Postpartale Hämorrhagie

Die postpartale Hämorrhagie tritt bei etwa 4% aller Entbindungen in industrialisierten Ländern auf und zeigt eine steigende Inzidenz. Die schwerwiegenden Auswirkungen auf das maternale Outcome erfordern eine rasche Diagnosestellung und Ursachenidentifizierung mit nachfolgendem zielgerichtetem sowie interdisziplinärem Management der Blutstillung, Kreislaufstabilisierung und Gerinnungstherapie.

Abstract

Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.

Kernaussagen

• Von einer peripartalen Hämorrhagie spricht man in der DACH-Region bei einem Blutverlust von > 500 ml nach vaginaler Geburt, > 1000 ml nach Sectio caesarea oder klinischen Zeichen eines hämorrhagischen Schocks.

• Mit Diagnosestellung sollte umgehend 1 g Tranexamsäure gegeben werden.

• Anhaltende schwere Blutungen erfordern ein interdisziplinäres Management, das in klinikinternen stadienbasierten Handlungsalgorithmen klar formuliert sein sollte.

• Oxytocin stellt das Uterotonikum der ersten Wahl zur Therapie der PPH dar, bei unzureichender Wirkung sollte rasch auf Sulproston umgestellt werden.

• Zur Prävention der PPH nach Schnittentbindung kommen Carbetocin (100 µg) oder Oxytocin zur Anwendung, bevor auch hier auf Sulproston gewechselt werden sollte.

• Die Uterustamponade wird sowohl zur Überbrückung als auch als definitive Therapie der PPH, z. B. in Kombination mit Kompressionsnähten, angewendet.

• Operative Techniken umfassen uterine Kompressionsnähte, Gefäßligaturen sowie die Hysterektomie als Ultima Ratio.

• Der Einsatz interventionell-radiologischer Maßnahmen ist sowohl bei antizipiertem als auch manifestem Blutverlust möglich, wird jedoch durch die jeweilige lokale Verfügbarkeit eingeschränkt.

• Volumen- und Transfusionstherapie sollten initial empirisch begonnen werden, dann jedoch möglichst rasch durch bettseitige und laborbasierte Parameter gezielt gesteuert werden.

• Die Substitution von Gerinnungsfaktoren bei Auftreten einer Koagulopathie sollte aufgrund der schwangerschaftsbedingten Hämostaseveränderungen möglichst individualisiert unter Berücksichtigung von Faktorenbestimmungen und viskoelastischen Tests erfolgen.

Schlüsselwörter

postpartale Blutung - vaginale Geburt - Kaiserschnitt - Uterusatonie - Koagulopathie

Keywords

postpartum haemorrhage - vaginal birth - cesarean section - uterine atony - coagulopathy

Publikationsverlauf

Artikel online veröffentlicht:
13. Oktober 2023

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