromised
women, blood should be transfused
• Group O negative blood or either type specific or
fully cross-matched blood, should be considered
(atleast 2 units).

20. STRATEGIES TO MINIMIZE BLOOD LOSS:
 Positioning of patient
 Controlled hypotension
 Maintaining Normothermia
 Regional anesthesia (epidural)
 Blood salvage technique
 Pharmacological agents
 Bimanual compresion of uterus
 Uterotonics

21. GENERAL ANESTHESIA
• Preoxygenate for more than 3min or 4 max vital
capacity breaths in 30 s with 100% O2.
• Assistant apply cricoid pressure.
• Administer induction agent ,propofol or ketamine
(if hypotensive) and muscle relaxation in rapid
sequence (succinylcholine or rocuronium) wait 30-
60 s ,and then laryngoscopy and intubation.
• Preferrably with smaller( 6.5 ) ETT and confirm
correct placement.

22. • Administer 50% N2O in oxygen with 0.5 to 0.75 MAC
of halogenated anesthetic.
• Maintain ETCO2 of 30-32 mm Hg
• After delivery of fetus, opioids , benzodiazepines and
barbiturates can be used.
• Administer uterotonics.
• Extubate trachea when following commands and
fully reversed.

23. • UTEROTONICS:
• WHO recommends 20 IU oxytocin in 1 litre of
crystalloid after uncomplicated LSCS, however
somewhat less is needed.
• Slow iv long term infusions preferred, as large and
bolus doses causes significant hypotension.
• If not controlled, others are methylergonovine 0.2mg
im , PGF2a 0.25 mg im, PGE1 600 ug orally,
sublingually, vaginally or rectally.

24. MASSIVE HEMORRHAGE
• Obtain direct communication with blood bank and
central lab, request prioritization of workflow to our
location.
• Consider use of blood salvage.
• Blood products in correct ratio of 1:1:1
(PRBC:FFP:Platelets) in cases of massive hemorrhage.
• Administer calcium during rapid transfusion to
prevent low ionized calcium levels.
• Reserve ICU bed for postoperative care.

25. • Consider cryoprecipitate (fibrinogen levels <
100mg/dl).
• Consider factor VIIa only after 10 units PRBCs and
factor replacement using FFP and cryoprecipitate.
• Recombinant activated factor VII in doses of 70-
90ug/kg reduces hemorrhage.

26. COAGULOPATHY
• Dilutional or consumptive coagulopathy.
• Dilutional coagulopathy can be the result of
replacement with crystalloid solutions and PRBCs.
• Thrombocytopenia is the most common finding.
• DIC causes include hemorrhagic shock, AFE, placental
abruption, sepsis and fetal demise.
• Hemolytic transfusion reactions can cause DIC.

27. SHEEHAN SYNDROME
• Postpartum pituitary infarction with necrosis after
obstetric hemorrhage.
• May present with any feature of hypopituitarism.
• If patient remains hypotensive after control and
adequate resuscitation, evaluation and treatment for
adrenal insufficiency required.
• Treatment with 4mg dexamethasone iv bolus
necessary.

28. SUMMARY
 Management of APH is primarily obstetric.
 Role of anesthesiologist comes during delivary.
 Primary aim is to prepare for anticipated blood loss
and its complications.
 Strategies to minimize blood loss.
 If not hypotensive with less risk of hemorrhage,
regional anesthesia can be considered.
 Observation for life threatening complications and
their immediate management .

29. THANK YOU