Postpartum hemorrhage is a leading cause of pregnancy-related morbidity and mortality.1 Primary postpartum hemorrhage, which occurs in 4–6% of pregnancies, is caused by uterine atony in 80% or more of cases. Other causes include trauma to the genital tract, retained placental tissue, and coagulopathy.2,3
When uterotonic agents fail to control postpartum hemorrhage, various approaches including uterine compression sutures, tamponade, uterine devascularization, and uterine artery embolization can be used to induce appropriate uterine contraction. When these methods are ineffective, however, a hysterectomy is necessary to achieve hemostasis. Uterine compression sutures are thought to be a safe and effective alternative for managing postpartum hemorrhage in the setting of uterine atony during cesarean delivery.4 The B-Lynch suture was first described by B-Lynch in 1997,5 and numerous variations such as Cho's square suture and Hayman's modification have since been widely used.6,7 The uterine compression suture is particularly useful because of its simplicity and capacity for preserving the uterus and subsequent fertility.
There have been isolated case reports of uneventful subsequent pregnancies after uterine compression sutures were used in primiparous women.8,9 However, fertility data in this population are very limited. This study sought to estimate the association between uterine compression sutures for postpartum hemorrhage and subsequent pregnancy outcomes.
MATERIALS AND METHODS
We retrospectively reviewed medical records of women who received uterine compression sutures at a single medical center (Cheil General Hospital, Seoul, Korea) between 2006 and 2011. In 2006, the obstetricians of this institution introduced the modified B-Lynch suture and square suture techniques for managing postpartum hemorrhage refractory to medical management. To select cases, we searched the administrative database of our hospital using key terms such as modified B-Lynch, square sutures, and compression sutures and then searched the outpatient registration database for subsequent pregnancy. We included women who received uterine compression sutures during their prior delivery and had a subsequent pregnancy for which they again received care at our hospital. Of these, we excluded women whose pregnancy outcomes were unknown. In the case group, all women but one woman had a cesarean delivery at the prior delivery. The control group consisted of pregnant women who did not require uterine compression sutures during prior cesarean delivery and had a subsequent pregnancy for which they received care at our hospital. We selected women for the control group who conceived closest to the woman in the case group in the subsequent pregnancy with same age and parity. This study was approved by the ethics committee of Cheil General Hospital and Women's Health Care Center (CGH-IRB-2013-1).
Uterine compression sutures were placed using the modified B-Lynch method or multiple square sutures.10 The modified B-Lynch suture technique of Hayman et al6 that we used is as follows: at one lateral side of uterus just above the reflection of the bladder, a straight needle with a long number 1 Vicryl suture traversed from the anterior to posterior uterine wall and the free end tied at the fundus. This was repeated on the contralateral side of the uterus. This left four free tags of suture, two of which were tied together in the midline (Fig. 1A). In one case (placenta accrete), multiple square sutures were inserted in areas of heavy bleeding (Fig. 1B).
Clinical characteristics collected included age, parity, type of delivery at prior delivery, interval to subsequent pregnancy, age at subsequent conception, method of conception, and number of fetuses at subsequent pregnancy. Pregnancy outcomes included the frequency of term delivery, preterm delivery, miscarriage, ectopic pregnancy, fetal death, chromosomal abnormalities, and perinatal loss. We also analyzed clinical findings at subsequent cesarean delivery including gestational age, birth weight, frequency of postpartum hemorrhage, transfusion rates, preoperative and postoperative hemoglobin, postoperative length of hospital stay, and operative findings such as estimated blood loss, pelvic adhesions, repeat placement of uterine compression sutures, and operation time. Pelvic adhesions included all adhesions described in operation records such as uterus–bladder, omentum, intestine, abdominal wall, adnexa, and omentum–abdominal wall adhesions. We could not use a scoring system as a result of our inability to assess the density of the adhesion; thus, we used a dichotomous (present or absent) measure of pelvic adhesion.
Data from 20 women who underwent uterine compression suture and subsequently conceived were collected from 2006 to 2009. However, we collected data for another 2 years (through December 2011) to obtain additional cases for analysis. Therefore, the final case group consisted of 42 participants. We did not perform an a priori sample size calculation.
Statistical analysis was performed using SPSS 20.0. Categorical variables were analyzed using the χ2 test or Fisher’s exact test. Continuous variables were analyzed using the Student’s t test. P<.05 was considered statistically significant.
Over the course of 6 years (2006–2011), there were 42,171 deliveries at our institution. A total of 336 (0.8%) women received uterine compression sutures including modified B-Lynch sutures or multiple square sutures. Of these, 49 women subsequently conceived again and received antenatal care at our hospital. We excluded seven women whose pregnancy outcomes were unknown. We analyzed subsequent pregnancy outcomes of the remaining 42 women (case group) and compared these data with that of 139 pregnant women matched for age and parity who did not require uterine compression sutures during prior cesarean delivery (control group) (Fig. 2).
Table 1 shows the clinical characteristics of the study population. In the case group, the mean age was 34.8±3.0 years and 39 (92.9%) women were nulliparous at the time of the previous delivery. The interval to subsequent pregnancy was 22.7±13.2 months, all of which were conceived naturally. A total of 34 (81%) of the initial deliveries required emergent cesarean delivery. Only one woman had a vaginal delivery, after which uterine compression sutures were inserted as a result of uterine atony. All clinical characteristics were statistically similar between the two groups.
Table 2 shows the outcomes of subsequent pregnancies for women who conceived after receiving (women in the case group) or not receiving (women in the control group) uterine compression sutures during the previous delivery. There were four (9.5%) miscarriages and one (2.4%) tubal pregnancy in the compression suture group compared with 14 (10.1%) miscarriages and two (1.5%) tubal pregnancies in the women in the control group (P=.92 and P=.68, respectively). In the compression suture group 34 (81.0%) women delivered at term and two (4.7%) women had preterm deliveries. In the control group, 114 (82.0%) women delivered at term and seven (5.0%) had preterm deliveries (P=.88 and P=.60, respectively). In the case group, one woman experienced perinatal loss. This patient was pregnant with twins and presented to the hospital with severe abdominal pain and heavy vaginal bleeding as a result of placenta previa at 21 weeks of gestation. During the operation, the uterus was found to be ruptured along the previous classic uterine incision site where a placenta increta was localized. Cesarean hysterectomy was performed as a result of massive postpartum bleeding despite medical therapy. In the control group, there was one fetal death at 16 weeks of gestation (P=.58) and one fetus with a chromosomal abnormality (45,X/46,XY) (P=.58) resulting in a cleft lip and palate.
Table 3 shows the clinical and operative findings during repeat cesarean delivery in women who did or did not receive uterine compression sutures during the previous delivery. In these analyses, we included only live births at more than 24 weeks of gestation and excluded one woman in the case group who delivered vaginally in the subsequent pregnancy. The mean gestational age at the time of delivery, estimated blood loss, transfusion rate, preoperative and postoperative hemoglobin, rate of uterine compression sutures on subsequent delivery, and operation time were not significantly different between the two groups. However, the incidence of pelvic adhesions was significantly higher in women who had uterine compression sutures compared with women in the control group (34.3% compared with 17.5%, P=.03).
In this case–control study, we found that subsequent pregnancy outcomes were similar for women who did and those who did not receive uterine compression sutures during their prior delivery, However, pelvic adhesions at repeat cesarean delivery were more prevalent in women who received uterine compression sutures. We searched PubMed from January 1997 to March 2013 using the search terms “uterine compression suture,” “B-Lynch,” “brace suture,” and “square suture” in combination with “fertility,” “complication,” “postpartum hemorrhage,” and “adhesion.” Based on this search, ours is the first case–control study to compare pregnancy outcomes of women who underwent repeat cesarean delivery after previous uterine compression suture placement with women who did not require uterine compression sutures during a previous cesarean delivery. Also, it represents the largest sample of women who have received compression sutures at a single medical center.
Uterine compression sutures such as the B-Lynch technique, modifications of the B-Lynch technique, or multiple square sutures can be easily applied during the early stages of postpartum hemorrhage to avoid hysterectomy. However, modified B-Lynch and multiple square sutures involve suturing directly through the anterior and posterior uterine walls, thus obliterating the uterine cavity. Several authors have reported uterine synechia after placement of compression sutures,11,12 which may influence subsequent fertility. As a result of our retrospective study design, we were unable to evaluate changes in menstrual volume or the presence of uterine synechia using hysterosalpingogram, so we instead measured pregnancy outcomes including methods of conception. In our study, all women with uterine compression sutures conceived naturally. Habek et al13 previously reported the earliest time to conception after uterine compression sutures as 3 months. In our study, the earliest time to conception was 6 months (two women). Of these two women, one delivered at term by repeat cesarean delivery and one had an ectopic pregnancy.
Data regarding the effect of uterine compression sutures on future fertility are limited to individual cases and a few case series with the vast majority of patients not experiencing serious complications. Ouahba et al14 described eight women who received compression sutures and were able to subsequently conceive. Six (75%) of these women had term deliveries, two of whom had uncomplicated spontaneous vaginal deliveries and four of whom had cesarean deliveries. In 2010, Fotopoulou and Dudenhausen15 reviewed the efficacy and complications of uterine compression sutures and their effect on future pregnancies. They reported that the majority of pregnancies showed no differences in prematurity rates, and in almost all cases, the mode of delivery chosen for the subsequent pregnancy was elective cesarean delivery. Similarly, most women (81%) with uterine compression sutures in our study delivered at term, and all but one woman delivered by cesarean. The rate of preterm delivery in our study was 4.7%, which was similar to that of women in the control group. In addition to term delivery rates and delivery mode, we compared the rates of miscarriage, ectopic pregnancy, and perinatal loss with those of the women in the control group. None of the measured outcomes was significantly different between the two groups, and all fell within in the ranges seen in the general population.16–20
There has been some debate regarding complications with respect to future pregnancies in women who have received uterine compression sutures. Akoury et al21 described a case in which a large triangular myometrial defect in the midanterior uterine wall was noted during a subsequent pregnancy after B-Lynch sutures plus two square sutures. Brink et al22 reported another serious pregnancy complication after uterine compression sutures in which uterine rupture occurred in the fundal area. In our study, one woman experienced uterine rupture in a subsequent pregnancy. However, the site of uterine rupture was a previous incision in which a placenta percreta had developed rather than at the fundus or along the lateral B-Lynch suture site. Thus, the single case of uterine rupture in our study was likely not associated with the previous uterine compression sutures.
The rate of pelvic adhesions in a subsequent pregnancy after receiving uterine compression sutures (34.3%) was higher than that observed in the women in the control group (17.5%) during repeat cesarean delivery. Habek et al13 reported a case in which neither reactive connective tissue along the sutures nor pelvic or intrauterine adhesions were found intraoperatively during subsequent cesarean delivery after combined B-Lynch sutures and unilateral ligation of the internal iliac artery. We used delayed absorbable sutures in all cases, which carry the risk of cutting through uterine tissue and causing an inflammatory reaction around the uterus.
Our study has limitations as a result of the number of cases and the retrospective nature of the study design. Although we collected data regarding subsequent pregnancy after uterine compression suture over 6 years, our study was underpowered to detect all but fairly large differences between the study groups in the various outcomes that we assessed. Pelvic adhesions were not quantified in an objective fashion and the operating surgeons for the subsequent cesarean delivery were not blinded to whether uterine compression sutures were inserted during the previous delivery. This may potentially introduce a bias. We assessed only women who achieved pregnancy and our study design does not allow us to evaluate the potential effect of uterine compression sutures on fertility.
Uterine compression sutures are both effective and easily implemented and may help preserve the uterus in cases of postpartum hemorrhage. The outcomes of subsequent pregnancies in women who received uterine compression sutures were no different from those of women in the control group with the exception of a higher rate of pelvic adhesions.
1. World Health Organization. Maternal mortality in 2000; estimates developed by WHO, UNICEF, and UNFPA. Geneva (Switzerland): WHO; 2004.
2. AbouZahr C. Global burden of maternal death and disability. Br Med Bull 2003;67:1–11.
3. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:69–76.
4. Mallappa Saroja CS, Nankani A, El-Hamamy E. Uterine compression sutures, an update: review of efficacy, safety and complications of B-Lynch suture and other uterine compression techniques for postpartum haemorrhage. Arch Gynecol Obstet 2010;281:581–8.
5. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive post partum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372–5.
6. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol 2002;99:502–6.
7. Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000;96:129–31.
8. Hwu YM, Chen CP, Chen HS, Su TH. Parallel vertical compression sutures: a technique to control bleeding from placenta praevia or accreta during caesarean section. BJOG 2005;112:1420–3.
9. Pereira A, Nunes F, Pedroso S, Saraiva J, Retto H, Meirinho M. Compressive uterine sutures to treat postpartum bleeding secondary to uterine atony. Obstet Gynecol 2005;106:569–72.
10. Chae YH, Kim YY, An GH, Woo JH, Chung JH, Choi JS, et al.. Treatment outcome of uterine compression sutures for massive postpartum hemorrhage. Korea J Obstet Gynecol 2010;53:769–77.
11. Ochoa M, Allaire AD, Stitely ML. Pyometria after hemostatic square suture technique. Obstet Gynecol 2002;99:506–9.
12. Wu HH, Yeh GP. Uterine cavity synechiae after hemostatic square suturing technique. Obstet Gynecol 2005;105:1176–8.
13. Habek D, Vranjes M, Bobić Vuković M, Valetić J, Krcmar V, Simunac J. Successful term pregnancy after B-Lynch compression suture in a previous pregnancy on account of massive primary postpartum haemorrhage. Fetal Diagn Ther 2006;21:475–6.
14. Ouahba J, Piketty M, Huel C, Azarian M, Feraud O, Luton D, et al.. Uterine compression sutures for postpartum bleeding with uterine atony. BJOG 2007;114:619–22.
15. Fotopoulou C, Dudenhausen JW. Uterine compression sutures for preserving fertility in severe postpartum haemorrhage: an overview 13 years after the first description. J Obstet Gynaecol 2010;30:339–49.
16. Ananth CV, Joseph KS, Oyelese Y, Demissie K, Vintzileos AM. Trends in preterm birth and perinatal mortality among singletons: United States, 1989 through 2000. Obstet Gynecol 2005;105:1084–91.
17. Joseph KS, Huang L, Liu S, Ananth CV, Allen AC, Sauve R, et al.. Reconciling the high rates of preterm and postterm birth in the United States. Obstet Gynecol 2007;109:813–22.
18. Centers for Disease Control and Prevention (CDC). Ectopic pregnancy—United States, 1990–1992. MMWR Morb Mortal Wkly Rep 1995;44:46–8.
19. Van Den Eeden SK, Shan J, Bruce C, Glasser M. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol 2005;105:1052–7.
20. Wilcox AF, Weinberg CR, O'Connor JF, Baird DD, Schlatterer JP, Canfield RE, et al.. Incidence of early loss of pregnancy. N Engl J Med 1998;319:189–94.
21. Akoury H, Sherman C. Uterine wall partial thickness necrosis following combined B-Lynch and cho square sutures for the treatment of primary postpartum haemorrhage. J Obstet Gynaecol Can 2008;30:1100–1.
22. van den Brink JW, Samlal RA. Pregnancy after ligation of the hypogastric artery combined with a B-Lynch brace suture for major postpartum haemorrhage: a case with a nearly fatal outcome. Eur J Obstet Gynecol Reprod Biol 2009;144:187–8.