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Blutungen während der Schwangerschaft

Hemorrhaging during pregnancy

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Zusammenfassung

Blutungen während der Schwangerschaft sind oft fulminant und für Mutter und Kind vital bedrohlich. Sie sind für etwa 25% aller peripartalen maternen Sterbefälle verantwortlich. Die besondere Pathophysiologie der schwangerschaftsbedingten hämostaseologischen Veränderungen, wie das erhöhte Gerinnungspotenzial, eine verminderte antikoagulatorische Aktivität und starke Alterationen des fibrinolytischen Systems, müssen dem Behandlungsteam bekannt sein, um eine zielgerichtete, konsequente und interdisziplinäre Therapie durchführen zu können. Zu den wichtigsten therapeutischen Eckpfeilern bei peripartalen Blutungen zählen neben der kausalen gynäkologischen Therapie die frühzeitige Detektion und Durchbrechung einer Hyperfibrinolyse, die Optimierung von Fibrinogen und Thrombozyten als Endstrecke der Gerinnung und die Kenntnis der Möglichkeiten einer erweiterten Gerinnungstherapie.

Abstract

Hemorrhaging during pregnancy is often fulminant and life-threatening for mother and child. Of maternal deaths occurring during pregnancy, 25% are caused by hemorrhaging. All physicians involved in the interdisciplinary treatment of hemorrhaging during pregnancy need to be familiar with the specific pathophysiology of hemostatic changes during pregnancy, e.g. elevated hemostatic capacity, reduced anti-coagulation activity and severe alterations of the fibrinolysis system. Therapists must be able to perform a consequent, goal-directed interdisciplinary approach to prevent adverse maternal and fetal outcomes. The major issues of therapy are causal obstetric treatment of the bleeding, early detection and therapy of hyperfibrinolysis, optimization of fibrinogen and platelet levels and knowledge of the possibilities of a targeted coagulation therapy.

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Literatur

  1. Ananth CV, Savitz DA (1994) Vaginal bleeding and adverse reproductive outcomes: a meta-analysis. Paediatr Perinat Epidemiol 8: 62–78

    Article  PubMed  CAS  Google Scholar 

  2. Astermark J, Donfield SM, DiMichele DM et al. (2007) A randomized comparison of bypassing agents in hemophilia complicated by an inhibitor: the FEIBA NovoSeven Comparative (FENOC) Study. Blood 109: 546–551

    Article  PubMed  CAS  Google Scholar 

  3. Axelsen SM, Henriksen TB, Hedegaard M et al. (1995) Characteristics of vaginal bleeding during pregnancy. Eur J Obstet Gynecol Reprod Biol 63: 131–134

    Article  PubMed  CAS  Google Scholar 

  4. Biron-Andreani C, Morau E, Schved JF et al. (2003) Amniotic fluid embolism with haemostasis complications: primary fibrinogenolysis or disseminated intravascular coagulation? Pathophysiol Haemost Thromb 33: 170–171

    Article  PubMed  CAS  Google Scholar 

  5. Bonn C, Wetzka B, Zahradnik HP (2002) The use of TEG with the roTEG in preeclampsia and HELLP syndrome. Hypertens Pregnancy [Suppl 1] 21: 80

  6. Bremme KA (2003) Haemostatic changes in pregnancy. Best Pract Res Clin Haematol 16: 153–168

    Article  PubMed  Google Scholar 

  7. Catena C, Zingaro L, Casaccio D et al. (2000) Abnormalities of coagulation in hypertensive patients with reduced creatinine clearance. Am J Med 109: 556–561

    Article  PubMed  CAS  Google Scholar 

  8. 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  PubMed  CAS  Google Scholar 

  9. Chowdhury P, Saayman AG, Paulus U et al. (2004) Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol 125: 69–73

    Article  PubMed  Google Scholar 

  10. Clenney TL, Viera AJ (2004) Corticosteroids for HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome. BMJ 329: 270–272

    Article  PubMed  Google Scholar 

  11. Collins PW (2003) Management of acquired haemophilia A – more questions than answers. Blood Coagul Fibrinolysis [Suppl 1] 14: S23–S27

  12. Crochetiere C (2003) Obstetric emergencies. Anesthesiol Clin North Am 21: 111–125

    Article  Google Scholar 

  13. Deneux-Tharaux C, Carmona E, Bouvier-Colle MH et al. (2006) Postpartum maternal mortality and cesarean delivery. Obstet Gynecol 108: 541–548

    PubMed  Google Scholar 

  14. Dildy GA (2002) Postpartum hemorrhage: new management options. Clin Obstet Gynecol 45: 330–344

    Article  PubMed  Google Scholar 

  15. Eder AF, Herron R, Strupp A et al. (2007) Transfusion-related acute lung injury surveillance (2003–2005) and the potential impact of the selective use of plasma from male donors in the American Red Cross. Transfusion 47: 599–607

    Article  PubMed  Google Scholar 

  16. FitzGerald MP, Floro C, Siegel J et al. (1996) Laboratory findings in hypertensive disorders of pregnancy. J Natl Med Assoc 88: 794–798

    PubMed  CAS  Google Scholar 

  17. Fonseca JE, Mendez F, Catano C et al. (2005) Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol 193: 1591–1598

    Article  PubMed  CAS  Google Scholar 

  18. Franchini M (2006) Postpartum acquired factor VIII inhibitors. Am J Hematol 81: 768–773

    Article  PubMed  CAS  Google Scholar 

  19. Franchini M, Lippi G, Franchi M (2007) The use of recombinant activated factor VII in obstetric and gynaecological haemorrhage. BJOG 114: 8–15

    Article  PubMed  CAS  Google Scholar 

  20. Fuchs AR, Romero R, Keefe D et al. (1991) Oxytocin secretion and human parturition: pulse frequency and duration increase during spontaneous labor in women. Am J Obstet Gynecol 165: 1515–1523

    PubMed  CAS  Google Scholar 

  21. Gai MY, Wu LF, Su QF et al. (2004) Clinical observation of blood loss reduced by tranexamic acid during and after caesarian section: a multi-center, randomized trial. Eur J Obstet Gynecol Reprod Biol 112: 154–157

    Article  PubMed  CAS  Google Scholar 

  22. Gerbasi FR, Bottoms S, Farag A et al. (1990) Increased intravascular coagulation associated with pregnancy. Obstet Gynecol 75: 385–389

    PubMed  CAS  Google Scholar 

  23. Goldszmidt E, Davies S (2003) Two cases of hemorrhage secondary to amniotic fluid embolus managed with uterine artery embolization. Can J Anaesth 50: 917–921

    Article  PubMed  Google Scholar 

  24. Green D (2006) The management of acquired haemophilia. Haemophilia [Suppl 5] 12: 32–36

    Google Scholar 

  25. Hansch E, Chitkara U, McAlpine J et al. (1999) Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience. Am J Obstet Gynecol 180: 1454–1460

    Article  PubMed  CAS  Google Scholar 

  26. Hardy JF, Moerloose P de, Samama CM (2006) Massive transfusion and coagulopathy: pathophysiology and implications for clinical management. Can J Anaesth [Suppl 6] 53: S40–S58

  27. Hatzopoulos FK (2005) Obstetric drug therapy. In: Koda-Kimble MA, Young LY, Kradjan WA et al. (eds) Applied therapeutics: the clinical use of drugs, 8th edn. Lippincott Williams & Wilkins, Philadelphia, p 126

  28. Hay CR, Brown S, Collins PW et al. (2006) The diagnosis and management of factor VIII and IX inhibitors: a guideline from the United Kingdom Haemophilia Centre Doctors Organisation. Br J Haematol 133: 591–605

    Article  PubMed  CAS  Google Scholar 

  29. Heilmann L, Wild C, Hojnacki B et al. (2006) Successful treatment of life-threatening bleeding after cesarean section with recombinant activated factor VII. Clin Appl Thromb Hemost 12: 227–229

    Article  PubMed  CAS  Google Scholar 

  30. Heindl B, Delorenzo C, Spannagl M (2005) High dose fibrinogen administration for acute therapy of coagulopathy during massive perioperative transfusion. Anaesthesist 54: 787–790

    Article  PubMed  CAS  Google Scholar 

  31. Hellgren M (2003) Hemostasis during normal pregnancy and puerperium. Semin Thromb Hemost 29: 125–130

    Article  PubMed  CAS  Google Scholar 

  32. Holmes VA (2003) Changes in haemostasis during normal pregnancy: does homocysteine play a role in maintaining homeostasis? Proc Nutr Soc 62: 479–493

    Article  PubMed  CAS  Google Scholar 

  33. Holmes VA, Wallace JM (2005) Haemostasis in normal pregnancy: a balancing act? Biochem Soc Trans 33: 428–432

    Article  PubMed  CAS  Google Scholar 

  34. Huch A, Chaoui R (2004) Sectio caesarea: In: SchneiderH, Husslein P, Schneider KTM (Hrsg) Die Geburtshilfe, 2. Aufl. Springer, Berlin Heidelberg New York

  35. Kam PC, Thompson SA, Liew AC (2004) Thrombocytopenia in the parturient. Anaesthesia 59: 255–264

    Article  PubMed  CAS  Google Scholar 

  36. Karalapillai D, Popham P (2007) Recombinant factor VIIa in massive postpartum haemorrhage. Int J Obstet Anesth 16: 29–34

    Article  PubMed  CAS  Google Scholar 

  37. Kobayashi T, Terao T, Maki M et al. (2001) Diagnosis and management of acute obstetrical DIC. Semin Thromb Hemost 27: 161–167

    Article  PubMed  CAS  Google Scholar 

  38. Koscielny J, Tempelhoff GF von, Ziemer S et al. (2004) A practical concept for preoperative management of patients with impaired primary hemostasis. Clin Appl Thromb Hemost 10: 155–166

    Article  PubMed  Google Scholar 

  39. Kretzschmar M, Zahm DM, Remmler K et al. (2003) „Anaphylactoid syndrome of pregnancy“ Pathophysiologische und therapeutische Aspekte der Fruchtwasserembolie („anaphylactoid syndrome of pregnancy“) anhand einer Kasuistik mit letalem Ausgang. Anaesthesist 52: 419–426

    Article  PubMed  CAS  Google Scholar 

  40. Krumnikl JJ, Böttiger BW, Strittmatter HJ et al. (2002) Complete recovery after 2 h of cardiopulmonary resuscitation following high-dose prostaglandin treatment for atonic uterine haemorrhage. Acta Anaesthesiol Scand 46: 1168–1170

    Article  PubMed  CAS  Google Scholar 

  41. Ku DH, Arkel YS, Paidas MP et al. (2003) Circulating levels of inflammatory cytokines (IL-1 beta and TNF-alpha), resistance to activated protein C, thrombin and fibrin generation in uncomplicated pregnancies. Thromb Haemost 90: 1074–1079

    PubMed  CAS  Google Scholar 

  42. Letsky EA (2001) Disseminated intravascular coagulation. Best Pract Res Clin Obstet Gynaecol 15: 623–644

    Article  PubMed  CAS  Google Scholar 

  43. Lindoff C, Rybo G, Astedt B (1993) Treatment with tranexamic acid during pregnancy, and the risk of thrombo-embolic complications. Thromb Haemost 70: 238–240

    PubMed  CAS  Google Scholar 

  44. Lockwood CJ (2006) Pregnancy-associated changes in the hemostatic system. Clin Obstet Gynecol 49: 836–843

    Article  PubMed  Google Scholar 

  45. Ojala K, Perala J, Kariniemi J et al. (2005) Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage. Acta Obstet Gynecol Scand 84: 1075–1080

    Article  PubMed  Google Scholar 

  46. Orlikowski CEP, Rocke DA, Murray WB et al. (1996) Thromboelastography changes in pre-eclampsia and eclampsia. Br J Anaesth 77: 157–161

    PubMed  CAS  Google Scholar 

  47. Parnas M, Sheiner E, Shoham-Vardi I et al. (2006) Moderate to severe thrombocytopenia during pregnancy. Eur J Obstet Gynecol Reprod Biol 128: 163–168

    Article  PubMed  Google Scholar 

  48. Pelage J-P, Le Dref O, Jacob D et al. (1999) Selective arterial embolization of the uterine arteries in the management of intractable post-partum hemorrhage. Acta Obstet Gynecol Scand 78: 698–703

    Article  PubMed  CAS  Google Scholar 

  49. Pfanner G, Kilgert K (2006) Geburtshilfliche Blutungskomplikationen. Hämostaseologie [Suppl 1] 26: S56–S63

  50. Poe MF (1959) Clot observation test for clinical diagnosis of clotting defects. Anesthesiology 20: 825–829

    Article  PubMed  CAS  Google Scholar 

  51. Prabu P, Parapia LA (2006) Bernard-Soulier syndrome in pregnancy. Clin Lab Haematol 28: 198–201

    Article  PubMed  CAS  Google Scholar 

  52. Ramanathan J, Bennett K (2003) Pre-eclampsia: fluids, drugs, and anesthetic management. Anesthesiol Clin North Am 21: 145–163

    Article  Google Scholar 

  53. Roberts JM, Gammill HS (2005) Preeclampsia: recent insights. Hypertension 46: 1243–1249

    Article  PubMed  CAS  Google Scholar 

  54. Roberts HR, Monroe DM, Oliver JA et al. (1998) Newer concepts of blood coagulation. Haemophilia 4: 331–334

    Article  PubMed  CAS  Google Scholar 

  55. Rouse DJ, MacPherson C, Landon M et al. (2006) Blood transfusion and cesarean delivery. Obstet Gynecol 108: 891–897

    Article  PubMed  Google Scholar 

  56. Schuurmans N, Mackinnin C, Lane C et al. (2000) Prevention and management of postpartum haemorrhage. J Soc Obstet Gynaecol Can 88: 271–281

    Google Scholar 

  57. Segal S, Shemesh IY, Blumenthal R et al. (2003) Treatment of obstetric hemorrhage with recombinant activated factor VII (rFVIIa). Arch Gynecol Obstet 268: 266–267

    Article  PubMed  CAS  Google Scholar 

  58. Shafi T, Jeha MT, Black L et al. (1997) Severe aquired haemophilia A treated with recombinant factor VIIa. Br J Haematol 98: 910–912

    Article  PubMed  CAS  Google Scholar 

  59. Sharma SK, Philip J, Whitten CW et al. (1999) Assessment of changes in coagulation in parturients with pre-eclampsia using thromboelastography. Anesthesiology 90: 3485–3490

    Article  Google Scholar 

  60. Silliman CC, Curtis BR, Kopko PM et al. (2007) Donor antibodies to HNA-3a implicated in TRALI reactions prime neutrophils and cause PMN-mediated damage to human pulmonary microvascular endothelial cells in a two-event in vitro model. Blood 109: 1752–1755

    Article  PubMed  CAS  Google Scholar 

  61. Smith JG, Merrill DC (2006) Oxytocin for induction of labor. Clin Obstet Gynecol 49: 594–608

    Article  PubMed  Google Scholar 

  62. Sobieszczyk S, Breborowicz GH, Platicanov V et al. (2006) Recombinant factor VIIa in the management of postpartum bleeds: an audit of clinical use. Acta Obstet Gynecol Scand 85: 1239–1247

    Article  PubMed  CAS  Google Scholar 

  63. Toy P, Popovsky MA, Abraham E et al. (2005) Transfusion-related acute lung injury: definition and review. Crit Care Med 33: 721–726

    Article  PubMed  Google Scholar 

  64. UNFPA (2003) Maternal mortality update 2002: a focus on emergency obstetric care. United Nations Population Fund, New York

  65. Vincent J-L, Rossaint R, Riou B et al. (2006) Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding: a European perspective. Crit Care 10: 1–12

    Article  Google Scholar 

  66. Weiner CP (1986) The obstetric patient and disseminated intravascular coagulation. Clin Perinatol 13: 705–717

    PubMed  CAS  Google Scholar 

  67. Whitta RK, Cox DJ, Mallett SV (1995) Thrombelastography reveals two causes of haemorrhage in HELLP syndrome. Br J Anaesth 74: 464–468

    Article  PubMed  CAS  Google Scholar 

  68. Xenakis EM, Piper JM (1997) Chemotherapeutic induction of labour. A rational approach. Drugs 54: 61–68

    PubMed  CAS  Google Scholar 

  69. Yang J, Savitz DA, Dole N et al. (2005) Predictors of vaginal bleeding during the first two trimesters of pregnancy. Paediatr Perinat Epidemiol 19: 276–283

    Article  PubMed  Google Scholar 

  70. Zelop CM, Harlow BL, Frigoletto FD (1993) Emergency peripartum hysterectomy. Am J Obstet Gynecol 168: 1443–1448

    PubMed  CAS  Google Scholar 

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung/en hin:

Vorträge bei Veranstaltungen von CSL Behring.

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Authors and Affiliations

  1. Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120 , Heidelberg, Deutschland

    S. Hofer, R. Schreckenberger, E. Martin & M.A. Weigand

  2. Klinik für Anästhesiologie, Ludwig-Maximilians-Universität München, München, Deutschland

    B. Heindl

  3. Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland

    K. Görlinger

  4. Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln, Köln, Deutschland

    H. Lier

  5. Universitätsfrauenklinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    H. Maul

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  1. S. Hofer
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Hofer, S., Schreckenberger, R., Heindl, B. et al. Blutungen während der Schwangerschaft. Anaesthesist 56, 1075–1090 (2007). https://doi.org/10.1007/s00101-007-1261-2

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