Uterus-Preserving Management of Intractable Haemorrhage Following Suction and Evacuation: A Case Series

Suction and evacuation (S&E) is a very common procedure in obstetric patients with minimal blood loss. Although rare, in cases of secondary postpartum haemorrhage (PPH) due to retained products of conception (RPOC) following delivery (vaginal or caesarean section) and in hydatidiform mole, there is a chance of intractable haemorrhage, following S&E, which may require a hysterectomy. Hysterectomies not only lead to premature menopause but also increase overall morbidity and risk of mortality to the patient. The objective of this study is to highlight the occurrence of intractable haemorrhage following S&E in cases of secondary PPH and molar pregnancies and to evaluate uterine-preserving surgical techniques as effective alternatives to hysterectomy. We present three cases of intractable bleeding following S&E that were managed with conservative uterine preservation. The first case was a 26-year-old primipara presented with secondary PPH one month post-caesarean, requiring blood transfusion. Ultrasound revealed RPOC, and she underwent suction evacuation, but massive bleeding occurred. Suspecting uterine perforation, an exploratory laparotomy was performed, revealing a normal uterus. Bilateral uterine artery ligation successfully controlled the haemorrhage, preserving the uterus. The patient had an uneventful recovery and was discharged on day 7. The second case was a 30-year-old female (Para 3, Live Births 2) with a history of two lower segment caesarean sections (LSCS), who presented with heavy postpartum bleeding 21 days after a preterm vaginal birth after caesarean section (VBAC). Ultrasound revealed RPOC, and she underwent S&E, but heavy bleeding persisted despite uterotonics. Laparoscopic bilateral uterine artery coagulation successfully controlled the bleeding, preserving the uterus. The patient recovered well and was discharged on postoperative day 3. In the third case, a 38-year-old female (Para 5, Live Births 3, Deaths 2) with a diagnosed molar pregnancy underwent S&E, during which she developed a massive haemorrhage. Despite medical management and uterine massage, the bleeding persisted. Laparoscopic uterine artery coagulation successfully controlled the haemorrhage, preserving the uterus. The patient received three units of packed red blood cells (PRBC), recovered well, and was discharged on postoperative day 3, with weekly monitoring until beta-human chorionic gonadotropin (β-hCG) levels normalized. For the conservation of the uterus, uterine artery ligation via laparotomy or laparoscopic coagulation of the uterine artery are both effective and safe procedures. In primigravida patients or those desiring future pregnancies, bilateral uterine artery ligation can be performed to save the uterus, either by laparotomy or laparoscopy, depending on the surgeon's expertise. Laparoscopy offers the added advantages of smaller incisions and a shorter hospital stay.