Fertility and Pregnancy Outcomes Following Uterine Devascularization
Fertility and Pregnancy Outcomes Following Uterine Devascularization
Background: To evaluate the fertility and pregnancy outcomes following uterine devascularization for postpartum haemorrhage (PPH).
Methods: All patients who required uterine devascularization, i.e. bilateral uterine artery ligation (Group A), and either bilateral utero-ovarian ligament (Group B) or suspensory ligament of ovary ligation (Group C) in cases of persistent haemorrhage, for PPH with no concomitant procedures from December 1997 to March 2004 were included. Data were retrieved from medical files and telephone interviews.
Results: Data were available for 32 of the 40 (80%) patients included in the study. All patients but 4 had a return to normal menses. Postpartum amenorrhea was secondary to ovarian failure in two cases, and synechiae or necrotic uterus each in one case. These four patients belonged to Group C, whereas no adverse events were observed in groups A and B. Thirteen patients had 16 pregnancies with 13 term deliveries, 1 ectopic pregnancy and 2 abortions. Clinical course of the 13 complete gestations were uneventful but PPH recurred in 4 (31%) due to placenta accreta in three cases.
Conclusions: Uterine artery ligation, whether or not associated with utero-ovarian ligament ligation, for PPH does not appear to compromise the patients' subsequent fertility and obstetrical outcome.
Severe bleeding is the most significant cause of maternal death worldwide as well as in France (Bouvier-Colle et al., 2001; AbouZahr, 2003). This is unfortunate because 90% of maternal deaths due to postpartum haemorrhage (PPH) are in fact preventable (Bouvier-Colle et al., 2001). One of the keys to the management of PPH is early stage diagnosis and treatment. In all cases, primary management involves the use of uterotonic agents, manual exploration of the uterus, suturing possible lacerations and fundal massage. In few cases, this primary management remains ineffective and other treatments are required (ACOG Practice Bulletin, 2006), including manual exploration of the uterus, suturing possible lacerations, fundal massage and the use of uterotonic agents such as oxytocin and/or prostaglandin analogues.
The easiest and less morbid procedures should be then preferred (Sergent et al., 2004). In the case of persistent bleeding following vaginal deliveries, pelvic arterial embolization seems to be the ideal procedure only when the patient is haemodynamically stable and the embolization unit is located close to the delivery room (Sergent et al., 2004; ACOG Practice Bulletin, 2006). Moreover, pelvic arterial embolization is limited by the specialized instrumentation and expertise that are required (ACOG Practice Bulletin, 2006). Balloon treatment might be more appropriate following failure of uterotonic agents after vaginal birth (Doumouchtsis et al., 2007). Even if success is incomplete it can at least provide time for performing embolization (Seror et al., 2005; Doumouchtsis et al., 2007). In the case of persistent bleeding following caesarean section, the ideal procedure is the vessel ligation (ACOG Practice Bulletin, 2006).
The first pelvic arteries ligation reported was the hypogastric arteries ligation at the end of the 19th century (Quenu and Duval, 1898). However, many practitioners are only slightly familiar with this technique and the procedure has been found to be considerably less successful than previously thought (Clark et al., 1985; ACOG Practice Bulletin, 2006). Bilateral uterine ligation, as described by O'Leary and O'Leary (1974), accomplishes the same goal and this procedure is quicker and easier to perform (ACOG Practice Bulletin, 2006). As several authors have reported failure of ligation in up to 20% of cases requiring subsequent hysterectomy (Fahmy, 1987), AbdRabbo (1994) subsequently reported a stepwise uterine devascularization procedure, involving normal and low bilateral uterine artery ligation with a bilateral ovarian vessel ligation in cases of persistent haemorrhage. This author reported a hysterectomy avoidance rate of 100% in a 103 case series (AbdRabbo, 1994). Nevertheless, little is known about the fertility and pregnancy outcomes for these patients who have undergone this surgical procedure for severe PPH. This cohort study was therefore undertaken to evaluate the impact on fertility and pregnancy outcomes of stepwise uterine devascularization performed for severe PPH.
Abstract and Introduction
Abstract
Background: To evaluate the fertility and pregnancy outcomes following uterine devascularization for postpartum haemorrhage (PPH).
Methods: All patients who required uterine devascularization, i.e. bilateral uterine artery ligation (Group A), and either bilateral utero-ovarian ligament (Group B) or suspensory ligament of ovary ligation (Group C) in cases of persistent haemorrhage, for PPH with no concomitant procedures from December 1997 to March 2004 were included. Data were retrieved from medical files and telephone interviews.
Results: Data were available for 32 of the 40 (80%) patients included in the study. All patients but 4 had a return to normal menses. Postpartum amenorrhea was secondary to ovarian failure in two cases, and synechiae or necrotic uterus each in one case. These four patients belonged to Group C, whereas no adverse events were observed in groups A and B. Thirteen patients had 16 pregnancies with 13 term deliveries, 1 ectopic pregnancy and 2 abortions. Clinical course of the 13 complete gestations were uneventful but PPH recurred in 4 (31%) due to placenta accreta in three cases.
Conclusions: Uterine artery ligation, whether or not associated with utero-ovarian ligament ligation, for PPH does not appear to compromise the patients' subsequent fertility and obstetrical outcome.
Introduction
Severe bleeding is the most significant cause of maternal death worldwide as well as in France (Bouvier-Colle et al., 2001; AbouZahr, 2003). This is unfortunate because 90% of maternal deaths due to postpartum haemorrhage (PPH) are in fact preventable (Bouvier-Colle et al., 2001). One of the keys to the management of PPH is early stage diagnosis and treatment. In all cases, primary management involves the use of uterotonic agents, manual exploration of the uterus, suturing possible lacerations and fundal massage. In few cases, this primary management remains ineffective and other treatments are required (ACOG Practice Bulletin, 2006), including manual exploration of the uterus, suturing possible lacerations, fundal massage and the use of uterotonic agents such as oxytocin and/or prostaglandin analogues.
The easiest and less morbid procedures should be then preferred (Sergent et al., 2004). In the case of persistent bleeding following vaginal deliveries, pelvic arterial embolization seems to be the ideal procedure only when the patient is haemodynamically stable and the embolization unit is located close to the delivery room (Sergent et al., 2004; ACOG Practice Bulletin, 2006). Moreover, pelvic arterial embolization is limited by the specialized instrumentation and expertise that are required (ACOG Practice Bulletin, 2006). Balloon treatment might be more appropriate following failure of uterotonic agents after vaginal birth (Doumouchtsis et al., 2007). Even if success is incomplete it can at least provide time for performing embolization (Seror et al., 2005; Doumouchtsis et al., 2007). In the case of persistent bleeding following caesarean section, the ideal procedure is the vessel ligation (ACOG Practice Bulletin, 2006).
The first pelvic arteries ligation reported was the hypogastric arteries ligation at the end of the 19th century (Quenu and Duval, 1898). However, many practitioners are only slightly familiar with this technique and the procedure has been found to be considerably less successful than previously thought (Clark et al., 1985; ACOG Practice Bulletin, 2006). Bilateral uterine ligation, as described by O'Leary and O'Leary (1974), accomplishes the same goal and this procedure is quicker and easier to perform (ACOG Practice Bulletin, 2006). As several authors have reported failure of ligation in up to 20% of cases requiring subsequent hysterectomy (Fahmy, 1987), AbdRabbo (1994) subsequently reported a stepwise uterine devascularization procedure, involving normal and low bilateral uterine artery ligation with a bilateral ovarian vessel ligation in cases of persistent haemorrhage. This author reported a hysterectomy avoidance rate of 100% in a 103 case series (AbdRabbo, 1994). Nevertheless, little is known about the fertility and pregnancy outcomes for these patients who have undergone this surgical procedure for severe PPH. This cohort study was therefore undertaken to evaluate the impact on fertility and pregnancy outcomes of stepwise uterine devascularization performed for severe PPH.
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