title: [Surgical treatment of postpartum hemorrhage].
abstract: OBJECTIVE
  Systematic revue of different conservative and non-conservative surgical treatment of postpartum hemorrhage (PPH). Elaboration of surgical strategy after failed medical treatment of PPH.
  
  
  METHODS
  French and English publications were identified through PubMed and Cochrane databases.
  
  
  RESULTS
  Each obstetrical unit has to rewrite a full protocol of management of PPH depending on local environment quickly available in theatre (professional consensus). Conservative surgical treatment of PPH: efficacy of vascular ligature (bilateral uterine artery ligation (BUAL) or bilateral hypogastric artery ligation (BHAL)) as a first line of surgical treatment of PPH is about 60 % to 70 % (EL4). Bilateral uterine artery ligation (BUAL) is easy to perform with low rate of immediate severe complication (professional consensus). BUAL as BHAL seems not to affected fertility and obstetrical outcomes of next pregnancies (EL4). Efficacy of haemostatics brace suturing in case of failed medical treatment of PPH is about 75 % (EL3), without risk of major obstetrical complications at the next pregnancy (EL4). Radical surgical treatment of PPH: total hysterectomy is not significantly associated with more urinary tract injury in comparison with subtotal hysterectomy (EL3). Choice of surgical procedure of hysterectomy (total or subtotal) will depend on local consideration and clinicians habits (professional consensus). Surgical strategy: conservative surgical treatment are efficient and associated with low morbidity, they have to be primarily performed in women with further fertility desire. Specific medical consideration as massive PPH or cardiovascular instability has to consider performing haemostatic hysterectomy as the first line surgical treatment of PPH. PPH during caesarean delivery: in case of PPH during caesarean section, embolisation is not recommended, surgical treatment using vascular devascularisation or compression brace suturing should be performed (professional consensus). Surgical conservative technique will depend on local considerations and clinicians habits (professional consensus). PPH diagnosed after caesarean section should indicate relaparotomy. Arterial embolisation, if quickly vacant in the same hospital, may be performed in case of cardiovascular stability without surgical complication diagnoses on intraperitoneal hemorrhage (professional consensus). PPH during vaginal delivery: cardiovascular instability centre indicate the interhospital transfer and must lead to achieve haemostatic surgery on site (professional consensus). In the presence of a unit of embolisation in the maternity delivery, it is preferable to move towards embolisation, if maternal hemodynamic status permits (professional consensus). In case of cardiovascular stability associated with absence of heavy bleeding, the interhospital transfer may be considered for arterial embolisation (professional consensus).
  
  
  CONCLUSIONS
  When medical treatment of PPH failed, conservative surgical treatment has a 70 % efficacy to stop hemorrhage whatever treatment used (vascular ligature or haemostatics brace suturing). In absence of rapid response to conservative medical and surgical treatment, hysterectomy should be performed without delay (professional consensus).
authors.affiliation: Service de gynécologie-obstétrique, gynépole Marseille, Aix-Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, CHU, chemin des Bourrely, 13915 Marseille cedex 20, France. Electronic address: jeanbaptiste.haumonte@ap-hm.fr.
authors.forename: J-B
authors.initials: JB
authors.lastname: Haumonté
authors.affiliation: Service de gynécologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49033 Angers cedex 01, France.
authors.forename: L
authors.initials: L
authors.lastname: Sentilhes
authors.affiliation: Service de gynécologie-obstétrique, gynépole Marseille, Aix-Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, CHU, chemin des Bourrely, 13915 Marseille cedex 20, France.
authors.forename: P
authors.initials: P
authors.lastname: Macé
authors.affiliation: Service de gynécologie-obstétrique, gynépole Marseille, Aix-Marseille université, hôpital Conception, Assistance publique-Hôpitaux de Marseille, 147, boulevard Baille, 13005 Marseille, France.
authors.forename: L
authors.initials: L
authors.lastname: Cravello
authors.affiliation: Service de gynécologie-obstétrique, gynépole Marseille, Aix-Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, CHU, chemin des Bourrely, 13915 Marseille cedex 20, France.
authors.forename: L
authors.initials: L
authors.lastname: Boubli
authors.affiliation: Service de gynécologie-obstétrique, gynépole Marseille, Aix-Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, CHU, chemin des Bourrely, 13915 Marseille cedex 20, France.
authors.forename: C
authors.initials: C
authors.lastname: d'Ercole
mesh_terms: D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000592:standards*; D008026:Ligation / Q000592:standards*; D013513:Obstetric Surgical Procedures / Q000592:standards*; D006473:Postpartum Hemorrhage / Q000601:surgery*; D017410:Practice Guidelines as Topic / Q000592:standards*
keywords: Capitonnage utérin; Compression utérine; Haemostatics brace suturing; Hysterectomy; Hystérectomie; Hémorragie du post-partum; Ligature vasculaire; Postpartum hemorrhage; Vascular ligature