Postpartum Hemorrhage: Guidelines for Clinical Practice Text of the Guidelines from CNGOF
Seance of wednesday 31 may 2017 (HÉMORRAGIE DE LA DÉLIVRANCE)
DOI number : 10.26299/4wc7-y617/emem.2017.4.008
Abstract
Postpartum hemorrhage (PPH) is an obstetrical and anesthetic emergency which constitutes the second cause of maternal mortality in France.
Nevertheless, it seems often avoidable. Once the hemorrhage settled, all delay or hesitation in multidisciplinary caretaking is harmful, because it favors the outbreak of coagulation disorders and the setting of a pervert circle. When possible, the arterial embolization constitutes a great progress in the non-invasive conservative treatment, above all after low access birth. The uterine staged devascularization is efficient and conserves maternal fertility.
Conservative surgical treatment: When there is no comparative study concerning the efficiency of various surgical conservative techniques, no one has to be favored. The hemorrhage-stopping efficiency of vascular ligature technologies (bilateral ligation of uterine or hypogastric arteries) at the beginning of conservative surgical treatment of PPH is successful in about 70%. The ligation of uterine arteries is a simple surgical technique with small risk of severe immediate complication. These vascular ligations seem to have no negative effect on later fertility or later obstetrical state. In case of resistance to medical treatment, the efficiency of compressive techniques or of uterine plication to stop the bleeding, is about 75%; those, too, will not induce complication for further pregnancy.
Radical surgery treatment: Comparing to subtotal hysterectomy, total hysterectomy does not seem to increase significantly the occurrence of wounds in the urinary system.
The choice between those two kinds of hysterectomy is left to the operators' judgement.
Surgical strategy: The conservative treatments of the uterus are efficient and rarely dangerous for the patient. They must be achieved prior to other treatments. For some situations (massive PPH or precarious hemodynamic state) the surgeon will probably decide to do an hemostatic hysterectomy in first intention. In case of hemorrhage during caesarean parturition (open surgery), the practice of embolization is not advisable; a conservative treatment with vascular ligation or uterine compression must be done. The choice of each conservative technique depends on the habits of the operating surgeons. A post-caesarian hemorrhage will lead to reoperation. However, if there is an interventional radiology unit in the hospital and if the hemodynamic state is preserved (of course without signs of peritoneal hemorrhage which may lead to surgical complications) an arterial embolization may be undertaken.
Hemorrhage after low-access birth: An unstable hemodynamic state is a strict contraindication of transferring the patient to other services and must lead to hemostatic surgery in place. If there is an embolization unit present in the birth-place it is better to prefer embolization, if the hemodynamic state of the mother and the hospital's organization of care allow to do it. If the hemodynamic state is stable and without any heavy bleeding of the patient, a transfer to another hospital having an embolization unit might be a good solution. If no medical treatment is efficient, the realization of a conservative surgical treatment of the uterus can be tried; we note an efficiency of 70% on stopping the bleeding whatever the used technique might be (vascular ligation or uterine compression).
If there is no rapid reply to the first conservative treatments, a hemostatic hysterectomy must be done without delay.
Facing the post-partum hemorrhage it is necessary to have a unambiguous and progressive plan and to fight against the uterine inertia (but also against the obstetrician's inertia?).
Nevertheless, it seems often avoidable. Once the hemorrhage settled, all delay or hesitation in multidisciplinary caretaking is harmful, because it favors the outbreak of coagulation disorders and the setting of a pervert circle. When possible, the arterial embolization constitutes a great progress in the non-invasive conservative treatment, above all after low access birth. The uterine staged devascularization is efficient and conserves maternal fertility.
Conservative surgical treatment: When there is no comparative study concerning the efficiency of various surgical conservative techniques, no one has to be favored. The hemorrhage-stopping efficiency of vascular ligature technologies (bilateral ligation of uterine or hypogastric arteries) at the beginning of conservative surgical treatment of PPH is successful in about 70%. The ligation of uterine arteries is a simple surgical technique with small risk of severe immediate complication. These vascular ligations seem to have no negative effect on later fertility or later obstetrical state. In case of resistance to medical treatment, the efficiency of compressive techniques or of uterine plication to stop the bleeding, is about 75%; those, too, will not induce complication for further pregnancy.
Radical surgery treatment: Comparing to subtotal hysterectomy, total hysterectomy does not seem to increase significantly the occurrence of wounds in the urinary system.
The choice between those two kinds of hysterectomy is left to the operators' judgement.
Surgical strategy: The conservative treatments of the uterus are efficient and rarely dangerous for the patient. They must be achieved prior to other treatments. For some situations (massive PPH or precarious hemodynamic state) the surgeon will probably decide to do an hemostatic hysterectomy in first intention. In case of hemorrhage during caesarean parturition (open surgery), the practice of embolization is not advisable; a conservative treatment with vascular ligation or uterine compression must be done. The choice of each conservative technique depends on the habits of the operating surgeons. A post-caesarian hemorrhage will lead to reoperation. However, if there is an interventional radiology unit in the hospital and if the hemodynamic state is preserved (of course without signs of peritoneal hemorrhage which may lead to surgical complications) an arterial embolization may be undertaken.
Hemorrhage after low-access birth: An unstable hemodynamic state is a strict contraindication of transferring the patient to other services and must lead to hemostatic surgery in place. If there is an embolization unit present in the birth-place it is better to prefer embolization, if the hemodynamic state of the mother and the hospital's organization of care allow to do it. If the hemodynamic state is stable and without any heavy bleeding of the patient, a transfer to another hospital having an embolization unit might be a good solution. If no medical treatment is efficient, the realization of a conservative surgical treatment of the uterus can be tried; we note an efficiency of 70% on stopping the bleeding whatever the used technique might be (vascular ligation or uterine compression).
If there is no rapid reply to the first conservative treatments, a hemostatic hysterectomy must be done without delay.
Facing the post-partum hemorrhage it is necessary to have a unambiguous and progressive plan and to fight against the uterine inertia (but also against the obstetrician's inertia?).