Johns Hopkins Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Jones).
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Dr Federspiel).
Am J Obstet Gynecol MFM. 2023 Feb;5(2S):100731. doi: 10.1016/j.ajogmf.2022.100731. Epub 2022 Aug 24.
Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide, with uterine atony estimated to account for 70% to 80% of cases, thereby remaining the single most common cause. Pharmacotherapy remains the first-line preventative therapy for postpartum hemorrhage. These therapies may be single (oxytocin, carbetocin, methylergonovine, ergometrine, misoprostol, prostaglandin analogs, or tranexamic acid) or combination therapies, acting in an additive, infra-additive, or synergistic fashion to prevent postpartum hemorrhage. Evidence is strong for the use of oxytocin, the first-line uterotonic agent in the United States for prevention of postpartum hemorrhage. Although carbetocin, a long-acting analog of oxytocin, is not yet available for use in the United States, it is likely the most effective single pharmacologic therapy for prevention of postpartum hemorrhage and need for additional uterotonics. Use of second-line uterotonics such as methylergonovine, misoprostol, and carboprost in combination with oxytocin has an additive or synergistic effect and a greater risk reduction for postpartum hemorrhage prevention compared with oxytocin alone. Therefore, combined therapy rather than oxytocin alone should be advised for preventing postpartum hemorrhage. Tranexamic acid has been found to be both effective and safe for decreasing maternal mortality in women with postpartum hemorrhage, and prophylactic use of tranexamic acid may decrease the need for packed red blood cell transfusions and/or uterotonics. The WOMAN-2 Trial, designed to assess if tranexamic acid prevents postpartum hemorrhage in women with moderate to severe anemia undergoing vaginal delivery, is currently recruiting participants. The additive, infra-additive, or synergistic action of oxytocin in combination with other second-line therapies deserves further study.
产后出血是全球孕产妇发病率和死亡率的主要原因，估计有 70%至 80%的病例是由于子宫收缩乏力引起的，因此它仍然是最常见的原因。药物治疗仍然是产后出血的一线预防治疗方法。这些治疗方法可以是单一药物（缩宫素、卡贝缩宫素、麦角新碱、马来酸麦角新碱、米索前列醇、前列腺素类似物或氨甲环酸）或联合治疗，以相加、次相加或协同的方式作用，以预防产后出血。在美国，缩宫素是预防产后出血的一线宫缩剂，其使用证据确凿。虽然卡贝缩宫素是一种长效的缩宫素类似物，尚未在美国使用，但它可能是预防产后出血和需要额外使用宫缩剂的最有效单一药物治疗方法。使用二线宫缩剂，如麦角新碱、米索前列醇和卡前列素与缩宫素联合使用，具有相加或协同作用，可降低产后出血的风险，与单独使用缩宫素相比，降低风险的效果更大。因此，建议联合治疗，而不是单独使用缩宫素，以预防产后出血。氨甲环酸已被发现可有效和安全地降低产后出血妇女的死亡率，预防性使用氨甲环酸可能减少需要输红细胞和/或宫缩剂的情况。WOMAN-2 试验旨在评估氨甲环酸是否可预防中度至重度贫血行阴道分娩的妇女发生产后出血，目前正在招募参与者。需要进一步研究缩宫素与其他二线治疗方法联合使用的相加、次相加或协同作用。
