Systematic review of conservative management of postpartum hemorrhage: What to do when medical treatment fails

We performed a systematic review to identify all studies evaluating the success rates of treatment of major postpartum hemorrhage by uterine balloon tamponade, uterine compression sutures, pelvic devascularization, and arterial embolization. We included studies reporting on at least 5 cases. All searches were performed independently by 2 researchers and updated in June 2006. Failure of management was defined as the need to proceed to subsequent or repeat surgical or radiological therapy or hysterectomy, or death. As the search identified no randomized controlled trials, we proceeded to search for observational studies. This identified 396 publications, and after exclusions, 46 studies were included in the systematic review. The cumulative outcomes showed success rates of 90.7% (95% confidence interval [CI], 85.7%-94.0%) for arterial embolization, 84.0% (95% CI, 77.5%-88.8%) for balloon tamponade, 91.7% (95% CI, 84.90%-95.5%) for uterine compression sutures, and 84.6% (81.2%-87.5%) for iliac artery ligation or uterine devascularization (P = 0.06). At present there is no evidence to suggest that any one method is better for the management of severe postpartum hemorrhage. Randomized controlled trials of the various treatment options may be difficult to perform in practice. As balloon tamponade is the least invasive and most rapid approach, it would be logical to use this as the first step in the management.