Major obstetric hemorrhage.
Major obstetric hemorrhage is a challenge for anesthesiologists because it remains responsible for over 10% of maternal deaths in high-income countries. A standardized multidisciplinary management, described in locally validated protocols and based on international guidelines is mandatory to prevent these deaths. The first difficulty relies on the systematic underestimation of the bleeding. Collection bags must be used to facilitate the diagnosis and therefore rapid management. The etiologies in antenatal or postpartum must be well-known in order to be treated adequately. A rapid recourse to prostaglandins (sulprostone in France) may reverse uterine atony. Invasive approach with surgery or radiology should be promptly implemented (uterine artery or internal iliac artery ligations±uterus plication) and hysterectomy should then be timely considered. Simultaneously, early and aggressive resuscitation with large-bore venous accesses should be implemented for rapid and massive transfusion (4:4:1 RBC:FFP:platelets ratio), along with an early use of fibrinogen concentrates and tranexamic acid. This transfusion strategy may be then guided by thromboelastography or thromboelastometry and bedside hemoglobin measurements. Activated factor VII remains indicated only before or after hysterectomy in case of uncontrolled bleeding. Management of placentation abnormalities (placenta previa, accreta, increta, percreta) must be well mastered as these etiologies may generate cataclysmic hemorrhages that can be and have to be anticipated.
['Le Gouez|A|A|', 'Mercier|F J|FJ|']
D016913:Blood Component Transfusion D003131:Combined Modality Therapy D015232:Dinoprostone D015942:Factor VIIa D005260:Female D005340:Fibrinogen D006801:Humans D007044:Hysterectomy D007083:Iliac Artery D008026:Ligation D008428:Maternal Mortality D057725:Operative Blood Salvage D010921:Placenta Accreta D010923:Placenta Previa D006473:Postpartum Hemorrhage D011247:Pregnancy D011248:Pregnancy Complications D011994:Recombinant Proteins D014148:Tranexamic Acid D055988:Uterine Artery D055357:Uterine Artery Embolization D014592:Uterine Hemorrhage D014593:Uterine Inertia
Hysterectomy Transfusion Fibrinogen Anomalies de placentation Approche multidisciplinaire Fibrinogène Hystérectomie Multidisciplinary approach Placentation anomalies