Later reproductive health after B-Lynch sutures: a follow-up study after 10 years' clinical use of the B-Lynch suture

Menstrual, fertility and psychological impacts after uterine compression sutures for postpartum hemorrhage: a prospective cohort study

BACKGROUND

Uterine compression suture is an important conservative surgical technique in managing atonic postpartum hemorrhage. In this study, we aim to evaluate the subsequent menstrual, fertility and psychological outcomes after uterine compression sutures.

METHODS

This was a prospective cohort study between 2009 and 2022 conducted in a tertiary obstetric unit (6000 deliveries per year) in Hong Kong SAR. Women with primary postpartum hemorrhage successfully treated with uterine compression sutures were followed-up in postnatal clinic for two years after delivery. Data on menstrual pattern were collected during each visit. Psychological impact after uterine compression suture was assessed using a standardized questionnaire. Subsequent pregnancies were identified by territory-wide computer registry and telephone interviews. Women with postpartum hemorrhage treated with uterotonic agents only were chosen as controls.

RESULTS

In our cohort (n = 80), 87.9% of women had return of menses within six months after delivery. Regular monthly cycle was observed in 95.6% of women. Majority of women reported similar menstrual flow (75%), menstrual days (85.3%) and no change in dysmenorrhea status (88.2%) as compared before. Among eight (11.8%) women who reported hypomenorrhea after uterine compression sutures, two cases of Asherman's syndrome were diagnosed. Among 23 subsequent pregnancies (16 livebirths), no significant differences in outcome were observed except more omental or bowel adhesions (37.5% vs. 8.8%, p = 0.007), recurrence of hemorrhage (68.8% vs. 7.5%, p < 0.001) and repeated compression sutures (12.5% vs. 0%, p = 0.024) were seen in women with previous compression sutures. Over half of the couple declined future fertility after uterine compression sutures with 38.2% of women recalled unpleasant memories and 22.1% reported life-long adverse impact especially tokophobia.

CONCLUSION

Majority of women with history of uterine compression sutures had similar menstruation and pregnancy outcomes as compared to those who did not have sutures. However, they had higher intrapartum risk of visceral adhesions, recurrence of hemorrhage and repeated compression sutures next pregnancy. Furthermore, couple could be more susceptible to negative emotional impact.

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.

Obstetric and Maternal Outcomes After B-Lynch Compression Sutures: A Meta-Analysis

This review article aimed to determine the obstetric and maternal outcomes after B-Lynch compression sutures to control atonic postpartum hemorrhage (PPH). This meta-analysis was performed after registering the protocol in the PROSPERO database with the registration number CRD42022355358. Two independent reviewers systematically searched electronic databases and search engines (PubMed, Cochrane Library, and Google Scholar) to retrieve published articles from inception to July 2022. The obstetric and maternal outcomes after the B-Lynch compression suture were computed using the random-effects model in pooled proportion with a 95% confidence interval (CI). Meta-regression analysis and subgroup analysis were performed to explain any source of possible heterogeneity. Quality assessment of the included studies was done using Joanna Briggs Institute (JBI) tools which are critical appraisal tools for systematic reviews and meta-analyses. This meta-analysis included a total of 30 studies involving 1,270 subjects. The pooled proportion of B-Lynch suture alone was 91% (95% CI = 82-97%). The combined proportion of B-Lynch suture plus another compression suture was 1% (95% CI = 0-3%), and the pooled proportion of B-Lynch suture plus vessel ligation was 3% (95% CI = 1-6%). The pooled proportions of PPH controlled and hysterectomies were 94% (95% CI = 91-97%, I² = 65.3%) and 7% (95% CI = 4-10%, I² = 72.13%), respectively. Therefore, B-Lynch suture (either alone or in combination with other techniques) is a simple and effective measure to control atonic PPH.

Placenta percreta presenting as uterine rupture following previous B-Lynch suture

Placenta accreta spectrum disorder varies from minimally adherent placenta to deeply invasive placenta. Placenta percreta is a rare cause for uterine rupture and the incidence of morbidly adherent placenta is on the rise due to increase in the rates of caesarean section. We report a case of a 32-year-old, G2P1L1 who presented to us at 27 weeks in a state of haemodynamic shock with intrauterine fetal death. She had a history of prior caesarean section complicated by postpartum haemorrhage requiring B-Lynch suturing. With an initial diagnosis of caesarean scar rupture, she underwent an emergency laparotomy. Intraoperatively, the caesarean scar was found to be intact and uterine fundal rupture with placental protrusion identified. She underwent caesarean hysterectomy and was discharged in a stable condition. The histopathology report confirmed the diagnosis of placenta percreta.

Subsequent pregnancy outcome after uterine compression suture placement for postpartum hemorrhage

OBJECTIVE

To evaluate the subsequent obstetrical outcome in women who received a uterine compression suture.

METHODS

This is a retrospective cohort study of women who received a uterine compression suture for postpartum hemorrhage (PPH) between January 2009 and December 2018 and had a subsequent pregnancy at a tertiary care hospital in India. Women who had PPH but did not receive uterine compression sutures and had a subsequent pregnancy were taken as controls.

RESULTS

Sixty-two women had a subsequent pregnancy after uterine compression suture and were included in this study. There were no significant differences in the subsequent pregnancy outcome between the study and control groups. However, women with a history of uterine compression suture were found to have a higher incidence of dense omental adhesions (15% versus 2.8%; P < 0.001), more intrapartum blood loss (740.5 ± 491.8 ml versus 638.8 ± 194 ml; P = 0.02), and were more likely to need repeat uterine compression suture (6.7% versus 0%; P = 0.004).

CONCLUSION

Women who received uterine compression sutures had similar obstetrical outcomes in their subsequent pregnancy compared with those who did not receive a suture for PPH management. However, they had a higher risk of dense omental adhesions, repeat uterine compression suture application, and intrapartum blood loss.

Obstetrical outcome after B-Lynch sutures and ligation of uterine arteries: A case report

Objective

To illustrate the obstetrical outcome after B-Lynch sutures and ligation of the uterine arteries.

Case

A 26-year-old nulliparous woman. A caesarean section performed for obstructed labour was complicated by uterine atony. A B-Lynch uterine compression suture technique was used combined with ligation of the ascending branches of the uterine arteries. Before the subsequent fertility treatment, gel instillation sonography and power Doppler imaging showed a normal uterine cavity and restored myometrial vascularization. Subsequent caesarean section showed external adhesions on the anterior uterine serosa. A healthy baby of normal weight was delivered. There was focal placenta accreta; the underlying myometrium was strikingly thinner and prone to inversion.

Discussion

After B-Lynch sutures and ligation of the ascending branches of the uterine arteries, the pregnancy was subsequently uncomplicated. The potential association between B-Lynch sutures and placenta accreta or uterine inversion in a subsequent pregnancy has to be assessed in further studies. This case report illustrates how 3D gel instillation sonography is a valuable tool to evaluate the integrity of the uterine cavity.

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3D gel instillation sonography gives the best evaluation of the uterus after B-Lynch sutures have been used.

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Normal fertility and pregnancy are possible after B-Lynch sutures have been used.

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Normal fertility and pregnancy are possible after ligation of the uterine arteries.

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B-Lynch sutures and ligation of the uterine arteries are useful in postpartum haemorrhage.

Intrauterine adhesions: What is the pregnancy rate after hysteroscopic management?

OBJECTIVE

To evaluate the rate of pregnancy following hysteroscopic management of intrauterine adhesions.

DESIGN

Retrospective study.

SETTING

From June 2009 to December 2014 in a teaching hospital.

PATIENTS

Women treated by operative hysteroscopy for intrauterine adhesions.

INTERVENTION

Operative hysteroscopy to manage intrauterine adhesions.

MAIN OUTCOME MEASURE

rate of intrauterine pregnancy after hysteroscopic management of intrauterine adhesions.

RESULTS

Out of the 202 women whom benefit from hysteroscopic adhesiolysis, 112(55%) had an effective pregnancy desire. Among them, an intrauterine pregnancy was obtained for 58 women (52%) with a trend to a lower rate for type IV and Vb intrauterine adhesions management (40.5%, p = 0.09). Pregnancy rates were similar for women undergoing one or more procedures.

CONCLUSION

Hysteroscopic management of intrauterine adhesions seems useful as it leads to a pregnancy rate of 52%. However, this rate is lower in case of type IV and Vb intrauterine adhesions. Repeated procedures don't seem to lead to less pregnancy; however, a more powerful prospective study should be performed to answer this specific question.

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.

Vaginal omentum prolapse due to uterine anterior wall necrosis after prophylactic compression suture for postpartum hemorrhage: case report and review of the literature

Introduction

Postpartum or peripartum hemorrhage (PPH) is a major cause of maternal death in Western industrialized countries. Fertility preserving second stage interventions following uterotonic drugs include embolization or ligation of relevant arteries, uterine tamponade or compression sutures. Little is known about the complications due to uterine compression sutures. We describe a case report in association with uterine compression sutures and provide a systematic review on necrosis due to compression sutures (CSU).

Data sources

A PubMed database search was done up to October 1, 2016 without any restrictions of publication date or journal, using the following key words: “compression suture” and “postpartum hemorrhage” or “peripartum hemorrhage”. Reported cases were considered eligible when reason for postpartum hemorrhage (PPH), type of compression suture, suture material and type of complication were described.

Results

Among 199 publications a total of 11 reported on uterus necrosis after CSU applied for PPH. B-Lynch and modifications were applied in seven cases, Cho compression sutures in three cases and in one case B-Lynch and Cho techniques were combined. In six cases no additional measures were applied, in two cases vessel ligation, in one case embolization and in one case intrauterine balloon application were applied. In one case of partial necrosis it is not reported if additional measures were applied.

Discussion and conclusion

Uterine compression sutures are a useful method for fertility preserving management of postpartum hemorrhage. The risk of serious complications demands the careful consideration of its use. More research is necessary to improve the technique.

[Obstetric outcomes after uterine compression suture for treatment of postpartum hemorrhage: Long-term monitoring of 40 cases]

OBJECTIVE

Uterine atony is the first cause of postpartum hemorrhage. In caesarean section, different techniques of uterine compression suture exist when uterotonic drugs fail. Their effectiveness is shown but little data on their effects on subsequent pregnancies are available. The aim of this work is analyze of the obstetrical long-term consequences after uterine compression suture.

PATIENTS AND METHODS

This is a retrospective study of 40 cases of uterine compression suture performed in a level III maternity, between 2004 and 2010. The main objective is the evaluation of the obstetrical prognosis of subsequent pregnancies. The efficacy and safety of surgical techniques, according to their transfixing character or not, were analyzed.

RESULTS

Eleven pregnancies after uterine compression suture were reported among 14 women whishing another pregnancy. The median time to be pregnant was 27 months (6-78 months). Nine pregnancies were conducted at term. One case of intrauterine growth restriction and a moderate prematurity at 32 weeks were observed. There was no significant difference in efficacy and early surgical complications according to the surgical technique; however, both infectious and ischemic complications were observed after transfixing compression suture.

CONCLUSION

The obstetric prognosis after a uterine compression suture is kept. The transfixing techniques may cause more infectious and ischemic complications. An evaluation of surgical techniques depending on their transfixing, or not, character on a large cohort is necessary for the evaluation of the influence of the technique on fertility and postoperative complications.

Fertility and pregnancy outcomes following B-Lynch sutures for post-partum hemorrhage

AIM

The aim of this study was to investigate the long-term fertility prognosis after B-Lynch sutures for post-partum hemorrhage (PPH).

METHODS

A retrospective observational study was conducted on patients who underwent B-Lynch sutures in our hospital between 2005 and 2010. Patient data was collected from hospital records. Information regarding subsequent pregnancies and menstrual complications were obtained by posted questionnaires and telephone interviews with patients who avoided hysterectomy.

RESULTS

A total of 28 B-Lynch sutures were performed in 3976 deliveries, all in patients that underwent cesarean section. Twenty-two of the 26 patients who avoided hysterectomy answered our questionnaire or took part in an interview. All patients recovered regular menstruation with no severe complications. Of the 19 patients who wanted another child, 12 patients (63.2%) had 14 subsequent pregnancies in a mean follow-up period of 52.1 months. The results of pregnancies were nine uncomplicated term pregnancies, all delivered by elective cesarean section, two artificial abortions and three miscarriages. A significant difference was observed in the age of patients with subsequent pregnancies and those without pregnancies (30.8 vs 34.6 years, P = 0.04).

CONCLUSION

B-Lynch sutures for PPH do not appear to jeopardize fecundity. An older age was a risk factor for achieving subsequent pregnancies.