title: Major obstetric hemorrhage.
abstract: Major obstetric hemorrhage is a challenge for anesthesiologists because it remains responsible for over 10% of maternal deaths in high-income countries. A standardized multidisciplinary management, described in locally validated protocols and based on international guidelines is mandatory to prevent these deaths. The first difficulty relies on the systematic underestimation of the bleeding. Collection bags must be used to facilitate the diagnosis and therefore rapid management. The etiologies in antenatal or postpartum must be well-known in order to be treated adequately. A rapid recourse to prostaglandins (sulprostone in France) may reverse uterine atony. Invasive approach with surgery or radiology should be promptly implemented (uterine artery or internal iliac artery ligations±uterus plication) and hysterectomy should then be timely considered. Simultaneously, early and aggressive resuscitation with large-bore venous accesses should be implemented for rapid and massive transfusion (4:4:1 RBC:FFP:platelets ratio), along with an early use of fibrinogen concentrates and tranexamic acid. This transfusion strategy may be then guided by thromboelastography or thromboelastometry and bedside hemoglobin measurements. Activated factor VII remains indicated only before or after hysterectomy in case of uncontrolled bleeding. Management of placentation abnormalities (placenta previa, accreta, increta, percreta) must be well mastered as these etiologies may generate cataclysmic hemorrhages that can be and have to be anticipated.
authors: Department of Anesthesia and Intensive Care, Hôpital Antoine-Beclere, Université Paris-Sud, AP-HP, 157, rue de la Porte-de-Trivaux, BP 405, 92141 Clamart cedex, France.
authors: A
authors: A
authors: Le Gouez
authors: Department of Anesthesia and Intensive Care, Hôpital Antoine-Beclere, Université Paris-Sud, AP-HP, 157, rue de la Porte-de-Trivaux, BP 405, 92141 Clamart cedex, France. Electronic address: frederic.mercier@aphp.fr.
authors: F J
authors: FJ
authors: Mercier
mesh_terms: D016913:Blood Component Transfusion; D003131:Combined Modality Therapy; D015232:Dinoprostone / Q000031:analogs & derivatives / Q000627:therapeutic use; D015942:Factor VIIa / Q000627:therapeutic use; D005260:Female; D005340:Fibrinogen / Q000627:therapeutic use; D006801:Humans; D007044:Hysterectomy; D007083:Iliac Artery / Q000601:surgery; D008026:Ligation; D008428:Maternal Mortality; D057725:Operative Blood Salvage; D010921:Placenta Accreta / Q000503:physiopathology; D010923:Placenta Previa / Q000503:physiopathology; D006473:Postpartum Hemorrhage / Q000209:etiology / Q000517:prevention & control / Q000601:surgery / Q000628:therapy*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000517:prevention & control / Q000601:surgery / Q000628:therapy*; D011994:Recombinant Proteins / Q000627:therapeutic use; D014148:Tranexamic Acid / Q000627:therapeutic use; D055988:Uterine Artery / Q000601:surgery; D055357:Uterine Artery Embolization; D014592:Uterine Hemorrhage / Q000517:prevention & control / Q000601:surgery / Q000628:therapy*; D014593:Uterine Inertia / Q000188:drug therapy
chemical_list: D011994:Recombinant Proteins; C016767:sulprostone; D014148:Tranexamic Acid; D005340:Fibrinogen; C103587:recombinant FVIIa; D015942:Factor VIIa; D015232:Dinoprostone
keywords: Anomalies de placentation; Approche multidisciplinaire; Fibrinogen; Fibrinogène; Hysterectomy; Hystérectomie; Multidisciplinary approach; Placentation anomalies; Transfusion