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
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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
