Single square hemostatic suture for postpartum hemorrhage secondary to uterine atony

Objective

The objective of this study is to describe a novel technique for the treatment of postpartum hemorrhage and evaluate its effectiveness and safety.

Methods

Single square hemostatic suture was performed for uterine atony when postpartum hemorrhage did not respond to medical therapy and bilateral uterine artery ligation. We retrospectively reviewed the data of 11 women and evaluated their endometrial cavity with hydrosonography after a follow-up period of 8–34 months.

Results

The single square hemostatic suture successfully stopped bleeding in all of the cases. Of the 11 women, 2 could not be traced. Menstruation started without delay in nine women. One of the women achieved pregnancy 25 months after surgery. The six women who underwent hydrosonography had an intact endometrial cavity.

Conclusions

For women who desire future fertility, and when bilateral uterine artery ligation is not sufficient to control PPH, single square suturing may be used as an effective and safe procedure.     

肝针缝合在剖宫产术时子宫收缩乏力性出血中的临床应用观察

目的:探讨剖宫产术时用肝针"8"字缝合子宫治疗子宫收缩乏力性出血的疗效.方法:2002年1月至2008年12月在我院行剖宫产而发生子宫收缩乏力性出血的产妇62例,32例采用肝针"8"字缝合术止血法(肝针缝合组);30例采用传统止血方法,其中15例采用宫腔填塞止血法(宫腔填塞止血组),15例采用盆腔血管结扎法(盆腔血管结扎组).比较3组的术中、术后情况.结果:肝针缝合组与官腔填塞止血组和盆腔血管结扎组在平均手术时间、平均术中出血量、切除子宫数、术后感染、二次手术例数等方面比较差异均有统计学意义(P＜0.05),但宫腔填塞止血组与盆腔血管结扎组之间比较,差异无统计学意义(P＞0.05).结论:肝针缝合用于剖宫产术中子宫收缩乏力性出血,术中能有效止血、减少出血量、缩短手术时间.     

Uterine compression suture may be useful not only for hemostasis in postpartum hemorrhage but also for prophylaxis of acute recurrence of uterine inversion

Uterine compression suture is a safe and effective technique for hemostasis in postpartum hemorrhage. This technique was useful for the prophylaxis of acute recurrence of uterine inversion, which was repositioned under laparotomy. We add a new compression suture to the list of those introduced by earlier researchers.     

Erosion of a B-Lynch suture through the uterine wall: a case report

BACKGROUND: The B-Lynch uterine suture brace has been used for the surgical treatment of postpartum hemorrhage. To date, no complications of this procedure have been reported. We describe B-Lynch suture erosion through the uterine wall identified at a 6-week postpartum visit. CASE: A 19-year-old primigravida underwent a primary low transverse cesarean section at term for arrest of descent. The surgery was complicated by postpartum hemorrhage secondary to uterine atony unresponsive to medical management. The patient underwent successful placement of a B-Lynch suture using delayed, absorbable suture for control of the hemorrhage and had an uneventful postoperative course. At her 6-week postpartum examination, she was found to have the suture protruding from the uterine cervical os. The suture was removed in its entirety without difficulty. Follow-up sonohysterography at 6 months identified a small defect in the anterior wall of the lower uterine segment, corresponding to the probable site of suture erosion. CONCLUSION: Erosion of suture through the uterine wall can be a complication of the B-Lynch uterine suture brace. Delayed, absorbable suture is less desirable than absorbable suture for this procedure due to the risk of erosion through the uterine wall.     

Use of FloSeal hemostatic matrix in a patient with severe postpartum hemorrhage

FloSeal (hemostatic gelatin matrix with a human-derived thrombin component; Baxter Healthcare, Deerfield, IL, USA) hemostatic matrix is used as an adjunct to hemostasis when conventional procedures have proved ineffective. In the present case, FloSeal was used in combination with transfusions, NovoSeven (recombinant activated human factor VIIa; Novo Nordisk, Copenhagen, Denmark) and compression to achieve hemostasis in a patient with postpartum bleeding and hypofibrinogenemia due to primary acute fatty liver of pregnancy. The patient presented with signs of acute hepatic failure, modified renal failure and bleeding disorder at week 37 of pregnancy. She suffered persistent hemorrhage after a soft vacuum-assisted delivery. Local hemostasis was achieved, but not maintained and metrorrhagia resumed requiring transfusion. FloSeal was applied intrauterine and to the vaginal walls, and stable hemostasis was achieved after 2 h. At the one-month post-delivery visit, anatomic and physiological status had returned to normal, although the patient had low fibrinogen and prothrombin activity. This case demonstrates the safety and effectiveness of FloSeal in combination with conventional procedures to achieve hemostasis in postpartum bleeding in a patient with hypofibrinogenemia.     

Hemostatic suturing technique for uterine bleeding during cesarean delivery

BACKGROUND: If medical management is unsuccessful in controlling postpartum hemorrhage, conservative surgical intervention or cesarean hysterectomy is required. TECHNIQUE: Hemostatic multiple square suturing using a straight number 7 or number 8 needle and number 1 chromic catgut is a new surgical technique to approximate anterior and posterior uterine walls, especially in areas where there is heavy bleeding. It controls postpartum hemorrhage by attachment and compression of the hemorrhage site of the endometrium or myometrium. EXPERIENCE: We used this technique in 23 women with postpartum hemorrhages at cesarean who did not respond to conservative treatment. In all 23 cases, bleeding decreased markedly and hysterectomy was avoided. All resumed normal menstrual flow after surgery. In four cases, further pregnancy was achieved after this method was used. CONCLUSION: Hemostatic multiple square suturing is an easy, safe, conservative surgical alternative to hysterectomy for treating uncontrollable postpartum hemorrhage.     

子宫背带式缝合术治疗剖宫产产后出血的临床研究

目的:探讨子宫背带式缝合术在治疗剖宫产产后出血中的应用价值.方法:研究组58例剖宫产术中宫缩乏力性出血病例采用子宫背带式缝合术治疗,随机选择30例剖宫产术中宫缩乏力性出血病例作为对照组采用传统方法治疗,在手术时间、产后出血量、产褥病率以及治疗效果等方面对比两组术式的临床疗效.结果:研究组病例治疗后临床效果显著,其手术时间、产后出血量、产褥病率以及有效率与对照组比较差异有统计学意义(P＜0.05),无一例因血液循环不良或再出血而再次手术或子宫切除,无并发症发生,子宫复旧、月经复潮时间无异常.结论:子宫背带式缝合术具有操作简单、止血迅速及安全易行等诸多优点,早应用可避免增加输血、感染机会以及失血性休克、DIC的发生,并能保留生育功能,是治疗剖宫产产后出血行之有效的外科止血方法.     

B-Lynch suture: a case series

OBJECTIVE: To report an 8-year institutional experience in the use of the B-Lynch Suture for the management of postpartum hemorrhage (PPH). STUDY DESIGN: Cases with B-Lynch suture utilization for severe postpartum hemorrhage were identified, from March 1997 to March 2005, at White Memorial Medical Center. Case charts were reviewed, and postoperative follow-up after hospital discharge was conducted by telephone interview and outpatient clinic chart review. Historical characteristics and outcome of these patients are described. RESULTS: B-Lynch suture was performed on 22 patients, between March 1997 and March 2005, to control intractable PPH at cesarean section that did not respond to uterotonic agents. In 12 instances, the B-Lynch suture was the only intervention, whereas in 10 it was combined with vessel ligation. The procedure resulted in control of bleeding with uterine preservation in 77% of the cases. In those cases where the etiology of PPH was uterine atony, the B-Lynch suture was successful in 85% of the cases. Hysterectomy was avoided in 17/22 cases. CONCLUSION: The B-Lynch suture is an alternative surgical procedure for uterine preservation that may be used to control postpartum hemorrhage from uterine atony.     

Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?

Among 23 women who underwent diagnostic hysteroscopy after triple uterine artery ligation with or without hemostatic multiple square suturing for the management of postpartum hemorrhage (PPH), five had abnormal findings. Endometritis was statistically significantly associated with abnormal diagnostic hysteroscopy findings. Twelve patients developed subsequent pregnancies, and four had abnormal obstetric outcomes: one placenta percreta, one placenta accreta, one recurrent postpartum hemorrhage, and one intrauterine growth retardation.     

Fertility after “only B-Lynch” suture: A case report and literature review

ObjectiveA new fertility assessment after a B-Lynch suture without a concomitant uterine devascularization is proposed.Case ReportThe case of a 37-year-old woman who experienced postpartum hemorrhage due to uterine atony during cesarean delivery of the previous pregnancy is reported. A B-Lynch brace suturing technique, not associated to any other hemostatic surgical procedure, was carried out. One year later and after an uncomplicated pregnancy of 39 weeks, the patient delivered a healthy infant by an elective cesarean section. Only omental adhesions were found on the anterior surface of the uterus as a consequence of the previous B-Lynch suture.ConclusionThe B-Lynch hemostatic surgical procedure, alone, does not seem to have a negative impact on fertility. Additional clinical evidences in a greater case-series of patients are needed to assess the value of the method for fertility preservation.     

子宫B-Lynch缝合术联合宫腔纱条填塞术在中央性前置胎盘剖宫产术中产后出血的应用

目的:探讨子宫B-Lynch缝合术联合宫腔纱条填塞术(即子宫三明治缝合术)在中央性前置胎盘剖宫产术中防治产后出血中的应用价值。方法:收集我院2014年1月—2016年1月中央性前置胎盘剖宫产术中产后出血患者50例,35例行宫腔纱条填塞术(对照组),15例行子宫B-Lynch缝合术联合宫腔纱条填塞术(观察组),对2组患者术中、术后情况及治疗结果进行分析。结果:观察组术中出血量[(1 140.00±184.00)mL]、输血量[(684.00±118.00)mL]低于对照组[(1 507.11±300.62)mL,(900.00±170.00)mL],差异有统计学意义(均P0.05)。观察组的止血成功率(93.33%)与对照组(82.86%)比较差异无统计学意义(χ~2=0.950,P=0.328)。结论:子宫B-Lynch缝合术联合宫腔纱条填塞术应用于中央性前置胎盘剖宫产术中能够降低出血量及输血量,提高止血成功率,值得临床应用。     

Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII

BACKGROUND: Postpartum hemorrhage is one of the most common causes of maternal mortality and morbidity worldwide. The aims of treatment are to maintain the circulation and to stop the bleeding. The latter is achieved by either medical or surgical management. In intractable bleeding, emergency hysterectomy is usually required. CASE: A 30-year-old nullipara presented with major postpartum hemorrhage due to uterine atony and vaginal lacerations. The patient developed hemorrhagic shock, resulting in prolonged prothrombin time, prolonged activated partial thromboplastin time, and low levels of factor VIII and fibrinogen. Treatments with uterotonic drugs, suturing, ligation of internal iliac arteries, subtotal hysterectomy, packing of the pelvis, and blood transfusion failed to control diffuse pelvic and vaginal bleeding. Recombinant activated factor VIIa (60-microg/kg intravenous bolus injection) was given as a final attempt to control the bleeding. The bleeding was successfully controlled within 10 minutes after administration. No side effects were noted. CONCLUSION: Recombinant factor VIIa may be an alternative hemostatic agent in a patient with life-threatening postpartum hemorrhage unresponsive to conventional therapy.     

A new uterine suture technique for postpartum hemorrhage

At present, postpartum hemorrhage is still an important cause of maternal mortality and morbidity. When medical therapy has no success, conservative surgical procedures are applied before making a hysterectomy. Three transverse sutures are applied to the entire uterine wall both to the right and the left side of the uterus. Our technique has been applied to 4 women with postpartum hemorrhage secondary to uterine atony. Bleeding was stopped immediately by compressive sutures. The four patients had normal menstruation cycles after delivery and had new pregnancies. No woman had postoperative complications. Uterus compressive suture is an effective alternative to hysterectomy to treat postpartum hemorrhage secondary to atony. This is a simple and quick procedure that preserves fertility.     

剖宫产手术中并发产后出血保守治疗

剖宫产手术过程中常发生出血增多，若不及时处理可导致严重产后出血。术中根据出血状况及时采取有效治疗措施，避免严重出血带来的一系列并发症极其重要。文章从药物治疗、宫腔填塞、子宫压迫缝合、血管阻断等方面对剖宫产手术中各类止血方案的优缺点和使用时机展开论述，强调止血宜及时，尽早达到止血效果，减少大量出血后并发症的发生。     

Successful of the B-Lynch compression suture in the management of massive postpartum hemorrhage: case reports and review

The authors describe three patients who developed massive primary postpartum hemorrhage and review the case reports. In two patients, primary postpartum hemorrhage was due to uterine atony, and in one patient it was due to atony and thrombophilia. In all three patients, excellent effect was achieved with hemorrhage reduction by a compression B-Lynch suture alone, with bimanual compression following medicamentous uterotonic therapy. B-Lynch suture is an efficient, safe, and simple method for the treatment of primary postpartum hemorrhage during cesarean section, which successfully reduces the number of urgent postpartum hysterectomies, also preserving subsequent fertility. In our opinion, the method should be included in the algorithm of primary postpartum hemorrhage management at all obstetric departments.     

Laparoscopic clips. Evaluation of absorbable and titanium with regard to hemostasis and tissue reactivity.

Advanced laparoscopic techniques require laparoscopic means of providing hemostasis. We tested the hemostatic ability of laparoscopic surgical clips and their tissue reactivity as assessed by adhesion formation in an animal model. Twenty-six New Zealand white rabbits were randomized at laparotomy to one of three treatment groups: titanium surgical clips, absorbable surgical clips (both applied with a laparoscopic clip applicator) and chromic sutures of equal mass. Either the right fallopian tube was transected, with clips or sutures applied proximally and distally to control bleeding, or the clips or sutures were applied 5 mm apart and the tube transected. A clip or suture of the same material was placed on the midportion of the left fallopian tube. Necropsy was performed at 42 days, and each clip/suture site was scored for adhesions. All the materials were easily applied and effective in achieving hemostasis. The adhesion scores tended to be lower with the absorbable clips; however, there were no statistically significant differences between the groups. Laparoscopic clips are effective in providing hemostasis, are easily applied and cause no more adhesion formation than do conventional suture materials.     

Hemostasis and cold knife cone biopsy: a prospective randomized trial comparing a suture versus non-suture technique

Two methods of obtaining hemostasis after cold knife cone biopsy were compared in a prospective randomized trial involving 200 patients. One method relied primarily on hemostatic sutures, and the other involved the use of a styptic solution (Monsel's solution) and vaginal pack, thus avoiding the use of sutures altogether. The short- and long-term morbidity in these two groups were compared and 12-month follow-up was completed. The use of sutures did not reduce the incidence of primary hemorrhage. Secondary hemorrhage was twice as frequent in the suture group, although this trend did not quite reach statistical significance. During long-term follow-up, significantly more patients in the suture group developed menstrual symptoms, cervical stenosis, and unsatisfactory colposcopy, requiring further operative intervention as a result.     

子宫排钉式缝合术用于剖宫产术中宫缩乏力性产后出血的治疗体会

目的：探讨子宫排钉式缝合术用于剖宫产术中宫缩乏力性产后出血的临床价值。方法：2007年1月—2014年5月在我院住院分娩发生产后出血218例,回顾性分析其中因剖宫产术中子宫收缩乏力性产后出血的82例经按摩子宫及应用缩宫素、欣母沛等保守治疗无效患者的临床资料。其中40例实施子宫排钉式缝合术（观察组）,20例实施B-Lynch缝合术（对照1组）,22例实施宫腔纱条填塞术（对照2组）。全子宫收缩乏力患者联合子宫动脉、卵巢动脉结扎。比较3组患者止血效果,术后子宫切口愈合及子宫血运情况,以及术后并发症、子宫复旧情况、恶露排净时间和月经复潮时间。结果：观察组止血率100%,对照1组止血率85.00%,对照2组止血率81.8%,3组间比较差异有统计学意义（P＜0.05）。3组产妇子宫切口均愈合良好,子宫血流恢复良好,卵巢血流丰富。观察组产妇6例发热;对照1组3例发热,1例肠梗阻;对照2组6例发热,2例误将纱条与子宫切口缝合。3组产妇发热的发生率差异无统计学意义（P＞0.05）。3组产妇子宫复旧佳、恶露排净时间、月经复潮时间差异均无统计学意义（P＞0.05）。结论：子宫排钉式缝合术治疗剖宫产术中子宫收缩乏力性产后出血,止血迅速,成功率高,并发症少,易于掌握,值得推广。     

Management of severe postpartum hemorrhage by intrauterine irrigation with prostaglandin E2

Continuous intrauterine irrigation with minute amounts of prostaglandin E2 was used in 22 patients with severe postpartum hemorrhage unmanageable by conventional therapy. Twenty-one women were treated because of uterine atonic hemorrhage and one because of late postpartum hemorrhage from subinvolution. A quick tetanic contraction of the uterine muscle with dramatic and sustained hemostasis was achieved in all patients. The therapeutic response was continuous and uninterrupted regardless of the predisposing factors for the hemorrhage or the hemodynamic condition of the patients. No side effects were observed.     

前置胎盘剖宫产时环形间断缝合止血方法的探讨

目的探讨环形间断缝合在前置胎盘剖宫产术时出血的止血效果。方法对54例前置胎盘剖宫产术病例进行总结。结果用环形间断缝合方法止血的9例病人手术时间少于子宫切除组(P＜0.05),出血及输血少于子宫切除组,但无统计学差异(P＞0.05),成功止血,保留子宫,且未发生术后合并症。结论环形间断缝合术是前置胎盘胎盘剥离面引起出血的有效止血方法之一。