Massoth Christina, Wenk Manuel, Meybohm Patrick, Kranke Peter
Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster.
Department of Anesthesiology and Intensive Care, Clemenshospital Münster, Münster.
Curr Opin Anaesthesiol. 2023 Jun 1;36(3):281-287. doi: 10.1097/ACO.0000000000001258. Epub 2023 Feb 22.
Excessive bleeding during and following childbirth remains one of the leading causes of maternal mortality.
Current guidelines differ in definitions and recommendations on managing transfusion and hemostasis in massive postpartum hemorrhage (PPH). Insights gained from trauma-induced coagulopathy are not directly transferable to the obstetric population due to gestational alterations and a differing pathophysiology.
Factor deficiency is uncommon at the beginning of most etiologies of PPH but will eventually develop from consumption and depletion in the absence of bleeding control. The sensitivity of point-of-care tests for fibrinolysis is too low and may delay treatment, therefore tranexamic acid should be started early at diagnosis even without signs for hyperfibrinolysis. Transfusion management may be initiated empirically, but is best to be guided by laboratory and viscoelastic assay results as soon as possible. Hypofibrinogenemia is well detected by point-of-care tests, thus substitution may be tailored to individual needs, while reliable thresholds for fresh frozen plasma (FFP) and specific components are yet to be defined. In case of factor deficiency, prothrombin complex concentrate or lyophilized plasma allow for a more rapid restoration of coagulation than FFP. If bleeding and hemostasis are under control, a timely anticoagulation may be necessary.
分娩期间及产后出血过多仍然是孕产妇死亡的主要原因之一。
目前的指南在大量产后出血（PPH）的输血和止血管理的定义及建议方面存在差异。由于妊娠改变和不同的病理生理学，创伤性凝血病的相关见解不能直接应用于产科人群。
在大多数PPH病因开始时，因子缺乏并不常见，但在出血未得到控制的情况下，最终会因消耗和耗竭而出现。床旁纤溶试验的敏感性过低，可能会延误治疗，因此即使没有高纤溶迹象，也应在诊断时尽早开始使用氨甲环酸。输血管理可凭经验启动，但最好尽快以实验室和粘弹性试验结果为指导。床旁试验能很好地检测到低纤维蛋白原血症，因此可根据个体需求进行替代，而新鲜冰冻血浆（FFP）和特定成分的可靠阈值尚未确定。在因子缺乏的情况下，凝血酶原复合物浓缩物或冻干血浆比FFP能更快地恢复凝血功能。如果出血和止血得到控制，可能需要及时进行抗凝治疗。
