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The diagnosis and treatment of excessive bleeding within the first 24 hours after delivery and its main causes, namely uterine atony, retained placental fragments, vascular lesions by local tissue rupture, and blood clotting disorder are presented. Of great interest is the iconography, which is suggestive and original.

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UNLABELLED: The aim of this study was to determine the optimal solution to the dilemma of "wait-and-see" or "evacuation of uterine contents" and to identify objective criteria in support of one or other of these management choices, in particular in 26-34 week pregnancies with PRM, which is the most difficult situation. On the basis of a clinical study of 54 cases, week pregnancies with PRM did not enable temporization for any considerable time because of the onset of amniotic infection, and a large number of premature newborn with a gestational age of 31-32 weeks, below 1500-1700 g respectively, died a short time after birth. CONCLUSIONS: In 26-34 week pregnancies with PRM, a "wait-and-see" attitude with its sometimes very considerable septic risks is justified by a high chance of fetal survival score (CFSS)--a concept suggested by the authors--, i.e. with a gestational age between 30-34 weeks and respective fetal weights (determined by ultrasonography) between 1400-2100 g, absence of intrauterine fetal pathology, favorable fetal vitality parameters, good prognosis foe vaginal delivery, low C-reactive protein levels, low-grade pathogenicity of cervicovaginal flora, etc. In their preliminary study, the authors suggest determination of a chance of fetal survival score (CFSS) which is of prognostic value and can be useful in determining optimal management in the dilemma raised by PRM in 26-34 week pregnancies.

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Vascular abnormalities may create difficulties during exposure of the lateral surface of the ureter during radical lymphadeno-hystero-colpectomy for uterine carcinoma. The aim is to avoid peroperative bleeding due to damage to abnormal vessels (in particular abnormal anastomotic uterine vein) crossing the lateral surface of the ureter. The authors have encountered such vascular abnormalities three times during radical lymphadeno-hystero-colpectomy. Recognition of the abnormal vessel crossing the lateral surface of the ureter and its division between two separate sutures prevented accidental peroperative bleeding as well as possible damage to the terminal (juxta-vesical) part of the ureter.

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In certain cases (i.e. selectively and not routinely) of radical lymphadeno-colpo-hysterectomy for uterine carcinoma, the authors section the uterosacral ligaments at the outset, which enables the uterus to be brought up and thus facilitates dissection, ligation and section of the supra-uterine vesico-uterine pedicles, avoiding damage to the terminal (juxta-vesical) ureter.

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The author describes the various indications for obstetric hemostatic vascular ligations accepted today by specialists. In serious post-partum uterine hemorrhage due to pathology of contraction and or retraction of the uterus, hemorrhage refractory to classical conservative treatment, specialists use either bilateral ligation of the uterine arteries at the site of their ascending branches, or bilateral ligation of the anterior branch of the internal iliac artery (BLILA), sometimes thus avoiding hemostatic hysterectomy. However hemostatic vascular ligations may be attempted only rarely, in particular when hemostasis procedures follow one after the other in the absence of an immediate threat to the mother's life. Prophylactic BLILA may be performed immediately after hemostatic hysterectomy (as a complement before closing the abdominal wall). It thus guarantees hemostasis and avoids the possibility of reoperation to achieve hemostasis, which could be fatal. BLILA performed at the postoperative (posthysterectomy) stage, during hemostatic reoperation, is of a curative nature and is effective only when hemorrhage is coming from a branch of the internal iliac artery. In severe post-partum hemorrhage coming from the peri-uterine regions supplied by the internal iliac arteries, only BLILA may be useful when local surgical hemostasis is ineffective or impossible.

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Based on a critical review of the specialized literature and on the analysis of 12 personal cases, the author develops a few considerations on the obstetrical treatment of retroplacental hematoma. Once the diagnosis of RPH has been established in 12 cases, the hypovolemia, anemia (possibly hemorrhagic shock), coagulation disorders are corrected and an abdominal caesarean section is performed. In 2 cases, the caesarean section was followed by a hemostatic hysterectomy, and in one of these 2 cases, a bilateral ligation of the hypogastric arteries was also performed. With the current advances of intensive treatments, the risk induced by caesarean section is much less severe than the one which could incur from a calculated delay. Emergency caesarean section reduces this delay and represents a prophylaxis of fetal and maternal complications (which may be sudden and irreversible, because of the unpredictable extension of the RPH).

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The authors studied the topographical anatomy of the areas involved in urethro-vesical suspension, type Burch, in 25 female cadavers. They notice that, with the Burch procedure, the specific haemorrhagic risks are represented by lesions of the external iliac vein and sometimes lesions of the anastomosis between epigastric and obturator artery, which may be caused when the needle goes through the most lateral portion of Cooper's ligament, if this needle is directed upwards and outwards.

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The author studies haemostatic vascular ligations in obstetrics, in order to codify the indication of BLUA and BLHA in obstetrical haemorrhages uncontrollable with classic therapeutic means. He comes to the following conclusions: in severe post-partum haemorrhages defined by a hypotonic uterus and resistant to classic therapy, BLUA is a simple, fast, harmless procedure when carried out on the ascending branches and providing a favorable result; in severe post-partum haemorrhages originating in the segmento-cervical area, one may resort: either to BLHA; or the BLUA, at their origin (but information is not yet available concerning clinical experiment). In severe haemorrhages originated in the parauterine areas, or the hypogastric arterial system, only BLHA may be effective; in severe obstetrical haemorrhages caused by coagulation disorders and untractable with classic methods, BLHA may be useful and prevent a haemostatic hysterectomy or a least decreases bleeding intra- or even post-operatively.

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In order to obtain, after caesarean section, a uterine scar of the best quality, the authors have studied the role of trauma on the edges of the wound during the procedure, especially the role of haemostatic clamps. Clinical studies (hysterography) and the comparison with experimental scars on dog's uterus, operated at term, show that instrumental trauma of the edges of the uterine wound affects the quality of the scar.

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Hemostasis of uterine incisions in Cesarean sections with longitudinal uterine incision may be secured with the various instruments devised by the authors. Hemostasis is immediate, which is quite interesting when the procedure is done for a hemorrhagic syndrome and in case of placenta praevia. In case of uterine hypotonicity and resistance to Pitocin, a temporary hemostasis permits to temporize.

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The authors propose a new technique of bilateral ligation of the uterine arteries at their origin, in order to save the patient's life, the uterus and the adnexae in cases of refractory post-partum haemorrhage, especially associated with placenta praevia. To date, they have only performed this operation on cadavers at the first stage in their study. This technique could be performed surgically in most cases and presents certain advantages over the bilateral ligation of the uterine arteries at the level of the arch.

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