A new uterine compression suture for postpartum haemorrhage with atony

1. 2. 3. 4. 5. J Zheng, X Xiong, Q Ma, X Zhang, M Li

Article first published online: 23 DEC 2010 DOI: 10.1111/j.1471-0528.2010.02809.x 2010 The Authors Journal compilation RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology Issue

BJOG: An International Journal of Obstetrics & Gynaecology

Volume 118, Issue 3, pages 370374, February 2011 Additional Information(Show All) How to CiteAuthor InformationPublication History How to Cite Zheng, J., Xiong, X., Ma, Q., Zhang, X. and Li, M. (2011), A new uterine compression suture for postpartum haemorrhage with atony. BJOG: An International Journal of Obstetrics & Gynaecology, 118: 370374. doi: 10.1111/j.1471-0528.2010.02809.x Author Information 1. Department of Obstetrics, Peoples Liberation Army 174th Hospital, Xiamen, Fujian, China *Correspondence: Dr J Zheng, Department of Obstetrics, Peoples Liberation Army 174th Hospital, 96 Wenyuan Road, Xiamen, Fujian, China. Email zhengdoc@hotmail.com

Publication History 1. Issue published online: 12 JAN 2011 2. Article first published online: 23 DEC 2010 3. Accepted 22 October 2010. Published Online 23 December 2010.

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Postpartum haemorrhage; surgical treatment; uterine compression suture

Abstract
Please cite this paper as: Zheng J, Xiong X, Ma Q, Zhang X, Li M. A new uterine compression suture for postpartum haemorrhage with atony. BJOG 2011;118:370374. Postpartum haemorrhage (PPH) is a major cause of worldwide maternal mortality and is still associated with significant morbidity. After the B-Lynch suture was reported in 1997, several different uterine compression sutures were found to be successful in controlling PPH. In this paper, we describe another simple variation of the uterine compression suture technique, which was performed without an incision in the uterine wall, without entering the uterine cavity and without suturing the anterior and posterior walls of the uterus together, so minimising the trauma to the uterus. This new uterine compression suture is an effective and safe surgical treatment for PPH caused by atony. It has the potential to apply to intractable PPH after vaginal delivery.

Introduction
Despite advances in medical and surgical therapies, obstetric haemorrhage remains a significant medical problem for both the developing and developed countries. Depending on the definition used, postpartum haemorrhage (PPH) complicates up to 18% of all deliveries. It is one of the most important causes of maternal mortality worldwide, accounting for 2530% of all maternal deaths.1 In addition, 64.7%2 of severe maternal morbidity is the result of obstetric haemorrhage. It is estimated that more than 125 000 women worldwide die every year because of obstetric haemorrhage,3 and 7590% of these casualties are the result of uterine atony. At least one study has indicated that 90% of the deaths from postpartum haemorrhage could be prevented with better medical care.4 Fertility is preserved in 46% of these women by successful arterial embolisation without hysterectomy.5 Uterine compression sutures are successful in avoiding hysterectomy in 82% of these women.6 Of the several different techniques noted in the literature, the B-Lynch suture,7 which was first reported in 1997, has gained the most popularity, with a number of subsequent publications attesting to its efficacy. However, concerns have been raised on the potential risk of occlusion of the uterine cavity and blood entrapment, as the uterus has to be transfixed from front to back to place the suture. As the other uterine compression suture

techniques are relatively new, data on their safety and efficacy are limited to a few case reports.8 In this paper, we describe another simple variation of uterine compression suture technique for which the preliminary results appear to be as effective as the original B-Lynch suture and its modifications, and may reduce the risk of complications.

Methods
Standard protocols for the management of obstetric haemorrhage are in use in our institution. Prophylactic oxytocics are offered routinely in the management of the third stage of labour. Once PPH has been identified and after vaginal/cervical lacerations or haematoma and retained products of conception have been ruled out, the following measures are used initially to manage the bleeding: uterine bimanual compression, uterine massage, uterine balloon tamponade, and appropriate use of uterotonic medications, such as oxytocin carboprost methylate suppositories, misoprostol tablets and carboprost tromethamine injection. If all these measures fail to control the haemorrhage and the woman continues to bleed and becomes haemodynamically unstable, surgical haemostasis would be initiated. In 2006, a new uterine compression suture was performed in the Obstetric Department of our hospital as the first-line surgical treatment in every case of uterine atony that resulted in an intractable PPH, which was defined as postpartum blood loss quickly or in excess of 2000 ml, either following the vaginal delivery or after caesarean section. The use of this procedure was approved by the institutional ethical committee. All the women signed a written informed consent form before their operation. When quick access was required in high-risk situations, a midline infraumbilical incision was preferred; otherwise a pfannenstiel incision would be used. In women with intractable PPH occurring after a caesarean delivery, the lower transverse uterine incision was closed in one layer with 1-polyglactin sutures first. Most of these women were placed in the semi-lithotomy position to allow assessment of vaginal bleeding. The uterus was exteriorised. Bimanual compression was applied to check whether this suture stopped the bleeding first and then a 1-polyglactin suture on a 40-mm curved needle (synthetic absorbable suture; United States Surgical, Norwalk, CT, USA) was inserted into the inner myometrial layer of the anterior wall of the right lower segment, 2 cm below the incision. A 4 cm long insertion was made, 2 cm equidistant on each side of the incision, 3 cm medial to the right lateral border, after the bladder peritoneum where the bladder had been dissected down (Figure 1A). The needle was then passed from the anterior, over the fundus, and a 2 cm long insertion was made into the middle myometrial layer, 4 cm medial to the right lateral border (Figure 1B). A 3 cm long insertion was then made into the inner myometrial layer of the posterior wall of the right lower segment, 2 cm medial to the right lateral border (Figure 1C). The needle was not allowed to completely penetrate the entire thickness of the wall to enter the uterine cavity. The two ends of the thread were tied on the fundus of the uterus as tightly as possible, while a bimanual compression was applied by an assistant (Figure 1D). The procedure was then repeated on the left (Figure 2). Care was taken not to damage the bowel, the bladder and the interstitium of the fallopian tubes. The knot was re-tied if the thread appeared to loosen after the uterus contracted within a 10-minute period. Before the abdomen was closed, normal vaginal bleeding was ensured. The main outcome evaluations were reduction or cessation of bleeding, whether re-

laparotomy or hysterectomy was needed to control haemorrhage, and whether minor or major complications of the procedure arose. A video of the procedure is given in the Supplementary material supplied (Supporting information Video S1). Figure 1. (A) The needle is inserted into the inner layer of the anterior wall of the lower segment and does not enter into the myometrium. (B) The needle is inserted into the middle layer of the fundus. (C) The needle is inserted into the inner layer of the posterior wall of the lower segment and does not enter into the myometrium. (D) The two ends of the thread are tied on the fundus of the uterus. The procedure is then repeated on the other side.

Figure 2. Perspective of the uterus after the knots are tied.

Results
Between October 2006 and September 2009, there were a total of 9201 deliveries in our department. The rate of PPH, defined as postpartum blood loss in excess of 500 ml, was 2.54% (65/2562), 2.48% (80/3224) and 2.25% (77/3415) in 2007, 2008 and 2009, respectively. Only nine women with obstetric haemorrhage underwent this new uterine compression suture in these 3 years. In all nine women, the PPH was caused by uterine atony, which was the failure to arrest blood loss after initial routine management. One of these procedures was 5 hours and 10 minutes after vaginal delivery (1/6762) and the others were during caesarean section (8/2439). Antibiotic prophylaxis was administered intravenously. All the infants were delivered in good condition. There was no maternal mortality or severe morbidity with cardiac, respiratory, renal or cerebral dysfunction as a result of complications. Eight of these women received blood transfusions and fresh frozen plasma perioperatively and in the immediate postoperative period. One woman, who had thrombocytopenia and anaemia, received this new uterine compression prophylactically without any transfusion when she lost 700 ml blood at the time of caesarean for twins, without any subsequent haemorrhage. Four of the women were kept in the intensive-care unit for up to 48 hours. For two of the women the procedure was accompanied by disseminated intravascular coagulation, where the pelvis and abdomen were closed after inserting a drain into the pelvis. For all the women, this uterine compression suture was performed either at caesarean section or at an interval after vaginal delivery; once haemostasis was achieved and the abdomen was closed, the haemorrhage did not recur. No women had delayed haemorrhage that required re-laparotomy or hysterectomy. Postoperative recovery was uneventful and all the women were discharged from the hospital on day six postpartum. The median follow-up time was 18 months (range 332 months). For all these women, a followup examination was performed 2 weeks after hospital discharge. Further follow ups were carried out every 2 or 3 months for the first year and then annually. An ultrasound showed no fluid

accumulation within the uterine cavity. There was no ischaemic complication during the postoperative period either during the inpatient stay or leading up to performing the procedure. Eight of the women breastfed their babies. All of them had normal lochia, and there was no delay in the resumption of normal menstruation. One of them had normal signs on hysteroscopy 1 year later. One of them conceived naturally 2 years later, and had an uneventful pregnancy and her uterus showed no scars from the previous uterine compression suture during the caesarean section delivery (Table 1). Table 1. Clinical data of women managed with the new uterine compression suture Blood Resumed Gravi Week Mode Adjunc Follow Ca Age loss Transfusi normal dity s of of Concomitan tive up se (yea perioper ons menstru and gestat delive t conditions proced (months no. rs) ation (units) ation parity ion ry ures ) (ml) (months) 1. Cryo, cryoprecipitate; DIC, disseminated intravascular coagulation; FFP, fresh-frozen plasma; GDM, gestational diabetes mellitus; ITP, idiopathic thrombocytopenic purpura; P, platelets; PRBC, packed red blood cells. 32 (spontan eous pregnanc y 2 years later

28

G3P1 39

+5

Caesar Placenta ean praevia section

4200

10 units PRBC 400 ml FFP 8 units PRBC 450 ml FFP 10 units PRBC 400 ml FFP 6 units cryoprecip itate 24 units PRBC 10 units cryoprecip itate; 1 units platelets 1 units platelets

36

G4P2 40+6

Placenta Caesar praevia; ean oligohydram 3500 section nios; anaemia

24

27

G1P1 41+3

Caesar ean Anaemia section

4000

Uterine arteries 7 ligation

11

33

G1P1 41+2

Vagin al DIC; deliver anaemia y

3000

Uterine arteries ligation uterine 6 balloon tampon ade

15 (normal hysterosc opic finding 1 year later

Table 1. Clinical data of women managed with the new uterine compression suture Blood Resumed Gravi Week Mode Adjunc Follow Ca Age loss Transfusi normal dity s of of Concomitan tive up se (yea perioper ons menstru and gestat delive t conditions proced (months no. rs) ation (units) ation parity ion ry ures ) (ml) (months) Caesar Oligohydra 2 units 5 34 G1P1 41 ean 1500 4 31 mnios PRBC section Twin pregnancy; Caesar coagulopath 6 28 G1P1 35+6 ean y ITP; 700 0 2 3 section thrombocyto penia; anaemia 6 units Caesar Protracted PRBC 7 26 G1P1 37+1 ean 1900 5 active phase 400 ml section FFP Placenta 14 units Caesar praevia; PRBC +4 8 31 G3P1 38 ean 4250 2 31 placenta 400 ml section increta FFP Placental 5 units Caesar abruption; PRBC 9 37 G4P1 39 ean GDM; DIC; 3000 7 8 400 ml section polyhydram FFP nios

Discussion
Postpartum haemorrhage is a major cause of worldwide maternal mortality, from 13% in developed countries to 34% in developing countries.9 It is still associated with significant morbidity, and is a major concern for the midwives and obstetricians. Prompt diagnosis and effective treatment are the cornerstones of management and are crucial to prevent fatal maternal haemorrhage. PPH typically occurs unpredictably and no woman is exempt from the risk of PPH. Known risk factors for atonic PPH include a history of PPH, history of retained placenta, placental abruption, placenta praevia, uterine fibroids, hydramnios, multiple pregnancies, augmentation of labour, prolonged labour and instrumental delivery. With the rising rate of caesarean section and the emergent nature of most PPH there is a constant need for effective intervention. The improvements for the conservative management of this life-threatening condition in the past decade include the invention of the B-Lynch suture7 and its

modifications.1014 The rationale for all the improved methods is based on haemodynamic studies,15 which showed that uterine compression sutures reduced pelvic blood flow and pulse pressure, resulting in venous pressures in the arterial circuit and so promoted haemostasis; the rationale is also based on the uterine compression suture rapidly reducing the surface of the uterine wall from which the placenta detached; and the third rationale is based on the lack of blood to stimulate uterine contractions, which should be further studied and clarified. Most of the uterine compression sutures attempted were successful in controlling PPH and avoiding the woman having to undergo hysterectomy, but all of them need careful evaluation.16 All of these techniques puncture the uterine walls. Most of them directly sutured the anterior and posterior uterine walls, obliterated the cavity and thereby effectively controlled the PPH as a result of uterine atony. There were reported complications resulting from these sutures, such as pyometrium,17 uterine synechiae,18 uterine necrosis,19 partial ischaemic necrosis2023 and, in a few of the procedures, hysterectomy was not averted because the sutures slid off at the uterine fundus and the epiploon inserted in it or uterine avulsion occurred after the knots were tied too tight. We modified and introduced this new uterine compression suture. The results from this case series suggest that our new compression suture is one of various conservative measures for the surgical treatment of PPH and should be further studied for performance prophylactically at caesarean section in women with a high-risk factor for developing PPH, such as coagulopathy, in the absence of any evident haemorrhage. This suture, without an incision into the uterine wall, can also be performed when PPH occurs after a vaginal delivery. During caesarean section it is feasible to close the lower segment incision quickly to decrease the blood loss volume; the suture was inserted at the uterine fundus, similar to Marasinghes procedure,14 which eliminated the risk of the sutures sliding off at the uterine fundus. We used two sutures and tied the knots side by side as reported by Bhal et al.,24 but the uterus was tighter because of using twin sutures; we used synthetic absorbable sutures instead of delayed, absorbable sutures, which avoided suture erosion or the suture protruding from the uterine cervical os several weeks later. The key point in this suture is that it is performed without entering the uterine cavity and without suturing the anterior and posterior walls of the uterus together, so reducing the risk of complications that normally follows the uterine compression suture. This needs to be clarified. In conclusion, our new uterine compression suture is one of various surgical treatments for PPH, and avoids having to perform an emergency hysterotomy. As preservation of reproductive capacity is the main outcome measure in these operations,25 our new uterine compression suture without an incision in the uterine wall, without entering the uterine cavity and without suturing the anterior and posterior walls of the uterus together, minimises the trauma to the atonic bleeding uterus and does not impact on the womans subsequent fertility and pregnancies. Therefore this procedure should be attempted when conservative management of PPH fails and before any extreme surgery is considered. In this study, the data on efficacy and safety are limited, and long-term follow-up information are lacking. More case series to confirm the potential advantages of this procedure are required. New studies assess the possibility that use of this procedure at an earlier stage in the treatment of severe postpartum haemorrhage will be advantageous.

Disclosure of interests We declare that we have no conflicts of interest. Contribution to authorship JLZ designed and performed the surgical procedure, analysed the data and wrote the manuscript. XX, QM, XZ and MLi assisted with surgery and observed the complications. Details of ethics approval The new uterine compression suture technique was approved by the Reproductive Medical Ethics Committee of Peoples Liberation Army 174th Hospital in 2006. Consents were obtained from the women and their families before the operation. Funding The study was financially supported by Nanjing Military Area Command Medicine and Health Lead Scientific Research Project (2007Z018) and the Xiamen Social Development Technologies Project (3502Z20074030). Acknowledgements The authors would like to acknowledge the financial support of the Nanjing Military Area Command Medicine Health Department and the Xiamen Social Development Technologies Branch in China. We warmly thank the women and their families who participated in this study, all the other departments of the Peoples Liberation Army 174th Hospital and the staff in our department. The authors would like to thank Mr Li Su, for his valuable contribution to the diagrams, and Mr Bin Wang from our Hospital, for his valuable contribution to the video work.

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