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Christopher B-Lynch


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Postpartum Hemorrhage (PPH) Is A Common Cause Of Maternal Mortality In Pakistan

Postpartum hemorrhage (PPH) is a common cause of maternal mortality in Pakistan[i]. 1.3% of all deliveries may lead to PPH with a blood loss of more than one liter, while life threatening hemorrhage occurs in 1 in 1000 deliveries.[ii] Maternal morbidity and mortality rises with delay in diagnosis and management. Most common cause of PPH is uterine atony (75-90%). Other causes include placenta accrete, lower genital tract lacerations, coagulopathy, uterine inversion and ruptured uterus.[iii] There are plenty of medical and surgical treatments available for control of PPH. Two cases of PPH managed by Brace suture are reported using the technique first published by C B Lynch.[iv]
Case Report I
A 28 years old, 4th grade with three alive females delivered by lower segment caesarean section, was admitted at 29 weeks gestation with the complaint of mild off and on bleeding per vaginum for five weeks. She was a diagnosed case of major degree of anterior placenta praevia with intrauterine growth restriction. She was managed conservatively during her antenatal stay for 22 days in the hospital. One unit of blood was transfused. She had an emergency caesarean section at 32 weeks for sudden onset of vaginal bleeding (more than 500 ml in two hours). An alive female baby weighing 1.2kg was delivered. Lower segment was highly vascular and bled more than 1000 ml during the operation despite ecbolics, haemostatic sutures to the placental bed in the lower uterine segment and pressure pack. B-Lynch suture was applied successfully. One unit of blood was transfused peroperatively. Patient remained well and was discharged on 5th postoperative day. She reported significant lower abdominal cramps on first two days after operation.
Case Report II
A 24-year-old, primapara with one previous missed abortion was admitted at gestational age of 37 weeks with pregnancy induced hypertension, gestational diabetes mellitus and polyhydramnios. She had an emergency caesarean section after six hours for uncontrolled hypertension and flexed breech presentation. An alive 3 kg male baby was delivered. Placenta was located in the upper segment, and removed completely. Uterus was bleeding profusely (estimated blood loss was about 1500 ml) due to atony. B-Lynch suture was applied successfully after failure of ecbolics and pressure packing.
DESCRIPTION OF TECHNIQUE: Prior to applying the B-Lynch suture, under general anesthesia, the patient is catheterized in the Lloyd Davies position (modified lithotomy position) to assess the control of bleeding subjectively by swabbing. The abdomen is opened by Pfannenstiel’s incision or if the patient has had caesarean section following which she bled, the same incision is re-opened. On entering the abdomen either a lower segment incision is made or sutures of a recent caesarean section are removed. Bimanual compression is first tried to assess the potential chance of success of the B-Lynch suturing technique.
For this procedure chromic catgut number 2 on rounded needle is used (Figure 1). The uterus is punctured at about 3 cm from the right lower edge of the uterine incision and 3 cm from the right lateral border. The thread is passed through the uterine cavity to emerge at the upper incision margin 3 cm above and approximately 4 cm from the lateral border. The catgut is passed over the uterine fundus approximately 3-4 cm from the right corneal border. The catgut is passed posteriorly to puncture the uterine cavity at the same level as the upper anterior entry point. The chromic catgut is pulled under moderate tension and is passed posteriorly through the same surface marking as for the right side, the suture lying horizontally. The catgut is passed vertically over the fundus compressing the fundus on the left side as occurred on the right. The needle is passed in the same fashion on the left side through the uterine cavity and out approximately 3 cm anteriorly and below the lower incision margin on the left side. The two lengths of catgut are pulled taut assisted by bimanual compression to minimize trauma and aid compression. The vagina is now checked for bleeding. If good hemostasis is secured and whilst the uterus is compressed by an assistant, the principal surgeon ties the two lengths of catgut to secure tension. The lower transverse uterine incision is now closed in the normal way.
DISCUSSION
A variety of surgical techniques have been proposed to avoid hysterectomy, each is associated with identifiable benefits and risks. In most cases of massive hemorrhage, hysterectomy[v] or ligation of ovarian,[vi] uterine[vii] or internal iliac artery is recommended.
In a review of over 200 women undergoing bilateral uterine artery ligation for caesarean section hemorrhage over a 30 years period in one hospital, O’Leary found this procedure helpful in 95% of cases. However, the technique failed in cases of placenta previa or accrete. Unilateral internal iliac artery ligation reduces ipsilateral blood flow by half. Bilateral internal iliac ligation is successful in avoiding hysterectomy in about half of the cases. However, delay in carrying out the procedure leads to a poorer prognosis. It also has a number of recognized potential complications, including ligature of external iliac artery, damage to internal or external iliac veins, ureteral injury and retroperitoneal hematoma.
Uterine packing is another attractive alternative but there is significant risk of continued hemorrhage and infection.[viii] Sangstaken Blakemore tube has also been sued successfully to control bleeding, but is normally not available on obstetrical floor usually.
The Brace suture first reported by B-Lynch is very useful as an alternative to hysterectomy and other surgical interventions for control of massive postpartum hemorrhage and success is likely even in cases of placenta praevia and accrete. The net effect is to compress the uterus (as in bimanual compression). The suture material, (chromic catgut) is inexpensive and readily available. Moreover, technique is simple and safe enough for the residents to learn and apply as identification of specific blood vessels is not required. Conservation of uterus and reproductive capacity as achieved by B-Lynch brace suture is its great advantage.
NB in the article end note 4 is used twice, but the 9th reference does not have an end note – the last endnote ref is 8. This suggests that there is an error in the original article – the 2nd endnote 4 should have read 5 and so on.
NB Hemorrhage is usually spelled haemorrhage. The UK spelling of caesarean has bee used (instead of cesarean) as the spellcheck auto-corrects this one.
NB Figure 1 to follow

 


[i] Ashraf M, Sheikh NH, Yousaf AW. Maternal mortality: a 10-year study at Lady Willingdon Hospital, Lahore. Annals KEMC 2001; 7: 205-7
[ii] Macphail S, Fitzgerald J. Massive postpartum haemorrhage. Curr Obstet Gynaecol 2001; 11: 108-14
[iii] Stanco LM, Schrimmer DB, Panel RH, Mishell DR. Emergency peripartum haemorrhage and associated risk factors. Am J Obstet Gynecol 1993; 163: 879-83
[iv] Lynch CB. The B-Lnych surgical technique for the control of massive PPH. Br J Obstet Gynecol 1997; 104: 372-5
[v] Noor S, Majid, S, Ruby, N. An audit of obstetrical hysterectomy. J Coll Physicians Surg Pakistan 2001; 11: 642-5
[vi] O’Leary JA. Stop of haemorrhage with uterine artery ligation. Contemp Obstet Gynecol  1998; 28: 13-6
[vii] Evans S, McShane P.   The efficacy of internal iliac artery ligation in obstetric haemorrhage. Surg Gynecol Obstet 1985; 66: 89-92
[viii] Wax JR, Channel JC, Vemelersloot JA. Packing of lower uterine segment – new approach to an old technique. Int J Obstet Gynecol 1993; 43: 197-8

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B-Lynch Suture Published Press Articles

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