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Non-conservative and Conservative Surgical Management of PPH

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Osanan GC, Charry RC, et al, Glob. libr. women’s med., ISSN: 1756-2228; DOI 10.3843/GLOWM.413063

Postpartum hemorrhage (PPH) represents one of the main causes of maternal mortality worldwide, representing approximately 25% of these deaths.1 Maternal mortality rates range from 15 to 443 for every 100,000 live births, most of which occur in low- and middle-income countries (LMIC).2 Thus, public policies and national strategies focused on reducing maternal deaths, including related to PPH, should be encouraged in these regions.3,4

Multidisciplinary teams in charge of treating patients with PPH must perform systematic and coordinated strategies. The procedures will increase in complexity as the golden hour for PPH treatment goes by. The golden hour aims to reduce morbidity and mortality related to the delayed management of PPH. It is well known that there is a direct relationship between the time taken to control the bleeding and a poor maternal outcome. Delayed control of bleeding may culminate in the lethal triad of hypovolemic shock, which consists of coagulopathy, hypothermia and acidosis. At this point, any strategy to avoid collapse or death can be unsuccessful.5

It is worthy noticing that the percentage of lethality from PPH is directly proportional to the elapsed time since its diagnosis. The golden hour can be divided into three periods of 20 minutes. The first 20 minutes mainly represents medical treatment, fluid replacement and identification and management of the main cause bleeding, taking into account the context of the 4 Ts: Tone, Trauma, Tissue, Thrombin.6 The following 20 minutes involves performing mechanical maneuvers, including the use of intrauterine tamponade balloon, uterine compressive sutures and pelvic vascular ligatures.7,8,9 Simultaneously, the non-pneumatic anti-shock garment (NASG) should be considered.10 Finally, the remaining 20 minutes are for non-conservative surgical techniques, which include hysterectomy and damage control surgery as final weapons to avoid maternal death.11

The following objectives are covered in this chapter:

Review of the practical anatomical landmarks of vascular structures and anatomical references that are necessary for the appropriate surgical management of the pelvic cavity;
Description of uterine-conservative hemostatic maneuvers and techniques;
Detail of the non-conservative surgical techniques steps;
Revision of the current evidence on the effectivity and rationale that sustain each procedure.

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