RSS-Feed abonnieren
DOI: 10.1055/s-0030-1271194
© Georg Thieme Verlag KG Stuttgart · New York
Aktuelle interdisziplinäre Handlungsempfehlungen bei schweren peri-(post-)partalen Blutungen (PPH)
Current Interdisciplinary Recommendations for the Management of Severe Postpartum Hemorrhage (PPH)Publikationsverlauf
eingereicht 14.2.2011
revidiert 7.5.2011
akzeptiert 17.5.2011
Publikationsdatum:
18. Juli 2011 (online)
![](https://www.thieme-connect.de/media/gebfra/201107/lookinside/thumbnails/10.1055-s-0030-1271194-1.jpg)
Zusammenfassung
Schwere peri-(post-)partale Blutungen (PPH) sind auch heute noch weltweit eine der häufigsten Ursachen der mütterlichen Mortalität und Morbidität. Sie sind eine interdisziplinäre Herausforderung und machen eine enge Kooperation insbesondere zwischen Geburtshelfern und Anästhesisten notwendig. Die Kenntnis aktueller Leitlinien und Empfehlungen, die Verfügbarkeit lokaler Handlungspläne, die regelmäßige Schulung des Personals sowie die adäquate Beurteilung des klinischen Zustands der Patientin mit sorgfältiger Einschätzung oder Messung des Blutverlusts sowie die zeitgerechte Erkennung eines drohenden hypovolämischen Schockes sind dabei wichtige Voraussetzungen. Bei schwerer PPH mit persistierender Blutung sind die Aufrechterhaltung der Normothermie und normaler Kalziumkonzentrationen sowie die Korrektur einer metabolischen Azidose durch den Anästhesisten wichtige Voraussetzungen für die Gabe von Gerinnungsfaktoren. Eckpfeiler der Behandlung ist die Wiederherstellung des Blutvolumens und die Erhaltung einer ausreichenden Oxygenierungskapazität durch die Substitution von Sauerstoffträgern. Zur Vermeidung eines hypovolämischen Schockes ist eine ausreichende Flüssigkeitstherapie mit kristalloiden und kolloidalen Lösungen (z. B. HES 130/0,4) unerlässlich, bei Hämoglobinspiegeln ≤ 6–8 g/dl die Transfusion von Erythrozyten. Bei klinischen Hinweisen auf eine Gerinnungsstörung (Hyperfibrinolyse) wird die intravenöse Gabe von 2 g Tranexamsäure empfohlen, noch bevor die Ergebnisse der Gerinnungsteste vorliegen. Tranexamsäure sollte immer vor der Gabe von Fibrinogen appliziert werden. Bei akuter und anhaltender Blutung sowie einem Blutverlust von 2000–3000 ml ist der unverzügliche Ersatz von Gerinnungsfaktoren durch die Gabe von gefrorenem Frischplasma (GFP, 20–30 ml/kgKG) und Fibrinogen (3–4 g) erforderlich. Fibrinogenkonzentrationen von > 1,5–2,0 g/l sollten aufrechterhalten werden. Entsprechend den vor Kurzem publizierten Leitlinien der BÄK (Bundesärztekammer) sollte bei schweren anhaltenden Blutungen durch die Gabe von Thrombozytenkonzentraten die Thrombozytenzahl auf > 100 000/µl gehalten werden. Die Anwendung von rekombinantem Faktor VIIa (rFVIIa, Dosis: 90 µg/kgKG) ist nur nach Ausschöpfung aller chirurgischen und die Hämostase stabilisierenden Maßnahmen (s. o.) zu erwägen, wenn möglich vor Durchführung einer Hysterektomie, um diese zu vermeiden. Vor der Gabe von rFVIIa müssen die hämostaseologischen Voraussetzungen für dessen Anwendung geschaffen werden. Antithrombin oder Heparin sollten bei Patientinnen mit PPH nicht gegeben werden, solange eine erhöhte Blutungsgefahr besteht. Die Anwendung eines Cell Savers ist eine geeignete Methode, um die Zahl der Bluttransfusionen zu reduzieren.
Abstract
Postpartum hemorrhage (PPH) remains one of the most frequent causes of maternal mortality and morbidity worldwide. This interdisciplinary challenge demands a close cooperation, especially between anesthesiologists and obstetricians. A knowledge of current guidelines, the adaptation of standard operating procedures to local conditions, and regular staff education and training are required. An appropriate assessment of the patient’s clinical status demands accurate estimation or measurement of blood loss and timely recognition of an impending hypovolemic shock. Point-of-care monitoring of coagulation by thromboelastometry or -graphy may be helpful. Preservation of normothermia and normocalcemia, prevention of acidosis, restoration of normovolemia by crystalloids and colloids, and an adequate oxygenation capacity (Hb ≥ 6–8 g/dl) are prerequisites for survival. Hyperfibrinolysis is frequent and antifibrinolytic therapy with 2 g tranexamic acid should be considered early, even before laboratory data are available and before administering fibrinogen. If blood loss exceeds 2000–3000 ml, a sufficient and timely application of hemostatic drugs is mandatory, i.e. fibrinogen (3–4 g, aiming at ≥1.5–2 g/l), fresh frozen plasma (20–30 ml/kg BW), and platelets (aiming at ≥ 100 000/µl). In cases with severe bleeding, prothrombin complex concentrates may be helpful to optimize thrombin generation. Desmopressin (DDAVP) is a therapeutic option for thrombocytopathic patients with diffuse bleeding. “Off label” use of rFVIIa (initially, 90 µg/kg BW) remains an option in individual situations with stringent indications when all other therapeutic procedures have failed and may help to avoid hysterectomy. Neither antithrombin nor heparin should be administered in patients with severe PPH as long as there is an increased risk of hemorrhage. Cell salvage is an appropriate tool to reduce blood transfusions.
Schlüsselwörter
schwere peri‐(post‐)partale Blutung - aktuelle Leitlinien und Empfehlungen - Gerinnungstherapie - Tranexamsäure - Fibrinogen
Key words
postpartum hemorrhage - drug therapy - blood coagulation factors - therapeutic use - erythrocyte transfusion - fibrinolysis - fibrinogen
Literatur
- 1 Mousa H A, Walkinshaw S. Major postpartum haemorrhage. Curr Opin Obstet Gynecol. 2001; 13 595-603
- 2 Khan K S, Wojdyla D, Say L et al. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006; 367 1066-1074
- 3 Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ. 2001; 322 1089-1093
- 4 Knight M, Callaghan W M, Berg C et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009; 9 55
- 5 Royal College of Obstetricians and Gynecologists (ROCG) .Postpartum haemorrhage, prevention and management (Green-top 52). Im Internet: http://www.rcog.org.uk/womens-health/clinical-guidance/prevention-and-management-postpartum-haemorrhage-green-top-52 Stand: 20.6.2009
- 6 Callaghan W M, Kuklina E V, Berg C J. Trends in postpartum hemorrhage: United States, 1994–2006. Am J Obstet Gynecol. 2010; 202 353-356
- 7 Rossen J, Okland I, Nilsen O B et al. Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions?. Acta Obstet Gynecol Scand. 2010; 89 1248-1255
- 8 Samangaya R, Pennington R, Vause S. Factors relating to a rising incidence of major postpartum haemorrhage. BJOG. 2010; 117 370-371
- 9 Dupont C, Touzet S, Colin C et al. Incidence and management of postpartum haemorrhage following the dissemination of guidelines in a network of 16 maternity units in France. Int J Obstet Anesth. 2009; 18 320-327
- 10 Oyelese Y, Ananth C V. Postpartum hemorrhage: epidemiology, risk factors, and causes. Clin Obstet Gynecol. 2010; 53 147-156
- 11 Berg C J, Harper M A, Atkinson S M et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol. 2005; 106 1228-1234
- 12 cemach.. Why mothers die 2003–2005. The seventh report of the confidential enquiries into maternal deaths in the United Kingdom. Im Internet: http://www.cemach.org.uk Stand: 6.1.2008
- 13 Upadhyay K, Scholefield H. Risk management and medicolegal issues related to postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2008; 22 1149-1169
- 14 Bundesärztekammer (BÄK) .Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten. (4. Auflage 2008, zuletzt geändert Januar 2011). Im Internet: http://www.bundesaerztekammer.de/page.asp?his=0.6.3288.8906 Stand: 8.1.2011
- 15 Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) .AWMF-Leitlinie 015/063: Diagnose und Therapie der peripartalen Blutung. Im Internet: http://leitlinien.net/ Stand: 15.1.2011
- 16 Leduc D, Senikas V, Lalonde A B et al. Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage: No. 235 October 2009 (replaces No. 88, April 2000). Int J Gynaecol Obstet. 2010; 108 258-267
- 17 Rath W, Schneider M. Definitionen und Diagnostik postpartaler Blutungen (PPH): Unterschätzte Probleme!. Geburtsh Frauenheilk. 2010; 70 36-40
- 18 Ickx B E. Fluid and blood transfusion management in obstetrics. Eur J Anaesthesiol. 2010; 27 1031-1035
- 19 Thachil J, Toh C H. Disseminated intravascular coagulation in obstetric disorders and its acute haematological management. Blood Rev. 2009; 23 167-176
- 20 Pfanner G. Geburtshilfliche Blutungskomplikationen. Hämostaseologie. 2006; 26 S56-S63
- 21 Franchini M. Haemostasis and pregnancy. Thromb Haemost. 2006; 95 401-413
- 22 Ahonen J, Stefanovic V, Lassila R. Management of post-partum haemorrhage. Acta Anaesthesiol Scand. 2010; 54 1164-1178
- 23 Fuller A J, Bucklin B A. Blood product replacement for postpartum hemorrhage. Clin Obstet Gynecol. 2010; 53 196-208
- 24 McLintock C. Obstetric haemorrhage. Thromb Res. 2009; 123 S30-S34
- 25 Cabero Roura L, Keith L G. Post-partum haemorrhage: diagnosis, prevention and management. J Matern Fetal Neonatal Med. 2009; 22 38-45
- 26 Winter C, Macfarlane A, Deneux-Tharaux C et al. Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe. BJOG. 2007; 114 845-854
- 27 Skupski D W, Lowenwirt I P, Weinbaum F I et al. Improving hospital systems for the care of women with major obstetric hemorrhage. Obstet Gynecol. 2006; 107 977-983
- 28 cemach.. Confidential enquiry into maternal and child health. Perinatal Mortality 2005: England, Wales and Northern Ireland. London: CEMACH; 2007
- 29 Zelop C M. Postpartum hemorrhage: becoming more evidence-based. Obstet Gynecol. 2011; 117 3-5
- 30 Driessen M, Bouvier-Colle M H, Dupont C et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. Obstet Gynecol. 2011; 117 21-31
- 31 Bonnar J. Massive obstetric haemorrhage. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000; 14 1-18
- 32 Hofmeyr G J, Mohlala B K. Hypovolaemic shock. Best Pract Res Clin Obstet Gynaecol. 2001; 15 645-662
- 33 Coker A, Oliver R. Definitions and Classifications. In: Lynch C B, Keith L, Lalonde A, Karoshi M, eds. A Textbook of postpartum Hemorrhage. Dumfriesshire: Sapiens Publishing; 2006: 11-16
- 34 Mukherjee S, Arulkumaran S. Post-partum haemorrhage. Obstet Gynaecol Reprod Med. 2009; 19 121-126
- 35 Karpati P C, Rossignol M, Pirot M et al. High incidence of myocardial ischemia during postpartum hemorrhage. Anesthesiology. 2004; 100 30-36
- 36 Gallos G, Redai I, Smiley R M. The role of the anesthesiologist in management of obstetric hemorrhage. Semin Perinatol. 2009; 33 116-123
- 37 Hofer S, Schreckenberger R, Heindl B et al. Blutungen während der Schwangerschaft. Anaesthesist. 2007; 56 1075-1089
- 38 Wise A, Clark V. Strategies to manage major obstetric haemorrhage. Curr Opin Anaesthesiol. 2008; 21 281-287
- 39 Rajan P V, Wing D A. Postpartum hemorrhage: evidence-based medical interventions for prevention and treatment. Clin Obstet Gynecol. 2010; 53 165-181
- 40 Kuczkowski K M. Anesthesia for the repeat cesarean section in the parturient with abnormal placentation: What does an obstetrician need to know?. Arch Gynecol Obstet. 2006; 273 319-321
- 41 Siddiqui N, Goldszmidt E, Haque S U et al. Ultrasound simulation of internal jugular vein cannulation in pregnant and non-pregnant women. Can J Anaesth. 2010; 57 966-972
- 42 Jin S L, Yu B W. Effects of acute hypervolemic fluid infusion of hydroxyethyl starch and gelatin on hemostasis and possible mechanisms. Clin Appl Thromb Hemost. 2010; 16 91-98
- 43 Lier H, Krep H, Schroeder S et al. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma. 2008; 65 951-960
- 44 Kashuk J L, Moore E E, Sawyer M et al. Primary fibrinolysis is integral in the pathogenesis of the acute coagulopathy of trauma. Ann Surg. 2010; 252 434-442
- 45 Stainsby D, MacLennan S, Thomas D et al. Guidelines on the management of massive blood loss. Br J Haematol. 2006; 135 634-641
- 46 Lier H, Krep H, Schochl H. Gerinnungsmanagement bei der Polytraumaversorgung. Anaesthesist. 2009; 58 1010-1026
- 47 Allam J, Cox M, Yentis S M. Cell salvage in obstetrics. Int J Obstet Anesth. 2008; 17 37-45
- 48 King M, Wrench I, Galimberti A et al. Introduction of cell salvage to a large obstetric unit: the first six months. Int J Obstet Anesth. 2009; 18 111-117
- 49 Fong J, Gurewitsch E D, Kang H J et al. An analysis of transfusion practice and the role of intraoperative red blood cell salvage during cesarean delivery. Anesth Analg. 2007; 104 666-672
- 50 Geoghegan J, Daniels J P, Moore P A et al. Cell salvage at caesarean section: the need for an evidence-based approach. BJOG. 2009; 116 743-747
- 51 Ashworth A, Klein A A. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth. 2010; 105 401-416
- 52 National Institute for Health and Clinical Excellence (NICE) .Intraoperative blood cell salvage in obstetrics. Im Internet: http://guidance.nice.org.uk/IPG144/Guidance/pdf/English Stand: 6.1.2011
- 53 The Association of Anaesthetists of Great Britain and Ireland (AAGBI) .Safety guideline – blood transfusion and the anaesthetist: intra-operative cell salvage. Im Internet: http://aagbi.org/publications/guidelines/docs/cell%2520_salvage_2009_amended.pdf Stand: 6.1.2011
- 54 Rossi A C, Lee R H, Chmait R H. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol. 2010; 115 637-644
- 55 Franchini M, Lippi G, Franchi M. The use of recombinant activated factor VII in obstetric and gynaecological haemorrhage. BJOG. 2007; 114 8-15
- 56 Holcomb J B, Hess J R. Early massive trauma transfusion: state of the art. J Trauma. 2006; 60 S1-S2
- 57 Stainsby D, Jones H, Asher D et al. Serious hazards of transfusion: a decade of hemovigilance in the UK. Transfus Med Rev. 2006; 20 273-282
- 58 Tinegate H N, Thompson C L, Jones H et al. Where and when is blood transfused? An observational study of the timing and location of red cell transfusions in the north of England. Vox Sang. 2007; 93 229-232
- 59 Arbeitskreis Blut des Robert Koch-Instituts (RKI) . Votum 39 – Maßnahmen zur Vermeidung der transfusionsbedingten Lungeninsuffizienz (TRALI). Bundesgesundheitsbl. 2009; 52 572
- 60 Arbeitskreis Blut des Robert Koch-Instituts (RKI) .Ergänzung zum Votum 38. Im Internet: http://www.rki.de/cln_169/nn_206138/DE/Content/Infekt/Blut/AK__Blut/Voten/Uebersicht/V__38/V38__manuskript,templateId=raw,property=publicationFile.pdf/V38_manuskript.pdf Stand: 6.1.2011
- 61 Sarani B, Dunkman W J, Dean L et al. Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection. Crit Care Med. 2008; 36 1114-1118
- 62 Watson G A, Sperry J L, Rosengart M R et al. Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome. J Trauma. 2009; 67 221-227
- 63 Hanke A A, Dellweg C, Kienbaum P et al. Effects of desmopressin on platelet function under conditions of hypothermia and acidosis: an in vitro study using multiple electrode aggregometry. Anaesthesia. 2010; 65 688-691
- 64 Rossaint R, Bouillon B, Cerny V et al. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010; 14 R52
- 65 Hardy J F, De M P, Samama M. Massive transfusion and coagulopathy: pathophysiology and implications for clinical management. Can J Anaesth. 2004; 51 293-310
- 66 Moloney W C, Phillips L L, Pritchard J A et al. Management of the obstetrical patient with hemorrhage due to an acute or subacute defibrination syndrome. Blood. 1959; 14 1354-1367
- 67 Huissoud C, Carrabin N, Audibert F et al. Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry. BJOG. 2009; 116 1097-1102
- 68 Brohi K, Cohen M J, Ganter M T et al. Acute coagulopathy of trauma: hypoperfusion induces systemic anticoagulation and hyperfibrinolysis. J Trauma. 2008; 64 1211-1217
- 69 Lier H, Bottiger B W, Hinkelbein J et al. Coagulation management in multiple trauma: a systematic review. Intensive Care Med. 2011; 37 572-582
- 70 Mercier F J, Bonnet M P. Use of clotting factors and other prohemostatic drugs for obstetric hemorrhage. Curr Opin Anaesthesiol. 2010; 23 310-316
- 71 Fries D, Innerhofer P, Perger P et al. Gerinnungsmanagement bei traumatisch bedingter Massivblutung. Empfehlungen der Arbeitsgruppe für perioperative Gerinnung der ÖGARI. Anasthesiol Intensivmed Notfallmed Schmerzther. 2010; 45 552-561
- 72 Shakur H, Roberts I, Bautista R et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010; 376 23-32
- 73 World Health Organisation (WHO) .WHO guidelines for the management of postpartum haemorrhage and retained placenta. Im Internet: http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241598514/en/ Stand: 6.1.2011
- 74 Ferrer P, Roberts I, Sydenham E et al. Anti-fibrinolytic agents in post partum haemorrhage: a systematic review. BMC Pregnancy Childbirth. 2009; 9 29
- 75 Novikova N, Hofmeyr G J. Tranexamic acid for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2010; (7) CD007872
- 76 Sekhavat L, Tabatabaii A, Dalili M et al. Efficacy of tranexamic acid in reducing blood loss after cesarean section. J Matern Fetal Neonatal Med. 2009; 22 72-75
- 77 Ducloy-Bouthors A S, Jude B, Duhamel A et al. High-dose tranexamic acid reduces blood loss in post-partum haemorrhage. Crit Care. 2011; 15 R117
- 78 Shakur H, Elbourne D, Gulmezoglu M et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010; 11 40
- 79 Chowdhury P, Saayman A G, Paulus U et al. Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol. 2004; 125 69-73
- 80 Szecsi P B, Jorgensen M, Klajnbard A et al. Haemostatic reference intervals in pregnancy. Thromb Haemost. 2010; 103 718-727
- 81 Charbit B, Mandelbrot L, Samain E et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007; 5 266-273
- 82 Mackie I J, Kitchen S, Machin S J et al. Guidelines on fibrinogen assays. Br J Haematol. 2003; 121 396-404
- 83 Franchini M, Franchi M, Bergamini V et al. The use of recombinant activated FVII in postpartum hemorrhage. Clin Obstet Gynecol. 2010; 53 219-227
- 84 Welsh A, McLintock C, Gatt S et al. Guidelines for the use of recombinant activated factor VII in massive obstetric haemorrhage. Aust N Z J Obstet Gynaecol. 2008; 48 12-16
- 85 Fries D, Haas T, Salchner V et al. Gerinnungsmanagement beim Polytrauma. Anaesthesist. 2005; 54 137-144
- 86 Tanaka K A, Taketomi T, Szlam F et al. Improved clot formation by combined administration of activated factor VII (NovoSeven) and fibrinogen (Haemocomplettan P). Anesth Analg. 2008; 106 732-738
- 87 Levi M, Levy J H, Andersen H F et al. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med. 2010; 363 1791-1800
- 88 NovoNordisk. Fachinformation NovoSeven®, Oktober 2010. Kapitel „Thrombembolische Ereignisse“. Im Internet: http://www.fachinfo.de/data/fi/jsearch?praep Stand: 12.2.2011
- 89 Afshari A, Wetterslev J, Brok J et al. Antithrombin III in critically ill patients: systematic review with meta-analysis and trial sequential analysis. BMJ. 2007; 335 1248-1251
- 90 Detti L, Mecacci F, Piccioli A et al. Postpartum heparin therapy for patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) is associated with significant hemorrhagic complications. J Perinatol. 2005; 25 236-240
- 91 McDonald V, Ryland K. Coagulopathy in trauma: optimising haematological status. Trauma. 2008; 10 109-123
- 92 Djelmis J, Ivanisevic M, Kurjak A et al. Hemostatic problems before, during and after delivery. J Perinat Med. 2001; 29 241-246
Dr. med. Heiko Lier
Klinik für Anästhesiologie und Operative Intensivmedizin
Universitätsklinikum Köln
Kerpener Straße 62
50924 Köln
eMail: heiko.lier@uk-koeln.de
Univ.-Prof. Dr. med. Werner Rath
Medizinische Fakultät des Universitätsklinikum Aachen (RWTH)
Gynäkologie und Geburtshilfe
Wendlingweg 2
52074 Aachen
eMail: wrath@ukaachen.de