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ORIGINAL ARTICLE
The Departments of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center, The Hebrew University,
Jerusalem, Israel
Abstract
Background. Secondary post-partum hemorrhage (PPH) is defined as any abnormal bleeding from the birth canal occurring
between 24 hours and 12 weeks postnatally. Treatment usually falls into one of the two categories: surgical evacuation of the
uterus or medical treatment. Objective. To compare the two different clinical approaches and the implications on future
fertility. Study design. A retrospective study. Setting. From 1990 to 2002, 168 women diagnosed with late PPH were admitted
to the Hadassah Medical Centers in Jerusalem. The cases were divided into two groups according to the planned initial
treatment: primary surgical treatment vs. primary medical treatment. Results. Primary surgical treatment was associated with
significantly more primary negative events (p0.01). After the primary event, primary surgical treatment was associated
with fewer future deliveries (p0.04) and resulted in increased rate of secondary infertility of borderline significance
(p0.06). Conclusions. Our results show that secondary PPH is related to high rates of immediate and long-term
complications. It is possible that a conservative medical approach for secondary PPH may be superior to surgical treatment.
Key words: Late post-partum hemorrhage, surgical management, medical treatment, infertility
Correspondence: Tomer Feigenberg, Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Ein-Kerem, POB 12000,
Jerusalem 91120, Israel. E-mail: feigenberg@013.net
Presentation information: The 2nd Asia Pacific Congress on Controversies in Obstetrics Gynecology & Infertility, The Academy of Clinical Debates &
Controversies in Medicine, Shanghai, China, November 811, 2007.
women in both groups were hospitalized for more group. Table III shows the main characteristics of the
than two days. deliveries preceding the event.
There was no difference between the two groups Ultrasonographic examination was performed
in the desire to conceive after the primary event: before the procedure in 45 out of 50 women in the
74.4% of the women from the primary medical surgical intervention group. A suspicion of retained
group vs. 65% of the women from the primary placental tissue was raised in 38 (84.4%). Histolo-
surgical group (Fisher’s exact, p0.3). gical examination was obtained in all of these cases
Of those who tried to conceive, 12.1% of the and confirmed placental remnants in 35 (77.8%;
women from the medical group, and 30.8% of the 85.7% sensitivity, 20% specificity).
surgical group suffered from secondary infertility
(Fisher’s exact, p 0.06).
Discussion
Various infertility treatments to achieve pregnancy
were required in 10.8% of the women from the To the best of our knowledge this may be the first
conservative group vs. 27.8% of the women in the study comparing medical and surgical approaches
surgical group (Fisher’s exact, p 0.13). In those for the treatment of late PPH. Our results demon-
women who tried to conceive after the event, the strate that medical treatment is related to less
mean number of deliveries following the event of primary negative outcomes. Furthermore, medical
secondary PPH varied between the two groups. treatment resulted in less secondary infertility and
Women after primary medical treatments had a better reproductive outcomes.
mean of 2.8 deliveries, while women after primary Secondary PPH is associated with serious mor-
surgical treatments had a mean of only 1.5 deliveries bidity and even mortality (6). In our study 22% of
(t 2.95, df 68.5, p 0.004). Because of differ- the women who were hospitalized had any one of
ences in the mean elapsed time between the event four life-threatening primary negative effects. The
and the telephone questionnaire, an analysis of incidence of uterine perforation after curettage was
co-variance was performed. For the average time of 4% in those who were treated surgically, consistent
86.4 months, women from the conservative group with the reported incidence (5). Minor secondary
had 2.23 deliveries, while those from the surgical complications were observed in over half of the
group had 1.6 (p0.05). There was no difference in women, with no differences between the groups,
the number of miscarriages between the two groups. although women who were treated medically needed
An adhesiolysis procedure was needed in 2.5% of more secondary evacuations of the uterus and had
the women after medical treatment, and in 16% of higher rates of re-admission to the hospital.
the women after surgical treatment (Fisher’s exact, The etiology of secondary PPH is variable and
p0.003). Table II shows the main findings of the includes sub-involution of uteroplacental vessels,
telephone questionnaire. retained placental tissue, placenta accreta, infection,
Mode of delivery leading to the secondary PPH trauma, and coagulopathies (2). Establishing the
did not differ between the two groups. History of correct cause is difficult and sometimes only possible
primary PPH after birth, manual separation of the after evacuation of the uterine cavity. It seems that
placenta, and manual exploration of the uterine the most common causes seen at pathological
cavity after birth were more common in the surgical examination of tissue collected after curettage or
912 T. Feigenberg et al.
Table II. Results of telephone questionnaire regarding the impact of the two different treatment modalities on fertility, after discharge from
the hospital.
hysterectomy, are sub-involution of uteroplacental the lack of data on the efficacy of each treatment
vessels and retained placental fragments (8). The modality, it is not surprising that choosing the
usefulness of ultrasound examination in order to appropriate therapy is difficult. Complications of
distinguish retained placental fragment from blood surgical evacuation of the uterus include short-term
clots is controversial. Edwards and Ellwood (9) tried complications as well as jeopardize to future fertility.
to define the ultrasonographic appearance of the In 1948, Joseph G. Asherman (12) described the
uterine cavity in women with a normal puerperium. syndrome of intra-uterine adhesions. Causes of
Their work revealed an echogenic mass in 51% of Asherman’s syndrome include trauma to the uterine
the women with normal post-partum bleeding after cavity by curettage, especially after birth, and infec-
seven days and 21% after 14 days, casting doubt on tion (13). In their work on the incidence of intra-
the significance of the finding of an echogenic mass uterine adhesions, Westendrop et al. found that 40%
in the uterus during the post-partum period. of women had intra-uterine adhesions after second-
Although some investigators have found ultrasono- ary removal of placental remnants after birth, or
graphic evaluation to be a useful and accurate tool to repeated curettage after incomplete abortion (14).
distinguish retained placental remnants from the We found that 16% of the women who later tried to
situation of an atonic uterus in such cases (10), conceive after surgical intervention, and 2.5% of
others have found it to have a limited diagnostic those who had primary medical treatment, needed
accuracy, not superior to clinical assessment (11). In hysteroscopy or curettage for adhesiolysis. Compli-
our study ultrasonographic examination had a high cations of medical management protocols are less
sensitivity for the detection of placental remnants, well studied, and the impact on future fertility is not
but the specificity was low. known. This observational prospective-historical
Considering the difficulties a clinician faces in study indicates that both medical and surgical
establishing the correct cause of secondary PPH, and treatments for secondary PPH have high rates of
Table III. The main characteristics of the deliveries leading to the event of late PPH.
both immediate and late complications, and may 6. Department of Health. Report on confidential enquiries into
jeopardize future fertility. Due to the possibility of maternal deaths in England and Wales 19911993. London:
HMSO, 1996. pp. 3247.
selection bias between the two groups in our study, 7. Alexander J, Thomas P, Sanghrea J. Treatments for secondary
and the lack of randomized trials comparing differ- postpartum hemorrhage. Cochrane Database Syst Rev. 2002:
ent treatment modalities for secondary PPH, we CD002867.
believe that a well-designed prospective study is 8. Khong TY, Khong TK. Delayed postpartum hemorrhage: a
needed, but meantime medical treatment for sec- morphologic study of causes and their relation to other
ondary PPH might be the preferable option when- pregnancy disorders. Obstet Gynecol. 1993;8291:1722.
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6403.
Declaration of interest: The authors report no 10. Mulic-Lutvica A, Axelsson O. Ultrasound finding of an
conflicts of interest. The authors alone are respon- echogenic mass in women with secondary postpartum he-
sible for the content and writing of the paper. morrhage is associated with retained placental tissue. Ultra-
sound Obstet Gynecol. 2006;28:3129. / /
Gynecol. 1975;82:28992.
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