Synechia after uterine compression sutures

Efficacy, Complications and Effects of Alcides Pereira's Sutures in the Management of Uterine Atony: A Retrospective Study

INTRODUCTION

Uterine compressive sutures are conservative measures applied in cases of severe postpartum hemorrhage unresponsive to uterotonics. Pereira's suture was introduced in 2005 and consists of two longitudinal and three transverse non-transfixes sutures. Previous studies reported favorable results, highlighting its benefits and value. The aim of this study was to assess the efficacy, complications, and impact on fertility and future pregnancies of Pereira's suture applied in cases of uterine atony and postpartum hemorrhage.

METHODS

An observational retrospective study was performed by consulting the medical records of women treated with Pereira's compressive sutures in a tertiary center between January 2013 and December 2022. We registered demographic data, pregnancy outcomes, short-term complications, and outcomes of subsequent pregnancies.

RESULTS

A total of 50 women were treated with Pereira's suture. The overall success rate was 96% and no hysterectomies were performed. Women who had sutures performed during an intra-cesarean section had better outcomes than those who had an after-cesarean section. Complications were reported in 12% (n = 6) of women, with the most frequent being pelvic infection (n = 3) and abdominal pain (n = 3). Regarding fertility, all women desiring a future pregnancy (n = 5) were able to conceive, resulting in three live births.

CONCLUSION

Pereira's suture is a type of suture that provides numerous advantages and should be considered when first-line medical treatment fails. When applied at an early stage, the sutures may prevent maternal morbidity. The Alcides Pereira's suture is a safe technique and appears to preserve fertility.

Mucosal adhesion phenomenon after maxillary sinus floor elevation: A preclinical study

AIM

To describe the histological events that occur after maxillary sinus floor elevation when the elevated and undetached sinus mucosa are in close proximity or in contact with each other.

MATERIALS AND METHODS

From 76 rabbits, 152 elevated maxillary sinuses were analyzed histologically. Sites without adhesions were classified as "No proximity," whereas the adhesion stages were divided into "Proximity," "Fusion," and "Synechia stages." The width of the pseudostratified columnar epithelium and the distance between the two layers of the elevated and undetached sinus mucosae were measured at various standardized positions.

RESULTS

Thirty-one sites presenting with adhesions were found. Twelve sites were in the proximity stage," presenting cilia of the two epithelial layers that were shortened and interlinked within the mucous context. Hyperactivity of the goblet cells was also observed. In the other cases, the hyperplastic epithelium showed attempts to reach the contralateral mucosa. The 15 "fusion stage" sites presented regions with epithelial cells of the two mucosal layers that penetrated each other. Four sites presented "synechiae stages," represented by bridges of connective tissue connecting the two lamina propria.

CONCLUSIONS

Close proximity or tight contact between the elevated and undetached mucosa adhering to the bone walls might occur after maxillary sinus floor elevation. This induced hyperplasia of the epithelial cells and adhesion of the two layers until synechiae formation.

Hysteroscopy after conservative surgical treatment of severe postpartum hemorrhage due to uterine atony: A systematic literature review

OBJECTIVE

To assess the prevalence of intrauterine anomalies, primarily intrauterine adhesions (IUAd), after conservative surgical treatment of severe postpartum hemorrhage with uterine atony (SPPH-UA) and determine patient eligibility for hysteroscopy.

METHODS

PubMed and the Cochrane Library were searched by combining keywords "postpartum hemorrhage", "uterine atony", and "hysteroscopy" to perform a literature review. Articles in French and English with more than five cases of hysteroscopy following SPPH-UA were selected. All cases that had hysteroscopy after conservative surgical treatment of SPPH-UA were collected. A blinded statistical analysis revealed IUAd risk factors.

RESULTS

In all, 83% of patients agreed to hysteroscopy and 38% of 71 cases had an IUAd. Age was not a risk factor (P = 0.950). Other factors included multiparity (odds ratio [OR] 1.93, P = 0.039), cesarean delivery (OR 3.58, P = 0.584) and postpartum infection (OR 3.33, P = 0.04). Risk was at 57% after uterine padding with multiple transfixing square stitches (Cho-technique) (P = 0.001), 6% after non-transfixing uterine folding brace suture (B-Lynch technique) when used alone, 29% after uterine artery embolization and after internal iliac artery ligation (OR 0.98, P = 0.645); uterine vascular ligation (OR 0.69, P = 0.253) and more than two procedures (OR 0.69, P = 2.53). Disparity between authors was observed (P = 0.015) and concerned only the surgical techniques used.

CONCLUSION

A classification is proposed for deciding post-SPPH hysteroscopy. Further studies are required to determine appropriateness.

Conservative surgical treatment of post-partum hemorrhage: Should we reconsider compression penetrating sutures?

OBJECTIVES

Evaluate the prevalence of uterine synechia after total uterine ligation (TUL) in comparison to TUL associated with compression-penetrating-sutures (CPS) in the conservative surgical management of severe postpartum hemorrhage (PPH).

METHODS

Prospective observational study of pregnant women that underwent conservative surgical management for PPH in a single French tertiary referral center. We compared the risk of uterine synechia with TUL, in comparison to performing TUL in addition to CPS. The synechia rate was calculated after uterine cavity assessment by 3D hysterosonography. Hysterectomies, women with placenta accreta spectrum and patients that received additional embolization treatment were excluded.

RESULTS

Over 6 years, 36 pregnant women underwent surgical treatment for PPH in 21,944 deliveries (1.64 per 1000). The median blood loss was 2700 [1570-3000] milliliters. Twenty-eight (77.7%) women underwent TUL, 8/36 (22.2%) underwent TUL in addition to CPS. Thirty-four (94,4%) cavity assessments were performed 2-to-6 months after delivery, since one woman of each group was lost to follow-up. When TUL was performed in addition to CPS, the prevalence of synechia was 42.9% (n = 3/7), versus 3.7% (n = 1/27) in TUL (p = 0.021; RR = 16.88, 95%CI [1.1-1051]). Synechia was absent in 30/34 (88.2%) women.

CONCLUSION

The prevalence of synechia was very low after TUL unlike CPS. Further studies should evaluate TUL in the conservative surgical management of PPH, to confirm the lower prevalence of synechiae in TUL and evaluate its impact on fertility.

Removable retropubic uterine compression suture for controlling postpartum hemorrhage

OBJECTIVE

To minimize the adverse events of uterine compression suture in controlling postpartum hemorrhage (PPH) and to search for a prophylactic approach to potential PPH.

METHODS

A retrospective analysis was performed in 39 women with removable retropubic uterine compression suture (RRUCS) to stop PPH due to uterine atony during cesarean section (CS). The procedure was to suspend and compress the uterus to the retropubic abdominal wall using an absorbable suture.

RESULTS

The technique was sufficient to stanch bleeding immediately in 36 patients (92.31%, 36/39). No morbidity or abnormalities occurred in women who underwent RRUCS. Subsequent pregnancies occurred in 10 cases, but the others lacked the desire for future pregnancy.

CONCLUSION

RRUCS is a simple, safe, and effective technique in controlling atonic PPH; it is also used as a prophylactic application in patients with potential PPH after CS.

Mechanical and surgical interventions for treating primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions.

OBJECTIVES

To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review's important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter ('condom catheter'), an air-filled latex balloon-loaded catheter ('latex balloon catheter'), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean 'intraoperative' blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.

Decision Tree Analysis: A Retrospective Analysis of Postoperative Recurrence of Adhesions in Patients with Moderate-to-Severe Intrauterine

OBJECTIVE

To establish and validate a decision tree model to predict the recurrence of intrauterine adhesions (IUAs) in patients after separation of moderate-to-severe IUAs.

DESIGN

A retrospective study.

SETTING

A tertiary hysteroscopic center at a teaching hospital.

POPULATION

Patients were retrospectively selected who had undergone hysteroscopic adhesion separation surgery for treatment of moderate-to-severe IUAs.

INTERVENTIONS

Hysteroscopic adhesion separation surgery and second-look hysteroscopy 3 months later.

MEASUREMENTS AND MAIN RESULTS

Patients' demographics, clinical indicators, and hysteroscopy data were collected from the electronic database of the hospital. The patients were randomly apportioned to either a training or testing set (332 and 142 patients, respectively). A decision tree model of adhesion recurrence was established with a classification and regression tree algorithm and validated with reference to a multivariate logistic regression model. The decision tree model was constructed based on the training set. The classification node variables were the risk factors for recurrence of IUAs: American Fertility Society score (root node variable), isolation barrier, endometrial thickness, tubal opening, uterine volume, and menstrual volume. The accuracies of the decision tree model and multivariate logistic regression analysis model were 75.35% and 76.06%, respectively, and areas under the receiver operating characteristic curve were 0.763 (95% CI 0.681-0.846) and 0.785 (95% CI 0.702-0.868).

CONCLUSIONS

The decision tree model can readily predict the recurrence of IUAs and provides a new theoretical basis upon which clinicians can make appropriate clinical decisions.

Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome

STUDY QUESTION

What are the live birth rate and risks of obstetric complications following the surgical management of intrauterine adhesions (IUA) such as Asherman syndrome (AS)?

SUMMARY ANSWER

The live birth rate is 63.7%, and obstetric complications including placentation issues, prematurity and postpartum hysterectomy require that pregnancies in women after treatment for IUA should be considered moderate to high risk.

WHAT IS KNOWN ALREADY

Studies reviewing short-term surgical, menstrual and fertility outcomes following hysteroscopic management are reassuring, with success correlated to the severity of IUA. There are limited data reporting live birth, neonatal and maternal complications.

STUDY DESIGN, SIZE, DURATION

This retrospective study included all women treated for IUA by hysteroscopic synechiolysis under fluoroscopic guidance in two tertiary University-affiliated hospitals. All women reported at least one pre-treatment symptom including menstrual dysfunction, subfertility or pelvic pain and intended to become pregnant post-treatment. Survival curve analysis was performed for time to pregnancy, and obstetric data were collated from a National Obstetric Database for delivery and neonatal outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 154 women were included in the study. Surgical intervention involved hysteroscopic synechiolysis under fluoroscopic guidance until cavity restoration was confirmed. Questionnaires regarding fertility and its outcomes were sent to all women undergoing surgery, with analysis of menstrual, fertility rates and outcomes of those pregnancies including risks and complications to the woman and the offspring.

MAIN RESULTS AND THE ROLE OF CHANCE

Women were followed up for a minimum of 1 year (range: 1-14 years) from index surgery. The chance of pregnancy was 98/124 (79.0% CI: 63.6, 83.1%) in women wishing to conceive and the chance of a live birth was 79/124 (63.7% CI: 51.3, 70.7%). The chance of a miscarriage was 29/124 (23.4% CI: 18.8, 37.1%). There were 93 live births in 79 women following surgery, with detailed obstetric data available for 85 of these births. They were complicated by abnormal placentation in 15/85 (17.6% CI: 13.0, 30.2%), postpartum hysterectomy in 4/85 (4.7% CI: -0.4, 7.0%), and prematurity in 25/85 (29.4% CI: 17.0, 35.3%) women.

LIMITATIONS, REASONS FOR CAUTION

The retrospective nature of the study and extended follow-up time may cause selection and recall bias, however, pregnancy and its outcomes-particularly in women with problems of subfertility-are frequently key milestones, with birthdates readily recalled. Menstrual outcomes are more likely to be subject to recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

Our surgical data are similar to the published literature with reassuring short-term outcomes for menstruation and cavity reconstruction following surgery for IUA. Long-term outcomes including pregnancy rates were higher than published data, however, the obstetric and neonatal complication rates were increased, indicating a continuation of risk beyond infertility and into pregnancy. An altered biochemical or vascular environment is a possible explanation for impaired implantation resulting in poorer reproductive obstetric and neonatal outcomes. The relative rarity of IUA-particularly severe disease-makes prospective data collection difficult. Our data suggest that women with IUA should be treated as moderate-high risk obstetric patients in subsequent pregnancy and counselled appropriately.

STUDY FUNDING/COMPETING INTEREST(S)

No funding and no competing interests.

Matsubara-Yano suture: a simple uterine compression suture for postpartum hemorrhage during cesarean section

AIMS

The aims of this study were to clarify: (i) the effectiveness of Matsubara-Yano uterine compression suture (MY) to achieve hemostasis in the presence of postpartum hemorrhage (PPH) during cesarean section, (ii) the type of PPH for which MY is effective, (iii) post-operative complications of MY, and (iv) outcomes of pregnancy after MY.

METHODS

This retrospective observational study was performed using medical records of patients for whom MY had been performed between January 1, 2009 and December 31, 2017.

RESULTS

MY was performed for 50 patients, with hemostasis achieved in 46 (92%). The other four (8%: 4/50) patients required transarterial embolization or hysterectomy. Of these four, three patients had placenta accreta spectrum (PAS) disorder-related bleeding. Post-operative complications were observed in three (6%: 3/50) patients, with all showing intrauterine infection. All three patients recovered solely with antibiotics. Eight pregnancies were confirmed (five livebirths, two spontaneous abortions in the first trimester, and one case of ongoing pregnancy). Of the five livebirths, one resulted in cesarean hysterectomy due to placenta previa with PAS disorders.

CONCLUSIONS

MY had a hemostatic effect on PPH. All cases except one with hemostatic failure were associated with PAS disorders, indicating that the hemostatic rate was lower in those with PAS than non-PAS disorders.

Laparoscopic removal of uterine vertical compression sutures

Uterine compression suturing is a relatively easy and effective way of hemostasis during cesarean section and is becoming widely accepted. However, complications such as necrosis or synechiae have been reported. We firstly report a case of laparoscopic removal of vertical compression sutures and discuss its benefits and improvements to be made. This case report is of a 32-year-oId woman with placenta previa who received uterine vertical compression sutures for controlling massive bleeding during cesarean section. Because she complained of unbearable pelvic pain, laparoscopic compression suture removal was performed. Her pain was relieved after the threads were removed, suggesting that the compression sutures were the cause of her pelvic pain due to uterine ischemia. Although the risks of reoperation during the early postpartum period still exist, compression suture thread removal should be considered in cases of suspected uterine ischemia.

Application of a hyaluronic acid gel after intrauterine surgery may improve spontaneous fertility: a randomized controlled trial in New Zealand White rabbits

Objective

Intrauterine adhesions (IUAs) are the most common complication after hysteroscopy in patients of reproductive age. Intra-abdominal anti-adhesion gel reduces the incidence of adhesions, but effects on fertility after uterine surgery are not known. The objective of our work was to evaluate the effect of intrauterine anti-adhesion gel on spontaneous fertility after repeated intrauterine surgery with induced experimental synechiae in the rabbit model.

Materials and Methods

Twenty New Zealand White rabbits underwent a double uterine curettage 10 days apart and were randomized into two groups. Each rabbit served as its own control: one uterine tube was the treatment group (A), the second uterine tube was the control group (B) to avoid bias through other causes of infertility. Group A received a post curettage intrauterine instillation of anti-adhesion gel whereas group B, the control group, underwent curettage without instillation of the gel. After a recovery period, the rabbits were mated. An abdominal ultrasound performed 21 days after mating allowed us to diagnose pregnancy and quantify the number of viable fetuses.

Results

There was a significant difference in total fetuses in favor of group A, with an average of 3.7 (range, 0–9) total fetuses per tube against 2.1 (0–7) in group B (p = .04). The number of viable fetuses shows a trend in favor of group A, with an average of 3.4 (0–7) viable fetuses per tube against 1.9 (0–6) viable fetuses per tube in group B (p = .05).

Conclusion

The use of immediate postoperative anti-adhesion gel improved fertility in an animal model after intrauterine surgery likely to cause uterine synechiae. This experimental model will permit comparison of different anti-adhesion solutions, including assessment of their tolerance and potential mucosal toxicity on embryonic development.

A new removable uterine compression by a brace suture in the management of severe postpartum hemorrhage

Postpartum hemorrhage (PPH) is a life-threatening complication of delivery. It is the leading cause of maternal mortality. During the last 15 years, several total uterine compressive sutures were described in literature. They have proven their effectiveness and safety in the management of severe PPH as an alternative to hysterectomy. We present in this paper a new technique of uterine compressive sutures based on removable uterine brace compressive sutures with compression of the uterus against the pubis. This technique may be more effective by using two mechanisms of uterine bleeding control and also may prevent uterine synechia by respecting the uterine cavity and the removal of the suture 1 or 2 days later. We also present the results of a 15 patients’ series using this new suture.

B-lynch: a technique for uterine conservation or deformation? A case report with literature review

Postpartum haemorrhage is a leading cause of global maternal mortality and morbidity, accounting for 25-30% of all maternal deaths, and 75-90% of these casualties result from uterine atony. Uterine compressive sutures are a well established measure for control of haemorrhage following atonic postpartum haemorrhage, when medical and nonmedical interventions fail. Here, we are reporting a case of secondary infertility in a 24-year-old lady who had undergone an elective caesarean section for central placenta previa in her first pregnancy. She had massive postpartum haemorrhage, for which B-Lynch suture and vessel ligation were done. Subsequently, she failed to conceive for 4 years. This was because of severe pelvic adhesions and uterine deformation which were found intraoperatively, as a consequence of previous use of B-Lynch suture. As no definitive treatment could be offered to her, we suggested her to go for adoption.

Treatment for primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries.

OBJECTIVES

To assess the effectiveness and safety of any intervention used for the treatment of primary PPH.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013).

SELECTION CRITERIA

Randomised controlled trials comparing any interventions for the treatment of primary PPH.

DATA COLLECTION AND ANALYSIS

We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information.

MAIN RESULTS

Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review.Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41).  Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering.Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre-specified outcomes.One study compared lower segment compression but was too small to assess impact on primary outcomes.We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics.

AUTHORS' CONCLUSIONS

Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first-line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit.The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy.

The Diagnosis and Management of Asherman's Syndrome Developed after Cesarean Section and Reproductive Outcome

Intrauterine adhesions (IUAs) frequently occur as a result of trauma to the basal layer of endometrium following pregnancy-related curettage such as incomplete abortion (33,3%), postpartum hemorrhage (37,5%), and elective abortion (8,3%). Hysterotomy, myomectomy, Cesarean section, hysteroscopic procedures, such as resection of submucosal leiomyomata or uterine septae, and endometrial ablation are less common etiologic factors resulting in IUA formation. Patients with Asherman's syndrome usually present with menstrual disturbances, infertility, or recurrent pregnancy loss. A successful treatment of infertility could be achieved by restoration of the uterine cavity, prevention of IUA reformation, and promotion of healing process. We presented the diagnosis and management of a case that suffers from menstrual disturbances and secondary infertility resulted from IUA formation developed after Cesarean section.

Fertility after "only B-Lynch" suture: a case report and literature review

OBJECTIVE

A new fertility assessment after a B-Lynch suture without a concomitant uterine devascularization is proposed.

CASE REPORT

The 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.

CONCLUSION

The 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.

Risk of postpartum uterine synechiae following uterine compression suturing during postpartum haemorrhage

BACKGROUND

Uterine compression suturing is considered a successful, safe, inexpensive and simple ‎method for the conservative treatment of atonic postpartum haemorrhage (PPH). However, insufficient data are available about the potential risk of subsequent intrauterine ‎synechiae (IUS).

AIM

To determine the risk of postpartum uterine synechiae in women who received isolated uterine compression suturing for the management of major uncontrolled PPH.

MATERIALS & METHODS

All women with major PPH from May 2005 to June 2011 were reviewed retrospectively. Diagnostic hysteroscopy was performed to assess the uterine cavity in the 27 women who successfully underwent isolated uterine compression suturing for major atonic PPH and fulfilled the study inclusion and exclusion criteria.

RESULTS

Among the 27 women who underwent isolated uterine compression suturing, 5 (18.5%) were found to have IUS on hysteroscopic examination. The mode of delivery for all women who developed IUS was caesarean section. Among these five women, three had mild IUS, one had moderate IUS and one had severe IUS. All adhesions were later successfully resected by hysteroscopy, except for one case with dense IUS.

CONCLUSIONS

Uterine compression suturing was found to be associated with a risk of postpartum uterine synechiae formation, which may subsequently affect future fertility.