SEARCH

SEARCH BY CITATION

Keywords:

  • Intrauterine synechia;
  • pelvic arterial embolisation;
  • placenta accreta or percreta;
  • postpartum haemorrhage;
  • pregnancy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

Objectives  To determine and compare the fertility and pregnancy outcomes following embolisation with or without uterine-sparing surgery for postpartum haemorrhage, and to attempt to identify specific risk factors associated with an increased likelihood of intrauterine synechia.

Design  Retrospective study.

Setting  University-affiliated tertiary referral centre.

Population  All consecutive women who had an embolisation with or without uterine-sparing surgery (vessel ligation and/or uterine compression) for postpartum haemorrhage between 1994 and 2007 were included.

Methods  Data were retrieved from medical files and telephone interviews.

Main outcome measure(s)  Fertility and pregnancy outcomes, synechia.

Results  Data were available for 68 of the 85 women (80%) included in the study. Among the 15 women who complained of amenorrhoea or decreased flow of menstruation, synechia was found in all those who decided to undergo an ambulatory hysteroscopy (n = 8). Seventeen women had 26 pregnancies with 19 term deliveries, one ectopic pregnancy, two abortions and four miscarriages. The clinical courses of the 19 complete gestations were uneventful, but postpartum haemorrhage recurred in six women (31.6%) (caused by placenta accreta in two women). Fertility and pregnancy outcomes did not differ between women who had undergone embolisation versus both embolisation and a uterine-sparing surgical procedure. The occurrence of synechia was significantly associated with a higher rate of placenta accreta/percreta (P < 0.001) and postpartum fever above 38.5 °C (P = 0.04).

Conclusions  Embolisation, whether or not associated with a uterine-sparing surgical procedure, for postpartum haemorrhage does not appear to compromise a woman’s subsequent fertility and obstetric outcome. Nevertheless, these women should be considered at high risk for postpartum haemorrhage during future deliveries.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

Postpartum haemorrhage (PPH) remains one of the major causes of maternal morbidity and mortality throughout the world.1 Approximately 1% of births are complicated by severe PPH of more than 1000 ml.2 Uterine-sparing medical (pelvic arterial embolisation) and surgical (vessel ligation including uterine artery ligation, stepwise uterine devascularisation and/or hypogastric artery ligation, and uterine compression suture) procedures are reliable and effective alternatives to haemostatic hysterectomy, and are currently recommended for the management of severe PPH by various authorities worldwide.3–7 All of these procedures offer the advantages of uterus-saving potential and the capacity to preserve the uterus and therefore, theoretically, the woman’s fertility. However, they may subsequently have hidden mid- and long-term effects.8 Primary long-term studies suggest that uterine-sparing surgical procedures do not appear to impair subsequent fertility and pregnancy outcomes.7–10 Previous studies of women undergoing embolisation have suggested that it does not impair subsequent fertility,11–24 but the cohort, methodology and follow-up rate of these small case series are limited.25 Moreover, in the majority of case series, no information is available regarding women with presumed preserved fertility and desire for pregnancy who do not become pregnant. Finally, there are currently no reported data on the long-term outcomes of women undergoing both embolisation and a uterine-sparing surgical procedure to control PPH. Indeed, multiple uterine devascularisation procedures may increase the risk of subsequent ischaemic complications of synechia and/or impair the subsequent fertility and pregnancy outcomes, rendering this strategy unwarranted.8,10

The primary objective of this study was to determine the impact on fertility and pregnancy outcomes of embolisation for severe PPH based on a large single-centre cohort. The secondary objectives were to compare maternal long-term outcomes between women undergoing embolisation versus both embolisation and a uterine-sparing surgical procedure, and to attempt to identify specific risk factors associated with an increased likelihood of intrauterine synechia.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

This study was approved by our National Ethics Committee (Comité d’Ethique de la Recherche en Obstétrique et Gynecologie). All consecutive women with PPH who underwent embolisation as either the sole procedure (Group A) or in combination with uterine-sparing surgery (Group B) at our tertiary obstetric centre (Rouen University Hospital) between May 1994 and July 2007 were included in the study. The long-term maternal outcomes of the initial 28 participants treated between 1994 and July 1999 have been reported previously,26 and the other women included up to July 2007 were added to the present study. The short-term maternal outcomes of these consecutive women have been reported previously in an earlier article.27 Women with peripartum hysterectomy or vaginal artery-only embolisation were excluded. The policy management for PPH has been reported previously.7,8,27 Digital subtraction angiography was performed using a right-sided unifemoral approach. After aortography to determine anatomy and to locate possible extravasation of contrast agent, selective catheterisation of the uterine artery or anterior trunk of the hypogastric artery was performed. Superselective catheterisation of the uterine artery was attempted in all participants. Other anastomotic vessels, such as vaginal branches, were assessed when necessary. The same procedure was then repeated for the contralateral artery. The embolisation material was mainly pledgets of absorbable gelatine sponge (Gelfoam, Upjohn, Kalamazoo, MI, USA) and inert microparticles (Embosphere, Biosphere Medical, Louvres, France), but also fibred steel (William Cook Europe, Bjaeverskov, Denmark) and fibred platinum microcoils (Target Therapeutics, Boston Scientific, Natick, MA, USA). These were used at the discretion of the angiographer (EC) performing the procedure. A control aortography was routinely performed to exclude residual contrast extravasation.

During the study period, two different treatments were performed for placenta accreta/percreta—an extirpative approach, in accordance with most previous recommendations from Europe and North America, with routine manual removal of the placenta to leave the uterine cavity empty,28 and conservative management, in accordance with recent publications, leaving the placenta in part or entirely in the uterus.29–31

The cause and management of PPH and the postpartum outcome were retrieved from the hospital records for all women. The definitions of primary and secondary PPH were as follows: PPH occurring within the first 24 hours, and 24 hours to 6 weeks following delivery, respectively.32 Vascular abnormality was defined by one of the following: aneurysm, pseudo-aneurysm, arteriovenous malformation or uterine artery injury at surgery. Mean conception delay was measured from the date at which the woman decided to attempt conception. During January 2009, in order to obtain at least 12 months of minimal follow-up, one of the authors (AG) attempted to contact by telephone all of the women in this cohort to determine the maternal mid- and long-term outcomes following embolisation. Informed consent for telephone survey was obtained from all interviewed participants. Women were asked about resumption of menses, menstrual histories, pelvic pain and dyspareunia, modification of sexual function and clinical symptoms of estrogen insufficiency, such as hot flushes and vaginal dryness. Intrauterine synechiae were classified according to the American Fertility Society into three stages, that is mild (stage I), moderate (stage II) and severe (stage III).33 Finally, women were also asked about their desire for subsequent pregnancies, attempts to conceive and results. Data regarding the previous and subsequent pregnancies were obtained from the medical records. Statistical analyses included Student’s t-test, Mann–Whitney U-test, chi-squared test and Fischer’s exact test when required. A statistically significant difference was considered when the P value was <0.05. Statistical analysis was carried out using StatXact.4 Software (Cytel Software Corporation, Cambridge, MA, USA).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

Short-term maternal outcome

During this 13-year period, there were 33 510 deliveries, 1916 of which were complicated by PPH (5.7%). Of these 1916 deliveries, PPH was treated by medical therapy only in 1658 (86.5%), surgery (including vessel ligation and/or uterine compression suture and/or peripartum hysterectomy) in 157 (8.2%), embolisation in 78 (4.1%), and both surgery and embolisation in 23 (1.2%). One woman underwent embolisation for two different pregnancies. Embolisation was performed in 13 women (12.9%) after surgical failure, that is peripartum hysterectomy (two women) and stepwise uterine devascularisation, isolated (10 women) or associated with bilateral hypogastric artery ligation (one woman). Embolisation failed to control haemorrhage in 11 of 100 women (11%), requiring a peripartum hysterectomy in seven of the 11 (63.6%). In the remaining four failures, PPH stopped after uterine artery ligation (one woman), stepwise uterine devascularisation (one woman), uterine artery ligation combined with splenectomy (caused by splenic artery aneurysm) (one woman) and stepwise uterine devascularisation followed by hypogastric artery ligation and B-Lynch suture (one woman).27 Embolisation of the vaginal arteries alone, with no embolisation of the uterine and/or hypogastric arteries, was performed in six women who presented with lower genital tract lacerations (three of these six women had subsequent full-term pregnancy with the birth of a live child). The details of the embolisation procedures have been reported previously.27

Long-term maternal outcome

After exclusions, the study population consisted of 85 women, and 68 women (80%) were contacted at follow-up (range, 12–152 months) (Figure 1). In our follow-up female population, embolisation alone was performed in 58 women (Group A) and embolisation with a concomitant uterine-sparing surgical procedure (vessel ligation and/or uterine compression suture) in ten women (Group B). At least one risk factor for placenta accreta (i.e. previous uterine surgery including curettage and caesarean section, and/or placenta praevia, and/or age >35 years) was identified in the ten women who had embolisation as a result of PPH related to placenta accreta/percreta. None of these ten women required curettage postpartum.

image

Figure 1.  Flow chart of the women.

Download figure to PowerPoint

Synechia following embolisation There were no significant differences in late adverse events between the two groups (Table 1). Of the 15 women who complained of amenorrhoea or decreased flow of menstruation, severe intrauterine synechia (stage III) was found in all who decided to undergo ambulatory hysteroscopy (n = 8). Except for two women in whom placenta accreta was the cause of PPH, severe intrauterine synechia was successfully treated by operative hysteroscopy (Table 1). The occurrence of severe synechia was significantly associated with a higher rate of placenta accreta/percreta (62.5% versus 8.3%, P < 0.001) and postpartum fever >38.5 °C (50% versus 15%, P = 0.04) only (Table 2).

Table 1.   Late adverse events for the total population as a function of the treatment of postpartum haemorrhage
 Total (n = 68)Group A (n = 58)Group B (n = 10)P
  1. Data presented as the number of participants with percentages in parentheses.

  2. *Recurrence of synechia despite four operative hysteroscopies for both women who had undergone pelvic arterial embolisation for placenta accreta.

  3. **All synechiae were severe (stage III) according to the American Fertility Society.33

  4. ***All women refused further investigation.

Menstruation
Resumed63 (92.6%)53 (91.4%)10 (100%)>0.99
Unchanged42 (61.8%)38 (65.5%)4 (40%)0.16
Increased flow of menstruation11 (16.2%)9 (15.5%)2 (20%)0.66
Amenorrhoea or decreased flow of menstruation15 (22.0%)11 (19%)4 (40%)0.21
 Change secondary to synechia**8 (11.8%)6 (10.3%)2 20%)0.33
 Change not investigated***7 (26.5%)5 (8.6%)2 (40%)0.27
Synechia**8 (11.8%)6 (10.3%)2 (20%)0.33
Failed hysteroscopic treatment2 (2.9%)*2 (3.4%)*0>0.99
Clinical ovarian insufficiency7 (10.3%)6 (10.3%)0>0.99
Normal hormonal profiles3 (4.4%)3 (5.2%)0>0.99
Not investigated***4 (5.9%)4 (6.9%)0>0.99
Table 2.   Characteristics of participants, postpartum haemorrhage (PPH), peri-embolisation and postpartum details as a function of the presence or absence of synechia postpartum
CharacteristicsNo synechia (n = 60)Synechia (n = 8)****P
  1. Data presented as the number of participants with percentages in parentheses.

  2. *Percentages were calculated on the basis of the number of women with placenta accreta/percreta.

  3. **Embolisation was performed after a failed surgical procedure or before a surgical procedure (in the case of failed embolisation).

  4. ***Total percentages exceed 100 because different embolisation agents were used for the same women at the discretion of the angiographer (EC).

  5. ****All synechiae were severe (stage III) according to the American Fertility Society.33

  6. *****All of these women received antibiotics in the postpartum period because of fever >38.5 °C.

Maternal characteristics
Age (years)
 <258 (13.3%)2 (25.%)0.33
 25–3545 (75.0%)4 (50%)
 >357 (11.7%)2 (25%)
Nulliparity24 (40%)4 (50%)0.70
Chorioamniotitis5 (8.3%)1 (12.5%)0.54
Caesarean delivery31 (51.7%)4 (50%)>0.99
Curettage to treat PPH001
PPH characteristics
Primary PPH54 (90%)8 (100%)>0.99
Cause of PPH
 Uterine atony35 (58.3%)3 (37.5%)0.45
 Placenta accreta/percreta5 (8.3%)5 (62.5%)0.001
  Retained placental tissue*1 (20%)2 (40%)>0.99
  Uterine cavity empty4 (80%)3 (60%)>0.99
 Praevia6 (10%)0>0.99
 Vascular abnormality9 (15%)00.58
 Lower genital tract lacerations3 (5%)0>0.99
 Coagulopathies2 (3.3%)0>0.99
Estimated blood loss >1500 ml28 (46.7%)2 (25%)0.29
Peri-embolisation characteristics
Embolisation combined with a surgical procedure**8 (13.3%)2 (25%)0.33
Nature of embolisation agent***
 Pledgets of absorbable gelatine sponge (Gelfoam)43 (71.7%)5 (62.5%)0.67
 Inert microparticles (Biosphere)35 (58.3%)4 (50%)0.71
 Fibred steel (William Cook Europe) and platinum (Target Therapeutics) microcoils10 (16.7%)1 (12.5%)>0.99
Postpartum characteristics
Postpartum fever >38.5 °C*****9 (15%)4 (50%)0.04
Endometritis5 (8.3%)1 (12.5%)0.54

Fertility outcome Of the 66 women in whom fertility was preserved, 36 (54.5%) had no desire for pregnancy, including the six women for whom severe intrauterine synechia was successfully removed. This was a result of the fear of the theoretical risk of PPH recurrence in 22 of 36 women (61.1%) (Figure 1). In the remaining 30 women, no secondary infertility occurred. Thirteen women attempted to become pregnant at a mean duration of 8 months (range, 3–12 months), whereas 17 women had 26 pregnancies with a mean conception delay of 11.5 months (range, 1–48 months) (Table 3). In the two women with a conception delay of more than 24 months, one woman had a previous history of infertility over 8 years with several failures of in vitro fertilisation. No women required an assisted reproductive procedure. Seven of the 26 pregnancies ended during the first trimester of pregnancy: two induced abortions (because of the fear of PPH recurrence in one woman), one ectopic pregnancy treated by salpingotomy and four miscarriages. All women who experienced a miscarriage or ectopic pregnancy, with a recurrent desire for pregnancy, were subsequently able to have a full-term pregnancy. There were no significant differences in subsequent fertility and pregnancy between the two groups (Table 3).

Table 3.   Subsequent fertility and pregnancy for the total population as a function of the treatment of the previous history of postpartum haemorrhage
 Total (n = 68)Group A (n = 58)Group B (n = 10)P
  1. Data presented as the mean ± SD with ranges in parentheses, or as the number of participants with percentages in parentheses. NA, not applicable because several participants had more than one pregnancy.

  2. *Percentages calculated on the basis of the number of women with preserved fertility.

  3. **Percentages calculated on the basis of the number of women with a desire for pregnancy.

  4. ***Percentages calculated on the basis of the number of pregnancies obtained.

  5. ****Percentages calculated on the basis of the number of pregnancies with birth of a live child.

  6. *****Percentages calculated on the basis of the number of women with recurrent postpartum haemorrhage.

Participants with available data (n = 68)2 (2.9%)2 (3.4%)01
Synechia with failed hysteroscopic treatment1 (1.5%)1 (1.7%)01
Biological ovarian insufficiency0001
Preserved fertility (n = 66)66 (97.1%)56 (96.6%)10 (100%)1
Synechia with successful hysteroscopic treatment*6 (9.1%)4 (7.1%)2 (20%)0.22
Desire for pregnancy (n = 30)*30 (45.5%)25 (44.6%)5 (50%)1
Previous history of infertility**2 (6.7%)02 (40%)0.02
Secondary infertility**0001
Participants attempting to become pregnant**13 (43.3%)13 (52%) 00.053
 Conception delay >24 months**0001
Participants succeeding in becoming pregnant**17 (56.7%)12 (48%)5 (100%)0.053
Pregnancies obtained (n = 26)26188NA
Mean conception delay***11.5 ± 11.9 (1–48) 11.6 ± 12.5 (1–48)12.3 ± 11.1 (3–36)0.82
Conception delay >24 months***1 (3.8%)1 (5.6%)1 (12.5%)0.53
With assisted reproductive techniques***0001
Miscarriages***4 (15.4%)4 (22.2%)00.55
Abortions***2 (7.7%)1 (5.6%)1 (12.5%)0.37
Ectopic pregnancy***1 (3.8%)01 (12.5%)0.20
Pregnancy with birth of live child (n = 19)***19 (73.1%)13 (72.2%)6 (75%)1
Full-term pregnancy with no complications****19 (100%)13 (100%)6 (100%)1
Caesarean delivery****6 (31.6%)4 (30.8%)2 (33.3%)1
Recurrent postpartum haemorrhage (n = 6)****6 (31.6%)3 (23.1%)3 (50%)0.32
Uterine atony*****4 (66.7%)3 (100%)1 (33.3%)0.40
Placenta accreta*****2 (33.3%)02 (66.7%)0.40

Outcome of full-term pregnancies The characteristics of the 19 subsequent full-term pregnancies are shown in Table 4. Ten women who had subsequent pregnancies belonged to Group A and five to Group B. These 15 women gave birth to 19 healthy babies and none had low birthweight for gestational age. One woman (case 5) and two women (cases 8 and 12) had three (cases 5–7) and two (cases 8 and 9, and cases 12 and 13) full-term deliveries, respectively (Table 4). Assessment of fetal growth and well-being by Doppler ultrasound examination, including uterine and umbilical artery Doppler examination, was available in 15 pregnancies (78.9%). It was normal in all pregnancies except in case 5 (Table 4). This woman had a history of severe uteroplacental insufficiency.

Table 4.   Characteristics of the pregnancies with the birth of a live child following pelvic arterial embolisation for severe postpartum haemorrhage (PPH)
PatientCaseCause of previous PPHVessel ligationConception delay (months)Clinical evolutionDoppler ultrasoundMode of deliveryTerm (weeks of gestation)Newborn (g)Third stage of labour
  1. BL, B-Lynch suture; CS, caesarean section; HAL, hypogastric artery ligation; SUD, stepwise uterine devascularisation; TPL, threatened preterm labour; UAL, uterine artery ligation.

11Uterine atonyNoUnknownFirst-trimester bleeding TPL at 31 weeks of gestationNormalVaginal delivery393340PPH caused by uterine atony requiring sulprostone
22Uterine atonyNo8NormalNormalVaginal delivery393700Normal
33Uterine atonyNo2NormalNormalVaginal delivery413720PPH caused by uterine atony requiring embolisation
44Uterine atonyNo6NormalNormalVaginal delivery403980Normal
55CoagulopathyNo1Low-dose acetylsalicylic therapy between the 12th and 34th weeks of gestationNormalCS for history of two previous CS393710Normal
 6  1Low-dose acetylsalicylic therapy between the 12th and 34th weeks of gestationFirst-trimester bilateral uterine artery notch Normal during the second and third trimesterCS for history of three previous CS383200Normal
 7  1Low-dose acetylsalicylic therapy between the 12th and 34th weeks of gestationNormalCS for history of four previous CS383100Normal
68Uterine atonyNo1Gestational diabetes mellitusNot availableOperative vaginal delivery413930Normal
79Vascular abnormalityNo48Ovarian cystectomy at 14 weeks of gestationNormalVaginal delivery403580Normal
810Placenta praevia        
 No17NormalNormalVaginal delivery414460Normal  
 11  12Suspicion of fetal macrosomiaNormalVaginal delivery414835PPH caused by uterine atony requiring sulprostone
912Placenta accretaNo24Placenta praevia Placenta accreta suspectedNormalCS for placenta praevia383220Normal
1013Lower genital tract lacerationsNo3NormalNot availableVaginal delivery414100Normal
1114Uterine atonySUD10Left pyelonephritisNormalVaginal delivery413000PPH caused by uterine atony requiring sulprostone
1215Vascular abnormalitySUD8NormalNormalVaginal delivery403590Normal
 16  UnknownNormalNot availableVaginal delivery403420Normal
1317Uterine atonySUD3NormalNot availableCS for fetal heart rate abnormalities before labour372540PPH caused by placenta accreta requiring SUD
1418Uterine atonyUAL36NormalNormalCS for placenta praevia373100PPH caused by placenta accreta requiring hysterectomy
1519Placenta accretaSUD + HAL + BL6NormalNormalVaginal delivery413350Normal

Recurrence of PPH occurred in six of the 19 pregnancies (31.6%) (Table 4). Of the 13 vaginal deliveries, uterine atony was responsible for the recurrence of PPH in four pregnancies, requiring local procedures (manual removal of placenta, exploration of genital tract, uterine massage) and prostaglandins to stop haemorrhage in three (cases 1, 11, 14) and embolisation in one (case 3). In the six caesarean deliveries, recurrence of PPH occurred in two, both caused by placenta accreta (cases 17 and 18). This condition was not suspected for these women, although one of these (case 18) presented with a risk factor of placenta accreta (i.e. placenta praevia). In one woman (case 17), haemorrhage was controlled by stepwise uterine devascularisation, whereas, in the other (case 18), first-line surgical treatment of PPH involved a peripartum hysterectomy because of the previous obstetric history, parity and absence of desire for a future pregnancy (Table 4).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

Our results suggest that embolisation for PPH does not appear to compromise a woman’s subsequent fertility and obstetric outcome, and that subsequent fertility and obstetric outcome do not differ between women undergoing isolated embolisation versus both embolisation and a uterine-sparing surgical procedure. The results also suggest that placenta accreta/percreta and postpartum fever >38.5 °C are significantly associated with subsequent severe intrauterine synechia. Our study, which reports the largest number of pregnancies (n = 26) and full-term pregnancies (n = 19), confirms the results reported previously in the literature.11–24 Contrary to our study, the majority of these case series, which have been published previously, did not use a systematic approach to follow-up and telephone contact with participants in an attempt to address subsequent fertility and obstetric outcome. Therefore, they did not assess accurately the fertility outcome as they did not take into consideration the evaluation of desire and attempts to conceive. Nevertheless, these 14 case series, in addition to our study, document a total of 113 pregnancies.11–24 Of the 92 pregnancies that did not end during the first trimester, all resulted in full-term delivery of a healthy eutrophic child. Nevertheless, in 16 pregnancies (17.4%), a recurrence of PPH occurred. This percentage may have been underestimated as no specific information regarding the third stage of labour has, to our knowledge, been reported in numerous studies.11–24 This result is not surprising as it is well known that a woman with a history of PPH has an increased risk of PPH in subsequent deliveries,32,34 and this result has also been observed in subsequent pregnancies following vessel ligation for PPH.7,9 Interestingly, as in our series, placenta accreta was one of the main causes of PPH recurrence when the aetiology was reported.11–24 It has been speculated that a previous devascularised uterus, either by stepwise uterine devascularisation or embolisation, might modify implantation and trophoblast invasion in subsequent pregnancies.7,11 However, one cannot exclude the possibility that the high rate of abnormal placentation observed in cases of recurrent PPH could simply be related to a well-known risk factor of accreta present during a previous pregnancy (age > 35 years, new caesarean section).

In our series, 22% (15/68) of the women with presumed preserved fertility complained of amenorrhoea or decreased flow of menstruation. This result has also been reported in previous case series.12,16,19,20,24 It is essential to research these possible alterations in the postpartum period: changes in menstruation are warning symptoms of possible intrauterine synechia, which is known to adversely affect fertility and, in some cases, subsequent pregnancy outcomes. Gaia et al.,24 in the six amenorrhoeic women in their study, found intrauterine diffuse synechia that was impossible to remove by hysteroscopy. Moreover, of the 11 (37.8%) women with a desire for pregnancy who did not become pregnant, five had synechia and six had oligomenorrhoea.24 In our study, severe intrauterine synechia was found in all women with decreased flow of menstruation who underwent an ambulatory hysteroscopy (n = 8/8), suggesting that the frequency of intrauterine synechia in the population with presumed preserved fertility is probably underestimated. Fertility was clearly altered in the two women for whom synechia was impossible to remove by hysteroscopy. In the remaining six women for whom severe synechia was successfully treated, it was unfortunately impossible to determine fertility and pregnancy outcomes because all of these women had no desire for a subsequent pregnancy. Intrauterine synechia may be related to endometrial ischaemia secondary to embolisation. Indeed, uterine necrosis following the isolated use of 45–150-μm35 and 200–500-μm36 polyvinyl alcohol particles and gelfoam pledgets,37 or the combined use of gelfoam pledgets and 150–250-μm polyvinyl alcohol particles,38 has been reported previously. Moreover, an experimental animal study on ewes found that polyvinyl alcohol particles were associated with more intense uterine necrosis than were calibrated microspheres, and uterine necrosis occurred more frequently with small rather than large polyvinyl alcohol particles and microspheres.39 In our study, polyvinyl alcohol particles were never used, and the nature of the embolisation agent did not differ between the women with or without synechia. The only factors significantly associated with severe synechia were a higher rate of abnormal placentation (62.5% versus 8.3%, P = 0.001) and postpartum fever >38.5 °C (50% versus 15%, P = 0.04). Nevertheless, because of the absence of a control group of women with PPH and no pelvic arterial embolisation, it cannot be totally excluded that pelvic arterial embolisation may cause uterine synechia.

To our knowledge, no reported studies have assessed the fertility and pregnancy outcomes following embolisation, combined with a uterine-sparing surgical procedure (vessel ligation and/or uterine compression) (before or after embolisation), for PPH. This assessment is crucial in order to determine whether multiple uterine devascularisation procedures rather than haemostatic hysterectomy are justified. It has been reported previously that embolisation following a failed uterine-sparing surgical procedure and a uterine-sparing surgical procedure following failed embolisation are both effective in controlling PPH with low short-term morbidity.27 Our results suggest that subsequent menstruation, fertility and obstetric outcome do not differ between women undergoing embolisation versus both embolisation and a uterine-sparing surgical procedure. Therefore, embolisation following a failed uterine-sparing surgical procedure and a uterine-sparing surgical procedure following failed embolisation seem to be reasonable options before considering peripartum hysterectomy when a woman is haemodynamically stable and the embolisation unit is located close to the operating room.

The main limitation of our study, as in all studies assessing long-term maternal outcome following embolisation for PPH, was its retrospective design. Another limitation was the lack of statistical power for the comparison between women undergoing embolisation versus both embolisation and a uterine-sparing surgical procedure, because the sample size of the latter group was low (n = 10), as it is a rare event. Finally, it is likely that the rate of synechia reported in our study was underestimated, as nearly one-half of the women who complained of amenorrhoea or decreased flow of menstruation refused further investigation. In addition, some of the synechia, in particular, mild or moderate synechia, may not have been clinically relevant.

In conclusion, our study confirms that embolisation for PPH does not appear to compromise a woman’s subsequent fertility and obstetric outcome. Nevertheless, these women should be informed that they present a risk of PPH recurrence that could reach 30%. Our study also suggests that fertility and pregnancy outcomes do not appear to differ between women undergoing embolisation versus both embolisation and a uterine-sparing surgical procedure. It further suggests that synechia may occur more frequently in cases of placenta accreta/percreta or postpartum fever >38.5 °C. Additional cohort studies are warranted to confirm these last two results.

Disclosure of interest

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

The authors have no direct or indirect commercial financial incentives associated with the publication of this article.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

LS and LM developed the original design. AG participated in the acquisition of the data. LS, BR, EV and LM primarily managed the women who presented with postpartum haemorrhage, and EC performed pelvic arterial embolisations. LS and AG wrote the first draft of the report. All authors contributed to the writing of the final manuscript.

Details of ethics approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

This study was approved by our national ethics committee (Comité d’Ethique de la Recherche en Obstétrique et Gynecologie) (CEROG-2008-045-R1).

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References

The authors would like to thank Richard Medeiros (Rouen University Hospital Medical Editor, Rouen, France) for valuable editorial assistance.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interest
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  • 1
    Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367:106674.
  • 2
    Mousa HA, Walkinshaw S. Major postpartum haemorrhage. Curr Opin Obstet Gynecol 2001;13:595603.
  • 3
    Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev 2007;1:CD003249.
  • 4
    ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol 2006;108:103947.
  • 5
    Royal College of Obstetricians and Gynaecologists (RCOG). Placenta Praevia: Diagnosis and Management. Guidelines No. 27. London: RCOG, 2001. Revised October 2005.
  • 6
    d’Ercole C, Shojai R, Desbriere R, Cravello L, Boubli L. Collège National des Gynécologues et Obstétriciens Français; Agence Nationale d’Accréditation et d’Evaluation en Santé. Surgical management of primary postpartum hemorrhage. J Gynecol Obstet Biol Reprod 2004;33:4S10319.
  • 7
    Sentilhes L, Trichot C, Resch B, Sergent F, Roman H, Marpeau L, et al. Fertility and pregnancy outcomes following uterine devascularization for postpartum haemorrhage. Hum Reprod 2008;23:108792.
  • 8
    Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization. Acta Obstet Gynecol Scand 2008;87:10206.
  • 9
    Nizard J, Barrinque L, Frydman R, Fernandez H. Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum hemorrhage. Hum Reprod 2003;18:8448.
  • 10
    Sentilhes L, Gromez A, Trichot C, Ricbourg-Schneider A, Descamps P, Marpeau L. Fertility after B-Lynch suture and stepwise uterine devascularization. Fertil Steril 2009;91:934.
  • 11
    Salomon LJ, de Tayrac R, Castaigne-Meary V, Audibert F, Musset D, Ciorascu R, et al. Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum hemorrhage. A cohort study. Hum Reprod 2003;18:84952.
  • 12
    Chauleur C, Fanget C, Tourne G, Levy R, Larchez C, Seffert P. Serious primary post-partum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases. Human Reprod 2008;23:15539.
  • 13
    Stancato-Pasik A, Mitty HA, Richard HM, Eshkar N. Obstetric embolotherapy: effect on menses and pregnancy. Radiology 1997;204:7913.
  • 14
    Pelage JP, Le Dref O, Mateo J, Soyer P, Jacob D, Kardache M, et al. Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 1998;208:35962.
  • 15
    Deux JF, Bazot M, Le Blanche AF, Tassart M, Khalil A, Berkane N, et al. Is selective embolization of uterine arteries a safe alternative to hysterectomy in women with postpartum hemorrhage? Am J Roentgenol 2001;177:1459.
  • 16
    Chung JW, Jeong H, Joh JH, Park SJ, Jun JK, Kim SH. Percutaneous transcatheter angiographic embolization in the management of obstetric hemorrhage. J Reprod Med 2003;48:26876.
  • 17
    Ornan D, White R, Pollak J, Tal M. Pelvic embolization for intractable postpartum hemorrhage: long-term follow-up and implications for fertility. Obstet Gynecol 2003;102:90410.
  • 18
    Hong TM, Tseng HS, Lee RC, Wang JH, Chang CY. Uterine artery embolization: an effective treatment for intractable obstetric haemorrhage. Clin Radiol 2004;59:96101.
  • 19
    Boulleret C, Chahid T, Gallot D, Mofid R, Tran Hai D, Ravel A, et al. Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases. Cardiovasc Intervent Radiol 2004;27:3448.
  • 20
    Shim JY, Yoon HK, Won HS, Kim SK, Lee PR, Kim A, et al. Angiographic embolization for obstetrical haemorrhage: effectiveness and follow-up outcome of fertility. Acta Obstet Gynecol Scand 2006;85:81520.
  • 21
    Vegas G, Illescas T, Munoz M, Perez-Pinar A. Selective pelvic arterial embolization in the management of obstetric hemorrhage. Eur J Obstet Gynecol Reprod Biol 2006;127:6872.
  • 22
    Soncini E, Pelicelli A, Larini P, Marcato C, Monaco D, Grignaffini A. Uterine artery embolization in the treatment and prevention of postpartum hemorrhage. Int J Gynecol Obstet 2007;96:1815.
  • 23
    Eriksson LG, Mulic-Lutvica A, Jangland L, Nyman R. Massive postpartum hemorrhage treated with transcatheter arterial embolization: technical aspects and long-term effects on fertility and menstrual cycle. Acta Radiol 2007;48:63542.
  • 24
    Gaia G, Chabrot P, Cassagnes L, Calcagno A, Gallot D, Botchorishvili R, et al. Menses recovery and fertility after artery embolization for PPH: a single-center retrospective observational study. Eur Radiol 2009;19:4817.
  • 25
    Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv 2007;62:5407.
  • 26
    Descargues G, Mauger-Tinlot F, Douvrin F, Clavier E, Lemoine JP, Marpeau L. Menses, fertility and pregnancy after arterial embolization for the control of postpartum hemorrhage. Hum Reprod 2004;19:33943.
  • 27
    Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage. Obstet Gynecol 2009;113:9929.
  • 28
    American College of Obstetricians and Gynecologists (ACOG). Postpartum Hemorrhage. ACOG Educational Bulletin 243. Washington, DC: ACOG, 1998.
  • 29
    Kayem G, Davy C, Goffinet F, Thomas C, Clément D, Cabrol D. Conservative versus extirpative management in cases of placenta accreta. Obstet Gynecol 2004;104:5316.
  • 30
    Bretelle F, Courbière B, Mazouni C, Agostini A, Cravello L, Boubli L, et al. Management of placenta accreta: morbidity and outcome. Eur J Obstet Gynecol Reprod Biol 2007;133:349.
  • 31
    Sentilhes L, Resch B, Clavier E, Marpeau L. Extirpative or conservative management for placenta percreta? Am J Obstet Gynecol 2006;195:18756.
  • 32
    Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD, editors. Williams Obstetrics, 21st edn. New York: McGraw Hill Companies, 2001.
  • 33
    American Fertility Society Classification of Intrauterine Adhesions. [http://www.asrm.org/Literature/classifications/intrauterine_adhesions.pdf]. Accessed 18 December 2008..
  • 34
    Tessier V, Pierre F. Risk factors of postpartum hemorrhage during labor and clinical and pharmacological prevention. J Gynecol Obstet Biol Reprod 2004;33:4S2956.
  • 35
    Eboué C, Barjot P, Huet H, Jeanne-Pasquier C, Herlicoviez M. Uterine and ovarian necrosis following embolization of the uterine arteries for postpartum hemorrhage. J Gynecol Obstet Biol Reprod 2007;36:298301.
  • 36
    Pirard C, Squifflet J, Gilles A, Donnez J. Uterus necrosis after embolization and surgical ligation in a patient with post-partum hemorrhage. Fertil Steril 2002;78:4123.
  • 37
    Porcu G, Roger V, Jacquier A, Mazouni C, Rojat-Habib MC, Girard G, et al. Uterus and bladder necrosis after uterine artery embolization for post partum haemorrhage. BJOG 2005;112:1223.
  • 38
    Cottier JP, Fignon A, Tranquart F, Herbreteau D. Uterine necrosis after arterial embolization for postpartum haemorrhage. Obstet Gynecol 2002;103:1834.
  • 39
    Pelage JP, Laurent A, Wassef M, Bonneau M, Germain D, Rymer R, et al. Acute effects of uterine artery embolization in the sheep: comparison between polyvinyl alcohol particles and calibrated microspheres. Radiology 2002;224:43645.