Prise en charge des hémorragies graves du post-partum : indications et techniques de l’embolisation artérielle

[Current indications for uterine artery embolization to treat postpartum hemorrhage]

Uterine artery embolization is an interventional radiology technique successfully used for more than 30 years in the management of gynecological or obstetrical hemorrhage. Precise indications for uterine artery embolization to treat postpartum hemorrhage have been recently published. Uterine artery embolization is indicated in case of uterine atony despite medical treatment particularly after vaginal delivery, in case of vaginal thrombus or cervical tear after failed surgical repair. Embolization can also be discussed in case of persistent hemorrhage after arterial ligation or hysterectomy. Finally, arterial embolization can be attempted in case of placenta accreta to avoid hysterectomy. In all situations, pluridisciplinary management of patients with involvement of interventional radiologists, anesthesiologists and obstetricians is mandatory. Early transportation of patients for embolization should be discussed taking into consideration time of onset of hemorrhage, expected transfer time and treatment options available on site. For validated indications, success rates of arterial embolization as high as 80% can be expected in experienced hands.

[Complete cost of surgery for postpartum haemorrhage]

OBJECTIVE

Reduction of maternal mortality is a major priority in the public health domain. One of the main causes of maternal mortality is postpartum haemorrhage. Because economic pressures favour the use of less expensive strategies, it is becoming now critical to know exactly the cost of the surgical procedures involved in the treatment of postpartum haemorrhage, in order to provide future guidelines in Implementing reforms in hospital.

MATERIALS AND METHODS

Evaluation was made on multiple data collected in the Gynecology-Obstetrics and Central Sterile Supplies departments of a tertiary care Hospital. Analysis of the production costs was made based on the actual costs. The receipts were figured on the basis of applicable reimbursement in France in 2005, taking into account the financial decisions of the producers.

RESULTS

From January 2004 to December 2005, 262 patients were treated for postpartum hemorrhage and patients files were available for review in 255 cases. Of these, surgery was performed in 52 cases. The costs of surgery in the postpartum care ranged from 275.04 euro per manual exploration of the uterine cavity (n=8), 302.48 euro per exploration with valve (n=26), 601.55 euro per vascular ligation (n=3), 725.53 euro per vaginal packing or unpacking (n=10) to 875.06 euro per hysterectomy (n=5). Cleaning and sterilizing of surgical instruments represented a substantial burden, ranging from 7.5% to 11.4% of the total cost of surgery.

DISCUSSION AND CONCLUSION

The costs of surgery for postpartum haemorrhage have been calculated to provide future guidelines for the directions and follow-up of these activities in light of the T2A-EPRD and poles of activity. The actual costs could be used to determine the bases of one or more French DRGs (PMSI) "postpartum hemorrhage" evolution.

Impact of the new French clinical practice recommendations in embolization in postpartum and post-abortion hemorrhage: study of 48 cases

AIM

To evaluate the use of arterial embolization in postpartum hemorrhage (PPH) by comparing the indications, efficacy, times to diagnosis, treatment, and embolization, and conditions of management of patients before and after publication of the Collège National des Gynécologues et Obstétriciens Français clinical practice recommendations (CPR).

METHODS

Forty-eight patients who underwent embolization between January 2000 and December 2005 were included in a retrospective, descriptive, and comparative study. We compared the management before (n=21) and after (n=27) publication of the CPR. The main outcome measures were time to diagnosis of PPH, time to treatment initiation, time to decision to implement embolization, time to embolization, hemodynamic characteristics.

RESULTS

The number of embolizations has quadrupled since publication of the CPR, and the time taken to decide on embolization has been reduced by 30%. The success rate was 96%, there were no second embolization procedures, and one complication was recorded (hematoma of pubic symphysis). Hemodynamic status was better in patients treated after the CPR (P=0.003).

CONCLUSION

Embolization is an effective and safe technique, with a low complication rate. In our healthcare network, the decision to use embolization was faster since the CPR, embolizations have quadrupled, and patients' hemodynamic status has improved.

Hémorragie de la délivrance « menaçant la vie » et utilisation du facteur VII recombinant activé rFVIIa NovoSeven®

Postpartum haemorrhage remains a dangerous obstetrical complication, which is the main cause of maternal mortality in developing countries. The diagnosis must be immediate and its management is both medically and surgically in life-threatening haemorrhage. We present a case of a thirty-three-year-old woman who asked a pregnancy interruption for premature rupture of membranes at 21(th) gestational week for her second pregnancy; she underwent a caesarean section at term for her first pregnancy. She delivered vaginally and developed a postpartum haemorrhage with hemorrhagic shock which was resistant to medical, surgical and radiological management. We decided to use recombinant activated factor VII (rFVIIa, NovoSeven) as a final attempt to rescue the patient. During surgery, two intravenous bolus injections (60, 120 mug/kg) were successfully given with a control of bleeding and haemoglobin. The patient developed later a splenic thrombosis that can be related to either rFVIIa or to the hypovolemic shock or to the sepsis. Recombinant activated factor VII is an interesting and promising haemostatic agent in the management of life-threatening postpartum haemorrhage unresponsive to conventional treatment.