Management in intractable obstetric haemorrhage: an audit study on 61 cases

Objective: To refine the indications or bilateral hypogastric artery ligati on (BHAL) and angiographic selective embolisation (ASE) in intractable obst etric haemorrhage. Design: an audit study. Setting: Tertiary care universit y hospital. Population and methods: Retrospective analysis of 61 cases of o bstetric intractable post partum haemorrhage (PPH) initially managed either by hysterectomy or a conservative approach in a tertiary referral centre b etween 1983 and 1998. Procedures were reviewed as a primary (P) or secondar y (S) attempt to arrest the haemorrhagic process. Results: Ten hysterectomi es (5 P, 5 S), 49 BHAL (48 P. 1 S)and 9 ASE (8 P, 1S) were successfully per formed 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 (n=21) and genital tract lace ration was associated with the worst prognosis. Time-elapse between deliver y and surgery appears to be the main prognostic factor. Nine patients becam e pregnant to 4 years later following a conservative approach. Conclusions: ASE seems to be indicated in haemodynamically stable patients with birth c anal trauma or uterine atony and clotting anomalies. BHAL is indicated when haemorrhage occurs after a cesarean section or when the patient is haemody namically unstable. BHAL should be taught to Junior doctors in an attempt t o decrease the number of patients transferred in tertiary referral centers for intractable PPH. This might also decrease the number of hysterectomies in intractable PPH. (C) 2001 Elsevier Science Ireland Ltd. All rights reser ved.