[Intractable postpartum haemorrhages: where is the place of vascular ligations, emergency peripartum hysterectomy or arterial embolization?].
OBJECTIVE
Update of knowledge on the various methods of management of intractable postpartum haemorrhage.


METHODS
PubMed, MEDLINE were the electronic sources, in English and French languages, used for data retrieval. Uterine atony and abnormal placental insertions (placenta praevia or accreta) are the major causes of primary postpartum haemorrhages. To preserve fertility, we dispose of angiographic selective embolization or surgical vascular ligations. Embolization is a non-invasive method practicable by simple catheterization under local anesthesia. Vascular ligations of the uterine vessels or internal iliac arteries require mostly laparotomy. New and easier surgical methods, such as uterine compression or hemostatic suturing techniques have been described for which we lack experience.


RESULTS
For uterine atony, the success rate of arterial embolization and uterine artery ligations is close to 100%. Ligation of internal iliac arteries is a little less effective and technically more difficult to carry out. It remains interesting in obstetrical traumatic hurts, which do not concern the uterus. If bleeding from the lower segment occurs during caesarean section, low uterine artery ligatures are necessary. These methods are all the more effective than they are prematurely implemented before the rise of major coagulopathy. In this case, uterine devascularization has also to be applied to ovarian vessels. With placenta accreta, accreta portion of the placenta can be left in place and arterial embolization or vascular ligations can be done. Nevertheless the main cause of failure with conservative treatments is placenta accreta.


CONCLUSIONS
The simplest and the least morbid methods must be retained. After vaginal birth, arterial embolization can be done, if there is no maternal haemodynamic disorder nor interventional vascular radiology unit nearby. During caesarean section, progressive uterine artery ligation can be done adapted to the bleeding cause. In case of failure of a conservative treatment, it would be dangerous to multiply techniques. Emergency peripartum then should remain the choice procedure.
Sergent
F
F
Clinique gynécologique et obstétricale, hôpital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France. fabrice.sergent@chu-rouen.fr
Resch
B
B
Verspyck
E
E
Rachet
B
B
Clavier
E
E
Marpeau
L
L
D001158:Arteries / Q000601:surgery; D004621:Embolization, Therapeutic; D004638:Emergency Treatment; D005260:Female; D006801:Humans; D007044:Hysterectomy; D007083:Iliac Artery / Q000601:surgery; D008026:Ligation; D016239:MEDLINE; D006473:Postpartum Hemorrhage / Q000601:surgery / Q000628:therapy*; D011247:Pregnancy; D013536:Suture Techniques; D014599:Uterus / Q000098:blood supply