Which surgery should be the first-line uterine-sparing procedure to control severe postpartum hemorrhage?

18 04 2011

To the Editor:

We read with great interest the case series reported by Rathat et al, which highlights the risk of synechia after uterine compression suture (1). The authors concluded that “even though ligation techniques require more surgical experience, we think that they should be the first choice for surgical management” (1).

We could not agree more with the authors, as we have been attempting to alert physicians to the possible hidden mid-term or long-term effects of uterine compression sutures (2–6), in particular in publishing our algorithm for management of postpartum hemorrhage (2, 7-8), whereas these procedures were adopted promptly throughout the world. In fact, to our knowledge, vessel ligation including uterine and/or hypogastric artery ligation seems to have no or limited impact on subsequent fertility (7). Nevertheless, we would like to highlight that surgical procedures involving uterine artery ligation (UAL), such as stepwise uterine devascularization or triple ligation (2, 4-5, 7-8), must absolutely be differentiated from hypogastric artery ligation (HAL), whereas many authors unfortunately pool these two procedures in the same entity of “vessel” (9) or “techniques” ligation (1).

First, the UAL success rate is likely higher to HAL’s one (respectively, 94.7% [288/304] and 69.0% [136/197]) (3, 9). Second, to date, no serious adverse events have been reported following UAL contrary to HAL (3). Third, UAL is clearly easier to perform and can be rapidly achieved by all physicians similarly to uterine compression suture and contrary to HAL, which requires a much longer learning curve.

Consequently, in our opinion, the take-home message for physicians is not that “ligation techniques should be the first choice for surgical management” (1), but rather that UAL should be the first-line surgical uterine-sparing procedure to control severe postpartum hemorrhage.

Loïc Sentilhes, M.D., Ph.D.
Philippe Descamps, M.D., Ph.D.
Department of Obstetrics and Gynecology
Angers University Hospital
Angers, France

References
1. Rathat G, Trinh PD, Mercier G, Reyftmann, Dechanet C, Boulot P, Giacalone PL. Fertil Steril 2011;95:405-9.

2. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-Lynch suture for persistent massive postpartum hemorrhage following vessel ligation. Acta Obstetricia et Gynecologica Scandinavica 2008; 87:1020-6.

3. Sentilhes L, Gromez A, Descamps P, Marpeau L. Why stepwise uterine devascularization should be the first-line conservative surgical treatment to control severe postpartum hemorrhage? Acta Obstetricia et Gynecologica Scandinavica 2009;88:490-2.

4. Sentilhes L, Gromez A, Trichot C, Ricbourg-Schneider A, Descamps P, Marpeau L. Fertility after B-lynch suture and stepwise uterine devascularization. Fertil Steril 2009;91:934.e5-9.

5. Sentilhes L, Gromez A, Marpeau L. Fertility after pelvic arterial embolization, stepwise uterine devascularization, hypogastric artery ligation and B-Lynch suture. Int J Gynaecol Obstet 2010;108:249.

6. Sentilhes L, Marpeau L, Descamps P. Does B-Lynch suture have hidden long-term effects? Fertil Steril 2010;94:e62.

7. Sentilhes L, Trichot C, Resch B, Sergent F, Marpeau L, Verspyck E. Fertility and pregnancy outcomes following uterine devascularization for postpartum hemorrhage. Hum Reprod 2008; 23:1087-92.

8. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage. Obstet Gynecol 2009;113:992-9.

9. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv 2007;62:540-7.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.05.058

The Authors Respond:

We are writing in reply to the comments raised by Dr. Sentilhes on our recently published paper (1). We much appreciate the remarks made by a team who have been working on surgical treatment to control severe postpartum hemorrhage and especially on uterine-sparing procedure (2, 3).

Our purpose was mostly to highlight the potential mid- and long-term effects of uterine compression sutures on fertility.

Regarding vessel ligation procedures, we agree with the authors on their analysis of the literature on the slightest impact on fertility (4-7). We also believe that we should start with uterine artery ligation, which is much easier to perform.

But, concerning the stepwise devascularisation (SWD) (8), our thinking is quite different. This surgical process must absolutely be differentiated from Tsirulnikov’s triple ligation (9) or hypogastric artery ligation (HAL).

The Tsirulnikov procedure (9) associates uterine artery ligation, round ligament ligation and utero-ovarian ligament ligation, preserving ovarian vascularization by the integrity of suspensory ligament of the ovary.

In SWD describe by AdbRabbo (8), all ways of ovarian vascularization are interrupted by ligation: uterine artery and suspensory ligament of ovary. No studies have evaluated ovarian function by anti-mullerian hormone (AMH) plasma level or antral follicle count by ultrasound after this type of procedure, which, if anatomy was not to change, leads to ovarian ischemia.
Moreover, in a study by Sentilhes et al.(6), 2 out of 12 patients (17%) had menopausal status after treatment by SWD as regularly described from AbdRabbo (8) (uterine artery ligation and suspensory ligament of ovary ligation.).
So, in our practice, we use the Tsirulnikov procedure in the first attempt (9). In case of failure, we prefer HAL over SWD, because HAL preserves ovarian vascularization by the integrity of suspensory ligament of ovary.

Finally, we try uterine compression sutures, so that if hemostatic hysterectomy is needed, ovarian function will be still preserved.

Dr. Phi Do Trinh
Dr. Gauthier Rathat
Pr. Pierre Ludovic Giacalone
Gynecologic and Obstetrical Unit
Centre Hospitalier Régional Universitaire de Arnaud de Villeneuve
Montpellier, France

References
1. Rathat G, Do Trinh P, Mercier G, Reyftmann L, Dechanet C, Boulot P, Giacalone PL. Synechia after uterine compression sutures.Fertil Steril 2011;95:405-9.

2. Sentilhes L, Gromez A, Trichot C, Ricbourg-Schneider A, Descamps P, Marpeau L. Fertility after B-lynch suture and stepwise uterine devascularization. Fertil Steril 2009;91:934.e5-9.

3. Sentilhes L, Marpeau L, Descamps P. Does B-Lynch suture have hidden long-term effects? Fertil Steril 2010;94:e62.

4. O’Leary JA. Pregnancy following uterine artery ligation. Obstet Gynecol 1980;55:112–3.

5. Fahmy K. Uterine artery ligation to control postpartum hemorrhage. Int J Gynaecol Obstet
1987; 25:363–7.

6. Sentilhes L,Trichot C,Resch B, Sergent F, Roman H, Marpeau L, et al. Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage.
Hum Reprod 2008; 23:1087–92.

7. Nizard J, Barrinque L, Frydman R, Fernandez H. Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum haemorrhage. Hum Reprod 2003; 18:844–8
8. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol. 1994 Sep;171(3):694-700

9. Tsirulnikov MS. Ligation of the uterine vessels during obstetrical hemorrhages. Immediate and long-term results (author’s transl). J Gynecol Obstet Biol Reprod 1979;8:751–3.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.04.059

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