B-Lynch Suture For Massive Persistent Postpartum Hemorrhage Following Stepwise Uterine Devascularization
B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization
LOI¨C SENTILHES1,2, ALEXIS GROMEZ1, KAI¨S RAZZOUK1, BENOIˆT RESCH1, ERIC VERSPYCK1 & LOI¨C MARPEAU1
1Department of Obstetrics and Gynecology, Rouen University Hospital, Charles Nicolle, Rouen, France, and 2Department of
Obstetrics and Gynecology, Angers University Hospital, Angers, France
Objective. To estimate the effectiveness and safety of the B-Lynch suture for severe persistent postpartum hemorrhage (PPH) following vessel ligation before considering hysterectomy and its impact on menstruation and uterine cavity. Design. Cohort study. Setting. University-affiliated tertiary referral center. Population. Fifteen consecutive women who underwent B-Lynch suture for persistent PPH despite vessel ligation. Methods. Data were retrieved from medical files and telephone interviews. Main outcome measure(s). Hysterectomy, infection, hysteroscopy, future menstruations. Results. In 13 of the 15 cases (86.7%), PPH occurred after cesarean deliveries. B-Lynch sutures controlled the hemorrhage and resulted in an avoidance of immediate hysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for 14 of 15 women (93.3%). In one case hysterectomy was required due to pyometra in an ischemic uterus. In the remaining 11 women where the uterus was preserved, ambulatory hysteroscopy was normal. No women reported any differences in menses or pain compared to that they experienced before pregnancy, or any clinical symptoms of early menopause. One woman reported a subsequent pregnancy with normal conception delay, whereas the ten remaining women had no desired pregnancy due to, in each case, the fear of PPH recurrence. Conclusions. B-Lynch technique appears to be an effective procedure with a relatively low morbidity to control persistent severe PPH following a failure of vessel ligation before considering hysterectomy.
Key words: Postpartum hemorrhage, B-Lynch suture, vessel ligation, hysteroscopy, fertility
Uterine Compression Sutures For Postpartum Hemorrhage – Efficacy, Morbidity, And Subsequent Pregnancy
Uterine Compression Sutures for Postpartum Hemorrhage – Efficacy, Morbidity, and Subsequent Pregnancy
Thomas F. Baskett, MB
From the Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.
OBJECTIVE: To review the efficacy, morbidity, and subsequent pregnancy outcome after uterine compression sutures for severe postpartum hemorrhage.
METHODS: A 7-year review (2000–2006) of all uterine compression sutures for postpartum hemorrhage at one tertiary obstetric hospital.
RESULTS: During the 7 years, 28 uterine compression sutures were performed in 31,519 deliveries (1 per 1,126). All were done at the time of cesarean delivery: 22 in 4,870 cesarean deliveries in labor (1 in 221) and 6 in 3,819 elective cesarean deliveries (1 in 637). The indications for suture were atonic postpartum hemorrhage in 25 of 28 (89%), placenta previa in 2 of 28 (7%), and partial placenta accreta in 1 of 28 (4%). Hysterectomy was avoided in 23 of 28 women (82%). Blood transfusion was needed in 13 of 28 (46%), and intensive care in 5 of 28 (18%). Seven women had subsequent uncomplicated term pregnancies, all delivered by elective repeat caesarean delivery.
CONCLUSION: Uterine compression sutures for severe postpartum hemorrhage may obviate the need for hysterectomy and appear not to jeopardize subsequent pregnancy.
LEVEL OF EVIDENCE: III
Too many wombs are removed needlessly, a leading obstetrician says
It was 2am, and Professor Christopher Balogun-Lynch had been called to Milton Keynes General Hospital to deal with a mother bleeding uncontrollably after childbirth. The patient was unconscious, and unable to sign a consent form for hysterectomy.
While getting prepared for theatre, Professor Lynch, as […]
Fetal and Maternal Medicine Review (2006), 17: 105-123 Cambridge University Press
Copyright © 2006 Cambridge University Press
Published online by Cambridge University Press 28 Jul 2006
CHRISTOPHER BALOGUN-LYNCH and NAOMI WHITELAW
a1 Department of Obstetrics and Gynaecology, Milton Keynes Hospital NHS Trust, Milton Keynes, United Kingdom.
The historical background of post partum haemorrhage (PPH) dates back to the 17th century. William Smelley published his famous treatise of the theory and practice of midwifery in 1752. His observations sent a clear message to practitioners of the time that haemorrhage in midwifery can be a messenger of death.
Christopher B-Lynch, Department of Obstetrics and Gynaecology, Milton Keynes Hospital NHS Trust, Standing Way, Eaglestone, Milton Keynes MK6 5LD United Kingdom
Gillian Penney: SPCERH Director
Lorraine Adamson: Administrator
Dawn Kernaghan: Research Fellow
Background and methods
1. During 2004, SPCERH and the Scottish Assessors for the Confidential Enquiry into Maternal Deaths identified and assessed cases of severe maternal morbidity throughout Scotland.
2. Fourteen categories of severe maternal morbidity were defined – representing women who were very ill and whose lives were threatened. Clinical risk management leads in each consultant-led maternity unit reported all women meting the inclusion criteria to SPCERH on a monthly basis.
3. The number of consultant-led maternity units in Scotland fell from 22 in 2003 to 17 by the end of 2004 (due to amalgamation or re-classification). Completed monthly returns were received for all 216 possible unit/months (100%).
Rates of events
4. During 2004, 246 women met one or more of our definitions, giving a Scottish rate of severe morbidity of 4.7% (95% CI, 4.2-5.4) per 1000 births (based on a denominator of 51,803 live births in the year to March 2004). The 2003 Scottish rate was 5.4 (4.8-6.1) per 1000 births. Rates in individual units in 2004 ranged from 0.8 (0.0-4.5) to 11.5 (8.4-15.3) per 1000 births. Differences between units are likely to reflect differences in case mix, population and case ascertainment, as well as differences in quality of care.
5. Major obstetric haemorrhage was the commonest category of morbidity, occurring in 171 women; Scottish rate, 3.2 (2.8-3.8) per 1000 births. The 2003 Scottish rate was 3.5 (3.0-4.1) per 1000 births.
6. Rates of: eclampsia, 0.3 (0.1-0.5); pulmonary oedema/respiratory dysfunction, 0.6 (0.4-1.0); renal/liver dysfunction, 0.2 (0.1-0.4); intensive care admission, 1.5 (1.2-1.9) per 1000 births. Other categories of even occurred more rarely.
7. During 2004, there were eight direct or indirect maternal deaths related to the categories covered by the Scottish Confidential Audit of Severe Maternal Morbidity; giving a ‘near miss:death ratio’ of 30:1. in 2003, there were four direct/indirect maternal deaths and a ‘near miss:death ratio’ of 67:1. (Inevitably, small numbers mean that these estimates are imprecise.)
Quality of care
8. Unit risk management teams assessed cases of major obstetric haemorrhage using a structured proforma. Case definition: Estimated blood loss >= 2500ml, or transfused 5 or more units of blood or received treatment for coagulopathy (fresh frozen plasma, cryoprecipitate, platelets).
9. Assessments were completed for 156 of 171 notified cases (91%). Mean estimated blood loss, 3.9 litres (range 1.0-15 litres); mean volume of blood transfused, 5 units (range 0-28 units).
10. Hysterectomy was undertaken in 21 women; a rate of 13%
among women with major obstetric haemorrhage and 0.41 per 1000 births. In 2003, hysterectomy was undertaken in 15% of women with major obstetric haemorrhage and 0.46 per 1000 births.
11. In general, cases were well-managed. Aspects of care which
measured up well against national guideline recommendations include:
• 95% received prophylactic oxytocics in the third stage of labour (compared with 90% in 2003).
• 97% had intravenous access and 89% had clear documentation of the use of two large bore cannulae (compared with 80% in 2003).
• Few women (6%) were infused more than 3.5 litres of clear fluid before receiving blood (compared with 9% in 2003).
• Basic monitoring was good with very frequent measurement of pulse, blood pressure and urine output in over 95% of women (compared with 90% in 2003).
• A consultant obstetrician was present, or immediately available, in 18/20 (90%) caesarean sections for placenta praevia (compared with 77% in 2003).
Aspects of care where there is scope for action planning and improvement include:
• A consultant obstetrician was present during the acute management of only 68% of all women with major haemorrhage (compared with 76% in 2003).
• A consultant anaesthetist was present, and a haematologist involved, in little over 50% of all cases.
• Central venous pressure (CVP) lines were inserted in 32% of cases. There were 17 women with estimated blood loss in excess of 4 litres where no CVP line was used.
• Discussion of transfer to an intensive therapy unit (ITU) was documented in 33% of cases. There were 12 women with estimated blood loss in excess of 4 litres who were not admitted to ITU.
12. No long-standing, general systems errors were identified.
Errors specific to the individual case were also uncommon; avoidable delay in diagnosis/treatment was identified in 14.4% and failure to follow protocol/plan in 11.6%.
13. Risk management teams graded the extent of sub-optimal
care using a scheme similar to that employed within the Confidential Enquiry into Maternal Deaths:
• 60% of cases were judged as ‘appropriate care, well managed’.
• 6% as ‘sub-optimal case – incidental – lessons can be learnt although it did not affect the final outcome’.
• 12% as ‘sub-optimal care – minor – different management may have resulted in a different outcome’.
• and only 2% as ‘sub-optimal care – major – the management of this case contributed significantly to the near-miss morbidity of this patient’.
14. Unit risk management teams also assessed 14 to 17
notified cases of eclampsia.
• Few women presented with the classic constellation of symptoms and signs of fulminating pre-eclampsia prior to fitting. Furthermore, hypertension and proteinuria were absent, or only moderately elevated, in most cases.
• A senior midwife, consultant obstetrician, and consultant anaesthetist were present during the acute management of only three of the 14 cases assessed.
• Magnesium sulphate was used as the first-line anticonvulsant in the majority of cases. However, two women received diazepam alone.
• After the fit, women were well managed with frequent monitoring of vital signs and fluid balance and universal use of magnesium sulphate for prophylaxis against further fits.
15. Risk management teams graded the extent of sub-optimal
care for 13 cases: eight were judged as ‘appropriate care’, two as ‘incidental sub-optimal’, one as minor sub-optimal’, and two as ‘major sub-optimal’.
Learning points and action plans
16. Risk management teams recorded learning points and
explicit local action plans in relation to most cases of both haemorrhage an eclampsia.
17. Lessons relevant to the national context have been drawn
from recurrent themes and important, though rare, instances. These include:
• Involve senior midwifery and medical staff early.
• Improve documentation.
• Assess blood loss, and degree of urgency, accurately
• Identify high-risk women and plan ahead for the involvement of other disciplines, eg radiology.
Local action plans were documented in 72 cases. Among the recurring themes were:
• Provide feedback to wider staff through a newsletter or meeting.
• Review content of local protocol.
• Review the use and implementation of existing protocols.
• Discussion/debriefing with individual staff.
• Review resources and prepare a business case (eg for access to interventional radiology).
• Institute practical training sessions.
• Positive feedback to the individuals concerned.
Gynaecology case reports
Kathryn Hillaby, Jill Ablett and Linda Cardozo
A 24-year-old Asian primagravida with a 13-week history of amenorrhoea presented to our early pregnancy assessment unit with a 4-day history of light vaginal bleeding and mild ‘crampy’ abdominal pains.
Transvaginal ultrasound revealed a fetus with a biparietal diameter of 20.2 mm, but no fetal heart activity was visualised. The fetus displayed features of maceration, Spalding’s sign was noted and the gestational sac was described as collapsed. A diagnosis of intrauterine death at around 13 week’s gestation was therefore made.
A Worldwide Review Of The Uses Of The Uterine Compression Suture Techniques As Alternative To Hysterectomy In The Management Of Severe Post-Psrtum Harmorrhage.
Journal of Obstetrics and Gynaecology Volume 25 Number 2 February 2005
E El-Hamamy & C B-Lynch
Postpartum haemorrhage (PPH) is a worldwide problem. The historical background dates back to William Smelley’s in the seventeenth century in his famous treaty of the theory and practice of midwifery in 1752. Changes in clinical factors and surgical expertise compel the modern day midwife and obstetrician to be vigilant in identifying risk factors and apply appropriate solution early. The recent confidential enquiry into maternal death (why mothers die (2000-2002)) identifies areas of substandard care. The rising caesarean section rate adds to the rising incidence of PPH. The reduction in junior doctor’s hours may limit the pool of experienced obstetric surgeons available to manage severe PPH competently. There can be major complications following radical surgery for PPH. These include loss of fertility, other morbidity and even maternal death.
The invention of the B-Lynch surgical technique for the conservative management of PPH was first performed and reported by a consultant obstetrician and gynaecological surgeon in Milton Keynes NHS Trust publishing the first series of now over 1300 successful applications of the technique worldwide (CB-Lynch personal communication). Other similar or modified techniques such as Cho’s Square Suture and Haymen’s modification of the B-Lynch Suture Technique have been introduced adding to more available methods of conservative surgery.
The current list of publications of successful applications of the B-Lynch compression technique is encouraging and more outcome data can be reported by a letter or e-mail to email@example.com . Obstetricians and midwives both in developed and underdeveloped countries should seek training and attend fire drills in PPH control to avoid maternal morbidity and death. There should be special concentration on effective conservative surgery such as uterine compression techniques to avoid major morbidity and loss of fertility.
Journal of Maternal-Fetal Medicine 9: 194-196 (2000)
John V Dacus, Mary T Busowski, John D Busowski, Stacy Smithson, Kimberly Masters and Baha M Sibai
Abstract: Postpartum hemorrhage remains a major cause of maternal morbidity and mortality. Four cases utilizing the B-Lynch technique for control of hemorrhage secondary to uterine atony are presented. The B-Lynch technique appears to be effective in controlling postpartum hemorrhage. More experience is needed before the B-Lynch technique can be accepted as routine practice.
Long Term Anatomical And Clinical Observations Of The Effect Of The B-Lynch Uterine Compression Suture For The Management Of Massive Post Partum Haemorrhage Ten Years On.
IntJ Fertil Med 2006 Nov- Dec
Department of Obstetrics and Gynaecology
Milton Keynes General Hospital
Abstract of case report
The B-Lynch surgical technique for the management of massive post partum haemorrhage (PPH) has been successfully used since 1989 where bleeding was due to uterine atony with failed conservative management. It allows for conservation of the uterus with subsequent future pregnancies. The application of the suture itself is away from the uterine cornua without major vessel or organ compromise. The procedure is far less complicated than more radical surgical techniques such as internal iliac arterial ligation or hysterectomy. The operating time is shorter as the procedure is fast and easy. In this report we present a follow up of a case with successful pregnancy ten years after PPH with the B-Lynch uterine compression suture to demonstrate no long term anatomical or clinical complications of this surgical technique ten years on.
Journal of the College of Physicians and Surgeons of Pakistan Vol. 13 No. 01 (January, 2003) pp: 51-52
Syeda Batool Mazhar, Shagufta Yasmin and Shamsa Gulzar
Department of Obstetrics & Gynaecology
Mother and Child Health Centre, PIMS
Two cases of intractable postpartum hemorrhage managed by the B-Lynch Brace suture, a new technique for control of massive postpartum hemorrhage, are presented. Because of its simplicity and capability of preserving uterus, this procedure may be considered as the first line surgical treatment before considering hysterectomy.
Why Mothers Die 2000-2002: Report On Confidential Enquiries Into Maternal Deaths In The United Kingdom. CEMACH
Among the eight women who sought care, there were elements of substandard care in seven. Most aspects of substandard care have been discussed earlier in this chapter, but one further point deserves discussion.
Recent changes in medical training may be relevant to the increased numbers of deaths from haemorrhage. Reduction in overall length of obstetric training and in working hours during training may have reduced the amount of experience gained. There is also a trend towards subspecialisation among consultants and thos with a special interest in obstetrics do not necessarily have highly developed surgical skills. The information available to the Enquiry does not permit any firm conclusion as to whether these factors contributed to the recent change in death rates. If they did contribute, this would strengthen the recommendation for regular ‘fire drills’ or ‘skills drills’ for management of obstetric emergencies, including major haemorrhage, for all grades of staff in every unit.
Obstetric haemorrhage: learning points
• Catastrophic haemorrhage is a persisting problem.
• All of the women who dies with placenta praevia had previous caesarean sections.
• Women at high risk of haemorrhage are still delivering in isolated or units ill-equipped to sudden, life-threatening emergencies. These units may be without immediate access to specialist consultant care, blood products or intensive care.
• Women who decline blood products should be treated with respect and a management plan in case of haemorrhage agreed with them before delivery is anticipated.
• During this triennium, two women who concealed their pregnancies for fear that their babies might be taken into care died of postpartum haemorrhage at home.
• Obstetric care was considered to be substandard in 12 out of 15 (80%) of cases where the woman had sought treatment; anaesthetic care was considered to be substandard for five (see Chapter 9).
• No deaths were reported in women who had had interventional radiology or B-Lynch suture.
Application Of The B-Lynch Brace Suture With Associated Intrauterine Balloon Catheter For Massive Haemorrhage Due To Placenta Accreta Following A Second-Trimester Miscarriage
N. PRICE1, N. WHITELAW2, & C. B-LYNCH2
Department of Obstetrics and Gynaecology,
1John Radcliffe Hospital, Oxford and
2Milton Keynes General Hospital, Milton Keynes, UK
A 25-year-old woman was in her fifth pregnancy. Previously, she had had two normal vaginal deliveries at term, although her second pregnancy was complicated by secondary postpartum haemorrhage, which was managed by uterine curettage with antibiotic cover. Subsequently she developed Asherman’s syndrome, which was treated by Nd:YAG-laser ablation and IUD insertion. Following this, she had two miscarriages at 7 and 20 weeks, which required uterine curettage.
In her current pregnancy, she was admitted to hospital at 19 weeks’ gestation with spontaneous rupture of membranes. This was confirmed on examination and an ultrasound scan showed anhydramnios. The poor prognosis was discussed with her and a conservative management approach agreed. Five days later she became pyrexial. Her C-reactive protein level rose to 92.2 mg/l. Chorioamnionitis was diagnosed. Intravenous infusion of cefuroxime and metronidazole at 8-hourly intervals was commenced and it was decided with her consent to terminate the pregnancy. The woman was given a single dose of mifepristone, followed by five doses of misoprostol at 3-hourly intervals. Cervical dilatation of only 1 cm was achieved. She was treated with an infusion of 10 IU Syntocinon in 500 ml of 0.9% NaCl for 12 h but the fetus remained undelivered. She had a spiking temperature but was otherwise clinically stable. Although her C-reactive protein level had risen to 172 mg/l, other blood tests were normal, with haemoglobin at 12 g/ dl; white cell count 8.36109/l; platelets 1536109/l; and normal coagulation. Intravenous gentamicin was added to the treatment. A further three doses of 800 mg misoprostol were given vaginally at 3-hourly intervals, followed by a further infusion of Syntocinon. Finally, a lifeless fetus was delivered more than 72 h after commencing the termination of pregnancy. However, the placenta still remained undelivered. In view of the woman’s previous history of Asherman’s syndrome, the risk of amorbidly adherent placenta was considered to be high and conservative management was planned. However, vaginal bleeding started 1 h after delivery. The woman was moved to theatre, where the placenta was removed in piecemeal fashion but not in its entirety and the bleeding continued. Laparotomy was then performed, the uterus opened and the remaining adherent placental tissue removed. The woman was resuscitated with intravenous fluids and given an infusion of Syntocinon, ergometrine and five doses of carboprost, but the bleeding rapidly become worse despite the above measures. At this stage, the total blood loss had exceeded 4,000 ml and was complicated by disseminated intravascular coagulation. At this time, her haemoglobin level was 4.1 g/dl, platelets 486109/l; activated partial thromboplastin time 54 s; activated partial thromboplastin ratio 2.07; prothrombin time 16.8 s; and fibrinogen 1.04 g/l. A transfusion of six units of blood and four units of fresh frozen plasma was given. However, diffuse bleeding continued as a result of both placenta accreta extending to the isthmus and the coagulopathy. A B-Lynch suture was applied, using a Monocryl suture on a 70 mm blunt curved Ethiguard needle, following a positive test for the potential success of this procedure, (i.e. uterus exteriorisation, bimanual compression, bleeding control). A 30 ml Foley catheter balloon was placed at the isthmus of the uterine cavity. The patient was nursed in the intensive care unit, where she received a further four units of blood. The intrauterine balloon was removed 40 h post-laparotomy and no significant bleeding was observed. The patient made a good recovery and was discharged 6 days later.
Application Of The B-Lynch Brace Suture With Associated Intrauterine Balloon Catheter For Massive Haemorrhage Due To Placenta Accreta Following A Second-Trimester Miscarriage
Authors: N. Price a; N. Whitelaw b; C. B-Lynch b
Affiliations: a Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford
b Milton Keynes General Hospital, Milton Keynes, UK
Publication Frequency: 8 issues per year
Published in: Journal of Obstetrics and Gynaecology, Volume 26, Issue 3 April 2006 , pages 267 – 268
Subject: Obstetrics, Gynecology & Women’s Health;
Andrei Rebarber, Ashley Roman.
Cover Story: Seven ways to control postpartum hemorrhage. Contemporary Ob/Gyn 2003;3:34-53
Although you can’t always anticipate a potentially catastrophic obstetric hemorrhage, rapid diagnosis and intervention can make all the difference in the world. The authors review interventions—new and old—and tell clinicians what to have on hand to implement them.
Massive uncontrolled hemorrhage after childbirth is the leading cause of pregnancy-related death in the United States and one of the most common causes of maternal death. 1 Even though infant mortality has steadily declined since 1982, thanks to modern advances in neonatal intensive care unit technology, maternal mortality in the US has not improved for two decades—holding steady at 7.7 deaths per 100,000 live births between 1982 and 1996. 2 Of 1,459 reported pregnancy-related deaths between 1987 and 1990, hemorrhage accounted for about three out of every 10 (29%). 3 Moreover, obstetric hemorrhage can cause shock, renal failure, and Sheehan’s syndrome (postpartum pituitary necrosis); if the bleeding cannot be stopped in time, hysterectomy is often necessary.
Postpartum hemorrhage (PPH) is traditionally defined as a blood loss of more than 500 mL after vaginal delivery and more than 1,000 mL after cesarean delivery, but intraoperative estimations of blood loss are notoriously inaccurate. Thus, the American College of Obstetricians and Gynecologists defines it as a decrease in hematocrit of more than 10% from before to after delivery. 4
Although PPH cannot always be anticipated, the cornerstones of effective treatment remain rapid diagnosis and intervention. Our goal here is to review new interventions—and revisit some old ones—that can assist in controlling acute hemorrhage.
The B-Lynch technique for postpartum haemorrhage: an option for every gynaecologist
Hilda HoltsemaCorresponding Author Contact Information, E-mail The Corresponding Author, a, b, Roel Nijlanda, b, Aad Huismanb, Julien Donya and Paul P. van den Berga
a Department of Obstetrics and Gynaecology, University Medical Centre St. Radboud, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
b Department of Obstetrics and Gynaecology, Rijnstate Hospital, Arnhem, The Netherlands
Received 25 October 2002; Revised 15 August 2003; accepted 24 September 2003. Available online 28 May 2004.
Postpartum haemorrhage may be a life threatening complication. Seven cases are described in which the B-Lynch surgical technique (a brace like suture over the uterus) was successful in obtaining haemostasis. In four cases, the B-Lynch technique was the first line of treatment. In three cases, the B-Lynch was used after, or in combination with artery or other vessel ligation.
Author Keywords: B-Lynch; Postpartum haemorrhage; Uterine atony
J.E Ferguson II, MD, F John Bourgeois, MD and Paul B. Underwood Jr, MD
University of Virginia school of medicine, Charlottesville Virginia
Obstetrics & Gynecology (June 2000, Vol 95, No.6 part 2)
Postpartum hemorrhage is a major contributor to maternal morbidity and mortality. Numerous medical and surgical therapies have been used, but none has been uniformly successful.
Technical Description Of The B-Lynch Brace Suture For Treatment Of Massive Postpartum Hemorrhage And Review Of Published Cases
Natalia Price MD
Christopher B-Lynch MA (Oxon), FRCS, FRCOG
Int J Fertil Womens Med. 2005 Jul-Aug;50(4):148-63.
Massive uncontrolled hemorrhage after childbirth is a leading cause of the pregnancy-related death and resulting morbidity. Uterine atony is the most common cause (75-90%) of primary postpartum hemorrhage. When simple massage of the uterus and uteronics such as oxytocsins, syntometrine and prostaglandins failed to manage this condition, various surgical solutions have been sought, including uterine artery ligation, more complicated stepwise devascularization of the uterus, internal iliac artery ligation and ultimately, hysterectomy. All these procedures require above average surgical skill. In contrast, the B-Lynch suturing technique (brace suture) is particularly useful because of its simplicity of application, life-saving potential, relative safety and capacity for preserving the uterus and subsequent fertility. The adequacy of haemostasis can be assessed both before and immediately after application of the suture. Only if it fails need other more radical surgical methods be considered. The special advantage of this innovative technique is that it presents an alternative to major surgical procedures for controlling pelvic arterial pulse pressure or hysterectomy. To date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications. This review provides an update on the B-Lynch brace suturing technique, including the choice of suturing material, use of the technique in early and late gestation, and comparison with other uterine compression surgical techniques. It also includes a comprehensive review and analysis of all published cases and their postoperative follow-up.
M.S. Allam, and C. B-Lynch
International Journal of Gynecology & Obstetrics – Volume 89, Issue 3 , June 2005, Pages 236-241
Department of Obstetrics and Gynaecology, South Glasgow University Hospitals, Glasgow, UK
Department of Obstetrics and Gynaecology, Milton Keynes General Hospital, Oxford Deanery, UK
Received 5 January 2005; revised 28 January 2005; accepted 4 February 2005. Available online 19 April 2005.
Postpartum hemorrhage (PPH) remains among the 5 main causes of maternal death in developing and developed countries, and uterine atony is the most common cause (75–90%) of primary PPH. Uterine compression sutures running through the full thickness of both uterine walls (posterior as well as anterior) have recently been described for surgical management of atonic PPH. Christopher B-Lynch was the first to highlight this revolutionary principle, and other uterine compression suture techniques have since been described by Hayman and Cho.
Step-by-step description of the B-Lynch brace suture and discussion of the current compression suture techniques.
The different uterine suture techniques have proved to be valuable and safe alternatives to hysterectomy in the control of massive PPH, and the present review can make the surgeon better aware of their effective use and the risks they may entail.
Keywords: B-Lynch; Uterine compression sutures
Cibba Toy Wohlmuth MD
Joslyn Gumbs MD
Jocelyn Quebral-Ivie MD
White Memorial Medical Center
Department of Obstetrics and Gynecology
Los Angeles, California
Objective – To report on an 8-year institutional experience in the use of the B-Lynch Suture for the management of postpartum hemorrhage (PPH). Study Design – Cases with B-Lynch suture utilization for severe PPH were identified from March 1997 to March 2005, at White Memorial Medical Center. Case charts were reviewed, and postoperative follow-up after hospital discharge was conducted by telephone interview and outpatient clinic chart review. Historical characteristics and outcome of these patients are described. Results – B-Lynch suture was performed on 22 patients, between March 1997 and March 2005, to control intractable PPH at cesarean section that did not respond to uterotonics agents. In 12 instances, the B-Lynch suture was the only intervention, whereas in 10 it was combined with vessel ligation. The procedure resulted in control of bleeding with uterine preservation in 77% of the cases. In those cases where the etiology of PPH was uterine atony, the B-Lynch suture was successful in 85% of the cases. Hysterectomy was avoided in 17/22 cases. Conclusion – The B-Lynch suture is an alternative surgical procedure for uterine preservation that may be used to control PPH from uterine atony. Int J Fertil 50(4): 164-173, 2005
A Worldwide Review Of The Uses Of The Uterine Compression Suture Techniques As Alternative To Hysterectomy In The Management Of Severe Post-Partum Haemorrhage
Authors: E. El-Hamamy a; C. B-Lynch b
Affiliations: a St George’s Hospital Medical School, London, UK
b Milton Keynes General Hospital, Milton Keynes, UK
Publication Frequency: 8 issues per year
Published in: Journal of Obstetrics and Gynaecology, Volume 25, Issue 2 February 2005 , pages 143 – 149
Subject: Obstetrics, Gynecology & Women’s Health;
Number of References: 30
Formats available: HTML […]
Kathmandu University Medical Journal (2003) Vol. 2, No. 2, Issue 6, 149-151
B-Lynch Brace suture for conservative surgical management forplacenta increta.
Chaudhary P 1,
Sharma S 2,
Yadav R 3, Dhaubhadel P 4
2 Senior Consultant,
3 Registrar, Maternity Hospital, Thapathali.
4 Post Graduate Resident, National Academy of Medical Sciences
Placenta accreta is defined as “an abnormal adherence, either in whole or in part, of the afterbirth to the underlying uterine wall”. Placenta increta occurs when the placenta invades deeply into the myometrium.
1. Placenta increta is a life threatening condition. We report a case of placenta increta managed by unilateral uterine artery and ovarian artery ligation followed by B- Lynch Brace suturing of the uterus to control bleeding from the placental bed.
Key words: Placenta increta, PPH, B-Lynch suture
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