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Christopher B-Lynch


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Successful Use Of The B-Lynch Brace Suture In Early Pregnancy

The patient underwent an initially uncomplicated evacuation of retained products of conception under general anaesthesia. This was performed by the senior house officer, with supervision from the specialist registrar, using a 12-mm uterine suction curette and ovum forceps under trans abdominal ultrasonic guidance. The cavity was confirmed to be empty using a sharp curette. The products of conception had an offensive smell, so she was given a single dose of intravenous gentamicin and commenced a course of intravenous cefuroxime and metronidazole. Blood loss during this procedure was minimal.
Approximately 1 hour after the procedure, while in the postoperative recovery area, the patient started to bleed heavily vaginally. The senior specialist registrar was called, uterine massage was performed, and 500 μg ergometrine was given intravenously. Despite these actions the bleeding persisted, and transabdominal ultrasound suggested the uterine cavity was distended with blood.
A second dose of ergometrine was given and the patient was returned to the operating theatre, re-anaesthetised, and under transabdominal ultrasound guidance the uterus was again evacuated using a 12-mm suction curette. A large Foley catheter was inserted into the uterine cavity and the balloon distended to 40 ml with sterile water. A vaginal pack was also inserted to reinforce the tamponade, and 800 μg misoprostol (Cytotec*; Searle, UK) was administered per rectum (unlicensed for this use). A urethal catheter was also inserted to allow close monitoring of the urine output.
During this second procedure the patient was given a blood transfusion of 4 units of packed cells and 4 units of fresh frozen plasma (FFP). The postoperative blood results showed her haemoglobin concentration to be 8.7 g/dl, packed cell volume 26.8%, platelets 71 x 109/1. The international normalised ratio (INR) was 1.25, activated partial thromboplastin time ratio (APTTR) 1.36, fibrinogen 1.6 g/l and fibrinogen degradation products (D dimmer) > 1.6 μg/ml.
Bleeding settled briefly, but within 1 hour vaginal bleeding had recommenced and the urine output had fallen. Transabdominal ultrasonography revealed that the uterus was again distended with blood, and the blood results indicated a coagulopathy. The consultant on call was called in at this stage.
Two hundred and fifty μg carboprost (Hemabate*; Pharmacia) was administered into the myometrium under trandabdominal ultrasound guidance, and the patient returned to the operating theatre. At examination under anaesthesia the uterus was atonic. Curettage with a sharp curette (using transabdominal ultrasound) was performed. No defects were identified in the uterus, and no products of conception were obtained.
Despite prolonged bimanual compression of the uterus the bleeding persisted and so a laparotomy was performed through a pfannenstiel incision. A further 250 μg of carboprost was administered directly into the myometrium and further bimanual compression performed, which achieved haemostasis. A B-Lynch brace suture was inserted using a No 2 polyglycolic suture (Dexon, Davies + Geck) on a hand-held needle, which achieved uterine compression. Further compression of the uterus by physical and medical means continued, causing the suture to become loose, and so a second, tighter, B-Lynch brace suture was inserted.
The vaginal bleeding eventually settled and the vagina was packed with a gauze role. The patient received a further transfusion of 5 units of packed cells, 10 units of cryoprecipitate and 4 units of FFP during this procedure. Postoperatively she was transferred to the intensive care unit (ITU), and an oxytocin infusion containing 50 i.u. in 500 ml normal saline was continued for 8 hours at a rate of 10 i.u. per hour.
She made a good postoperative recovery, remaining on the ITU for less than 48 hours, vaginal blood loss was minimal, and the vaginal pack was removed after 24 hours without complication. Postoperative haemoglobin was 7.7 g/dl, and a further 2 units of packed cells was given. On the sixth postoperative day she was discharged home, with a post-transfusion haemoglobin of 10.4 g/dl. No organism was identified from the cultures.
Discussion
The B-Lynch suture was first described in 1997 by B-Lynch et al (1997). The successful use of this ‘brace’ suture was described in five patients with postpartum haemorrhage following term pregnancies as an alternative to hysterectomy.
Fergusson et al (2000) described the further successful use of this new technique in two patients again in the third trimester, and more recently Smith and Blaskett (2003) in Canada concluded that the B-Lynch suture should be considered before resorting to hysterectomy in cases of sever atonic postpartum haemorrhage.
There have been, up to now, no reports of the use of this brace suture in earlier pregnancy. We found this technique to be highly successful in achieving uterine compression and avoided hysterectomy in a young primagravida in whom all forms of conventional medical therapy had failed.
The technique was carried out as per the original description; however, while we found that the initial suture achieved good uterine compression further contraction of the relatively small uterus, due to medical and physical measures, necessitated the insertion of a second suture, inserted in the same fashion, to attain maximal uterine compression. We also used No 2 Dexon instead of catgut, which was originally described by B-Lynch. We chose this suture as it was thought to be thick enough to avoid cutting through the uterus, but absorbable, thus reducing the potential for bowel entrapment in the sutures as they become loose, and also due to the lack of availability of catgut.
Sepsis remains an important cause of death in early pregnancy. In the Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1997-1999 six women were identified who died as a result of sepsis related to spontaneous abortion (Department of Health, 2001).
In this case the patient was treated aggressively with intravenous antibiotics as soon as the first signs of sepsis were suspected. The uterus, however, became atonic and the patient went on to develop a coagulopathy, probably as a result of the sepsis and massive haemorrhage. This case also illustrates the massive transfusion requirements of such cases – our patient was transfused in a total of 11 units of packed cells, 10 units of cryoprecipitate and 8 units of FFP.
The management of primary postpartum haemorrhage was reviewed by Drife in 1997. We followed the steps described in this, including that of using intrauterine balloon catheter, described most recently by Johanson et al (2001). We also used Misoprostol (a postglandin E1 analogue) rectally. This drug, developed initially for peptic ulcer disease, is currently unlicensed for this use in obstetrics and gynaecology. Its rectal administration was described by O’Brien et al (1998) in the third trimester, for treatment of postpartum haemorrhage. There are currently no reports of the use of the B-Lynch brace suture to arrest haemorrhage in earlier trimesters.
This conserative surgical  technique proved to be highly effective in early pregnancy and the woman described left hospital well, and we assume, able to contemplate further pregnancies.
References
B-Lynch C, Coker A, Lawal A H, Abu J and Cowen M J (1997) The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. British Journal of Obstetrics and Gynaecology, 104, 372-375
Department of Health (2001) Why Mothes Die. Report on the Confidential Enquiry into Maternal Deaths in the United Kingdom 1997-1999. London, HMSO
Drife J (1997) Management of primary postpartum haemorrhage. British Journal of Obstetrics and Gynaecology, 104, 275-277
Fergusson J E, Bourgeois F J and Underwood, P B (2000) B-Lynch suture for postpartum haemorrhage.Obstetrics and Gynaecology, 95, 1020-1022
Johanson R J, Kumar M, Obrai, M and Young, P (2001) Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy. British Journal of Obstetrics and Gynaecology, 108, 420-422
O’Brien O, El-Refay H, Gordon A, Geary, M and Rodeck C H (1998) Rectally administered Misoprostol for the treatment of postpartum haemorrhage unresponsive to Oxytocin and Ergometrine: a descriptive study.  Obstetrics and Gynaecology, 92, 212-214
Smith K L and Blaskett T F (2003) Uterine compression sutures as an alternative to hysterectomy for severe postpartum haemorrhage. Journal of Obstetrics and Gynaecology Canada, 25, 197-200

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