Procedures and uterine-sparing surgeries for managing postpartum hemorrhage: A systematic review

Importance: Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality and morbidity worldwide. Objective: The aim of this study was to systematically review literature on procedures (eg, uterine artery embolization) and uterine-sparing surgeries for PPH. Evidence Acquisition: We searched MEDLINE and other databases from 1990 to November 2014. Two reviewers independently evaluated studies against predetermined criteria, extracted data, and assessed study quality and strength of the evidence (confidence in the effect). Results: Twenty-eight small studies addressed 1 or more procedures (19 studies of embolization, 5 of uterine tamponade) or surgeries (5 studies of arterial ligation, 5 of uterine compression sutures). Studies primarily evaluated bleeding control and adverse effects. Rates of hemostasis were typically greater than 60% in studies reporting such data after failure of conservative management. Postprocedure infertility occurred in 0% to 43% of women in a small number of studies that reported these data. Uterine tamponade successfully controlled bleeding in more than 50% of women, with few harms reported. Success rates for ligation and sutures ranged from 36% to 96%; harms included surgical injury, infection, and fertility-associated effects. Conclusions and Relevance: A limited body of evidence addresses these interventions for PPH. Median rates of hemostasis ranged from 36% to 98%; however, these data come from few studies with less than 2100 total participants. Harms were not well characterized. Some studies with longer-term follow-up reported infertility in women undergoing embolization. Few adverse events with tamponade, ligation, or sutures were reported. Given the insufficient evidence, cliniciansmust continue to make individual care decisions based on eachwoman's clinical situation and available management options. Target Audience: Obstetricians and gynecologists, family physicians. Learning Objectives: After completing this activity, the learner should be better able to understand the effects of procedures and uterine-sparing surgeries for PPH on control of bleeding and adverse effects including infertility and adverse pregnancy outcomes; understand the issues in defining and diagnosing PPH; and understand the areas of future research need.