Although individual studies in our review differ in study design and outcome measures, their conclusions appear consistent, and suggest that most women do not have adverse menstrual and fertility outcomes in the long term following radiological or surgical techniques for the control of severe PPH. It is important to recognise while interpreting fertility outcomes from individual studies that many women do not desire another pregnancy following a major event such as massive life-threatening PPH, and choose not to conceive again. It is also pertinent to note that many studies suffer from inadequate reporting of outcomes such as desire of pregnancy and duration of follow-up after the procedures.
Strengths and limitations
Our results are based on data from prospective and retrospective studies, and not all studies have comparison groups matched for variables such as age, parity, ethnicity, and medical problems. Our search did not reveal any studies of long-term outcomes after uterine balloon temponade for PPH. We also could not identify any randomised controlled trials (RCTs) addressing the issue. Therefore, these results need to be interpreted with caution and there is a need for good-quality evidence based on RCTs.
A review of the data from various study groups indicates that uterine artery embolisation is a safe and effective intervention in the management of severe PPH, and it does not appear to compromise a woman's subsequent fertility and obstetric outcomes.[6, 13, 15-20] Results suggest that women who undergo this procedure can expect to have a return of normal menses, with no long-term adverse effect on fertility.
In the study by Hardeman et al., no statistically significant difference was noted between the non-embolised and embolised groups (P = 0.30) regarding occurrence of pregnancy. However, the results suggested a trend towards fewer pregnancies in the embolisation group, and reported three severe complications in that group. This trend deserves to be explored by further studies with higher statistical power. The drawbacks of UAE include the necessity of the availability of a skilled interventional radiologist and radiology set-up, and occasional complications such as post-procedure fever, infection, uterine necrosis, and vascular perforation.
Hypogastric artery ligation appears to be a safe and effective alternative procedure in the treatment of major PPH. Moreover, it does not appear to negatively affect menstruation or fertility outcomes.[24-26] However, this surgical technique can often prove difficult and requires a high degree of surgical skill and training, and may be associated with ureteric injury. Uterine artery ligation, whether associated with utero-ovarian ligament ligation or not, is yet another surgical alternative for PPH that does not appear to compromise the woman's subsequent fertility and obstetric outcomes.
Uterine compression sutures are simple, safe, cost-effective uterine preserving procedures, which can be adopted in emergency situations even by obstetricians with limited training and skill for more complex procedures. Complications of infections and synechiae have been described after compression techniques, but overall data appear reassuring regarding long-term fertility outcomes.[29-34]
Blanc et al. suggested that uterine compression sutures exposed patients to risks of subsequent abnormalities of the uterine cavity and development of uterine synechiae. Other reports have also linked amenorrhea and uterine synechiae to pelvic arterial embolisation.[5, 17] Post-procedure endometritis (inflammation and scarring) and endometrial ischaemia secondary to embolisation are thought to be the possible mechanisms responsible for the development of such adhesions. Hardeman et al. advised against the use of non-absorbable materials for embolisation to prevent this complication. Gaia et al. found intrauterine diffuse synechiae that were impossible to remove by hysteroscopy in the six women reporting amenorrhea in their study. In the study by Sentilhes et al., of the 15 women who complained of amenorrhoea or decreased flow of menstruation, severe intrauterine synechiae were found in all eight who decided to undergo ambulatory hysteroscopy. Except for two women in whom placenta accreta was the cause of PPH, severe intrauterine synechiae were successfully treated by operative hysteroscopy. The occurrence of severe synechiae was significantly associated with a higher rate of placenta accreta/percreta and postpartum fever >38.5°C. Although these complications are uncommon and may be amenable to surgical management, women should be made aware of the possibility of uterine synechiae following the procedure, and follow-up hysteroscopy should be advised for those who experience decreased flow or amenorrhoea beyond 2–3 months following the procedure.
It has been hypothesised that procedures such as pelvic vascular embolisation or ligation could lead to endometrial or myometrial damage and cause placental dysfunction in subsequent pregnancies. Our findings do not agree with this suggestion. Almost all studies included in our review had uncomplicated full-term deliveries in the majority of women who became pregnant following the conservative management of PPH. In a few studies that reported occasional complications in pregnancy, such as fetal growth restriction or pre-eclampsia, their incidence was not in excess of the respective incidence in the general population. Although some reports suggest higher rates of caesarean deliveries in pregnancies following uterine compression sutures, this finding needs confirmation from larger studies. The association may simply arise from the confounding effects of elective repeat caesarean deliveries in women with previous caesarean sections, or from delivery in a controlled environment that avoids the risks of repeat severe obstetric haemorrhage.
The literature also presents conflicting evidence about the risks of abnormal placentation and recurrent PPH following fertility-sparing procedures for PPH. Although some studies have reported an increased risk of placenta accreta or placenta percreta and PPH following pelvic embolisation or uterine devascularisation,[9, 17, 24] others have failed to find a similar association. Salomon et al. hypothesised that the high frequency of abnormal placental insertion could result from endometrial damage caused by embolisation, which in turn leads to abnormal trophoblastic invasion during a subsequent pregnancy. But the numbers studied are too small to draw any definite conclusions and speculate whether the risk of abnormal placentation/PPH is related to an underlying uterine tendency to bleed or a result of reporting bias. Although there is a lack of certainty about these associations, it is clinically prudent to be vigilant for these complications in women who conceive following such procedures.