[Anesthesic practices in patients with severe postpartum hemorrhage with persistent or worsening bleeding]

Severe postpartum hemorrhage (PPH) is a rare and critical situation which requires fast and well-planned management where close collaboration between obstetricians and anesthesiologists is essential. In case of persisting or worsening bleeding in spite of initially adequate management, the main goal of the anesthesiologist is to maintain hemodynamic stability (fluid resuscitation, transfusion, vasoactive drugs) and optimal respiratory state (oxygenation) and to correct the frequent clotting disorders, whereas the obstetrician and/or the radiologist have to achieve definitive hemostasis. Assessment of the severity of PPH is determined from: quantity of blood loss and/or duration of bleeding, difficulty in maintaining a correct hemodynamic state in spite of active vascular fluid resuscitation, need for vasoactive therapy and transfusion, occurrence and worsening of clotting disorders. Continuous drip Sulprostone requires close clinical surveillance and continuous monitoring (electrocardiography, non-invasive blood pressure monitor, pulse oximetry). When this treatment does not enable sufficiently rapid control of the bleeding (consensus = within 30 minutes), invasive therapy (arterial embolization, vascular ligation even hysterectomy) should be started promptly. When the bleeding continues despite aggressive medical treatments, general anesthesia (even if an epidural catheter is already in place) is needed to proceed with the invasive surgical procedure. This anaesthesia of a "full stomach" patient justifies a rapid-sequence induction with cricoid pressure and intubation. The risk is particularly high in case of hemorrhagic shock. Angiographic embolization should be carried out in an angiography suite which must be equipped for this kind of situation (anesthesia and resuscitation material, adapted monitoring). A member of the anesthesia team must be present throughout this procedure. At best, a multidisciplinary team, specially trained for this purpose, including obstetrician, anesthesiologist, radiologist and biologist should be available. When one or several invasive treatments were necessary to control the bleeding, it is recommended to transfer the patient to a specialized unit (intensive care unit or recovery room).