Practice Bulletin No. 183: Postpartum Hemorrhage.
Practice Bulletin No. 183: Postpartum Hemorrhage.
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DOI：
10.1097/aog.0000000000002398
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发表时间：
2017-10-01
影响因子：
7.2
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中科院分区：
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剖腹产后试产（TOLAC）是指有计划地尝试由以前有过剖腹产的妇女阴道分娩，无论结果如何。这种方法为希望阴道分娩的妇女提供了实现这一目标的可能性-剖宫产后阴道分娩（VBAC）。除了满足患者对阴道分娩的偏好外，在个体水平上，VBAC还与孕产妇发病率降低和未来妊娠并发症风险降低以及总体剖宫产率降低相关（1-3）。然而，尽管TOLAC适用于许多妇女，但有几个因素增加了试产失败的可能性，与成功试产（即VBAC）和择期重复剖宫产相比，这反过来又与孕产妇和围产期发病率增加有关（4-6）。因此，在确定谁是TOLAC的合适候选人时，评估VBAC的可能性以及个体风险非常重要。因此，本文件的目的是审查TOLAC在各种临床情况下的风险和益处，并为在先前剖宫产后尝试阴道分娩的患者提供咨询和管理的实用指南。产妇出血，定义为累积失血量大于或等于1，在分娩过程后24小时内，000 mL或失血伴随低血容量症的体征或症状，仍然是全球孕产妇死亡的主要原因（1）。出血还存在其他重要的继发性后遗症，包括成人呼吸窘迫综合征、休克、弥散性血管内凝血、急性肾衰竭、生育能力丧失和垂体坏死（Sheehan综合征）。在美国，导致输血的出血是导致严重孕产妇死亡的主要原因，其次是弥散性血管内凝血（2）。在美国，1994年至2006年期间，产后出血率增加了26%，主要是因为张力缺乏率增加（3）。相比之下，产后产科出血的孕产妇死亡率自20世纪80年代末以来有所下降，2009年占孕产妇死亡率的10%略多（约为每10万例活产1.7例死亡）（2，4）。观察到的死亡率下降与输血率和围产期子宫切除率的增加有关（2-4）。本实践公报的目的是讨论产后出血的危险因素及其评估、预防和管理。此外，本文件将鼓励妇产科医生和其他产科护理提供者在实施产后出血管理的标准化护理包（例如，政策，指南和算法）中发挥关键作用。
Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (1-3). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (4-6). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.Maternal hemorrhage, defined as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process, remains the leading cause of maternal mortality worldwide (1). Additional important secondary sequelae from hemorrhage exist and include adult respiratory distress syndrome, shock, disseminated intravascular coagulation, acute renal failure, loss of fertility, and pituitary necrosis (Sheehan syndrome).Hemorrhage that leads to blood transfusion is the leading cause of severe maternal morbidity in the United States closely followed by disseminated intravascular coagulation (2). In the United States, the rate of postpartum hemorrhage increased 26% between 1994 and 2006 primarily because of increased rates of atony (3). In contrast, maternal mortality from postpartum obstetric hemorrhage has decreased since the late 1980s and accounted for slightly more than 10% of maternal mortalities (approximately 1.7 deaths per 100,000 live births) in 2009 (2, 4). This observed decrease in mortality is associated with increasing rates of transfusion and peripartum hysterectomy (2-4).The purpose of this Practice Bulletin is to discuss the risk factors for postpartum hemorrhage as well as its evaluation, prevention, and management. In addition, this document will encourage obstetrician-gynecologists and other obstetric care providers to play key roles in implementing standardized bundles of care (eg, policies, guidelines, and algorithms) for the management of postpartum hemorrhage.