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Technical Description Of The B-Lynch Brace Suture For Treatment Of Massive Postpartum Hemorrhage And Review Of Published Cases

Natalia Price MD
Christopher B-Lynch MA (Oxon), FRCS, FRCOG
Int J Fertil Womens Med. 2005 Jul-Aug;50(4):148-63.

ABSTRACT

Massive uncontrolled hemorrhage after childbirth is a leading cause of the pregnancy-related death and resulting morbidity. Uterine atony is the most common cause (75-90%) of primary postpartum hemorrhage. When simple massage of the uterus and uteronics such as oxytocsins, syntometrine and prostaglandins failed to manage this condition, various surgical solutions have been sought, including uterine artery ligation, more complicated stepwise devascularization of the uterus, internal iliac artery ligation and ultimately, hysterectomy. All these procedures require above average surgical skill. In contrast, the B-Lynch suturing technique (brace suture) is particularly useful because of its simplicity of application, life-saving potential, relative safety and capacity for preserving the uterus and subsequent fertility. The adequacy of haemostasis can be assessed both before and immediately after application of the suture. Only if it fails need other more radical surgical methods be considered. The special advantage of this innovative technique is that it presents an alternative to major surgical procedures for controlling pelvic arterial pulse pressure or hysterectomy. To date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications. This review provides an update on the B-Lynch brace suturing technique, including the choice of suturing material, use of the technique in early and late gestation, and comparison with other uterine compression surgical techniques. It also includes a comprehensive review and analysis of all published cases and their postoperative follow-up.

INTRODUCTION

Postpartum hemorrhage (PPH) remains among the top five causes of maternal death in both the developing and the developed world. Uterine atony is the most common cause (75-90%) of primary PPH. Of all the major obstetric complications, postpartum hemorrhage is perhaps the most dramatic, menacing, yet potentially avoidable in the majority of cases. Together with the rapidity of blood loss, a volume in excess of 1,000mL following delivery (or 500Ml in cases complicated by predelivery anemia) is used to indicate the clinical diagnosis of a major PPH. This occurs in approximately 4% of vaginal deliveries and 6% of cesarean deliveries [1]. The World Health Organization estimates that 20 million maternal morbidities annually are due to hemorrhage [2]. In the developing world, the risk of maternal death from PPH is approximately one in 1,000 deliveries [1]. Even in the United States [3], PPH accounts for up to 4% of maternal deaths. In the United Kingdom, the “Confidential Enquiry Reports into Maternal Death” over the last 20 years also show that PPH has played, and continues to play, a significant role in maternal mortality [4].

The cornerstone of management of PPH is a team approach and early diagnosis. Resuscitation, uterotonics, uterine tamponade procedures and selective radiological embolisation of the bleeding vessel have all been used successfully. However, the failure of conservative management often mandates surgical intervention. In such instances, the choice of type of surgical intervention depends on several factors, not the least of which is the experience of the surgeon. Other factors include parity and the desire for future children, the extent of the hemorrhage, and the general condition of the patient. Ligation of the uterine artery or its main supply (internal iliac artery) may be considered in selected cases. However, this operation may be technically difficult, requires above average surgical skill and may be successful in less than half of cases [3, 5, 6]. Selective arterial embolisation may also on principle be an attractive management option, but an interventional radiologist will need to be available on site to perform the procedure, and, moreover, the patient must be in a hemodynamically stable condition. If medical as well as surgical interventions for control of the hemorrhage should fail, then hysterectomy becomes the inevitable last resort. Irrespective of the type of hysterectomy, this option carries the obvious disadvantage of significant physical and psychological morbidity in addition to permanent sterility and often must be performed on a patient in extremis with disseminated intravascular coagulation, complicating the operation.

In contrast, the B-Lynch suturing technique [7, 8] for the control of massive PPH is a conservative surgical treatment that can be recommended for the majority of situations. When correctly applied, the suture maintains longitudinal compression, with an even distribution of tension on uterine walls, even when the pelvic pulse pressure returns to normal.

This review provides a description of the B-Lynch Brace Suturing technique, emphasizing its special features and comparing it with alternative approaches. In particular, it discusses improvements in suture material that have occurred over the years. It also reviews recent applications of the technique and provides postoperative follow-up data on them.

HISTORY

The procedure was first performed in 1989 and then described in the peer-reviewed journals in 1997 by Mr Christopher B-Lynch, a consultant obstetrician and gynecological surgeon now based at Milton Keynes General Hospital, Oxford Deanery, in the United Kingdom, during the management of a patient with a massive PPH who declined hysterectomy [7, 8]. To date, it is estimated that around 1,300 cases have been performed worldwide [9]. The largest number of successful applications, over 250, have been reported from the Indian subcontinent, followed by Africa, South America, and North America, and Europe.

PRINCIPLES

A patient can be considered a potential candidate for the B-Lynch procedure if bimanual compression of the exteriorized uterus markedly decreases the uterine bleeding. The patient is catheterized and placed in the Lloyd Davies or dorsal lithotomy position. An assistant stands between the patient’s legs and intermittently swabs the vagina to determine the presence and extent of the bleeding. The uterus is then exteriorized and bimanual compression performed. In order to do this, the bladder peritoneum is reflected inferiorly to a level below the cervix. The whole uterus is then compressed by placing one hand posteriorly with the ends of the fingers at the level of the cervix and the other hand anteriorly just below the bladder reflection. If the bleeding stops after applying such compression, the likelihood is good that application of the B-Lynch suture will be beneficial. It is not sufficient, however, to apply temporary compression and assume that the bleeding is controlled, as there might be clots in the vagina impeding the escape of blood. This is why it is essential to use the dorsal lithotomy position, which allows direct swabbing and visualization of the vagina to assess the control of bleeding after compression has been performed.

If the patient has not undergone a cesarean section prior to laparotomy, a low transverse incision must be made in the uterus in order to explore the cavity, ascertain that the internal os can be dilated with a finger, and ensure that correct application of the suture will give maximum compression effect. The purpose of this is not only to remove any remaining products of conception but also to examine the cavity for decidual tear or placenta accreta or increta. Any obvious bleeding points can also be identified at that time and secured with independent figure-eight sutures [7,8]. In a patient with placenta praevia, a figure-eight or compressions suture of the lower anterior or posterior segment can be tried first, to see if that will control bleeding. If it does not, then the placement of the B-Lynch suture can be considered for hemostasis. In both instances, an incision in the uterus is required to place the B-Lynch suture. Care should always be taken to ensure that drainage is possible, to avoid risk of clot retention and pyometria [8, 10]. The purpose of the B-Lynch a suture is to exert continuous vertical compression on the vascular system. In cases of low placental implantation, pressure is also applied to the placental bed by transverse fixation and compression [8].

TECHNIQUE AND MATERIALS

The following steps are involved in competent application of the B-Lynch suturing technique:

    1. The patient is catheterized under general anaesthesia and placed in the dorsal lithotomy (Lloyd Davis) position for access to the vagina and to assess objectively the control of bleeding by swabbing.
    2. The abdomen is opened by an appropriate sized Pfannenstiel incision or, if the patient has had a cesarean section after which she bled, the same incision is re-opened.
    3. On entering the abdomen, either a lower segment incision is made after dissecting of the bladder or the sutures of the recent cesarean section are removed and he uterine cavity entered. The uterine cavity is evacuated, examined and swabbed out.
    4. The uterus is exteriorized and rechecked to identify any bleeding point, which might be controlled with a figure-eight suture. If no obvious bleeding point is observed, then bi-manual compression is first tried, to assess the potential chance of success of a B-Lynch suture. At the same time, the vagina is swabbed out by an assistant to confirm adequate control of bleeding.
    5. If vaginal bleeding is controlled, for a left-handed surgeon or a surgeon electing to stand on the left side of the patient, the procedure is as follows:
      • A blunt, 70mm semicircular needle, mounted with a No. 1 Monocryl (polyglecaprone 25) absorbable suture (code W3709), 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 (Figure 1).
      • The suture is threaded through the uterine cavity to emerge at the upper incision margin 3 cm above and approximately 4 cm from the lateral border (because the uterus widens from below upwards).
      • The suture is now passed over to compress the uterine fundus approximately 3 to 4 cm from the right cornual border.
      • The suture is pulled under moderate tension, assisted by manual compression exerted by an assistant. The length of the suture is passed back posteriorly through the same surface, marking as for the right side, the suture lying horizontally
      • The suture is fed through posteriorly and vertically over the fundus to lie anteriorly and vertically 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 (Figure 1).
    6. The two lengths of suture are pulled tight, assisted by bi-manual compression to minimize trauma and to achieve or aid compression. During such compression the vagina is checked to confirm control of bleeding.
    7. As good homeostasis is secured, and while the uterus is compressed by an assistant,the principal surgeon ties a knot (double throw) followed by two or three further knots to secure tension.
    8. The lower transverse uterine incision is now closed in the normal fashion, in two layers, with or without closure of the lower uterine segment peritoneum.
    9. For a major placenta praevia an independent figure-eight suture can be placed anteriorly or posteriorly – or both – prior to application of the B-Lynch suture as described above, if necessarily.
    10. The suture should be more or less vertical and lying about 4 cm from the cornua (Figure 1). It does not tend to slip laterally toward the broad ligament, because the uterus has already been compressed and the suture milked through prior to tying, ensuring that proper placement is achieved and maintained. During the compression the vagina is checked to confirm that the bleeding is controlled.

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