Prise en charge chirurgicale d’une hémorragie du post-partum

Surgical treatment of postpartum haemorrhage: national survey of French residents of obstetrics and gynecology

Background

Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and one of the leading causes of maternal mortality worldwide. Many medical treatments and interventions are available nowadays, but surgical treatment is sometimes required when less invasive methods are unsuccessful. This study aimed to assess the theoretical and practical knowledge of French residents of Obstetrics and Gynecology concerning the surgical treatment of postpartum haemorrhage.

Study design

We performed a questionnaire study for senior residents of Obstetrics and Gynecology in France (fourth and fifth year of training). An anonymous survey was sent by email. Between December 2013 and April 2014, a total of 370 residents responded.

Result

The response rate was 47.6% (176/370). Only 156 questionnaires were fully completed and included for analysis. In all, 74% (115/156) of residents reported not mastering sufficiently or at all the technique for bilateral ligation of uterine arteries, 79% (123/156) for uterine compression sutures, 95% (148/156) for ligation of the internal iliac arteries, and 78% (122/156) for emergency peripartum hysterectomy. More than half of respondents (55%, 86/156) stated that they had not mastered any of these techniques.

Conclusion

An alarmingly high number of French senior residents in Obstetrics and Gynecology report that they have not acquired the sufficient surgical skills during their training to be able to perform the surgeries required for the management of PPH.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2237-3) contains supplementary material, which is available to authorized users.

Abdomino-pelvic packing revisited: An often forgotten technique for managing intractable venous obstetric haemorrhage

BACKGROUND

Surgical packing should not be seen as a 'bail out' for the less skilled obstetrician who is unable to control obstetric haemorrhage using conventional techniques. Rather, this should be considered in cases of coagulopathy or where haemorrhage persists from raw surfaces, venous plexuses and inaccessible areas.

MATERIALS AND METHODS

Data from seven women who underwent abdomino-pelvic packing for intractable postpartum bleeding were collected. The primary outcome was success of intra-abdominal packing and secondary outcomes included estimated blood loss, units transfused, length of stay and postoperative complications.

RESULTS

All seven women (median age 39 years, interquartile range (IQR) 3.25) had caesarean section deliveries with median estimated blood loss of 5521.4 mL (IQR 4475) and median of 6.9 (IQR 4.75) units transfused. Abdomino-pelvic packing was successful in all cases including in three women who had continued bleeding after peripartum hysterectomy. In the remaining four, bleeding stopped with packing, enabling the uterus to be conserved. The median number of packs inserted was 6.1 (IQR 4.2) and median shock index at time of decision to pack was 0.98 (IQR 0.13). The median pack dwell time was 30.8 h (IQR 24), while median length of stay following removal was 48 h (IQR 2.14).

CONCLUSION

Intractable bleeding in these seven cases was successfully controlled by abdomino-pelvic packing, allowing supportive correction of hypothermia, tissue acidosis, coagulopathy and hypovolemia. The technique of packing is an essential skill in managing massive obstetric haemorrhage, in addition to uterine balloon tamponade, compression sutures and peripartum hysterectomy.

[Which surgical strategy to adopt for the management of postpartum haemorrhage and how to improve the effects of hypogastric arteries ligation?]

L'objectif était d'identifier les facteurs de succès de la ligature bilatérale des artères hypogastriques et évaluer sa place dans le traitement chirurgical des hémorragies du post-partum. Nous avons réalisé une étude rétrospective regroupant tous les cas d'hémorragie du post-partum ayant nécessité un traitement chirurgical entre Janvier 2008 et Décembre 2011. L'étude a concerné 88 patientes (0,47% du total des accouchements). L'atonie utérine était l'étiologie la plus fréquente (64,8 % des patientes). La ligature bilatérale des artères hypogastriques a été réalisée chez 81,8% des patientes. Quand elle était le premier geste chirurgical réalisé, son taux de succès était de 66%. Ce taux était variable en fonction de l'étiologie de l'hémorragie, de la présence ou non de troubles de l'hémostase et du temps écoulé entre le diagnostic et la réalisation du geste chirurgical. En cas atonie utérine, l'association d'une deuxième technique conservatrice lorsque la première était insuffisante, a permis d'arrêter le saignement dans 98% des cas. La ligature des artères hypogastriques est une technique chirurgicale efficace pour le traitement de l'hémorragie du post-partum. Son taux de succès est augmenté par sa réalisation précoce ainsi que son association à d'autres techniques conservatrices.