Arterial Embolisation other institutions that did not have either an intensive care unit or a vascular imaging unit. Severe PPH was defined as a blood loss greater than 1500 cc and either haemodynamic shock (defined by the need for continuous perfusion of vasopressors) or disseminated 3 intravascular coagulation (platelet count ,50 000 per mm , elevated prothrombin time, defined as greater than twice the control values, hypofibrinogenemia, defined as less than 150 mg/ dl, and a prothrombin rate less than 50%), or both. Blood loss was estimated by collection bag which was systematically placed at the end of the delivery. For the patients transferred from other institutions, we added the estimated blood loss evaluated by the medical team of the hospital of origin with the estimated blood loss in our hospital. Description of Procedures or Investigations undertaken All patients were treated according to the same treatment protocol for PPH, summarised in the decision algorithm approved by the three departments involved in this study (Figure 1). Anaesthesiology management in the intensive care unit included initial evaluation and resuscitation. Patients were monitored with continuous oximetry, heart rate and blood pressure, indwelling urinary catheter for hourly urine output measurements, and femoral venous and arterial catheters. Resuscitation involved fluid (colloids and crystalloids) replacement and blood and plasma transfusion responsive to laboratory results. In case of uncontrolled hypotension, continuous norepinephrine infusion was started on the femoral line. Mechanical ventilation was initiated in case of uncontrolled haemorrhagic shock with neurological failure. For sedation we used midazolam and sufentanil or ketamine in case of severe shock. Amoxicillin and clavulanic acid were systematically administered for antibiotic prophylaxis. Basic obstetrical management for patients with vaginal delivery involved bimanual uterine examination, removal of any retained placental parts or membranes, and careful inspection of the genital tract for lacerations or tears. Any surgical tears was repaired before performing the SAE. Patients who had caesarean deliveries underwent abdominal ultrasound to verify the absence of retained placental pieces in the uterus and to rule out hemoperitoneum. Medical management included uterine massage, intravenous diluted oxytocin up to a cumulative dose of 55 IU (Syntocinon; Sandoz, Reuil-Malmaison, France) and sulprostone, a prostaglan- din-E2 analogue (a first injection of 500 mg over an hour and a Figure 1. Decision algorithm for treatment of post-partum haemorrhage by selective arterial embolisation in our institution. doi:10.1371/journal.pone.0003819.g001 PLoS ONE | www.plosone.org 2 November 2008 | Volume 3 | Issue 11 | e3819