A new step-wise surgical technique of knapsack-like uterine compression sutures for intractable postpartum hemorrhage in cesarean section

BACKGROUND

Intractable postpartum hemorrhage (PPH) during cesarean section has been a significant concern for obstetricians. We aimed to explore the effectiveness and safety of a new type of uterine compression suture, the step-wise surgical technique of knapsack-like sutures for treating intractable PPH caused by uterine atony and placenta factors in cesarean section.

METHODS

The step-wise surgical technique of knapsack-like sutures was established on the basis of the artful combination of vertical strap-like sutures and an annular suture-ligation technique. This novel surgical technique was applied to 34 patients diagnosed with PPH during cesarean section due to severe uterine atony and placental factors in our department. The hemostatic effects, clinical outcomes and follow-up visit results were all reviewed and analyzed.

RESULTS

This new uterine compression suture successfully stopped bleeding in 33 patients, and the effective rate was 97.06%. Only 1 patient failed and was changed to use bilateral uterine arterial embolization and internal iliac artery embolization. The follow-up visits indicated that 33 patients restored menstruation except for 1 who was diagnosed with amenorrhea. The gynecological ultrasound tests of all the patients suggested good uterine involutions, and they had no obvious complaints such as hypogastralgia.

CONCLUSIONS

This step-wise surgical technique of knapsack-like uterine compression sutures can compress the uterus completely. It is a technique that can conserve the uterus and fertility function without special equipment in caesarean section for PPH, with the characteristics of being safe, simple and stable (3 S) with rapid surgery, reliable hemostasis and resident doctor to operation (3R).

The uterine tourniquet, a simple maneuver that may facilitate surgical management of postpartum hemorrhage

The uterine tourniquet is a temporary intervention that facilitates the application of other procedures for definitive control of postpartum hemorrhage.

Outcome Of B-Lynch Application In Patients With Post-Partum Hemorrhage Following Cesarean Section

BACKGROUND

The most common cause of post partum hemorrhage after a cesarean section is uterine atony.

Aims and Objective

The main aim of this study was to examine the outcomes of the B-Lynch procedure in patients who experienced primary PPH after cesarean section.

METHODS

This study spanned one year, from August 2020 to August 2021, at Ayub Teaching Hospital. Patients who developed post-partum hemorrhage after a cesarean section were enrolled in this study and a thorough review of their records was conducted to identify those who received B-Lynch sutures and assess the resulting outcomes.

RESULTS

Out of the 87 patients who experienced PPH, 24 (27.6%) patients received the B-Lynch procedure. Among these 24 patients, only two (8.3%) needed hysterectomy, while the remaining 22 successfully recovered after receiving the B-Lynch procedure.

CONCLUSIONS

The B-Lynch technique proves to be a safe, effective, and easily applicable method for stopping hemorrhage in patients who experienced significant initial postpartum hemorrhage due to uterine atony.

Comparison of H-Hayman uterine compression suture with conventional vertical sutures: A cross-sectional study in a tertiary center

OBJECTIVE

To compare H-Hayman, a modified uterine compression suturing technique (UCS) that we describe for the first time in the literature, with conventional vertical UCS techniques.

METHODS

The H-Hayman technique was used in 14 women and the conventional UCS technique in 21 women. In order to provide standardization in the study, only patients who had developed upper-segment atony during cesarean section were recruited for the study.

RESULTS

Bleeding control was achieved in 85.7% (12/14) of the cases using the H-Hayman technique. In the remaining two patients with persistent hemorrhage in this group, bleeding control was provided with bilateral uterine artery ligation, and a hysterectomy was avoided in all cases. With the conventional technique, bleeding control was achieved in 76.1% (16/21) of the patients, and the overall success rate was 95.2% after bilateral uterine artery ligation in those with persistent hemorrhage. In addition, the estimated blood loss and the need for erythrocyte suspension transfusion were significantly lower in the H-Hayman group (P = 0.01 and P = 0.04, respectively).

CONCLUSION

We found the H-Hayman technique to be at least as successful as conventional UCS. In addition, patients who underwent suturing with the H-Hayman technique had less blood loss and a lower requirement for erythrocyte suspension transfusion.

Peripartum Hysterectomy among Patients Admitted to the Department of Obstetrics and Gynaecology in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Emergency peripartum hysterectomy is a life-saving procedure performed as an emergency procedure to control torrential bleeding and it is associated with significant maternal morbidity and mortality. There are only a few studies regarding this topic so this study guides us to monitor the trend and start appropriate policies to reduce unnecessary caesarean deliveries. The aim of this study was to find out the prevalence of peripartum hysterectomy among patients admitted to the Department of Obstetrics and Gynaecology in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted in the Department of Obstetrics and Gynaecology of the tertiary care centre. Data from 1 January 2015 to 31 December 2022 were collected between 25 January 2023 and 28 February 2023 from the hospital records. Ethical approval was obtained from the Institutional Review Committee of the same institute (Reference number: 2301241700). Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated.

Results

Among 54,045 deliveries, peripartum hysterectomy was seen in 40 (0.074%) (0.05-0.10, 95% Confidence Interval). The major indication of emergency peripartum hysterectomy was abnormal placentation (placenta accreta spectrum) which was 25 (62.50%) followed by uterine atony in 13 (32.50%) of patients and uterine rupture in 2 (5%).

Conclusions

The prevalence of peripartum hysterectomy was lower than in other studies done in similar settings. The indication for Emergency peripartum hysterectomy has changed in recent years from uterine atonicity to the morbidly adherent placenta which is due to a rise in the caesarean section rate.

Keywords

caesarean section; hysterectomy; placenta accreta.

Uterine Compression Sutures in Controlling Postpartum Haemorrhage: A Narrative Review

INTRODUCTION

Postpartum haemorrhage is still the main cause of maternal morbidity and mortality. Many treatments are available, but they may threaten fertility potential. As a uterine sparing procedure, we aimed to review uterine compression sutures in order to better understand when they should represent an appropriate option.

MATERIAL AND METHODS

A comprehensive search in MEDLINE and PubMed databases including the terms 'postpartum haemorrhage' and 'uterine compression sutures' was performed. Results were revised and articles reviewing or presenting case reports of uterine compression sutures to treat postpartum haemorrhage were included.

RESULTS

The first description of uterine compression sutures to control postpartum haemorrhage was published in 1997, by B-Lynch et al. After this publication, many others have reported successful management of postpartum haemorrhage with different suturing techniques. Most of them describe success rates above 75% and the possibility of fertility preservation, with cases of uneventful pregnancy after uterine compression sutures already published. Complications associated with each technique are rare.

DISCUSSION

Reports of use of uterine compression sutures include small series of cases or even single case reports which limits the quality of existing evidence to support one technique over another. Nevertheless, uterine compression sutures are recognized as an effective surgical conservative strategy to control postpartum haemorrhage due to uterine atony and its use is recommended, if possible, prior to hysterectomy.

CONCLUSION

Uterine compression sutures are effective, safe and simple to perform in an emergent situation and preserve fertility potential in cases of postpartum haemorrhage.

Esike's three-brace suture technique for controlling life-threatening postpartum hemorrhage - A report of two cases

Postpartum hemorrhage is a great cause of maternal morbidity and mortality worldwide with these effects being worse in developing countries. Uterine atony is the commonest cause. Esike's three brace suture technique is a novel simple but effective method that was used to successfully control life-threatening postpartum hemorrhage due to uterine atony in two women with the preservation of their uterus. Vicryl or chromic catgut 2 was used to apply compression sutures on the atonic uterus. This simple, effective, less invasive, easy to learn uterine-sparing technique is presented for further evaluation and possible wider use in saving the lives of our PPH patients and sparing their uteri.

Emergency obstetric hysterectomy for life-threatening postpartum hemorrhage: A 12-year review

The aim of the study was to review the operative experiences of emergency hysterectomy for life-threatening postpartum hemorrhage (PPH) performed over a 12-year period at Fujian Provincial Maternity and Children's Hospital; to examine the incidence and risk factors for emergency obstetric hysterectomy; and to evaluate the curative effectiveness and safety of subtotal hysterectomy for life-threatening PPH.The records of all cases of emergency obstetric hysterectomy performed at Fujian Maternity and Children Health Hospital between January 2004 and June 2016 were analyzed. The incidence, risk factors, and outcomes of hysterectomy, the peripartum complications, and the coagulation function indices were evaluated.A total of 152,023 of women were delivered. The incidence of emergency postpartum hysterectomy was 0.63 per 1000 deliveries: 96 patients underwent hysterectomy for uncontrolled PPH, 19 (0.207‰) underwent hysterectomy following vaginal delivery, and 77 (1.28‰) underwent the procedure following cesarean delivery (P < .001). Common risk factors included postpartum prothrombin activity ≤ 50% (61.5%), placenta accreta (43.76%), uterine atony (37.5%), uterine rupture (17.5%), and grand multiparity > 6 (32.3%). Forty-one patients underwent subtotal abdominal hysterectomy (STH) and 55 patients underwent total abdominal hysterectomy (TH). The mean operation time was significantly shorter for TH (193.59 ± 83.41 minutes) than for STH (142.86 ± 78.32 minutes; P = .002). The mean blood loss was significantly greater for TH (6832 ± 787 mL) than for STH (6329 ± 893 mL; P = .003). The mean number of red cell units transfusion was higher during TH (16.24 ± 9.48 units vs 12.43 ± 7.2, respectively; P = .047). Postoperative prothrombin activity was significantly higher than preoperative levels (56.84 ± 14.74 vs 44.39 ± 15.69, respectively; P < .001) in women who underwent TH and in those who underwent STH (57.63 ± 15.68 vs 47.87 ± 12.86, respectively; P < .001). There was no significant difference in the maternal complications after TH or STH for PPH.Cesarean deliveries were associated with an increased risk of emergency hysterectomy, and postpartum prothrombin activity < 50% was the greatest risk factor for hysterectomy in most women who underwent hysterectomy. STH was the preferred procedure for emergency obstetric hysterectomy.

Potentially Avoidable Peripartum Hysterectomies in Denmark: A Population Based Clinical Audit

Objective

To audit the clinical management preceding peripartum hysterectomy and evaluate if peripartum hysterectomies are potentially avoidable and by which means.

Material and Methods

We developed a structured audit form based on explicit criteria for the minimal mandatory management of the specific types of pregnancy and delivery complications leading to peripartum hysterectomy. We evaluated medical records of the 50 Danish women with peripartum hysterectomy identified in the Nordic Obstetric Surveillance Study 2009–2012 and made short narratives of all cases.

Results

The most frequent indication for hysterectomy was hemorrhage. The two main initial causes were abnormally invasive placenta (26%) and lacerations (26%). Primary atony was third and occurred in 20%. Before hysterectomy another 26% had secondary atony following complications such as lacerations, retained placental tissue or coagulation defects. Of the 50 cases, 24% were assessed to be avoidable and 30% potentially avoidable. Hysterectomy following primary and secondary atony was assessed to be avoidable in 4/10 and 4/13 cases, respectively. Early sufficient suturing of lacerations and uterine ruptures, as well as a more widespread use of intrauterine balloons alone or in combination with uterine compression sutures (the sandwich model), could presumably have prevented about one fourth of the peripartum hysterectomies.

Conclusion

More than 50% of peripartum hysterectomies seem to be avoidable by simple measures. In order to minimize the number of unnecessary peripartum hysterectomies, obstetricians and anesthesiologists should investigate individual cases by structured clinical audit, and disseminate and discuss the results for educational purposes. An international collaboration is warranted to strengthen our recommendations and reveal if they are generally applicable.

[Analysis of emergency obstetric hysterectomy: the change of indications and the application of intraoperative interventions]

OBJECTIVE

To investigate the change of indications of emergency obstetric hysterectomy and the clinical application of intraoperative interventions. And to provide evidence for prevention of hysterectomy and improvement of obstetric quality.

METHODS

Clinical data were collected from 97 patients who received emergency obstetric hysterectomy at Shengjing Hospital of China Medical University between January 1st, 2004 and December 31st, 2013. The patients were divided into two groups by the time point of January 1st, 2009: the first group was cases treated between January 1st, 2004 and December 31st, 2008, while the second group was cases treated between January 1st, 2009 and December 31st, 2013. The clinical indicators, surgical indications, intraoperative interventions, and blood loss between the two groups were analyzed retrospectively.

RESULTS

(1) Incidence: 54 857 women delivered at Shengjing Hospital of China Medical University between January 1st, 2004 and December 31st, 2013. Of them, 97 patients received emergency obstetric hysterectomy, with an incidence of 0.177% (97/54 857). (2) The 17 patients delivered vaginally (18%,17/97) and 80 by caesarean section (83%,80/97). Forty-nine patients experienced repregnancy with scar uterus (51% , 49/97). About 41 patients underwent abdominal total hysterectomy (42%,41/97) and 56 received subtotal hysterectomy (58%, 56/97). (3) The number of patients were comparable between the two groups (50 vs 47; P > 0.05). (4) The main surgical indication was uterine inertia (45%, 44/97). The main causes of uterine inertia were excessive uterine tension (45%, 20/44) and placental abruption due to gestational hypertension (32%, 14/44). Of all the indications, 29 patients in the first group (58%, 29/50) and 15 patients in the second group (32%, 15/47) suffered from postpartum hemorrhage. Pathological placenta embedment occurred in 15 patients in the first group (30%, 15/50) and 25 patients in the second group (53%, 25/47). The incidences of postpartum hemorrhage due to uterine inertia or pathological placenta embedment were significantly different between the two groups (both P < 0.05), respectively. (5) In the first group, the average preoperative blood loss was (2 900±1 900) ml, and the average intraoperative amount of infused white & red blood cells was (5.9±3.5) U, with the average operation time of (2.2±1.8) hours and the average in-hospital duration of (7.8±2.3) days. In the second group, the average preoperative blood loss was (3 100± 2 200) ml, and the intraoperative amount of infused white & red blood cells was (6.2±5.2) U, with the average operation time of (2.5±2.1) hours and the average in-hospital duration of (7.9±2.9) days. There was no significant difference between the two groups in any of these indicators (P > 0.05). Postpartum hemorrhage was usually treated with uterine packing in the first group, but was preferentially treated with potent uterine contraction agents, arterial ligation, uterine balloon compression or B-Lynch suture in the second group. The therapeutic effects of these new treatments were significantly better than uterine packing (P < 0.05).

CONCLUSIONS

The incidence of emergency obstetric hysterectomy did not change significantly in the past decade. However, the indications and intraoperative interventions have changed significantly in the second five years compared with the first five years. The main surgical indications were uterine inertia and postpartum hemorrhage due to pathological placenta embedment. Therefore, strict control of caesarean section indications was important to reduce emergency obstetric hysterectomy.

Novel modification of B-Lynch uterine compression sutures for management of atonic postpartum hemorrhage: VV uterine compression sutures

AIM

The aim of this study was to demonstrate a novel modification of uterine compression sutures for use in women with primary postpartum hemorrhage and to evaluate its effectiveness.

MATERIAL AND METHODS

This was a prospective observational study. Nineteen patients with atonic postpartum hemorrhage were subjected to the novel VV uterine compression sutures at the time of cesarean delivery.

RESULTS

The procedure was successful in 18 out of 19 women (94.7%) in controlling the bleeding and preserving the patient's uterus. Only one patient required supravaginal hysterectomy.

CONCLUSIONS

VV compression sutures comprise an easy, safe and effective procedure that can be applied in cases of atonic postpartum hemorrhage.

The outcomes of surgical treatment modalities to decrease "near miss" maternal morbidity caused by peripartum hemorrhage

BACKGROUND

The treatment of patients with peripartum hemorrhage is unfortunately characterized by inadequate treatment that does not adhere to standard therapeutic measures.

AIM

Assessment of different management strategies among patients with severe hemorrhage, particularly the ones with "near-miss" maternal morbidity and mortality to establish clinically useful guidelines for the prevention and management of peripartum hemorrhage.

PATIENTS AND METHODS

In this study, the medical records of 458 patients who have experienced peripartum hemorrhage between March 2009 and March 2012 in a tertiary perinatal center were retrospectively reviewed. Specific surgical treatment modalities utilized to 61 patients with severe peripartum hemorrhage with respect to the procedure timing and effectivity were compared according to the outcomes and efficiency.

RESULTS

Sixty-one patients who have been diagnosed as severe peripartum hemorrhage have been included to the study. Six (75%) of the 8 patients who were treated with B-Lynch brace suture for uterine atony and 9 (60%) of the 15 patients who were treated with the Bakri balloon tamponade system for uterine atony or placenta accreta required hysterectomy following the initial therapeutic measures. The patients who have been treated with bilateral hypogastric artery ligation and B-Lynch brace suture or Bakri balloon uterine tamponade system were less likely to need a complementary hysterectomy for definitive treatment of peripartum hemorrhage when compared with patients treated with either B-Lynch brace suture or Bakri uterine tamponade balloon system alone.

CONCLUSIONS

The efficiency of B-Lynch compression brace sutures and the Bakri balloon uterine tamponade system is unpredictable in terms of the need for hysterectomy for peripartum hemorrhage patients diagnosed as either uterine atony or placenta previa. Regardless of the initial diagnosis, these modalities seem to be more effective in alleviating peripartum hemorrhage when accompanied by hypogastric artery ligation.

Exaggerated placental site leading to postpartum hemorrhage: a case report

BACKGROUND

Exaggerated placental site (EPS) reaction is defined as exuberant infiltration of the endometrium and myometrium at the implantation site by intermediate trophoblastic cells. It is a relatively rare, benign lesion related to pregnancy. The diagnosis of EPS depends mainly on pathologic findings, and it should be distinguished from placental site trophoblastic tumor, placental site nodule and choriocarcinoma.

CASE

We present a case of EPS which led clinically to postpartum hemorrhage. During cesarean delivery uterine atony persisted despite pharmacological and surgical intervention. Finally, supracervical hysterectomy was performed due to severe postpartum hemorrhage.

CONCLUSION

When postpartum hemorrhage caused by uterine inertia is unresponsive to conventional management, EPS should be considered. Besides timely recognition and intervention with appropriate maneuvers, hysterectomy should be performed as soon as possible to avoid further obstetrical shock and disseminated intravascular coagulation.

Emergency peripartum hysterectomy in a tertiary hospital in southern Nigeria

INTRODUCTION

Emergency peripartum hysterectomy, a maker of severe maternal morbidity and near miss mortality is an inevitable surgical intervention to save a woman's life when uncontrollable obstetric haemorrhage complicates delivery. This study was conducted in order to determine the incidence, types, indications and maternal complications of emergency peripartum hysterectomy at the University of Uyo Teaching Hospital, Uyo, Nigeria.

METHODS

The case records of all women who underwent emergency peripartum hysterectomy between 1(st) January 2004 and 31(st) December 2011 were studied.

RESULTS

There were 12,298 deliveries during the study period and 28 emergency peripartum hysterectomies were performed resulting in a rate of 0.2% or 1 in 439 deliveries. The modal age group of the patients was 26-30 years (35.7%), majority were of low parity (64.4%), while 17.9% attained tertiary level education. Half of the patients (50.0%) were unbooked while 14.3% were antenatal clinic defaulters. Extensive uterine rupture (67.8%) was the most common indication for emergency hysterectomy distantly followed by uterine atony with uncontrollable haemorrhage (17.9%). Subtotal abdominal hysterectomy was performed in 92.8% of the cases. The case fatality rate was 14.3% while the perinatal mortality rate was 64.3%.

CONCLUSION

Emergency peripartum hysterectomy is not uncommonly performed in our centre and extensive uterine rupture from prolonged obstructed labour is the most common indication. In addition, it is associated with significant maternal and perinatal mortality. There is need to enlighten women in our communities on the benefits of ANC and hospital delivery as well as the dangers of delivering without skilled attendance. Government should consider enacting legislation to discourage people or organisations who operate unlicensed maternity homes in our environment.

Incidence and determinants of peripartum hysterectomy in the metropolitan area of the District of Columbia

OBJECTIVE

To review the impact of the changes that have occurred in the standard of care in obstetrics and in the trend of cesarean delivery rates in recent times and factors associated with peripartum hysterectomy procedure.

STUDY DESIGN

A retrospective analysis of all cases of peripartum hysterectomies among inpatient hospitalizations at 4 major hospitals in the Washington metropolitan areas of the District of Columbia from January 1, 2000, through December 31, 2009, was conducted.

RESULTS

The total number of deliveries and postpartum hysterectomies that occurred at all 4 locations was 150,847 and 128, respectively. The rate of peripartum hysterectomies per 1,000 deliveries was 0.85. Primary and repeat cesarean deliveries, advanced maternal age, obesity, and grand multiparity have direct association with peripartum hysterectomy. Up to 80% of all cases of peripartum hysterectomy are accounted for by class III and IV hemorrhage. Peripartum hysterectomy is associated with increased prevalence of uterine atony, placenta previa, and placenta accreta.

CONCLUSION

Our results suggest that primary and repeat cesarean deliveries, advanced maternal age, obesity, and grand multiparity, uterine atony, placenta previa, and placental accreta, and class III and IV hemorrhage are independently associated with an increased risk for peripartum hysterectomy. These findings may be of concern given the increasing rate of cesarean deliveries in the District.

[Clinical research on bilateral arcuate artery suture hemostasis of corpus uteri for postpartum hemorrhage due to uterine inertia during caesarean section]

OBJECTIVES

To investigate the effect of bilateral arcuate artery suture hemostasis of corpus uteri (haemostasia) for postpartum hemorrhage due to uterine inertia during caesarean section, and to explore the change of blood vessels and blood flow of the uterus after surgery.

METHODS

From May 2009 to Dec. 2011, the 212 patients in No. 202 People's Liberation Army Hospital received bilateral arcuate artery suture hemostasis of corpus uteri for postpartum hemorrhage due to uterine inertia during caesarean section. Among them, 127 patients who failed to respond to conservative management and received haemostasia were defined as the 'haemostasia' group. 23 patients who received the suture after they failed to respond to conservative management and other conventional surgical hemostasis were defined as the 'other + haemostasia' group. 62 patients who received the suture simultaneously with conservative management were defined as the 'drug + haemostasia' group. The suture was done by the following steps: (1) The uterus should be exteriorised, and the fundus of uterus should be towards the head. (2) Transfix the anterior and posterior wall of corpus uteri with big blunt round needle and absorbable suture. The entry point was 2 cm above the uterine incision and 2 cm to lateral border of corpus uteri. The suture spanned the fundus of uterus, and was stretched tightly in front of the fundus, then tied knots were made. Bleeding volume, prompt hemostatic rate, effect rate, total effect rate and operation time were recorded. The resistance index (RI) of uterine artery, systolic/diastolic blood pressure (S/D), the visualization ratio of uterine artery and the mean value of artery diameter were obtained through color Doppler ultrasonography and enhancement CT 6 - 12 months after the surgery.

RESULTS

(1) In the 'drug + haemostasia' group, the bleeding volume was (532 ± 28) ml. The operation time was (34 ± 3) min, and the prompt hemostatic rate was 97%. While the 'haemostasia' group had more bleeding volume, longer operation time and lower prompt hemostatic rate than the 'drug + haemostasia' group, with no statistically significant difference (P > 0.05). In 'other + haemostasia' group, the bleeding volume was (1379 ± 95) ml. The operation time was (79 ± 15) min, and the prompt hemostatic rate was 78%. The differences were significant when compared to the other groups (P < 0.01). There was no statistically significant difference on total effect rate among the three groups (P > 0.05). (2) There was no statistically significant difference on the RI and S/D of bilateral uterine artery among all the groups 6-12 months after the surgery. (3) The visualization ratio of left uterine artery of the 'other + haemostasia' group was lower (87%) than the 'haemostasia' group (97%) and the 'drug + haemostasia' group (95%, P < 0.05). There was no statistically significant difference between the 'haemostasia' group and the 'drug + haemostasia' group on the visualization ratio of bilateral uterine artery and the mean value of bilateral uterine artery diameter (P > 0.05).

CONCLUSIONS

The bilateral arcuate artery suture hemostasis of corpus uteri is a simple, rapid, effective and safe method to control postpartum hemorrhage due to uterine inertia during caesarean section. The ovary and uterine blood flow are not affected after the surgery.

[Ligation of internal iliac arteries for severe hemorrhage in obstetric]

AIM

To assess the efficiency of arteries ligation in intractable obstetrical hemorrhage.

METHODS

Prospective study which concerned 53 patients who underwent internal iliac arteries ligation for persistent and severe obstetrical hemorrhage from January 2007 to June 2010.

RESULTS

The average age of patients was 29.3 years. The mean parity was 2.2. Main etiology of hemorrhage were: uterine atony (62.2%), abruptio placentae (15.1%). Coagulation disorders and hypovolemic shock were observed respectively in 20.7 % and 37.7%. Blood transfusion was performed in all cases. Internal iliac arteries ligation allowed hemorrhage control in 90.5 % of cases. In five cases a hysterectomy was necessary to control bleeding.. No peroperative complication were observed.

CONCLUSION

Internal iliac arteries ligation is a prerequisite treatment of severe postpartum hemorrhage. It is a good alternative to arterial embolization.

Emergency peripartum hysterectomy: a 10-year review in a tertiary obstetric hospital

AIM

To evaluate the incidence, indications and complications associated with emergency peripartum hysterectomy (EPH) performed at Christchurch Women's Hospital, New Zealand.

METHODS

A retrospective case series analysis of EPH from 2000-2009. Cases were identified using the hospital's computerised database. Those medical records were reviewed. EPH was defined as one performed for major postpartum haemorrhage unresponsive to other treatment within 24 hours of delivery.

RESULTS

Nineteen EPH cases were identified among 47,520 deliveries, giving an incidence of 0.4 per 1000 deliveries. The indications were invasive placental adhesion--accreta, increta, percreta (63%), uterine atony (16%), placenta praevia (10.5%) and uterine tear with atony (10.5%). All cases of abnormal placentation in this study had previous caesareans or curettages. A significant association between previous uterine surgery and abnormal placentation was shown (p=0.02), especially those with previous caesarean (p=0.003). No maternal or perinatal mortality was recorded. Maternal morbidity was prevalent, including eight disseminated intravascular coagulopathies, seven intensive care, three bladder injuries, two re-explorations, one respiratory failure and one pulmonary embolism.

CONCLUSION

Invasive placental adhesion is the major indication for EPH. This study demonstrates an association between the presence of scarred uteri as a result of previous uterine surgery, and abnormal placentation.

A novel use of a classification system to audit severe maternal morbidity

OBJECTIVE

obstetric haemorrhage remains a significant cause of maternal morbidity and mortality worldwide and is significant in terms of patient safety and quality of care. One drastic outcome of haemorrhage is the need for peripartum hysterectomy. A classification system that can be used to audit severe events such as peripartum hysterectomy would be a useful adjunct to patient safety systems, but it would need to account for pre-existing risk factors, such as previous caesarean section. One system that accounts for important risk factors is the Robson Ten Group Classification System (TGCS). The aim of this study was to examine whether the TGCS could be extended in a novel way to classify who required peripartum hysterectomy.

SETTING

population-based matched case-control study data from the UK Obstetric Surveillance System was used. All eligible UK hospitals participated.

PARTICIPANTS

women who underwent peripartum hysterectomy between February 2005 and February 2006 and their matched controls.

METHODS

cases and controls were categorised using the TGCS. The odds of having a peripartum hysterectomy in each classification group were calculated using logistic regression. An adjusted analysis was undertaken controlling for potential confounders.

FINDINGS

307 of the 315 women who had a peripartum hysterectomy were classified into one of the 10 groups; 606 of the 608 control women were classified. Women who underwent a peripartum hysterectomy were predominantly from the more complex classification groups. After adjusting for age, ethnicity and socio-economic status, the groups with an increased odds of peripartum hysterectomy were those who had a previous caesarean section.

CONCLUSIONS

the TGCS can be used in a novel way, that is, to examine an outcome other than caesarean section, and could be part of a new system to monitor patient safety. Population-based data were used as an example of how an existing classification system could be used in a different way from that for which it was created, and could make comparisons across institutions and countries while adjusting for case mix in a simple manner. The TGCS may not necessarily be a useful way to monitor other events in childbirth. Further work is needed to develop other classification systems which could be used as a benchmarking tools to monitor patient safety in maternity care.

B-Lynch suture for the treatment of uterine atony

INTRODUCTION

Over 125,000 women die of postpartum haemorrhage (PPH) each year, with the commonest cause being uterine atony (75-90 percent). Failing conservative management, hysterectomy is usually the final resort. In 1997, Christopher B-Lynch devised an innovative technique to treat uterine atony, and it has been widely used around the world since its original report. However, there are hardly any reports of this technique being utilised in East Asian countries, including Singapore. Our study reviews the cases in which the B-Lynch suture was used to treat uterine atony, and the clinical outcomes of these cases.

METHODS

A retrospective study of data of all women who delivered between May 2004 and June 2007 was collected from the department's database, to identify patients who had undergone the B-Lynch procedure. Primary PPH is defined as a blood loss of more than 500 ml at or within 24 hours of delivery.

RESULTS

There were a total of 5,470 deliveries during this period, with primary PPH occurring in 100 cases. The B-Lynch procedure was performed in seven women, avoiding the need for a hysterectomy in five cases.

CONCLUSION

Our series of cases treated with the B-Lynch procedure showed that it is an effective method of containing PPH. It has the advantage of being applied easily and rapidly, and should be taught to all trainees and registrars in obstetrics. It should be attempted when conservative management of PPH fails and before any radical surgery is considered.

Uterine surgery in postpartum hemorrhage

Uterine atony accounts for the majority of primary postpartum hemorrhage. Timely recognition and intervention are fundamental in preventing serious maternal morbidity and mortality. Combinations of conservative manual and medical therapies are adequate and successful treatment options in most cases. However, when the hemorrhagic process continues and when either clotting abnormalities or hemodynamic instability develop, the next step must be an invasive intervention. Depending on the mode of delivery a vaginal approach (i.e. curettage and uterine packing) after spontaneous delivery or an abdominal surgical approach (i.e. compression sutures and systematic devascularization) after a Cesarean delivery can be performed. Uterine compression sutures are especially highly effective and a straightforward and easy emergency procedure which conserves fertility. The ultima ratio in all cases of persistent haemorrhage after conservative and uterus preserving surgical therapy is the emergent hysterectomy. It might be of advantage to perform a subtotal or supracervical hysterectomy compared to a total hysterectomy in an emergency setting.

Placental cord drainage and the effect on the duration of third stage labour, a randomized controlled trial

OBJECTIVE

To assess the effect of placental cord drainage on the duration of third stage labor, and to clarify the safety of this method regarding to postpartum hemorrhage, retained placenta, incidence of manual removal of placenta, and the need for blood transfusion.

DESIGN

Randomized controlled trial.

SETTING

King Chulalongkorn Memorial Hospital.

MATERIAL AND METHOD

One hundred women in the third stage of labour after vaginal delivery were randomized. In the study group, placental cord drainage was performed. In both groups, the placenta was delivered by Brandt Andrew method. One case of placenta succenturiata was subsequently excluded. The duration of third stage was compared as the primary outcome. The incidence of postpartum hemorrhage, retained placenta, manual removal of placenta, and the need for blood transfusion were compared.

RESULTS

In 99 cases with normal placentas, 49 cases were assigned to the study group, 50 cases were assigned to the control group. The third stage of labor was significantly shorter after placental cord drainage (5.1 +/- 2.4 minutes vs. 7.0 +/- 6.1 minutes). There was no postpartum hemorrhage, uterine atony, hypovolemic shock, or the need for blood transfusion in neither groups.

CONCLUSION

Placental cord drainage shortens the duration of third stage labour. This method appears to be safe and does not increase postpartum complication.

Emergency peripartum hysterectomy: frequency, indications and maternal outcome

BACKGROUND

Emergency Peripartum Hysterectomy (EPH), although rare in modern obstetrics, remains a life saving procedure in cases of severe haemorrhage. The aim of present study was to review the frequency, indication, associated risk factors, maternal morbidity and mortality associated with emergency peripartum hysterectomy in a private sector teaching hospital.

METHODS

This was a retrospective review carried out from August 2003 to September 2008. Main outcome measures were frequency, indications, associated risk factors and maternal morbidity and mortality associated with Emergency Peripartum Hysterectomy.

RESULTS

The frequency of emergency peripartum hysterectomy over a study period was 0.42%. Mean age and parity of patients was 30.9 +/- 5.0 years and 4.52 +/- 1.8 respectively. The mean gestational age at the time of delivery was 36 +/- 3.4 weeks. Nine (42.9%) patients had previous history of caesarean delivery. Main indication for EPH were rupture uterus 7 (33.3%), uterine atony 6 (28.6%), morbid adherence of placenta 5 (23.8%) and severe bleeding from placental bed in 3 (14.3%) patients. All woman required blood transfusion, 11 (52%) require ICU admission, 81% were anaemic, 3 (14.3%) developed DIC, 4 (19%) pulmonary oedema, febrile illness 6 (28.6%) and wound disruption was seen in 3 (14.3%). The maternal mortality occurred in 4 (19%) cases.

CONCLUSION

Frequency of emergency peripartum hysterectomy is high in our set up. High parity, rupture uterus, increase number of caesarean deliveries and abnormal placentation was identified as risk factors for EPH. High frequency of maternal morbidity and mortality was observed in the present study.

[Obstetric hysterectomy. Incidence, indications and complications]

BACKGROUND

Obstetric hysterectomy is indicated when patient's life is at risk, and it is a procedure that requires a highly experienced and skilled medical team to solve any complication.

OBJECTIVE

To identify incidence, indications, and complications of obstetric hysterectomy within a high-risk population.

PATIENTS AND METHODS

Transversal, retrospective study from July 1st 2004 to June 30 2006 at Unidad Medica de Alta Especialidad, Hospital de Ginecoobstetricia, Centro Medico Nacional de Occidente, IMSS. There were reviewed 103 patient' files with obstetric hysterectomy. Incidence was calculated, and clinical and socio-demographic characteristics, indications, and complications of obstetric hysterectomy identified and expressed in frequency, percentages, and central tendency measurements.

RESULTS

Incidence of obstetric hysterectomy was 8 cases within every 1,000 obstetric consultation. Age average was 31.1 +/- 5.1 years. 72.8% had cesarean surgery history. Main indication was placenta previa associated with placenta accreta (33%), followed by uterine hypotony (22.3%). Complications were hypovolemic shock (56.3%), and vesical injuries (5.8%). There were no maternal deaths.

CONCLUSIONS

Cesarean history induces higher obstetric hysterectomy incidence in women with high-risk pregnancy, due to its relation to placentation disorders, as placenta previa that increases hemorrhage possibility, and thus, maternal morbidity and mortality.

The uterine sandwich for persistent uterine atony: combining the B-Lynch compression suture and an intrauterine Bakri balloon

OBJECTIVE

The objective of the study was to evaluate the effectiveness of a combination of surgical interventions for control of postpartum hemorrhage.

STUDY DESIGN

At cesarean delivery, patients with persistent bleeding from uterine atony after the administration of oxytonics were treated with the placement of a B-Lynch suture. When the B-Lynch failed, subsequent placement of an intrauterine Bakri balloon followed. This combination is termed the uterine sandwich.

RESULTS

The uterine sandwich was successful for all 5 patients undergoing this approach. The median nadir hematocrit was 21.1% (range 20.1% to 28%). The balloon was in place for a median duration of 11 hours (range 10-24 hours). The median volume infused into the balloon was 100 mL (range 60-250 mL). No complications were observed.

CONCLUSION

Placing an intrauterine Bakri balloon in conjunction with the B-Lynch uterine compression suture was successful in treating uterine atony.

Uterine compression sutures for postpartum bleeding with uterine atony

OBJECTIVE

To assess the efficacy of a new uterine compression suturing technique in reducing postpartum haemorrhage secondary to severe uterine atony.

DESIGN

Retrospective study.

SETTING

University hospital between December 2000 and March 2006.

POPULATION

Twenty women with uterine atony and postpartum bleeding that did not react to usual medical management.

METHODS

All these women underwent compression suturing of the uterus, in which the anterior and posterior walls of the uterus were attached so as to compress the uterus.

MAIN OUTCOME MEASURES

Arrest of the bleeding, complications and fertility.

RESULTS

Uterine compression suturing was sufficient to stop the bleeding immediately in 95% of the women. None of the women developed complications related to the procedure. All the women recovered normal menstrual cycles. Since uterine compression suturing, eight women have tried to conceive and six (75%) have had a term delivery.

CONCLUSION

Uterine compression suturing is a simple conservative procedure to stop postpartum haemorrhage in the case of failure of the usual management. This surgical technique can be performed quickly and does not seem to decrease fertility.

Leptomeningeal cyst due to vacuum extraction delivery in a twin infant

A rare case of a leptomeningeal cyst is reported in a twin male neonate delivered using a vacuum extractor, who presented a huge, non-pulsating, oedematous mass overlying the frontal fontanelle after birth. The mass was initially diagnosed as a cephalo haematoma. Ultrasonography indicated intracranial bleeding and a subsequent CT scan revealed an intraparenchymal bleeding above the left frontal horn, combined with a thin, left-sided, subdural haematoma and subarachnoid haemorrhage in the left Sylvian fissure. Apart from a bulging soft and round formation (2 x 2 x 3 cm) next to the anterior fontanel growing since birth, the neurological development of the infant was normal. MRI examination at the age of 7 months revealed that it consisted of a cystic mass (leptomeningeal cyst) connected to the left frontal horn, stretching right through the brain and also penetrating the dura mater. No signs of the perinatal haematomas were observed at this time. Surgical treatment, with fenestration of the cyst into the frontal horn and a watertight duraplasty with a periosteal flap and thrombin glue covered by small bone chips, was performed at 9 months of age. Due to a residual skull bone defect a second cranioplasty with autologous skull bone was performed three and half years later. During a follow-up period of 12 years the neurological and psychological development of the boy has been indistinguishable to that of his twin brother, indicating the satisfactory outcome of the treatment.

A reflective case study in the obstetric theatre: focusing on the principles of care involved

This article focuses on the principles of care involved in a reflective case study of a patient undergoing a caesarean section. Unplanned caesarean sections are often emotionally charged procedures. Often a mother has had no warning of a surgical intervention for the birth of her child and is understandably both distressed and frightened.

Ten year follow-up of the effect of the B-Lynch uterine compression suture for massive postpartum hemorrhage

The B-Lynch surgical technique for the management of massive postpartum hemorrhage (PPH) has been used successfully since 1989 in cases where bleeding was secondary to uterine atony with failed conservative management. It allows for conservation of the uterus for subsequent menstrual function and pregnancies. In this report, we present a follow up of a case with successful pregnancy ten years after PPH was managed with the B-Lynch uterine compression suture to demonstrate the long-term anatomical consequences of this operation. This case represents the longest follow up after the application of the B-Lynch suture (brace suture) technique for the control of massive PPH as an alternative to hysterectomy. Published data have confirmed that on the balance of probability, the B-Lynch surgical technique is safe, effective and free of short- and long-term complication.

[B lynch suture for post partum heamorrhage due to uterine atony]

Uterine atony and concomittant massive haemorrhage is one of the most dangerous complications of labour. Conventional, conservative treatment approach comprising of oxytocics such as oxytocin, methergin or prostaglandins may fail in some cases, mandating surgical techniques, including hysterectomy. B Lynch compression uterine suture may be a safe and effective method of treatment in post partum heamorrhage and in most of cases may replace more complicated techniques. In this article, together with referring the technical aspects of this procedure, we present a case of successful treatment.

Fertility after B-Lynch suture and hypogastric artery ligation

OBJECTIVE

To report a case of successful pregnancy after hypogastric artery ligation and the B-Lynch brace suturing technique.

DESIGN

Case report.

SETTING

Education and research hospital.

PATIENT(S)

A 22-year-old woman, whose first pregnancy was terminated by cesarean section owing to abruptio placenta and intrauterine fetal demise diagnosed at the 26th week of gestation, referred to our clinic for uterine atony.

INTERVENTION(S)

Hypogastric artery ligation and the B-Lynch brace suturing technique.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and live birth.

RESULT(S)

Two years after the surgery, the patient conceived spontaneously and delivered a healthy infant after an uneventful pregnancy.

CONCLUSION(S)

This is the first reported case of successful pregnancy after hypogastric artery ligation and B-Lynch suturing technique. This life-saving therapeutic option for severe postpartum hemorrhage appears to be a safe procedure that does not impair subsequent fertility and pregnancy outcomes. The B-Lynch suturing technique seems to be simple and has the capability of preserving the uterus; therefore it may be considered as the first-line surgical treatment for uterine atony before considering hysterectomy.

Emergency peripartum hysterectomy: A prospective study in The Netherlands

OBJECTIVE

To determine the incidence, indication, association with caesarean section (CS) and outcome of emergency peripartum hysterectomy (EPH) in The Netherlands.

STUDY DESIGN

All 100 Dutch obstetric departments were asked to participate in a prospective nationwide registration of EPH between 1 April 2002 and 1 April 2003. For every case, a form with questions about obstetrical history, current pregnancy and delivery, maternal and neonatal outcome was completed.

RESULTS

Eighty-nine (89%) hospitals participated and registered in total 48 EPH. The estimated incidence of EPH is 0.33/1000 births. The main indication for EPH was placenta accreta (50%), followed by uterine atony (27%). There were two maternal deaths (4%). Severe maternal morbidity included: urinary tract injury 15%, relaparotomy 25%, transfusion >10 units red blood cells 67%, intensive care admission 77%. Both previous CS and CS in the index pregnancy were associated with a significant increased risk of EPH. The number of previous CS was related to an increased risk of placenta accreta, from 0.19% for one previous CS to 9.1% for four or more previous CS.

CONCLUSION

Emergency peripartum hysterectomy is associated with a high incidence of maternal morbidity and a case fatality rate of 4%. It is significantly related to CS in index or previous pregnancy. Placenta accreta is the most common indication to perform a peripartum hysterectomy.

B-Lynch suture: a case series

OBJECTIVE

To report an 8-year institutional experience in the use of the B-Lynch Suture for the management of postpartum hemorrhage (PPH).

STUDY DESIGN

Cases with B-Lynch suture utilization for severe postpartum hemorrhage were identified, from March 1997 to March 2005, at White Memorial Medical Center. Case charts were reviewed, and postoperative follow-up after hospital discharge was conducted by telephone interview and outpatient clinic chart review. Historical characteristics and outcome of these patients are described.

RESULTS

B-Lynch suture was performed on 22 patients, between March 1997 and March 2005, to control intractable PPH at cesarean section that did not respond to uterotonic agents. In 12 instances, the B-Lynch suture was the only intervention, whereas in 10 it was combined with vessel ligation. The procedure resulted in control of bleeding with uterine preservation in 77% of the cases. In those cases where the etiology of PPH was uterine atony, the B-Lynch suture was successful in 85% of the cases. Hysterectomy was avoided in 17/22 cases.

CONCLUSION

The B-Lynch suture is an alternative surgical procedure for uterine preservation that may be used to control postpartum hemorrhage from uterine atony.

Technical description of the B-Lynch brace suture for treatment of massive postpartum hemorrhage and review of published cases

Massive uncontrolled hemorrhage after childbirth is a leading cause of the pregnancy-related death and resulting morbidity. Uterine atony is the most common cause (75-90%) of primary postpartum hemorrhage. When simple massage of the uterus and uterotonics such as oxytocins, syntometrine and prostaglandins failed to manage this condition, various surgical solutions have been sought, including uterine artery ligation, more complicated stepwise devascularization of the uterus, internal iliac artery ligation and, ultimately, hysterectomy. All these procedures require above average surgical skill. In contrast, the B-Lynch suturing technique (brace suture) is particularly useful because of its simplicity of application, life saving potential, relative safety and capacity for preserving the uterus and subsequent fertility. The adequacy of haemostasis can be assessed both before and immediately after application of the suture. Only if it fails need other more radical surgical methods be considered. The special advantage of this innovative technique is that it presents an alternative to major surgical procedures for controlling pelvic arterial pulse pressure or hysterectomy. To date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications. This review provides an update on the B-Lynch brace suturing technique, including choice of suture material, use of the technique in early and late gestation, and comparison with other uterine compression surgical techniques. It also includes a comprehensive review and analysis of all published cases and their postoperative follow-up.

Peripartum hysterectomy in a teaching hospital in the eastern region of Turkey

OBJECTIVES

The aim of this study was to find the incidence and clinical implications of peripartum hysterectomy in our hospital at the Eastern region of Anatolia.

STUDY DESIGN

We analyzed retrospectively all cases of peripartum hysterectomy performed at YYU Medical Faculty Hospital between January 1995 and April 2003. Emergency peripartum hysterectomy was performed for hemorrhage which cannot be controlled with other conventional treatments within 24h of a delivery. There were 24 cases of emergency peripartum hysterectomy performed.

RESULTS

The incidence of emergency peripartum hysterectomy was 5.09 per 1000 deliveries. Half of the hysterectomies followed cesarean section. Eleven patients were referred to our clinics from other hospitals. Uterine atony (45.8%) was the most common indication and placenta accreta (25.0%) was the second most common. Eighteen patients (75%) had subtotal hysterectomy. Bladder injury was seen in three cases. Re-exploration was performed in three cases (12.5%). Seventeen patients stayed in hospital over 7 days. There were four (16.7%) maternal deaths all of whom were referred from other hospitals.

CONCLUSION

The mortality and morbidity of performing a peripartum hysterectomy is elevated, especially if performed in critical patients referred from other hospitals.

The B-Lynch and other uterine compression suture techniques

BACKGROUND

Postpartum hemorrhage (PPH) remains among the 5 main causes of maternal death in developing and developed countries, and uterine atony is the most common cause (75-90%) of primary PPH. Uterine compression sutures running through the full thickness of both uterine walls (posterior as well as anterior) have recently been described for surgical management of atonic PPH. Christopher B-Lynch was the first to highlight this revolutionary principle, and other uterine compression suture techniques have since been described by Hayman and Cho.

OBJECTIVES

Step-by-step description of the B-Lynch brace suture and discussion of the current compression suture techniques.

CONCLUSIONS

The different uterine suture techniques have proved to be valuable and safe alternatives to hysterectomy in the control of massive PPH, and the present review can make the surgeon better aware of their effective use and the risks they may entail.

Re-laparotomy after Cesarean section

OBJECTIVE

The objective of the study was to find out the indications for management and the outcomes of reopening the abdomen during the puerperium after Cesarean section.

PATIENTS AND METHODS

This was a retrospective descriptive survey at the Korle Bu Teaching Hospital in Accra, Ghana.

RESULTS

There were 6120 Cesarean sections (17%) out of a total of 36,010 deliveries. Re-laparotomy was done in 44 patients (0.7%) of the Cesarean sections. The indications were: hemorrhage from uterine atony, hemorrhage from placental bed after operation for placenta previa, uterine sepsis with hemorrhage, hemorrhage after Cesarean section, myomectomy and hemorrhage from anterior abdominal wound dehiscence. The main surgeries performed were: hysterectomy, ligation of ascending branches of uterine arteries, ligation of hypogastric arteries, debridement and re-suturing of the uterine incision and secondary suturing of anterior abdominal wall. There were 6 near missed fatalities. There were 4 mortalities caused by excessive hemorrhage and severe sepsis.

CONCLUSION

The case fatality rate for re-laparotomy after Cesarean section is high (9%). Near missed-fatalities are common. To reduce the unfavorable outcomes, instituting more intensive education on the use of the partograph should prevent prolonged labor. Centers carrying out Cesarean section should have efficient blood transfusion service in place.

Analysis of 59 cases of emergent peripartum hysterectomies during a 13-year period

OBJECTIVE

The objective was to investigate the incidence, indications, and risk factors of peripartum emergent hysterectomy.

METHOD

Fifty-nine cases of emergent peripartum hysterectomy performed at Zeynep Kamil Women and Children's Education and Research Hospital during a 13-year period between January 1990 and January 2003 were evaluated retrospectively. Emergent peripartum hysterectomy was defined as that performed for haemorrhage unresponsive to other therapeutic interventions within the first 24 h of delivery.

RESULT

Emergent peripartum hysterectomy was performed in 59 cases of 234,958 women (25.1/100,000). Total and subtotal hysterectomy was performed in 25 and 34 cases respectively. The rates of emergent peripartum hysterectomy after vaginal and caesarean deliveries were 8.7/100,000 and 104.5/100,000 respectively. Uterine atony was the most frequent indication (62.7%). The rates of emergent peripartum hysterectomy due to uterine atony in primiparous and multiparous women were 61.1 and 65.2% respectively. The rate of maternal mortality was 8% (5 cases).

CONCLUSION

Uterine atony was the most common indication for emergent peripartum hysterectomy.

Emergency peripartum hysterectomy: a comparison of cesarean and postpartum hysterectomy

OBJECTIVES

The purpose of this study was to evaluate the incidence, risk factors, indications, outcomes, and complications of emergency hysterectomy performed after cesarean deliveries (cesarean hysterectomy) and vaginal deliveries (postpartum hysterectomy).

STUDY DESIGN

We conducted a retrospective cohort study from 1990 to 2002 of patients who had peripartum hysterectomies at a single tertiary hospital. Comparisons were made between cesarean and postpartum hysterectomies.

RESULTS

There were 55 cases of emergency peripartum hysterectomy (38 cesarean hysterectomies, and 17 postpartum hysterectomies), for a rate of 0.8 per 1000 deliveries. Overall, the most common indication for hysterectomy was uterine atony (56.4%), followed by placenta accreta (20.0%). Average estimated blood loss was 3325.6+/-1839.2 mL, average operating time was 157.1+/-75.4 minutes, average time from delivery to completing the hysterectomy was 333.8+/-275.7 minutes, and the average length of hospitalization was 11.0+/-7.9 days. The cesarean delivery rate at Grady Memorial Hospital during the study period was 14.2%. There were no statistically significant differences between variables examined when comparisons were made by cesarean vs postpartum hysterectomy.

CONCLUSION

Uterine atony is the leading indication for emergency hysterectomy performed following cesarean and vaginal deliveries.

B-Lynch Brace Suturing in primary post-partum hemorrhage during cesarean section

Primary atonic post-partum hemorrhage during lower segment cesarean section, which was not controlled by ecbolics--oxytocin, methylergometrine, 15-methyl-prostaglandinF2alpha--was managed by applying a B-Lynch Brace Suture. The test of potential efficacy was the control of hemorrhage by bimanual uterine compression. Six primigravida patients at their term gestation, who underwent emergency cesarean section, all except one under spinal anesthesia, received this type of suture. Interestingly, in every case hemorrhage was controlled successfully with the compression suture. None of them received blood or blood products transfusions or developed disseminated intravascular coagulopathy. Postoperative recovery was good and all patients are in follow-up to assess their future reproductive activity. B-Lynch Brace Suturing is an invaluable procedure for the control of atonic primary post-partum hemorrhage following cesarean delivery.

[Rupture of a renal artery aneurysm during delivery]

INTRODUCTION

Renal artery aneurysms represent a rare entity with an incidence of 0.3 - 1.3% in angiographies. Rupture of such aneurysms are rare. During pregnancy there is an increased risk of rupture with a high mortality for mother and child. We report the first case of rupture of a left renal artery aneurysm during delivery with survival of mother and child.

CASE REPORT

Due to arrest of labor during a home birth, the patient was admitted to the hospital, where an immediate forceps extraction on account of fetal asphyxia was performed. Immediately after delivery a hypovolemic shock developed. Ultrasound examination showed a huge subsplenic hematoma. Emergency laparotomy revealed a ruptured renal artery aneurysm. The renal artery was ligated on the assumption of a lower pole vessel. Despite hemodynamic stability a drop in hemoglobin occurred the following day. Angiography showed no perfusion of the left kidney. A left nephrectomy was performed without complications. The further course was uneventful. Mother and child survived.

CONCLUSIONS

Rupture of aneurysms of the splenic and renal artery during later stages of pregnancy, during delivery or after childbirth are possible etiologies in cases of unexplained shock and abdominal pain. An emergency angiography in such cases helps to reveal the underlying cause and renders possible a targeted operative approach.

Surgical treatment of uterine atony employing the B-Lynch technique

Postpartum hemorrhage remains a major cause of maternal morbidity and mortality. Four cases utilizing the B-Lynch technique for control of hemorrhage secondary to uterine atony are presented. The B-Lynch technique appears to be effective in controlling postpartum hemorrhage. More experience is needed before the B-Lynch technique can be accepted as routine practice.