OB Hemorrhage - Hemostatic Sutures Resources

BACKGROUND: Postpartum hemorrhage (PPH) remains among the 5 main causes of maternal death in developing and developed countries, and uterine atony is the most common cause (75-90%) of primary PPH. Uterine compression sutures running through the full thickness of both uterine walls (posterior as well as anterior) have recently been described for surgical management of atonic PPH. Christopher B-Lynch was the first to highlight this revolutionary principle, and other uterine compression suture techniques have since been described by Hayman and Cho.
OBJECTIVES: Step-by-step description of the B-Lynch brace suture and discussion of the current compression suture techniques.
CONCLUSIONS: The different uterine suture techniques have proved to be valuable and safe alternatives to hysterectomy in the control of massive PPH, and the present review can make the surgeon better aware of their effective use and the risks they may entail.

OBJECTIVE: To review the efficacy, morbidity, and subsequent pregnancy outcome after uterine compression sutures for severe postpartum hemorrhage.
METHODS: A 7-year review (2000-2006) of all uterine compression sutures for postpartum hemorrhage at one tertiary obstetric hospital.
RESULTS: During the 7 years, 28 uterine compression sutures were performed in 31,519 deliveries (1 per 1,126). All were done at the time of cesarean delivery: 22 in 4,870 cesarean deliveries in labor (1 in 221) and 6 in 3,819 elective cesarean deliveries (1 in 637). The indications for suture were atonic postpartum hemorrhage in 25 of 28 (89%), placenta previa in 2 of 28 (7%), and partial placenta accreta in 1 of 28 (4%). Hysterectomy was avoided in 23 of 28 women (82%). Blood transfusion was needed in 13 of 28 (46%), and intensive care in 5 of 28 (18%). Seven women had subsequent uncomplicated term pregnancies, all delivered by elective repeat caesarean delivery.
CONCLUSION: Uterine compression sutures for severe postpartum hemorrhage may obviate the need for hysterectomy and appear not to jeopardize subsequent pregnancy.

Massive postpartum hemorrhage (PPH) is a major cause of maternal mortality in the United Kingdom and worldwide. Life-threatening PPH occurs with a frequency of 1 in 1000 deliveries in the developed world. In the latest triennial Why Mothers Die: Confidential Enquiries into Maternal Deaths in the United Kingdom (1997-1999), PPH was the fifth most common cause of maternal mortality. In this review, we discuss the role of medical management in primary PPH and the use of the "tamponade test" when such management fails. The less radical surgical options discussed include uterine compression sutures, uterine or internal iliac artery ligation, and arterial embolization, all of which have the advantage of potentially preserving reproductive function. Radical surgical options, including subtotal or total hysterectomy, are not discussed in this review. A systematic or algorithmic method of tackling the problem is described. The suggested management approach is likely to reduce maternal morbidity from bleeding, hysterectomies, and maternal deaths.

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, 84.9%-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

Postpartum haemorrhage (PPH) is a worldwide problem. The historical background dates back to William Smelley's in the seventeenth century in his famous treaty of the theory and practice of midwifery in 1752. Changes in clinical factors and surgical expertise compel the modern day midwife and obstetrician to be vigilant in identifying risk factors and apply appropriate solution early. The recent confidential enquiry into maternal death (why mothers die (2000-2002)) identifies areas of substandard care. The rising caesarean section rate adds to the rising incidence of PPH. The reduction in junior doctor's hours may limit the pool of experienced obstetric surgeons available to manage severe PPH competently. There can be major complications following radical surgery for PPH. These include loss of fertility, other morbidity and even maternal death. The invention of the B-Lynch surgical technique for the conservative management of PPH was first performed and reported by a consultant obstetrician and gynaecological surgeon in Milton Keynes NHS Trust publishing the first series of cases in BJOG 1997. This has made a significant impact on the conservative surgical management of massive PPH. There are now over 1300 successful applications of this technique worldwide (CB-Lynch personal communication). Other similar or modified techniques such as Cho's Square Suture and Haymen's modification of the B-Lynch Suture Technique have been introduced adding to more available methods of conservative surgery. The current list of publications of successful application of the B-Lynch compression technique is encouraging and more outcome data can be reported by a letter or e-mail to enquiries@cblynch.com. Obstetricians and midwives both in developed and underdeveloped countries should seek training and attend fire drills in PPH control to avoid maternal morbidity and death. There should be special concentration on effective conservative surgery such as uterine compression techniques to avoid major morbidity and loss of fertility.

BACKGROUND: Postpartum hemorrhage is a major contributor to maternal morbidity and mortality. Numerous medical and surgical therapies have been used, but none has been uniformly successful.
CASE: Two women with postpartum hemorrhage due to uterine atony after cesarean for twins are presented. Neither responded to medical management. In the first subject, O'Leary uterine artery ligation and utero-ovarian branch ligations were done without benefit. The B-Lynch suture immediately sustained correction of hemorrhage in both subjects. Magnetic resonance imaging and hysterosalpingogram after the first case showed no uterine defects.
CONCLUSION: The B-Lynch suture might be a valuable addition to the surgical treatment of postpartum hemorrhage due to uterine atony.

BACKGROUND: It has been estimated that worldwide, over 125,000 women die of postpartum hemorrhage each year. The traditional management of this condition includes the use of oxytocics, such as oxytocin, ergometrine, and prosta- glandins, before proceeding to ligation of the internal iliac arteries and even hysterectomy. The B-Lynch technique is a surgical procedure that may be used to arrest postpartum hemorrhage resulting from uterine atony.
CASES: This paper describes simple modifications of this technique that make this procedure less complex to perform. Three clinical case scenarios illustrate the context in which the sutures may be used.
CONCLUSION: Compression sutures placed into the post-partum uterus may provide a simple first surgical step to control bleeding when routine oxytocic measures have failed. We suggest that the technique we have described is a simple procedure and should be tried before more complex interventions are used.

OBJECTIVE: The objective of the study was to evaluate the effectiveness of a combination of surgical interventions for control of postpartum hemorrhage.
STUDY DESIGN: At cesarean delivery, patients with persistent bleeding from uterine atony after the administration of oxytonics were treated with the placement of a B-Lynch suture. When the B-Lynch failed, subsequent placement of an intrauterine Bakri balloon followed. This combination is termed the uterine sandwich.
RESULTS: The uterine sandwich was successful for all 5 patients undergoing this approach. The median nadir hematocrit was 21.1% (range 20.1% to 28%). The balloon was in place for a median duration of 11 hours (range 10-24 hours). The median volume infused into the balloon was 100 mL (range 60-250 mL). No complications were observed.
CONCLUSION: Placing an intrauterine Bakri balloon in conjunction with the B-Lynch uterine compression suture was successful in treating uterine atony.

OBJECTIVE: To assess the use of B-Lynch type uterine compression sutures as an alternative to hysterectomy for severe postpartum hemorrhage (PPH) due to uterine atony.
METHODS: The use of uterine compression sutures for severe postpartum hemorrhage was reviewed over a 30-month period (January 2000 June 2002) in a tertiary obstetric unit.
RESULTS: In 7 cases of uterine atony at the time of Caesarean section, which were unresponsive to all oxytocic agents, a B-Lynch type compression suture was used before resorting to hysterectomy. In 6 of the 7 women, the bleeding was controlled with the suture, while the other required hysterectomy.
CONCLUSION: At the time of writing there were 6 reports in the literature involving a total of 20 women who were successfully treated with this type of compression suture for severe atonic PPH. Our review adds 7 cases and found that the B-Lynch compression suture is easy to apply and should be considered in cases of severe atonic PPH when oxytocic agents fail, and before resorting to hysterectomy.

Life-threatening post-partum haemorrhage (PPH) occurs with a frequency of 1 per 1000 deliveries in the developed world. In the 1994-1996 Triennial Confidential Enquiry into Maternal Deaths in the United Kingdom primary PPH was responsible for five deaths. In this chapter we discuss briefly the assessment and initial medical management of the patient with primary PPH but concentrate on the surgical management where medical treatment has failed. The surgical management discussed includes both traditional or long-established management strategies together with newer, less radical surgical options, such as embolization techniques, uterine compression sutures and methods involving uterine tamponade, which are less hazardous to perform and have the advantage of preserving reproductive function. The recommendations of the reports from the Confidential Enquiries into Maternal Deaths in the UK are summarized at the end of the chapter. Copyright 2002 Elsevier Science Ltd.

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.

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.