[Risk of uterine synechiae following uterine compression sutures during postpartum haemorrhage]

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.

The effectiveness of the double B-lynch suture as a modification in the treatment of intractable postpartum haemorrhage

A broader range of more effective compression techniques are needed in the patients who have an intractable postpartum haemorrhage due to uterine atony despite medical treatment and B-Lynch sutures. The aim of this study was to report the outcome of a series of patients with haemorrhage who were managed by double B-Lynch suture. Fourteen patients who were treated in a tertiary hospital between July 2010 and February 2015 were included in the study. The intractable haemorrhage rate was 0.35% over 5 years (14/4000 births). Bleeding was controlled in all the patients with a double B-Lynch suture. The mean age of the patients was 24 ± 3.4 years. The mean estimated blood loss was 1696 ± 272.075 mL, and the mean transfusion rate was 4.2 ± 2.5 units. Pregnancy was observed in five patients at follow up. The double B-Lynch suture seems to be an effective and reliable solution to an intractable postpartum haemorrhage resulting from uterine atony and has no unfavourable impacts on fertility. It should be considered before the use of any aggressive surgical techniques such as a hypogastric artery ligation or a hysterectomy. This the first study to investigate the effectiveness of the double B-Lynch suture, and we showed that the hysterectomy and/or hypogastric artery ligation rate can be decreased by adding a second B-Lynch suture in cases where the medical treatment or a single B-Lynch has failed. Impact statement What is already known on the subject? Uterine atony is the most common cause of a primary postpartum haemorrhage. When a simple massage of the uterus and medication failed to manage this condition, various surgical solutions have been sought, including uterine compression sutures, uterine artery ligation, devascularisation of the uterus, internal iliac artery ligation and, ultimately, a hysterectomy. The B-Lynch suturing technique is particularly useful because of its simplicity of application, life-saving potential, relative safety and capacity for preserving the uterus and subsequent fertility. To-date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications. However in the cases of when it falls, usually a hysterectomy or a hipogastric artery ligation is preferred. What does this study add? A 'double B-Lynch suture seems to be an effective and reliable method in an intractable postpartum haemorrhage due to a uterine atony and has no unfavourable impact on fertility'. What are the implications of these findings for clinical practice? The double B-Lynch suture seems to be an effective, reliable and technically easy method. With this aspect, it might be considered before any aggressive surgical techniques, such as a hypogastric artery ligation and hysterectomy in selected cases.