J. Perinat. Med. 35 (2007) 532–537 • Copyright  by Walter de Gruyter • Berlin • New York. DOI 10.1515/JPM.2007.113 Article in press - uncorrected proof Impact of the new French clinical practice recommendations in embolization in postpartum and post-abortion hemorrhage: study of 48 cases Marie-Lise Mathe 1, *, Estelle Morau 2 , He ´ le ` ne Vernhet-Kovacsik 3 , Marie-Christine Picot 4 and Pierre Boulot 1 1 Service de Gyne ´ cologie Obste ´ trique C et Me ´ decine Maternofoetale, CHU Arnaud de Villeneuve, Montpellier Cedex 5, France 2 De ´ partement d’Anesthe ´ sie Re ´ animation, CHU Arnaud de Villeneuve, Montpellier Cedex 5, France 3 Service de Radiologie vasculaire interventionnelle, CHU Arnaud de Villeneuve, Montpellier Cedex 5, France 4 De ´ partement d’information me ´ dicale, CHU Arnaud de Villeneuve, Montpellier Cedex 5, France Abstract Aim: To evaluate the use of arterial embolization in post- partum hemorrhage (PPH) by comparing the indications, efficacy, times to diagnosis, treatment, and embolization, and conditions of management of patients before and after publication of the Colle ` ge National des Gyne ´ co- logues et Obste ´ triciens Francais clinical practice rec- ¸ ommendations (CPR). Methods: Forty-eight patients who underwent emboli- zation between January 2000 and December 2005 were included in a retrospective, descriptive, and comparative study. We compared the management before (ns21) and after (ns27) publication of the CPR. The main outcome measures were time to diagnosis of PPH, time to treat- ment initiation, time to decision to implement emboliza- tion, time to embolization, hemodynamic characteristics. Results: The number of embolizations has quadrupled since publication of the CPR, and the time taken to decide on embolization has been reduced by 30%. The success rate was 96%, there were no second emboli- zation procedures, and one complication was recorded (hematoma of pubic symphysis). Hemodynamic status was better in patients treated after the CPR (Ps0.003). *Corresponding author: M.L. Mathe Service de Gyne ´ cologie Obste ´ trique C et Me ´ decine Maternofoetale CHU Arnaud de Villeneuve 371 av du Doyen Gaston Giraud 34295 Montpellier Cedex 5 France E-mail: p-boulot@chu-montpellier.fr Conclusion: Embolization is an effective and safe tech- nique, with a low complication rate. In our healthcare net- work, the decision to use embolization was faster since the CPR, embolizations have quadrupled, and patients’ hemodynamic status has improved. Keywords: Arterial embolization; clinical practice rec- ommendations; hemorrhage after delivery; postpartum hemorrhage. Introduction The rate of death due to postpartum hemorrhage (PPH) in France is at least twice that in other developed coun- tries w 21x . PPH occurs in 4% of vaginal births and 11% of cesarean sections, and is defined by the abundance of bleeding ()500 mL) from the genital tract. PPH is qualified as severe if blood loss exceeds 1000 mL in the 24 h following delivery w 21x . Primary (or early) PPH during the first 24 h is classically distinguished from secondary (or delayed) PPH, which occurs after the first 24 h and up to 6 weeks of the puerperal period w 16x . These figures prompted the Colle ` ge National des Gyne ´ cologues et Obste ´ triciens Francais to produce clin- ¸ ical practice recommendations (CPR) in December 2004 w 21x . These recommendations define a very precise sequence of procedures: within 30 min of the start of hemorrhage, implementation of induced delivery or of examination of the uterine cavity, or both, speculum examination of the cervix, initiation of oxytocin infusion; then, if the hemorrhage persists after 30 min, administra- tion of sulprostone, whose efficacy must be assessed after 30 min, and if there is no improvement, arterial embolization or surgery. Embolization appears very effective in the manage- ment of PPH w 16x , with a success rate ranging from 73% to 100% w 4, 6, 7, 15, 16, 18, 23–25x , and very rare com- plications w 12, 14, 19x . The aim of our study was to eval- uate the use of arterial embolization in hemorrhage after delivery in our maternity ward since January 2000, with comparison of indications, efficacy, times to diagnosis, treatment, and embolization, and conditions of manage- ment before and after publication of national recommen- dations in December 2004. Brought to you by | University of Iowa Libraries Authenticated Download Date | 5/26/15 1:06 AM