Evaluation of postoperative gynecological and long-term fertility status in cases with hypogastric artery ligation due to severe postpartum bleeding

Objective: To investigate whether hypogastric artery ligation (HGAL) is an effective fertility-sparing surgical procedure that can be performed safely in young and low-parity patients who desire fertility or who would be more appropriate to preserve fertility in severe postpartum hemorrhage and to evaluate the gynecological complaints and future pregnancy outcomes of patients in the long-term postoperative period. Materials and Methods: Patients (n = 68) who were hospitalized in the Obstetrics and Gynecology Service of Dicle University Medical Faculty Hospital between January 2007 and December 2018 and who underwent unilateral or bilateral HGAL using a similar surgical technique with obstetric bleeding indication and whose uterus was preserved were included in the study. The records of the patients were collected retrospectively from the files in the hospital archive. The use of invasive and / or surgical additional methods to provide hemostasis during the operation, presence of maternal morbidity, intraoperative and / or postoperative complications were evaluated in cases. Long-term operation-related gynecological complaints and menstrual cycle patterns of the patients were questioned through a questionnaire. 37 patients who did not undergo bilateral tubal ligation (BTL) during the operation were analyzed in terms of all parameters as a separate group. In this group, the percentage of patients who were diagnosed with secondary infertility in the following years and who could conceive with fertility desire was calculated. Long-term pregnancy outcomes of cases with pregnancy were evaluated. Results: The mean value of the operative age of 68 patients included in the study was 30.7 ± 6. HGAL procedure was applied in one of ~ 243 live births performed in our hospital. Bilateral HGAL was applied to 59 patients (86.8%) and unilateral HGAL was applied to 9 patients (13.2%) using the fertility-sparing procedure. It was observed that the HGAL procedure was performed most frequently (79.4% and n = 54) during cesarean section and associated with placenta previa and / or invasion anomaly (69.1% and n = 47). During the operation, the most preferred additional hemostasis method by the surgeon was bilateral or unilateral uterine artery ligation (64% and n = 32). The overall complication rate was 23.5% (n = 16), and left ureter ligation occurred in 1 patient associated with the HGAL procedure. Postoperative complications or maternal morbidity were present in 50% of the patients (n = 34) and the most common postoperative complications were disseminated intravascular coagulation and incision site infection (n = 5 and 35.7%), while maternal morbidity was massive blood transfusion (n = 29 and 42.6%). It was observed that the need for complete blood replacement during the hospitalization period was higher in the patient group who did not use additional hemostasis and / or surgical procedures during the operation compared to the patient group used (p = 0.039). There was no statistically significant difference between the groups in terms of replacement needs of other blood product types. In addition, as the age of operation of the patients increased, it was observed that the need for replacement with FFP (p = 0.039), fresh whole blood (p = 0.025) and fibrinogen (p = 0.021) during clinical follow-up increased. There was no statistically significant relationship between the increasing operative age and the replacement amount of other blood product types. It was observed that the patients were followed up for an average of 8.74 ± 7.13 days in the clinic and 5.48 ± 5.31 days in the intensive care unit. BTL procedure was applied to 45.6% (n = 31) of the patients during the operation. Secondary infertility was detected in 6 patients (23.1%) in the non-BTL group. In this group, the fertility rate was calculated as 76.9% (n = 20). Gynecological complaints were recorded in 50% (n = 34) of the patients in the long term after the operation. The most common complaint was found to be secondary dysmenorrhea (n = 17 and 50%). In 25 cases, pregnancy status developed in the postoperative long term after HGAL. 15 of the pregnancies resulted in term delivery, 7 with preterm delivery and 3 with abortion. Conclusion: Internal iliac artery ligation does not adversely affect the long-term menstrual cycle pattern and quality of life of the patients in terms of gynecological complaints. It preserves the fertility of patients and should be the preferred surgical procedure, especially in women with low parity at a young age. The HGAL procedure, which should be performed by experienced surgeons who have a good command of the retroperitoneal area, should become a viable technique by most obstetricians and should be an integral part of obstetric-gynecological surgical training.