Management in intractable obstetric haemorrhage: an audit study on 61 cases.
OBJECTIVE
To refine the indications of bilateral hypogastric artery ligation (BHAL) and angiographic selective embolisation (ASE) in intractable obstetric haemorrhage.


METHODS
an audit study.


METHODS
Tertiary care university hospital.


METHODS
Retrospective analysis of 61 cases of obstetric intractable post partum haemorrhage (PPH) initially managed either by hysterectomy or a conservative approach in a tertiary referral centre between 1983 and 1998. Procedures were reviewed as a primary (P) or secondary (S) attempt to arrest the haemorrhagic process.


RESULTS
Ten hysterectomies (5 P, 5 S), 49 BHAL (48 P, 1 S) and 9 ASE (8 P, 1S) were successfully performed in arresting the haemorrhagic process. There were 7 maternal deaths, 5 following hysterectomy and 2 following a conservative approach. Atony of the uterus was the main cause of haemorrhage (n=21) and genital tract laceration was associated with the worst prognosis. Time-elapse between delivery and surgery appears to be the main prognostic factor. Nine patients became pregnant 1 to 4 years later following a conservative approach.


CONCLUSIONS
ASE seems to be indicated in haemodynamically stable patients with birth canal trauma or uterine atony and clotting anomalies. BHAL is indicated when haemorrhage occurs after a cesarean section or when the patient is haemodynamically unstable. BHAL should be taught to Junior doctors in an attempt to decrease the number of patients transferred in tertiary referral centers for intractable PPH. This might also decrease the number of hysterectomies in intractable PPH.
Lédée
N
N
Department of Obstetrics and Gynecology, Antoine Béclère Hospital, AP-HP, 157, Rue de la Porte de Trivaux, 92141 Clamart cedex, France.
Ville
Y
Y
Musset
D
D
Mercier
F
F
Frydman
R
R
Fernandez
H
H
D000328:Adult; D001803:Blood Transfusion; D002585:Cesarean Section; D015232:Dinoprostone / Q000008:administration & dosage / Q000627:therapeutic use; D004621:Embolization, Therapeutic; D017809:Fatal Outcome; D005260:Female; D005836:Genitalia, Female / Q000293:injuries; D006801:Humans; D007044:Hysterectomy; D007083:Iliac Artery / Q000601:surgery; D022125:Lacerations / Q000601:surgery; D008026:Ligation; D008485:Medical Audit; D010121:Oxytocin / Q000008:administration & dosage / Q000627:therapeutic use; D006473:Postpartum Hemorrhage / Q000628:therapy*; D011247:Pregnancy; D011379:Prognosis; D012189:Retrospective Studies; D013997:Time Factors; D014597:Uterine Rupture / Q000601:surgery
D010121:Oxytocin; D015232:Dinoprostone