Fertility Outcomes Post Uterine Sparing Surgeries for Post Partum Hemorrhage
November 8, 2019
Today we’re going to talk about fertility outcomes in post uterine-sparing surgeries for postpartum hemorrhage, or PPH. Our discussion will focus on the literature review and discussion. And the group members are Eric, Daniel, Alfred, myself. We are supervised by Dr. T. C. Tan as well as Dr. Sonali. Today, for our presentation, we are going to give a brief introduction of the topic as well as provide the patient case scenario, followed by the actual critique of the article based on the systematic review. We are also going talk about the KK experience as well as the study conducted in KKH on postpartum hemorrhage, followed by conclusion. Now, introduction. Why is the topic of fertility outcomes in post-uterine intervention important? Because health is not just a concept but a state of complete physical, mental, and social well-being. And not just simply about the absence of disease. The case we are presenting is the case of Mrs. P, who is a 29-year-old G2P1 female at 29 weeks gestation. She basically present PV bleeding associated with abdominal pain. The bleeding was noted to be fresh, without clots. She had no prior provisional bleeding during her pregnancy. Routine antenatal blots were normal. Currently she has no fever, headache, or hematemesis. She also has no history of falls or trauma. Obstetric history-wise, includes intra-uterine fetal demise at 24 weeks gestation previously, delivered by lower segment Cesarean section for preeclampsia three years ago, complicated by PPH. Code Green was activated three hours after admission based non-reassuring fetal status. The baby was 1.3 kilograms, delivered by LSCS, complicated by a tear in the bladder serosa, with significant PPH and a blood loss of 2.5 liters. Following which are uterine compressions and B-lynch suture was done. Post-op-wise, her recovery was uncomplicated. The patient was discharged well post-op day 5. Now, based on the case, what are the considerations that a patient might have? Of course, the patient might definitely think about whether she can get pregnant again, the risk to her pregnancies, especially subsequent pregnancies after this episode of postpartum hemorrhage, which is a complication of pregnancy. And if possible, when is the best time to get pregnant again? So the article we’re talking about is actually this article on “Menstrual and Fertility Outcomes Following the Surgical Management of Postpartum Hemorrhage– a Systematic Review.” For the article, they used study selection and literature search involving the following databases. Data extraction-wise, they’ve studied the characteristics of trial participants, the types of intervention, the time of follow up, outcomes, complications, as well as a quality assessment of the procedures done. Now, basically, this slide is the most important slide of the whole article. Mainly the focus on three procedures, which is pelvic and uterine artery embolization, uterine devascularization, and uterine compression sutures. If you note, normal resumption of menstruation was 460 of 503 patients, which was 91%. Out of which 168 women desired future pregnancies. And the number of patients who actually got pregnant was 126, which is 25%. Patiently with recurrent postpartum hemorrhage is 18. For the next procedure, uterine devascularization, 28 out of 32, which is close to 88%, had normal resumption of menstruation within six months, out of which 39 desired pregnancies, but only 33 actually achieved pregnancies. For the uterine compression sutures, 65 out of 71, which is 90.27%, had normal resumption of menstruation within six months. Out of which 28 desired pregnancies and 24 actually achieved pregnancies. If you look at this slide, it seems that the number of patients who have post-procedure complications is the lowest in the uterine compression sutures, where there are actually no complications in terms of preterm labor, early pregnancy loss, as well as recurrent postpartum hemorrhage. However, the data does suggest that pelvic uterine embolization is the most studied procedure in this paper. But we actually noted that patients who actually undergo this procedure are patients who actually need to be stable, because such procedures are interventional radiological techniques, and require the expertise of an interventional radiologist on standby. As for the reported complications and associations, we are going to look at embolization and devascularization techniques, as well as uterine compression suture, or the B-lynch suture. For uterine artery embolization or pelvic devascularization, complications included endometritis as well as endometrial ischemia, uterine synechiae and amenorrhea, otherwise known as Asherman’s syndrome, increased risk of abnormal presentation in subsequent pregnancies. For uterine compression sutures, which is the B-lynch suture, complications such as uterine synechiae and amenorrhea, or Asherman’s syndrome, have been reported. The article basically reported that most women do not have adverse menstrual and fertility outcomes following surgical intervention of severe postpartum hemorrhage, as shown in the slides. The strengths of this paper, generally, was that a wide range of studies were reviewed because it was a literature review. The studies were prospective as well as retrospective. They were drawn from all around the world, and did not focus only on the British journals, but also to a majority of articles from Europe as well. The use of common endpoints to compare each study was also a strength of this paper. The authors provided a good discussion on limitations of studies done, as well as some conclusions. However the weaknesses for these people are that the quality assessment of selection was subjective, because the endpoints were not really very clear. No randomized controlled trials were done in the papers reviewed, but only prospective as well as retrospective studies based on the complications. There was insufficient representation of compression procedures in the meta analysis, such as the compression sutures. We are now going to talk about the experience and study in KKH. Complications and pregnancy outcomes following uterine compression suture for postpartum hemorrhage, a single center experience. Basically, the KK people studied 59,655 deliveries over a four year period, starting from first January, 2008 to 31st December, 2012. Out of which 23 deliveries required B-lynch sutures to be performed as a result of postpartum hemorrhage, and out of which only three pregnancies were achieved following B-lynch compression sutures. As mentioned, there were only three pregnancies in two patients reported from this study. For Patient 1, she had a miscarriage in the first trimester. The second successful pregnancy was a 39-week pregnancy, which was delivered by elective Cesarean section due to a placenta previa as well as a transverse lie. For Patient 2, it was also an elective Cesarean section for a term baby at 39 weeks. If you look at the picture in this slide, it shows that for Patient 2, following B-lynch compression sutures. This picture was basically taken at the Cesarean delivery of the second baby, following the B-lynch compression suture of the first pregnancy as a result of postpartum hemorrhage. This picture basically shows fundal distortion, which is a complication noted for B-lynch compression sutures. So basically, uterine compression sutures have been shown to be effective at preserving the uterus as compared to procedures such as hysterectomy. The risk of loss of fertility and subsequent pregnancy outcomes remains. And the total risk remains unknown. So while adverse pregnancy outcomes have been reported, there have still been successful conceptions and deliveries following compression sutures, such as the two successful pregnancies reported in this paper. The low rate of successful term pregnancies following compression sutures may be related to factors which are non-medical, such as psychological stress from traumatic delivery causing mothers to choose not to have subsequent pregnancies. Most women do not have adverse menstrual or fertility outcomes in the long term after uterine-sparing surgical procedures due to postpartum hemorrhages, basically from all the papers we have seen. Data from the 2014 paper from KK, which studied fertility outcomes after B-lynch suture, are consistent with the other studies. Adverse outcomes in subsequent pregnancies remain restricted to isolated case reports. And the study and follow-up for this cohort of women remains very important. So now, going back to the Conclusions slide. The questions frequently asked by women. Can they get pregnant again? The answer is definitely yes. Because such procedures aim to preserve the uterus, and that more women actually resume menstruation as chosen to be an endpoint or parameter to measure fertility. In terms of risk to the pregnancy, it seems to be comparable with patients with past abdominal pelvic surgery, basically because all procedures done have complications, and they are no different or no higher than patients undergoing normal pelvic surgery. As to the question of, when is the best possible time to get pregnant again? There are basically no guidelines as of yet. But anecdotal advice is to wait one year or more to allow for healing of the uterus to prevent possible complications. Thank you.