Which uterine sparing technique should be used for uterine atony during cesarean section? The Bakri balloon or the B-Lynch suture?

Comparison of H-Hayman uterine compression suture with conventional vertical sutures: A cross-sectional study in a tertiary center

OBJECTIVE

To compare H-Hayman, a modified uterine compression suturing technique (UCS) that we describe for the first time in the literature, with conventional vertical UCS techniques.

METHODS

The H-Hayman technique was used in 14 women and the conventional UCS technique in 21 women. In order to provide standardization in the study, only patients who had developed upper-segment atony during cesarean section were recruited for the study.

RESULTS

Bleeding control was achieved in 85.7% (12/14) of the cases using the H-Hayman technique. In the remaining two patients with persistent hemorrhage in this group, bleeding control was provided with bilateral uterine artery ligation, and a hysterectomy was avoided in all cases. With the conventional technique, bleeding control was achieved in 76.1% (16/21) of the patients, and the overall success rate was 95.2% after bilateral uterine artery ligation in those with persistent hemorrhage. In addition, the estimated blood loss and the need for erythrocyte suspension transfusion were significantly lower in the H-Hayman group (P = 0.01 and P = 0.04, respectively).

CONCLUSION

We found the H-Hayman technique to be at least as successful as conventional UCS. In addition, patients who underwent suturing with the H-Hayman technique had less blood loss and a lower requirement for erythrocyte suspension transfusion.

Effectiveness of preventive B-Lynch sutures in patients at a high risk of postpartum hemorrhage

AIM

We aimed to evaluate the clinical outcomes and adverse events of preventive B-Lynch suture performed during cesarean section in patients at a high risk of postpartum hemorrhage.

METHODS

This retrospective observational study included patients who underwent a cesarean section and the B-Lynch suture at a tertiary perinatal medical center between January 2019 and May 2021. The B-Lynch sutures were placed preventively before excessive blood loss occurred in patients with uterine atony, placental position abnormality (placenta previa and low-lying placenta), placenta accreta, thrombocytopenia, coagulopathy, and other risk factors of bleeding. Partial compression sutures for bleeding points and vaginal gauze packing were placed if required.

RESULTS

The B-Lynch suture was performed in 38 patients, and hysterectomy was avoided in all patients. Only one patient required intrauterine balloon tamponade as an additional treatment 5 days after the cesarean section. No apparent postoperative bleeding occurred within 2 h after the cesarean section in 35 patients (92%), and blood transfusion was avoided in 14 patients (37%). Thirty-three adverse events occurred in 23 patients; these included an inflammatory response, hematomas, retained products of conception, and ileus in one, two, and two patients, respectively. In most cases, the events were not severe and were unrelated to the procedure. In one patient, a second-look operation was performed and no complications were observed in the uterus and abdominal cavity.

CONCLUSIONS

Preventive B-Lynch suture seemed effective and safe after a short-term observation. When excessive bleeding is expected during a cesarean section, an early introduction of this procedure is recommended.

Spiral Suture of the Lower Uterine Segment with Temporary Aortic Balloon Occlusion in Morbidly Adherent Placenta Previa Cases

Purpose

We aimed to investigate the combined effect of spiral suture of the lower uterine segment with intraoperative aortic balloon occlusion in morbidly adherent placenta previa cases.

Patient and Methods

This retrospective, single-center study involved patients from 2017 to 2020. The study considered 68 cases of morbidly adherent placenta previa cases from medical records retrospectively with age ranging from 23 to 42 years. Bilateral uterine artery embolization was performed, to control excessive bleeding. Perioperative blood loss, hysterectomy rate, amount of blood transfusion, balloon occlusion time, fetal and maternal radiation dose, and postpartum complications were assessed.

Results

A total of 68 patients underwent surgery. Hysterectomy was performed in three patients and uterine artery embolization in 21 patients. Of 53 patients who required blood transfusions, the amount of packed red blood cells given was 800 mL and the amount of plasma given was 400 mL. Median abdominal aortic balloon occlusion time was 17 minutes. Fetal and maternal radiation doses were 5 mGy and 12 mGy, respectively. One patient experienced surgery-related complications, a bladder injury. No major catheterization-related and postpartum complications were observed.

Conclusion

Fertility-sparing surgery for women with morbidly adherent placenta could include abdominal aortic balloon occlusion and spiral suture of lower uterine segment.

The Discriminant Use of Intrauterine Balloon Tamponade and Compression Sutures for Management of Major Postpartum Hemorrhage: Comparison of Patient Characteristics and Clinical Outcome

Background

Intrauterine balloon tamponade (IUBT) and compression sutures have been widely used in recent years in the management of postpartum hemorrhage (PPH). However, there is scant literature directly comparing the clinical scenarios that led to the discriminant selection of these management modalities and the direct clinical outcomes. The purpose of this study is to compare the patient characteristics and clinical risk factors that led to the use of IUBT and compression sutures in the management of major PPH as well as the immediate outcome in a retrospective cohort.

Methods

Patients who had IUBT or compression sutures applied due to major PPH (>1000 ml) from 2014 to 2018 in a single obstetric unit were recruited. The patient characteristics and clinical outcome of the two groups were compared.

Results

A total of 67 patients had IUBT and 29 patients had compression sutures applied as the first uterine sparing technique. Apart from more vaginal deliveries (25.4% vs. 3.5%) in the IUBT group compared to compression sutures, there were no significant differences between the two groups in terms of patient characteristics. The IUBT group had a slightly higher blood loss at the start of the uterine sparing procedure (239 ml, p = 0.049) and received more transfusions, despite no differences in the total blood loss, hemogloblin level, incidence of coagulopathy, and intensive care unit admission between the two groups. There was no significant difference in the overall success rate between IUBT and compression sutures to control PPH without additional surgical intervention or hysterectomy (73.1% vs. 55.1%, p = 0.15) or the success rate for PPH due to uterine atony (32.8% vs. 20.7%), though IUBT apparently performed better than compression sutures in cases of placenta praevia (77.3% vs. 16.7%, p = 0.01). Blood loss > 1.5 l at the start of the procedure, presence of placenta accreta, and presence of coagulopathy were found to be significant poor prognostic factors for both procedures to control PPH.

Conclusions

There were no dominating patient characteristics that favoured the selection of either IUBT or compression sutures in the management of severe PPH except for the mode of delivery. Both procedures had equally high overall success rates to control PPH, but IUBT performed better in placenta praevia cases as compared to compression sutures.

Cost-effectiveness of uterine tamponade devices for the treatment of postpartum hemorrhage: A systematic review

Background

Uterine tamponade is widely promoted for treating refractory postpartum hemorrhage (PPH); however, its cost‐effectiveness may vary depending on unit costs and setting.

Objective

To review available data on cost‐effectiveness of uterine tamponade devices when used for PPH treatment.

Search strategy

PubMed and EMBASE were searched (1980 to January 2020), as well as the National Health Services Economic Evaluation database from inception (1995) to March 2015.

Selection criteria

Eligible studies were any type of economic evaluation, or effectiveness studies that provided cost or economic data.

Data collection and analysis

Two reviewers independently screened studies, extracted data, and assessed quality.

Main results

Eleven studies using a range of devices (condom catheter, uterine suction devices, Bakri, Inpress, Ellavi) were identified. Cost of condom catheter devices or kits ranged from US$0.64 to US$6, whereas purpose‐designed device costs were up to US$400. Two studies that took a health system perspective assessed the cost‐effectiveness of using uterine balloon tamponade and suggested that it was highly cost‐effective because of the low cost per disability‐adjusted life‐year averted, although both used effect estimates from case series.

Conclusions

Evidence on the cost‐effectiveness of uterine tamponade devices was limited and not generalizable. Rigorous economic evaluations based on updated effect estimates are needed.

Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis

OBJECTIVE

To assess the efficacy, effectiveness, and safety of uterine balloon tamponade for treating postpartum hemorrhage.

STUDY DESIGN

We searched electronic databases (from their inception to August 2019) and bibliographies. We included randomized controlled trials, nonrandomized studies, and case series that reported on the efficacy, effectiveness, and/or safety of uterine balloon tamponade in women with postpartum hemorrhage. The primary outcome was the success rate of uterine balloon tamponade for treating postpartum hemorrhage (number of uterine balloon tamponade success cases/total number of women treated with uterine balloon tamponade). For meta-analyses, we calculated pooled success rate for all studies, and relative risk with 95% confidence intervals for studies that included a comparative arm.

RESULTS

Ninety-one studies, including 4729 women, met inclusion criteria (6 randomized trials, 1 cluster randomized trial, 15 nonrandomized studies, and 69 case series). The overall pooled uterine balloon tamponade success rate was 85.9% (95% confidence interval, 83.9-87.9%). The highest success rates corresponded to uterine atony (87.1%) and placenta previa (86.8%), and the lowest to placenta accreta spectrum (66.7%) and retained products of conception (76.8%). The uterine balloon tamponade success rate was lower in cesarean deliveries (81.7%) than in vaginal deliveries (87.0%). A meta-analysis of 2 randomized trials that compared uterine balloon tamponade vs no uterine balloon tamponade in postpartum hemorrhage due to uterine atony after vaginal delivery showed no significant differences between the study groups in the risk of surgical interventions or maternal death (relative risk, 0.59; 95% confidence interval, 0.02-16.69). A meta-analysis of 2 nonrandomized before-and-after studies showed that introduction of uterine balloon tamponade in protocols for managing severe postpartum hemorrhage significantly decreased the use of arterial embolization (relative risk, 0.29; 95% confidence interval, 0.14-0.63). A nonrandomized cluster study reported that use of invasive procedures was significantly lower in the perinatal network that routinely used uterine balloon tamponade than that which did not use uterine balloon tamponade (3.0/1000 vs 5.1/1000; P < .01). A cluster randomized trial reported that the frequency of postpartum hemorrhage-related invasive procedures and/or maternal death was significantly higher after uterine balloon tamponade introduction than before uterine balloon tamponade introduction (11.6/10,000 vs 6.7/10,000; P = .04). Overall, the frequency of complications attributed to uterine balloon tamponade use was low (≤6.5%).

CONCLUSION

Uterine balloon tamponade has a high success rate for treating severe postpartum hemorrhage and appears to be safe. The evidence on uterine balloon tamponade efficacy and effectiveness from randomized and nonrandomized studies is conflicting, with experimental studies suggesting no beneficial effect, in contrast with observational studies. Further research is needed to determine the most effective programmatic and healthcare delivery strategies on uterine balloon tamponade introduction and use.

Clinical outcomes of prophylactic compression sutures for treatment of uterine atony during the cesarean delivery of twins

BACKGROUND

Twin pregnancy has a high risk for developing uterine atony (UA). This study aimed to evaluate efficacy and clinical outcomes of prophylactic compression sutures to treat UA during twin cesarean section (CS).

METHODS

All patient records of twin deliveries by CS after gestational age of 24 weeks in a large maternity hospital in South Korea between January 2013 and June 2018 were reviewed. Patients with monochorionic monoamniotic twins were excluded from data analysis. In total, 953 women were eligible for data analysis.

RESULTS

Of the 953 patients, compression sutures were applied to 147 cases with postpartum bleeding that were refractory to uterine massage and uterotonics. Out of the 147, two patients (1.4%) proceeded to additional uterine artery ligation to achieve hemostasis, yielding a success rate of 98.6%. The rate of transfusion after the first 24 h of delivery in the suture group was not significantly different from that in the non-suture group, suggesting that both groups achieved hemostasis at an equal rate after the first 24 h of delivery. The difference in the operation time between the two groups was only 8.5 min. The rate of subsequent pregnancy among the patients who received compression sutures was 44.4%.

CONCLUSIONS

Overall, our findings suggest that with early and fast implementation of compression sutures, UA can be treated in the setting of twin cesarean delivery without significantly increasing maternal morbidity.

Conservative surgical management for immediate postpartum hemorrhage

Background

Conservative surgical management for postpartum hemorrhage (PPH), such as balloon tamponade, uterine compression suture, and uterine artery ligation, has the benefit of preserving reproductive function.

Objectives

To assess the efficacy and subsequent pregnancy outcome of conservative surgical management for patients with immediate PPH.

Methods

Medical records of patients who had PPH between January 2011 and December 2016 were reviewed. Conservative surgical management included B-Lynch uterine compression suture, Bakri balloon tamponade, and uterine artery ligation. The treatments were considered successful if patients did not require subsequent hysterectomy. Perioperative complications and subsequent pregnancy outcomes were recorded.

Results

Of 30,271 deliveries, 669 patients experienced PPH or 2.2% of total deliveries. Sixty-one patients (9.1%) did not respond to medical treatment with various uterotonic agents. Hysterectomy was selected initially in 30 patients. Conservative surgical management was performed in 31 patients: 15 Bakri balloon tamponade, 13 uterine compression suture, and 3 uterine artery ligation. There were 3 patients who failed Bakri balloon tamponade and proceeded to perform uterine compression suture with successful outcome. The success rates for conservative surgical treatment were 66.7%, 75%, and 66.7%, respectively. All patients who had successful conservative surgical management resumed normal menstruation. Three out of 11 patients (27.3%) who desired subsequent pregnancy were able to conceive and carry out a viable pregnancy.

Conclusion

Conservative surgical management has acceptable success rates for controlling intractable immediate PPH. Implementation of such procedures should be done to preserve fertility and decrease maternal morbidity and mortality.

Uterine flexion suture: modified B-Lynch uterine compression suture for the treatment of uterine atony during cesarean section

Objective

The aim of this study was to report our clinical experience of applying a uterine flexion suture, which was modified from the B-Lynch uterine compression suture, for treating uterine atony during cesarean section.

Materials and methods

This is a retrospective descriptive study describing the use of a new technique, uterine flexion suture, for treating uterine atony during cesarean section. The study period was from January 2009 to December 2017 at Udonthani Hospital, Udonthani, Thailand. Uterine atony during cesarean section was treated by manual compression, intravenous oxytocin, methylergonovine maleate, and prostaglandins and then was observed for 10-15 minutes before applying a uterine flexion suture in the failed medical treatment cases. The patients were observed for vaginal bleeding, hematometra, and infection after operation. Uterine ultrasound scan results on days 1, 7, and 30 postoperation were also reviewed.

Results

Fifty-seven patients with uterine atony during cesarean delivery received the uterine flexion suture. The mean age of patients was 27.0 (15-44 years). Thirty-four patients were primipara. The indications for cesarean section were cephalopelvic disproportion in 27 (47.4%) cases, and previous cesarean section in 11 (19.3%) cases. Neither postoperative excessive bleeding nor hysterectomy was observed. There was no hematometra or serious postoperative complication after surgery. The estimated time for uterine flexion suture is only 2-3 minutes and was very easy to perform.

Conclusion

Uterine flexion suture technique, which was modified from the B-Lynch suture, was inexpensive, quick, and effective in the treatment of atonic postpartum uterus in women undergoing cesarean section.

Comparing success rates of the Hayman compression suture and the Bakri balloon tamponade

Background: Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality around the world. Medical treatments and uterus-sparing interventions including balloon tamponades and compression sutures are the first line options before the decision is made to perform a hysterectomy. Our aim is to compare the success rates of the Hayman compression suture and the Bakri balloon tamponade (BBT) in patients with PPH. Methods: We enrolled 82 patients who were diagnosed with uterine atony during their cesarean sections and failed to respond to uterotonic agents. The patients were treated with either a Hayman suture or a BBT. Results: The success rates of the both methods were similar (76.7% in the Hayman group and 74.4% in the BBT group). In both groups, the success rate increased with the addition of artery ligations (93% in the Hayman group and 87.2% in the BBT). Conclusion: The Hayman suture and the BBT's performances were identical in the management of PPH due to uterine atony. All methods have pros and cons and the choice of the intervention depends on a variety of factors including the severity of bleeding, experience of the surgeon and the accessibility of the tools.