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Christopher B-Lynch


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A Case Study From The University Of Virginia School Of Medicine

Case 1

from the department of obstetrics and gynaecology, university of Virginia school of medicine, Charlottesville Virginia

A 14 year old girl, gravida 1, was transported to the University of Virginia school of Medicine with a 31 6/7 weeks’ twin gestation and was treated with intravenous magnesium sulphate 2-3g/hour and betamethasone 12mg intramuscularly every 12 hours X 2. Ultrasound showed breech-breech twins with biometric characteristics consistent with gestational age. Uterine contractions persisted, and on the second day of hospitalisation, a 3 day course of sulindac 200 mg orally every 12 hours, combined with magnesium sulphate, was initiated. Membranes ruptured spontaneously on the fifth hospital day, and low transverse cesarean was done on the fifth hospital day, and low transverse cesarean was done for footling breech – footling breech presentation. Birth weight of the first twin (female) was 2037g and for the second twin (female) 1685g. Apgar scores where 4 and 8, and 6 and 9 at 1 and 5 minutes, respectively.

Delivery was unremarkable but uterine atony was noted after the placenta was removed. There was an initial response to fundal massage, intravenous oxytocin (40 U in 1 L of lactated Ringer’s solution 200 ML/hour), and carboprost tromethanine 250ug intramuscularly, so the hysterotomy incision was closed. Uterine atony recurred and further medical therapy was unsuccessful, so bilateral uterine artery ligation was done with the O’Leary technique. 3 Uterine atony and bleeding continued, so bilateral utero-ovarian ligation was done, without effect. The patient was placed in the frog leg supine position by flexing her hips and knees 15-30o, externally rotating her hips and bringing her heels together at midline. We retracted the surgical drapes over her legs to allow direct view of and access to the perineum and vagina. The surgeon applied bimanual compression to the uterus while an assistant swabbed out the vagina and bleeding stopped. The hysterotomy incision was reopened and a B-Lynch suture was placed. Because no 2 chromic catgut recommended by B-Lynch et al2, is not used on our unit we used a 36-inch 0 Vicryl (Ethicon, Sommersville, NJ) suture. The needle was inserted through the anterior uterine wall at site 1(figure 1) the from the intrauterine position it is brought out though the anterior uterine wall (site 2) wrapped over the fundus 3-4 cm medial to the corneal area of the fallopian tube and inserted through the posterior uterine wall at site 3 (Figure 2) From the intrauterine position the needle was directed through the posterior wall at site 4 then wrapped over the fundus and directed into and out of the anterior uterine wall at sites 5 and 6, respectively  (figure 1). We then compressed the uterus in an accordion like fashion, rechecked the perineum to assure that bleeding was controlled, and tied the suture across the lower uterine segment (figure 3). We closed the hysterotomy incision in a running, locking fashion and inspected the vagina again, which showed complete cessation of uterine bleeding. Postoperatively, endomyometritis was diagnosed and treated with antibiotics. The patient was discharged on postoperative day 4. Four months postpartum and hysterosalpingogram showed no uterine cavity defects and prompt spill of dye from both fallopian tubes. Magnetic resonance imaging (MRI) showed a possible 5-mm leiomyoma in the uterine fundus and myometrium that was slightly thickened anteriorly with a normal endometrial cavity.

Case 2

A 17 year old girl, gravida 1, presented in labour at 39 6/7 weeks’ gestation with a vertex-oblique lie twin gestation. Labour progressed uneventfully and the first twin, a 2840-g male, was spontaneously delivered with apgar scores of 7 and 8 at 1 and 5 minutes respectively. The second twin presented with an arm on vaginal examination and a cesarean was done without difficulty to deliver a 2979g male with apgar scores of 9 and 9 at 1 an 5 minutes respectively. Despite medical therapy, the uterus remained atonic. A B-Lynch suture was placed immediately ceasing vaginal bleeding. The woman did well postoperatively and was discharged on day 3.

Comment

These cases show that the B-Lynch suture might be A valuable technique for treating postpartum hemorrhage due to uterine atony that does not respond to multiple oxytocic agents or ligation of the ascending branch of the uterine artery or utero-ovarian vessels. In our cases, vaginal bleeding ceased with manual compression of the uterus. Success of this preliminary maneuvre indicates its potential usefulness. The frog leg supine position is important for assessing vaginal bleeding intraoperatively and determining the success of manual compression and the B-Lynch suture. (Although B-Lynch et al 2 used the Lloyd–Davies position [a combination of lithotomy and trendelenburg], we found the frogleg supine position completely satisfactory for assessing cessation of bleeding. It is expedient [stirrups do not need to be located and positioned] and comfortable for surgeons [the operating field remains level instead of the significant tilt  if the woman where in the steep trendelenburg].)

Post delivery imaging studies also documented normalcy of uterine anatomy. In the report by B-Lynch et al2, two of five women had subsequent full-term deliveries. One woman had a spontaneous vertex delivery and the second had no uterine abnormalities at the time of elective cesarean. Our first subject had a normal postoperative hysterosalpingogram and an MRI. There is little experience with this surgical technique, so patients should be followed up carefully in subsequent pregnancies to assess uterine integrity. The extreme degree of uterine compression with this technique raises concerns about uterine anatomic damage. The few women followed up have had no uterine defects, which might be secondary to rapid involution of the uterus lessening the suture tension on each postpartum day. Although in our cases, a uterine incision had been made for cesarean, which was reopened easily to place the sutures, it might not be necessary to make hysterotomy incision if one is not already present. A vesicouterine flap could be taken down and a large mayo needle used to blindly enter and exit the anterior uterine wall at sites 1 and 2 (Figure 1) and the suture could then be looped over the fundus, as described. It would then blindly enter and exit the posterior uterine wall at sites 3 and 4 (Figure 2). The suture would again be looped over the uterine fundus and inserted blindly into the uterine cavity at site 5 and exit at site 6 (Figure1), avoiding a uterine incision. The distended, thin, pliable uterine might make the blind passage of the suture easy to accomplish.

References

1. American College of Obstetricans and Gynecologiests. Postpartum hemorrhage, ACOG educational bulletin no 243 Washington DC: American college of Obstetricans and Gynecologiests. 1998

2. B-Lynch C, Coker A, Lawal AH, Abu J,Cowen MJ, The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Mr J Obstet Gynaecol 1997; 104:372-5

3. O’Leary Ja. Uterine artery ligation in the control of post cesarean hemorrhage. J Repord Med 1995;40:189-93

Topics: B-Lynch Suture Published Press Articles |

B-Lynch Suture Published Press Articles

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