Fertility after pelvic arterial embolization, stepwise uterine devascularization, hypogastric artery ligation, and B-Lynch suture to control postpartum hemorrhage

Abstract

0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2009.10.003 A 28-year-old primiparous womanwas referred to our center with secondary postpartum hemorrhage (PPH). The patient had a previous history of two curettages. Secondary PPH occurred 10 days after an uneventful vaginal delivery of a healthy neonate. Ultrasound examination showed a poorly-defined, hyperechogenic intrauterine mass measuring 54 mm at its greatest diameter, which was consistent with a diagnosis of retained placenta. Emergency curettage performed under ultrasound guidance was not successful in removing the retained placenta or in stopping the hemorrhage. Sulprostone administrationwas started because of persistent bleeding unresponsive to oxytocics. Owing to stable hemodynamics the patient was transferred for pelvic arterial embolization that was performed successfully using pledgets of absorbable gelatin sponge and 900 to 1200-μm inert microparticles. PPH had stopped by completion of the procedure. However, recurrent bleeding occurred 3 hours later. Because the patient was primiparous and hemodynamically stable, subsequent uterine-sparing surgical procedures were undertaken according to our protocol for the management of PPH, as reported previously [1,2]. Our protocol outlines vessel ligation and B-Lynch suture as firstand second-line procedures, respectively, for the management of severe PPH [1,2] because there is no evidence to suggest that any one method is better than the other and because reassuring data regarding subsequent fertility are currently more numerous for vessel ligation than B-Lynch suture [3]. A stepwise uterine devascularization was performedfirst, without success. Therefore, hypogastric artery ligation was performed and, because the bleeding continued, a B-Lynch suture was placed prior to considering hysterectomy [1,2]. PPH stopped after B-Lynch suture. The postoperative period was uneventful. The patient had an unplanned pregnancy 4 months following the previous delivery. The pregnancy proceeded unremarkably. Labor was spontaneous at 41 weeks of pregnancy and a healthy female neonate weighing 3350 g was delivered vaginally. The third stage of labor was uneventful and no recurrent abnormal placentation was observed. Some authors have proposed that a second (or even a third) uterine-sparing procedure should be performed in case of a failed first (or second) procedure before considering peripartum hysterectomy in a hemodynamically stable patient with a desire for subsequent pregnancy [1–4]. Nevertheless, one can speculate that using multiple uterine-sparing procedures increases the risk of impairing the subsequent fertility and pregnancy outcomes, which would render this strategy unwarranted. The present case describes how 4 different uterine-sparing procedures to control PPH resulted in an uneventful postoperative period and a subsequent uncomplicated full-term pregnancy and vaginal delivery.