Butwick Alexander J, Goodnough Lawrence T
aDepartment of Anesthesiology bDepartment of Pathology cDepartment of Medicine, Stanford University School of Medicine, Stanford, California, USA.
Curr Opin Anaesthesiol. 2015 Jun;28(3):275-84. doi: 10.1097/ACO.0000000000000180.
Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage.
Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9-2.3%), and investigators have questioned whether a predelivery 'type and screen' is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin clot quality during PPH, which correlate with low fibrinogen levels.
A massive transfusion protocol provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula-driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH.
严重产科出血是孕产妇发病和死亡的主要原因。我们将综述输血策略以及在严重产科出血期间监测孕产妇凝血指标的价值。
流行病学研究表明，资源丰富国家的严重产后出血（PPH）发生率正在上升。尽管发生率有所增加，但产科输血率较低（0.9 - 2.3%），研究人员质疑产前“血型鉴定和筛查”对所有产科患者是否具有成本效益。相反，针对产科患者的用血申请方案可以减少不必要的抗体检测。当发生严重PPH时，大量输血方案作为一种关键治疗资源受到关注，它可确保向产房持续供应血液制品。在产后早期出血期间，最近的研究表明，低纤维蛋白原血症是严重PPH后期发展的重要预测指标。即时检测技术，如血栓弹力图和旋转血栓弹力测定法，可识别PPH期间纤维蛋白凝块质量下降，这与低纤维蛋白原水平相关。
大量输血方案是严重PPH管理的关键资源。然而，未来需要开展研究来评估公式驱动型与目标导向型输血疗法是否能改善严重PPH女性的孕产妇结局。
