Hysteroscopy after conservative surgical treatment of severe postpartum hemorrhage due to uterine atony: A systematic literature review

Abstract Objective To assess the prevalence of intrauterine anomalies, primarily intrauterine adhesions (IUAd), after conservative surgical treatment of severe postpartum hemorrhage with uterine atony (SPPH‐UA) and determine patient eligibility for hysteroscopy. Methods PubMed and the Cochrane Library were searched by combining keywords “postpartum hemorrhage”, “uterine atony”, and “hysteroscopy” to perform a literature review. Articles in French and English with more than five cases of hysteroscopy following SPPH‐UA were selected. All cases that had hysteroscopy after conservative surgical treatment of SPPH‐UA were collected. A blinded statistical analysis revealed IUAd risk factors. Results In all, 83% of patients agreed to hysteroscopy and 38% of 71 cases had an IUAd. Age was not a risk factor ( P = 0.950). Other factors included multiparity (odds ratio [OR] 1.93, P = 0.039), cesarean delivery (OR 3.58, P = 0.584) and postpartum infection (OR 3.33, P = 0.04). Risk was at 57% after uterine padding with multiple transfixing square stitches (Cho‐technique) ( P = 0.001), 6% after non‐transfixing uterine folding brace suture (B‐Lynch technique) when used alone, 29% after uterine artery embolization and after internal iliac artery ligation (OR 0.98, P = 0.645); uterine vascular ligation (OR 0.69, P = 0.253) and more than two procedures (OR 0.69, P = 2.53). Disparity between authors was observed ( P = 0.015) and concerned only the surgical techniques used. Conclusion A classification is proposed for deciding post‐SPPH hysteroscopy. Further studies are required to determine appropriateness.