**Abstract**

Worldwide, every minute a woman dies due to complications during pregnancy, obstetric hemorrhage being the leading cause. However, most of these deaths are preventable with prompt recognition and management. The main objective of its management in the initial phase of resuscitation is to aggressively optimize macro and microhemodynamic parameters by ensuring effective resuscitation. Patient blood management (PBM) consists in the timely application of evidence-based medical and surgical procedures aimed at maintaining hemoglobin concentration, optimizing hemostasis and minimizing blood loss to improve patient outcome, all of these based in three pillars: endogenous erythropoiesis, platelet and coagulation factors function and physiological reserve of anemia. PBM consider various strategies to reach the main goal, including transfusional, non-transfusional and surgical measures. At preoperative period the prevention and treatment of anemia is the corner stone of the PBM guideline. Once at the operating room the fluid management, uterotonic and pro-coagulant drugs, fibrinogen and blood products transfusion play a key role and surgical techniques have to be done if the patient life is threatened. Manage postpartum anemia by appropriate iron administration. Optimize the patient's physiological response to anemia, treat infections and maximize oxygen delivery to minimize transfusions if they are not strictly necessary.

**Keywords:** obstetric hemorrhages, massive transfusion, pregnancy Anemia, fibrinogen, blood management

### **1. Introduction**

Worldwide, every minute, a woman dies due to complications during pregnancy, obstetric hemorrhage being the leading cause; however, most of these deaths are preventable. Hypovolemic shock is the main consequence of obstetric hemorrhage. Obstetric hemorrhage is one of the five leading causes of maternal mortality in both high-resource countries and resource-limited countries, although the absolute risk of death from obstetric hemorrhage is much lower in the former [1–3].

#### *New Aspects in Cesarean Sections*

Prompt recognition, availability of appropriate resources, and adequate responses are critical to preventing mortality and severe maternal morbidity [1–3].

Normally, hemostasis occurs with the separation of the placenta, and control of uterine bleeding is done through a combination of two mechanisms: [4].


Once obstetric bleeding occurs, the goals of treatment are to aggressively optimize macro and microhemodynamic parameters by ensuring effective resuscitation and timely replacement of blood products in addition to subsequent surgical management.

Patient blood management (PBM) consists of the timely application of evidence-based medical and surgical procedures aimed at maintaining hemoglobin concentration, optimizing hemostasis, and minimizing blood loss to improve patient outcome, all of these based on three pillars: endogenous erythropoiesis, platelet & coagulation factor functions, and physiological reserve of anemia, guided by the obstetric hemorrhage scenario. The multidisciplinary approach plays a key role even from preoperative to postoperative period, improving outcomes and reducing morbimortality in this population and hospitalization length and costs.

PBM considers various strategies to reach the main goal, including transfusional, non-transfusional, and surgical measures. In the preoperative period, the prevention and prompt treatment of anemia is one of the cornerstones of the PBM guideline; despite all the physiological changes during pregnancy, every single pregnant woman has an increased risk for a major bleeding due to several risk factors specific to pregnancy and each patient. Once at the operating room, leading causes for postpartum hemorrhage are widely described, so it is important that both the gynecologist and the anesthesiologist be prepared to solve the emergency, the fluid management, uterotonic and pro-coagulant drugs, fibrinogen, and, finally, blood product transfusion with all the concerns about it. Surgical techniques like B-lynch, Hayman technique, or others more advance like postpartum hysterectomy have to be used if the patient's life is threatened [5].

Manage postpartum anemia by appropriate iron administration. Optimize the patient's physiological response to anemia, treat infections, and maximize oxygen delivery to minimize transfusions if they are not strictly necessary.
