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

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.

Uterine necrosis, infection, and subinvolution: complications observed after combined application of modified B-Lynch suture and vascular ligation

Compression sutures are primarily used to treat atonic postpartum hemorrhage. We herein describe three cases of selective arterial ligation combined with B-Lynch or modified B-Lynch suture for the treatment of intractable postpartum hemorrhage unresponsive to available conservative interventions. Three pregnant women underwent a cesarean section for a macrosomic fetus, fetal distress, and oligohydramnios, respectively. All three women developed intractable postpartum hemorrhage due to uterine atony with no chance of embolization therapy. B-Lynch or modified B-Lynch suture and additional selective arterial ligation were performed using braided absorbable suture. The first woman developed postoperative hematometra and infection without response to drainage and antibiotic therapy. Although laparoscopic exploration was performed to loosen the suture line and drain the hematometra and pyometra, the necrosis and infection could not be controlled. Subtotal hysterectomy was therefore conducted, and the necrotic uterine adnexa was removed. The other two women developed subinvolution of the uterus resulting in prolonged menstruation and amenorrhea, although the uterus was preserved and the bleeding was controlled. Modified B-Lynch suture combined with vascular ligation is an invaluable technique for women with severe intractable postpartum hemorrhage. However, it can lead to serious complications such as uterine necrosis, infection, and subinvolution.

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.

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.