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Christopher B-Lynch


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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

Abstract

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

Introduction
Postpartum hemorrhage (PPH) remains one of the major causes of maternal morbidity and mortality throughout the world (1). The key to management of PPH is early identification and treatment. In all
cases, primary management involves manual exploration of the uterus, suturing possible lacerations, fundal massage and the use of uterotonic agents such as oxytocin or/and prostaglandin analogues. In few cases, this primary management remains ineffective and other treatments are required.
Conservative management such as pelvic arterial embolization, stepwise uterine devascularization and/or hypogastric artery ligation have become reliable and effective alternatives to hemostatic hysterectomy (2_4). Although further long-term follow-up studies are required, these procedures do not appear to impair subsequent fertility and pregnancy outcomes (5_8). Embolization is preferably used if the hemorrhage occurs following vaginal delivery in a hemodynamically stable patient. In other cases, vessel ligation is preferred (8_10). In 1997, B-Lynch et al. reported the original so-called B-Lynch suturing technique as a new conservative treatment in PPH (11). This technique offers the advantages of simplicity of application, uterus-saving potential and its capacity for preserving the uterus and theoretically therefore the patient fertility. As the B-Lynch technique is a new procedure, little is known about its efficacy while only few cases have been reported in the literature (12). Moreover, results regarding fertility and pregnancy outcomes
for patients who have undergone B-Lynch suture for severe PPH remain very limited. In fact, these
uterus-preserving procedures may subsequently have hidden mid and long-term effects. Since
2002, cases of pyometra and ischemic necrosis of the uterus have been reported following Brace
compression suture and B-Lynch procedure (13_15).
Considering the potential effectiveness of the B-Lynch suture, this method was integrated in our
standard procedure for the management of PPH in 2003 (8). As our knowledge remains limited regarding
fertility and pregnancy outcomes, we decided to reserve this procedure only for cases of persistent
severe PPH following vessel ligation prior to considering hysterectomy. Thus, our algorithm for
management of PPH remained in accordance with the recommendations of the French College of
Obstetricians and Gynecologists (9).
The primary objective of this cohort study was to estimate the efficacy and safety of the B-Lynch
suture for severe persistent PPH following vessel ligation. The secondary objective was to estimate its
impact on menstruation and uterine cavity.

Material and methods
This study was approved by our Institutional Review Board. All patients who had B-Lynch suture for
severe persistent PPH following vessel ligation in our tertiary obstetric hospital, from July 2003 to
March 2007 were included in the study. Our policy management for PPH is shown in Figure 1 (8).
Blood transfusions were performed when there was clinical evidence of inadequate oxygen-carrying
capacity or of a hemoglobin concentration B70g/L, and fresh frozen plasma were transfused in the
presence of consumption coagulopathy and persistent bleeding. Vessel ligation routinely included a
stepwise uterine devascularization, i.e. a bilateral uterine artery ligation as described by O’Leary (16),
a bilateral uteroovarian ligament ligation, and in some cases bilateral hypogastric artery ligation for
the five practitioners who were familiar with this technique. All the B-Lynch sutures were performed
due to persistent PPH following vessel ligation and were considered as the last stage before performing
hemostatic hysterectomy

(Figure 1). The technique of the B-Lynch suture has been previously described


(11). The suture material used was absorbable  sutures (Vicryl 1/0, Ethicon, France, Neuilly-sur-
Seine, France). The following data were retrieved from the hospital records: parity, induction of labor,
indication for cesarean delivery, use of uterotonic drugs, blood transfusion, method of anesthesia,
additional surgical procedures, need for intensive care, postpartum complications. As this technique
was relatively new, data on subsequent fertility was very limited and there was theoretical concern about
the risk of subsequent synechiae, all patients that had a successful B-Lynch suture for PPH underwent
ambulatory hysteroscopy six months after the delivery.
No routine evaluation of the hormone status was performed. During December 2007, one of the
authors contacted all the patients in the cohort to determine the mid-term outcome of this procedure.
Patients were asked about resumption of menses, menstrual histories, pelvic pain and dyspareunia,
modification of sexual function and clinical symptoms of estrogen insufficiency such as hot flushes
and/or vaginal dryness. Patients were also asked about their desire for subsequent pregnancies, attempt
to conceive and results. Data about the progress and outcome of these subsequent pregnancies
were obtained from the medical records. Descriptive characteristics were calculated for the
variables of interest. All the data were evaluated with StatXact.4 (Cytel Software Corporation, Cambridge, MA).

Results

During the study period, 15 patients underwent BLynch suture by six practitioners for persistent
severe PPH following vessel ligation in 11,058 deliveries (one per 737). In two of the 15 cases
(13.3%), PPH followed vaginal deliveries. For those two cases, as the patient’s hemodynamics did not
permit to perform a pelvic artery embolization, a laparotomy was carried out to control the hemorrhage.
No suture was placed prophylactically. The perioperative details are shown in Table I. Induction
of labor was performed in seven cases (46.7%). The indication for cesarean section was a non-progression
of the first stage of labor in 10 out of the 13 cases (77%), and all but one of these 10 cases
concerned primiparous patients. B-Lynch sutures failed to control hemorrhage in three of 15 cases
(20%). In two of these three cases a hypogastric ligation was previously associated to stepwise uterine
devascularization. The postpartum period was uneventful for 14 out of 15 patients (93.3%). In one
case hysterectomy was required due to a persistent septic condition, despite a two-week course of
intravenous antibiotics, secondary to pyometra in a voluminous and ischemic uterus that occurred six
weeks following the delivery (15). In the remaining 11 patients where hysterectomy was not required,
ambulatory hysteroscopy was normal in each case.
In these 11 cases, all patients resumed menstruation after 5_17 weeks (mean 10 weeks) and considered
these menses comparable, in duration and quantity, to those before pregnancy. No patients reported
pelvic pain or dyspareunia, change in sexual function, or clinical symptoms of menopause, such as hot
flushes or vaginal dryness. One patient became pregnant with a conception delay Btwo months.
At the time of evaluation, the course of this ongoing pregnancy was uneventful. As regards the remaining
10 patients where uterus was preserved, all used contraception and none reported a subsequent
pregnancy (i.e. abortion, ectopic or full term pregnancy) or a desire for pregnancy due to, in each case,
the fear of PPH recurrence.
Discussion
This cohort study suggests that the B-Lynch technique is an effective procedure to control PPH
following failure of vessels ligation. The strength of this study was that in all cases, hysterectomy was the
next stage to achieve hemostasis. This was avoided in 80% of cases.
Since the first report by B-Lynch in 1997 (11), several isolated observations or limited case series
have been reported in the literature (12). They represent 46 cases with two failures. Nonetheless,
in these reports, the place of the B-Lynch procedure in the algorithm for the management of PPH widely
varied from one case to another. In fact, in these cases the B-Lynch procedure was performed prophylactically or following failure of uterotonic agents, intrauterine tamponade, vessel ligation or
other procedures such as hemostatic sutures (12).
Due to this heterogeneity and the small cohort, these studies have reported only limited data on the
effectiveness of the B-Lynch suture to control PPH. In order to limit bias and assess the outcome
of a homogenous population, we decided to perform the B-Lynch and not the Hayman suture in cases of
PPH following vaginal delivery although the Hayman suture, a modification of the B-Lynch suture
that presents the main advantage to avoid performing a lower segment hysterotomy, may be more
adequate after vaginal delivery (17,18).

Table I. Characteristics and follow-up of the patients who underwent a B-Lynch suture for severe persistent PPH following vessel ligation.

Patient number Maternal age Parity Pathologies
during pregnancy
Induction of labor Vaginal delivery Indication for cesarean
delivery or laparotomy
Cause of PPH Type of anesthesia Hypogastric ligation Immediate associated surgical procedures Estimated blood loss (ml) Transfusion Need for intensive care Complications in postpartum period
1 31 1 None Yes Yes PPH with patient hemodinamically non-stable Atony General Yes Hysterectomy 5,000 16 RCBU and 10 FFPU Yes None
2 25 1 None Yes No Dystocia Atony Regional then general Yes Hysterectomy 3,000 8 RCBU and 3 FFPU Yes None
3 27 3 IUFD at 24 w.a. Yes No Dystocia Atony Regional then general No Hysterectomy 4,500 18 RCBU and 6 FFU Yes None
4 29 2 Placenta previa No No Bleeding due to placenta previa Placenta previa General Yes No 3,000 7 RCBU and 3FFPU Yes None
5 29 1 None No No Dystocia Atony Regional then general Yes No 2,500 7 RCBU and 2 FFPU Yes None
6 19 1 None No No Dystocia Atony Regional No No 3,000 6 RCBU and 3 FFPU Yes None
7 29 1 None No No Dystocia Atony Regional then general No No 3,000 6 RCBU and 3 FFPU Yes None
8 33 2 Placenta previa No No Placenta previa Placenta previa General No No 2,000 4 RCBU and 2 FFPU Yes None
9 38 1 None No No Fetal heart rate abnormalities Atony Regional then general No No 1,700 3 RCBU and 1 FFPU Yes Pyometra in a ischemic uterusoccurring 6 weeks following
delivery andrequiring hysterectomy
10 28 1 None Yes No Dystocia Atony Regional then general No No 3,000 10 RCBU and 4 FFPU Yes None
11 24 1 Auto-immune thrombocytopenia No No Dystocia Atony General No No 2,000 3 RCBU and 1 FFPU Yes None
12 23 1 None No No Dystocia Atony Regional then general Yes No 3,000 5 RCBU and 2 FFPU Yes None
13 42 1 None Yes No Dystocia Atony Regional No No 2,000 3 RCBU and 1 FFPU No Pyelonephritis
requiring antiobiotherapy
14 38 2 TOP at 25 w.a. for severe fetal cardiopathy Yes Yes PPH with patient hemodinamically non-stable Atony Regional
then
general
No No 3,300 10 RCBU and 3 FFPU Yes None
15 36 1 Moderate
preeclampsia
Yes No Dystocia Atony Regionalthen general No No 2,000 6 RCBU and 3 FFPU Yes None

To our knowledge, there are only three other large series from a single hospital. Baskett recently reported
a case series of 28 patients (19). Although non-medical procedures to control PPH (i.e.
vessels ligation, uterine artery embolization, uterine 1022 L. Sentilhes et al. packing) was performed in only six out of 28, the B-Lynch procedure was performed in each case prior to considering hysterectomy. This was avoided in 82% of cases (19). Wohlmuth et al. reported in a 22 case series, where the B-Lynch procedure was performed alone or in combination with vessel ligation, a uterine preservation rate of 77% (20).
Finally, Allahdin et al. reported 11 cases, where hemostasis was achieved in eight patients with the
B-Lynch suture, while three (28%) required hysterectomy (21). These three case series in addition to
our study document a total of 76 cases with avoidance of hysterectomy in 60 (79%) (19_21).
According to Price and B-Lynch, the possible causes of B-Lynch suture failure are a lack of tightness,
improper suture application or delay in application (12). As regards our case one (Table I) delay in
application may be a plausible cause as B-lynch suture was only carried out at a late stage as the
patient had a severe disseminated intravascular coagulopathy with persistent bleeding.
As the possible effects on menstruation, ovarian function, uterine cavity and fertility of this recent
procedure were unknown, the B-Lynch suture was performed only in cases of persistent hemorrhage
following vessel ligation prior to considering hemostatic hysterectomy. To our knowledge, this is the
first cohort study to assess, with the exception of the fertility, these factors. In all the cases where the
uterus was preserved, menses resumed soon after procedure. No women reported any differences in
menses or pain compared with their condition before the pregnancy, or any clinical symptoms of early
menopause. Ambulatory hysteroscopy was normal in each case, in particular no synechia was observed.
This is consistent with the limited data reported in the literature. In fact, both magnetic resonance
imaging and hysterosalpingography were performed in one patient following the B-Lynch procedure. No
uterine cavity defects and patent fallopian tubes were observed (22). Furthermore, Baskett observed a
previous B-Lynch procedure during direct visualization of the uterus at the time of subsequent elective
cesarean sections in seven cases (19). This author reported, in a first case, a thin fibrous band between
the anterior and posterior wall of the uterine cavity in the lower uterine segment, and in three cases the
possible marks of a previous B-Lynch procedure, i.e. fundal grooves, that did not interfere with the
pregnancy (19). In the remaining three cases and in four published reports, no complication or marks
of the previous B-Lynch procedure was observed (11,19,23,24). Thus, the initial fears regarding
possible anatomical damage due to extreme uterine compression have not to date materialized.
In our series, only one ongoing subsequent pregnancy following B-Lynch suture was reported.
This may be related to a too narrow period between the beginning and the end of the study. Also the
patients, even the primipara, were too reluctant to experience a PPH recurrence and take the risk of a
subsequent pregnancy. A total of only 13 pregnancies following B-Lynch suture have been reported in
the literature (11,19,23_26). All patients but one were delivered by elective cesarean section and all
gave birth to healthy and eutrophic infants. Twelve pregnancies were uneventful. One was complicated
due to preeclampsia, in a patient with a previous history of preeclampsia, and PPH which required a
hemostatic hysterectomy (26). Although these cases are reassuring, there still remains insufficient data in
our opinion to widely recommend the B-Lynch suture in the first-line surgical treatment of PPH.
Nevertheless, subsequent pregnancies following massive PPH are rare, as many women do not
want to repeat the experience of severe trauma (5_8).
The prevalence of the complications following the B-Lynch suture has seemed to increase in relation to
the number of procedures performed (13_15,27). In this cohort series, one patient developed a septic
condition secondary to pyometra in an ischemic uterus which required a hysterectomy six weeks after
the delivery (15). Other authors have reported uterine necrosis or pyometra following B-Lynch
suture where all but one patient required subsequent hysterectomy (13,14,27). Although the direct responsibility of the B-Lynch procedure in these complications is difficult to prove (28), these occurrences
underline that it is essential to collect data on the patient population before adopting this procedure
as the first-line surgical treatment of PPH.
Acknowledgements
The authors are grateful to Richard Medeiros, Rouen University Hospital Medical Editor, for his valuable editorial assistance.

References
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