Obstetrical and fertility outcomes following pelvic arterial embolization for postpartum hemorrhage – a cohort follow-up study

Objectives:

Management of severe postpartum hemorrhage (PPH) includes pelvic arterial embolization (PAE). Despite its widespread use, there is still insufficient data regarding fertility and obstetrical outcomes following PAE for PPH. The purpose of our study was to evaluate long-term outcomes of patients who underwent PAE for PPH, particularly with regard to subsequent fertility and following pregnancies.

Material and methods:

28 patients who underwent pelvic arterial embolization for PPH at our institution between 2009 and 2019 were included in our retrospective study. Data were assessed by reviewing patients’ charts and directly contacting the patients.

Results:

Six (21%) patients had elective PAE prior to caesarean hysterectomy in placenta increta/percreta, and were therefore excluded from this analysis. Data from 22 (79%) of the remaining patients could be successfully assessed.

13 (59%) of the interviewed patients reported having regular menstruation after PAE, two of them only after hysteroscopy was performed (either because of cervical stenosis or presence of Ashermann syndrome). In 3 (14%) patients, menstruation was either irregular or weak. One of the patients reported having lactational amenorrhea. In 5 patients information regarding resumed menstruation was missing.

11 women had no desire for a subsequent pregnancy. Seven of the remaining patients (63%) had a total of 13 spontaneous pregnancies. Nine of these pregnancies resulted in a miscarriage in the first trimester, seven of them in the same patient. Of the four patients (36%) who had a successful term pregnancy, one delivered vaginally (25%) and three underwent repeat cesarean section (75%). Two patients (50%) had recurrent postpartum hemorrhage, which could be treated with conservative measures. One patient suffered from recurrent placenta accreta and one pregnancy presented with vasa previa.

Of the patients with infertility (n = 4, 36%), two (18%) underwent assisted reproductive technology (ART) treatment without success.

Tab. 1: Fetal outcomes in subsequent pregnancies after PAE

Fig. 1: Patients' outcomes after PAE

Conclusion:

Our study suggests that fertility of patients undergoing pelvic arterial embolization due to PPH in a previous pregnancy is limited. In women who become pregnant, first trimester miscarriage as well as recurrent PPH seem to be increased. If this is the consequence of the underlying cause of PPH or of the PAE treatment remains unknown. Larger follow-up cohorts are needed. In the meantime, patients who desire pregnancy after PAE for PPH should be counseled accordingly.