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Christopher B-Lynch


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The B-Lynch Technique For Postpartum Haemorrhage: An Option For Every Gynaecologist

Postpartum haemorrhage is a serious complication, which often occurs unexpectedly. In 5% of all deliveries, vaginal blood loss is more than 1000 cc. Effective action is required to prevent major morbidity or even mortality. When con­servative management of postpartum haemorrhage fails to control non-traumatic blood loss, operative intervention is required. Before deciding on the last option, hysterectomy, the B-Lynch surgical technique, uterine artery ligation or uterine artery embolisation can be applied. The latter two require special surgical training or the possibility of emer­ gency intervention radiology, and may thus not be an option in an emergency situation.
Most gynaecologists are familiar with the name of the B-Lynch technique but have no practical experience with it, a reason why it is not often used in emergency situa­tions. After its first description [1], only very few studies [2,3] have reported upon this new technique. The B-Lynch technique is an option for stopping heavy bleeding caused by uterine atony. If bimanual compression of the uterus decreases the blood loss significantly it can be applied (see Fig. 1). After laparotomy, if the patient has not undergone a caesarean section, a lower uterine transverse incision is performed. This is to remove products of conception and to examine the cavity for decidual tear or placenta accreta or increta. One must be sure that drainage is possible because of the risk of cloth retention. Two to three centimeter below the incision, the suture is at first led into the uterus left or right. Hereafter, the suture is led out of the uterus 2- 3 cm above the incision and is then brought over the anterior side of the uterus, like a brace, to the posterior side of the uterus. Then, it is once more led into the uterus just above the insertion of the sacro-uterine ligaments on the ipsilateral side and thereafter from inside to outside of the uterus on the contra-lateral side. Finally, it is brought back from posterior to anterior over the uterus and pulled through at the contra lateral side. Both ends are then tied (see Fig. 1). During the procedure, an assistant compresses the uterus.

In this report, we present seven cases of postpartum haemorrhage in which the B-Lynch surgical technique was successfully applied and will discuss several aspects of the procedure.
Case reports

Two cases are described in detail. A summary of all seven patients is presented in Table 1.

2.1. Case 1

A 30-year-old patient was in her second pregnancy. Her first pregnancy was complicated by the HELLP-syndrome.

Fig. 1. Parts (a) and (b) demonstrate the anterior and posterior views of the uterus showing the application of the B-Lynch brace suture. Part (c) shows the anatomical appearance after compotent application (1).

Because of the maternal condition a caesarean section was performed at 26 weeks of gestation. The baby died 15 weeks postpartum because of prematurity.

Her second pregnancy had an uncomplicated prenatal course. At 38 weeks, she vaginally delivered a healthy boy of 3510 g. After delivery of the placenta, heavy vaginal bleeding started. Conservative management with oxytocin infusion did not stop the bleeding and therefore inspection was carried out under anaesthesia. The uterus seemed to be adequately contracted. It was empty and a rupture of the cervix, which was not bleeding vitally, was repaired. There was no vaginal rupture. Uterine tamponade was performed to stop the haemorrhage. Blood loss after this intervention was 4000 cc. Despite prostaglandin infusion, administration of cyclokapron intravenously and the tamponade, the patient kept on bleeding vaginally. Therefore, a laparotomy was performed. The uterus was found to be moderately con­ tracted. Firstly, the internal iliac arteries were ligated on both sides, and some weak spots of the previous caesarean section scar were corrected. Despite these operative interventions, haemostasis was still inadequate. Secondly, the B-Lynch procedure was performed, using a catgut 2 suture. Good compression of the uterus was achieved and haemostasis was established. Blood loss was 6000 cc. The patient received 14 packed red cells, 5 fresh-frozen plasma and 1 platelet transfusion. Postoperative course was uncompli­ cated. She was discharged on the eight day after the opera­ tion. Two years later, she gave birth of a healthy girl, delivered by an uncomplicated caesarean section. During this operation, the uterus showed no marks of the former B-Lynch procedure.

2.2. Case 2

A 35-year-old gravida 1 was referred to our hospital because of gestational diabetes, for which she was treated with a diet and insulin. Labour was induced at 39 weeks of gestation, using oxytocin intravenously after artificial rupture of membranes. Arrest of labour occurred at 5 cm, and a caesarean section was performed. A healthy boy of 3975 g was born. After delivery of the baby, the uterus did not contract well and heavy bleeding started. Uterotonics were given intravenously but had no effect. Compression on the uterus decreased the bleeding, and therefore the B-Lynch-procedure was performed, using a vicryl suture no. 2. With the B-Lynch suture, adequate haemostasis was achieved. Total blood loss was 3000 cc. The patient received four packed red cells. On the seventh day after delivery, she was discharged from the hospital in good condition.

3. Comments

Postpartum haemorrhage can be a life threatening condition. Common causes are uterine atony, retained pla­ centa or fragments, lower genital tract lacerations, coagulo- pathy, uterine rupture and uterine inversion. When classic conservative measures fail to control non-traumatic haemor­ rhage operative interventions are required.

B-Lynch [1] first described a simple procedure to treat a life threatening postpartum haemorrhage, when the uterus remains atonic after treatment with uterotonics.

The procedure is carried out under general anaesthesia, avoiding the use of isoflurane and halothane which results in uterine relaxation. The first step is catheterisation. The next step is to place the patient in a Lloyd Davies position [1] (a combination of a Trendelburg and lithotomy position) or a frog leg supine position, in which hips and knees are flexed 15-30° and the hips are externally rotated [2]. In this way, a direct view of the perineum and vagina can be obtained. After laparotomy, a transverse lower uterine incision is made or the caesarean section incision is re-opened. The uterine cavity should be evacuated of blood and examined. It is probably easier to exteriorise the uterus. Haemostatic sutures should treat separate bleeding points. In cases of placenta previa, horizontal sutures can be placed in the lower segment to achieve transverse compression. If the uterus is bleeding diffusely due to atony, coagulopathy or diffuse placental bed bleeding, then the uterus can be bimanually compressed and its effect evaluated. If this procedure stops the bleeding it can be expected that the B-Lynch technique will be successful. The suture is then placed in the manner as described in Section 1 and depicted in Fig. 1. It is important that an assistant bimanually compresses the uterus to mini­ mise trauma and to achieve a good compression. It is essential is to create a supportive brace around the uterus. After placing the suture the uterus and abdomen are closed as usual.

In cases 3-7, the B-Lynch technique was the primary technique giving good haemostasis. Case 5 was combined with venous plexus ligation on one side. In the first two cases, the surgeon began with internal iliac artery or uterine artery ligation, respectively, which was ineffective. Unfortunately, it was not clear from the records whether bimanual compression was given first and its effect eval­uated, as valuable delay and blood loss could have been prevented.

B-Lynch [1] used a chromic catgut no. 2 suture. We used several different sutures as catgut no. 2 was not always available. When choosing the suture its thickness is probably most important and should be at least no. 1. Moreover, it should be absorbable in reasonable time, to avoid intestinal entrapment. The needle should be atraumatic and large.

In the limited number of studies published up to now, no complications have been reported.

The suture is placed away from major vessels and ureter. Our results indicate that fertility may not be affected (patient 1 and 4 became pregnant again and consecutive caesarean section was uneventful). This corresponds with the observa­ tions of Lynch et al. [1]. In one patient, a hysterosalpingo- gram and MRI showed no uterine cavity defects and she had patent fallopian tubes [21. The optimal timing of placement of the sutures is not known, and should be investigated.
Further experience is also necessary to detect possible short- or long-term complications.

Compared to other surgical interventions the B-Lynch technique has the advantage that it can be applied fast and easy. It should therefore be an option for every gynaecol­ogist. For artery embolisation, an intervention radiologist should be available. Furthermore, the patient needs to be in a haemodynamic stable condition [4]. Ligation of the uterine artery [5], stepwise uterine devascularisation [6] or hypo- gastric (internal iliac) artery ligation [7] are other possibi­ lities to control massive postpartum haemorrhage. However, not every gynaecologist is familiar with these techniques and may lack sufficient training. Ligation techniques may then become hazardous as major blood vessels are involved and the ureter is close to the puncture side. In every case of postpartum haemorrhage, it is important to administer, if necessary, adequate bloodtransfusions and in case of (con­ sumptive) coagulopathy, platelets and coagulationfactors.

It is hardly possible to compare the different techniques regarding their effectiveness as all reports are based on cases lacking adequate controls. Both embolisation and ligation techniques have been reported to be effective in 80-95% [4-7].

If an emergency hysterectomy has eventually to be carried out, it is probably best to start with a subtotal hysterectomy [8]. A total abdominal hysterectomy is the preferred treat­ ment for haemorrhage secondary to an abnormal adherent placenta involving the lower uterine segment [8].

In conclusion, the B-Lynch suture technique can be considered to be a good option for the treatment of post­partum haemorrhage due to an atony of the uterus orcoagulopathy, when conservative management fails. It should therefore be taken into account as a treatment option by every gynaecologist.

References

[1] B-Lynch CB, Coker A, Lawal AH, Abu J, Cowen M. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynecol 1997; 104:372-5.

[2] Ferguson JE, Bourgeois FJ, Underwood PB. B-Lynch suture for postpartum hemorrhage. Obstet Gynecol 2000;95:1020-2.

[3] Dacus JV, Busowski MT, Busowski JD, Smithson S, Masters K, Sibai BM. Surgical treatment of uterine atony employing the B-Lynch technique. J Matern Fetal Med 2000;9(3): 194-6.

[4] Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997;176(4):938-48.

[5] O’Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med 1995;40(3): 189-93.

[6] Abdrabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrollable postpartum hemorrhage with pre­ servation of the uterus. Am J Obstet Gynecol 1994;171(3):694-700.

[7] Clark SL, Phelan JP, Yeh S, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol 1985;66:353-6.

[8] Zelop CM, Harlow BL, Frigoletto FD, Safon LE, Salzman DH. Emergency peripartum hysterectomy. Am J Obstet Gynecol 1993;168(5): 1443-8.

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B-Lynch Suture Published Press Articles

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