Anesthesia for ANTEPARTUM HAEMORHHAGE (APH)

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. Mild = <50 mL loss of blood Major = 50-1000mL loss Massive => 1000mL loss Bleeding >1 occasion regarded as recurrent APH . Pl a c e n t a pre v ia an d a b ru p t i o pl a c e n ta a r e most common causes of APH.

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

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

5. Risk factors Direct trauma e.g. RTA and external cephalic version. Multi parity : Uterine over distention (as in polyhydramnios and multiple pregnancy ). Sudden decompression of the uterus e.g. after delivery of 1 st twin or release of polyhydramnios. Hypertension Smoking Folic acid deficiency

6. Diagnos i s 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 . US G can be helpful in some cases, demonstrating retro placental clot and excluding placenta previa. U sually occurs near term and frequently during labor.

7. Clinical Presentation: 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: The uterus is woody hard; due to a tonic contraction. The fetal parts cannot be felt . The fetus may be dead .

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

9. Placenta previa I mplantation 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. Multiple gestation. Previous LACS scar. A advanced maternal age Multiparity Previous history of placenta previa Uterine structural anomaly (e.g. septate uterus). Smoking Fetal Cong. Anomaly or Malpresentation Predisposing Factors

11. Diagnosis This is based on the presence of recurrent painless late-trimester vaginal bleeding . The ut e r u s non-te n d e r an d fe t al hear t is 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 concentration of not more than 0.5 MAC , else the chances of uterine atony and postpartum hemorrhage become high .

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