1. 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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3. 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

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

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

6. 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)

7. 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

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

9. 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

10. 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

11. 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?

12. 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

13. 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?

14. 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

15. Suggested Reading
Centre for Reviews and Dissemination. Systematic Reviews: CRD's guidance for undertaking reviews in health care ISBN Weblink:
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 Feb 5.