A new uterine compression suture for postpartum haemorrhage with atony

Postpartum haemorrhage (PPH) is a major cause of worldwide maternal mortality and is still associated with significant morbidity. After the B-Lynch suture was reported in 1997, several different uterine compression sutures were found to be successful in controlling PPH. In this paper, we describe another simple variation of the uterine compression suture technique, which was performed without an incision in the uterine wall, without entering the uterine cavity and without suturing the anterior and posterior walls of the uterus together, so minimising the trauma to the uterus. This new uterine compression suture is an effective and safe surgical treatment for PPH caused by atony. It has the potential to apply to intractable PPH after vaginal delivery.     

Ten year follow-up of the effect of the B-Lynch uterine compression suture for massive postpartum hemorrhage

The B-Lynch surgical technique for the management of massive postpartum hemorrhage (PPH) has been used successfully since 1989 in cases where bleeding was secondary to uterine atony with failed conservative management. It allows for conservation of the uterus for subsequent menstrual function and pregnancies. In this report, we present a follow up of a case with successful pregnancy ten years after PPH was managed with the B-Lynch uterine compression suture to demonstrate the long-term anatomical consequences of this operation. This case represents the longest follow up after the application of the B-Lynch suture (brace suture) technique for the control of massive PPH as an alternative to hysterectomy. Published data have confirmed that on the balance of probability, the B-Lynch surgical technique is safe, effective and free of short- and long-term complication.     

Uterine compression sutures for post-partum bleeding with atony; modification of the B-Lynch suture

We have described a modification of the B-Lynch uterine compression suture which is simple and effective. This technique apposes the anterior and posterior uterine walls, obliterating the cavity and thereby provides effective control of post-partum haemorrhage as a result of uterine atony. It comprises of vertical compression sutures and is distinct from B-Lynch and Haymen's suture by having an additional firm puncture just below the uterine fundus. This means that the suture is transfixed at the uterine fundus, thus eliminating the risk of the sutures sliding off at the uterine fundus.     

Uterine compression suture without hysterotomy--why a non-absorbable suture should be avoided.

We describe 2 cases of uterine compression suture without hysterotomy, only described once in the literature previously (Hayman et al. 2002). We consider in detail the suture material used for this technique and show photos of the compression suture at laparoscopy 4 weeks after insertion to demonstrate why it is inappropriate to use a non-absorbable suture. Modified compression sutures are being used increasingly and a wide variety of suture materials are being chosen, including vicryl, PDS and nylon (verbal communications). We feel it important to report our findings so that others can avoid the use of non or slowly absorbable sutures.     

A technique for fixation of retention sutures using two bolsters

Retention sutures using two bolsters provide inherent mechanical advantages in approximating wound edges. As demonstrated in geometric terms, distribution of tension along a bolster maximizes closing force while at the same time reducing stress at the individual suture site. This technique also eliminates circumferential compression of the interceding tissues as well as providing easy access to the wound for daily care. These features make this technique ideal for patients at high risk of wound disruption.     

B-Lynch suture — An experience

Objectives

To study the effectiveness of B-Lynch suture to control postpartum hemorrhage. To know the effect of this extreme degree of compression (produced by B- Lynch suture) on uterine anatomy three months after delivery.

Method

B-Lynch suture (Classical / modified form) was applied in 75 cases. A No. 2 chromic catgut suture was used on a big size round body needle. During the placement of suture, patient was placed in frog-leg position to assess the compression effect of B-Lynch suture. In 62 cases (82.66%) B-Lynch suture was the only intervention. In 8 cases (10.66%) uterine arteries (O’Leary method) were also ligated and in Ave cases (6.66%) cervico-isthmic apposition suture was also applied in addition to B-Lynch suture.

Result

Failure rate was 2.67%. Hysterectomy was required in two cases

Conclusion

B-Lynch suture technique is a simple, effective, safe, life saving and fertility preserving method to control atonic postpartum hemorrhage.     

Modified anchored B-Lynch uterine compression suture for post partum bleeding with uterine atony

A prospective observational study was performed to evaluate the performance of a modified uterine compression suturing technique for the management of refractory post partum hemorrhage (PPH) at two leading tertiary referral centers in Colombo, Sri Lanka. An modified anchored B-Lynch suture was done in 17 women with PPH due to uterine atony. In 13 of the women (76%), bleeding was arrested and the uterus conserved. Four women (24%) did not respond to the anchored compression sutures, necessitating emergency post partum hysterectomy. Mean age was 31.2 years. Nine of the women (53%) were primiparous and eight (47%) parous. Mean estimated blood loss was 1994 ml (range 1200-3300 ml). This newly modified anchor B-Lynch compression suture appeared effective in controlling about 75% of PPH due to uterine atony, which allowed uterine conservation. This simple modification can provide a first line surgical step to control PPH.     

产后出血的保守性手术治疗

产后出血是分娩期常见而且严重的并发症,在药物和子宫按摩不能控制出血时,需采取手术干预。保守性手术是指保留子宫的手术方法,包括血管结扎、宫腔填塞压迫止血、子宫压迫缝合等。B-Lynch缝合技术在产后出血的保守性手术治疗中具有里程碑式的意义,并且由此改良出多种子宫压迫缝合方法。这些技术各有利弊和不同的适应证,根据产后出血的不同原因选择合适的保守性手术方式,才能达到良好止血和减少并发症的目的。     

Technical description of the B-Lynch brace suture for treatment of massive postpartum hemorrhage and review of published cases

Massive uncontrolled hemorrhage after childbirth is a leading cause of the pregnancy-related death and resulting morbidity. Uterine atony is the most common cause (75-90%) of primary postpartum hemorrhage. When simple massage of the uterus and uterotonics such as oxytocins, syntometrine and prostaglandins failed to manage this condition, various surgical solutions have been sought, including uterine artery ligation, more complicated stepwise devascularization of the uterus, internal iliac artery ligation and, ultimately, hysterectomy. All these procedures require above average surgical skill. In contrast, the B-Lynch suturing technique (brace suture) is particularly useful because of its simplicity of application, life saving potential, relative safety and capacity for preserving the uterus and subsequent fertility. The adequacy of haemostasis can be assessed both before and immediately after application of the suture. Only if it fails need other more radical surgical methods be considered. The special advantage of this innovative technique is that it presents an alternative to major surgical procedures for controlling pelvic arterial pulse pressure or hysterectomy. To date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications. This review provides an update on the B-Lynch brace suturing technique, including choice of suture material, use of the technique in early and late gestation, and comparison with other uterine compression surgical techniques. It also includes a comprehensive review and analysis of all published cases and their postoperative follow-up.     

Die B-Lynch-Naht

The B-Lynch suture technique is an established low-risk method for managing postpartum uterine haemorrhaging while conserving the uterus. A less invasive alternative is bimanual compression of the uterus. Both methods represent valid options for conservative procedures in order to maintain fertility.     

Uterine compression sutures, an update: review of efficacy, safety and complications of B-Lynch suture and other uterine compression techniques for postpartum haemorrhage

Since the advent of uterine compression suture by B-Lynch, numerous techniques have been advocated. We aim to discuss these various techniques with respect to their efficacy, safety, complications, complexity of the technique itself, future fertility and menstrual periods. Since no randomized controlled trials are available, the conclusions are based on weak data derived from observational studies and case series. A success rate of 91.7% has been reported for various uterine compression sutures. There are concerns regarding closure of uterine cavity and blood entrapment resulting in infection, pyometra and adhesions as the uterus will be transfixed from front to back in some of the suturing techniques. Long-term follow-up regarding fertility of patients who had uterine compression sutures is urgently needed. Data on menstrual periods after uterine compression sutures is limited. Our review is limited in nature due to lack of consistent data on many important outcomes and also preclinical variables.     

Transverse parallel compression suture: a new suturing method for successful treating pernicious placenta previa during cesarean section

To report a novel method to achieve hemostasis and to evaluate efficacy and safety of controlling hemorrhage from the lower uterine segment (LUS) during cesarean section for placenta previa and accrete compared with conventional surgery. From January 2017 to June 2019, there were 65 cases of pernicious placenta previa admitted in our obstetric department. They all had performed selective cesarean sections. Transverse parallel compression suture was applied in 32 cases during cesarean sections. The bladder was reflected downward till the lowest point of placenta implanted. Two plastic drains were inserted into internal and through the external os, as a support for compressing and draining the uterine cavity. First, at one side of LUS, a Vicryl number one stitch was inserted borderline of myometrium from the anterior to the posterior. The stitch was then inserted borderline of myometrium from the posterior to anterior at the other side in horizontal direction and tightened on the anterior wall of uterine surface. Another suture was inserted superiorly or inferiorly to the first one, at 1 cm interval. Then, such sutures were stitched until the bleeding and dilated LUS became all compressed. The uterine incision was then stitched [group 1 (Gr1)]. Other 33 cases were managed with conventional surgery [group 2 (Gr2)]. The efficiency of this novel technique, in term of blood loss, operation time, the intensive-care unit (ICU) admission rate and hospitalization time after surgery, complications, and postoperative recovery, was compared over the same period. With our transverse parallel compression suture, we were able to preserve the uterus in all cases, while two patients underwent hysterectomy in Gr2. Our success rate in hemostasis was 93.8% (30/32). The operation time, the length of ICU stay, and the rate of ICU admission of Gr1 were lower than Gr2. All patients resumed a normal menstrual flow, and no long-term complications were observed during follow-up. Transverse parallel compression suture is an easy, effective, and safe method to stop bleeding from the lower uterine segment in women with placenta previa and accrete.     

Combination of B-lynch and modified Cho sutures for postpartum hemorrhage caused by low-lying placenta and placenta accreta

Many types of uterine packing are attempted to control PPH, including B-Lynch suture, Cho's suture, and so on. A female PPH caused by a low-lying placenta and placenta accreta did not respond to bimanual compression massage, administration of oxytocin and prostaglandins. A combination of B-Lynch with a modified Cho suture were tried to manage the PPH and succeeded. Combining sutures of B-Lynch with a modified Cho suture not only effectively manage PPH but also conserve the uterus, and avoid infection or adhesions of the endometria and empyema in the cavity of uterus.     

子宫压迫缝合术：过去、现在和将来

子宫压迫缝合术是20世纪末期兴起的产后出血保守性手术方法,虽然取得很好的效果,但仍不断有改良的子宫压迫缝合术或子宫压迫缝合术结合其他方法治疗产后出血的报道。通过介绍子宫压迫缝合术适应证的扩展、以及目前尚未解决的问题,阐述子宫压迫缝合术的研究方向。     

COMOC-MG Stitch: Modification of B-Lynch Suturing Technique to Control Atonic Post-partum Haemorrhage

The COMOC-MG (Compression Of Myometrium and OCclusion of uterine artery by Dr. Mahesh Gupta), a modified B-Lynch stitch technique, utilized polyglycolic acid double strand suture with 80 mm long straight taper point and 50 mm half circle round bodied needle. Its dual action of causing hemostatic compression as well as reduced uterine blood flow, in managing PPH is exemplified using 3 cases. The COMOC-MG stitch technique was found to be effective, with fewer complications, in controlling post-partum haemorrhage (PPH). One subsequent full-term pregnancy occurred after 6 years of this surgery. The COMOC-MG stitch technique is a valuable and safe alternative to B-Lynch or other modified B-Lynch suturing techniques for successful management of atonic PPH, while preserving fertility.     

子宫压迫缝合术治疗产后出血

子宫压迫缝合术是一种简便高效的产后出血保守性手术方法,本文分析目前国内外的多种子宫压迫缝合术在临床应用中存在的局限性与弊端,并讨论在产后出血中的临床应用及注意事项。     

A single continuous suture as a possible alternative to the interrupted suture for tubal anastomosis

A simple alternative for microsurgical anastomosis of the fallopian tube is presented. The anastomosis is composed of a single continuous suture (8-0 nylon) extending through the serosa and muscularis, avoiding the mucosa. Experimentally this technique was performed on the uterine horns of 30 female rats and compared with the conventional interrupted suture technique on 30 additional female rats. Patency was established histologically in 100% of operated horns in both groups, with an average nidation index of 0.7 in the study group as compared with 0.6 in the conventional technique group. The results indicate that this simple method of anastomosis, which reduces operative time significantly, does not affect patency or nidation index in this model as compared with the conventional interrupted suture technique. It may, therefore, be a suitable procedure for anastomosis of equal-sized segments of the fallopian tubes, especially in cases of reversal of sterilization.     

Parallel vertical compression sutures to control bleeding in cases of placenta previa and accreta

Objective: To evaluate the effectiveness of full-thickness vertical compression suture and intrauterine catheter in cases with placenta previa/accreta.

Study design: This study was conducted on Obstetrics and Gynecology emergency unit of Sohag University Hospital. Two longitudinal parallel full-thickness suture was taken using delayed absorbable suture (No. 2 Vicryl…) the entry of needle through anterior wall of lower uterine segment just above the internal os 2–3?cm medial to lateral aspect of lower uterine segment then completely piercing the posterior wall and then return from posterior wall to anterior wall 1–2?cm below incision line of the uterus. Another suture was taken in other side in the same manner. The Foley’s catheter was inserted through the incision line into the cervix and balloon was inflated by 20–30?cc saline.

Results: Two hundred and seventy-eight cases were included in the research. There were 107 cases without significant bleeding from lower uterine segment and no maneuver was needed. The remaining 171 cases were managed by vertical compression suture and intrauterine Foley’s catheter which was successful in 168 cases (98.2%) to stop the bleeding. Only three cases cesarean total hysterectomy was needed.

Conclusions: Vertical lateral compression sutures with inserting inflated balloon of Foley’s catheter is an effective method for controlling bleeding in cases of placenta previa/accreta.