Haumonté J-B, Sentilhes L, Macé P, Cravello L, Boubli L, d'Ercole C
Service de gynécologie-obstétrique, gynépole Marseille, Aix-Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, CHU, chemin des Bourrely, 13915 Marseille cedex 20, France.
Service de gynécologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49033 Angers cedex 01, France.
J Gynecol Obstet Biol Reprod (Paris). 2014 Dec;43(10):1083-103. doi: 10.1016/j.jgyn.2014.10.003. Epub 2014 Nov 4.
Systematic revue of different conservative and non-conservative surgical treatment of postpartum hemorrhage (PPH). Elaboration of surgical strategy after failed medical treatment of PPH.
French and English publications were identified through PubMed and Cochrane databases.
Each obstetrical unit has to rewrite a full protocol of management of PPH depending on local environment quickly available in theatre (professional consensus). Conservative surgical treatment of PPH: efficacy of vascular ligature (bilateral uterine artery ligation (BUAL) or bilateral hypogastric artery ligation (BHAL)) as a first line of surgical treatment of PPH is about 60 % to 70 % (EL4). Bilateral uterine artery ligation (BUAL) is easy to perform with low rate of immediate severe complication (professional consensus). BUAL as BHAL seems not to affected fertility and obstetrical outcomes of next pregnancies (EL4). Efficacy of haemostatics brace suturing in case of failed medical treatment of PPH is about 75 % (EL3), without risk of major obstetrical complications at the next pregnancy (EL4). Radical surgical treatment of PPH: total hysterectomy is not significantly associated with more urinary tract injury in comparison with subtotal hysterectomy (EL3). Choice of surgical procedure of hysterectomy (total or subtotal) will depend on local consideration and clinicians habits (professional consensus). Surgical strategy: conservative surgical treatment are efficient and associated with low morbidity, they have to be primarily performed in women with further fertility desire. Specific medical consideration as massive PPH or cardiovascular instability has to consider performing haemostatic hysterectomy as the first line surgical treatment of PPH. PPH during caesarean delivery: in case of PPH during caesarean section, embolisation is not recommended, surgical treatment using vascular devascularisation or compression brace suturing should be performed (professional consensus). Surgical conservative technique will depend on local considerations and clinicians habits (professional consensus). PPH diagnosed after caesarean section should indicate relaparotomy. Arterial embolisation, if quickly vacant in the same hospital, may be performed in case of cardiovascular stability without surgical complication diagnoses on intraperitoneal hemorrhage (professional consensus). PPH during vaginal delivery: cardiovascular instability centre indicate the interhospital transfer and must lead to achieve haemostatic surgery on site (professional consensus). In the presence of a unit of embolisation in the maternity delivery, it is preferable to move towards embolisation, if maternal hemodynamic status permits (professional consensus). In case of cardiovascular stability associated with absence of heavy bleeding, the interhospital transfer may be considered for arterial embolisation (professional consensus).
When medical treatment of PPH failed, conservative surgical treatment has a 70 % efficacy to stop hemorrhage whatever treatment used (vascular ligature or haemostatics brace suturing). In absence of rapid response to conservative medical and surgical treatment, hysterectomy should be performed without delay (professional consensus).
系统回顾产后出血（PPH）的不同保守及非保守手术治疗方法。阐述PPH药物治疗失败后的手术策略。
通过PubMed和Cochrane数据库检索法语和英语出版物。
每个产科单位必须根据手术室可快速获取的当地情况（专业共识）重写一份完整的PPH管理方案。PPH的保守手术治疗：血管结扎术（双侧子宫动脉结扎术（BUAL）或双侧髂内动脉结扎术（BHAL））作为PPH手术治疗的一线方法，其疗效约为60%至70%（证据水平4）。双侧子宫动脉结扎术（BUAL）操作简便，即刻严重并发症发生率低（专业共识）。与双侧髂内动脉结扎术（BHAL）一样，双侧子宫动脉结扎术（BUAL）似乎不影响下次妊娠的生育能力和产科结局（证据水平4）。PPH药物治疗失败时，止血带缝合术的疗效约为75%（证据水平3），对下次妊娠无重大产科并发症风险（证据水平4）。PPH的根治性手术治疗：与次全子宫切除术相比，全子宫切除术与更多泌尿系统损伤无显著相关性（证据水平3）。子宫切除术（全子宫或次全子宫）的手术方式选择将取决于当地情况和临床医生的习惯（专业共识）。手术策略：保守手术治疗有效且发病率低，对于有生育意愿的女性应首先采用。对于大量PPH或心血管不稳定等特殊医学情况，必须考虑将止血性子宫切除术作为PPH的一线手术治疗方法。剖宫产术中的PPH：剖宫产术中发生PPH时，不建议进行栓塞治疗，应采用血管去血管化或压迫带缝合等手术治疗方法（专业共识）。手术保守技术将取决于当地情况和临床医生的习惯（专业共识）。剖宫产术后诊断为PPH应行再次剖腹探查术。如果在同一家医院能迅速进行，对于心血管稳定且无腹腔内出血手术并发症诊断的情况，可进行动脉栓塞治疗（专业共识）。阴道分娩时的PPH：心血管不稳定时应转院，并必须在现场进行止血手术（专业共识）。如果产妇血流动力学状况允许，且产科有栓塞治疗设备，最好进行栓塞治疗（专业共识）。对于心血管稳定且无大量出血的情况，可考虑转院进行动脉栓塞治疗（专业共识）。
当PPH的药物治疗失败时，无论采用何种治疗方法（血管结扎或止血带缝合），保守手术治疗止血的有效率为70%。如果对保守药物和手术治疗无快速反应，应立即进行子宫切除术（专业共识）。
