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Management der postpartalen Blutung (PPH)

Algorithmus der Interdisziplinären D-A-CH-Konsensusgruppe PPH (Deutschland – Österreich – Schweiz)

Management of postpartum hemorrhage (PPH)

Algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany – Austria – Switzerland)

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Zusammenfassung

Die postpartale Blutung (PPH) zählt zu den Hauptursachen der Müttersterblichkeit auch in der westlichen Welt. Die PPH stellt eine Notfallsituation dar, die eine rasche Entscheidung und v. a. eine exakte Diagnose und Ursachenanalyse notwendig macht, um die korrekten therapeutischen Maßnahmen in interdisziplinärer Zusammenarbeit rechtzeitig einzuleiten. Neben etablierten Leitlinien ist der Nutzen standardisierter Therapiealgorithmen belegt. Ein Therapiealgorithmus für den geburtshilflichen Notfall „postpartale Hämorrhagie“ fehlte bisher im deutschsprachigen Raum. Die Erstellung des länderübergreifenden (Deutschland, Österreich und Schweiz: D-A-CH) „Handlungsalgorithmus Postpartale Blutung“ erfolgte interdisziplinär, basierend auf den bisherigen Leitlinien der jeweiligen Fachgesellschaften (Anästhesie und Intensivmedizin, Geburtshilfe) der 3 Länder sowie internationalen vergleichbaren Algorithmen zur Therapie der PPH.

Das geburtshilfliche und anästhesiologische Personal muss für den Notfall eine ausreichende Expertise trotz geringer Fallzahl besitzen. Die Seltenheit, mit der das Ereignis für die einzelne Patientin auftritt, sowie die vitale Bedrohung in der Situation, erfordern ein strukturiertes Vorgehen nach vorgegebenen Handlungsalgorithmen. Dies kann mit dem nun ausgearbeiteten Algorithmus erfolgen. Darüber hinaus bietet dieser Algorithmus die Möglichkeit, den Notfall im interdisziplinären Team zu trainieren.

Abstract

Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) “treatment algorithm for postpartum hemorrhage” was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.

The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.

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Literatur

  1. Bateman BT, Berman MF, Riley LE, Leffert LR (2010) The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 110:1368–1373

    Article  PubMed  Google Scholar 

  2. Callaghan WM, Kuklina EV, Berg CJ (2010) Trends in postpartum hemorrhage: United States, 1994–2006. Am J Obstet Gynecol 202:353.e1–6

    PubMed  Google Scholar 

  3. Knight M, Callaghan WM, Berg C et al (2009) Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 9:55–65

    Article  PubMed Central  PubMed  Google Scholar 

  4. Samangaya R, Pennington R, Vause S (2010) Factors relating to a rising incidence of major postpartum haemorrhage. BJOG 117:370–371

    Article  PubMed  Google Scholar 

  5. Kramer MS, Dahhou M, Vallerand D et al (2011) Risk factors for postpartum haemorrhage: can we explain the recent temporal increase? J Obstet Gynaecol Can 33:810–819

    PubMed  Google Scholar 

  6. Buchanan SL, Patterson JA, Roberts CL et al (2012) Trends and morbidity associated with oxytocin use in labour in nulliparas at term. Aust N Z J Obstet Gynaecol 52:173–178

    Article  PubMed  Google Scholar 

  7. Khan KS, Wojdyla D, Say L et al (2006) WHO analysis of causes of maternal death: a systematic review. Lancet 367:1066–1074

    Article  PubMed  Google Scholar 

  8. Haeri S, Dildy GA 3rd (2012) Maternal mortality from hemorrhage. Semin Perinatol 36:48–55

    Article  PubMed  Google Scholar 

  9. World Health Organization (o J) The World Health Report 2005: make every mother and child count. http://www.who.int/whr/2005/whr2005_en.pdf

  10. Ronsmans C, Graham WJ, Lancet Maternal Survival Series steering group (2006) Maternal mortality: who, when, where, and why. Lancet 368:1189–1200

    Article  PubMed  Google Scholar 

  11. Mousa HA, Walkinshaw S (2001) Major postpartum hemorrhage. Curr Opin Obstet Gynecol 13:595–603

    Article  CAS  PubMed  Google Scholar 

  12. Waterstone M, Bewley S, Wolfe C (2001) Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 322:1089–1093

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  13. AbouZahr C (2003) Global burden of maternal death and disability. Br Med Bull 67:1–11

    Article  PubMed  Google Scholar 

  14. Henrich W, Surbek D, Kainer F et al (2008) Expert panel recommendation: diagnosis and treatment of peripartum bleeding. J Perinat Med 36:467–478

    Article  CAS  PubMed  Google Scholar 

  15. AWMF-Leitlinie Nr. 015/063. Diagnostik und Therapie peripartaler Blutungen. AWMF online. http://www.awmf.org/uploads/tx_szleitlinien/015-063l_S1_Peripartale_Blutungen.pdf

  16. Carroli G, Cuesta C, Abalos E, Gulmezoglu AM (2008) Epidemiology of postpartum haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynaecol 22:999–1012

    Article  PubMed  Google Scholar 

  17. Bose P, Regan F, Paterson-Brown S (2006) Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 113:919–924

    Article  CAS  PubMed  Google Scholar 

  18. Rath W, Schneider M (2010) Definitionen und Diagnostik postpartaler Blutungen (PPH): unterschätzte Probleme! Geburtsh Frauenheilkd 70:36–40

    Article  Google Scholar 

  19. Rath W, Bohlmann MK (2011) Postpartale Hämorrhagie – Prävention und Therapie. Gynakologe 44:538–548

    Article  CAS  Google Scholar 

  20. Farquhar C, Sadler L, Masson V et al (2011) Beyond the numbers: classifying contributory factors and potentially avoidable maternal deaths in New Zealand, 2006–2009. Am J Obstet Gynecol 205:331.e1–8

    PubMed  Google Scholar 

  21. Mukherjee S, Arulkumaran S (2009) Post-partum haemorrhage. Obstet Gynaecol Reprod Med 19:121–126

    Article  Google Scholar 

  22. RCOG Green –top Guideline No. 52: Prevention and management of postpartum haemorrhage. http://www.rcog.org.uk/files/rcog-corp/GT52PostpartumHaemorrhage0411.pdf

  23. Driessen M, Bouvier-Colle MH, Dupont C et al (2011) Postpartum hemorrhage resulting from uterine atony after vaginal delivery. Obstet Gynecol 117:21–31

    Article  PubMed Central  PubMed  Google Scholar 

  24. Dupont C, Touzet S, Colin C et al (2009) Groupe PITHAGORE 6. Incidence and management of postpartum haemorrhage following the dissemination of guidelines in a network of 16 maternity units in France. Int J Obstet Anesth 18:320–327

    Article  CAS  PubMed  Google Scholar 

  25. Upadhyay K, Scholefield H (2008) Risk management and medicolegal issues related to postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol 22:1149–1169

    Article  PubMed  Google Scholar 

  26. Shields LE, Smalarz K, Reffigee L et al (2011) Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 205:368.e1–8

    PubMed  Google Scholar 

  27. Dupont C, Deneux-Tharaux C, Touzet S et al (2011) Pithagoras6 Group. Clinical audit: a useful tool for reducing severe postpartum haemorrhages? Int J Qual Health Care 23:583–859

    Article  PubMed Central  PubMed  Google Scholar 

  28. Helmer H (2008) Leitlinie zum Management der postpartalen Blutung. Speculum 26:15–20

    Google Scholar 

  29. Surbek D, Irion O, Hess T, Drack G (2009) Aktuelle Therapieoptionen der postpartalen Hämorrhagie. Expertenbrief No. 26. Kommission Qualitätssicherung – Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe. http://sggg.ch/files/Expertenbrief_No_26.pdf

  30. Rath W, Helmer H, Beinder E (2009) Postpartale Blutungen (PPH). Leitlinien in Deutschland, Österreich und der Schweiz – Gemeinsamkeiten und Differenzen. Geburtsh Frauenheilkd 69:866–871

    Article  Google Scholar 

  31. Schorn MN (2010) Measurement of blood loss: review of the literature. J Midwifery Womens Health 55:20–27

    Article  PubMed  Google Scholar 

  32. Prata N, Gerdts C (2010) Measurement of postpartum blood loss. BMJ 340:c555

    Article  PubMed  Google Scholar 

  33. Al Kadri HM, Al Anazi BK, Tamim HM (2011) Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study. Arch Gynecol Obstet 283:1207–1213

    Article  Google Scholar 

  34. Thomas JS, Koh SH, Cooper GM (2007) Haemodynamic effects of oxytocin given as i.v. bolus or infusion on women undergoing Caesarean section. Br J Anaesth 98:116–119

    Article  CAS  PubMed  Google Scholar 

  35. Mörtl MG, Friedrich S, Kraschl J et al (2011) Haemodynamic effects of carbetocin and oxytocin given as intravenous bolus on women undergoing caesarean delivery: a randomised trial. BJOG 118:1349–1356

    Article  Google Scholar 

  36. Bolliger D, Görlinger K, Tanaka KA (2010) Pathophysiology and treatment of coagulopathy in massive hemorrhage and hemodilution. Anesthesiology 113:1205–1219

    Article  PubMed  Google Scholar 

  37. Hiippala ST, Myllylä GJ, Vahtera EM (1995) Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 81:360–365

    CAS  PubMed  Google Scholar 

  38. Ducloy-Bouthors AS, Jude B, Duhamel A et al (2011) High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care 15:R117

    Article  PubMed Central  PubMed  Google Scholar 

  39. CRASH-2 trial collaborators, Shakur H, Roberts I et al (2010) 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 376:23–32

    Google Scholar 

  40. Shaz BH, Dente CJ, Harris RS et al (2009) Transfusion management of trauma patients. Anesth Analg 108:1760–1768

    Article  PubMed Central  PubMed  Google Scholar 

  41. Charbit B, Mandelbrot L, Samain E et al (2007) The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 5:266–273

    Article  CAS  PubMed  Google Scholar 

  42. Cortet M, Deneux-Tharaux C, Dupont C et al (2012) Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth 108:984–989

    Article  CAS  PubMed  Google Scholar 

  43. James AH, McLintock C, Lockhart E (2012) Postpartum hemorrhage: when uterotonics and sutures fail. Am J Hematol 87(Suppl 1):16–22

    Article  Google Scholar 

  44. Huissoud C, Carrabin N, Benchaib M et al (2009) Coagulation assessment by rotation thrombelastometry in normal pregnancy. Thromb Haemost 101:755–761

    CAS  PubMed  Google Scholar 

  45. Macafee B, Campbell JP, Ashpole K et al (2012) Reference ranges for thromboelastography (TEG(®)) and traditional coagulation tests in term parturients undergoing caesarean section under spinal anaesthesia. Anaesthesia 67:741–747

    Article  CAS  PubMed  Google Scholar 

  46. Fries D, Innerhofer P, Perger P et al (2010) Gerinnungsmanagement bei traumatisch bedingter Massivblutung Empfehlungen der Arbeitsgruppe für perioperative Gerinnung der ÖGARI. Anasthesiol Intensivmed Notfallmed Schmerzther 45:552–561

    Article  PubMed  Google Scholar 

  47. Valeri CR, Feingold H, Cassidy G et al (1987) Hypothermia-induced reversible platelet dysfunction. Ann Surg 205:175–181

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  48. Cosgriff N, Moore EE, Sauaia A et al (1997) Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidosis revisited. J Trauma 42:857–861

    Article  CAS  PubMed  Google Scholar 

  49. Wolberg AS, Mang ZH, Monroe DM 3rd, Hoffman M (2004) A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma 56:1221–1228

    Article  CAS  PubMed  Google Scholar 

  50. Aibar L, Aguilar MT, Puertas A, Valverde M (2012) Bakri balloon for the management of postpartum haemorrhage. Acta Obstet Gynecol Scand 92:465–467

    Article  PubMed  Google Scholar 

  51. Forna F, Miles AM, Jamieson DJ (2004) Emergency peripartum hysterectomy: a comparison of cesarean and postpartum hysterectomy. Am J Obstet Gynecol 190:1440–1444

    Article  PubMed  Google Scholar 

  52. Lau WC, Fung HY, Rogers MS (1997) Ten years experience of caesarean and postpartum hysterectomy in a teaching hospital in Hong Kong. Eur J Obstet Gynecol Reprod Biol 74:133–137

    Article  CAS  PubMed  Google Scholar 

  53. Roethlisberger M, Womastek I, Posch M et al (2010) Early postpartum hysterectomy: incidence and risk factors. Acta Obstet Gynecol Scand 89:1040–1044

    Article  PubMed  Google Scholar 

  54. Rath W, Hackethal A, Bohlmann MK (2012) Second-line treatment of postpartum haemorrhage (PPH). Arch Gynecol Obstet 286:549–561

    Article  CAS  PubMed  Google Scholar 

  55. Stocks G (2011) Monitoring transfusion requirements in major obstetric haemorrhage: out with the old and in with the new? Int J Obstet Anesth 20:275–278

    Article  PubMed  Google Scholar 

  56. Armstrong S, Fernando R, Ashpole K et al (2011) Assessment of coagulation in the obstetric population using ROTEM® thromboelastometry. Int J Obstet Anesth 20:293–298

    Article  CAS  PubMed  Google Scholar 

  57. Wilson AK, Martel MJ, Arsenault MY et al (2005) Society of Obstetricians and Gynaecologists of Canada. Maternal transport policy. J Obstet Gynaecol Can 27:956–963

    PubMed  Google Scholar 

  58. Crofts JF, Draycott TJ, Winter C et al (2007) Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 114:1534–1541

    Article  CAS  PubMed  Google Scholar 

  59. Merién AE, Ven J van de, Mol BW et al (2010) Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol 115:1021–1031

    Article  PubMed  Google Scholar 

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Einhaltung ethischer Richtlinien

Interessenkonflikt. D. Schlembach, M.G. Mörtl, T. Girard, W. Arzt, E. Beinder, C. Brezinka, K. Chalubinski, D. Fries, W. Gogarten, B.-J. Hackelöer, H. Helmer, W. Henrich, I. Hösli, P. Husslein, F. Kainer, U. Lang, G. Pfanner, W. Rath, E. Schleussner, H. Steiner, D. Surbek und R. Zimmermann geben an, dass kein Interessenkonflikt besteht. Der Beitrag enthält keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Abteilung für Geburtshilfe, Universitätsfrauenklinik, Universitätsklinikum Jena, Bachstr. 18, 07732, Jena, Deutschland

    D. Schlembach & E. Schleussner

  2. Klinik für Gynäkologie und Geburtshilfe, Perinatalzentrum, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Österreich

    M.G. Mörtl

  3. Departement Anaesthesie, UniversitätsSpital Basel, Basel, Schweiz

    T. Girard

  4. Abteilung für Geburtshilfe und Pränatalmedizin, Landesfrauen- und Kinderklinik Linz, Linz, Österreich

    W. Arzt

  5. Klinik für Ge­burtsmedizin, Charite – Universitätsmedizin Ber­lin, Berlin, Deutschland

    E. Beinder & W. Henrich

  6. Department Frauenheil­kunde, Universitätsklinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich

    C. Brezinka

  7. Universitätsfrauenklinik, Medizinische Universität Wien, Wien, Österreich

    K. Chalubinski, H. Helmer & P. Husslein

  8. Klinische Abteilung für Allgemeine & Chirurgische Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich

    D. Fries

  9. Klinik für Anäs­thesiologie, operative In­tensivmedizin, Notfallme­dizin und Schmerzthera­pie, Klinikum Bielefeld, Bielefeld, Deutschland

    W. Gogarten

  10. Amedes Experts, Hamburg, Deutschland

    B.-J. Hackelöer

  11. Abteilung Geburtshilfe & Schwangerschaftsmedi­zin, UniversitätsSpital Basel, Basel, Schweiz

    I. Hösli

  12. Klinik Haller­wiese, Geburtshilfe und Pränatalmedizin, Diakonie Neuen­dettelsau, Nürnberg, Deutschland

    F. Kainer

  13. Universitätsklinik für Geburtshilfe und Frauenheilkunde, Medizinische Universität Graz, Graz, Österreich

    U. Lang

  14. Abteilung für Anästhesiologie und Intensivmedizin, LKH Feldkirch, Feldrich, Deutschland

    G. Pfanner

  15. Universitätsfrauen­klinik, Universitätsklini­kum RWTH Aachen, Aachen, Deutschland

    W. Rath

  16. -, Salzburg, Österreich

    H. Steiner

  17. Universitätsklinik für Frauenheilkunde, InselSpital, Medizinische Universität Bern, Bern, Schweiz

    D. Surbek

  18. Klinik für Geburtshilfe, Universi­tätsspital Zürich, Zürich, Schweiz

    R. Zimmermann

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  1. D. Schlembach
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  2. M.G. Mörtl
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  3. T. Girard
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  4. W. Arzt
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  10. B.-J. Hackelöer
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  11. H. Helmer
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  18. W. Rath
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  19. E. Schleussner
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  20. H. Steiner
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  21. D. Surbek
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  22. R. Zimmermann
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Corresponding author

Correspondence to D. Schlembach.

Additional information

D. Schlembach, M.G. Mörtl, T. Girard sind die hauptverantwortlichen Autoren bei der Manuskripterstellung. D. Schlembach, M.G. Mörtl: Leitung des Konsensusteams „D-A-CH Handlungsalgorithmus Postpartale Hämorrhagie“. Erstpublikation in Der Frauenarzt (2013)11:1072–1080; Abdruck mit freundlicher Genehmigung der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG).

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Schlembach, D., Mörtl, M., Girard, T. et al. Management der postpartalen Blutung (PPH). Anaesthesist 63, 234–242 (2014). https://doi.org/10.1007/s00101-014-2291-1

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