Ligatures vasculaires en cas d'hémorragie grave du post-partum. Indications et techniques

In case of severe post-partum haemorrhage, resuscitation and surgical techniques are complementary and should be adjusted to both the aetiology and severity of haemorrhage. In the most severe cases, hysterectomy should not be delayed. In all women with stable haemodynamic status, conservative surgical approaches should be applied. Indications, feasibility and safety of the vascular ligations techniques are described and discussed herein, in regard with our personal experience. Uterine compressions techniques as well as abdomino-pelvic packing are also developed. When conservative surgery appears to be feasible, the first line technique should be a bilateral “distal” ligation of the uterine arteries: easy to perform, its morbidity is low and the bleeding can be stopped in more than 80% of cases. In women with persistent bleeding, the uterine devascularisation can be completed by applying a triple ligation as described by Tsirulnikov, which can be completed by a “proximal” ligation of the uterine arteries. This procedure should be preferred to the so called “stepwise ligation sequence” that involves lombo-ovarian vessels with a high risk of further ovarian failure. Bilateral ligation of hypogastric arteries is also a high effective and widely spread first line approach for experienced surgeons. As potentially technically challenging for non-trained surgeons, this technique is used after failure of triple ligation.