Menstrual and Fertility Outcomes Following Surgical Management of Post-partum Haemorrhage: A Systematic Review Doumouchtsis S.K. Nikolopoulos K Sinai Talaulikar V Archana K Arulkumaran S

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Background WHO: Postpartum haemorrhage (PPH) responsible for an estimated 25% of all maternal deaths worldwide Conservative surgical interventions form the next line of management after failed medical treatment The risks of impairment of subsequent fertility following uterine sparing surgical interventions remain unclear. Fertility sparing procedures include: intrauterine balloon temponade haemostatic brace sutures (B-Lynch or modified compression) bilateral ligation of uterine arteries bilateral ligation of hypogastric (internal iliac) arteries selective radiological arterial embolisation Power calculations: based on small RCT by Fairlie et al, 1999, BJOG

The Clinical Question What are the menstrual and fertility outcomes following radiological or conservative surgical interventions for severe PPH?

Background How is post-partum haemorrhage (PPH) classified in the guideline(s) used in your clinical practice?

Description of Research Participants Women who had severe post-partum haemorrhage (PPH) Intervention Radiological or conservative surgical interventions for severe PPH Comparison No radiological or surgical interventions for severe PPH Outcomes (Primary) Menstrual and fertility outcomes Design Systematic review (without meta-analysis)

5 studies (195 women) after uterine devascularisation and Total number of citations (n= 402) Excluded after evaluation inclusion criteria- human, female, n>5, exclude duplication (n= 170) N=232 Title screening N=62 Abstract screening N=39 Full text screening & reference search 17 (675 women): after uterine artery embolisation 5 (195 women): after uterine devascularisation 6 (125 women): after uterine compression sutures Seventeen studies (675 women) reported on the fertility outcomes after uterine artery embolisation 5 studies (195 women) after uterine devascularisation and 6 studies (125 women) following uterine compression sutures N=28

Methods How did the authors assess the quality of the included studies? Was this assessment adequate?

Results Overall 553/606 (91.25%) women resumed menstruation within 6 months 183/235 (77.87%) women who desired another pregnancy achieved conception After uterine artery embolisation (UAE)- 675 women from 17 studies 460/503 (91.45%) resumed menstruation within normal time 126/168 (75%) who desired another pregnancy achieved conception

Results After hypogastric artery ligation- 112 women from 3 studies 20/23 (86.95%) who desired another pregnancy achieved conception After uterine compression sutures- 71 women from 6 studies 65/71 (91.54%) resumed menstruation within normal time 24/28 (85.71%) who desired another pregnancy achieved conception

Results Why is it always useful to report confidence intervals (CI) with all percentage results? Is the observed association likely to be causal? What are the tools to help you assess causality?

Authors’ summary Despite heterogeneity between individual studies, their conclusions were consistent- most women do not have long-term adverse menstrual and fertility outcomes following the use of conservative surgical interventions for severe PPH Complications of infection and synechiae have been described after uterine compression techniques. Women should be made aware of this risk and advised for follow-up hysteroscopy in those who experience decreased menstrual flow or amenorrhoea beyond 2-3 months post-partum. The numbers studied for the risks of abnormal placentation and recurrent PPH remained too small to draw definite conclusion

Take home messages How would you design a study to answer this clinical question in the future? Can you briefly summarise the results of this study? How would the results of this study influence your practice?

Authors’ suggestions for future research Large prospective clinical studies evaluating menstrual, fertility and obstetric outcomes following fertility sparing procedures Defining the subgroup of women more likely at risk of developing uterine synechiae following compression sutures To study if there are differences between the four procedures in relation to the ‘time to conception’ following such procedures

Suggested Reading Centre for Reviews and Dissemination. Systematic Reviews: CRD's guidance for undertaking reviews in health care. 2009. ISBN-978-1900640473. Weblink: http://bit.ly/18DYiZ7 Hemingway H, Croft P, Perel P, Hayden JA, Abrams K, Timmis A, et al; PROGRESS Group. Prognosis research strategy (PROGRESS) 1: a framework for researching clinical outcomes. BMJ. 2013 Feb 5. http://www.bmj.com/content/346/bmj.e5595