Geburtshilfliche Anästhesie – Update postpartale Atonie

Zusammenfassung

Postpartale Hämorrhagien nehmen in ihrer Inzidenz zu und tragen wesentlich zu einer erhöhten mütterlichen Morbidität bei, auch wenn die Mortalität sinkt. Führende Ursache der postpartalen Hämorrhagie sind Uterusatonien, gefolgt von Plazentalösungsstörungen, welche insbesondere nach vorangegangener Sectio gehäuft beobachtet werden. Die Therapie der postpartalen Atonie besteht in der Gabe von Uterotonika sowie in chirurgischen Maßnahmen. Gleichzeitig sollte frühzeitig mit einer Gerinnungsoptimierung begonnen werden. Als Initialtherapie ist hierfür Tranexamsäure, ggf. zusätzlich Fibrinogen, geeignet. Im weiteren Verlauf sollte abgeleitet aus Traumastudien frühzeitig ein Verhältnis von Frischplasmen zu Erythrozytenkonzentraten von 1:1 angestrebt werden, da hierdurch bei mehreren Fallserien die Mortalität gesenkt werden konnte. In allen Kreißsälen ist es empfehlenswert, Handlungsempfehlungen zum Management parat zu haben, die regelmäßig trainiert werden sollten.

Abstract

Postpartum hemorrhage remains a major cause of maternal morbidity and mortality. The incidence of postpartum hemorrhage appears to be increasing in developed countries due to an increased number of placenta accreta or percreta after previous Cesarean deliveries. The initial therapy of postpartum hemorrhage consists of uterotonic drugs and inspection of the uterine cavum. At the same time, optimization of the clotting potential should be initiated early. Tranexamic acid may be considered as a first line choice, followed by fibrinogen if necessary. If bleeding continues, fresh frozen plasma and packed red cells should be ordered in a ratio of 1:1, as this ratio has been shown to improve survival in trauma victims. All labor and delivery suites should have standard operating procedures for the management of postpartum hemorrhage in place with regular drills.

Schlüsselwörter:

postpartale Hämorrhagie - Uterotonika - Uterusatonie - Fibrinogen - Frischplasma

Keywords:

postpartum hemorrhage - oxytocics - uterine atony - fibrinogen - fresh frozen plasma

• Literatur

• 1 Cantwell R et al. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118 (Suppl. 01)
• 2 Phillips LE et al. Recombinant activated factor VII in obstetric hemorrhage: experiences from the Australian and New Zealand Haemostasis Registry. Anesth Analg 2009; 109: 1908-1915
• 3 Silver RM et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107: 1226-1232
• 4 George RB, McKeen D, Chaplin AC, McLeod L. Up-down determination of the ED(90) of oxytocin infusions for the prevention of postpartum uterine atony in parturients undergoing Cesarean delivery. Can J Anaesth 2010; 57: 578-582
• 5 Jonsson M, Hanson U, Lidell C, Norden-Lindeberg S. ST depression at caesarean section and the relation to oxytocin dose. A randomised controlled trial. BJOG 2010; 117: 76-83
• 6 Sartain JB et al. Intravenous oxytocin bolus of 2 units is superior to 5 units during elective Caesarean section. Br J Anaesth 2008; 101: 822-826
• 7 Marcus HE et al. Survey on the use of oxytocin for cesarean section. Minerva Anestesiol 2010; 76: 890-895
• 8 Gogarten W et al. Durchfuehrung von Analgesie- und Anaesthesieverfahren in der Geburtshilfe. 2. Ueberarbeitete Empfehlungen der Deutschen Gesellschaft für Anaesthesiologie und Intensivmedizin. Anaesth Intensivmed 2009; 50
• 9 Mathe ML et al. Impact of the new French clinical practice recommendations in embolization in postpartum and post-abortion hemorrhage: study of 48 cases. J Perinat Med 2007; 35: 532-537
• 10 Borruto F, Treisser A, Comparetto C. Utilization of carbetocin for prevention of postpartum hemorrhage after cesarean section: a randomized clinical trial. Arch Gynecol Obstet 2009; 280: 707-712
• 11 Winikoff B et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet 2010; 375: 210-216
• 12 Shakur H 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
• 13 Roberts I et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011; 377: 1-2
• 14 Gungorduk K et al. Efficacy of intravenous tranexamic acid in reducing blood loss after elective cesarean section: a prospective, randomized, double-blind, placebo-controlled study. Am J Perinatol 2011; 28: 233-240
• 15 Ferrer P et al. Anti-fibrinolytic agents in post partum haemorrhage: a systematic review. BMC Pregnancy Childbirth 2009; 9: 29-29
• 16 Charbit B et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 2007; 5: 266-273
• 17 Huissoud C et al. Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry. BJOG 2009; 116: 1097-1102
• 18 de Lloyd L et al. Standard haemostatic tests following major obstetric haemorrhage. Int J Obstet Anesth 2011; 20: 135-141
• 19 Fenger-Eriksen C et al. Fibrinogen substitution improves whole blood clot firmness after dilution with hydroxyethyl starch in bleeding patients undergoing radical cystectomy: a randomized, placebo-controlled clinical trial. J Thromb Haemost 2009; 7: 795-802
• 20 Bell SF et al. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anesth 2010; 19: 218-223
• 21 Meyer MA et al. Fibrinogen concentrates for bleeding trauma patients: what is the evidence?. Vox Sang [Epub ahead of print] 2011;
• 22 Franchini M, Franchi M, Bergamini V et al. The use of recombinant activated FVII in postpartum hemorrhage. Clin Obstet Gynecol 2010; 53: 219-227
• 23 Levi M et al. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med 2010; 363: 1791-1800
• 24 Sperry JL et al. An FFP:PRBC transfusion ratio >/=1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma 2008; 65: 986-993
• 25 Johansson PI, Ostrowski SR, Secher NH. Management of major blood loss: an update. Acta Anaesthesiol Scand 2010; 54: 1039-1049
• 26 Shaz BH et al. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion 2010; 50: 493-500
• 27 Borgman MA et al. The effect of FFP:RBC ratio on morbidity and mortality in trauma patients based on transfusion prediction score. Vox Sang 2011; 101: 44-54
• 28 Zanati J et al. [Buttock necrosis after subtotal hysterectomy, bilateral internal iliac arteries ligature and pelvic embolization for control of severe post-partum haemorrhage]. J Gynecol Obstet Biol Reprod 2010; 39: 57-60
• 29 Kayem G et al. Specific second-line therapies for postpartum haemorrhage: a national cohort study. BJOG 2011; 118: 856-864
• 30 Knight M. Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage. BJOG 2007; 114: 1380-1387
• 31 CEMACH.. Saving mothers' lives: Reviewing maternal deaths to make motherhood safer - 2003-2005. www.cemachorguk/publications/ 2007