Peripartum Kanamada Anestezi Yönetimi
Özet
Peripartum kanama, maternal morbidite ve mortalitenin en önemli nedenlerinden biri olup hızlı ve multidisipliner bir yaklaşım gerektirir. Antepartum kanamaların en yaygın nedenleri placenta previa ve placenta dekolmanı iken; uterus rüptürü ve vasa previa daha nadir görülür. Placenta previalı hastalarda planlı sezaryen için nöraksiyel anestezi tercih edilirken, aktif kanama veya acil durumlarda genel anestezi ön plana çıkar. Plasenta dekolmanında koagülopati riski nedeniyle nöraksiyel işlemler öncesi pıhtılaşma testleri istenmelidir. Postpartum kanama (PPK) durumunda anestezi yönetimi kanamanın şiddetine, doğum tipine ve hastanın hemodinamik durumuna göre belirlenir. Hemodinamik olarak stabil hastalarda epidural, spinal veya kombine spinal-epidural gibi nöraksiyel teknikler ya da orta derecede sedasyon uygulanabilirken; ileri hipovolemi ve şiddetli PPK varlığında hava yolu kontrolü ve kardiyovasküler stabilite için genel anestezi tercih edilir. Ayrıca PPK tanılı hastalara doğumdan sonraki üç saat içinde oksitosinle birlikte traneksamik asit uygulanması önerilir. İleri derecede yapışık plasenta olgularında planlanan sezaryen histerektomi ise masif kanama riski taşıdığından multidisipliner planlama, erken kan ürünü hazırlığı ve uygun venöz erişim gerektirir; anestezi yöntemi olarak hastanın durumuna göre nöraksiyel veya genel anestezi seçilir.
Peripartum hemorrhage is a leading cause of maternal morbidity and mortality, requiring a prompt and multidisciplinary approach. While placenta previa and placental abruption are the most common causes of antepartum hemorrhage, uterine rupture and vasa previa occur more rarely. Neuraxial anesthesia is preferred for planned cesarean sections in placenta previa patients, whereas general anesthesia is prominent in active bleeding or emergencies. In placental abruption, coagulation tests must be requested before neuraxial procedures due to the risk of coagulopathy. Anesthesia management in postpartum hemorrhage (PPH) is determined by the severity of bleeding, mode of delivery, and hemodynamic status. Neuraxial techniques such as epidural, spinal, or combined spinal-epidural, or moderate sedation can be applied in hemodynamically stable patients; however, general anesthesia is preferred in the presence of severe PPH and advanced hypovolemia for airway control and cardiovascular stability. Additionally, the administration of tranexamic acid along with oxytocin is recommended within three hours after delivery for patients diagnosed with PPH. Scheduled cesarean hysterectomy in cases of abnormally invasive placenta carries a massive bleeding risk, requiring multidisciplinary planning, early blood product preparation, and appropriate venous access, with either neuraxial or general anesthesia chosen based on the patient's condition.
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