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Acta Obstetricia et Gynecologica.

2009; 88: 909913

ORIGINAL ARTICLE

Surgical versus medical treatment for secondary post-partum


hemorrhage

TOMER FEIGENBERG, YAEL EITAN, HEN Y. SELA, URIEL ELCHALAL,


ASSAF BEN-MEIR & NATHAN ROJANSKY

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

Introduction 40 years. Secondary PPH has received little attention


or research study, although cases of severe morbidity
Secondary post-partum hemorrhage (PPH) is
and even mortality are still reported (6). Treatment
defined as any abnormal bleeding from the birth
canal occurring between 24 hours and 12 weeks usually falls into one of two categories: surgical
postnatally (1). Since blood loss is difficult to evacuation of the uterus or medical treatment with
assess, the diagnosis is subjective and based on various drugs. In 2005, the Cochrane database
clinical observation. Normal post-partum blood published its review on treatment for secondary
loss varies in amount and duration, with a median PPH (7). No prospective randomized controlled
span of 30 days (2). The loss may be intermittent trials addressing the issue were found, emphasizing
and generally diminishes in 36 weeks. Usually, the lack of research focusing on this problem. In
secondary PPH is defined as heavy bleeding with addition, complications of secondary PPH and its
an abrupt onset, lasting from 7 to 14 days following impact on future fertility have not been sufficiently
delivery. investigated.
The incidence of secondary PPH in developed The aim of our study was to compare initial
countries ranges in different studies from 0.5 to 2% surgical intervention and medical treatment with
(35). Despite a dramatic improvement in perinatal regard to immediate complications and future
care, its occurrence has not changed over the last reproductive performance.

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.

(Received 3 September 2008; accepted 2 June 2009)


ISSN 0001-6349 print/ISSN 1600-0412 online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.1080/00016340903093559
910 T. Feigenberg et al.

Material and methods primary medical treatment (76.3%) and 41 (82%)


from the primary surgical group (Fisher’s exact
Secondary PPH was defined as any excessive vaginal
p0.54). The mean interval from the primary event
bleeding occurring between 24 hours after the end of
to the interview was 88.3 months for the conserva-
the third stage of labor and up to 12 weeks later, in
an amount sufficient to prompt hospitalization. Data tive group, and 81.6 months for the surgical group
were collected from the computerized archives and (not significant). The women were questioned about
medical records were reviewed for relevant data. side effects of the primary treatment, a need for
From 1990 to 2002, 168 women diagnosed with late further intervention after discharge, the desire for
PPH were admitted to the Hadassah Ein-Kerem and future pregnancy after the event, the number of
Mount Scopus Hebrew University hospitals, two future pregnancies, any secondary infertility after the
major referral medical centers in Jerusalem, Israel. primary event, and need for fertility treatment.
The patients were divided into two groups accord- Fisher’s exact test was used for comparisons of
ing to the planned initial treatment: 118 women were variables with two categories between treatment
initially treated medically, while 50 had, as their groups. For other categorical variables the chi-
primary treatment, surgical evacuation of the uterus. squared test was applied. Numeric variable differ-
The mean time between delivery and the day of ences were tested by Student’s t-test. Analysis of
admission was 16.8 days for the group treated co-variance was performed to control for various
conservatively, and 27.9 days for the group treated confounders. Microsoft Excel 2003 and the SPSS/
surgically (t 3.8, df 68, p0.0003). The mean PC package were used for statistical evaluation.
age was 28.5 years for the women treated medically A p B0.05 was considered significant. The local
and 29.9 for the women treated surgically (t 1.4, institutional review board (IRB) approved exemp-
df 166, p 0.16). Women who were treated medi- tion of consent for the use of retrospective files.
cally had a mean of three pregnancies prior to the
event of PPH, while women who were treated
Results
surgically had a mean of 2.7 pregnancies (t0.57,
df 166, p 0.57). There was no difference between Any primary negative outcome (hysterectomy, blood
the groups in mean number of deliveries or transfusion, perforation of the uterus, and systemic
miscarriages prior to the event of PPH (t0.42, infection) was identified in 16.5% of the women who
df 166, p 0.68; t 1.01, df 166, p 0.32). had medical treatment compared to 37.5% of the
A negative primary outcome was defined as any of women who had primary surgical intervention (Fish-
the following severe events: er’s exact, p 0.01). One woman needed a hyster-
ectomy because of uncontrollable bleeding during
1. need for blood transfusion for women whose curettage. Perforation of the uterus was identified
hemoglobin levels were higher than 80 g/L after primary surgical evacuation in two additional
upon admission and dropped during hospitali- cases. Of the subgroup of women who were admitted
zation; to the hospital with a hemoglobin level higher than
2. hysterectomy; 80 g/L and normal blood pressure, as many as 20%
3. perforation of the uterus during primary or of the surgically treated women vs. 9.3% of the
secondary evacuation of the uterus; and women who were treated medically required blood
4. need for broad-spectrum antibiotics due to transfusion after admission (Fisher’s exact, p 
systemic infection. 0.07). Primary negative outcomes are shown in
Table I.
A negative secondary outcome was defined as any
Secondary negative outcomes were observed in
of the following events:
59.1% of the women who had conservative medical
1. need for second evacuation of the uterus or any treatment, and in 53.1% of the women who had
evacuation of the uterus if one was not initially primary surgical treatment. The secondary negative
planned; outcomes are displayed in Table I. Evacuation after
2. re-admission to the hospital after discharge; failure of medical treatment was more common than
3. hospitalization for more than three days; and secondary evacuation after surgical intervention
4. a drop in hemoglobin level of more than 20 g/L (26.3% vs. 8.0%; Fisher’s exact, p0.01).
for those who did not receive blood. Re-admission to the hospital after discharge was
also more common in the conservative medical
A telephone questionnaire was completed for 131 group, although this was not significant (15.5% vs.
(78%) of the women, i.e. 90 women from the 8.2%; Fisher’s exact, p 0.32). Almost half of the
Secondary post-partum hemorrhage 911
Table I. Comparison of primary and secondary negative outcomes of women who were treated medically vs. surgically.

Primary medical (n118) Primary surgical (n 50)

Event No. Percentage (%) No. Percentage (%) p-Value

Blood transfusiona 11 9.3 10 20.0 0.07


Broad-spectrum antibioticsa 10 8.5 9 18.4 0.11
Hysterectomya 0 0 1 2.0 0.30
Perforationa 0 0 2 4.1 0.09
Any negative primary outcomea 19 16.5 18 37.5 0.01
Re-admissiona 18 15.5 4 8.2 0.32
Hospitalizationtwo daysa 48 41.0 22 44.0 0.73
Secondary surgical evacuationa 31 26.3 4 8.0 0.01
Hemoglobin drop20 g/La 16 13.6 5 10.0 0.62
Any negative secondary outcomea 68 59.1 26 53.1 0.49
a
Fisher’s exact test.

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.

Primary medical Primary surgical

Event n Percentage (%) n Percentage (%) p-Value


a
Answered the questionnaire 90 76.3 41 82.0 0.54
Tried to conceive after the eventa 67 74.4 26 65.0 0.30
Secondary infertilitya 8 12.1 8 30.8 0.06
Need for adhesiolysisa 3 2.5 8 16.0 0.03
Infertility treatmentsa 4 10.8 5 27.8 0.13
Mean no. pregnanciesb 2.24 1.85 0.20
Mean no. deliveriesc 2.28 1.5 0.04
Mean no. miscarriagesd 0.4 0.42 0.89
a
Fisher’s exact.
b
t 1.30, df69.9.
c
t 2.95, df68.5.
d
t 0.13, df91.

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.

Primary conservative Primary surgical

Event n Percentage (%) n Percentage (%) p-Value


a
Primary PPH 15 12.8 14 28.0 0.03
Manual separation of the placentaa 5 4.2 8 16.0 0.02
Manual exploration of uterusa 6 5.1 7 14.0 0.06
Mode of deliveryb 0.58
Vaginal delivery 92 78.0 42 84.0
Cesarean section 16 13.6 4 8.0
Vacuum extraction 10 8.5 4 8.0
a
Fisher’s exact.
b 2
x 1.082, df2.
Secondary post-partum hemorrhage 913

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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9. Edwards A, Ellwood DA. Ultrasonographic evaluation of the


ever possible.
postpartum uterus. Ultrasound Obstet Gynecol. 2000;16: / /

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. / /

11. Neil AMC, Nixon RM, Thornton S. A comparison of clinical


assessment with ultrasound in the management of secondary
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