Antepartum Hemorrhage 

 

 

Considerations 

 

  • Emergency situation

  • Pregnancy considerations (difficult intubation, aspiration, ↓ time to desaturation, aortocaval compression, 2 patients)

  • Potential for maternal massive hemorrhage, hemodynamic instability & lethal triad (coagulopathy, acidosis, hypothermia)

  • Potential for fetal distress & need for FHR monitoring

  • Discussion with obstetrics to determine the extent & cause of hemorrhage & whether emergency cesarean is required 

 

 

Management 

 

  • Simultaneous diagnosis & management in collaboration with obstetrics 

  • Monitors (maternal & fetal), O2, & start 2 large bore IVs

  • Obtain history, perform physical examination including airway exam & intravascular volume status

  • Resuscitate to goal end points including FHR stability 

  • Gather resources, get help, have OR set up for emergency cesarean section & possible massive hemorrhage:

    • ​Rapid transfuser

    • Massive transfusion protocol

    • Blood conservation techniques (cell saver, tranexamic acid, avoid lethal triad)

  • If emergency cesarean, will likely need GA (provided airway is reassuring) & titrated induction with ketamine & succinylcholine  

 

 

Differential Diagnosis for Antepartum Hemorrhage 

 

  • Placenta previa (painless) 

  • Placenta abruption (painful) 

  • Uterine rupture (true emergency) 

  • Vasa previa (lethal to fetus, ok for mom) 

  • Other less serious causes 

 

 

Conflicts 

 

  • Full stomach (RSI) vs. hemodynamic instability & need for titrated induction 

  • Difficult airway vs. STAT cesarean section

 

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