POSTPARTUM HEMORAJİ: KANITA DAYALI GÜNCEL YÖNETİM VE MASİF TRANSFÜZYON PROTOKOLLERİ
Özet
Postpartum hemoraji (PPH), dünya çapında maternal morbidite ve mortalitenin en önde gelen, ancak önlenebilir nedenlerinden biridir. Bu bölüm; PPH yönetimindeki geleneksel yaklaşımları modern obstetrik anestezi ve cerrahi kanıtlarla sentezleyerek, güncel uluslararası kılavuzlar (ACOG, RCOG, FIGO, WHO) ışığında kapsamlı bir klinik algoritma sunmaktadır. Kan kaybının görsel tahmininden kantitatif ölçümüne geçiş, erken tanının temelini oluşturur. Etkili bir PPH yönetimi; etiyolojiye yönelik "4T" prensibinin hızlıca değerlendirilmesini, profilaktik ve terapötik uterotoniklerin akılcı kullanımını ve kanamanın ilk 3 saati içerisinde traneksamik asit uygulamasını şart koşar. Farmakolojik müdahalelere yanıtsız olgularda en kritik paradigma değişimi, yüksek hacimli kristaloid infüzyonunun terk edilerek hasar kontrol resüsitasyonu stratejisine geçilmesidir. Masif Transfüzyon Protokollerinin erken aktivasyonu, ampirik dengeli transfüzyon (1:1:1) ve viskoelastik testler eşliğinde hedefe yönelik fibrinojen replasmanı, koagülopatinin önlenmesinde hayati öneme sahiptir. Tıbbi tedaviye dirençli tablolar zaman kaybedilmeksizin; intrauterin balon tamponad sistemleri, uterin kompresyon sütürleri, devaskülarizasyon teknikleri, ileri endovasküler müdahaleler ve nihai olarak peripartum histerektomi gibi basamaklı mekanik/cerrahi prosedürlerle yönetilmelidir. Sonuç olarak başarılı bir hemostaz; yalnızca medikal veya cerrahi müdahalelerle değil, kapalı çevrim iletişim stratejilerini kullanan multidisipliner bir kriz kaynak yönetimi ile mümkündür.
Anahtar Kelimeler: Postpartum hemoraji, hasar kontrol resüsitasyonu, masif transfüzyon protokolü, uterin balon tamponad, viskoelastik testler, obstetrik kanama yönetimi
Konu Alanı: Tıp -> Tıp (diğer) -> Kadın Hastalıkları ve Doğum
Kaynaklar
American College of Obstetricians and Gynecologists. (2017). Practice Bulletin No. 183: Postpartum hemorrhage. Obstetrics & Gynecology, 130(4), e168–e186. https://doi.org/10.1097/AOG.0000000000002351
American College of Obstetricians and Gynecologists. (2019). Committee Opinion No. 794: Quantitative blood loss in obstetric hemorrhage. Obstetrics & Gynecology, 134(6), e150–e156. https://doi.org/10.1097/AOG.0000000000003563
American College of Obstetricians and Gynecologists. (2020). Committee Opinion No. 814: Delayed umbilical cord clamping after birth. Obstetrics & Gynecology, 136(6), e100–e106. https://doi.org/10.1097/AOG.0000000000004167
American College of Obstetricians and Gynecologists, & Society for Maternal-Fetal Medicine. (2018). Obstetric Care Consensus No. 7: Placenta accreta spectrum. Obstetrics & Gynecology, 132(6), e259–e275. https://doi.org/10.1097/AOG.0000000000002983
Bakri, Y. N., Amri, A., & Abdul Jabbar, F. (2001). Tamponade-balloon for obstetrical bleeding. International Journal of Gynecology & Obstetrics, 74(2), 139–142. https://doi.org/10.1016/S0020-7292(01)00395-2
B-Lynch, C., Coker, A., Lawal, A. H., Abu, J., & Cowen, M. J. (1997). The B-Lynch surgical technique for the control of massive postpartum haemorrhage: An alternative to hysterectomy? Five cases reported. British Journal of Obstetrics and Gynaecology, 104(3), 372–375. https://doi.org/10.1111/j.1471-0528.1997.tb11471.x
Begley, C. M., Gyte, G. M., Devane, D., McGuire, W., Weeks, A., & Biesty, L. M. (2019). Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews, 2019(2), Article CD007412. https://doi.org/10.1002/14651858.CD007412.pub5
Brenner, A., Ker, K., Shakur-Still, H., & Roberts, I. (2019). Tranexamic acid for post-partum haemorrhage: What, who and when. Best Practice & Research Clinical Obstetrics & Gynaecology, 61, 66–74. https://doi.org/10.1016/j.bpobgyn.2019.04.005
Charbit, B., Mandelbrot, L., Samain, E., Mebazaa, G., & de Prost, D. (2007). The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. Journal of Thrombosis and Haemostasis, 5(2), 266–273. https://doi.org/10.1111/j.1538-7836.2007.02297.x
Collins, P. W., Bell, S. F., de Lloyd, L., Collis, R. E., Shapiro, S. E., & Hunt, B. J. (2016). Management of coagulopathy associated with postpartum hemorrhage: Guidance from the SSC of the ISTH. Journal of Thrombosis and Haemostasis, 14(1), 205–210. https://doi.org/10.1111/jth.13171
Collins, P. W., Cannings-John, R., Bruynseels, D., Mallaiah, S., Newton-Lewis, J., Collis, R. E., Morgan, C., Hickmott, G., Hall, J. E., Giles, G., Paranjothy, S., Rayment, J., Macgillivray, A., Hall, J., Prescott, D., Evans, A., Vijayalingam, B., Woolf, K., Oakley, L. L., & Klein, N. J. (2017). Viscoelastometric-guided early fibrinogen concentrate replacement during post-partum haemorrhage: OBS2, a double-blind randomized controlled trial. British Journal of Anaesthesia, 119(3), 411–421. https://doi.org/10.1093/bja/aex181
D'Alton, M. E., Rood, K. M., Smid, M. C., Simhan, L. A., Skupski, B. S., Subramaniam, A., Gibson, K. S., Shields, L. E., Pflum, M. M., Szychowski, J. M., & Goffman, D. (2020). Intrauterine vacuum-induced hemorrhage-control device for rapid treatment of postpartum hemorrhage. Obstetrics & Gynecology, 136(5), 882–891. https://doi.org/10.1097/AOG.0000000000004138
Escobar, M. F., Nassar, A. H., Theron, G., Barnea, E. R., Nicholson, W. K., Ramasauskaite, D., Lloyd, I., Armson, B. A., Garcia-Elorrio, E., Bula, A. N., & Hanson, C. (2022). FIGO recommendations on the management of postpartum hemorrhage 2022. International Journal of Gynecology & Obstetrics, 157(Suppl. 1), 3–50. https://doi.org/10.1002/ijgo.14116
Evensen, A., Anderson, J. M., & Fontaine, P. (2017). Postpartum hemorrhage: Prevention and treatment. American Family Physician, 95(7), 442–449. 4 Ağustos 2026 tarihinde https://www.aafp.org/pubs/afp/issues/2017/0401/p442.html adresinden erişilmiştir.
Franchini, M., Franchi, M., Bergamini, V., Montagnana, M., Salvagno, G. L., Targher, G., & Lippi, G. (2008). The use of recombinant activated factor VII in obstetric hemostasis: A systematic review. Journal of Thrombosis and Haemostasis, 6(1), 18–24. https://doi.org/10.1111/j.1538-7836.2007.02804.x
Gallos, I., Devall, A., Martin, J., Middleton, H., Price, L., Al-beity, F. A., Abdel-Aleem, H., Nair, M., Patel, A., Hofmeyr, G. J., Althabe, F., Ogutu, M., Ameh, C., Edusei, A. K., Vogel, J. P., Ndirangu, G., Osoti, A., Galadanci, H., Bukar, M., & Coomarasamy, A. (2023). Randomized trial of early detection and treatment of postpartum hemorrhage. New England Journal of Medicine, 389(1), 11–21. https://doi.org/10.1056/NEJMoa2303966
Giancarelli, A., Birrer, K. L., Alban, R. F., Hobbs, B. P., & Liu-DeRyke, X. (2020). Hypocalcemia in trauma and massive transfusion: A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery, 89(3), 588–596. https://doi.org/10.1097/TA.0000000000002773
Holcomb, J. B., Tilley, B. C., Baraniuk, S., Fox, E. E., Wade, C. E., Podbielski, J. M., del Junco, D. J., Thomas, K. O., Robinson, A. T., Stein, D. M., Cotton, B. A., Schreiber, M. A., Cohen, M. J., Dutton, R. P., Moore, L. J., Minei, J. P., Brasel, C. N., Bulger, E. M., DuBose, J. J., & Rahbar, M. H. (2015). Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial. JAMA, 313(5), 471–482. https://doi.org/10.1001/jama.2015.12
Mallaiah, S., Barclay, P., Harrod, I., Chevannes, C., & Bhalla, A. (2015). Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia, 70(2), 166–175. https://doi.org/10.1111/anae.12859
Menard, M. K., Main, E. K., & Currigan, S. M. (2014). Executive summary of the reVITALize initiative: Standardizing obstetric data definitions. Obstetrics & Gynecology, 124(1), 150–153. https://doi.org/10.1097/AOG.0000000000000322
Muñoz, M., Stensballe, J., Ducloy-Bouthors, A. S., von Heymann, C., Meier, T., Maniatis, A., Bodnar, D., Shander, A., & Van der Linden, P. (2019). Patient blood management in obstetrics: Prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfusion, 17(2), 112–136. https://doi.org/10.2450/2019.0120-19
Ordoñez, C. A., Manzano-Nunez, R., Parra, M. W., Rasmussen, T. E., Nieto, A. I., Herrera-Escobar, J. P., Rodriguez-Holguin, F., Garcia, A. F., Salamea, J. C., Naranjo, M. P., & Ferrada, P. (2018). Prophylactic use of resuscitative endovascular balloon occlusion of the aorta in women with abnormal placentation: A systematic review, meta-analysis, and case series. *Journal of Trauma and Acute Care Surgery*, *84*(5), 809–818. https://doi.org/10.1097/TA.0000000000001821
Pelage, J. P., Le Dref, O., Mateo, J., Soyer, P., Jacob, D., Kardache, M., Dahan, R., Repessé, A., Rymer, R., & Truc, M. (1998). Life-threatening primary postpartum hemorrhage: Treatment with emergency selective arterial embolization. Radiology, 208(2), 359–362. https://doi.org/10.1148/radiology.208.2.9680559
Royal College of Obstetricians and Gynaecologists. (2017). Prevention and management of postpartum haemorrhage (Green-top Guideline No. 52). BJOG: An International Journal of Obstetrics & Gynaecology, 124(5), e106–e149. https://doi.org/10.1111/1471-0528.14178
Shakur, H., Roberts, I., Fawole, B., Chaudhry, R., Nair, S., Allen, E., John-Akinola, Y., & Alfirevic, Z. (2017). Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): An international, randomised, double-blind, placebo-controlled trial. The Lancet, 389(10084), 2105–2116. https://doi.org/10.1016/S0140-6736(17)30638-4
Silver, R. M., & Branch, D. W. (2018). Placenta accreta spectrum. New England Journal of Medicine, 378(16), 1529–1536. https://doi.org/10.1056/NEJMcp1709324
Spahn, D. R., Bouillon, B., Cerny, V., Duranteau, J., Filipescu, D., Hunt, B. J., Komadina, R., Maegele, M., Nardi, G., Riddez, L., Samama, C. M., Vincent, J. L., & Rossaint, R. (2019). The European guideline on management of major bleeding and coagulopathy following trauma: Fifth edition. Critical Care, 23(1), Article 98. https://doi.org/10.1186/s13054-019-2347-3
World Health Organization. (2012). WHO recommendations for the prevention and treatment of postpartum haemorrhage. 4 Ağustos 2026 tarihinde https://www.who.int/publications/i/item/9789241548502 adresinden erişilmiştir.
World Health Organization. (2017). WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. 4 Ağustos 2026 tarihinde https://www.who.int/publications/i/item/9789241550154 adresinden erişilmiştir.
World Health Organization. (2018). WHO recommendations: Uterotonics for the prevention of postpartum haemorrhage. 4 Ağustos 2026 tarihinde https://www.who.int/publications/i/item/9789241550420 adresinden erişilmiştir.
World Health Organization. (2023). WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage. 4 Ağustos 2026 tarihinde https://www.who.int/publications/i/item/9789240085398 adresinden erişilmiştir.
Erel Muğurtay, T. (2026). POSTPARTUM HEMORAJİ: KANITA DAYALI GÜNCEL YÖNETİM VE MASİF TRANSFÜZYON PROTOKOLLERİ. In YURTCU, N. (Ed.), Obstetrik ve Jinekolojik Acillerde Multidisipliner Güncel Yaklaşım (pp. 154-184). Vizetek Yayıncılık. https://doi.org/10.54637/vizetek.9786253823962
| Kitap: |
| Yayınevi:
Vizetek Yayıncılık |