Primary postpartum hemorrhage is the most common cause of direct maternal death in the developing world.1 Even in the developed world, where postpartum hemorrhage is fifth among the leading causes of direct maternal death, it is the commonest cause of severe maternal morbidity.2,3 When, at the time of cesarean delivery, uterotonic drugs failed to control uterine atony, B-Lynch et al4 reported a compression suture technique used successfully in five cases to avoid hysterectomy. Others modified the B-Lynch technique using vertical compression sutures5 and square suture techniques to appose the anterior and posterior walls of the uterus.6 Case reports of single or small numbers of successful use, mainly for uterine atony at the time of cesarean delivery, but also for placenta previa and partial placenta previa accreta, have been reported.7–11 Most of the case reports were from one to three cases, and all were successful in controlling the hemorrhage and avoiding hysterectomy. In 2003, we reported our preliminary experience in seven cases with one failure.12 Wohlmuth et al13 documented a series of 22 patients, with a success rate of uterine preservation in 77%. In most of the series, there have been no serious postoperative sequelae, but rare cases of uterine necrosis have been reported.14,15 There have been isolated case reports of uneventful subsequent pregnancies after previous compression sutures.10,11,16,17 This report covers a 7-year review of 28 cases with the efficacy, perioperative morbidity, and outcome of subsequent pregnancies.
MATERIALS AND METHODS
A 7-year prospective review was performed from 2000 through 2006 of all cases of uterine compression sutures at a tertiary obstetric hospital (Women’s Hospital, IWK Health Centre, Halifax, Nova Scotia) at which there are approximately 4,500 deliveries annually. All cases were managed directly by consultant obstetricians. The technique of the B-Lynch compression suture has been previously described.4 The suture material used was No. 2 chromic or No. 1 Vicryl (Ethicon, Somerville, NJ). In a number of cases the individual obstetrician chose to perform additional compression sutures of the vertical type5 or the square suture technique.6 These additional sutures were performed when, in the judgement of the obstetrician, there were areas of the uterus that were not completely compressed by the B-Lynch technique. In one case of placenta previa, the square compression technique alone was used in the lower uterine segment because the upper uterine segment was well contracted. The following data were extracted from the hospital charts and interview with the obstetrician within 72 hours after each case: parity, induction of labor, duration of second stage of labor, indication for cesarean delivery, use of uterotonic drugs, blood transfusion, method of anesthesia, additional surgical procedures, preoperative and postoperative hemoglobin and hematocrit changes, postpartum stay, need for intensive care, postpartum complications, and duration of stay. Details of subsequent pregnancies were also obtained from the hospital chart and the individual obstetrician. Ethical approval for this study was obtained from the Research Ethics Board at the IWK Health Centre, Halifax, Nova Scotia. Descriptive characteristics were calculated for the variables of interest.
During the 7 years, 2000–2006, there were 28 uterine compression sutures 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 per 221) and six in 3,819 elective cesarean deliveries without labor (1 per 637). All but three (33, 34, and 36 weeks) were at 37–41 weeks of gestation at the time of cesarean delivery. The indications for compression sutures were uterine atony in 25 of 28 (89.3%), placenta previa in 2 of 28 (7.2%), and partial placenta accreta in 1 of 28 (3.6%). All sutures were placed because of hemorrhage, and none were placed prophylactically. The perioperative details are shown in Table 1. There were 10 women, all primiparous, who reached full dilatation in whom the range of duration of the second stage was 2–7 hours (mean 4.8).Uterine compression sutures failed to control hemorrhage in 5 of 28 (17.9%). In the failed cases the indication for cesarean delivery was dystocia in four and elective repeat cesarean delivery in one. The type of suture in the failed cases was B-Lynch (3), B-Lynch+ square (1), vertical (1). All women were given a single dose of a broad-spectrum antibiotic at the time of the cesarean delivery. Of the 22 women in labor, postoperative endomyometritis occurred in eight (36.4%).
Of the 28 cases, five had hysterectomy and three had tubal ligation at the same time as the cesarean delivery and compression suture. There were thus 20 women able to have another pregnancy. Of these, five were para 2 after their second cesarean delivery and compression sutures. There were seven subsequent pregnancies, and all of these were in the 15 women who were primiparous at the time of the compression suture. The type of initial compression suture in those who had subsequent pregnancy was B-Lynch (6) and B-Lynch+square (1). All seven pregnancies were uneventful and were delivered by elective repeat cesarean, at the request of the patient, between 37 and 39 weeks. In each case the uterus was examined for any signs of the previous compression suture, and these were found in four cases. In one twin pregnancy there were grooves over the lateral aspects of the fundus at the site of the previous B-Lynch suture. There was also a thin fibrous band between the anterior and posterior wall of the uterine cavity at the level of the lower uterine segment. This did not interfere with the twin pregnancy and was divided at the time of repeat cesarean delivery without incident. In another pregnancy two fundal grooves with whitened myometrium at their base were noted at the time of repeat elective cesarean delivery. In the third case there was light grooving of the fundus and puckering at the posterior entry and exit sites of the previous B-Lynch suture. In addition, a loop of small bowel was adherent to the anterior lower uterine segment and omental adhesions to the posterior uterine wall. A fourth case had dense adhesions of the omentum to the anterior uterine wall. In the other three patients, there were no signs of the previous uterine compression sutures or adhesions at subsequent cesarean delivery
This series reports 28 cases from one hospital of uterine compression sutures for severe postpartum hemorrhage. In all cases hysterectomy was the next step to achieve hemostasis, and the fact that this was avoided in 82% of cases attests to the value of this relatively simple technique in achieving hemostasis and preserving the uterus. A strength of this study is that it comes from one hospital and represents the collective experience of several obstetricians in active clinical practice. In addition, this report includes the largest number of pregnancies subsequent to uterine compression sutures. All of these pregnancies were uneventful and went to term, to be delivered by repeat elective cesarean. A weakness of this study is that early pregnancy losses, including spontaneous miscarriage and ectopic pregnancy that were treated medically or those seen in another hospital, may have been missed in this review.
In 2005 Price and B-Lynch18 presented a detailed review of 15 published reports, which included 46 cases with two failures. The other large series from a single hospital is that of Wohlmuth et al13 In their 22 cases, 11 achieved hemostasis with the B-Lynch suture alone and six with the suture combined with uterine and/or ovarian artery ligation. Five of their 22 cases required hysterectomy to secure hemostasis, so that their success rate in avoiding hysterectomy (77.3%) was similar to this study (82.1%). In another hospital-based series, Bhal et al,19 using a minor modification of the B-Lynch technique, were able to avoid hysterectomy in 10 of 11 cases of severe postpartum hemorrhage at the time of cesarean delivery. Allahdin et al17 had to resort to hysterectomy in only three of 11 cases of severe postpartum hemorrhage at cesarean delivery using the B-Lynch technique. These four publications,13,17–19 in addition to this series, document a total of 118 cases with avoidance of hysterectomy in 102 (86.4%).
A common theme in many of the reports is the need for uterine compression sutures to control severe postpartum hemorrhage due to uterine atony after prolonged labor and dystocia. This was the case in 20 of the 25 cases of uterine atony in this series. Chorioamnionitis was implicated in many of our cases, as shown by the prevalence of postpartum sepsis: the infected and exhausted uterus may not respond to uterotonic drugs. In some cases the uterine compression suture may not be completely successful, but it reduces the blood flow enough to allow time to muster resources for uterine artery embolization, as happened in one of our patients.
The seven uneventful pregnancies after uterine compression sutures in this series is reassuring. Most of the other isolated reports of subsequent pregnancy have also been successful. None have described the fundal grooves that were seen in three of our seven cases at the time of repeat cesarean delivery. These grooves suggest that there was a degree of ischemic necrosis. However, in all these cases, it did not have clinical implications either in the postpartum period after the compression suture or in the subsequent pregnancy. There have been only isolated cases of severe uterine necrosis necessitating hysterectomy in the immediate postoperative period after compression sutures.14,15 Pyometria has also been described after the hemostatic square suture technique.20 It is important to have the equipment readily available to perform uterine compression sutures. A No. 1 Monocryl (Ethicon; polyglecaprone 25) suture on a 70-mm blunt semicircular needle is now available for this purpose.18,21 We have found it helpful to have a special obstetric hemorrhage tray adjacent to the cesarean theater, upon which is included the necessary equipment required, along with diagrams of the various types of compression sutures.22
Recent studies from Australia and Canada have shown an increasing prevalence of severe postpartum hemorrhage.23,24 Along with the increase in morbidity and risks of blood transfusion, there may be considerable morbidity associated with emergency hysterectomy. Furthermore, in a study of our own obstetric population, emergency hysterectomy, with all of its fertility-ending implications, was performed in primiparous women in 25% of the cases.25 Obstetric compression sutures, therefore, represent a valuable clinical aid to the general obstetrician as an alternative to hysterectomy when dealing with severe postpartum hemorrhage. The outcome of subsequent pregnancies is reassuring.
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