|Year : 2022 | Volume
| Issue : 3 | Page : 345-350
Efficacy of B-Lynch compression suture for control of intractable hemorrhage during cesarean section
Priya Manohar Bagade
Department of Obstetrics and Gynecology, MIMER Medical College and BSTR Hospital, Talegaon Dabhade, Maharashtra 410507, India
|Date of Submission||30-Mar-2022|
|Date of Acceptance||23-Jun-2022|
|Date of Web Publication||29-Sep-2022|
Dr. Priya Manohar Bagade
Department of Obstetrics and Gynecology, MIMER Medical College and BSTR Hospital, Talegaon Dabhade, Maharashtra 410507
Source of Support: None, Conflict of Interest: None
Background: Primary postpartum hemorrhage (PPH) due to atonicity during lower segment cesarean section is commonly seen in obstetric practice. Usually, it responds to uterotonics but at times it may lead to life-threatening complications. B-Lynch brace suture is a fertility-preserving alternative surgical technique used in patients with primary atonic PPH not responding to uterotonics. This study was conducted to find out the efficacy of B-Lynch sutures in the surgical management of atonic PPH and prevention of obstetric hysterectomy in the same patients. Materials and Methods: The study included 34 patients with primary atonic PPH during cesarean section refractory to oxytocics and managed with B-Lynch brace sutures. It was a cross-sectional observational study conducted over 1 year at a tertiary hospital. The amount of blood loss, any additional surgical procedure required, and associated complications were studied in these patients. Results: Fertility could be preserved in 100% of the patients undergoing B-Lynch sutures for primary atonic PPH, following the failure of the medical line of management. No major complications including uterine wall necrosis or pyometra were observed in any of these patients. Conclusion: B-Lynch suture is a safe, effective, simple, life-saving, and fertility-preserving surgical technique in the treatment of primary PPH that requires lesser expertise. So it can easily be used before major interventions such as uterine devascularization or obstetric hysterectomy.
Keywords: B-Lynch suture, cesarean section, primary postpartum hemorrhage
|How to cite this article:|
Bagade PM. Efficacy of B-Lynch compression suture for control of intractable hemorrhage during cesarean section. MGM J Med Sci 2022;9:345-50
|How to cite this URL:|
Bagade PM. Efficacy of B-Lynch compression suture for control of intractable hemorrhage during cesarean section. MGM J Med Sci [serial online] 2022 [cited 2022 Nov 29];9:345-50. Available from: http://www.mgmjms.com/text.asp?2022/9/3/345/357467
| Introduction|| |
Postpartum hemorrhage (PPH) is a grave obstetric crisis that may lead to maternal morbidity as well as maternal mortality. It has been attributed to be one of the major causes of maternal mortality even in industrialized nations. Nearly 13% of mothers in developed countries and 34% in developing countries have succumbed to PPH. Every year, an estimated 127,000 women worldwide die due to obstetric hemorrhage. The Indian Council of Medical Research in 2003 also showed PPH as a leading cause of maternal mortality. The World Health Organization defines primary PPH as bleeding over 500 mL in the first 24 h following delivery. The American College of Obstetrics and Gynecology, however, has proposed a clinically more appropriate definition of PPH as a drop in the hematocrit by 10% of the pre-delivery status that requires a blood transfusion.
The most common cause of primary PPH is atonicity (90%), followed by trauma (10%) to the genital tract. The atonic uterus is a preventable cause of maternal morbidity and mortality in 80% of the cases of PPH. Primary management is crucial to control bleeding and avoid serious complications such as hypovolemic shock, disseminated intravascular coagulopathy, respiratory arrest, and multi-organ failure. Bleeding due to uterine atonicity is usually controlled by uterine bimanual compression, uterine massage, uterotonic agents, uterine tamponades, and at times arterial embolization. The failure of these procedures is life-threatening to the mother and warrants the need for surgical intervention in the form of uterine devascularization and/or obstetric hysterectomy. However, all these procedures require surgical expertise, and hysterectomy deprives a woman of future fertility.
In the past few years, uterine compression techniques have emerged as alternative conservative surgical methods for treating PPH. The uterine compression technique involves a suture that passes through the full thickness of both the uterine walls when tied it brings about tight compression of the uterine walls and stops the bleeding. Single or multiple sutures may be placed at the same time and depending on the shape, they are named brace sutures (B-Lynch), a simple brace (Hayman), or square sutures (Cho).,, B-Lynch suture described by Balogun Lynch Christopher in 1997 has become more acceptable. It has effectively been used in approximately 1300 cases worldwide since its invention. B-Lynch suture brings about mechanical compression of the uterine vascular sinuses, which inhibits further engorgement with blood. This study aimed to determine the efficacy of the B-Lynch technique as a conservative surgical method for the management of primary atonic PPH in cesarean section patients.
| Materials and methods|| |
The study was conducted at a tertiary healthcare center over 1 year after the Institutional Ethics Committee approval. It was a cross-sectional observational study including 34 pregnant patients undergoing lower segment cesarean section (LSCS) with atonic PPH refractory to oxytocics. B-Lynch brace sutures were used in these patients as an alternative surgical technique to conserve the uterus.
All the patients undergoing LSCS with atonic PPH with failure of the medical line of management were included.
- Patients with traumatic PPH;
- PPH following vaginal delivery;
- PPH due to coagulopathy.
The demographic variables of all the mothers included in the study were recorded after their consent. The pre-operative investigations essential for cesarean section were noted. The indication for cesarean sections and factors contributing to primary PPH were observed. A thorough medical history about any contraindication to the use of a medical line of management was obtained from all the patients. The medical line of management for atonic PPH in these patients included Inj. oxytocin, Inj. methyl ergometrine, Inj. prostaglandin F2 alfa, and PGE1 tablets. Despite using all these uterotonics repeatedly, if the uterus remained atonic, then the B-Lynch brace suture was applied using 1 Chromic catgut.
The amount of blood loss was estimated by the blood collected in the suction bottle after the placental delivery, the mops soaked with blood and the clots, and blood collected during vaginal swabbing after the section. The suction bottles were changed before the placental delivery to exclude the amount of amniotic fluid. Blood transfusion was done according to the intra-operative blood loss and post-operative hemoglobin status. The need for any other operative method such as uterine artery ligation, internal artery ligation, and obstetric hysterectomy to control atonic PPH was noted in all these patients having B-Lynch sutures. Post-operatively, vital parameters of the patients along with urine output, tone of the uterus, and bleeding per vagina were observed. Blood investigations were repeated after 24 h. The patients were discharged on day 10 only after suture removal.
Maternal and fetal parameters were recorded. The data of the patients were collected, compiled, and analyzed using an MS Excel worksheet. Statistical analysis was done by using percentages.
| Results|| |
A total of 34 patients were analyzed over a study period of 1 year. The clinical and demographic variables were recorded in all of these patients. As observed in [Table 1], B-Lynch sutures were taken predominantly in emergency cesarean (76.47%) section when compared with elective LSCS (23.52%). The associated risk factors are more in emergency cesarean sections when compared with elective procedures. The mean age of the patients was 26.8 years, and the majority of the patients were between 26 and 30 years (52.94%) [Table 2]. No significant difference could be seen in the parity of the patients [Table 3] leading to atonic PPH in our study. [Table 4] shows that most of the patients were term patients (41.17%) in the current study. The mean gestational age was 38 weeks. The baby weight was in the range of 2.1–3.0 kg in 47.05% of the cases with a mean baby weight of 2.8 kg [Table 5].
The risk factors leading to atonic PPH are described in [Table 6]. The majority of the cases were of severe preeclampsia. Some of the patients had combinations of two or more causative factors. Most of the patients (52.94%) had blood loss in the range of 1000–1500 mL as seen in [Table 7], with a mean blood loss of 1450 mL. The need for blood transfusion depended on the amount of blood lost intra-operatively as well as the post-operative hemoglobin levels. Two pints of blood were required in most of the patients (64.70%) in the present study, as seen in [Table 8]. B-Lynch suture alone was effective to control atonic PPH in 82.35% of the patients [Table 9]. The additional effective methods used for uterine conservation were bilateral uterine artery ligation in 11.76% of the patients and bilateral internal iliac artery ligation in 5.88% of the patients. Uterine conservation was achieved in 100% of the patients in the present study [Table 10]. In the present study, out of 34 patients, only minor complications were seen. Post-operative fever was noted in three patients, wound gape was observed in three patients, and abdominal wall hematoma was noticed in one patient [Table 11].
| Discussion|| |
PPH is a manageable life-threatening complication. If not corrected promptly, it can lead to devastating maternal morbidities and at times maternal mortality also. Although uterine massage with bimanual compression along with uterotonics is the first line of management in primary atonic PPH, the timely shift to surgical alternatives plays a crucial role in saving the life of the mother. Here we present a simple, effective technique in the form of B-Lynch compression sutures for efficacious surgical management of primary atonic PPH where the medical line of management fails. This technique can easily be used even in emergencies, requires less proficiency and it is a fertility-conserving method as well. The well-timed application of B-Lynch brace sutures also decreased the need for blood transfusion. The different variables in the current study have been compared with those of the other studies.
Mode of cesarean delivery
In the present study, 23.52% of the patients had elective LSCS, whereas 76.47% of the patients had undergone emergency LSCS [Table 1]. This is comparable with a study done by Kulsange and co-workers, in which 72% of the patients had emergency LSCS and 14% of the patients had elective LSCS. Similarly, in a study done by Nalini and Singh, 76% of the patients had emergency LSCS and only 24% of the patients had elective LSCS. This suggests that atonic PPH is more commonly seen in emergency procedures due to a lot of other contributing factors.
The mean age in our study was 26.8 years with a range between 18 and 38 years [Table 2]. This is more or less similar to a study done by Kalkal et al., in which the mean age of the patients was 26.6 years [Table 12]. However, the mean age of presentation in a study done by Vachhani and Virkud was 20 years, whereas it was 35 years in a study done by Koh et al. [Table 12]. The average age of 26.8 years in our study is due to cultural customs of marriages in the twenties in our country.
Atonic PPH was seen nearly equally distributed in both the primigravida (52.94%) and multigravida (41.17%) in our study [Table 3]. Similar findings were noted in a study done by Kalkal et al. and Gadappa et al. in their respective studies.
Most of the patients were term patients (41.17%) in the current study, the mean gestational age being 38 weeks [Table 4]. This is comparable with most of the studies done in the past such as those of Nalini and Singh, Vachhani and Virkud, Allahdin et al., and Tariq et al. [Table 12]. Gestational age at presentation in our study ranged between 31.4 and 41.6 weeks.
The average birth weight in our study was 2.8 kg (range 1.9–4.2) [Table 5]. This can be compared with a study done by Kalkal et al. [Table 13]. Babies with more birth weight lead to an atonic uterus due to its overdistension. This is seen in a study done by Allahdin et al., in which the average birth weight of babies was 3.5 kg [Table 13]. The average birth weight in our study was less probably due to patients coming from lower socio-economic status and more patients with severe preeclampsia that leads to intrauterine growth restriction and less birth weight.
Causative factors for primary postpartum hemorrhage
Severe preeclampsia was the major cause leading to atonic PPH in our study [Table 6]. [Table 14] shows the comparison of different factors discussed in various studies resulting in atonic PPH. In most of the studies, it is noted that severe preeclampsia was the most predominant factor responsible for atonic PPH except for studies done by Nalini and Singh and Kalkal et al., in which prolonged labor was the major cause.
The average blood loss in the current study was 1450 mL with a range between 1000 and 2500 mL. Most of the patients (52.94%) had a blood loss in the range of 1000–1500 mL [Table 7]. This is comparable with a study done by Kalkal et al., Gadappa et al., and Tariq et al., in which the majority of patients had blood loss in the range of 1000–1500 mL. Extensive blood loss (range, 2,000–10,000 mL) was seen in a study done by Allahdin et al. [Table 12]. The less amount of blood loss in our study contributes to the timely decision of abandoning the medical line of management and going for compression suture application. This decision plays a major role in the amount of blood loss as well as the amount of blood transfused to the patients.
The present study showed 100% conservation of the uterus mostly by the B-Lynch technique and in some cases by additional uterine devascularization techniques [Tables 9] and . Success of 100% was also observed in studies done by Kalkal et al., Hackethal et al., and Pal et al. [Table 15]. On average, the success rate varied between 82% and 95% in most of the studies [Table 15]. The difference in the success rate in various studies may be due to variations in the patient selection criteria.
In a study conducted by Kulsange and co-workers, out of the 50 patients who had undergone B-Lynch brace suture, 2 had a post-operative fever and 1 patient had wound gape. Similarly, in studies done by Gadappa et al. and Ghodke et al., post-operative pyrexia was seen in four and five patients, respectively, and wound gape was seen in two and three patients, respectively [Table 16]. In the current study, out of the 34 patients, 3 patients had post-operative fever, 3 patients had wound gape, and 1 patient had abdominal wall hematoma [Table 11]. All patients were effectively managed in our study. Major complication was not seen in any of the above-mentioned studies.
However, literature has shown few isolated cases. Joshi and Shrivastava reported partial ischemic necrosis of the uterus following 12 h after cesarean section with B-Lynch sutures, and a case of fundal necrosis on post-operative day 8 following post-compression sutures has been described by Gottlieb et al.
| Conclusion|| |
The present study emphasizes the use of B-Lynch brace suture as an effective alternative surgical treatment in the management of primary atonic PPH, refractory to medical line of management. It is an easy procedure and simple to apply within a very short time. It can be labeled as a lifesaving procedure that stops blood loss almost instantly in the majority of cases and preserves future fertility. To conclude, B-Lynch brace suture should be used prophylactically in patients who are at higher risk of atonic PPH. The post-graduate students, all trainees, and registrars in Obstetrics and Gynecology should be taught the procedure so that it can be effectively used during emergencies.
The Institutional Ethics Committee has approved the proposal to undertake the clinical study entitled: “B Lynch compression brace suture: A stitch in time saves a life” at its meeting held on March 6, 2020 communicated vide letter no. IEC/2020/684 dated March 6, 2020.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stirrat GM Confidential enquiries into maternal deaths in the UK 1991–1993: Lessons for risk management. AVMA Med Legal J 1997;3:9-14.
Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF WHO analysis of causes of maternal death: A systematic review. Lancet 2006;367:1066-74.
World Health Organization, Department of Making Pregnancy Safer. Making pregnancy safer: A newsletter of worldwide activity. Hot Topics 2007:8. Available from: https://www.afro.who.int/sites/default/files/2017-06/mps%20newsletter_issue4.pdf
Rastogi A Postpartum haemorrhage. National Health Portal of India. Last updated: March 16, 2017. Available from: http://nhp.gov.in/disease/gynaecology-and-obstetrics/postpartum-haemorrhage
. [Last accessed on 16 Mar 2017].
Edmonds DK Third stage of labour and abnormalities. In: Edmonds K, ed. Dewhurst′s Textbook of Obstetrics and Gynaecology for Postgraduates. 6th ed. London: Wiley–Blackwell; 1999. p. 640.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: Postpartum hemorrhage. Obstet Gynecol 2006;108:1039-47.
Christopph L, Campbell S Obstetrics by Ten Teachers. 17th ed. London: Hodder Arnold H&S; 2000. p. 308.
Mousa HA, Walkinshaw S Major postpartum haemorrhage. Curr Opin Obstet Gynecol 2001;13:595-603.
Lynch C, Coker A, Larval A, Abul J, Cowen L The B-Lynch surgical technique for the control of massive postpartum haemorrhage, an alternative to hysterectomy: Five cases reported. Br J Obstet Gynaecol 1997;104:372-5.
Hayman R, Arulkumaran S, Steer PJ Uterine compression sutures: Surgical management of PPH. Obstet Gynecol 2002;99:502-6.
Cho JH, Ion HS, Lee CN Hemostatic suturing technique for uterine bleeding during caesarean delivery. Obstet Gynecol 2000;96:129-31.
Price N, B-Lynch C Technical description of the B-Lynch brace suture for treatment of massive postpartum haemorrhage and review of published cases. Int J Fertil Womens Med 2005;50:148-63.
Kalyankar V, Kalyankar B, Yelikar K, Kulsange P Assessment of efficacy of modified Balogun-Lynch stitch in management of atonic post-partum haemorrhage. Int J Biomed Adv Res 2014;5:258-61.
Nalini N, Singh JK B-Lynch suture—An experience. J Obstet Gynecol 2010;60:128-34.
Kalkal N, Sarmalkar MS, Nayak AH The effectiveness of B-Lynch sutures in management of atonic postpartum haemorrhage during caesarean section. Int J Reprod Contracept Obstet Gynecol 2016;5:2915-20.
Vachhani M, Virkud A Prophylactic B-Lynch suturing emergency caesarean section in women at high risk of uterine atony: A pilot study. Internet J Gynecol Obstet 2006;7:1-5.
Koh E, Devendra K, Tan LK B-Lynch suture for the treatment of uterine atony. Singapore Med J 2009;50:693-7.
Gadappa SN, Gavit YB, Sharma D, Mahajan R Study of the efficacy of compression suture in the surgical management of atonic PPH. Int J Reprod Contracept Obstet Gynecol 2018;7:4261-6.
Allahdin S, Aird C, Danielian P B-Lynch sutures for major primary postpartum haemorrhage at caesarean section. J Obstet Gynaecol 2006;26:639-42.
Tariq S, Wazir S, Moeen G Efficacy of B-Lynch brace suture in postpartum haemorrhage. Ann King Edward Med Univ 2011;17:116.
Hackethal A, Bruggmann D, Oehmke F, Tinneberg HR Uterine compression sutures in primary PPH after caesarean section: Fertility preservation with a simple and effective technique. Human Reprod 2008;23:74-9.
Pal M, Biswas A, Bhattacharya S B-Lynch brace suturing in primary post-partum haemorrhage during cesarean section. J Obstet Gynaecol Res 2003;29:317-20.
Ghodke VB, Pandit SN, Umbardand SM. Role of modified B-Lynch suture in modern-day management of atonic PPH. Bombay Hosp J 2008;50:205-10.
Joshi VM, Shrivastava M Partial ischemic necrosis of the uterus following a uterine brace compression suture. BJOG 2004;111: 279-80.
Gottlieb AG, Pandipati S, Davis KM, Gibbs RS Uterine necrosis: A complication of uterine compression sutures. Obstet Gynecol 2008;112:429-31.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16]