Journal of Obstetrics and Gynaecology, July 2014; 34: 383–386 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.895309
OBSTETRICS
Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: A single centre experience S. Liu1, M. Mathur1 & S. Tagore2
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
1Department of Obstetrics and Gynaecology and 2Peripartum Unit, Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
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. Keywords: Atony, B-Lynch, postpartum haemorrhage, pregnancy outcome, uterine compression suture
Introduction Obstetric haemorrhage is the leading cause of maternal mortality in Asia, accounting for 31% of deaths (Khan et al. 2006). Uterine atony remains the commonest cause of obstetric haemorrhage (Brace 2007) but death can be prevented with a good multidisciplinary approach and clear guidelines (CMACE 2011). However, in less developed countries, obstetric haemorrhage remains one of the major causes of maternal deaths (Africa, Asia and Latin America), with up to 50% of the estimated 500,000 maternal deaths occurring globally each year attributable to its effects (Khan et al. 2006). Hysterectomy is often life-saving and is used as a last resort in the management of uncontrolled obstetric haemorrhage but this has serious consequences in terms of future fertility and psychological sequelae. It was first suggested in 1997 that compression of the uterus can be achieved following caesarean section using a suture technique now known as B-Lynch suture (B-Lynch et al. 1997). It helps to reduce the need for a hysterectomy and also aids in preserving fertility. Since 1997, many centres around the world have been using this technique in the treatment of postpartum haemorrhage with good results, and there have been reports
about women conceiving following a previous B-Lynch suture (Holtsema et al. 2004; Api et al. 2005; Habek et al. 2006; Baskett 2007; An et al. 2013). KK Women’s and Children’s Hospital (KKH) is a busy tertiary unit with over 12,000 deliveries every year. It is also a regional referral centre for all complex obstetric cases. Our study reviews the long-term outcomes, including any pregnancies in women who had uterine compression sutures at KKH during the study period. The findings of our study will enable us to provide women with uterine compression sutures more accurate information about the complication rate and pregnancy outcome in our centre, thus enabling these women to make informed choices about their future fertility options.
Methods Utilising the KKH’s patient database, we retrospectively reviewed women treated in our hospital from 1 January 2008 to 31 December 2012, who had uterine compression sutures inserted post-delivery. The relevant case notes were reviewed and data was collected and recorded on a specially designed datasheet. Data was analysed using an Excel spreadsheet. The study was approved by our institution’s research ethics committee and informed consent was waived, as this study was a retrospective review. The demographic data collected included women’s age, gravidity, parity, indication for uterine compression suture, type of suture and associated procedures used. Results regarding post-delivery outcomes were also examined. They were followed-up for a period ranging from 1–4 years. Clinical data and findings are presented in Tables I and II.
Results From 1 January 2008 to 31 December 2012, a total of 23 women had uterine compression sutures performed, out of a total of 59,665 deliveries at KKH. The mean age of the women was 31.5 years. Of the women, 47.8% were multiparous and the maximum parity was six. Only one woman was a grandmultipara and the caesarean section was done due to maternal collapse from eclamptic seizure. A B-Lynch suture was inserted prophylactically because of her parity and risk of postpartum haemorrhage. All women were treated by different obstetricians. The suture material used was No. 1 Vicryl in all of the cases. Most had a B-Lynch suture placed but six women had a modified B-Lynch. Three women had multiple horizontal haemostatic sutures inserted
Correspondence: S. Liu, Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore 229899. E-mail: [email protected]
384
S. Liu et al.
Table I. Uterine compression sutures: perioperative aspects.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
Variable Age (years) (range, mean) ⬍ 35 35 or older Parity Primipara Multiparae Indication for caesarean delivery Failure-to-progress CPD NRFS Placenta abruption Placenta praevia Maternal collapse Breech Previous caesarean section Twins NVD Indication for suture Atony Prophylactic Grandmultiparae maternal collapse Fibroid Associated procedure Rusch balloon Uterine artery ligation Caesarean hysterectomy Type of suture B-Lynch Modified B-Lynch Postnatal complications No complications Persistent vaginal discharge Persistent vaginal discharge and pyometra Retained product of conception Endometritis Subsequent pregnancy Yes No Lost to follow-up
n
(%)
21–41 16 7
31.5 69.6 30.4
12 11
52.1 47.8
2 3 6 3 1 1 1 4 1 1
8.7 13.0 26.0 13.0 4.3 4.3 4.3 17.4 4.3 4.3
21 – 1 1
91.3
3 1 3
13.0 4.3 13.0
17 6
73.9 26.1
12 1 1 1 1
75.0 6.3 6.3 6.3 6.3
2 17 4
8.7 73.9 17.4
4.3 4.3
in addition to the B-Lynch suture and three women had multiple B-Lynch sutures placed. In our study, three of the 23 women went on to have caesarean hysterectomies in view of persistent bleeding, and one woman had an interval abdominal hysterectomy two-months later for pyometra. However, in the remaining nineteen women, hysterectomy was avoided due to the successful use of uterine compression sutures. There were three concep-
Figure 1. B-Lynch suture at the previous delivery.
tions in two women following a uterine compression suture, as described below and in Table II. The other seventeen women did not have subsequent pregnancies booked at our institution.
Case 1 The first case was a 30-year-old woman who had a B-Lynch compression suture placed in June 2010 for uterine atony. It was done in the caesarean section, which was carried out for failureto-progress for her first child. She had a first trimester complete miscarriage one-year later in September 2011, followed by another pregnancy in early 2012. The latter pregnancy was uneventful. She was delivered by an elective caesarean section at 39 weeks and had a healthy baby of 3,165 g. Her uterus was found to be normal intraoperatively, with no signs of the previous B-Lynch suture.
Case 2 The second case was a 28-year-old woman who had a B-Lynch compression suture placed in December 2010 for uterine atony (Figure 1). It was done in a caesarean section for cephalo-pelvic disproportion for her first child. She had a subsequent pregnancy in 2012 that was complicated by placenta praevia major and malposition of the baby, i.e. transverse lie. She underwent an elective caesarean section at 39 weeks. Intraoperatively, anatomical distortion of the uterus at the fundus due to the previous B-Lynch suture was found (Figure 2). The anterior uterine wall was also adhered to the anterior abdominal wall, with omental adhesions around it. Overall, the postoperative complication rate was 25% (4/16). Three women had an immediate caesarean hysterectomy for
Table II. Clinical data of women with subsequent pregnancies. Indication for initial Indication for Case Age Parity caesarean section B-Lynch suture
Type of suture
1
29
Para 2 Failure to progress
Uterine atony
2
26
Para 2 Cephalo-pelvic disproportion
Uterine atony
B-Lynch 1 complete miscarriage 1 full-term pregnancy Elective caesarean section for previous caesarean section B-Lynch 1 full-term pregnancy Elective caesarean section for placenta praevia major and malposition of baby (transverse lie)
Subsequent pregnancy
Interval to pregnancy from B-Lynch suture
Intraoperative findings
8 months 2 years
Normal Uterus, bilateral tubes and ovaries normal
2 years
Anatomical distortion of uterus due to previous B lynch suture at fundus Anterior uterine wall adherent to anterior abdominal wall with surrounding omental adhesions
Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage 385
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
Figure 2. Fundal distortion at the subsequent pregnancy.
persistent bleeding and four women were lost to follow-up. Of the remaining sixteen women, two women had persistent vaginal discharge after delivery and one of these two women developed pyometra, which required an abdominal hysterectomy two-months after the initial uterine compression suture. One woman had retained products of conception secondary to placenta accreta, requiring uterine evacuation. Another woman had endometritis, which resolved with a course of oral antibiotics. The other twelve women had uneventful postnatal follow-up.
Discussion Uterine compression sutures have been reported to be highly effective in preserving the uterus (B-Lynch et al. 1997; Holtsema et al. 2004; Baskett 2007). It is usually used if uterine atony does not respond to manoeuvres such as uterine massage, bimanual compression and the use of uterotonics, e.g. oxytocin, ergometrine, carbetocin, misoprostol and carboprost. It has been shown to decrease the need for a hysterectomy from massive blood loss after delivery, avoiding the inherent surgical risks of a hysterectomy for the women, while at the same time offering them the potential preservation of future fertility (Wohlmuth et al. 2005). There is a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in complications, such as pyometra, formation of synechiae (Ochoa et al. 2002) and ischaemic necrosis (Treloar et al. 2006). This is reflected in one woman who had multiple uterine compression sutures placed for uterine atony. She also had a Rusch balloon placed and bilateral uterine artery ligation in the management of her postpartum haemorrhage. Postnatally, she complained of persistent vaginal discharge and was readmitted 8 weeks after her delivery, complaining of fever and abdominal pain. Ultrasound confirmed the presence of pyometra, which was unresolved, despite intravenous antibiotics. She subsequently underwent an abdominal hysterectomy and was discharged well. She remained well at her follow-up visit. The formation of pyometra could be due to the placement of multiple uterine compression sutures but it could have been contributed to or caused by, other factors, which include the insertion of a Rusch balloon and bilateral uterine artery ligation. As such, there remains a risk of loss of fertility and the theoretical risk of adverse pregnancy outcomes following the use of uterine compression sutures. Training and the proper use of uterine compression suture is mandatory to reduce these risks. Although some uterine defects have been found at subsequent pregnancies, most reports have not been shown to have detrimental
effects on pregnancy outcomes, with most carrying their pregnancies to term (Baskett 2007). Data is very sparse on long-term outcomes following uterine compression suture, including future pregnancies. Successful pregnancies have been described following the use of uterine compression sutures (Baskett 2007). In his series of seven women, four had signs of the previous compression suture used, ranging from a fibrous band in the uterine cavity, fundal grooves in the myometrium to adhesions from bowel and omentum to the uterine wall. The other three women did not have any signs of use of the previous compression sutures. All these pregnancies were uncomplicated and were delivered at term via repeat caesarean section (Baskett 2007). An et al. (2013) recently published a report on a series of 42 women who had pregnancies after uterine compression sutures and matched them with a control group. They found that pregnancy outcomes were similar in the two groups, however uterine adhesions were more common in women who received uterine compression sutures. Apart from these series, there have also been other single case reviews reporting successful pregnancy outcomes following the use of uterine compression sutures (Holtsema et al. 2004; Api et al. 2005; Habek et al. 2006). On the other hand, adverse pregnancy outcomes regarding uterine compression sutures remain largely confined to isolated case reports. In 2009, Saman Kumara et al. reported a case of a full thickness defect in the uterine wall in a subsequent pregnancy following B-Lynch suture, which resulted in painful antepartum haemorrhage at 33 weeks. This woman underwent an emergency caesarean section for fetal distress and fetal membranes were found bulging through the fundal defect. In our institution, two out of our 23 women became pregnant and went on to deliver term babies. While this number is low, we postulate that it could be attributed to a variety of reasons. First, the stress and psychological trauma caused by the traumatic delivery would adversely affect decisions related to future pregnancies. Second, other successful pregnancies could remain unaccounted for if they were booked and followed-up at other institutions and thus lost to our follow-up. Also, four women were lost to follow-up and could have potentially attended other hospitals for their pregnancy follow-up. Another possible reason is that the uterine compression suture technique has only become more established at our institution in recent years, as a result of improved and more structured training with twelve of the 23 uterine compression sutures carried out in 2012 alone. Future pregnancies following uterine compression sutures usually occur within the range of 1–3 years (Fotopoulou and Dudenhausen 2010). As such, there remains the theoretical possibility that additional successful pregnancies will ensue shortly in the next few years, and we will know the true pregnancy rates. Overall, the findings at our centre appear consistent with previously published case series and reports (Holtsema et al. 2004; Api et al. 2005; Habek et al. 2006; Baskett 2007; An et al. 2013). Of our 23 women, there were three conceptions with two successful pregnancies. Although our second case was found to have slight anatomical distortion of the uterus and intra-abdominal adhesions, there was no long-term deleterious effect on her postnatal follow-up and delivery.
Conclusion In summary, the number of women with subsequent pregnancies following uterine compression sutures remains small worldwide. Continued and longer-term follow-up of women who have undergone uterine compression sutures is required to further understand the progress of their recuperation and elucidate the
386
S. Liu et al.
outcomes of their subsequent pregnancies. Uterine compression suture has been associated with a few complications but despite this, it has been shown to successfully avoid the need for hysterectomy in the majority of cases with preservation of future fertility. The outcome of subsequent pregnancies in our series is reassuring, with a low serious complication rate and conceptions occurring in two women. We can continue to use this information to better counsel women during the postpartum period. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
References An GH, Ryu HM, Kim MY, Han JY, Chung JH, Kim MH. 2013. Outcomes of subsequent pregnancies after uterine compression sutures for postpartum haemorrhage. Obstetrics and Gynecology 122:565–570. Api M, Api O, Yayla M. 2005. Fertility after B-Lynch suture and hypogastric artery ligation. Fertility and Sterility 84:509. Baskett TF. 2007. Uterine compression sutures for postpartum haemorrhage. Obstetrics and Gynecology 110:68–71. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. 1997. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. British Journal of Obstetrics and Gynaecology 104:372–375. Brace V. 2007. Learning from adverse outcomes – major haemorrhage in Scotland in 2003–2005. British Journal of Obstetrics and Gynaecology 114:1388–1396.
CMACE (Centre for Maternal and Child Enquiries). 2011. Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology 118(Suppl 1):1–203. Fotopoulou C, Dudenhausen JW. 2010. Uterine compression sutures for preserving fertility in severe postpartum haemorrhage: an overview 13 years after the first description. Journal of Obstetrics and Gynaecology 30:339–349. Habek D, Vranjes M, Bobic Vukovic M, Valetic J, Kremar V, Simunac J. 2006. Successful term pregnancy after B-Lynch compression suture in a previous pregnancy on account of massive primary postpartum haemorrhage. Fetal Diagnosis and Therapy 21:475–476. Holtsema H, Nijland R, Huisman A. 2004. The B-Lynch technique for postpartum haemorrhage: an option for every gynaecologist. European Journal of Obstetrics, Gynecology, and Reproductive Biology 115: 39–42. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. 2006. WHO analysis of causes of maternal death: a systematic review. Lancet 367:1066–1074. Ochoa M, Allaire AD, Stitely ML. 2002. Pyometria after hemostatic square suture technique. Obstetrics and Gynecology 99:506–509. Saman Kumara Y, Marasinghe J, Condous G, Marasinghe U. 2009. Pregnancy complicated by a uterine fundal defect resulting from a previous B-Lynch suture. British Journal of Obstetrics and Gynaecology 116:1815–1817. Treloar E, Anderson R, Andrews H Bailey J. 2006. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage. British Journal of Obstetrics and Gynaecology 113:486–488. Wohlmuth CT, Gumbs J, Quebral-lvie J. 2005. B-Lynch suture: a case series. International Journal of Fertility and Women’s Medicine 50: 164–173.
OBSTETRICS
Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: A single centre experience S. Liu1, M. Mathur1 & S. Tagore2
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
1Department of Obstetrics and Gynaecology and 2Peripartum Unit, Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
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. Keywords: Atony, B-Lynch, postpartum haemorrhage, pregnancy outcome, uterine compression suture
Introduction Obstetric haemorrhage is the leading cause of maternal mortality in Asia, accounting for 31% of deaths (Khan et al. 2006). Uterine atony remains the commonest cause of obstetric haemorrhage (Brace 2007) but death can be prevented with a good multidisciplinary approach and clear guidelines (CMACE 2011). However, in less developed countries, obstetric haemorrhage remains one of the major causes of maternal deaths (Africa, Asia and Latin America), with up to 50% of the estimated 500,000 maternal deaths occurring globally each year attributable to its effects (Khan et al. 2006). Hysterectomy is often life-saving and is used as a last resort in the management of uncontrolled obstetric haemorrhage but this has serious consequences in terms of future fertility and psychological sequelae. It was first suggested in 1997 that compression of the uterus can be achieved following caesarean section using a suture technique now known as B-Lynch suture (B-Lynch et al. 1997). It helps to reduce the need for a hysterectomy and also aids in preserving fertility. Since 1997, many centres around the world have been using this technique in the treatment of postpartum haemorrhage with good results, and there have been reports
about women conceiving following a previous B-Lynch suture (Holtsema et al. 2004; Api et al. 2005; Habek et al. 2006; Baskett 2007; An et al. 2013). KK Women’s and Children’s Hospital (KKH) is a busy tertiary unit with over 12,000 deliveries every year. It is also a regional referral centre for all complex obstetric cases. Our study reviews the long-term outcomes, including any pregnancies in women who had uterine compression sutures at KKH during the study period. The findings of our study will enable us to provide women with uterine compression sutures more accurate information about the complication rate and pregnancy outcome in our centre, thus enabling these women to make informed choices about their future fertility options.
Methods Utilising the KKH’s patient database, we retrospectively reviewed women treated in our hospital from 1 January 2008 to 31 December 2012, who had uterine compression sutures inserted post-delivery. The relevant case notes were reviewed and data was collected and recorded on a specially designed datasheet. Data was analysed using an Excel spreadsheet. The study was approved by our institution’s research ethics committee and informed consent was waived, as this study was a retrospective review. The demographic data collected included women’s age, gravidity, parity, indication for uterine compression suture, type of suture and associated procedures used. Results regarding post-delivery outcomes were also examined. They were followed-up for a period ranging from 1–4 years. Clinical data and findings are presented in Tables I and II.
Results From 1 January 2008 to 31 December 2012, a total of 23 women had uterine compression sutures performed, out of a total of 59,665 deliveries at KKH. The mean age of the women was 31.5 years. Of the women, 47.8% were multiparous and the maximum parity was six. Only one woman was a grandmultipara and the caesarean section was done due to maternal collapse from eclamptic seizure. A B-Lynch suture was inserted prophylactically because of her parity and risk of postpartum haemorrhage. All women were treated by different obstetricians. The suture material used was No. 1 Vicryl in all of the cases. Most had a B-Lynch suture placed but six women had a modified B-Lynch. Three women had multiple horizontal haemostatic sutures inserted
Correspondence: S. Liu, Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore 229899. E-mail: [email protected]
384
S. Liu et al.
Table I. Uterine compression sutures: perioperative aspects.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
Variable Age (years) (range, mean) ⬍ 35 35 or older Parity Primipara Multiparae Indication for caesarean delivery Failure-to-progress CPD NRFS Placenta abruption Placenta praevia Maternal collapse Breech Previous caesarean section Twins NVD Indication for suture Atony Prophylactic Grandmultiparae maternal collapse Fibroid Associated procedure Rusch balloon Uterine artery ligation Caesarean hysterectomy Type of suture B-Lynch Modified B-Lynch Postnatal complications No complications Persistent vaginal discharge Persistent vaginal discharge and pyometra Retained product of conception Endometritis Subsequent pregnancy Yes No Lost to follow-up
n
(%)
21–41 16 7
31.5 69.6 30.4
12 11
52.1 47.8
2 3 6 3 1 1 1 4 1 1
8.7 13.0 26.0 13.0 4.3 4.3 4.3 17.4 4.3 4.3
21 – 1 1
91.3
3 1 3
13.0 4.3 13.0
17 6
73.9 26.1
12 1 1 1 1
75.0 6.3 6.3 6.3 6.3
2 17 4
8.7 73.9 17.4
4.3 4.3
in addition to the B-Lynch suture and three women had multiple B-Lynch sutures placed. In our study, three of the 23 women went on to have caesarean hysterectomies in view of persistent bleeding, and one woman had an interval abdominal hysterectomy two-months later for pyometra. However, in the remaining nineteen women, hysterectomy was avoided due to the successful use of uterine compression sutures. There were three concep-
Figure 1. B-Lynch suture at the previous delivery.
tions in two women following a uterine compression suture, as described below and in Table II. The other seventeen women did not have subsequent pregnancies booked at our institution.
Case 1 The first case was a 30-year-old woman who had a B-Lynch compression suture placed in June 2010 for uterine atony. It was done in the caesarean section, which was carried out for failureto-progress for her first child. She had a first trimester complete miscarriage one-year later in September 2011, followed by another pregnancy in early 2012. The latter pregnancy was uneventful. She was delivered by an elective caesarean section at 39 weeks and had a healthy baby of 3,165 g. Her uterus was found to be normal intraoperatively, with no signs of the previous B-Lynch suture.
Case 2 The second case was a 28-year-old woman who had a B-Lynch compression suture placed in December 2010 for uterine atony (Figure 1). It was done in a caesarean section for cephalo-pelvic disproportion for her first child. She had a subsequent pregnancy in 2012 that was complicated by placenta praevia major and malposition of the baby, i.e. transverse lie. She underwent an elective caesarean section at 39 weeks. Intraoperatively, anatomical distortion of the uterus at the fundus due to the previous B-Lynch suture was found (Figure 2). The anterior uterine wall was also adhered to the anterior abdominal wall, with omental adhesions around it. Overall, the postoperative complication rate was 25% (4/16). Three women had an immediate caesarean hysterectomy for
Table II. Clinical data of women with subsequent pregnancies. Indication for initial Indication for Case Age Parity caesarean section B-Lynch suture
Type of suture
1
29
Para 2 Failure to progress
Uterine atony
2
26
Para 2 Cephalo-pelvic disproportion
Uterine atony
B-Lynch 1 complete miscarriage 1 full-term pregnancy Elective caesarean section for previous caesarean section B-Lynch 1 full-term pregnancy Elective caesarean section for placenta praevia major and malposition of baby (transverse lie)
Subsequent pregnancy
Interval to pregnancy from B-Lynch suture
Intraoperative findings
8 months 2 years
Normal Uterus, bilateral tubes and ovaries normal
2 years
Anatomical distortion of uterus due to previous B lynch suture at fundus Anterior uterine wall adherent to anterior abdominal wall with surrounding omental adhesions
Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage 385
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
Figure 2. Fundal distortion at the subsequent pregnancy.
persistent bleeding and four women were lost to follow-up. Of the remaining sixteen women, two women had persistent vaginal discharge after delivery and one of these two women developed pyometra, which required an abdominal hysterectomy two-months after the initial uterine compression suture. One woman had retained products of conception secondary to placenta accreta, requiring uterine evacuation. Another woman had endometritis, which resolved with a course of oral antibiotics. The other twelve women had uneventful postnatal follow-up.
Discussion Uterine compression sutures have been reported to be highly effective in preserving the uterus (B-Lynch et al. 1997; Holtsema et al. 2004; Baskett 2007). It is usually used if uterine atony does not respond to manoeuvres such as uterine massage, bimanual compression and the use of uterotonics, e.g. oxytocin, ergometrine, carbetocin, misoprostol and carboprost. It has been shown to decrease the need for a hysterectomy from massive blood loss after delivery, avoiding the inherent surgical risks of a hysterectomy for the women, while at the same time offering them the potential preservation of future fertility (Wohlmuth et al. 2005). There is a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in complications, such as pyometra, formation of synechiae (Ochoa et al. 2002) and ischaemic necrosis (Treloar et al. 2006). This is reflected in one woman who had multiple uterine compression sutures placed for uterine atony. She also had a Rusch balloon placed and bilateral uterine artery ligation in the management of her postpartum haemorrhage. Postnatally, she complained of persistent vaginal discharge and was readmitted 8 weeks after her delivery, complaining of fever and abdominal pain. Ultrasound confirmed the presence of pyometra, which was unresolved, despite intravenous antibiotics. She subsequently underwent an abdominal hysterectomy and was discharged well. She remained well at her follow-up visit. The formation of pyometra could be due to the placement of multiple uterine compression sutures but it could have been contributed to or caused by, other factors, which include the insertion of a Rusch balloon and bilateral uterine artery ligation. As such, there remains a risk of loss of fertility and the theoretical risk of adverse pregnancy outcomes following the use of uterine compression sutures. Training and the proper use of uterine compression suture is mandatory to reduce these risks. Although some uterine defects have been found at subsequent pregnancies, most reports have not been shown to have detrimental
effects on pregnancy outcomes, with most carrying their pregnancies to term (Baskett 2007). Data is very sparse on long-term outcomes following uterine compression suture, including future pregnancies. Successful pregnancies have been described following the use of uterine compression sutures (Baskett 2007). In his series of seven women, four had signs of the previous compression suture used, ranging from a fibrous band in the uterine cavity, fundal grooves in the myometrium to adhesions from bowel and omentum to the uterine wall. The other three women did not have any signs of use of the previous compression sutures. All these pregnancies were uncomplicated and were delivered at term via repeat caesarean section (Baskett 2007). An et al. (2013) recently published a report on a series of 42 women who had pregnancies after uterine compression sutures and matched them with a control group. They found that pregnancy outcomes were similar in the two groups, however uterine adhesions were more common in women who received uterine compression sutures. Apart from these series, there have also been other single case reviews reporting successful pregnancy outcomes following the use of uterine compression sutures (Holtsema et al. 2004; Api et al. 2005; Habek et al. 2006). On the other hand, adverse pregnancy outcomes regarding uterine compression sutures remain largely confined to isolated case reports. In 2009, Saman Kumara et al. reported a case of a full thickness defect in the uterine wall in a subsequent pregnancy following B-Lynch suture, which resulted in painful antepartum haemorrhage at 33 weeks. This woman underwent an emergency caesarean section for fetal distress and fetal membranes were found bulging through the fundal defect. In our institution, two out of our 23 women became pregnant and went on to deliver term babies. While this number is low, we postulate that it could be attributed to a variety of reasons. First, the stress and psychological trauma caused by the traumatic delivery would adversely affect decisions related to future pregnancies. Second, other successful pregnancies could remain unaccounted for if they were booked and followed-up at other institutions and thus lost to our follow-up. Also, four women were lost to follow-up and could have potentially attended other hospitals for their pregnancy follow-up. Another possible reason is that the uterine compression suture technique has only become more established at our institution in recent years, as a result of improved and more structured training with twelve of the 23 uterine compression sutures carried out in 2012 alone. Future pregnancies following uterine compression sutures usually occur within the range of 1–3 years (Fotopoulou and Dudenhausen 2010). As such, there remains the theoretical possibility that additional successful pregnancies will ensue shortly in the next few years, and we will know the true pregnancy rates. Overall, the findings at our centre appear consistent with previously published case series and reports (Holtsema et al. 2004; Api et al. 2005; Habek et al. 2006; Baskett 2007; An et al. 2013). Of our 23 women, there were three conceptions with two successful pregnancies. Although our second case was found to have slight anatomical distortion of the uterus and intra-abdominal adhesions, there was no long-term deleterious effect on her postnatal follow-up and delivery.
Conclusion In summary, the number of women with subsequent pregnancies following uterine compression sutures remains small worldwide. Continued and longer-term follow-up of women who have undergone uterine compression sutures is required to further understand the progress of their recuperation and elucidate the
386
S. Liu et al.
outcomes of their subsequent pregnancies. Uterine compression suture has been associated with a few complications but despite this, it has been shown to successfully avoid the need for hysterectomy in the majority of cases with preservation of future fertility. The outcome of subsequent pregnancies in our series is reassuring, with a low serious complication rate and conceptions occurring in two women. We can continue to use this information to better counsel women during the postpartum period. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
References An GH, Ryu HM, Kim MY, Han JY, Chung JH, Kim MH. 2013. Outcomes of subsequent pregnancies after uterine compression sutures for postpartum haemorrhage. Obstetrics and Gynecology 122:565–570. Api M, Api O, Yayla M. 2005. Fertility after B-Lynch suture and hypogastric artery ligation. Fertility and Sterility 84:509. Baskett TF. 2007. Uterine compression sutures for postpartum haemorrhage. Obstetrics and Gynecology 110:68–71. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. 1997. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. British Journal of Obstetrics and Gynaecology 104:372–375. Brace V. 2007. Learning from adverse outcomes – major haemorrhage in Scotland in 2003–2005. British Journal of Obstetrics and Gynaecology 114:1388–1396.
CMACE (Centre for Maternal and Child Enquiries). 2011. Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology 118(Suppl 1):1–203. Fotopoulou C, Dudenhausen JW. 2010. Uterine compression sutures for preserving fertility in severe postpartum haemorrhage: an overview 13 years after the first description. Journal of Obstetrics and Gynaecology 30:339–349. Habek D, Vranjes M, Bobic Vukovic M, Valetic J, Kremar V, Simunac J. 2006. Successful term pregnancy after B-Lynch compression suture in a previous pregnancy on account of massive primary postpartum haemorrhage. Fetal Diagnosis and Therapy 21:475–476. Holtsema H, Nijland R, Huisman A. 2004. The B-Lynch technique for postpartum haemorrhage: an option for every gynaecologist. European Journal of Obstetrics, Gynecology, and Reproductive Biology 115: 39–42. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. 2006. WHO analysis of causes of maternal death: a systematic review. Lancet 367:1066–1074. Ochoa M, Allaire AD, Stitely ML. 2002. Pyometria after hemostatic square suture technique. Obstetrics and Gynecology 99:506–509. Saman Kumara Y, Marasinghe J, Condous G, Marasinghe U. 2009. Pregnancy complicated by a uterine fundal defect resulting from a previous B-Lynch suture. British Journal of Obstetrics and Gynaecology 116:1815–1817. Treloar E, Anderson R, Andrews H Bailey J. 2006. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage. British Journal of Obstetrics and Gynaecology 113:486–488. Wohlmuth CT, Gumbs J, Quebral-lvie J. 2005. B-Lynch suture: a case series. International Journal of Fertility and Women’s Medicine 50: 164–173.
