Die neue deutsche Leitlinie zur peripartalen Hämorrhagie - Wichtige Aspekte für die Gerinnungs- und Kreislauftherapie

Zusammenfassung

Die peripartale Blutung (PPH) ist weltweit weiterhin eine der führenden Gründe mütterlicher Sterblichkeit. Die Deutsche Gesellschaft für Gynäkologie und Geburtshilfe hat zusammen mit der Gesellschaft für Thrombose- und Hämostaseforschung, dem deutschen Hebammenverband und der DGAI die alte Leitlinie aktualisiert. Die Empfehlungen dieser Leitlinie stellen das Ergebnis einer umfassenden Literaturanalyse und eines formalen Konsensusprozesses dar (Konsensus-basierte Leitlinie, S2K) und umfassen alle Aspekte der peripartalen Blutung einschließlich Definition, Ursachen, Risikofaktoren und Therapie. Kernpunkt der anästhesiologisch-hämostaseologischen Behandlung ist die Entwicklung einer interdisziplinären Standard Operating Procedure (SOP), welche die medikamentöse Behandlung inkl. der Transfusion von Blutprodukten in Abhängigkeit von Ursache und Schwere der Blutung und der chirurgischen Behandlung beinhaltet. Die Leitlinie betont dabei die Bedeutung klinischer und laborgestützter Diagnostik, wenn eine peripartale Blutung vermutet wird, da nur diese die frühe Erkennung der Blutungsursachen und ursachengerechte Therapie ermöglicht. Die Empfehlungen zum anästhesiologisch-hämostaseologischen Management umfassen die evidenzbasierte Gabe von Uterotonika im Falle der atonen Blutung sowie die Gabe von Tranexamsäure und Blutprodukten wie Faktorenkonzentraten, gerinnungsaktivem Frischplasma ,Thrombozytenkonzentraten, Erythrozytenkonzentraten als auch in Ausnahmefällen rekombinantem aktivierten Faktor VII und Desmopressin. In Ergänzung der genannten Behandlungsoptionen werden – basierend auf verfügbaren Daten aus der Literatur - Empfehlungen zur blutsparenden Therapie mit dem Einsatz des Cell Savers, der kontrollierten Hypotension und restriktiven Transfusionstriggern gegeben.

Abstract

Worldwide, post-partum haemorrhage (PHH) remains one of the leading causes for maternal mortality. The German Society of Gynaecology and Obstetrics, the German Midwifes’ Society, the German Society of Thrombosis and Haemostasis and the German Society of Anaesthesiology and Intensive Care updated the former guideline. The resulting recommendations are the results of a structured literature search and a formal consensus process and contain all aspects of PPH including diagnosis, causes, risk factors and therapy. Key aspect of the anaesthesiological and haemostatic therapies is the development of an interdisciplinary standard operating procedure containing medical options related to the bleeding’s cause and severity as well as the surgical option. For suspected PPH, this guideline emphasizes clinical and laboratory-based diagnostics, as only those will enable an early identification of the bleeding’s causes and the resulting causative therapy. Recommendations cover evidence-based application of uterotonics for atony as well as tranexamic acid, calcium, factor concentrates and blood products. Additionally, recommendations are given on the topics of cell salvage, controlled hypotension and restrictive transfusion triggers.

Kernaussagen

• Jedes Krankenhaus soll eine interdisziplinäre Handlungsanweisung für Diagnostik und Therapie der peripartalen Hämorrhagie entwickeln, die an die jeweiligen Gegebenheiten angepasst ist.

• Im Falle der atonen Blutung ist eine evidenzbasierte Gabe von Uterotonika angezeigt.

• Tranexamsäure sollte frühzeitig verabreicht werden.

• Es wird eine zielgerichtete Gabe von Blutprodukten wie Erythrozytenkonzentraten, Faktorenkonzentraten, gerinnungsaktives Frischplasma, Thrombozytenkonzentraten empfohlen.

• Innerhalb von 24 h nach Beendigung der Blutung soll mit einer Thromboseprophylaxe begonnen werden.

Schlüsselwörter:

peripartale Blutung - Standard Operating Procedures - Uterotonika - Hämostase - Tranexamsäure - Gerinnungsfaktorenkonzentrate - blutsparende Maßnahmen

Keywords:

post-partum haemorrhage - standard operating procedure - uterotonics - tranexamic acid - factor concentrates

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