**3. Second Pillar: Minimization of bleeding and targeted transfusion therapy**

After optimizing the volume of bleeding, the second pillar of management consists of minimizing blood loss, for which it is necessary to identify the forecast of surgical bleeding; adequate management of antiplatelet agents and anticoagulants; optimal anesthetic techniques to minimize bleeding; monitoring of the bleeding and coagulopathy; and devising an anesthetic plan.

According to the Spanish Scientific Society of Anesthesiology, Resuscitation and Pain Treatment, in order to achieve an efficient anesthetic plan, the anesthesiologist is required to use a multimodal approach within their perioperative management, including the following:


Hemostatic management of intraoperative bleeding requires careful control of coagulation.

### **4. Hypotensive resuscitation**

Its fundamental objective is based on lowering blood pressure until definitive hemostasis and adequate tissue perfusion are achieved [12].

Their approach narrows to using small volumes of crystalloids as they are less likely to create dilutional coagulopathy, and lower blood pressure is less likely to break up or fragment the already formed clot; however, when large volumes of fluid are administered, this can initiate dilution of coagulation factors, resulting in impaired coagulation and coagulopathy [12].

A cohort study showed that lower fluid administration showed fewer signs of shock and less blood product administration, as fibrinogen, hemoglobin, hematocrit, and platelet concentrations decreased during increased fluid administration, whereas PT and aPTT were more prolonged [13].

Therefore, the most recent studies have reported that resuscitation with >4 L of fluids is associated with subsequent bleeding and more adverse maternal outcomes [14]. Hypoperfusion can be tolerated for short periods of time and may decrease the volume of overall hemorrhage [12].

During hemorrhagic shock, the endothelial glycocalyx is thinned, and administration of crystalloids exacerbates this state, leading to more fluid extravasation and general volume depletion, leading to worsening bleeding [12].
