Pakistan J. Med. Res.

Vol. 42 No.3, 2003

CASE REPORT

“B-lynch” brace suture as an alternative to. Hysterectomy for severe PPH

 

Shakila Yasmin

Quaid- e- Azam Medical College, Bahawalpur 

Two cases of intractable postpartum hemorrhage managed by B-lynch Brace Suture, a new technique for control of massive post-partum hemorrhage are being presented. The B-lynch suturing technique (brace suture) may particularly be useful because of its simplicity of application, life saving potential, relative safety and capacity for preserving the uterus and thus fertility. So, it should be considered as first line surgical treatment before going for hysterectomy.

INTRODUCTION: 

PPH is a serious obstetrical problem. It has been estimated that worldwide, over 125,000 women die of PPH each year.1 In Pakistan, it is also a major cause of maternal mortality.2 2-5% of deliveries may lead to PPH with a blood loss >1000mls within the first 24 hours,3 while the life threatening hemorrhage occurs in 1 in 1000 deliveries.4 Maternal morbidity and mortality rises with delay in diagnosis and management. Uterine atony, degree of retained placenta including placenta accreta and its variants, and genital tract laceratios account for most cases of PPH. In the past 20 years, placenta accreta has overtaken uterine atony as the most common cause of postpartum hemorrhage of sufficient severity to mandate hysterectomy.5,6 There are a variety of medical and surgical treatments available for control of PPH. Two cases of PPH managed by Brace Suture are bieng reported using the technique first published by C.B. Lynch.7 

CASE REPORT 1

A 20 years old primigravida was admitted at gestational age of 41 weeks for induction of labour. Physical examination revealed a lady of average build and pink look. Her respiratory and cardiovascular systems were unremarkable. On abdominal examination fetus was longitudinal, cephalic 5/5th palpable. Bishop score was poor and pelvis was adequate clinically. On ultrasonography, placental maturity was grade III and liqour was just adequate, BPD 92 and FL 73. After doing CTG record for 10 minutes, prostin E2 was placed in the posterior vaginal fornix. Partogram was maintained, artificial rupture of membranes done after 4 hours when she was 5cm dilated, fully effaced and vertex reached at -2 station. Outlet forceps delivery with episiotany was done, due to type II decelerations. Third stage managed actively. Immediately after the stitching of episiotomy, patient got heavy bleeding per vaginum: uterine massage and bimanual compression were performed along with intravenous oxytocics. Blood transfusion was started and patient shifted to operation theatre due to failure of conservative measures to arrest PPH. Examination under anesthesia done and cervical, vaginal, or perineal lacerations were ruled out. Meanwhile, PGF2µ was also given. Since the patient was still bleeding profusely so laparotomy performed. Bilateral uterine and internal iliac arteries ligation resulted in no benefit. Uterus was getting atonic again and again between the acts of compression and massage. So, the B-Lynch Suture was applied as a “Last Ditch” measure before hysterectomy which proved to be successful. Patient remained well and was discharge on 6th post operative day.  

CASE REPORT 2

A 29 year old, fourth gravida with three alive females delivered vaginally, was admitted at 35 weeks of gestation with complaint of bleeding per vaginum. On ultrasonography, major degree placenta previa was diagnosed. One unit of blood was transfused and emergency cesarean section performed for sudden onset of heavy vaginal bleeding (more than 500ml in two hours). An alive female baby weighing 2kg was delivered. Lower segment was highly vascular and bled more than 1000 mls during the operation despite oxytocics and haemostatic sutures to the placental bed. B-Lynch Suture was then applied successfully, after failure of ecbolics and pressure packing. Two units of blood were transfused preoperatively. Patient remained well in postoperative period and was discharged on 6th postoperative day.  

MATERIAL AND METHOD 

Prior to applying B-Lynch Suture6, under general anesthesia, the patient is catherized and placed in the Lloyd Davis Position (modified lithotomy position) to assess the control of bleeding subjectively by swabbing. The abdomen is opened by Pfannensteil’s incision or if the patient has had cesarean section following which she bled, the same incision is reopened. On entering the abdomen either a lower segment incision is made or sutures of a recent cesarean section are removed. Bimanual compression is first tried to assess the potential chance of success of the B-Lynch suturing technique.

For this procedure chromic catgut No. 2 on rounded needle is used (Figure 1).  

 The uterus is punctured at about 3cm from the right lower edge of the uterine incision and 3cm from the right lateral border. The thread is passed through the uterine cavity to emerge at the upper incision margin 3cm above and approximately 4cm from the lateral border. The catgut is passed over the uterine fundus approximately 3-4cm from the right cornual border. The catgut is passed posteriorly to puncture the uterine cavity at the same level as the upper anterior entry point. The chromic catgut is pulled under moderate tension and is passed posteriorly through the same surface marking as for the right side, the suture lying horizontally. The catgut is passed vertically over the fundus compressing the fundus on the left side as occurred on the right. The needle is pased in the same fashion on the left side through the uterine cavity and out approximately 3cm anteriorly and below the lower incision margin on the left side. The two lengths of catgut are pulled taut assisted by bimanual compression to minimize trauma and aid compression. The vagina is now checked for bleeding. If good hemostasis is secured and whilst the uterus is compressed by an assistant, the principal surgeon ties the two lengths of catgut to secure tension. The lower transverse uterine incision is now closed in the normal way.  

DISCUSSION 

In severe obstetrical hemorrhage, postpartum hysterectomy may be life saving. Placental implantation disorders, to include placenta previa and variations of placenta accreta, often in association with repeat cesarean delivery, are now common indications for cesarean hysterectomy.8 Recently, Seago and associates, have reported increased blood loss, operative time, infection morbidity and transfusion rates, in addition to future loss of fertility in women undergoing emergency postpartum hysterectomy.10 A variety of surgical techniques have been proposed to avoid hysterectomy, each is associated with identifiable benefits and risks. Ligation of ovarian, uterine or internal iliac arteries is recommended, in most cases of massive hemorrhage. O’Leary found bilateral uterine artery ligation helpful in 95% of cases,10 however, technique failed in cases of placenta previa or accreta. Bilateral internal iliac ligation is successful in avoiding hysterectomy in about half of the cases. However, delay in carrying out procedure leads to a poor prognosis. It also has a number of recognized potential complications, including ligature of external iliac artery, damage to internal or external iliac veins, ureteral injury and retroperitoneal hematoma. Uterine packing is another attractive alternative but there is a significant risk of continued hemorrhage and infection.

The Brace suture first reported by B-Lynch is very useful as an alternative to hysterectomy and other surgical interventions for control  of massive postpartum hemorrhage and success is likely even in cases of placenta previa and accreta. The net effect of suture is to compress the uterus (as in bimanual compression). The suture material, (chromic catgut) is inexpensive and readily available. Moreover, technique is simple and safe enough for the residents to learn and apply as identification of specific blood vessels is not required. Conservation of uterus and reproductive capacity as achieved by B-Lynch brace suture is its greatest advantage.

 More recently, Smith KL and Baskett TF11 have assessed the use of B-Lynch suture as an alternative to hysterectomy for severe postpartum hemorrhage. In seven cases of uterine atony at the time of cesarean section, which were unresponsive to all Oxytocic agents a B-Lynch compression suture was used before resorting to hysterectomy. In six out of seven women, the bleeding was controlled with the suture. They concluded that that B-Lynch Compression Suture is easy to apply and should be considered in cases of severe atonic uterus when oxytocic agents fail, and before resorting to hysterectomy. Wergeland H, Alag KL, and Lokvik B,12 have also concluded that stepwise devascularization and hysterectomy are technically difficult and time consuming while B-Lynch if performed early, is less multilating to women and can arrest serious postpartum hemorrhage. They showed 100% results in their study. Hence, B-Lynch suturing technique has been successfully applied with no problems to date and no apparent complications.  

REFERENCES 

1.             Hayman RG, Arulkumaran, Stear PJ. Uterine compression suture: Surgical management of postpartum hemorrhage. Obstet Gynecol 2002; Mar 99(3): 502-6.

2.             Ashraf M, Sheikh NH, Sheikh AH, Yousaf AW. Maternal mortality: a 10 year study at lady Willingdon Hospital, Lahore. Annals KEMC 2001; 7: 205-7.

3.             Vangsgaard K. B-Lynch Suture in uterine atony: ugeskr Laeger. 2000 June 12: 162(24):

4.             Macphail S, FitMacphail S, Fitald J. Massive Postpartum hemorrhage. Curr Obstet Gynecol. 2001; 11: 108-14.

5.             Chestnut DH, Eden SD, Gall SA, Parker RT: Peripartum Hysterectomy: A review of cesarean and postpartum hysterectomy. Obstet Gynecol. 1985; 85: 365.

6.             Zelop CM, Harlow BL, Frigeletto FD, Safon LE, Saltzman DH: Emergency peripartum hysterectomy. Am J Obstet Gynecol. 1993; 95: 365. 

7.             CB Lynch. The B Lynch surgical technique for the control of massive PPH. Br J Obstet Gynecol. 1997; 104: 372-5.

8.             Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa, placenta accreta. Am J Obstet Gynecol. 1997; 177: 210.

9.             Seago DP, Roberts WE, Johnson VK, Martin RW, Morrison JC, Martin JN: Planned cesarean hysterectomy: A preferred alternative to separate operations. Am J Obstet Gynecol. 1999; 180: 1385.

10.           O’ Leary JA. Stop of hemorrhage with uterine artery ligation. Contemp. Obstet Gynecol. 1986; 28: 13-6.

11.           Smith KL, Baskett JF. Uterine compression sutures as an alternative to hysterectomy for severe postpartum hemorrhage. J Obstet Gynecol. 2003; 25(3): 197-200.

12.           Weryeland H, Alagic E, Lokvik B. Use of B-Lync Suture technique in postpartum hemorrhage. Tiddskr Nor laegeforen. 2002; 122(4): 370-2.