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Hemostatic cervical suturing technique for management of uncontrollable postpartum haemorrhage originating from the cervical canal
European Journal of Obstetrics & Gynecology and Reproductive Biology 110 (2003) 35–38
Hemostatic cervical suturing technique for management of uncontrollable postpartum haemorrhage originating from the cervical canal Hasan Kafalia,*, Nurettin Demira, Feride Soylemezb, Seniz Yurtsevena a
Department of Obstetrics & Gynecology, Harran University, Medical School, 63100 Sanlıurfa, Turkey b Department of Obstetrics & Gynecology, Ankara University, Medical School, Ankara, Turkey Received 17 October 2002; received in revised form 21 October 2002; accepted 9 January 2003
Abstract Objective: To evaluate the efficacy and safety of a novel cervical suturing technique for management of uncontrollable postpartum haemorrhage originating from the cervical canal. Study design: Cervical suturing was performed on three women to control intractable postpartum haemorrhage originating from the cervical canal and not responding to classic management. Haemostatic cervical suturing by using no. 1 chromic catgut is a new surgical technique which approximates anterior and posterior cervical lips. It controls cervical haemorrhage by attachment and compression of the haemorrhage site of the cervical lips and lower uterine segment. Results: The procedure was effective in all cases and hysterectomy was not needed in any case. No complication occurred and the survival rate was 100%. The procedure required no special expertise or extraordinary equipment. Conclusion: Cervical suturing technique for management of postpartum haemorrhage originating from the cervical canal is an easy, safe and highly effective conservative surgical technique that may be alternative to hysterectomy. # 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Cervical suturing; Postpartum haemorrhage; Prostaglandins
1. Introduction In industrialized countries, and particularly in the developing world, severe postpartum haemorrhage is an important cause of maternal mortality and death [1,2]. Once uterine inertia and retained placenta have been excluded, efforts must be directed at exploration of upper and lower genital tract lacerations and maintaining hemodynamic stability. Traditionally, when uterine massage, oxytocin, methergine, and prostaglandin therapies fail to halt blood loss, the physician must resort to some sort of invasive procedures that obstruct the blood supply to the uterus either surgically by vessel ligation or radiologically by embolisation of the vessels. The success rates of these procedures are variable, and many times hysterectomy is ultimately required [3]. Cervical lacerations up to 2 cm must be regarded as inevitable in childbirth. Such tears heal rapidly and are rarely source of any difficulty. However, on rare occasions, lacerations at the level of internal os [4], placental implantation in the noncontractile cervical segment of the uterus [5], cervi*
Corresponding author. Tel.: þ90-414-314-21-59; fax: þ90-414-316-88-21. E-mail address: [email protected] (H. Kafali).
cal varices [6], and inner myometrial lacerations [7] may present challenges during and after the third stage of labour. Bleeding originating from the cervical canal should always be suspected, particularly if the uterus is firmly contracted. We have used cervical suturing technique on three women for control of acute, profuse cervical haemorrhage.
2. Materials and methods The study was performed at Obstetrics and Gynaecology Department, Faculty of Medicine, Harran University, from July 1999 to Aug 2001. Three women with the ages of 21, 38, and 30 years underwent cervical suturing for control of profuse cervical haemorrhage. We present two cases of profuse haemorrhage following normal vaginal deliveries and one case of severe haemorrhage following labour induction with misoprostol for management of intrauterine fetal demise. Although an infusion of 40 U of oxytocin in 500 ml saline and intravenous ergometrine (500 ml) was started after the delivery of the babies, according to our unit’s protocol, all three women had persistent profuse bleeding in the presence of a firmly contracted uterus. For definitive diagnosis a thorough examination was made. Best exposure was gained
0301-2115/$ – see front matter # 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0301-2115(03)00104-0
36
H. Kafali et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 110 (2003) 35–38
Fig. 1. (A) Start of cervical suturing procedure with a suture of number 1 catgut being placed superiorly thorough the lips of cervix very near the level of the cervicovesical reflection; (B) tying of two free ends anteriorly; (C) completion of procedure by tying suture ends after needles are passed thorough same points.
by use of right-angle vaginal retractor by an assistant while the operator grasped the anterior and posterior lips of cervix with a ring forceps. Any cervical or vaginal tear or cervical lesion which could be the cause of the haemorrhage was not found. The uterine cavity was explored manually to exclude retained placental fragments and uterine rupture. Because of persistent profuse bleeding (estimated blood loss was 1000, 1400 and 1300 ml, respectively), the patient’s blood pressure fell to 80/ 50, 60/40 and 90/50, respectively, and their medical status was getting worse. Repeated examinations revealed that haemorrhage was continuing from inside of the uterus despite a firm, well-contracted uterus. Therefore, we resorted other means to control the bleeding simultaneously providing volume and blood replacement to the women (each patient received two units of blood perioperatively), Foley catheter insertion into the cervical canal and lower uterine segment packing were tried but these procedures were completely unsuccessful in two cases and partially successful in one case. Finally, after obtaining informed consent from all patients and their next of kin, the cervix of these women was sutured with catgut as described below. 2.1. Procedure Adequate anaesthesia and good exposure of surgical field were keyed. Under intravenous propofol anaesthesia, visualisation of the full circumference of cervix was best accomplished by application of firm downward pressure on the uterus while the operator was exerting traction on the lips of the cervix with fenestrated ovum forceps. The vaginal walls were held apart with retractors manipulated with the aid of the assistant. The operation was initiated with determination of the cervicovesical reflection by a metal urinary catheter to avoid inadvertent bladder entry and two lubricated no. 1 catgut sutures were selected as suture material. The needles were passed from anterior to posterior on each side of the cervix with the needles transversing the cervical lips (Fig. 1A). The sutures were placed as close to the cervicovesical reflection as possible anteriorly and as high as
possible without transversing the pouch of Douglas posteriorly. Knots were placed anteriorly with free ends left long enough to allow easy tying. After tying of two free ends anteriorly (Fig. 1B), needles were passed through the same points of cervix from anterior to posterior. Sutures were tightened sufficiently to reduce the cervical canal as much as possible and were then securely tied posteriorly (Fig. 1C). All women were administered a broad spectrum antibiotic and uterine contractions were stimulated by intravenous oxytocin (40 U in 1 l of lactated Ringer’s solution 200 ml/h) during postpartum 24 h continuously. All women were followed till the postpartum 48 h; then, sutures were opened and observed for vaginal bleeding.
3. Results All three women had their haemorrhage arrested dramatically after cervical suture placement and then the patient’s blood pressure which had fallen, recovered rapidly. All three patients had a firmly contracted uterus and minimal oozing type bleeding which lasted not more than a few hours after procedure. Hysterectomy or other treatment modality was not needed in any case. On the postpartum 48 h when the sutures were opened, 100–150 cm3 gush of blood product were drained but active bleeding had been stopped. Any cervical lesion that may be cause of cervical bleeding was not detected via inspection. In all women, cervical lips were ischemic in appearance but resolved within four days. No complication occurred and the survival rate was 100%. Any case of infection or cervical pathology attributable to this technique such as cervical stenosis was not detected during the follow-up period. Normal menstruation resumed in all women.
4. Discussion Postpartum haemorrhage might lead to severe postpartum anaemia and hemorrhagic shock requiring blood transfu-
H. Kafali et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 110 (2003) 35–38
sions or surgical interventions to stop uncontrolled bleeding [8]. However, there are many factors of importance, singly or in combination in the genesis of postpartum haemorrhage, uterine atony and lacerations of genital tract are the most common cause of immediate haemorrhage. The differentiation between bleeding from uterine atony and from lacerations is tentatively made on the condition of the uterus. If bleeding persists despite a firm, well-contracted uterus, the cause of the haemorrhage most probably is lacerations. To ascertain the role of lacerations as a cause of bleeding, careful inspection of vagina, cervix, and uterus is essential. Slight degrees of cervical laceration must be regarded as an inevitable accompaniment of childbirth. Commonly, lacerations of the cervix at both 3 and 9 o’clock are noted. Significant lacerations are most prone to occur in association with an instrumental delivery, intrauterine manipulation, tumultuous and precipitous labour. However, prostaglandins are known to be useful in the treatment of severe postpartum haemorrhage; they can also cause severe cervical lacerations and postpartum haemorrhage by themselves. So, use of a lower dose of the medication as well as tocodynamometry is recommended [9].On rare occasions, local bleeding sites located in cervical canal can present a challenge and cannot be visualised due to its location and active profuse bleeding. Schuitemaker and Mackenzie [4] reported that laceration in the endocervical canal at the level of internal os may be the cause of severe postpartum haemorrhage. Hayashi et al. [7] have stated another cause of postpartum haemorrhage which has been called inner myometrial laceration and develops on the uterine cervix when the stress on the uterine muscle is stronger than a specific value. Although we could not determine the exact cause of cervical haemorrhage of our cases, there was a strong evidence of cervical mucosal avulsions which may be result of inadvertent grasping of cervix by inexperienced assistant in two cases and inner myometrial laceration which may be result of over dose prostaglandin application by a mistake in one case. Women in whom haemorrhage is refractory to conservative measures, another therapeutic manoeuvres including packing of lower uterine segment with gauze or Foley catheter insertion into the cervical canal and lower uterine segment may be employed before further invasive procedure that obstruct the blood supply of uterus or hysterectomy be performed [10,11]. In this study, Foley catheter insertion into cervical canal and lower uterine segment packing were tried but these procedures were completely unsuccessful in two cases and partially successful in one case. To our knowledge, there is only one article related to the cervical suturing for management of postpartum haemorrhage which was reported by Balak and Pokorny in 1984 but we could not reach original article and could not learn how and for what cervical suturing was made [12]. In fact, we were not aware of it when we decided to employ our novel technique for this situation. Hemostatic suturing technique used for uterine bleeding in case of uterine inertia has inspired us with hope to be applicable to the cervical haemor-
37
rhage [13,14]. It was reported that B-lynch suture are likely to reduce the blood flow to the uterus from its lateral margin and may also occlude placental blood vessel by the apposition of the anterior and posterior walls [14,15]. In a similar way our new surgical technique approximates anterior and posterior lips of cervix especially in areas where there is heavy bleeding, then control the haemorrhage by attachment and compression of the bleeding site of the cervix. Descending branch of uterine artery might also be obstructed by this technique and it might provide additional benefit. However, both B-lynch surgical suturing technique and our cervical suturing technique have a similar mechanism of action, each having different indications. B-lynch sutures are used when the postpartum haemorrhage is due to uterine atony and these sutures compress the uterus vertically; on the other hand, exclusion of uterine atony is mandatory for application of cervical suturing technique, which is used in case of cervical haemorrhage, compresses the cervix transversely. In search for probable objections to the practice of cervical suturing, four can be identified. That the procedure is unphysiologic cannot be denied, but this objection can be set aside for lack of specific scientific relevance. The other three objections may be concealed retrograde haemorrhage, infection, and cervical lips necrosis and separation. Concealed haemorrhage is unlikely if uterine contraction is stimulated properly, however, improperly stimulated uterus may invite continuation of the haemorrhage because accumulation of blood in the uterine cavity can cause uterine inertia. In our cases, uterine contractions were stimulated by continuous oxytocin infusion during postpartum 24 h and no case of retrograde haemorrhage was detected. The potential for infection seems likely when the uterine cavity is filled with a blood. But it was lessened by administration of prophylactic antibiotic and removal of the cervical sutures about within two days of suturing. Although we have not encountered with it in any case, lowered perfusion of cervix after suturing may result in ischemia sufficiently severe that the cervical lips can undergo necrosis and separation. Therefore, cervical sutures should be removed within two days. In conclusion, this novel cervical suturing technique for management of haemorrhage originated from cervical canal is an easy, safe and highly effective conservative surgical technique which can preclude further invasive approach.
Acknowledgements We thanks Dr. Dogan Unal for preparing the figures.
References [1] Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the United States, 1987–1990. Obstet Gynecol 1996; 88:161–7.
38
H. Kafali et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 110 (2003) 35–38
[2] Li XF, Fortney JA, Kotelchuck M, Glover LH. Postpartum period: the key to maternal mortality. Int J Gynecol Obstet 1996;54:1–10. [3] Hansch E, Chitkara U, McAlpine J, El-Sayed Y, Dake MD, Razavi MK. Pelvic arterial embolization for control of obstetric haemorrhage: a five-year experience. Am J Obstet Gynecol 1999;180:1454–60. [4] Schuitemaker NW, Mackenzie MR. Postpartum haemorrhage due to a laceration in the endocervical canal. Eur J Obstet Gynecol Reprod Biol 1989;30:183–5. [5] Bowen LW, Beeson JH. Use of large Foley catheter balloon to control postpartum hemorhage resulting from a low placental implantation. J Reprod Med 1985;30:623–5. [6] Hurton T, Morrill H, Mascola M, York C, Bromley B. Cervical varices: an unusual etiology for third-trimester bleeding. J Clin Ultrasound 1998;26:317–9. [7] Hayashi M, Mori Y, Nogami K, Takagi Y, Yaoi M, Ohkura T. A hypothesis to explain the occurrence of inner myometrial laceration causing massive postpartum hemorhage. Acta Obstet Gynecol Scand 2000;79:99–106. [8] Surbek DV, Fehr PM, Ho¨ sli I, Holzgreve W. Oral misoprostol for third stage of labour. Obstet Gynecol 1999;94:255–7.
[9] Kent DR, Goldstein AI, Linzey EM. Safety and efficiency of vaginal prostaglandin E2 suppositories in the management of third-trimester fetal demise. Reprod Med 1984;29:101–2. [10] Durizin ML. Packing of lower uterine segment for control of postcesarean bleeding in instance of placenta previa. Surg Gynecol Obstet 1989;169:543–5. [11] Goldrath MH. Uterine tamponade for the control of acute uterine bleeding. Am J Obstet Gynecol 1983;147:869–72. [12] Balak K, Pokorny P. Urgent suture of the cervix for haemorrhage after childbirth. Gynecology 1984;49:263–6. [13] Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000; 96:129–31. [14] Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum hemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372–5. [15] Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorhage. Obstet Gynecol 2002;99:502–6.
Hemostatic cervical suturing technique for management of uncontrollable postpartum haemorrhage originating from the cervical canal Hasan Kafalia,*, Nurettin Demira, Feride Soylemezb, Seniz Yurtsevena a
Department of Obstetrics & Gynecology, Harran University, Medical School, 63100 Sanlıurfa, Turkey b Department of Obstetrics & Gynecology, Ankara University, Medical School, Ankara, Turkey Received 17 October 2002; received in revised form 21 October 2002; accepted 9 January 2003
Abstract Objective: To evaluate the efficacy and safety of a novel cervical suturing technique for management of uncontrollable postpartum haemorrhage originating from the cervical canal. Study design: Cervical suturing was performed on three women to control intractable postpartum haemorrhage originating from the cervical canal and not responding to classic management. Haemostatic cervical suturing by using no. 1 chromic catgut is a new surgical technique which approximates anterior and posterior cervical lips. It controls cervical haemorrhage by attachment and compression of the haemorrhage site of the cervical lips and lower uterine segment. Results: The procedure was effective in all cases and hysterectomy was not needed in any case. No complication occurred and the survival rate was 100%. The procedure required no special expertise or extraordinary equipment. Conclusion: Cervical suturing technique for management of postpartum haemorrhage originating from the cervical canal is an easy, safe and highly effective conservative surgical technique that may be alternative to hysterectomy. # 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Cervical suturing; Postpartum haemorrhage; Prostaglandins
1. Introduction In industrialized countries, and particularly in the developing world, severe postpartum haemorrhage is an important cause of maternal mortality and death [1,2]. Once uterine inertia and retained placenta have been excluded, efforts must be directed at exploration of upper and lower genital tract lacerations and maintaining hemodynamic stability. Traditionally, when uterine massage, oxytocin, methergine, and prostaglandin therapies fail to halt blood loss, the physician must resort to some sort of invasive procedures that obstruct the blood supply to the uterus either surgically by vessel ligation or radiologically by embolisation of the vessels. The success rates of these procedures are variable, and many times hysterectomy is ultimately required [3]. Cervical lacerations up to 2 cm must be regarded as inevitable in childbirth. Such tears heal rapidly and are rarely source of any difficulty. However, on rare occasions, lacerations at the level of internal os [4], placental implantation in the noncontractile cervical segment of the uterus [5], cervi*
Corresponding author. Tel.: þ90-414-314-21-59; fax: þ90-414-316-88-21. E-mail address: [email protected] (H. Kafali).
cal varices [6], and inner myometrial lacerations [7] may present challenges during and after the third stage of labour. Bleeding originating from the cervical canal should always be suspected, particularly if the uterus is firmly contracted. We have used cervical suturing technique on three women for control of acute, profuse cervical haemorrhage.
2. Materials and methods The study was performed at Obstetrics and Gynaecology Department, Faculty of Medicine, Harran University, from July 1999 to Aug 2001. Three women with the ages of 21, 38, and 30 years underwent cervical suturing for control of profuse cervical haemorrhage. We present two cases of profuse haemorrhage following normal vaginal deliveries and one case of severe haemorrhage following labour induction with misoprostol for management of intrauterine fetal demise. Although an infusion of 40 U of oxytocin in 500 ml saline and intravenous ergometrine (500 ml) was started after the delivery of the babies, according to our unit’s protocol, all three women had persistent profuse bleeding in the presence of a firmly contracted uterus. For definitive diagnosis a thorough examination was made. Best exposure was gained
0301-2115/$ – see front matter # 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0301-2115(03)00104-0
36
H. Kafali et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 110 (2003) 35–38
Fig. 1. (A) Start of cervical suturing procedure with a suture of number 1 catgut being placed superiorly thorough the lips of cervix very near the level of the cervicovesical reflection; (B) tying of two free ends anteriorly; (C) completion of procedure by tying suture ends after needles are passed thorough same points.
by use of right-angle vaginal retractor by an assistant while the operator grasped the anterior and posterior lips of cervix with a ring forceps. Any cervical or vaginal tear or cervical lesion which could be the cause of the haemorrhage was not found. The uterine cavity was explored manually to exclude retained placental fragments and uterine rupture. Because of persistent profuse bleeding (estimated blood loss was 1000, 1400 and 1300 ml, respectively), the patient’s blood pressure fell to 80/ 50, 60/40 and 90/50, respectively, and their medical status was getting worse. Repeated examinations revealed that haemorrhage was continuing from inside of the uterus despite a firm, well-contracted uterus. Therefore, we resorted other means to control the bleeding simultaneously providing volume and blood replacement to the women (each patient received two units of blood perioperatively), Foley catheter insertion into the cervical canal and lower uterine segment packing were tried but these procedures were completely unsuccessful in two cases and partially successful in one case. Finally, after obtaining informed consent from all patients and their next of kin, the cervix of these women was sutured with catgut as described below. 2.1. Procedure Adequate anaesthesia and good exposure of surgical field were keyed. Under intravenous propofol anaesthesia, visualisation of the full circumference of cervix was best accomplished by application of firm downward pressure on the uterus while the operator was exerting traction on the lips of the cervix with fenestrated ovum forceps. The vaginal walls were held apart with retractors manipulated with the aid of the assistant. The operation was initiated with determination of the cervicovesical reflection by a metal urinary catheter to avoid inadvertent bladder entry and two lubricated no. 1 catgut sutures were selected as suture material. The needles were passed from anterior to posterior on each side of the cervix with the needles transversing the cervical lips (Fig. 1A). The sutures were placed as close to the cervicovesical reflection as possible anteriorly and as high as
possible without transversing the pouch of Douglas posteriorly. Knots were placed anteriorly with free ends left long enough to allow easy tying. After tying of two free ends anteriorly (Fig. 1B), needles were passed through the same points of cervix from anterior to posterior. Sutures were tightened sufficiently to reduce the cervical canal as much as possible and were then securely tied posteriorly (Fig. 1C). All women were administered a broad spectrum antibiotic and uterine contractions were stimulated by intravenous oxytocin (40 U in 1 l of lactated Ringer’s solution 200 ml/h) during postpartum 24 h continuously. All women were followed till the postpartum 48 h; then, sutures were opened and observed for vaginal bleeding.
3. Results All three women had their haemorrhage arrested dramatically after cervical suture placement and then the patient’s blood pressure which had fallen, recovered rapidly. All three patients had a firmly contracted uterus and minimal oozing type bleeding which lasted not more than a few hours after procedure. Hysterectomy or other treatment modality was not needed in any case. On the postpartum 48 h when the sutures were opened, 100–150 cm3 gush of blood product were drained but active bleeding had been stopped. Any cervical lesion that may be cause of cervical bleeding was not detected via inspection. In all women, cervical lips were ischemic in appearance but resolved within four days. No complication occurred and the survival rate was 100%. Any case of infection or cervical pathology attributable to this technique such as cervical stenosis was not detected during the follow-up period. Normal menstruation resumed in all women.
4. Discussion Postpartum haemorrhage might lead to severe postpartum anaemia and hemorrhagic shock requiring blood transfu-
H. Kafali et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 110 (2003) 35–38
sions or surgical interventions to stop uncontrolled bleeding [8]. However, there are many factors of importance, singly or in combination in the genesis of postpartum haemorrhage, uterine atony and lacerations of genital tract are the most common cause of immediate haemorrhage. The differentiation between bleeding from uterine atony and from lacerations is tentatively made on the condition of the uterus. If bleeding persists despite a firm, well-contracted uterus, the cause of the haemorrhage most probably is lacerations. To ascertain the role of lacerations as a cause of bleeding, careful inspection of vagina, cervix, and uterus is essential. Slight degrees of cervical laceration must be regarded as an inevitable accompaniment of childbirth. Commonly, lacerations of the cervix at both 3 and 9 o’clock are noted. Significant lacerations are most prone to occur in association with an instrumental delivery, intrauterine manipulation, tumultuous and precipitous labour. However, prostaglandins are known to be useful in the treatment of severe postpartum haemorrhage; they can also cause severe cervical lacerations and postpartum haemorrhage by themselves. So, use of a lower dose of the medication as well as tocodynamometry is recommended [9].On rare occasions, local bleeding sites located in cervical canal can present a challenge and cannot be visualised due to its location and active profuse bleeding. Schuitemaker and Mackenzie [4] reported that laceration in the endocervical canal at the level of internal os may be the cause of severe postpartum haemorrhage. Hayashi et al. [7] have stated another cause of postpartum haemorrhage which has been called inner myometrial laceration and develops on the uterine cervix when the stress on the uterine muscle is stronger than a specific value. Although we could not determine the exact cause of cervical haemorrhage of our cases, there was a strong evidence of cervical mucosal avulsions which may be result of inadvertent grasping of cervix by inexperienced assistant in two cases and inner myometrial laceration which may be result of over dose prostaglandin application by a mistake in one case. Women in whom haemorrhage is refractory to conservative measures, another therapeutic manoeuvres including packing of lower uterine segment with gauze or Foley catheter insertion into the cervical canal and lower uterine segment may be employed before further invasive procedure that obstruct the blood supply of uterus or hysterectomy be performed [10,11]. In this study, Foley catheter insertion into cervical canal and lower uterine segment packing were tried but these procedures were completely unsuccessful in two cases and partially successful in one case. To our knowledge, there is only one article related to the cervical suturing for management of postpartum haemorrhage which was reported by Balak and Pokorny in 1984 but we could not reach original article and could not learn how and for what cervical suturing was made [12]. In fact, we were not aware of it when we decided to employ our novel technique for this situation. Hemostatic suturing technique used for uterine bleeding in case of uterine inertia has inspired us with hope to be applicable to the cervical haemor-
37
rhage [13,14]. It was reported that B-lynch suture are likely to reduce the blood flow to the uterus from its lateral margin and may also occlude placental blood vessel by the apposition of the anterior and posterior walls [14,15]. In a similar way our new surgical technique approximates anterior and posterior lips of cervix especially in areas where there is heavy bleeding, then control the haemorrhage by attachment and compression of the bleeding site of the cervix. Descending branch of uterine artery might also be obstructed by this technique and it might provide additional benefit. However, both B-lynch surgical suturing technique and our cervical suturing technique have a similar mechanism of action, each having different indications. B-lynch sutures are used when the postpartum haemorrhage is due to uterine atony and these sutures compress the uterus vertically; on the other hand, exclusion of uterine atony is mandatory for application of cervical suturing technique, which is used in case of cervical haemorrhage, compresses the cervix transversely. In search for probable objections to the practice of cervical suturing, four can be identified. That the procedure is unphysiologic cannot be denied, but this objection can be set aside for lack of specific scientific relevance. The other three objections may be concealed retrograde haemorrhage, infection, and cervical lips necrosis and separation. Concealed haemorrhage is unlikely if uterine contraction is stimulated properly, however, improperly stimulated uterus may invite continuation of the haemorrhage because accumulation of blood in the uterine cavity can cause uterine inertia. In our cases, uterine contractions were stimulated by continuous oxytocin infusion during postpartum 24 h and no case of retrograde haemorrhage was detected. The potential for infection seems likely when the uterine cavity is filled with a blood. But it was lessened by administration of prophylactic antibiotic and removal of the cervical sutures about within two days of suturing. Although we have not encountered with it in any case, lowered perfusion of cervix after suturing may result in ischemia sufficiently severe that the cervical lips can undergo necrosis and separation. Therefore, cervical sutures should be removed within two days. In conclusion, this novel cervical suturing technique for management of haemorrhage originated from cervical canal is an easy, safe and highly effective conservative surgical technique which can preclude further invasive approach.
Acknowledgements We thanks Dr. Dogan Unal for preparing the figures.
References [1] Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the United States, 1987–1990. Obstet Gynecol 1996; 88:161–7.
38
H. Kafali et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 110 (2003) 35–38
[2] Li XF, Fortney JA, Kotelchuck M, Glover LH. Postpartum period: the key to maternal mortality. Int J Gynecol Obstet 1996;54:1–10. [3] Hansch E, Chitkara U, McAlpine J, El-Sayed Y, Dake MD, Razavi MK. Pelvic arterial embolization for control of obstetric haemorrhage: a five-year experience. Am J Obstet Gynecol 1999;180:1454–60. [4] Schuitemaker NW, Mackenzie MR. Postpartum haemorrhage due to a laceration in the endocervical canal. Eur J Obstet Gynecol Reprod Biol 1989;30:183–5. [5] Bowen LW, Beeson JH. Use of large Foley catheter balloon to control postpartum hemorhage resulting from a low placental implantation. J Reprod Med 1985;30:623–5. [6] Hurton T, Morrill H, Mascola M, York C, Bromley B. Cervical varices: an unusual etiology for third-trimester bleeding. J Clin Ultrasound 1998;26:317–9. [7] Hayashi M, Mori Y, Nogami K, Takagi Y, Yaoi M, Ohkura T. A hypothesis to explain the occurrence of inner myometrial laceration causing massive postpartum hemorhage. Acta Obstet Gynecol Scand 2000;79:99–106. [8] Surbek DV, Fehr PM, Ho¨ sli I, Holzgreve W. Oral misoprostol for third stage of labour. Obstet Gynecol 1999;94:255–7.
[9] Kent DR, Goldstein AI, Linzey EM. Safety and efficiency of vaginal prostaglandin E2 suppositories in the management of third-trimester fetal demise. Reprod Med 1984;29:101–2. [10] Durizin ML. Packing of lower uterine segment for control of postcesarean bleeding in instance of placenta previa. Surg Gynecol Obstet 1989;169:543–5. [11] Goldrath MH. Uterine tamponade for the control of acute uterine bleeding. Am J Obstet Gynecol 1983;147:869–72. [12] Balak K, Pokorny P. Urgent suture of the cervix for haemorrhage after childbirth. Gynecology 1984;49:263–6. [13] Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000; 96:129–31. [14] Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum hemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372–5. [15] Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorhage. Obstet Gynecol 2002;99:502–6.