Postpartum Kanama Yönetimi ve Postpartum Histerektomi
Özet
Postpartum kanama (PPK), plasenta ayrılmasından sonra uterus kasılması veya pıhtılaşma mekanizmalarındaki bozukluklar ile doğum sırasındaki travmalardan kaynaklanan, anne ölümlerinin en önemli nedenlerinden biri olan obstetrik bir acil durumdur. Tanı, kümülatif kan kaybının 1000 mL veya üzerinde olması ya da hipovolemi belirtilerinin görülmesiyle konur; ancak kan basıncındaki ciddi düşüşlerin geç fark edilmesi tanıyı geciktirebilir. En sık karşılaşılan neden uterus atonisi olup, bunu genital travmalar ve koagülopatiler izlemektedir. PPK yönetiminde kantitatif kan kaybı ölçümü (QBL), erken müdahale ve maternal erken uyarı sistemleri mortaliteyi azaltmada kritik rol oynar. Hastanelerde acil durum protokollerinin, müdahale kitlerinin ve masif transfüzyon planlarının hazır bulundurulması, personelin düzenli simülasyon eğitimi alması hayati önem taşır. Tedavide öncelikle oksitosin gibi uterotonik ilaçlar, traneksamik asit, intrauterin balon tamponadı veya anti-şok giysileri (NASG) kullanılır; bu önlemlerin yetersiz kaldığı masif kanamalarda kompresyon dikişleri, arteriyel embolizasyon ve son çare olarak kesin tedavi sağlayan histerektomi gibi cerrahi prosedürlere başvurulur.
Postpartum hemorrhage (PPH) is an obstetric emergency caused by disorders in uterine contraction or coagulation mechanisms after placental separation, as well as birth trauma, and it stands as one of the leading causes of maternal mortality. Diagnosis is established with a cumulative blood loss of 1000 mL or more or the presence of hypovolemia symptoms; however, delayed manifestation of significant blood pressure drops can delay diagnosis. The most common cause is uterine atony, followed by genital trauma and coagulopathies. In PPH management, quantitative blood loss measurement (QBL), early intervention, and maternal early warning systems play a critical role in reducing mortality. It is vital for hospitals to have emergency protocols, intervention kits, and massive transfusion plans in place, along with regular simulation training for staff. Treatment primarily involves uterotonic drugs like oxytocin, tranexamic acid, intrauterine balloon tamponade, or non-pneumatic anti-shock garments (NASG); if these measures prove insufficient in massive bleeding, surgical procedures such as compression sutures, arterial embolization, and, as a last resort, definitive hysterectomy are utilized.
Referanslar
Anger H, Durocher J, Dabash R, Winikoff B. How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin? PLoS One 2019; 14:e0221216.
Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol 2017; 130:e168. Reaffirmed 2019.
Sheldon WR, Blum J, Vogel JP, et al. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG 2014; 121 Suppl 1:5.
Reale SC, Easter SR, Xu X, et al. Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesth Analg 2020; 130:e119.
Deneux-Tharaux C, Bonnet MP, Tort J. [Epidemiology of post-partum haemorrhage]. J Gynecol Obstet Biol Reprod (Paris) 2014; 43:936.
Lockwood CJ, Schatz F. A biological model for the regulation of peri-implantational hemostasis and menstruation. J Soc Gynecol Investig 1996; 3:159.
Lockwood CJ, Nemerson Y, Krikun G, et al. Steroid-modulated stromal cell tissue factor expression: a model for the regulation of endometrial hemostasis and menstruation. J Clin Endocrinol Metab 1993; 77:1014.
Lockwood CJ. Regulation of plasminogen activator inhibitor 1 expression by interaction of epidermal growth factor with progestin during decidualization of human endometrial stromal cells. Am J Obstet Gynecol 2001; 184:798.
Lockwood CJ, Krikun G, Schatz F. The decidua regulates hemostasis in human endometrium. Semin Reprod Endocrinol 1999; 17:45.
Ende HB, Lozada MJ, Chestnut DH, et al. Risk Factors for Atonic Postpartum Hemorrhage: A Systematic Review and Meta-analysis. Obstet Gynecol 2021; 137:305.
Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 2010; 110:1368.
Bell SF, Collis RE, Bailey C, et al. The incidence, aetiology, and coagulation management of massive postpartum haemorrhage: a two-year national prospective cohort study. Int J Obstet Anesth 2021; 47:102983.
Conrad LB, Groome LJ, Black DR. Management of Persistent Postpartum Hemorrhage Caused by Inner Myometrial Lacerations. Obstet Gynecol 2015; 126:266.
Mhyre JM, Shilkrut A, Kuklina EV, et al. Massive blood transfusion during hospitalization for delivery in New York State, 1998-2007. Obstet Gynecol 2013; 122:1288.
Rouse DJ, Leindecker S, Landon M, et al. The MFMU Cesarean Registry: uterine atony after primary cesarean delivery. Am J Obstet Gynecol 2005; 193:1056.
Cheng YW, Delaney SS, Hopkins LM, Caughey AB. The association between the length of first stage of labor, mode of delivery, and perinatal outcomes in women undergoing induction of labor. Am J Obstet Gynecol 2009; 201:477.e1.
Blomberg M. Maternal obesity and risk of postpartum hemorrhage. Obstet Gynecol 2011; 118:561.
Wetta LA, Szychowski JM, Seals S, et al. Risk factors for uterine atony/postpartum hemorrhage requiring treatment after vaginal delivery. Am J Obstet Gynecol 2013; 209:51.e1.
Kramer MS, Berg C, Abenhaim H, et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 2013; 209:449.e1.
Sharp GC, Saunders PT, Greene SA, et al. Intergenerational transmission of postpartum hemorrhage risk: analysis of 2 Scottish birth cohorts. Am J Obstet Gynecol 2014; 211:51.e1.
Bruning AH, Heller HM, Kieviet N, et al. Antidepressants during pregnancy and postpartum hemorrhage: a systematic review. Eur J Obstet Gynecol Reprod Biol 2015; 189:38.
Oberg AS, Hernandéz-Diaź S, Frisell T, et al. Genetic contribution to postpartum haemorrhage in Swedish population: cohort study of 466,686 births. BMJ 2014; 349:g4984.
Giannella L, Mfuta K, Pedroni D, et al. Delays in the delivery room of a primary maternity unit: a retrospective analysis of obstetric outcomes. J Matern Fetal Neonatal Med 2013; 26:593.
Grzeskowiak LE, McBain R, Dekker GA, Clifton VL. Antidepressant use in late gestation and risk of postpartum haemorrhage: a retrospective cohort study. BJOG 2016; 123:1929.
Nyfløt LT, Sandven I, Oldereid NB, et al. Assisted reproductive technology and severe postpartum haemorrhage: a case-control study. BJOG 2017; 124:1198.
Nyfløt LT, Sandven I, Stray-Pedersen B, et al. Risk factors for severe postpartum hemorrhage: a case-control study. BMC Pregnancy Childbirth 2017; 17:17.
Skalkidou A, Sundström-Poromaa I, Wikman A, et al. SSRI use during pregnancy and risk for postpartum haemorrhage: a national register-based cohort study in Sweden. BJOG 2020; 127:1366.
Butwick AJ, Liu C, Guo N, et al. Association of Gestational Age with Postpartum Hemorrhage: An International Cohort Study. Anesthesiology 2021; 134:874.
Linde LE, Ebbing C, Moster D, et al. Recurrence of postpartum hemorrhage in relatives: A population-based cohort study. Acta Obstet Gynecol Scand 2021; 100:2278.
Bonnar J. Massive obstetric haemorrhage. Baillieres Best Pract Res Clin Obstet Gynaecol 2000; 14:1.
https://www.cmqcc.org/resource/ob-hem-emergency-management-plan-table-chart (Accessed on September 13, 2017).
American College of Surgeons. Advanced Trauma Life Support (Student Manual). American College of Surgeons 1997.
Joint Commission. Proposed Standards for Perinatal Safety Hospital (HAP) Accreditation Program https://jointcommission.az1.qualtrics.com/CP/File.php?F=F_2bMhcokkpaksMvz (Accessed on June 11, 2021).
Dilla AJ, Waters JH, Yazer MH. Clinical validation of risk stratification criteria for peripartum hemorrhage. Obstet Gynecol 2013; 122:120.
Kawakita T, Mokhtari N, Huang JC, Landy HJ. Evaluation of Risk-Assessment Tools for Severe Postpartum Hemorrhage in Women Undergoing Cesarean Delivery. Obstet Gynecol 2019; 134:1308.
Neary C, Naheed S, McLernon DJ, Black M. Predicting risk of postpartum haemorrhage: a systematic review. BJOG 2021; 128:46.
https://www.cmqcc.org/resource/ob-hem-risk-factor-assessment (Accessed on December 02, 2019).
Lim G, Melnyk V, Facco FL, et al. Cost-effectiveness Analysis of Intraoperative Cell Salvage for Obstetric Hemorrhage. Anesthesiology 2018; 128:328.
Lakshmi SD, Abraham R. Role of Prophylactic Tranexamic Acid in Reducing Blood Loss during Elective Caesarean Section: A Randomized Controlled Study. J Clin Diagn Res 2016; 10:QC17.
Clark SL, Frye DR, Meyers JA, et al. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. Am J Obstet Gynecol 2010; 203:449.e1.
Bailit JL, Grobman WA, McGee P, et al. Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes? Am J Obstet Gynecol 2015; 213:86.e1.
Grobman WA, Bailit JL, Rice MM, et al. Can differences in obstetric outcomes be explained by differences in the care provided? The MFMU Network APEX study. Am J Obstet Gynecol 2014; 211:147.e1.
Rizvi F, Mackey R, Barrett T, et al. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG 2004; 111:495.
Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol 2015; 212:272.
Skupski DW, Brady D, Lowenwirt IP, et al. Improvement in Outcomes of Major Obstetric Hemorrhage Through Systematic Change. Obstet Gynecol 2017; 130:770.
Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011; 205:368.e1.
McCall SJ, Henriquez D, Edwards HM, et al. A total blood volume or more transfused during pregnancy or after childbirth: Individual patient data from six international population-based observational studies. PLoS One 2021; 16:e0244933.
Margarido C, Ferns J, Chin V, et al. Massive hemorrhage protocol activation in obstetrics: a 5-year quality performance review. Int J Obstet Anesth 2019; 38:37.
Muñoz M, Stensballe J, Ducloy-Bouthors AS, et al. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfus 2019; 17:112.
Erfani H, Fox KA, Belfort MA, Shamshirsaz AA. Preventing severe hypocalcemia during surgery for placenta accreta spectrum. Acta Obstet Gynecol Scand 2019; 98:1358.
Elmer J, Wilcox SR, Raja AS. Massive transfusion in traumatic shock. J Emerg Med 2013; 44:829.
http://www.jointcommission.org/Sentinel_Event_Alert__Issue_30_Preventing_infant_death_and_injury_during_delivery_Additional_Resources/ (Accessed on June 10, 2015).
Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 2006; 113:919.
Lyndon A, Miller S, Huwe V, Rosen M, et al. Blood loss: Clinical techniques for ongoing quantitative measurement. California Maternal Quality Care Collaborative. CMQCC Obstetric Hemorrhage Toolkit; 1/6/2010.
Diaz V, Abalos E, Carroli G. Methods for blood loss estimation after vaginal birth. Cochrane Database Syst Rev 2018; 9:CD010980.
Quantitative Blood Loss in Obstetric Hemorrhage: ACOG COMMITTEE OPINION, Number 794. Obstet Gynecol 2019; 134:e150.
Gerdessen L, Meybohm P, Choorapoikayil S, et al. Comparison of common perioperative blood loss estimation techniques: a systematic review and meta-analysis. J Clin Monit Comput 2021; 35:245.
Prata N, Gerdts C. Measurement of postpartum blood loss. BMJ 2010; 340:c555.
Main EK, McCain CL, Morton CH, et al. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol 2015; 125:938.
Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14 https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202016%20-%20website.pdf (Accessed on October 23, 2019).
Shields LE, Wiesner S, Klein C, et al. Use of Maternal Early Warning Trigger tool reduces maternal morbidity. Am J Obstet Gynecol 2016; 214:527.e1.
Mhyre JM, DʼOria R, Hameed AB, et al. The maternal early warning criteria: A proposal from the national partnership for maternal safety. Obstet Gynecol 2014; 124:782.
El Ayadi AM, Butrick E, Geissler J, Miller S. Combined analysis of the non-pneumatic anti-shock garment on mortality from hypovolemic shock secondary to obstetric hemorrhage. BMC Pregnancy Childbirth 2013; 13:208.
Magwali TL, Butrick E, Ayadi AE, et al. A cluster randomized controlled trial of the non-pneumatic anti-shock garment for obstetric haemorrhage: sub-analysis of the Zimbabwean Arm. Cent Afr J Med 2015; 61:27.
Mbaruku G, Therrien MS, Tillya R, et al. Implementation project of the non-pneumatic anti-shock garment and m-communication to enhance maternal health care in rural Tanzania. Reprod Health 2018; 15:177.
Pileggi-Castro C, Nogueira-Pileggi V, Tunçalp Ö, et al. Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage: a systematic review. Reprod Health 2015; 12:28.
Figo Safe Motherhood and Newborn Health Committee, International Federation of Gynecology and Obstetrics. Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage. Int J Gynaecol Obstet 2015; 128:194.
Novello A, King JC. Health advisory: Prevention of maternal deaths through improved management of hemorrhage. www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=1517 (Accessed on May 02, 2006).
Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician 2017; 95:442.
James AH, McLintock C, Lockhart E. Postpartum hemorrhage: when uterotonics and sutures fail. Am J Hematol 2012; 87 Suppl 1:S16.
Ruiz Labarta FJ, Pintado Recarte MP, Alvarez Luque A, et al. Outcomes of pelvic arterial embolization in the management of postpartum haemorrhage: a case series study and systematic review. Eur J Obstet Gynecol Reprod Biol 2016; 206:12.
