Department of Obstetrics and Gynaecology, University Hospital Maastricht, Maasticht, The Netherlands E-mail: cwing{at}sgyn.azm.nl
Dear Sir,
I have read with interest the two papers about ligation and embolization of a pelvic artery and impact on fertility and pregnancy. The authors have to be commended for allowing us to share in their vast experience. I would like to make a few remarks.
First of all, it is intruiging that, with a stated incidence of severe intractable haemorrhage post-partum of 1.8 in 1000 pregnancies, the authors where able to present 84 cases (48 ligations, 28 embolizations and eight hysterectomies) in a time period from 1995 to 2000 (Salomon et al., 2003) and 68 cases of ligation in a time period from 1989 to 2001 (Nizard et al., 2003
). This means that these cases had to be coming from a population of >46 000 pregnancies, which seems rather unlikely. What then is the definition of intractable haemorrhage post-partum that calls for a procedure like this? Looking carefully at Table II in the article by Nizard et al. I find that in six patients there were no complications, not even an indication for a blood transfusion. Furthermore I find it amazing that almost all ligations have been performed by a single surgeon. Since the indications for an embolization instead of a ligation were clearly stated, how was it then possible that every time a ligation was needed this particular person was available, throughout these years?
Second, in both articles there are several factors that could have caused bias. There is the fact that many patients were lost to follow-up. And the second study is presented as a cohort study. In both studies, for some patients there was a long time between the procedure and the follow-up, and they were contacted many years after the procedure, which also causes concern for bias. Moreover, the term cohort study is actually not appropriate in this case.
Third, the figures that are presented in the paper by Salomon et al. (2003) do not match. In this article they state that there was one case of secondary infertility after the procedure (patient no. 12), although this patient had been in need of assisted reproduction treatment before the procedure as well. But as appears from Table I, patient no. 12 was not in need of assisted reproduction treatment before the embolization. Furthermore, patient no. 4 was considered as not needing assisted reproduction treatment even though she had not yet conceived after the procedure, because she had only been trying for 4 months. Since she had only been trying for 4 months it could not yet be known whether she would be in need of assisted reproduction treatment later on. Anyhow, she should not have been considered as not needing assisted reproduction treatment.
Even with the above remarks, however, these articles are of great importance. Their importance lies in the fact that in all these women no major complications were encountered and that obstruction of the hypogastric or uterine artery post-partum seems to have had no impact on fertility or subsequent pregnancies. These procedures should be considered early in the management of patients with severe post-partum haemorrhage. Dramatic events like this require fast action. If all else fails, no time should be wasted and obstruction of the hypogastric artery should be performed, one way or the other. If not, only an irreversible procedure such as hysterectomy remains. Residents and gynaecological surgeons should train themselves in identifying the hypogastric artery in situations where there is no stress, so that in case of an emergency this procedure should not be a problem.
References
Nizard, J., Barrinque, L., Frydman, R. and Fernandez, H. (2003) Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum haemorrhage. Hum. Reprod., 18, 844848.
Salomon, L.J., de Tayrac, R., Castaigne-Meary, V., Audibert, F., Musset, D., Ciorascu, R., Frydman, R. and Fernandez, H. (2003) Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum. Reprod., 18, 849852.