- Email: [email protected]
Dr. Thomas replies
' ' '
LETTERS
TO
RE: WOMEN WHO REFUSE BLOOD TRANSFUSION:
T H E
2.
UTERINE DEVASCULARIZATION FOR POST-PARTUM HAEMORRHAGE.
J Soc
0BSTET GYNAECOL CAN
1998;20(11): 1051-2. To THE EDITOR:
I'd like to make some comments about the description of a so-called novel technique for managing uncontrollable post-partum haemorrhage (PPH) with "100 percent success in 103 cases, seven of which involved both placenta and accreta." First, "uterine devascularization" was actually first described and published 20 years ago by a Russian obstetrician working in Paris as a visiting Fellow at CochinPort-Royal maternity, and from then on we called this technique of three steps uterine vessels ligation the "Tsirulnikov technique", 1•2 and many operators tum to this before going to the bilateral hypogastric artery ligation which is more technically demanding and risky. We all know too well the contribution of PPH to maternal death in developing countries is more marked in domiciliary or rural settings where trained staff are scarce, transport facilities are inadequate and the availability of uterotonicagents and blood are limited 3 but I am not naive enough to accept "a 100 percent success rate", even in the richest developed country with a technique for devascularizing the uterus but not the cervix, where all the anastomoses with the collateral circulation of the pelvis are converging (middle sacral-lateral sacral, lumbar iliolumbar and superior-middle haemorrhoidal). Sometimes you know what cold sweat means, especially in the middle of the night when you are confronted with a bleeding anterior praevia and a previous caesarean section. In France, due to the alleged risk of prion disease with catgut (plain or chronic) we do not use this material, and use instead Vicryl rapide® N 0., plain polyglactin, polydioxanone or polyglycolic material. Yours sincerely, Bernard Guyot, AIHP, ACCA,FSOGC, Gynecologue-accoucheur des Hopitaux, Saint-Germain-en-Laye, France.
3.
Taurelle R, Bauwens C, Guyot B, Coulaud JM, lcole B. Les urgences maternelles au cours et au decours de I' accouchement. Conduite pratique. Mises a jour en gynecologie obstetrique Tome VIII, 1984; pp:313-45. College National des Gynecologues Obstetriciens Francais. Vigot editeur, Paris. Gulmezoglu AM. Prostaglandins for management of the third stage of labour (Cochrane Review). In: The Cochrane Library, Issue 4, 1998. Oxford: Update Software.
To THE EDITOR:
I would like to thank Dr. Bernard Guyot for his interest, and for pointing out the "tsirulnikov technique" of uterine vessel ligation for post-partum haemorrhage. As Solomon wrote: "What has happened will happen again, and what has been done will be done again, and there is nothing new under the sun." 1 First, my information on the subject was based on recent English-language medical articles. Although the procedure I discussed cannot achieve complete uterine devascularizationas Guyot points out, the 100 percent success rate was reported by AbdRabbo based on his experience in 103 cases, which involved both placenta accreta and praevia. His references included an article by a Tsirulniko V (sic) .3 Second, the intention of my original letter was to argue prompt, expeditious and decisive intervention for cases of severe post-partum haemorrhage in "women who refuse blood transfusion." Single-stage uterine devascularization (performing all of AbdRabbo's steps in rapid succession) constitutes a relatively simple preliminary step towards hysterectomy which, if successful, could preserve both fertility and the life of the woman making an informed choice of nonblood obstetric management. As Guyot points out, the technical challenge of hypogastric artery ligation is considerable. It does not result in the complete cessation of bleeding because of the extensive pelvic collateral circulation. Embolization is an option that has a well-established place in controlling haemorrhage. There have been reports of its use prophylactically in cases of placenta accreta and praevia, and abdominal wall pregnancy. 4 However, the limitation of this technique is the requirement for early involvement of a skilled interventional radiologist. Further on the subject of blood conservation in obstetric
Tsirulnikov MS. La ligature des vaisseaux uterins au cours des hemorragies obstetricales. J Gyn Obstet Bioi Reprod 1979;8:751-3.
JOURNAL SOGC
' ' '
DR. THOMAS REPLIES
REFERENCES 1.
EDITOR
1140
OCTOBER 1999
' ' ' haemorrhage, a recent multicentre retrospective study concludes that there is "no demonstrably increased risk of complications in patients receiving autologous blood collection autotransfusion during cesarean section." 5 In summary, single-stage uterine devascularization is an effective and viable alternative before hysterectomy for many women with post-partum haemorrhage. It would be interesting to know how widespread the knowledge and use of this procedure is in Quebec, the rest of Canada, and other countries. Yours sincerely, J. Mervyn Thomas, MB, FRCSC, Nanaimo, British Columbia.
step may be the one which accounts for his high success rate. It seems to be an advisable one for women who refuse blood transfusion. Yours sincerely, J. Mervyn Thomas, MB, FRCSC, Nanaimo, British Columbia. REFERENCES 1. 2.
3.
REFERENCES 1.
2.
3. 4.
5.
The New English Bible. Standard edition. London: Oxford University Press/Cambridge University Press; 1970. Ecclesiastes 1:9. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol1994;171(3):694-700. Tsirulniko V. An operation for preserving the uterus in atonic bleeding. Agkuvepetbo Ginegkologiia 1962;6:24-6. Mitty HA, Sterling KM, Alvarez M, Gendler R. Obstetric hemorrhage: prophylactic and emergency arterial catheterization and embolotherapy. Radiology 1993;188(1 ):183-7. Rebarber A, Lonser R, Jackson S, Cope I JA, Sipes S. The safety of intraoperative autologous blood collection and autotransfusion during cesarean section. Am J Obstet Gynecol1998;179(3 Pt 1):715-20.
To THE EDITOR: An error appeared in the Committee Opinion Number 79 entitled Prenatal Genetic Screening for Down Syndrome and Open Neural Tube Defects using Maternal Serum Marker Screening. This was said to have been prepared by the SOGC/GOC/SCC Policy and Practice Guideline Committee. This statement should not have appeared in association with this committee opinion. This opinion was prepared, reviewed and approved by the members of the Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada in consultation with the Members of the Ministry of Health of Ontario Committees and approved by the Council of the SOGC. Yours sincerely, K. Milne, MD, FRCSC, Associate Executive Vice-President, SOGC, Ottawa, Ontario.
To THE EDITOR: Further to my response to Dr. Bernard Guyot's comments on the letter "Re: Women who refuse blood transfusion: uterine devascularization for post-partum haemorrhage." Copies of the two articles on the subject by Tsirulnikov, 1•2 one in Russian, the other in French, are now in my possession. His procedure differs from AbdRabbo.3 Firstly, he ties the ovarian vessels between the ovary and the uterus, whereas AbdRabbo describes mass ligation of the ovarian vessels in the infundibula-pelvic ligament, lateral to the ovary. More importantly, only AbdRabbo describes a second ligation of the uterine artery at a much lower level down the uterine wall than the initial one. This latter
JOURNAL SOGC
Tsirulnikov MS. An operation preserving the uterus in atonic bleeding. Akush Ginekol1962;6:24-6. Tsirulnikov MS. Ligation of the uterine vessels during obstetrical hemorrhages. J Gynecol Obstet Bioi Reprod 1979;8:751-3. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol1994;171 :694-700.
1141
OCTOBER 1999
LETTERS
TO
RE: WOMEN WHO REFUSE BLOOD TRANSFUSION:
T H E
2.
UTERINE DEVASCULARIZATION FOR POST-PARTUM HAEMORRHAGE.
J Soc
0BSTET GYNAECOL CAN
1998;20(11): 1051-2. To THE EDITOR:
I'd like to make some comments about the description of a so-called novel technique for managing uncontrollable post-partum haemorrhage (PPH) with "100 percent success in 103 cases, seven of which involved both placenta and accreta." First, "uterine devascularization" was actually first described and published 20 years ago by a Russian obstetrician working in Paris as a visiting Fellow at CochinPort-Royal maternity, and from then on we called this technique of three steps uterine vessels ligation the "Tsirulnikov technique", 1•2 and many operators tum to this before going to the bilateral hypogastric artery ligation which is more technically demanding and risky. We all know too well the contribution of PPH to maternal death in developing countries is more marked in domiciliary or rural settings where trained staff are scarce, transport facilities are inadequate and the availability of uterotonicagents and blood are limited 3 but I am not naive enough to accept "a 100 percent success rate", even in the richest developed country with a technique for devascularizing the uterus but not the cervix, where all the anastomoses with the collateral circulation of the pelvis are converging (middle sacral-lateral sacral, lumbar iliolumbar and superior-middle haemorrhoidal). Sometimes you know what cold sweat means, especially in the middle of the night when you are confronted with a bleeding anterior praevia and a previous caesarean section. In France, due to the alleged risk of prion disease with catgut (plain or chronic) we do not use this material, and use instead Vicryl rapide® N 0., plain polyglactin, polydioxanone or polyglycolic material. Yours sincerely, Bernard Guyot, AIHP, ACCA,FSOGC, Gynecologue-accoucheur des Hopitaux, Saint-Germain-en-Laye, France.
3.
Taurelle R, Bauwens C, Guyot B, Coulaud JM, lcole B. Les urgences maternelles au cours et au decours de I' accouchement. Conduite pratique. Mises a jour en gynecologie obstetrique Tome VIII, 1984; pp:313-45. College National des Gynecologues Obstetriciens Francais. Vigot editeur, Paris. Gulmezoglu AM. Prostaglandins for management of the third stage of labour (Cochrane Review). In: The Cochrane Library, Issue 4, 1998. Oxford: Update Software.
To THE EDITOR:
I would like to thank Dr. Bernard Guyot for his interest, and for pointing out the "tsirulnikov technique" of uterine vessel ligation for post-partum haemorrhage. As Solomon wrote: "What has happened will happen again, and what has been done will be done again, and there is nothing new under the sun." 1 First, my information on the subject was based on recent English-language medical articles. Although the procedure I discussed cannot achieve complete uterine devascularizationas Guyot points out, the 100 percent success rate was reported by AbdRabbo based on his experience in 103 cases, which involved both placenta accreta and praevia. His references included an article by a Tsirulniko V (sic) .3 Second, the intention of my original letter was to argue prompt, expeditious and decisive intervention for cases of severe post-partum haemorrhage in "women who refuse blood transfusion." Single-stage uterine devascularization (performing all of AbdRabbo's steps in rapid succession) constitutes a relatively simple preliminary step towards hysterectomy which, if successful, could preserve both fertility and the life of the woman making an informed choice of nonblood obstetric management. As Guyot points out, the technical challenge of hypogastric artery ligation is considerable. It does not result in the complete cessation of bleeding because of the extensive pelvic collateral circulation. Embolization is an option that has a well-established place in controlling haemorrhage. There have been reports of its use prophylactically in cases of placenta accreta and praevia, and abdominal wall pregnancy. 4 However, the limitation of this technique is the requirement for early involvement of a skilled interventional radiologist. Further on the subject of blood conservation in obstetric
Tsirulnikov MS. La ligature des vaisseaux uterins au cours des hemorragies obstetricales. J Gyn Obstet Bioi Reprod 1979;8:751-3.
JOURNAL SOGC
' ' '
DR. THOMAS REPLIES
REFERENCES 1.
EDITOR
1140
OCTOBER 1999
' ' ' haemorrhage, a recent multicentre retrospective study concludes that there is "no demonstrably increased risk of complications in patients receiving autologous blood collection autotransfusion during cesarean section." 5 In summary, single-stage uterine devascularization is an effective and viable alternative before hysterectomy for many women with post-partum haemorrhage. It would be interesting to know how widespread the knowledge and use of this procedure is in Quebec, the rest of Canada, and other countries. Yours sincerely, J. Mervyn Thomas, MB, FRCSC, Nanaimo, British Columbia.
step may be the one which accounts for his high success rate. It seems to be an advisable one for women who refuse blood transfusion. Yours sincerely, J. Mervyn Thomas, MB, FRCSC, Nanaimo, British Columbia. REFERENCES 1. 2.
3.
REFERENCES 1.
2.
3. 4.
5.
The New English Bible. Standard edition. London: Oxford University Press/Cambridge University Press; 1970. Ecclesiastes 1:9. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol1994;171(3):694-700. Tsirulniko V. An operation for preserving the uterus in atonic bleeding. Agkuvepetbo Ginegkologiia 1962;6:24-6. Mitty HA, Sterling KM, Alvarez M, Gendler R. Obstetric hemorrhage: prophylactic and emergency arterial catheterization and embolotherapy. Radiology 1993;188(1 ):183-7. Rebarber A, Lonser R, Jackson S, Cope I JA, Sipes S. The safety of intraoperative autologous blood collection and autotransfusion during cesarean section. Am J Obstet Gynecol1998;179(3 Pt 1):715-20.
To THE EDITOR: An error appeared in the Committee Opinion Number 79 entitled Prenatal Genetic Screening for Down Syndrome and Open Neural Tube Defects using Maternal Serum Marker Screening. This was said to have been prepared by the SOGC/GOC/SCC Policy and Practice Guideline Committee. This statement should not have appeared in association with this committee opinion. This opinion was prepared, reviewed and approved by the members of the Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada in consultation with the Members of the Ministry of Health of Ontario Committees and approved by the Council of the SOGC. Yours sincerely, K. Milne, MD, FRCSC, Associate Executive Vice-President, SOGC, Ottawa, Ontario.
To THE EDITOR: Further to my response to Dr. Bernard Guyot's comments on the letter "Re: Women who refuse blood transfusion: uterine devascularization for post-partum haemorrhage." Copies of the two articles on the subject by Tsirulnikov, 1•2 one in Russian, the other in French, are now in my possession. His procedure differs from AbdRabbo.3 Firstly, he ties the ovarian vessels between the ovary and the uterus, whereas AbdRabbo describes mass ligation of the ovarian vessels in the infundibula-pelvic ligament, lateral to the ovary. More importantly, only AbdRabbo describes a second ligation of the uterine artery at a much lower level down the uterine wall than the initial one. This latter
JOURNAL SOGC
Tsirulnikov MS. An operation preserving the uterus in atonic bleeding. Akush Ginekol1962;6:24-6. Tsirulnikov MS. Ligation of the uterine vessels during obstetrical hemorrhages. J Gynecol Obstet Bioi Reprod 1979;8:751-3. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol1994;171 :694-700.
1141
OCTOBER 1999