Language: English German. The aim is to provide a consensus-based overview of the diagnosis and management of peripartum bleeding obtained from an evaluation of the relevant literature. This S2k guideline was developed from the structured consensus of representative members of the various professional associations and professions commissioned by the Guideline Commission of the DGGG. The guideline encompasses recommendations on definitions, risk stratification, prevention and management. Information on the guidelines programme is available at the end of the guideline. Peripartum haemorrhage, diagnosis and therapy.
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We'd like to understand how you use our websites in order to improve them. Register your interest. About , deaths annually are attributed to hemorrhage. From , there were 7. In the USA, embolic disease, preeclampsia, and hemorrhage remain leading causes of maternal death.
There are many causes of postpartum hemorrhage; however, the most prevalent cause is uterine atony. It is difficult to determine the contribution that uterine atony makes to maternal death from hemorrhage. The investigators of this study found a strong association between PPH and a number of serious complications, including acute renal failure, coagulopathy, and acute respiratory failure. All of these complications were likely a consequence of hypovolemia and subsequent massive transfusion.
In this cohort, PPH, secondary to uterine atony, was also a significant source of maternal mortality, accounting for approximately one-fifth of all deaths in delivering patients. Disturbingly, they were unable to identify antenatal risk factors for this trend, as the increase in PPH could not be accounted for by adjusting for changes in maternal demographics, maternal comorbidity, or delivery mode. Also noteworthy in this cohort was the observation that the rates of PPH from other causes, including retained placenta and coagulopathy, remained relatively stable during the study.
The investigators also noted that PPH is more common among patients delivering at hospitals in the bottom quartile for delivery volume compared with those delivering at hospitals in the top quartile, which may be a factor with overall management of hemorrhage situations. In an year population-based cohort study from Ireland, similar results were found. These increasing trends in rates of atonic PPH were observed across all modes of delivery, i.
In their cohort, data were collected on , childbirth hospitalizations, with a 2. In the patients with PPH, They noted that the incidence of atony as a cause for PPH was consistently higher among deliveries that involved induction.
The lowest rates of atonic PPH were among non-induced vaginal deliveries, and in general, the highest rates were among Cesarean deliveries following induction. In addition, they found the incidence of atonic PPH was higher for emergency than for elective Cesarean deliveries.
This information does not come as a big surprise for those who provide anesthesia services on the obstetrical ward. This has essentially been spurred by large cohort studies suggesting better neonatal outcomes. We have observed a phenomenon of apparent oxytocin desensitization in patients receiving infusions of oxytocin prior to delivery. At the clinical level, this results in the need for accelerated doses of oxytocin to achieve adequate uterine tone.
In a recently published study by Balki et al. The authors concluded that this is likely attributable to a phenomenon of oxytocin receptor desensitization. Nature tries to protect woman from uterine atony and postpartum hemorrhage.
Endogenous oxytocin undergoes a pulsatile secretion. The amount released into the circulation does not change throughout pregnancy and early labour, but it increases during the last part of the second stage of labour.
Within minutes of the crowning of the fetal head, endogenous oxytocin levels reach a peak and then plateau until delivery of the placenta when oxytocin levels then gradually decrease. Prostaglandins rise gradually in the first stage of labour, steeply during the second stage, and reach a peak immediately before and after the delivery of the placenta.
Both of these hormones are responsible for endogenous contraction of the uterus after delivery, and these related hormonal physiological perturbations can make it somewhat confusing for studying the additive effect of peripartum pharmacologic interventions. Oxytocin, an endogenous 9-amino acid polypeptide produced in the posterior pituitary, has been the first-line treatment of uterine atony for a number of years.
As a gravid woman nears term, there is a significant increase in the number of high-affinity receptors for oxytocin. The exogenous form of the drug routinely used for deliveries worldwide is a synthetic preparation that closely mimics the effect of the endogenous form. Side effects of exogenous oxytocin include a minor anti-diuretic hormone ADH-like effect with a small risk of dilutional hyponatremia, peripheral vasodilation with resulting hypotension, increase in heart rate, increases in pulmonary arterial pressure, and nonspecific electrocardiogram changes.
In recent years, we have seen an increased focus on the cardiovascular side effects of oxytocin. In , a review of anesthesia-related causes of maternal death in the United Kingdom from highlighted the adverse effects of bolus administration of oxytocin and prompted a number of studies to evaluate all effective dose ED 90 for bolus administration of oxytocin. For most clinicians, these low doses came as a surprise. In all these studies, an infusion of oxytocin was required to maintain uterine tone.
Also noteworthy was the observation of a higher incidence of hypotension in the higher-dose oxytocin groups. These findings were further supported by additional publications. During the past decade, there has been growing interest in the use of carbetocin as a uterotonic. Carbetocin is a long-acting synthetic analogue of oxytocin that combines the safety profile of oxytocin with the sustained uterotonic activity of ergometrine. Currently, the drug is indicated for the prevention of uterine atony following Cesarean delivery.
It was noteworthy, however, that no difference in blood loss was shown when comparing these two agents; however, in the oxytocin group, there was a higher need for rescue doses of uterotonic agents. With the high incidence of hypotension associated with this dose, it became a focus of investigators to determine if a lower dose could be both clinically efficacious and reduce side effects.
Similar to their previous study, the investigators were unable to find any difference between the doses in regard to efficacy or side effect profile. In this cohort, their incidence of hypotension was again high at They concluded once again that they were unable to determine the ED95 of the agent, and the high incidence of hypotension warranted further investigation of lower doses of carbetocin.
Neither study was able to show differences in efficacy between the two drugs. Recent studies to assess the ED95 of carbetocin and previous studies examining oxytocin clearly suggest that the doses in current use are higher than necessary. Surprisingly, however, the investigators in these studies have been unable as yet to show a significant reduction in side effects with reduction in dose. In this recent study evaluating carbetocin, the incidence of hypotension was similar at An earlier study from this institution looking at the minimal effective dose of oxytocin doses as low as 0.
In the study by Rosseland et al. So, why is there such a high level of interest and discussion on these agents? It is clear that these agents are critical in the reduction of uterine atony and, thus, postpartum hemorrhage and maternal death. Nevertheless, the risks associated with the uterotonic agents are equally apparent despite our search to determine minimal effective doses. The side effects are of relatively short duration and, for the most part, of little consequence to the average healthy parturient who has appropriate monitoring and treatment with intravenous hydration and vasopressors.
Even so, given the ever increasing population of high-risk parturients, use of these agents with currently recommended doses can have devastating consequences as a result of the hemodynamic alterations. The current investigation evaluating reduced dosing of carbetocin showed no benefit with respect to hemodynamic stability. The ongoing related investigations from the University of Toronto group are important. With an alarming increase in postpartum hemorrhage due to uterine atony and the need for effective uterotonics — with favourable side effect profiles, in the correct dose, at the right time — it is important that we continue to address the devastating consequences of uterine atony and the unnecessarily high related worldwide incidence of hemorrhage-related maternal death.
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Ann Intern Med ; Oxytocin pretreatment attenuates oxytocin-induced contractions in human myometrium in vitro. Anesthesiology ; DOI: Maternal deaths from anaesthesia. Br J Anaesth ; Oxytocin requirements at elective cesarean delivery: a dose-finding study.
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J Prenat Med ; 7: Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial.
Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can ; Carbetocin at elective cesarean delivery: a randomized controlled trial to determine the effective dose. Haemodynamic effects of carbetocin and oxytocin given as intravenous bolus on women undergoing caesarean delivery: a randomised trial.
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Carbetocin at elective Cesarean delivery: a randomized controlled trial to determine the effective dose, part 2. Can J Anesth ; this issue. DOI: Download references.
Translation of "atonie utérine" in English
Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscles during labor compresses the blood vessels and reduces flow, thereby increasing the likelihood of coagulation and preventing hemorrhage. A lack of uterine muscle contraction, however, can lead to an acute hemorrhage , as the uterine blood vessels are not sufficiently compressed. Many factors can contribute to the loss of uterine muscle tone, including: . By abdominal exam to measure the fundal height of the uterus, for normal uterus it should be under the umbilicus after the labor. The first step in management of uterine atony is uterine massage. The next step is pharmacological therapies, the first of which is oxytocin , used because it initiates rhythmic contractions of the uterus, compressing the spiral arteries which should reduce bleeding.
Postpartum haemorrhage is one of the major causes of maternal mortality worldwide. The leading cause of primary postpartum haemorrhage is uterine atony and active management of the third stage of labour with oxytocin is recommended for preventing primary postpartum haemorrhage. Parenteral oxytocin is also the drug of choice for medical management of postpartum haemorrhage secondary to uterine atony. Condom uterine balloon tamponade is a low cost technique that can be used as a second-line option for treatment. We report retrospectively three cases of primary PPH secondary to uterine atony which were managed successfully with condom tamponade.
Results: Exact: Elapsed time: 68 ms. All rights reserved.