European Journal of Obstetrics & Gynecology and Reproductive Biology 94 (2001) 189–196 www.elsevier.com / locate / ejogrb Management in intractable obstetric haemorrhage: an audit study on 61 cases a a b c a ´´ ´´ ´ Nathalie Ledee , Yves Ville , Dominique Musset , Frederic Mercier , Rene Frydman , a, * ´ Herve Fernandez a ´ ` Department of Obstetrics and Gynecology, Antoine Beclere Hospital, AP-HP , 157, Rue de la Porte de Trivaux, 92141 Clamart cedex, France b ´ ` Department of Radiology, Antoine Beclere Hospital, AP-HP , 157, Rue de la Porte de Trivaux, 92141 Clamart cedex, France c ´ ` Department of Anesthesiology, Antoine Beclere Hospital, AP-HP , 157, Rue de la Porte de Trivaux, 92141 Clamart cedex, France Accepted 31 March 2000 Abstract Objective: To refine the indications of bilateral hypogastric artery ligation (BHAL) and angiographic selective embolisation (ASE) in intractable obstetric haemorrhage. Design: an audit study. Setting: Tertiary care university hospital. Population and methods: Retrospective analysis of 61 cases of obstetric intractable post partum haemorrhage (PPH) initially managed either by hysterectomy or a conservative approach in a tertiary referral centre between 1983 and 1998. Procedures were reviewed as a primary (P) or secondary (S) attempt to arrest the haemorrhagic process. Results: Ten hysterectomies (5 P, 5 S), 49 BHAL (48 P, 1 S) and 9 ASE (8 P, 1S) were successfully performed in arresting the haemorrhagic process. There were 7 maternal deaths, 5 following hysterectomy and 2 following a conservative approach. Atony of the uterus was the main cause of haemorrhage ( n521) and genital tract laceration was associated with the worst prognosis. Time-elapse between delivery and surgery appears to be the main prognostic factor. Nine patients became pregnant 1 to 4 years later following a conservative approach. Conclusions: ASE seems to be indicated in haemodynamically stable patients with birth canal trauma or uterine atony and clotting anomalies. BHAL is indicated when haemorrhage occurs after a cesarean section or when the patient is haemodynamically unstable. BHAL should be taught to Junior doctors in an attempt to decrease the number of patients transferred in tertiary referral centers for intractable PPH. This might also decrease the number of hysterectomies in intractable PPH.  2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Post partum haemorrhage; Bilateral hypogastric artery ligation; Angiographic selective embolisation; Hysterectomy 1. Introduction following intractable PPH could have been prevented [1]. Ante and post-partum haemorrhage usually responds to Obstetrical haemorrhage occurring mainly in the post- limited conservative therapy such as intrauterine manual partum period is the first cause of maternal death and examination, uterine massage and uterotonic drugs; this is represents a real problem of public health, especially in performed together with treatment of the underlying developed countries [1–3]. Excessive blood loss of over condition as well as early and continuous maintenance of 500 and 1000 ml after vaginal delivery or cesarean section maternal haemodynamics. However when the haemor- respectively complicates 4% to 11% of deliveries; whereas rhagic process continues and when either clotting abnor- major post-partum haemorrhage (PPH) of more than 1000 malities or haemodynamic instability develop, the next ml occurs following less than 1% of all deliveries [2]. The step is often to either opt for a conservative approach by report from Confidential Enquiry into Maternal Deaths embolizing the selective pelvic vessels (ASE) or ligating (CEIMD) demonstrated that 90% of maternal deaths the hypogastric arteries (BHAL) or to proceed to perform a hysterectomy. Aortic angiographic studies have identified anastomotic *Corresponding author. Tel.: 133-1-4537-4469; fax: 133-1-4537- 4963. branches of the lumbar, sacral and rectal arteries as the 0301-2115 / 01 / $ – see front matter  2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115(00)00349-3