Title: B-LYNCH TRANSVERSE COMPRESSION SUTURE FOR PLACENTA PREVIA BLEEDING Professor Christopher B-Lynch, Karenmarie K. Meyer FCOG MD Dr Tahira A Javaid
Abstract Post Partum Haemorrhage is a serious condition. It is well established that atonic uterus is a major cause. However, in some cases bleeding from placenta previa can be a serious cause. Currently, nothing is assured to control such bleeding when the placenta separates from the lower segment. Since the description of the Brace suture in 1997 by C B Lynch et al, it seems as though compression suture can be helpful. There is no reason why transverse compression cannot be considered to treat bleeding from placenta previa. We have used this method since 2006 with successful outcome and I hereby, describe the method.
This is the model used for demonstration
METHOD The operating surgeon stands on the right side of the patient, exteriorises the uterus and compresses the lower segment transversely whilst an assistant checks the vagina to document that bleeding is controlled. This is test of compliance of the procedure. He uses the suture material 1 VICRYL with a 70mm ½ circle needle mounted on a 90 cms VICRYL suture. He uses the needle blunt ended to puncture the uterus 3 cms above the upper margin of the incision posteriorly and behind the vascular bundle with the uterus tilted towards him.
This picture demonstrates the occlusion of the vessel that supply the lower segments, Uterine at the top and vaginal artery below.
The needle is retrieved through the cavity of the uterus and pulled inferiorly with the suture material lying on the posterior wall of the uterine cavity. The needle then perforates the posterior wall of the uterus 3 cms below the inferior margin of the Caesarean incision and exists behind the vascular bundle of the same side of the uterus retrieved and runs on the surface of the lower segment below the incision margin parallel to it and taking a 1 cm bite of tissue for stabilization running to the other side. After encircling the parauterine vasculature, the needle then perforates the posterior side of the uterus behind the vascular bundle entering the uterine cavity. The suture is allowed to lie freely on the posterior wall of the uterine cavity and exists 3 cms above the upper margin of the Caesarean incision. It exits posteriorly and behind the vascular bundle to meet the suture from the other side.
This picture demonstrates occlusion of the vessels that supply the lower segments on the opposite side
It is essential that the ureters are identified by palpation or visual observation after the bladder is displaced inferiorly and held by traction. Any observed bleeding should be dealt with in the usual way. At the end of the suture application and before tying the knots, the lower segment is compressed again transversely whilst the suture is held taut to ensue that bleeding has ceased by swabbing the vagina again.
This picture demonstrates occlusion of vessel to the lower segment and transverse compression at the end of the procedure
If all is satisfactory, the lower segment incision is closed in the traditional way by the 1 or 2 layer technique as appropriate. The lower segment is compressed again, whilst both limbs of the suture are milked through with sufficient tension to maintain haemostasis. The suture is then tied to ensure the tension is maintained. During the period of 2006-2010, 12 patients, were treated by this method and followed up to 2014, 3 have been pregnant with normal placenta positions and normal delivery. One was delivered by Caesarean section without any sign of irregularity in the lower segment. One patient was sterilised by laparoscopy showing no sign of abnormal isthmus or bladder distortion. We feel very strongly that this method is new and effective in the management of placenta previa PPH.
COMMENTS Bleeding from placenta previa can be serious and life threatening. In order to facilitate this demonstration of transverse compressed sutures, the authors have used an appropriate model of the uterus and appendage plus the vascular distribution on the lateral side of the uterus. By following the description in the text, 2 important observations are made. Firstly, the transverse compression is carried out manually and vaginal bleeding monitored to test compliance of the described procedure. Secondly, the bladder is displaced as much as possible inferiorly thus allowing the ureters to descend with it. In our experience the ureters are not visually or by palpation present at the site of uterine puncture therefore never in danger of trauma. The patients followed up gave us sufficient reassurance that is a safe procedure.
REFERENCE B-Lynch C, Coker A, Lawal AH, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? \five cases reported, Br J Obstet Gynaecol 1997: 104:372-5
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