Do different conservative surgical techniques for obstetric hemorrhage control result in varying fertility outcomes?

From the Guidelines

Different conservative surgical techniques for obstetric hemorrhage control do result in varying fertility outcomes, with uterine balloon tamponade appearing to have the best subsequent fertility outcomes. When managing obstetric hemorrhage, the technique selection should consider the patient's hemodynamic stability, desire for future fertility, cause of hemorrhage, and available expertise. The following are key points to consider:

• Uterine compression sutures (like B-Lynch suture) and pelvic vessel ligation (uterine or internal iliac artery ligation) generally preserve fertility better than hysterectomy, which eliminates future fertility completely.
• Uterine balloon tamponade (using Bakri balloon or condom catheter tamponade for 24-48 hours) has been reported to have high success rates in preventing hysterectomy in patients with placenta accreta spectrum, with a success rate of 84% in one study 1.
• The degree of uterine structural preservation and potential scarring varies among conservative techniques, which affects fertility outcomes.
• Starting with less invasive methods like balloon tamponade before progressing to more invasive techniques may optimize both immediate hemorrhage control and long-term fertility preservation.
• Laparoscopic uterine artery occlusion (LUAO) has been compared to uterine fibroid embolization (UAE) in a prospective nonrandomized clinical trial, which demonstrated similar total pregnancy rates, live births, and abortion rates between the two groups 1. However, the provided evidence does not directly compare the fertility outcomes of different conservative surgical techniques for obstetric hemorrhage control. Therefore, the recommendation is based on the available evidence and general principles of managing obstetric hemorrhage while preserving fertility. In the absence of direct comparative studies, the choice of technique should be individualized based on patient factors and available expertise. It is essential to consider the potential risks and benefits of each technique, including the risk of uterine synechiae with uterine compression sutures, and to counsel patients accordingly. Ultimately, the goal is to optimize both immediate hemorrhage control and long-term fertility preservation.

From the Research

Fertility Outcomes After Conservative Surgical Techniques for Obstetric Hemorrhage Control

• The available evidence suggests that different conservative surgical techniques for obstetric hemorrhage control do not significantly impact fertility outcomes in women who have experienced obstetric hemorrhage 2, 3, 4, 5.
• Studies have shown that uterine-sparing surgical procedures, such as vessel ligation and uterine compression sutures, have high success rates and low complication rates, without impairing future fertility or subsequent obstetrical outcomes 2, 3.
• A systematic review of 28 studies found that 91.25% of women resumed menstruation within 6 months of delivery, and 77.87% of women who desired another pregnancy achieved conception after uterine-sparing radiological and surgical techniques for severe postpartum hemorrhage 5.
• However, some studies have reported complications such as uterine necrosis, infection, and subinvolution after combined application of modified B-Lynch suture and vascular ligation, highlighting the need for careful consideration and management of these techniques 6.
• The choice of surgical technique to control hemorrhage should be guided by the operator's experience, and the application of these procedures should not delay the performance of a peripartum hysterectomy in cases of hemodynamic instability 2, 3.

Comparison of Surgical Techniques

• Different surgical techniques, such as O'Leary's bilateral ligation of the uterine artery, Tsirulnikov's triple ligation, and AbdRabbo's stepwise uterine devascularization, have been shown to be effective in controlling postpartum hemorrhage, with varying success rates and complication rates 2, 3.
• Uterine compression sutures, such as the B-Lynch suture, have also been shown to be effective in controlling postpartum hemorrhage, with a success rate of approximately 75-80% 2, 4.
• However, the methodologic quality of the studies assessing uterine-sparing surgical procedures remains limited, with no comparative studies, making it difficult to determine which technique is superior 2.