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Christopher B-Lynch


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B-Lynch Sutures: A Case Series

Cibba Toy Wohlmuth MD
Joslyn Gumbs MD
Jocelyn Quebral-Ivie MD
White Memorial Medical Center
Department of Obstetrics and Gynecology
Los Angeles, California
ABSTRACT
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
INTRODUCTION
Postpartum Hemorrhage (PPH) remains a significant risk to reproductive health, accounting for 30% of pregnancy-related deaths worldwide [1]. Life-threatening PPH may result from hemorrhage of uterine origin, including the conditions of uterine atony and placenta accreta, increta, and percreta. Other diagnoses include uterine rupture and inversion. Uterine atony remains a leading source of PPH and is responsible for 60-70% of cases.
In addition to hemodynamic stabilization, management options for uterine bleeding include bimanual uterine compression, medical therapy with uterotonics agents [2], uterine artery ligation [3], ovarian vessel ligation [4], hypogastric artery ligation [5], uterine packing [6], angiographic selective artery embolisation [7], and intrauterine balloon tamponade [8, 9]. In cases of intractable hemorrhage, despite the use of conservative measures, the surgeon often must resort to hysterectomy in order to avert an untimely mortality [10]. In 1997, Christopher B-Lynch introduced the B-Lynch technique as an alternative surgical management for PPH of uterine origin [11]. This technique is a uterine compression suture utilizing a continuous suture over sewing the fundus with two loops medial to each cornual border. B-Lynch et al [11] described the procedure as follows:
“…The abdomen is opened by an appropriate sized Pfannenstiel incision or if the patient had had cesarean section following which she bled, the same incision is re-opened…
…bimanual compression is first tried to assess he potential chance of success of the B-Lynch suturing technique…
…a 70 mm round bodied hand needle on which a No. 2 chromic catgut suture is mounted is used to puncture the uterus 3 cm from the right lower edge of the uterine incision and 3 cm from the right lateral border. The mounted No. 2 catgut is threaded through the uterine cavity to emerge at the upper incision margin 3 cm above and approximately 4 cm from the lateral border…The chromic catgut, now visible, is passed over to compress the uterine fundus, approximately 3-4 cm from the cornual border. The catgut is fed posteriorly and vertically to enter the posterior wall of the uterus cavity at the same level as the upper anterior entry point…The length of the catgut is passed back posteriorly through the same surface marking as for the right side, the suture lying horizontally. The catgut is fed through posteriorly and vertically over the fundus to lie anteriorly and vertically, compressing the funds…
The needle is passed in the same fashion on the left side and out approximately 3 cm anteriorly and below the lower incision margin on the left side. The two lengths of catgut are pulled taught, assisted by bi-manual compression to minimize trauma and to achieve and aid compression…the principal surgeon throws a knot…The lower transverse uterine incision is now closed in the normal way…”
Figures 1(a) and 1 (b) illustrate the approximate landmark dimensions for B-Lynch suture placement. Figure 1(c) illustrates uterine compression after the B-Lynch suture is tied.
Since the introduction of B-Lynch surgical technique, several case reports and small case series, ranging from one to seven cases, have been published [12-25].
This study presents the experience with the B-Lynch technique in 22 cases encountered between March 1997 and March 2005 at White Memorial Medical Center
MATERIALS AND METHODS
A retrospective review of delivery records at White Memorial Medical Center, from March 1997 to March 2005 was conducted. Deliveries withs diagnosis “hemorrhage” were identified using the Labor & Delivery log and a search request at the Department of Medical Records. From the 25,826 deliveries, 22 cases were identified where the delivering physician chose B-Lynch suture for PPH at cesarean section. Charts were surveyed for representative historical characteristics, and for intraoperative and postoperative clinical details. Long-term follow-up and hospital discharge was performed using outpatient clinical chart review and telephone interview. The postoperative questionnaire included questions regarding postprocedure menstrual history, reproduction, and contraception. The review process and study design received Institutional Review Board approval.
RESULTS
Twenty-two cases of B-Lynch procedure were identified. The patients’ ages ranged from 16 to 40 years, with a mean of 26.2 years. Ten patients were primiparus, nine patients were para 1, and one patient was para 6 (this refers to parity at the start of the pregnancy, consistent with case reports in the literature; these patients had delivered when hemorrhage diagnosed). The estimated gestational ages (EGA) ranged from 37 to 43 weeks, with an average EGA of 40.1 weeks. Table 1 is a presentation of the 22 patients and related biodata and clinical details
All cases were delivered by cesarean section. Uterine atony was the intraoperative clinical working diagnosis for PPH in all 22 instances. All received intra-operative uterine compression and medical uterotonic age agents. Of the 22, 11 achieved hemorrhage control with the B-Lynch suture alone; 6 cases achieved control with combined B-Lynch suture and vessel ligation. The other five proceeded to hysterectomy for intractable bleeding, and two of these five were found to have focal placenta accreta on histological study.
Antenatal obstetric problems described in these patients included: prior cesarean section (11 cases, 50%), arrest disorder of labor (12 cases, 55%), oxytocin labor induction/augmentation (11 cases, 50%), chorioamnionitis (8 cases, 36%), pre-eclampsia (5 cases, 23%), pre-operative magnesium sulfate (4 cases, 18%), and gestational diabetes (2 cases, 9%).
All cases received intra-operative uterine compression and medical uterotonic agents (oxytocin, methylergonovine, 15-methyl prostaglandin F2-alpha [carboprost] [26]). Twelve patients did not receive methylergonovine; seven of these had hypertensive disease.

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