Does a hemorrhage increase the risk of uterine scarring and potentially affect future fertility?

Impact of Hemorrhage on Uterine Scarring and Future Fertility

Uterine hemorrhage can increase the risk of uterine scarring and potentially affect future fertility, with up to 12% of patients developing uterine synechiae (intrauterine adhesions) after treatments for hemorrhage such as transarterial embolization. 1

Relationship Between Hemorrhage and Uterine Scarring

Uterine hemorrhage can lead to scarring through several mechanisms:

1. Direct tissue damage: Severe hemorrhage can cause ischemic damage to the endometrium and myometrium
2. Treatment-related scarring: Interventions to control hemorrhage may cause scarring:
   • Transarterial embolization (TAE): Up to 12% of patients develop uterine synechiae after TAE for postpartum hemorrhage 1
   • Surgical interventions: Uterine compressive sutures and curettage carry even higher risks of adhesion formation than TAE 1
   • Infection risk: Hemorrhage increases risk of infection, which can lead to scarring

Impact on Future Fertility

The evidence regarding future fertility after uterine hemorrhage and its treatments shows:

• Pregnancy rates after TAE: A systematic review demonstrated a 76% subsequent pregnancy rate after transarterial embolization for postpartum hemorrhage 1
• Pregnancy complications: While fertility may be preserved, pregnancies after hemorrhage requiring TAE have:
  • No significant increase in miscarriage rates 1
  • No increase in intrauterine growth restriction 1
  • Elevated risk of invasive placental disorders in subsequent pregnancies 1
  • Nearly 20% risk of recurrent postpartum hemorrhage 1

Risk Factors for Increased Scarring After Hemorrhage

Certain factors increase the likelihood of scarring after hemorrhage:

• Pre-existing uterine damage: Previous cesarean sections or other uterine surgeries 2
• Treatment modality: Curettage and compressive sutures carry higher adhesion risk than TAE 1
• Severity of hemorrhage: More severe bleeding requiring more aggressive interventions
• Infection: Postpartum or post-procedure infections increase scarring risk

Clinical Implications and Management

For women who have experienced uterine hemorrhage:

1. Fertility preservation considerations:

   • TAE is preferable to surgical interventions when possible for hemorrhage control, as it has a lower risk of synechiae formation (12%) compared to compressive sutures or curettage 1
   • In a recent study, 12 out of 16 women who desired pregnancy after UAE for postpartum hemorrhage were able to conceive 3

2. Monitoring for complications:

   • Women with history of hemorrhage should be monitored for signs of intrauterine adhesions if fertility issues arise
   • Subsequent pregnancies require close monitoring for placental disorders and recurrent hemorrhage 1, 3

3. Risk of uterine rupture:

   • Hemorrhage requiring invasive treatments may increase risk of uterine rupture in subsequent pregnancies 3, 4
   • One case of uterine rupture was observed in a subsequent pregnancy after UAE for postpartum hemorrhage 3

Conclusion

While uterine hemorrhage does increase the risk of scarring that can affect fertility, modern interventions like transarterial embolization offer better outcomes than traditional surgical approaches. With proper management and monitoring, many women can maintain fertility after experiencing uterine hemorrhage, though they face increased risks of certain complications in subsequent pregnancies.