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Christopher B-Lynch


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Application Of The B-Lynch Brace Suture With Associated Intrauterine Balloon Catheter For Massive Haemorrhage Due To Placenta Accreta Following A Second-Trimester Miscarriage

Of all the causes of death in maternity, haemorrhage plays the most important and dramatic role. The most common causes of such haemorrhage are uterine atony, retained and/or morbidly adherent placenta, coagulopathy, uterine rupture and uterine inversion. BLynch et al. (1997) first described a simple procedure to treat lifethreatening postpartum haemorrhage, when the uterus remains atonic after treatment with ecbolics such as oxytocin, syntometrine and prostaglandins. The special advantage of this technique is that it provides an alternative to major surgical procedures for controlling pelvic arterial pulse pressure and to hysterectomy.

The B-Lynch suturing technique has become very popular worldwide since the original report in 1997 (Roman and Rebarber 2003; Baskett, 2004). In the literature, there are 45 reported cases of its successful use in controlling haemorrhage secondary to uterine atony following delivery in third trimester with no apparent complications. However, the use of this technique in early pregnancy is much less widely acknowledged. At the time of writing, there has been only one such report by Hillaby et al. (2004), who successfully used a B-Lynch suture in the management of severe bleeding following miscarriage at 13 weeks’ gestation. Our report provides further evidence that the B-Lynch technique is highly successful in achieving uterine compression and controlling bleeding in early pregnancy, when all forms of conventional medical therapy have failed.

Compared with other surgical interventions the B-Lynch technique has the advantage that it can be applied fast and easily. A patient can be considered a potential candidate for the B-Lynch procedure if bimanual compression of the exteriorised uterus markedly decreases the uterine bleeding. If, after laparotomy, the patient has not undergone a caesarean section, a lower uterine transverse incision should be performed. The purpose of this is to remove the products of conception, examine the cavity for decidual tear, placenta accreta or increta. Care should be taken to ensure that drainage is possible to avoid the risk of clot retention and pyometra (B-Lynch et al. 1997; Ochoa et al. 2002). The suture is at first led into the uterus 3 cmbelow the incision. Thereafter, the suture is led out of the uterus 3 cm above the incision and is then brought over the anterior side of the uterus, like a brace, to the posterior side of the uterus. Then it is once more led into the uterus just above the insertion of the sacro-uterine ligaments on the ipsilateral side and thereafter from inside to outside on the contralateral side. Finally, it is brought back from posterior to anterior over the uterus and passed in the same fashion through the uterine cavity and out approximately 3 cm anteriorly and below the lower incision margin on this side. After closure of the uterine incision, both ends of the B-Lynch suture are then tied (Figure 1), while the uterus is compressed by an assistant. During this compression, the vagina is checked to confirm that bleeding is controlled. The whole procedure is simple, effective and cheap.

 The authors wish to emphasise the importance of opening the uterine cavity, examining it for any retained products of conception, and removing these to ensure drainage of the uterus. The obvious bleeding points can also be identified at that time and secured with an independent figure-of-8 suture (B-Lynch et al. 1997). Other types of uterine compression sutures have been described, such as vertical and square sutures (Cho et al. 2000; Hayman et al. 2002). These are placed without opening the uterine cavity, which could permit fragments of retained placenta to be left behind and cause further bleeding. Also, drainage of the uterine cavity is restricted by the way square and vertical sutures are placed, which could lead to clot retention and pyometra (Ochoa et al. 2002) and inevitably compromise uterine tone, involution and viability of the myometrium. In our case, the combination of placenta accreta with severe coagulopathy (disseminated intravascular coagulation) made the management particularly challenging.
Performing a hysterectomy could have risked maternal mortality from substantial blood loss and compromised the patient’s critical condition. Insertion of a 30 ml Foley catheter balloon after applying the B-Lynch brace suture ensured compression of the isthmus of the uterus and cervical haemostasis. Vaginal bleeding stopped completely. Coagulopathy was corrected and no significant bleeding was observed after removal of the intrauterine balloon 40 h later. In conclusion, the B-Lynch suture technique is highly effective in early pregnancy. Use of the brace suture in association with an intrauterine balloon should be considered a suitable option for the treatment of massive haemorrhage due to placenta accreta following pregnancy loss in early gestation.
B-Lynch C, Coker A, Lawal AH et al. 1997. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? British Journal of Obstetrics and Gynaecology 104:372 – 375.
Baskett TF. 2004. Surgical management of the severe obstetric haemorrhage: experience with an obstetric haemorrhage equipment tray. Journal of Obstetrics and Gynaecology Canada 26:805 – 808.
Cho JH, Jun HS, Lee CN. 2000. Haemostatic suturing technique for uterine bleeding during caesarean delivery. Obstetrics and Gynecology 96:129 – 131.
Hayman RG, Arulkumaran S, Steer PJ. 2002. Uterine compression sutures: surgical management of postpartum haemorrhage. Obstetrics and Gynecology 99:502 – 506.
Hillaby K, Ablett J, Cardozo L. 2004. Successful use of the B-Lynch Brace suture in early pregnancy. Journal of Obstetrics and Gynaecology 2004 24:841 – 842.
Ochoa M, Allaire AD, Stitely ML. 2002. Pyometria after haemostatic square suture technique. Obstetrics and Gynecology 99:506 – 509.
Roman AS, Rebarber A. 2003. Seven ways to control postpartum haemorrhage. Contemporary Obstetrics and Gynaecology 48: 34 – 53. Correspondence: N. Price. E-mail: price@clara.co.uk
 Figure 1. (a, b) Anterior and posterior views of the uterus during application of the B-Lynch suture. (c) Anatomical appearance after competent application. (Illustrations courtesy of Mr P Wilson FMAA, AIMI).

References

 

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B-Lynch Suture Published Press Articles

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