Service de gynécologie-obstétrique, hôpital Lariboisière, université Paris 7 Diderot, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France.
J Visc Surg. 2011 Apr;148(2):e95-102. doi: 10.1016/j.jviscsurg.2011.02.002. Epub 2011 Apr 7.
In cases of serious bleeding postpartum, resuscitation and surgical techniques are complementary and should be adapted to both the etiology and severity of bleeding. In extremely severe cases, the performance of a hysterectomy should not be delayed. For women with stable hemodynamic status, so-called "conservative" surgical techniques can instead be used. In this study, we describe and discuss the indications and feasibility of various techniques of vascular ligation. Uterine mattress suture compression techniques and abdomino-pelvic packing are also described. When conservative management is feasible, the first line approach should be bilateral distal ligation of the uterine arteries: this simple and low-risk technique is immediately effective in 80% of cases. If bleeding persists, uterine devascularization can be completed by a triple ligation as described by Tsirulnikov, with or without supplemental proximal ligation of the uterine arteries. This procedure should be performed in preference to the so-called "stepwise ligation sequence", which involves ligation of the ovarian pedicles and poses a risk of subsequent ovarian failure. Bilateral hypogastric artery ligation is also an effective and widely used first-line technique for experienced surgeons. This approach is technically challenging for less-experienced surgeons and is reserved for cases of failed triple ligation.
在产后严重出血的情况下，复苏和手术技术是互补的，应根据病因和出血的严重程度进行调整。在极其严重的情况下，不应延迟进行子宫切除术。对于血流动力学稳定的女性，可以采用所谓的“保守”手术技术。在本研究中，我们描述并讨论了各种血管结扎技术的适应证和可行性。还描述了子宫压迫缝合技术和腹盆腔填塞技术。如果可行保守治疗，应首先采用双侧子宫动脉远端结扎：这种简单且低风险的技术在 80%的情况下立即有效。如果出血持续存在，可以采用 Tsirulnikov 描述的三重结扎来完成子宫去血管化，可加用或不加用子宫动脉近端结扎。与所谓的“逐步结扎顺序”相比，这种方法应优先采用，因为后者结扎卵巢蒂有导致随后卵巢功能衰竭的风险。对于有经验的外科医生来说，双侧下腹动脉结扎也是一种有效且广泛应用的一线技术。对于经验较少的外科医生来说，这种方法具有技术挑战性，仅保留用于三重结扎失败的情况。
