Prevention and management of severe intra-operative and post-operative bleeding in gynaecologic surgery

Severe intra-operative and post-operative bleeding is a potentially life-threatening complication of gynaecologic surgery. A sound clinical judgement and the adequate assessment and preparation of the patient are the best pre-operative means to avoid its occurrence. Intra-operative prevention requires knowledge of surgical anatomy and haemostatic techniques. The management of haemorrhagic complications can be extremely challenging. Its success depends on the perfect integration of surgical expertise, the supporting role of the anaesthesiologist and on the availability of a fully equipped interventional radiology team with much experience. A methodical and stepwise surgical approach is needed to selectively dissect and identify the bleeding site without damaging adjacent structures. In case of more diffuse or massive bleeding, the performance of a bilateral ligation of the anterior branch of the internal iliac arteries at an early stage is an appropriate measure. The anaesthesiologist is responsible for the maintenance of the patient’s haemodynamic function and the prevention of coagulopathy. Compression or atraumatic clamping of the aorta or placement of a pelvic packing can be temporarily applied to stabilize the patient’s condition. Only once this is achieved, can the subsequent option of angiographic arterial embolisation be considered.