Menstrual, fertility and psychological impacts after uterine compression sutures for postpartum hemorrhage: a prospective cohort study

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In this study, we aim to evaluate the subsequent menstrual, fertility and psychological outcomes after uterine compression sutures. Methods This was a prospective cohort study between 2009 and 2022 conducted in a tertiary obstetric unit (6000 deliveries per year) in Hong Kong SAR. Women with primary postpartum hemorrhage successfully treated with uterine compression sutures were followed-up in postnatal clinic for two years after delivery. Data on menstrual pattern were collected during each visit. Psychological impact after uterine compression suture was assessed using a standardized questionnaire. Subsequent pregnancies were identified by territory-wide computer registry and telephone interviews. Women with postpartum hemorrhage treated with uterotonic agents only were chosen as controls. Results In our cohort (n = 80), 87.9% of women had return of menses within six months after delivery. Regular monthly cycle was observed in 95.6% of women. Majority of women reported similar menstrual flow (75%), menstrual days (85.3%) and no change in dysmenorrhea status (88.2%) as compared before. Among eight (11.8%) women who reported hypomenorrhea after uterine compression sutures, two cases of Asherman’s syndrome were diagnosed. Among 23 subsequent pregnancies (16 livebirths), no significant differences in outcome were observed except more omental or bowel adhesions (37.5% vs 8.8%, p = 0.007), recurrence of hemorrhage (68.8% vs 7.5%, p < 0.001) and repeated compression sutures (12.5% vs 0%, p = 0.024) were seen in women with previous compression sutures. Over half of the couple declined future fertility after uterine compression sutures with 38.2% of women recalled unpleasant memories and 22.1% reported life-long adverse impact especially tokophobia. Conclusion Majority of women with history of uterine compression sutures had similar menstruation and pregnancy outcomes as compared to those who did not have sutures. However, they had higher intrapartum risk of visceral adhesions, recurrence of hemorrhage and repeated compression sutures next pregnancy. Furthermore, couple could be more susceptible to negative emotional impact. Uterine compression sutures B-lynch suture Hayman suture Cho suture pregnancy menstruation fertility psychological impact 1. Background Uterine atony is the commonest etiology of primary postpartum hemorrhage (PPH), ranging from 30 to 80% worldwide [ 1 ]. In the event of failed hemostasis with uterotonic agents, early recourse to conservative surgical management is advisable to prevent maternal morbidity and mortality [ 2 ]. Since 1997, various techniques of uterine compression sutures were described to treat atony, such as B-lynch suture, Hayman suture and Cho suture [ 3 – 5 ]. Being relatively easy and quick to perform, these sutures were efficacious in preventing 97% of hemostatic hysterectomies [ 6 ]. In our previous publication, 75% of hysterectomies were prevented in women treated with uterine compression sutures with additional second-line hemostatic procedures [ 7 ]. Overall, the short-term complication rate was low. While uterine compression sutures were considered effective and safe, literatures on long-term menstruation and fertility outcomes were scarce. The fertility rate after different sutures ranged from 11 to 75% [ 6 ]. Limiting by small number of women included, these studies suggested most pregnancies were uncomplicated and carried till term [ 8 – 11 ]. Nevertheless, rare complications of fundal uterine rupture at third trimester and placenta accreta spectrum overlying the rupture site were reported which raised the concern of whether localized uterine necrosis after compression sutures might increase the risk of myometrial weakening and abnormal placental implantation [ 12 – 16 ]. Menstrual outcome is another important indicator of fertility preservation, especially in women with no desire for future pregnancy. Limited available studies suggested no significant change in menstrual pattern was observed after compression sutures with 91.5 to 100% of these women reported return of menstruation within eight months after delivery [ 17 , 18 ]. Nevertheless, these data might subject to recall bias as most studies were retrospective. Psychological impact among women with PPH without hysterectomy is often neglected. Women described the experience as ‘a feeling of powerlessness’ and ‘a fear of bleeding until death takes over’ [ 19 , 20 ]. Sentilhes reported two-third of women with pervasive negative memory and fear of death after PPH [ 19 ]. In addition, 5.9% of women reported sexual problems and 60% suffered from intense anxiety during their next pregnancy [ 19 ]. Up till now, there has been no research investigating the psychological impacts of both women and their partners after uterine compression sutures for PPH. In the present study, we aim to determine any change in menstrual pattern, adverse pregnancy outcomes and psychological impact in women after uterine compression sutures. 2. Methods This was a prospective cohort study conducted in Tuen Mun Hospital, Hong Kong SAR over a 13-year period. The inclusion criteria were women delivered with primary PPH (blood loss > = 500ml) successfully treated with uterine compression sutures between January 2009 to June 2022 who consented to this study. Principles outlined in the Declaration of Helsinki were followed and this study was approved by the New Territories West Cluster Research Ethics Committee, Hospital Authority, Hong Kong SAR. Uterine compression suture was performed when PPH was not controlled by uterotonic agents. All compression sutures were applied by specialists who had regular training on obstetric emergencies. B-lynch suture, Hayman suture and Cho suture were included in our study design and surgical techniques were strictly followed [ 3 – 5 ]. Monocryl-1 (polyglecaprone 25) absorbable suture was used for B-Lynch and Hayman suture while Vicryl-1 (polyglactin 910) was used for Cho suture. In the event of failed hemostasis, the next performed hemostatic procedure was decided at the discretion of the attending obstetricians. Uterine artery ligations were performed with Vicryl-1 (polyglactin 910) suture. Bakri balloon (Cook Medical, US) was used as intrauterine balloon tamponade. Uterine artery embolization involved injection of absorbable gelatin sponges to extravasating uterine vessels for devascularization. Women were excluded from the present study if hemostatic hysterectomies were performed. Baseline characteristics and clinical details of women were identified through both clinical notes and electronic patient record system. 2.1 Menstrual and psychological assessment Women were assessed in postnatal clinic at six weeks, four months, one year and two years after delivery. Informed consent was obtained. During each visit, they were enquired about the mode of feeding, contraception, cessation of lochia, return of menstruation and a full menstrual history. Primary endpoints were defined as regular cycle, no change in menstrual flow, no change in menstrual days, no dysmenorrhea or no change in the severity of dysmenorrhea as compared to before. In case of menstrual abnormalities, gynecological examination, pregnancy test, cervical smear, ultrasound of pelvis (GE Healthcare Voluson) and endometrial biopsy with or without diagnostic hysteroscopy (KARL STORZ) were performed to rule out structural causes. Genital swabs and serum hormone level (estradiol, follicle-stimulating hormone, prolactin and thyroid hormone) were performed if clinically indicated. In the last session of the follow-up, women were assessed on their psychological impact using a standardized questionnaire designed by Sentilhes [ 19 ]. 2.2 Subsequent pregnancy outcomes In June 2022, we identified all subsequent pregnancies of these women delivered in any public hospitals in Hong Kong SAR through territory-wide electronic registry system. To identify any subsequent pregnancies delivered in private sector or outside our territory, all women received telephone interviews and a list of questions relating to their pregnancies outcomes were asked. A standardized script was available for obtaining consent over telephone. Control group was identified by the next five consecutive women who suffered from atonic PPH, successfully treated with uterotonic agents and had subsequent pregnancies. Women in both groups were matched by their order of pregnancies, number and mode of deliveries. Women with any other previous surgeries were excluded. The demographics and clinical details of these women were retrieved in the same manner as study group. Baseline characteristics of subsequent pregnancies including age of women, interpregnancy interval and order of pregnancy were collected. Number of subsequent ectopic pregnancies, miscarriages, terminations, pregnancies beyond 24 weeks gestation, hypertensive disease, placenta previa, placenta accreta, preeclampsia and uterine rupture were compared. Gestation at delivery, birth weight, numbers of small-for-gestational age fetuses, operative findings, recurrence of atonic PPH and number of repeated compression sutures were compared between the two groups. 2.3 Statistical analysis SPSS Statistics version 21 (IBM, Armonk, NY) was used. Categorical and continuous variables were presented as n (%) and median (range) respectively. Pearson chi-square test and Fisher’s exact test were used for comparing dichotomous data while Student’s t -test and Mann-Whitney U test were used for comparing continuous data. A two-sided P value less than 0.05 was considered statistically significant. 3. Results 3.1 Study participants Over the 13-year study period, 90 uterine compression sutures (0.1%) were performed in the background of 80,087 deliveries. After excluding 10 women who had hysterectomies performed due to failed hemostasis, 80 women were eligible for this study (Figure S1). The baseline characteristics of women with uterine compression sutures were shown in Table 1 . Most participants were primiparous young women with singleton pregnancy. All women delivered by cesarean sections with 86.3% of uterine compression sutures applied for uterine atony. There were nine postpartum short-term complications identified, including four hematometra requiring drainage, four endometritis treated with antibiotics and one retained product of conception requiring surgical evacuation. Majority (97.5%) of women had no antecedent psychiatric disorders with a median Edinburgh Postnatal Depression Scale (EPDS) score of three at their sixth week appointment. Seventy-six (95%) of them had EPDS score fewer than 10. Table 1 Clinical characteristics of women successfully treated with uterine compression sutures Uterine compression suture (n = 80) Age (years) 33 (24–53) Singleton pregnancy 66 (82.5) Multiparity 27 (33.8) Hypertensive disease 5 (6.3) Diabetes mellitus 12 (15) Psychological disorder 2 (2.5) Placenta previa 10 (12.5) Placenta abruptio 6 (7.5) Gestation (weeks) 38 (25–41) Indication for suture - Uterine atony - Placenta previa 69 (86.3) 11 (13.8) Detail of procedures - B-lynch - Hayman - B-lynch + Hayman - B-lynch + UAL - Hayman + UAL - Cho + UAL - B-lynch + UAL + IUBT - Hayman + UAL + UAE 19 (23.8) 27 (33.8) 1 (1.3) 10 (12.5) 19 (23.8) 2 (2.5) 1 (1.3) 1 (1.3) Blood loss (mL) 2800 (500-10000) Birth weight (g) 3060 (795–4470) Postpartum complications - Hematometra - Pyometra - RPOC - Endometritis - Uterine necrosis 4 (5) 0 1 (1.3) 4 (5) 0 EPDS 3 (0–17) UAL, uterine artery ligation; Cho, Cho suture; IUBT, intrauterine balloon tamponade; UAE, uterine artery embolization; RPOC, retained product of conception; EPDS, Edinburgh Postnatal Depression Scale Data are expressed as n (%) or median (range) 3.2 Menstrual outcome and psychological impact Sixty-eight (85%) out of 80 women were compliant to our prospective assessment. The median follow-up period was 12 months (range 6–20 months). Of those who were not on exclusive breastfeeding, 87.9% of women reported return of menses within six months after delivery at a median of nine weeks (Table 2 ). Of note, all participants had return of menses by the end of their last visits. Regular monthly cycle was observed in 95.6% of women with over three quarters of them reporting similar menstrual flow (75%), menstrual days (85.3%) and no change in dysmenorrhea status (88.2%) when compared to before. Table 2 Menstrual outcomes of women after uterine compression sutures Women with prospective follow-up (n = 68) Exclusive breastfeeding 10 (14.7) Resumption of menses < 6 months Ϯ 51 (87.9) Return of menses after delivery (weeks) Ϯ 9 (4–36) Regular monthly cycle 65 (95.6) Menstrual flow • No change in flow • Hypomenorrhea Workup completed* • Asherman’s syndrome • Mild synechiae • Perimenopause • Menorrhagia Workup completed* 51 (75) 8 (11.8) 8 (100) 2 (25) 1 (12.5) 1 (12.5) 9 (13.2) 5 (55.6) Menstrual days • No change in days • Shortened Workup completed* • Perimenopause • Lengthened Workup completed* 58 (85.3) 3 (4.4) 2 (66.7) 1 (50) 7 (10.3) 6 (85.7) Dysmenorrhea • No/ No change • Increased Workup completed* • Decreased Workup completed* 60 (88.2) 5 (7.4) 5 (100) 3 (4.4) 3 (100) ϮWomen on exclusive breastfeeding were not included. *Ultrasound of pelvis, endometrial investigation +/- blood test for hormone level. Data are expressed as n (%) or median (range). Eight (11.8%) women reported hypomenorrhea after uterine compression sutures. Among them, two (25%) were diagnosed with Asherman’s syndrome (Figure S2), one (12.5%) with mild synechiae and one (12.5%) delivered at age 53 was perimenopausal. None of them had future fertility wish. Among other women experiencing changes in menstrual pattern, workup did not reveal any structural causes. Regarding assessment on psychological impact, all women completed questionnaires at the end of their last visits (Table 3 ). Among them, 72.1% declined any more fertility wish with 26.5% did so due to fear of recurrence of PPH. Importantly, 38.2% of women recalled unpleasant memories especially fear of pain and death; and 22.1% of them reported life-long adverse impact especially tokophobia (73.3%). All participants denied any long-term effects on sexual function or marital relationship. When women were asked about their partners’ views on the delivery episodes, 54.4% of them recalled unpleasant memories and 51.5% declined any wish for future pregnancy Table 3 Psychological impact on couple after uterine compression sutures Frequency (n = 68) 1. I plan to get pregnant again. - Yes - No Cause(s) ♣ Already completed family ♣ Personal health issue ♣ Fear of recurrence of PPH 19 (27.9) 49 (72.1) 17 (34.7) 15 (30.6) 13 (26.5) 2. Do you have any unpleasant memory of the experience of PPH? - Yes Cause(s) ♣ Fear of death ♣ Fear of pain ♣ Fear of separation from baby - No 26 (38.2) 10 (38.5) 12 (46.2) 4 (15.4) 42 (61.8) 3. Are there any long-term adverse impacts in your life after PPH? - Yes Cause(s) ♣ Tokophobia ♣ Phobia of hospital ♣ Phobia when seeing blood ♣ Fear of death ♣ Sexual dysfunction ♣ Marital problem - No 15 (22.1) 11 (73.3) 3 (20) 3 (20) 3 (20) 0 0 53 (77.9) 4. Does your partner have any unpleasant memory after the index pregnancy? - Yes - No 37 (54.4) 31 (45.6) 5. Does your partner wish for further child after the index pregnancy? - Yes - No 33 (48.5) 35 (51.5) PPH, postpartum hemorrhage. Data are expressed as n (%) Table 3 Psychological impact on couple after uterine compression sutures PPH, postpartum hemorrhage. Data are expressed as n (%) Frequency (n = 68) 6. I plan to get pregnant again. - Yes - No Cause(s) ♣ Already completed family ♣ Personal health issue ♣ Fear of recurrence of PPH 19 (27.9) 17 (34.7) 49 (72.1) 15 (30.6) 13 (26.5) 7. Do you have any unpleasant memory of the experience of PPH? - Yes Cause(s) ♣ Fear of death ♣ Fear of pain ♣ Fear of separation from baby - No 26 (38.2) 17 (34.7) 10 (38.5) 12 (46.2) 4 (15.4) 42 (61.8) 8. Are there any long-term adverse impacts in your life after PPH? - Yes Cause(s) ♣ Tokophobia ♣ Phobia of hospital ♣ Phobia when seeing blood ♣ Fear of death ♣ Sexual dysfunction ♣ Marital problem - No 17 (34.7) 15 (22.1) 11 (73.3) 3 (20) 3 (20) 3 (20) 0 0 53 (77.9) 9. Does your partner have any unpleasant memory after the index pregnancy? - Yes - No 37 (54.4) 31 (45.6) 10. Does your partner wish for further child after the index pregnancy? - Yes - No 33 (48.5) 35 (51.5) 3.3 Subsequent pregnancy outcomes All women responded to our telephone interviews. None of them reported infertility. Among all 23 subsequent pregnancies, there were 16 livebirths, four miscarriages, two terminations due to fetal anomaly and one ectopic pregnancy (Table 4 ). All pregnancies were conceived naturally. Of the 16 singleton livebirths, there were no cases of preeclampsia, placenta accreta spectrum or uterine rupture. The median gestational age, birth weight and the proportion of small-for-gestational-age fetuses were comparable between both study and control groups. All women with previous uterine compression sutures decided to have repeated cesarean sections in their next pregnancies. Concerning operative finding, there were significant higher risk of omental or bowel adhesions to the uterus in women with previous uterine compression sutures (37.5% vs 8.8%, p = 0.007). Eleven out of 16 women suffered from recurrence of atonic PPH (68.8% vs 7.5%, p < 0.001) with a median blood loss of 800mL compared with 250mL in the control group ( p < 0.001). Two women in the study group failed medical treatment requiring repeated uterine compression sutures for hemostasis (12.5% vs 0%, p = 0.024). No peripartum hysterectomies were performed in our cohort. Table 4 Subsequent pregnancy outcomes of women with or without uterine compression sutures. Uterine compression suture (n = 23) Control (n = 90) P value Age (years) 32 (26–39) 33 (21–44) 0.937 Interpregnancy interval (months) 36 (5-108) 36 (10–120) 0.483 Ectopic pregnancy 1 (4.3) 0 0.204 Miscarriage 4 (17.4) 7 (7.8) 0.260 Termination of pregnancy 2 (8.7) 3 (3.3) 0.268 Pregnancy beyond 24 weeks 16 (69.6) 80 (88.9) 0.044 Antenatal course Hypertensive disease 0 4 (5) > 0.999 Diabetes mellitus 2 (12.5) 16 (20) 0.728 Placenta previa 1 (6.3) 0 0.167 Intrapartum course Gestation (weeks) 38 (36–40) 38 (29–41) 0.257 Preterm delivery 2 (12.5) 11 (13.8) > 0.999 Birth weight (kg) 2.85 (2.30–3.59) 3.05 (1.30–3.80) 0.212 Small-for-gestational age fetus 1 (6.3) 2 (2.5) 0.425 Caesarean section 16 (100) 80 (100) Operative finding • Groove over uterus • Omental/ bowel adhesion 1 (6.3) 6 (37.5) 0 7 (8.8) 0.167 0.007 Blood loss (mL) • Recurrence due to uterine atony 800 (200–1400) 11 (68.8) 250 (100–1000) 6 (7.5) < 0.001 < 0.001 Repeated uterine compression suture 2 (12.5) 0 0.024 PPH, postpartum hemorrhage Values are expressed as n (%) or median (range) To editor: all tables can be put inside the manuscript alongside the text. Thank you. 4. Discussion 4.1 Main findings Our study demonstrated majority of women had return of menstruation with similar patterns after uterine compression sutures. Two cases of Asherman’s syndrome and one mild uterine synechiae were diagnosed among eight women with hypomenorrhea. None of our subjects contemplating next pregnancy reported infertility. Among the 23 subsequent pregnancies, despite most outcome parameters were comparable between women in both study and control groups, we observed a higher incidence of omental or bowel adhesion, recurrence of atonic PPH and repeated compression sutures in the study group. A significant proportion of women were reluctant for future pregnancy after compression sutures with more than one-fifth of them admitting unpleasant memories and long-term adverse impact. 4.2 Strengths and limitations The main strength in our study is the two-year longitudinal clinical follow-up with high patients’ compliance. Thus, clinical information was recorded prospectively minimizing recall bias. In addition, by retrieving pregnancy outcomes from both electronic system and telephone interviews, we improved our data quality in terms of accuracy and exhaustiveness by including early pregnancy loss and terminations which might not had been managed in public sectors. Apart from pregnancies, we also investigated other indicators of subsequent fertility including couple’s fertility wish, workup of any subfertility and return of menstruation. Most of the previous publications included women with B-lynch sutures while there have been reports suggesting probable higher rate of complications after Cho sutures or when compression suture was combined with pelvic vessel ligation [ 21 ]. Thus, another distinct advantage is that we included a variety of compression sutures and a combination with other uterine sparing techniques. Our study is also the first which reported the psychological impact of women after uterine compression sutures. One of our limitations is the potential underestimation of women with mild asymptomatic uterine synechiae as the indication of hysteroscopy was symptom-driven. In addition, the psychological outcomes of our cohort were not compared with women who did not have compression sutures. Moreover, since we did not invite the partners for direct interview, their responses were indirectly collected from our participants. 4.3 Interpretation Uterine compression sutures are easier, quicker and cost-effective to perform comparing with other uterine conservation techniques. Overall, data on long-term pregnancy outcomes has been reassuring [ 2 , 8 – 11 ]. Nevertheless, most of the literatures were case reports or small case series. Poujade O et al. reported uterine synechiae in one-fourth of their cohort which is higher than our result [ 22 ]. It is likely that our study might have underestimated women with mild asymptomatic uterine synechiae as hysteroscopy was offered only in symptomatic women. In our study, there were two women with Asherman’s syndrome and one mild uterine synechiae. Both of our women with Asherman’s syndrome had Hayman sutures applied during their elective cesarean sections. Their immediate post-operative course was unremarkable. The first woman with uterine atony secondary to amniotic fluid embolism also had uterine artery ligations and later pelvic vessel embolization six hours after operation due to persistent bleeding. We postulated the severe hemodynamic shock and the combination of three devascularization techniques might have contributed to uterine ischemia and scarring over the endometrium. The second woman had caesarean sections performed due to cephalopelvic disproportion. Hayman sutures and uterine artery ligations were performed due to uterine atony. Another woman with mild uterine synechiae had elective caesarean sections performed complicating with uterine atony requiring Hayman’s sutures. Presenting with pelvic pain at her second week after delivery, hematometra was diagnosed requiring drainage twice. We agree with other authors that compression sutures might potentiate the formation of endometrial scarring and ischemic damage by excessive suture tension on the myometrium [ 23 ]. Moreover, hematometra and uterine synechiae might be more prevalent after Hayman and Cho sutures as they directly obliterate the anterior and posterior uterine walls. In order to prevent endometrial scarring, application of appropriate tension on uterine walls by suture material which is firm, monofilament and quickly absorbed is of paramount importance. Recently, there were reports of novel compression sutures which were removed in early postoperative period [ 24 ]. Nevertheless, the sample size was small and further evaluation on long-term outcome is needed before clinical application. Our subsequent pregnancy rate was 29% which corresponds well with previous studies [ 6 , 11 ]. Pregnancies from three months to ten years after uterine compression sutures have been reported [ 25 ]. Similarly, in the present study, the interpregnancy interval was between five months to nine years. Comparing with control group with no compression sutures performed, we did not identify any differences in the rate of preterm birth and small-for-gestational-age fetus. Regarding mode of delivery, literatures reported successful vaginal deliveries in up to one-third of the cases [ 8 ]. Interestingly, none of our women chose vaginal delivery. Taking into account of their response in the psychological interviews, their negative memories and fear of recurrence of PPH might explain their wish of having the deliveries conducted in a relatively more controlled manner. We observed significantly more atonic PPH (68.8%) and repeated compression sutures (12.5%) in our cohort. Similar findings were reported by Fuglsang who observed 15% of subsequent deliveries required repeated B-Lynch sutures or hysterectomies [ 8 ]. In addition, significantly more omental or bowel adhesions were noted in one-third of our cohort. Hence, our results suggest a higher level of anticipation of PPH and surgical difficulty should be considered in subsequent deliveries. Previous studies reported severe complications of uterine rupture in next pregnancies [ 11 – 13 ]. In our cohort, we reported none but one woman with evidence of grooves over the uterus which was likely an ischemic defect suggestive of excessive pressure on the myometrium. The number of women with uterine grooves is likely to be underreported as these features could only be diagnosed during operation. Therefore, high vigilance of uterine dehiscence or rupture should be maintained in any women presenting with abdominal pain antenatally. Overall, with the small sample size, it is difficult to draw a conclusion about the effect of compression sutures on subsequent pregnancy outcomes. Remarkably, 72.1% of women and 51.5% of their partners were reluctant for future pregnancy. Nearly one-fourth of them and over half of their partners reported negative memories afterwards. Significantly, among those with long-term adverse impact after the delivery episodes, 73.3% had tokophobia. With our result, we suggest involving professional input in debriefing and providing psychological support sensitively to couple would be beneficial in early postnatal period. Conducting a longer period of research is required to assess the impact to their long-term quality of life. 5. Conclusions Majority of women with history of uterine compression sutures had similar menstruation and pregnancy outcomes as compared to those who did not have sutures. In their future pregnancies, despite most pregnancies were carried till term uneventfully, a higher risk of women with atonic PPH, repeated compression sutures, omental and bowel adhesions were observed. Professional input may be beneficial to address couple’s traumatic memory and emotional recovery after delivery episodes. Large-scale study is needed to narrow this risk estimate. Abbreviations PPH Postpartum hemorrhage EPDS Edinburgh Postnatal Depression Scale Declarations Ethical approval and consent to participate The study was approved by the New Territories West Cluster Ethics Committee (reference: NTWC/CREC/15039) on 13 April 2015. Informed consent was obtained from all study participants. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare they have no competing interests. Funding This study received no funding. Authors’ contributions SFW was involved in conceptualizing the research. PLS designed the study. PLS and LTK involved in data collection and carrying out the study. LTK analyzed the data and wrote the manuscript. PLS and SFW approved the final version. Acknowledgements Authors thank Sim Kuen Chu for conducting the telephone interviews. References Balki M, Wong CA. Refractory uterine atony: still a problem after all these years. Int J Obst Anesth. 2021;48:103207. Nanda S, Singhal SR. Hayman uterine compression stitch for arresting atonic postpartum hemorrhage: 5 years experience. Taiwan J Obstet Gynecol. 2011 Jun;50(2):179–81. Lynch CB, Coker A, Lawal A, Abu J, Cowen M. 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Catastrophic uterine rupture associated with placenta accreta after previous B-Lynch sutures. J Obstet Gynaecol. 2018 Feb;38(2):282–4. Saha S, Abraham A, Raja Navaneethan P, Abraham K. Placenta percreta presenting as uterine rupture following previous B-Lynch suture. BMJ Case Rep. 2021 Oct 1;14(10):e245593. Doumouchtsis SK, Nikolopoulos K, Talaulikar V, Krishna A, Arulkumaran S. Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG. 2014 Mar;121(4):382–8. Tadakawa M, Sugawara J, Saito M, Nishigori H, Utsunomiya H, Nagase S, et al. Fertility and pregnancy outcomes following B-Lynch sutures for post-partum hemorrhage. J Obstet Gynaecol Res. 2015 Apr;41(4):559–64. Sentilhes L, Gromez A, Clavier E, Resch B, Descamps P, Marpeau L. Long-term psychological impact of severe postpartum hemorrhage. Acta Obstet Gynecol Scand. 2011;90(6):615–20. Dunning T, Harris JM, Sandall J. Women and their birth partners' experiences following a primary postpartum hemorrhage: a qualitative study. BMC Pregnancy Childbirth. 2016;16:80. Benkirane S, Saadi H, Serji B, Mimouni A. Uterine necrosis following a combination of uterine compression sutures and vascular ligation during a postpartum hemorrhage: A case report. Int J Surg Case Rep. 2017;38:5–7. Poujade O, Grossetti A, Mougel L, Ceccaldi PF, Ducarme G, Luton D. Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage. BJOG. 2011;118:433–9. Ochoa M, Allaire AD, Stitely ML. Pyometria after hemostatic square suture technique. Obstet Gynecol. 2002;99:506–9. Zhang ZW, Liu CY, Yu N, Guo W. Removable uterine compression sutures for postpartum haemorrhage. BJOG. 2015 Feb;122(3):429–33. Fotopoulou C, Dudenhausen JW. Uterine compression sutures for preserving fertility in severe postpartum haemorrhage: an overview 13 years after the first description. J Obstet Gynaecol. 2010 May;30(4):339–49. Additional Declarations No competing interests reported. Supplementary Files FigureS1studypopulation.docx FigureS2Ashermanssyndrome.docx Cite Share Download PDF Status: Published Journal Publication published 29 Mar, 2023 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Major revision 08 Mar, 2023 Reviews received at journal 10 Feb, 2023 Reviewers agreed at journal 03 Feb, 2023 Reviewers invited by journal 03 Jan, 2023 Editor assigned by journal 03 Jan, 2023 Editor invited by journal 02 Jan, 2023 Submission checks completed at journal 02 Jan, 2023 First submitted to journal 19 Dec, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2394490","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":164288278,"identity":"41b0ac32-f8da-4b81-86ee-2dbe107d8c9e","order_by":0,"name":"Lee Ting Kwong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACPgYGgwMMB0BMxsYHDBAWCBwwwKWFDaGFudmAaC1QhextEsRpkUjeeODHmcNy5vwL26p5au7I8TMwP3x0g+GOMW4taQUHe24cNrac8bDtNs+xZ8aSDWzGxjkMz8xwa8kxOMDz4XbihhsHgVrYDiduOMDDJp3DcNgGn5aDf6Bainn+EanlMM8NoJbzjW3MvG0ILbgdxvOs4LDMmf/GBjcYmyXn9h02lmwG+cXgME7v87Mnb/745lianMH54w8/vPl2WI6fvfnh45yKw4YNuPQIJEAZEgkMTDwgBjOIwBkrIGsOIBiMP/AoHAWjYBSMgpELAO+YZOqOJF6vAAAAAElFTkSuQmCC","orcid":"","institution":"Tuen Mun Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Lee","middleName":"Ting","lastName":"Kwong","suffix":""},{"id":164288279,"identity":"0c37547f-80ef-4d15-9376-08a144d3636f","order_by":1,"name":"Sai Fun Wong","email":"","orcid":"","institution":"Tuen Mun Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sai","middleName":"Fun","lastName":"Wong","suffix":""},{"id":164288280,"identity":"b67679c7-ca1f-41bc-bf14-8afc82db76c1","order_by":2,"name":"Po Lam So","email":"","orcid":"","institution":"Tuen Mun Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Po","middleName":"Lam","lastName":"So","suffix":""}],"badges":[],"createdAt":"2022-12-19 16:59:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2394490/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2394490/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-023-05530-8","type":"published","date":"2023-03-29T20:15:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44723965,"identity":"a09bac23-8633-4373-803d-dc62fac375b3","added_by":"auto","created_at":"2023-10-16 20:23:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":414118,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2394490/v1/1ee96aed-a75f-4aaa-9f49-69175616b9f8.pdf"},{"id":31184064,"identity":"412364d5-30e9-4c7d-a742-51f068cc576b","added_by":"auto","created_at":"2023-01-05 20:41:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30731,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS1studypopulation.docx","url":"https://assets-eu.researchsquare.com/files/rs-2394490/v1/66e6e972019eef551d36bdd4.docx"},{"id":31184348,"identity":"2cbc909c-7415-4db2-991c-e2e5af487204","added_by":"auto","created_at":"2023-01-05 20:49:16","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":218186,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS2Ashermanssyndrome.docx","url":"https://assets-eu.researchsquare.com/files/rs-2394490/v1/1c7decb720b2442b1e2d1e13.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Menstrual, fertility and psychological impacts after uterine compression sutures for postpartum hemorrhage: a prospective cohort study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eUterine atony is the commonest etiology of primary postpartum hemorrhage (PPH), ranging from 30 to 80% worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In the event of failed hemostasis with uterotonic agents, early recourse to conservative surgical management is advisable to prevent maternal morbidity and mortality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Since 1997, various techniques of uterine compression sutures were described to treat atony, such as B-lynch suture, Hayman suture and Cho suture [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Being relatively easy and quick to perform, these sutures were efficacious in preventing 97% of hemostatic hysterectomies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In our previous publication, 75% of hysterectomies were prevented in women treated with uterine compression sutures with additional second-line hemostatic procedures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Overall, the short-term complication rate was low.\u003c/p\u003e \u003cp\u003eWhile uterine compression sutures were considered effective and safe, literatures on long-term menstruation and fertility outcomes were scarce. The fertility rate after different sutures ranged from 11 to 75% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Limiting by small number of women included, these studies suggested most pregnancies were uncomplicated and carried till term [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Nevertheless, rare complications of fundal uterine rupture at third trimester and placenta accreta spectrum overlying the rupture site were reported which raised the concern of whether localized uterine necrosis after compression sutures might increase the risk of myometrial weakening and abnormal placental implantation [\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMenstrual outcome is another important indicator of fertility preservation, especially in women with no desire for future pregnancy. Limited available studies suggested no significant change in menstrual pattern was observed after compression sutures with 91.5 to 100% of these women reported return of menstruation within eight months after delivery [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Nevertheless, these data might subject to recall bias as most studies were retrospective.\u003c/p\u003e \u003cp\u003ePsychological impact among women with PPH without hysterectomy is often neglected. Women described the experience as \u0026lsquo;a feeling of powerlessness\u0026rsquo; and \u0026lsquo;a fear of bleeding until death takes over\u0026rsquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Sentilhes reported two-third of women with pervasive negative memory and fear of death after PPH [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In addition, 5.9% of women reported sexual problems and 60% suffered from intense anxiety during their next pregnancy [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Up till now, there has been no research investigating the psychological impacts of both women and their partners after uterine compression sutures for PPH.\u003c/p\u003e \u003cp\u003eIn the present study, we aim to determine any change in menstrual pattern, adverse pregnancy outcomes and psychological impact in women after uterine compression sutures.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis was a prospective cohort study conducted in Tuen Mun Hospital, Hong Kong SAR over a 13-year period. The inclusion criteria were women delivered with primary PPH (blood loss\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;500ml) successfully treated with uterine compression sutures between January 2009 to June 2022 who consented to this study. Principles outlined in the Declaration of Helsinki were followed and this study was approved by the New Territories West Cluster Research Ethics Committee, Hospital Authority, Hong Kong SAR.\u003c/p\u003e \u003cp\u003eUterine compression suture was performed when PPH was not controlled by uterotonic agents. All compression sutures were applied by specialists who had regular training on obstetric emergencies. B-lynch suture, Hayman suture and Cho suture were included in our study design and surgical techniques were strictly followed [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Monocryl-1 (polyglecaprone 25) absorbable suture was used for B-Lynch and Hayman suture while Vicryl-1 (polyglactin 910) was used for Cho suture. In the event of failed hemostasis, the next performed hemostatic procedure was decided at the discretion of the attending obstetricians. Uterine artery ligations were performed with Vicryl-1 (polyglactin 910) suture. Bakri balloon (Cook Medical, US) was used as intrauterine balloon tamponade. Uterine artery embolization involved injection of absorbable gelatin sponges to extravasating uterine vessels for devascularization. Women were excluded from the present study if hemostatic hysterectomies were performed.\u003c/p\u003e \u003cp\u003eBaseline characteristics and clinical details of women were identified through both clinical notes and electronic patient record system.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Menstrual and psychological assessment\u003c/h2\u003e \u003cp\u003eWomen were assessed in postnatal clinic at six weeks, four months, one year and two years after delivery. Informed consent was obtained. During each visit, they were enquired about the mode of feeding, contraception, cessation of lochia, return of menstruation and a full menstrual history. Primary endpoints were defined as regular cycle, no change in menstrual flow, no change in menstrual days, no dysmenorrhea or no change in the severity of dysmenorrhea as compared to before. In case of menstrual abnormalities, gynecological examination, pregnancy test, cervical smear, ultrasound of pelvis (GE Healthcare Voluson) and endometrial biopsy with or without diagnostic hysteroscopy (KARL STORZ) were performed to rule out structural causes. Genital swabs and serum hormone level (estradiol, follicle-stimulating hormone, prolactin and thyroid hormone) were performed if clinically indicated. In the last session of the follow-up, women were assessed on their psychological impact using a standardized questionnaire designed by Sentilhes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Subsequent pregnancy outcomes\u003c/h2\u003e \u003cp\u003eIn June 2022, we identified all subsequent pregnancies of these women delivered in any public hospitals in Hong Kong SAR through territory-wide electronic registry system. To identify any subsequent pregnancies delivered in private sector or outside our territory, all women received telephone interviews and a list of questions relating to their pregnancies outcomes were asked. A standardized script was available for obtaining consent over telephone. Control group was identified by the next five consecutive women who suffered from atonic PPH, successfully treated with uterotonic agents and had subsequent pregnancies. Women in both groups were matched by their order of pregnancies, number and mode of deliveries. Women with any other previous surgeries were excluded. The demographics and clinical details of these women were retrieved in the same manner as study group.\u003c/p\u003e \u003cp\u003eBaseline characteristics of subsequent pregnancies including age of women, interpregnancy interval and order of pregnancy were collected. Number of subsequent ectopic pregnancies, miscarriages, terminations, pregnancies beyond 24 weeks gestation, hypertensive disease, placenta previa, placenta accreta, preeclampsia and uterine rupture were compared. Gestation at delivery, birth weight, numbers of small-for-gestational age fetuses, operative findings, recurrence of atonic PPH and number of repeated compression sutures were compared between the two groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eSPSS Statistics version 21 (IBM, Armonk, NY) was used. Categorical and continuous variables were presented as n (%) and median (range) respectively. Pearson chi-square test and Fisher\u0026rsquo;s exact test were used for comparing dichotomous data while Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test and Mann-Whitney \u003cem\u003eU\u003c/em\u003e test were used for comparing continuous data. A two-sided \u003cem\u003eP\u003c/em\u003e value less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003e3.1 Study participants\u003c/h2\u003e\n \u003cp\u003eOver the 13-year study period, 90 uterine compression sutures (0.1%) were performed in the background of 80,087 deliveries. After excluding 10 women who had hysterectomies performed due to failed hemostasis, 80 women were eligible for this study (Figure S1). The baseline characteristics of women with uterine compression sutures were shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Most participants were primiparous young women with singleton pregnancy. All women delivered by cesarean sections with 86.3% of uterine compression sutures applied for uterine atony. There were nine postpartum short-term complications identified, including four hematometra requiring drainage, four endometritis treated with antibiotics and one retained product of conception requiring surgical evacuation. Majority (97.5%) of women had no antecedent psychiatric disorders with a median Edinburgh Postnatal Depression Scale (EPDS) score of three at their sixth week appointment. Seventy-six (95%) of them had EPDS score fewer than 10.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical characteristics of women successfully treated with uterine compression sutures\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 41.8815%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003eUterine compression suture (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e33 (24\u0026ndash;53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eSingleton pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e66 (82.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eMultiparity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e27 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eHypertensive disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e5 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e12 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003ePsychological disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e2 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003ePlacenta previa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e10 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003ePlacenta abruptio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e6 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eGestation (weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e38 (25\u0026ndash;41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eIndication for suture\u003c/p\u003e\n \u003cp\u003e- Uterine atony\u003c/p\u003e\n \u003cp\u003e- Placenta previa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e69 (86.3)\u003c/p\u003e\n \u003cp\u003e11 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eDetail of procedures\u003c/p\u003e\n \u003cp\u003e- B-lynch\u003c/p\u003e\n \u003cp\u003e- Hayman\u003c/p\u003e\n \u003cp\u003e- B-lynch\u0026thinsp;+\u0026thinsp;Hayman\u003c/p\u003e\n \u003cp\u003e- B-lynch\u0026thinsp;+\u0026thinsp;UAL\u003c/p\u003e\n \u003cp\u003e- Hayman\u0026thinsp;+\u0026thinsp;UAL\u003c/p\u003e\n \u003cp\u003e- Cho\u0026thinsp;+\u0026thinsp;UAL\u003c/p\u003e\n \u003cp\u003e- B-lynch\u0026thinsp;+\u0026thinsp;UAL\u0026thinsp;+\u0026thinsp;IUBT\u003c/p\u003e\n \u003cp\u003e- Hayman\u0026thinsp;+\u0026thinsp;UAL\u0026thinsp;+\u0026thinsp;UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (23.8)\u003c/p\u003e\n \u003cp\u003e27 (33.8)\u003c/p\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003cp\u003e10 (12.5)\u003c/p\u003e\n \u003cp\u003e19 (23.8)\u003c/p\u003e\n \u003cp\u003e2 (2.5)\u003c/p\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eBlood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e2800 (500-10000)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eBirth weight (g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e3060 (795\u0026ndash;4470)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003ePostpartum complications\u003c/p\u003e\n \u003cp\u003e- Hematometra\u003c/p\u003e\n \u003cp\u003e- Pyometra\u003c/p\u003e\n \u003cp\u003e- RPOC\u003c/p\u003e\n \u003cp\u003e- Endometritis\u003c/p\u003e\n \u003cp\u003e- Uterine necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (5)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003cp\u003e4 (5)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 41.8815%;\"\u003e\n \u003cp\u003eEPDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 57.8608%;\"\u003e\n \u003cp\u003e3 (0\u0026ndash;17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eUAL, uterine artery ligation; Cho, Cho suture; IUBT, intrauterine balloon tamponade; UAE, uterine artery embolization; RPOC, retained product of conception; EPDS, Edinburgh Postnatal Depression Scale\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eData are expressed as n (%) or median (range)\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003e3.2 Menstrual outcome and psychological impact\u003c/h2\u003e\n \u003cp\u003eSixty-eight (85%) out of 80 women were compliant to our prospective assessment. The median follow-up period was 12 months (range 6\u0026ndash;20 months). Of those who were not on exclusive breastfeeding, 87.9% of women reported return of menses within six months after delivery at a median of nine weeks (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Of note, all participants had return of menses by the end of their last visits. Regular monthly cycle was observed in 95.6% of women with over three quarters of them reporting similar menstrual flow (75%), menstrual days (85.3%) and no change in dysmenorrhea status (88.2%) when compared to before.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMenstrual outcomes of women after uterine compression sutures\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWomen with prospective follow-up (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExclusive breastfeeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResumption of menses\u0026thinsp;\u0026lt;\u0026thinsp;6 months\u003csup\u003eϮ\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (87.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReturn of menses after delivery (weeks)\u003csup\u003eϮ\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (4\u0026ndash;36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegular monthly cycle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (95.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMenstrual flow\u003c/p\u003e\n \u003cp\u003e\u0026bull; No change in flow\u003c/p\u003e\n \u003cp\u003e\u0026bull; Hypomenorrhea\u003c/p\u003e\n \u003cp\u003eWorkup completed*\u003c/p\u003e\n \u003cp\u003e\u0026bull; Asherman\u0026rsquo;s syndrome\u003c/p\u003e\n \u003cp\u003e\u0026bull; Mild synechiae\u003c/p\u003e\n \u003cp\u003e\u0026bull; Perimenopause\u003c/p\u003e\n \u003cp\u003e\u0026bull; Menorrhagia\u003c/p\u003e\n \u003cp\u003eWorkup completed*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e51 (75)\u003c/p\u003e\n \u003cp\u003e8 (11.8)\u003c/p\u003e\n \u003cp\u003e8 (100)\u003c/p\u003e\n \u003cp\u003e2 (25)\u003c/p\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003cp\u003e9 (13.2)\u003c/p\u003e\n \u003cp\u003e5 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMenstrual days\u003c/p\u003e\n \u003cp\u003e\u0026bull; No change in days\u003c/p\u003e\n \u003cp\u003e\u0026bull; Shortened\u003c/p\u003e\n \u003cp\u003eWorkup completed*\u003c/p\u003e\n \u003cp\u003e\u0026bull; Perimenopause\u003c/p\u003e\n \u003cp\u003e\u0026bull; Lengthened\u003c/p\u003e\n \u003cp\u003eWorkup completed*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58 (85.3)\u003c/p\u003e\n \u003cp\u003e3 (4.4)\u003c/p\u003e\n \u003cp\u003e2 (66.7)\u003c/p\u003e\n \u003cp\u003e1 (50)\u003c/p\u003e\n \u003cp\u003e7 (10.3)\u003c/p\u003e\n \u003cp\u003e6 (85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDysmenorrhea\u003c/p\u003e\n \u003cp\u003e\u0026bull; No/ No change\u003c/p\u003e\n \u003cp\u003e\u0026bull; Increased\u003c/p\u003e\n \u003cp\u003eWorkup completed*\u003c/p\u003e\n \u003cp\u003e\u0026bull; Decreased\u003c/p\u003e\n \u003cp\u003eWorkup completed*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60 (88.2)\u003c/p\u003e\n \u003cp\u003e5 (7.4)\u003c/p\u003e\n \u003cp\u003e5 (100)\u003c/p\u003e\n \u003cp\u003e3 (4.4)\u003c/p\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eϮWomen on exclusive breastfeeding were not included.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e*Ultrasound of pelvis, endometrial investigation +/- blood test for hormone level.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eData are expressed as n (%) or median (range).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eEight (11.8%) women reported hypomenorrhea after uterine compression sutures. Among them, two (25%) were diagnosed with Asherman\u0026rsquo;s syndrome (Figure S2), one (12.5%) with mild synechiae and one (12.5%) delivered at age 53 was perimenopausal. None of them had future fertility wish. Among other women experiencing changes in menstrual pattern, workup did not reveal any structural causes.\u003c/p\u003e\n \u003cp\u003eRegarding assessment on psychological impact, all women completed questionnaires at the end of their last visits (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Among them, 72.1% declined any more fertility wish with 26.5% did so due to fear of recurrence of PPH. Importantly, 38.2% of women recalled unpleasant memories especially fear of pain and death; and 22.1% of them reported life-long adverse impact especially tokophobia (73.3%). All participants denied any long-term effects on sexual function or marital relationship. When women were asked about their partners\u0026rsquo; views on the delivery episodes, 54.4% of them recalled unpleasant memories and 51.5% declined any wish for future pregnancy\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePsychological impact on couple after uterine compression sutures\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. I plan to get pregnant again.\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003cp\u003eCause(s)\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Already completed family\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Personal health issue\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of recurrence of PPH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (27.9)\u003c/p\u003e\n \u003cp\u003e49 (72.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (34.7)\u003c/p\u003e\n \u003cp\u003e15 (30.6)\u003c/p\u003e\n \u003cp\u003e13 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. Do you have any unpleasant memory of the experience of PPH?\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003eCause(s)\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of death\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of pain\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of separation from baby\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26 (38.2)\u003c/p\u003e \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (38.5)\u003c/p\u003e\n \u003cp\u003e12 (46.2)\u003c/p\u003e\n \u003cp\u003e4 (15.4)\u003c/p\u003e\n \u003cp\u003e42 (61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. Are there any long-term adverse impacts in your life after PPH?\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003eCause(s)\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Tokophobia\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Phobia of hospital\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Phobia when seeing blood\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of death\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Sexual dysfunction\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Marital problem\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (22.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (73.3)\u003c/p\u003e\n \u003cp\u003e3 (20)\u003c/p\u003e\n \u003cp\u003e3 (20)\u003c/p\u003e\n \u003cp\u003e3 (20)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e53 (77.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4. Does your partner have any unpleasant memory after the index pregnancy?\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (54.4)\u003c/p\u003e\n \u003cp\u003e31 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5. Does your partner wish for further child after the index pregnancy?\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33 (48.5)\u003c/p\u003e\n \u003cp\u003e35 (51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003ePPH, postpartum hemorrhage. Data are expressed as n (%)\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePsychological impact on couple after uterine compression sutures PPH, postpartum hemorrhage. Data are expressed as n (%)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6. I plan to get pregnant again.\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003cp\u003eCause(s)\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Already completed family\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Personal health issue\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of recurrence of PPH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (27.9)\u003c/p\u003e\n \u003cp\u003e17 (34.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e49 (72.1)\u003c/p\u003e\n \u003cp\u003e15 (30.6)\u003c/p\u003e\n \u003cp\u003e13 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7. Do you have any unpleasant memory of the experience of PPH?\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003eCause(s)\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of death\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of pain\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of separation from baby\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26 (38.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (34.7)\u003c/p\u003e\n \u003cp\u003e10 (38.5)\u003c/p\u003e\n \u003cp\u003e12 (46.2)\u003c/p\u003e\n \u003cp\u003e4 (15.4)\u003c/p\u003e\n \u003cp\u003e42 (61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8. Are there any long-term adverse impacts in your life after PPH?\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003eCause(s)\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Tokophobia\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Phobia of hospital\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Phobia when seeing blood\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Fear of death\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Sexual dysfunction\u003c/p\u003e\n \u003cp\u003e\u0026clubs; Marital problem\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (34.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (22.1)\u003c/p\u003e\n \u003cp\u003e11 (73.3)\u003c/p\u003e\n \u003cp\u003e3 (20)\u003c/p\u003e\n \u003cp\u003e3 (20)\u003c/p\u003e\n \u003cp\u003e3 (20)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e53 (77.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9. Does your partner have any unpleasant memory after the index pregnancy?\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (54.4)\u003c/p\u003e\n \u003cp\u003e31 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10. Does your partner wish for further child after the index pregnancy?\u003c/p\u003e\n \u003cp\u003e- Yes\u003c/p\u003e\n \u003cp\u003e- No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (48.5)\u003c/p\u003e\n \u003cp\u003e35 (51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003e3.3 Subsequent pregnancy outcomes\u003c/h2\u003e\n \u003cp\u003eAll women responded to our telephone interviews. None of them reported infertility. Among all 23 subsequent pregnancies, there were 16 livebirths, four miscarriages, two terminations due to fetal anomaly and one ectopic pregnancy (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). All pregnancies were conceived naturally. Of the 16 singleton livebirths, there were no cases of preeclampsia, placenta accreta spectrum or uterine rupture. The median gestational age, birth weight and the proportion of small-for-gestational-age fetuses were comparable between both study and control groups. All women with previous uterine compression sutures decided to have repeated cesarean sections in their next pregnancies. Concerning operative finding, there were significant higher risk of omental or bowel adhesions to the uterus in women with previous uterine compression sutures (37.5% vs 8.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007). Eleven out of 16 women suffered from recurrence of atonic PPH (68.8% vs 7.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with a median blood loss of 800mL compared with 250mL in the control group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Two women in the study group failed medical treatment requiring repeated uterine compression sutures for hemostasis (12.5% vs 0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024). No peripartum hysterectomies were performed in our cohort.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u003cbr\u003e\n \u003ctable border=\"1\" id=\"Tab5\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSubsequent pregnancy outcomes of women with or without uterine compression sutures.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUterine compression suture (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (26\u0026ndash;39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (21\u0026ndash;44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.937\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInterpregnancy interval (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (5-108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (10\u0026ndash;120)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.483\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEctopic pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.204\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiscarriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTermination of pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePregnancy beyond 24 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (69.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (88.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntenatal course\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertensive disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.728\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlacenta previa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntrapartum course\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestation (weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (36\u0026ndash;40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (29\u0026ndash;41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreterm delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBirth weight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.85 (2.30\u0026ndash;3.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.05 (1.30\u0026ndash;3.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmall-for-gestational age fetus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.425\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOperative finding\u003c/p\u003e\n \u003cp\u003e\u0026bull; Groove over uterus\u003c/p\u003e\n \u003cp\u003e\u0026bull; Omental/ bowel adhesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (6.3)\u003c/p\u003e\n \u003cp\u003e6 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e7 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlood loss (mL)\u003c/p\u003e\n \u003cp\u003e\u0026bull; Recurrence due to uterine atony\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e800 (200\u0026ndash;1400)\u003c/p\u003e\n \u003cp\u003e11 (68.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e250 (100\u0026ndash;1000)\u003c/p\u003e\n \u003cp\u003e6 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepeated uterine compression suture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ePPH, postpartum hemorrhage\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eValues are expressed as n (%) or median (range)\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eTo editor: all tables can be put inside the manuscript alongside the text. Thank you.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Main findings\u003c/h2\u003e \u003cp\u003eOur study demonstrated majority of women had return of menstruation with similar patterns after uterine compression sutures. Two cases of Asherman\u0026rsquo;s syndrome and one mild uterine synechiae were diagnosed among eight women with hypomenorrhea. None of our subjects contemplating next pregnancy reported infertility. Among the 23 subsequent pregnancies, despite most outcome parameters were comparable between women in both study and control groups, we observed a higher incidence of omental or bowel adhesion, recurrence of atonic PPH and repeated compression sutures in the study group. A significant proportion of women were reluctant for future pregnancy after compression sutures with more than one-fifth of them admitting unpleasant memories and long-term adverse impact.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Strengths and limitations\u003c/h2\u003e \u003cp\u003e The main strength in our study is the two-year longitudinal clinical follow-up with high patients\u0026rsquo; compliance. Thus, clinical information was recorded prospectively minimizing recall bias. In addition, by retrieving pregnancy outcomes from both electronic system and telephone interviews, we improved our data quality in terms of accuracy and exhaustiveness by including early pregnancy loss and terminations which might not had been managed in public sectors. Apart from pregnancies, we also investigated other indicators of subsequent fertility including couple\u0026rsquo;s fertility wish, workup of any subfertility and return of menstruation. Most of the previous publications included women with B-lynch sutures while there have been reports suggesting probable higher rate of complications after Cho sutures or when compression suture was combined with pelvic vessel ligation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Thus, another distinct advantage is that we included a variety of compression sutures and a combination with other uterine sparing techniques. Our study is also the first which reported the psychological impact of women after uterine compression sutures.\u003c/p\u003e \u003cp\u003eOne of our limitations is the potential underestimation of women with mild asymptomatic uterine synechiae as the indication of hysteroscopy was symptom-driven. In addition, the psychological outcomes of our cohort were not compared with women who did not have compression sutures. Moreover, since we did not invite the partners for direct interview, their responses were indirectly collected from our participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Interpretation\u003c/h2\u003e \u003cp\u003eUterine compression sutures are easier, quicker and cost-effective to perform comparing with other uterine conservation techniques. Overall, data on long-term pregnancy outcomes has been reassuring [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Nevertheless, most of the literatures were case reports or small case series.\u003c/p\u003e \u003cp\u003ePoujade O et al. reported uterine synechiae in one-fourth of their cohort which is higher than our result [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. It is likely that our study might have underestimated women with mild asymptomatic uterine synechiae as hysteroscopy was offered only in symptomatic women. In our study, there were two women with Asherman\u0026rsquo;s syndrome and one mild uterine synechiae. Both of our women with Asherman\u0026rsquo;s syndrome had Hayman sutures applied during their elective cesarean sections. Their immediate post-operative course was unremarkable. The first woman with uterine atony secondary to amniotic fluid embolism also had uterine artery ligations and later pelvic vessel embolization six hours after operation due to persistent bleeding. We postulated the severe hemodynamic shock and the combination of three devascularization techniques might have contributed to uterine ischemia and scarring over the endometrium. The second woman had caesarean sections performed due to cephalopelvic disproportion. Hayman sutures and uterine artery ligations were performed due to uterine atony. Another woman with mild uterine synechiae had elective caesarean sections performed complicating with uterine atony requiring Hayman\u0026rsquo;s sutures. Presenting with pelvic pain at her second week after delivery, hematometra was diagnosed requiring drainage twice. We agree with other authors that compression sutures might potentiate the formation of endometrial scarring and ischemic damage by excessive suture tension on the myometrium [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Moreover, hematometra and uterine synechiae might be more prevalent after Hayman and Cho sutures as they directly obliterate the anterior and posterior uterine walls. In order to prevent endometrial scarring, application of appropriate tension on uterine walls by suture material which is firm, monofilament and quickly absorbed is of paramount importance. Recently, there were reports of novel compression sutures which were removed in early postoperative period [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Nevertheless, the sample size was small and further evaluation on long-term outcome is needed before clinical application.\u003c/p\u003e \u003cp\u003eOur subsequent pregnancy rate was 29% which corresponds well with previous studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Pregnancies from three months to ten years after uterine compression sutures have been reported [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Similarly, in the present study, the interpregnancy interval was between five months to nine years. Comparing with control group with no compression sutures performed, we did not identify any differences in the rate of preterm birth and small-for-gestational-age fetus. Regarding mode of delivery, literatures reported successful vaginal deliveries in up to one-third of the cases [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Interestingly, none of our women chose vaginal delivery. Taking into account of their response in the psychological interviews, their negative memories and fear of recurrence of PPH might explain their wish of having the deliveries conducted in a relatively more controlled manner. We observed significantly more atonic PPH (68.8%) and repeated compression sutures (12.5%) in our cohort. Similar findings were reported by Fuglsang who observed 15% of subsequent deliveries required repeated B-Lynch sutures or hysterectomies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition, significantly more omental or bowel adhesions were noted in one-third of our cohort. Hence, our results suggest a higher level of anticipation of PPH and surgical difficulty should be considered in subsequent deliveries. Previous studies reported severe complications of uterine rupture in next pregnancies [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our cohort, we reported none but one woman with evidence of grooves over the uterus which was likely an ischemic defect suggestive of excessive pressure on the myometrium. The number of women with uterine grooves is likely to be underreported as these features could only be diagnosed during operation. Therefore, high vigilance of uterine dehiscence or rupture should be maintained in any women presenting with abdominal pain antenatally. Overall, with the small sample size, it is difficult to draw a conclusion about the effect of compression sutures on subsequent pregnancy outcomes.\u003c/p\u003e \u003cp\u003eRemarkably, 72.1% of women and 51.5% of their partners were reluctant for future pregnancy. Nearly one-fourth of them and over half of their partners reported negative memories afterwards. Significantly, among those with long-term adverse impact after the delivery episodes, 73.3% had tokophobia. With our result, we suggest involving professional input in debriefing and providing psychological support sensitively to couple would be beneficial in early postnatal period. Conducting a longer period of research is required to assess the impact to their long-term quality of life.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eMajority of women with history of uterine compression sutures had similar menstruation and pregnancy outcomes as compared to those who did not have sutures. In their future pregnancies, despite most pregnancies were carried till term uneventfully, a higher risk of women with atonic PPH, repeated compression sutures, omental and bowel adhesions were observed. Professional input may be beneficial to address couple\u0026rsquo;s traumatic memory and emotional recovery after delivery episodes. Large-scale study is needed to narrow this risk estimate.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostpartum hemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEPDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEdinburgh Postnatal Depression Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the New Territories West Cluster Ethics Committee (reference:\u003c/p\u003e\n\u003cp\u003eNTWC/CREC/15039) on 13 April 2015. Informed consent was obtained from all study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSFW was involved in conceptualizing the research. PLS designed the study. PLS and LTK involved in data collection and carrying out the study. LTK analyzed the data and wrote the manuscript. PLS and SFW approved the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors thank Sim Kuen Chu for conducting the telephone interviews.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBalki M, Wong CA. Refractory uterine atony: still a problem after all these years. Int J Obst Anesth. 2021;48:103207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNanda S, Singhal SR. Hayman uterine compression stitch for arresting atonic postpartum hemorrhage: 5 years experience. Taiwan J Obstet Gynecol. 2011 Jun;50(2):179\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLynch CB, Coker A, Lawal A, Abu J, Cowen M. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynecol. 1997;104:372e5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of post partum hemorrhage. Obstet Gynecol. 2002;99:502e6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol. 2000;96:129\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum hemorrhage: An overview. Acta Obstet Gynecol Scand. 2013;92:378\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwong LT, So PL, Wong SF. Uterine compression sutures with additional hemostatic procedures for the management of postpartum hemorrhage. J Obstet Gynaecol Res. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFuglsang J. Later reproductive health after B-Lynch sutures: a follow-upstudy after 10 years\u0026rsquo; clinical use of the B-Lynch suture. Fertil Steril. 2014;101(4):1194\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAn GH, Ryu HM, Kim MY, Han JY, Chung JH, Kim MH. Outcomes of subsequent pregnancies after uterine compression sutures for postpartum hemorrhage. Obstet Gynecol. 2013;122(3):565\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCowan AD, Miller ES, Grobman WA. Subsequent pregnancy outcome after B-lynch suture placement. Obstet Gynecol. 2014;124(3):558\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubbaiah M, Chaturvedula L, Kubera NS, Raj A. Subsequent pregnancy outcome after uterine compression suture placement for postpartum hemorrhage. Int J Gynaecol Obstet. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePechtor K, Richards B, Paterson H. Antenatal catastrophic uterine rupture at 32 weeks of gestation after previous B-Lynch suture. BJOG. 2010 Jun;117(7):889\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmarasekara S, Dissanayake D, Jayawardana A, Silva D. Uterine rupture at 33 weeks following previous B-lynch suture. Ceylon Med J. 2011 Sep;56(3):121\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaman Kumara YV, Marasinghe JP, Condous G, Marasinghe U. Pregnancy complicated by a uterine fundal defect resulting from a previous B-Lynch suture. BJOG. 2009 Dec;116(13):1815\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarlow FH, Smith RP, Nortje J, Anigbogu BO, Tyler X. Catastrophic uterine rupture associated with placenta accreta after previous B-Lynch sutures. J Obstet Gynaecol. 2018 Feb;38(2):282\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaha S, Abraham A, Raja Navaneethan P, Abraham K. Placenta percreta presenting as uterine rupture following previous B-Lynch suture. BMJ Case Rep. 2021 Oct 1;14(10):e245593.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoumouchtsis SK, Nikolopoulos K, Talaulikar V, Krishna A, Arulkumaran S. Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG. 2014 Mar;121(4):382\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTadakawa M, Sugawara J, Saito M, Nishigori H, Utsunomiya H, Nagase S, et al. Fertility and pregnancy outcomes following B-Lynch sutures for post-partum hemorrhage. J Obstet Gynaecol Res. 2015 Apr;41(4):559\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSentilhes L, Gromez A, Clavier E, Resch B, Descamps P, Marpeau L. Long-term psychological impact of severe postpartum hemorrhage. Acta Obstet Gynecol Scand. 2011;90(6):615\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunning T, Harris JM, Sandall J. Women and their birth partners' experiences following a primary postpartum hemorrhage: a qualitative study. BMC Pregnancy Childbirth. 2016;16:80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenkirane S, Saadi H, Serji B, Mimouni A. Uterine necrosis following a combination of uterine compression sutures and vascular ligation during a postpartum hemorrhage: A case report. Int J Surg Case Rep. 2017;38:5\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoujade O, Grossetti A, Mougel L, Ceccaldi PF, Ducarme G, Luton D. Risk of synechiae following uterine compression sutures in the management of major postpartum haemorrhage. BJOG. 2011;118:433\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOchoa M, Allaire AD, Stitely ML. Pyometria after hemostatic square suture technique. Obstet Gynecol. 2002;99:506\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang ZW, Liu CY, Yu N, Guo W. Removable uterine compression sutures for postpartum haemorrhage. BJOG. 2015 Feb;122(3):429\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFotopoulou C, Dudenhausen JW. Uterine compression sutures for preserving fertility in severe postpartum haemorrhage: an overview 13 years after the first description. J Obstet Gynaecol. 2010 May;30(4):339\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Uterine compression sutures, B-lynch suture, Hayman suture, Cho suture, pregnancy, menstruation, fertility, psychological impact","lastPublishedDoi":"10.21203/rs.3.rs-2394490/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2394490/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUterine compression suture is an important conservative surgical technique in managing atonic postpartum hemorrhage. In this study, we aim to evaluate the subsequent menstrual, fertility and psychological outcomes after uterine compression sutures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a prospective cohort study between 2009 and 2022 conducted in a tertiary obstetric unit (6000 deliveries per year) in Hong Kong SAR. Women with primary postpartum hemorrhage successfully treated with uterine compression sutures were followed-up in postnatal clinic for two years after delivery. Data on menstrual pattern were collected during each visit. Psychological impact after uterine compression suture was assessed using a standardized questionnaire. Subsequent pregnancies were identified by territory-wide computer registry and telephone interviews. Women with postpartum hemorrhage treated with uterotonic agents only were chosen as controls.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn our cohort (n\u0026thinsp;=\u0026thinsp;80), 87.9% of women had return of menses within six months after delivery. Regular monthly cycle was observed in 95.6% of women. Majority of women reported similar menstrual flow (75%), menstrual days (85.3%) and no change in dysmenorrhea status (88.2%) as compared before. Among eight (11.8%) women who reported hypomenorrhea after uterine compression sutures, two cases of Asherman\u0026rsquo;s syndrome were diagnosed. Among 23 subsequent pregnancies (16 livebirths), no significant differences in outcome were observed except more omental or bowel adhesions (37.5% vs 8.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007), recurrence of hemorrhage (68.8% vs 7.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and repeated compression sutures (12.5% vs 0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024) were seen in women with previous compression sutures. Over half of the couple declined future fertility after uterine compression sutures with 38.2% of women recalled unpleasant memories and 22.1% reported life-long adverse impact especially tokophobia.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMajority of women with history of uterine compression sutures had similar menstruation and pregnancy outcomes as compared to those who did not have sutures. However, they had higher intrapartum risk of visceral adhesions, recurrence of hemorrhage and repeated compression sutures next pregnancy. Furthermore, couple could be more susceptible to negative emotional impact.\u003c/p\u003e","manuscriptTitle":"Menstrual, fertility and psychological impacts after uterine compression sutures for postpartum hemorrhage: a prospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-01-05 20:41:12","doi":"10.21203/rs.3.rs-2394490/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-03-08T06:07:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-02-10T21:24:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9bb21428-270e-45c6-8f03-f806052c2ad5","date":"2023-02-03T07:54:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-01-03T09:50:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-01-03T09:45:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-01-02T11:17:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-01-02T11:08:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2022-12-19T16:57:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67d51a98-7f71-4b61-8dcc-867a64571658","owner":[],"postedDate":"January 5th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:20:35+00:00","versionOfRecord":{"articleIdentity":"rs-2394490","link":"https://doi.org/10.1186/s12884-023-05530-8","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2023-03-29 20:15:31","publishedOnDateReadable":"March 29th, 2023"},"versionCreatedAt":"2023-01-05 20:41:12","video":"","vorDoi":"10.1186/s12884-023-05530-8","vorDoiUrl":"https://doi.org/10.1186/s12884-023-05530-8","workflowStages":[]},"version":"v1","identity":"rs-2394490","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2394490","identity":"rs-2394490","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}