[Obstetric and anesthetic specificities in the management of a postpartum hemorrhage (PPH) associated with cesarean section]

Abstract

Objectives: To describe the characteristics of post-partum hemorrhage (PPH) associated with cesarean section (CS), the modalities diagnosis and specific obstetric and anesthetic management.

Materials and methods: Bibliographic search restricted to French and English languages using Medline database(®) and international guidelines of medical societies.

Results: Primary PPH associated with CS (incidence 3-15%) is defined as vaginal bleeding ≥500mL within 24hours after surgery. Severe PPH is defined by bleeding ≥1000mL (professional consensus). The intervention threshold to initiate an active management depends on the flow rate of bleeding, the etiology and the clinical context. It can be higher than 500mL after cesarean (professional consensus). The main risk factor for bleeding is the realization of an emergency CS during labor (EL 3). In the case of persistent or severe intraoperative PPH due to uterine atony, conservative surgical procedures should be initiated in association with maternal resuscitation and second-line uterotonic therapy (sulprostone) (professional consensus). If general anesthesia is required, it is recommended to opt for a maintenance treatment limiting sevoflurane or desflurane in case of uterine atony (professional consensus). Severe bleeding during or after cesarean is a thrombotic risk factor and requires antithrombotic prophylaxis with heparin (the duration of treatment may vary depending on the associated risk factors) after normalization of coagulation (professional consensus). Postoperative hemoperitoneum (ultrasound) or suspected vascular wound require urgent laparotomy under general anesthesia (professional consensus). Otherwise, an uterotonic therapy (oxytocin or sulprostone depending on the severity) should be initiated. Balloon intrauterine tamponade or embolization may be discussed in the absence of hemodynamic instability (professional consensus).

Conclusion: The occurrence of PPH associated with cesarean delivery requires close collaboration between obstetrician and anesthesiologist to ensure a rapid and coordinated management (professional consensus).

Keywords: Anesthesia; Anesthésie; Cesarean section; Chirurgie d’hémostase; Césarienne; Decision making; Hemostatic surgery; Hémorragie du post-partum; Post-partum hemorrhage; Stratégie décisionnelle.