Successful Term Pregnancy after B-Lynch Compression Suture in a Previous Pregnancy on Account of Massive Primary Postpartum Hemorrhage

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.

[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.

Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience

In the treatment of postpartum haemorrhage from uterine atony, uterine compression sutures, such as the B-Lynch suture and its modifications have a role with the advantage of preservation of the uterus for fertility. There is however, a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in undesirable complications. We undertook a five-year retrospective study of all women who underwent uterine compression sutures at the KK Women's and Children's Hospital, between 2008 and 2012. In total, 23 women had uterine compression sutures during the study period, of which, nineteen women managed to conserve their uterus. Our complication rate was 25%, which included persistent vaginal discharge, pyometra and endometritis. There were three conceptions, with two successful pregnancies. Our study shows uterine compression suture to be a safe and effective alternative to avoid hysterectomy with preservation of fertility at the time of major postpartum haemorrhage. The outcome of subsequent pregnancies is reassuring.

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.

Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature

OBJECTIVE

To investigate the most appropriate surgical technique for optimizing hemostasis and preservation of subsequent fertility after postpartum hemorrhage (PPH).

DESIGN

Systematic review of the literature.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTION(S)

Review of MEDLINE, EMBASE, ScienceDirect, and the Cochrane Library.

MAIN OUTCOME MEASURE(S)

Comparison of the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus), fertility rate (subsequent pregnancies or the return of regular menstrual cycles), complication rate of the procedure, and the outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications.

RESULT(S)

Compressive sutures and vessel embolization may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation.

CONCLUSION(S)

Pelvic vessel embolization and compressive sutures are associated with high rates of restoration of regular menses and successive pregnancies, even if the former is burdened by an increased rate of placental disorders and fetal growth restriction and the latter by an increased risk of cesarean deliveries and PPH recurrence. Randomized trials would be desirable to define the best management of PPH.

B-Lynch suture technique to control postpartum hemorrhage in a patient with mullerian anomaly

Congenital anomalies of the uterus may cause gynecologic, obstetric and fertility problems. Obstetrical complications are reported to occur more commonly with mullerian duct anomalies, such as postpartum hemorrhage (PPH). Uterine compression sutures may be effective in controlling PPH in these conditions as an alternative to hysterectomy, especially if the patient has a desire to conceive. As the shape of the uterus is changed in congenital malformation, the usage of compression sutures such as B-Lynch can be more difficult. In this study we report a case of PPH accompanying a large septae, treated with B-Lynch suture. A 24 year old, multigravid and nulliparous patient (G:3) was admitted to our clinic with vaginal bleeding and abdominal pain at 31 weeks of gestation. Emergency cesarean section was performed for abruptio placenta and PPH occurred subsequently. A deep uterine septum was revealed during operation. Intermittent fundal massage and intravenous uterotonics were used to improve uterine tonicity without any improvement. After the B-Lynch suture was performed, the bleeding diminished dramatically. As the shape of the uterus is changed in congenital malformation, the application of secondary interventions in postpartum hemorrhage can be more difficult. There can be slippage or overlapping of the suture while using a B-Lynch suture. Because the uterine shape is not completely distorted, patients with septate uterus can be candidates for a B-Lynch suture. There is no such reported case from the literature regarding efficacy of B-Lynch suture in mullerian anomalies. his case illustrates the potential benefits of B-Lynch compression suture in an uterus with mullerian anomalies.

Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage

OBJECTIVE

Describe a case of secondary infertility due to the development of severe Asherman Syndrome after the B-Lynch compression suture and uterine artery ligation, and to review the B-Lynch technique and documented complications.

DESIGN

Case report.

SETTING

Tertiary care hospital.

PATIENT(S)

A 29-year-old primigravida patient.

INTERVENTION(S)

B-Lynch suture and uterine artery ligation.

MAIN OUTCOME MEASURE(S)

Development of Asherman syndrome.

RESULT(S)

Development of secondary infertility due to Asherman syndrome after the B-Lynch suture.

CONCLUSION(S)

The B-Lynch suture is a highly successful conservative surgical technique used to treat this condition. There is little information regarding any potential for compromised future fertility, although there have been several reports of successful pregnancy after the use of the B-Lynch compression suture. In this report, we present a case of Asherman syndrome with complete obliteration of the uterine cavity after the B-Lynch suture.

Uterine compression sutures, an update: review of efficacy, safety and complications of B-Lynch suture and other uterine compression techniques for postpartum haemorrhage

Since the advent of uterine compression suture by B-Lynch, numerous techniques have been advocated. We aim to discuss these various techniques with respect to their efficacy, safety, complications, complexity of the technique itself, future fertility and menstrual periods. Since no randomized controlled trials are available, the conclusions are based on weak data derived from observational studies and case series. A success rate of 91.7% has been reported for various uterine compression sutures. There are concerns regarding closure of uterine cavity and blood entrapment resulting in infection, pyometra and adhesions as the uterus will be transfixed from front to back in some of the suturing techniques. Long-term follow-up regarding fertility of patients who had uterine compression sutures is urgently needed. Data on menstrual periods after uterine compression sutures is limited. Our review is limited in nature due to lack of consistent data on many important outcomes and also preclinical variables.

Using recombinant activated factor VII, B-Lynch compression, and reversible embolization of the uterine arteries for treatment of severe conservatively intractable postpartum hemorrhage: new method for management of massive hemorrhage in cases of placenta increta

OBJECTIVE

To investigate a new method for management of massive postpartum hemorrhage in cases of abnormal placenta adhesion.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

An 18-year-old nullipara presented with fulminant postpartum bleeding after cesarean section due to placenta increta. The patient developed hemorrhagic and septic shock associated with disseminated intravascular coagulation.

INTERVENTION(S)

Treatment with uterotonic drugs like oxytocin and prostaglandins and conservative procedures like transfusion of packed red cells and fresh frozen plasma failed to control the diffuse bleeding. Further intervention consisted of B-Lynch sutures, recombinant activated factor VII, and reversible embolization of the uterine arteries.

RESULT(S)

The bleeding stopped after operative B-Lynch compression and recombinant activated factor VII. In the interval, the bleeding continued under therapeutically resistant disseminated intravascular coagulation, and finally bilateral reversible embolization of the uterine arteries was performed to avoid an emergency hysterectomy to preserve fertility in this young woman.

CONCLUSION(S)

This is a case of abnormal placenta adhesion with massive postpartum hemorrhage in which different conservative and operative treatments were combined to avoid a hysterectomy with loss of fertility and major psychological impact for the young mother.