Objective: the primary objective of these guidelines is to review the clinical aspects of Postpartum Haemorrhage (PPH) and provide guidelines to help clinicians prevent and manage excessive bleeding postpartum. Options: prevention, appropriate intervention, keys to minimizing its impact. Outcomes: establish practices to facilitate the identification of women who may be at particularly high risk of PPH and to allow prompt intervention should excessive bleeding occur Evidence: follows the Qualify of Evidence of The Canadian Task Force on the Periodic Health Examination. Values: developed by experts in the field of obstetrics. Benefits, harms and costs: the use of uterotonic drugs and other active management techniques have been evaluated based on their convenience, accuracy, availability and safety Recommendations: the 12 recommendations listed in the guidelines have been graded according to the level of evidence on which they are based Validation: Medline references were sought using the MeSH heading postpartum haemorrhage. The Cochrane Library was searched for relevant studies. The ALARM course Manual was consulted. Sponsors: developed and reviewed by the Clinical Practice Obstetrics Committee and approved by the Council of the SOGC. DEVELOPMENT

Prevention and Management of Postpartum Haemorrhage

Stepwise uterine devascularization: A novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus

Worldwide, postpartum hemorrhage (PPH) remains one of the most common causes of maternal mortality. In the United States and other industrialized nations, PPH has generally ranked among the top three etiologies of maternal death, along with embolism and hypertension. Hemorrhage is the leading cause of pregnancy-related death in the United States. In 1990 the Center for Disease Control reported 1,459 pregnancyrelated deaths the United States and 29% were due to hemorrhage. In developing countries, where maternal mortality rates are exponentially higher, PPH plays an even greater role. For example, in Ghana between 1981 and 1989, the maternal mortality rate was 1,140 per 100,000 births, 27% due to PPH. The World Health Organization estimated that there were more than 585,000 maternal deaths in 1990 worldwide, of which 25% were due to severe bleeding. The World Health Organization also estimated 20 million annual maternal morbidities due to hemorrhage.

Postpartum hemorrhage: new management options.

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

Eleven patients had ischemic complications secondary to ligation, hypoperfusion, exclusion, or thrombosis of the hypogastric arteries after aortoiliac reconstruction or spontaneous aortoiliac thrombosis. Ligation of one hypogastric artery resulted in persistent ipsilateral buttock claudication in three patients. Bilateral acute hypogastric artery ischemia occurred in eight patients and resulted in paralysis in all eight patients, buttock necrosis in four patients, anal and bladder sphincteric dysfunction in two patients, and colorectal ischemia in three patients. Five of these patients (63 percent) died. The mortality rate was 100 percent when buttock necrosis developed. In most of these patients, the neurologic deficit suggested ischemic injury of the lumbosacral plexus rather than spinal cord ischemia. These complications occurred despite patent bypass grafts to the iliac or femoral vessels. These observations suggest that it is essential to maintain patency of the hypogastric vessels in all aortoiliac reconstructions.

Burchell Rc

Papers

Internal iliac artery ligation: hemodynamics.