Hémorragies graves de la délivrance : ligatures vasculaires, hystérectomie ou embolisation ?

This review is an update on the various methods of management of the intractable postpartum haemorrhage. PubMed and MEDLINE® were the electronic sources for data retrieval, in english and french languages. Uterine atony and abnormal placental insertions (placenta praevia or accreta) are the major causes of primary postpartum haemorrhages. To preserve fertility, the available techniques are angiographic selective embolization or surgical vascular ligations. Embolization is a non-invasive method that consists in a simple catheterization under local anaesthesia. Vascular ligation of the uterine vessels or internal iliac arteries requires most of the time a laparotomy. New and easier surgical methods, such as uterine compression or haemostatic suturing techniques have been described, for which we lack experience. For uterine atony, the success rate of arterial embolization and uterine artery ligations is close to 100%. Ligation of internal iliac arteries is a little less effective and technically more difficult to carry out. It remains interesting in case of obstetrical traumatic hurts that do not concern the uterus. If bleeding from the lower segment occurs during caesarean section, low uterine artery ligatures are necessary. These methods are all the more effective than they are prematurely implemented before the rise of major coagulopathy. In such case, uterine devascularization has also to be applied to ovarian vessels. With placenta accreta, accreta portion of the placenta can be left in place and arterial embolization or vascular ligations can be done. Nevertheless the main cause of failure with conservative treatments is placenta accreta. The simplest and the least morbid methods must be retained. After vaginal birth, arterial embolization can be undertaken, if there is no maternal haemodynamic disorder, and if the interventional vascular radiology unit is nearby. During caesarean section, progressive uterine artery ligation can be carried out, taking into account the bleeding cause. In case of conservative treatment failure, it would be dangerous to multiply techniques. In such cases, emergency peripartum should remain the choice procedure.