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.
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