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Christopher B-Lynch


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Scottish Confidential Audit Of Severe Maternal Morbidity

Surgical management of post-partum haemorrhage
Between 2003 and 2004 there has been an increase in use of the B-Lynch uterine compression suture and the hydrostatic balloon catheter and a fall in the use of angiographic techniques. In the light of these changes in practice, we include a brief commentary on these haemostatic techniques here.
Traditionally, when pharmacological measures to arrest post-partum haemorrhage failed, the options available to the surgeon were limited and included ligation of pelvic arteries and hysterectomy. In 1979, Brown first described angiographic arterial embolisation as a new approach to control haemorrhage.[1]   Several case series followed, reporting high success rates with this technique and it soon became established as an adjuvant strategy in the management of post partum haemorrhage. Successful embolisation allows retention of the uterus and potential preservation of the woman’s fertility. Follow-on case series have indeed shown an uncomplicated future pregnancy to be a possibility.[2] The main drawback of embolisation is that the technique may not be available locally and immediately, limiting its use.
B-Lynch uterine compression suture
This haemorrhage suturing technique was first performed in 1989 by Christopher B-Lynch in a patient with massive postpartum haemorrhage who refused hysterectomy.[3] The B-Lynch suture aims to control bleeding by reducing pelvic pulse pressures – the dame principle that underlies surgical ligature and radiologically guided embolisation of pelvic arteries. The B-Lynch suture achieves this by exerting continuous vertical vascular compression on the uterus.[4] The main advantage of the suture is its simplicity. Application of the suture is far less surgically complex than ligation of pelvic arteries or hysterectomy; neither does it require involvement of interventional radiologists – whose expertise may not be available immediately. The suture boasts good efficacy which can be assessed prior to its application by applying bimanual compression. If this appears to control haemorrhage, it can be assumed that the B-Lynch suture, when applied, will have a similar effect. A laparotomy is required, but not necessarily a hysterectomy.
Hydrostatic balloon
Hydrostatic balloons mimic the tamponade effect of uterine packing. The Sengstaken-Blakemore tube (oesophageal balloon) has been successfully used in cases of post-partum haemorrhage.[5] However, this has largely been superseded by the Rusch hydrostatic balloon catheter (previously widely used in urology) which was successfully used and described by Johanson in 2001.[6] As with the B-Lynch suture, balloon tamponade is a relatively easy technique to implement and has the further advantage that laparotomy is not required. It presents an advance on uterine packing, as concealed continued bleeding and infection do not appear to be significant problems.
The future
Although uterine atony remains the most common cause of postpartum haemorrhage, placenta accrete is emerging as an increasingly common contributor, both in our own Scottish population and worldwide. This may be explained by the increasing caesarean section rate and rising maternal age – two of the biggest risk factors for placenta accreta.[7]
In 2004, the cause of haemorrhage was documented as placenta accreta in 8 of our 156 cases. The median age in this group of women was 36. Of these eight women, four had one previous caesarean section and three had two previous sections. Five of these women underwent hysterectomy, with only one having any conservative surgical procedure performed prior to this (uterine artery ligation). In the remaining three cases of placenta accreta, the haemorrhage was controlled with use of the B-Lynch suture.
It is likely that the number of cases of haemorrhage due to placenta acrreta will rise because of the factors mentioned above. However, both the B-Lynch suture and the hydrostatic balloon catheter represent additional strategies for controlling haemorrhage due to placenta accreta. Furthermore, both techniques have been used successfully in cases of massive haemorrhage due to placenta accreta where radiologically guided embolisation and uterine artery ligation had failed to adequately control bleeding.6;[8]
It seems appropriate that as such simple techniques exist, staff working in Scottish maternity units should be familiar with their implementation.
Commentary References
[1] Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ, Jr. Uncontrolled postpartum bleeding: a new approach to hemostasis through angiographic arterial embolisation. Obstet. Gyencol. 1979; 54: 361-5
2 Descargues G, Mauger TF, Douvrin F, Claver E, Lemoine JP, Marpeau L. Menses, fertility and pregnancy after arterial embolisation for the control of postpartum haemorrhage. Hum. Reprod. 2004; 19: 339-43
3 Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br Obstet. Gynaecol. 1997; 104: 372-5
4 Allam MS, Lynch C. The B-Lynch and other uterine compression suture techniques. Int Gyaenocol. Obstet. 2005; 89: 236-41
5 Seror J, Allouche C, Elhaik S. Use of Sengstaken-Blakemore tube in massive postpartum haemorrhage: a series of 17 cases. Acta Obstet. Gynaecol. Scand. 2005; 84: 660-4
6 Johanson R, Kumar M, Young P. Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy. BJOG. 2001; 108: 420-2
7 Wu S, Kocherginsky M, Hibbard JU. Abnormal placenta: twenty-year analysis. Am. J. Obstet, Gynecol. 2005; 192: 1458-61
6;8 El Hamamy E, Lynch C. A worldwide review of the uses of the uterine compression suture techniques as alternative to hysterectomy in the managements of severe post-partum haemorrhage. J. Obstet. Gynaecol. 2005; 25: 143-9.

 


[1] Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ, Jr. Uncontrolled postpartum bleeding: a new approach to hemostasis through angiographic arterial embolisation. Obstet. Gyencol. 1979; 54: 361-5
[2] Descargues G, Mauger TF, Douvrin F, Claver E, Lemoine JP, Marpeau L. Menses, fertility and pregnancy after arterial embolisation for the control of postpartum haemorrhage. Hum. Reprod. 2004; 19: 339-43
[3] Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br Obstet. Gynaecol. 1997; 104: 372-5
[4] Allam MS, Lynch C. The B-Lynch and other uterine compression suture techniques. Int Gyaenocol. Obstet. 2005; 89: 236-41
[5] Seror J, Allouche C, Elhaik S. Use of Sengstaken-Blakemore tube in massive postpartum haemorrhage: a series of 17 cases. Acta Obstet. Gynaecol. Scand. 2005; 84: 660-4
[6] Johanson R, Kumar M, Young P. Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy. BJOG. 2001; 108: 420-2
[7] Wu S, Kocherginsky M, Hibbard JU. Abnormal placenta: twenty-year analysis. Am. J. Obstet, Gynecol. 2005; 192: 1458-61
[8] El Hamamy E, Lynch C. A worldwide review of the uses of the uterine compression suture techniques as alternative to hysterectomy in the managements of severe post-partum haemorrhage. J. Obstet. Gynaecol. 2005; 25: 143-9.

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B-Lynch Suture Published Press Articles

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