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Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment
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OBSTETRICS
Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment Souhail Alouini, MD, PhD; Sekou Coly, MD; Pascal Mégier, MD; Bruno Lemaire, MD; Louis Mesnard, MD; Alain Desroches, MD OBJECTIVE: The purpose of this study was to evaluate the efficiency
and morbidity of multiple square sutures in severe postpartum hemorrhage. STUDY DESIGN: A retrospective study encompassed 30 multiple square sutures that were performed for severe postpartum hemorrhage in 26,605 deliveries in a tertiary maternity center. The main outcome measures were the ability to stop hemorrhage and the assessment of the uterine cavity by hysteroscopy at 3 months. RESULTS: Multiple square sutures stopped postpartum hemorrhage in
28 of 30 cases (93%). Twenty women underwent hysteroscopy after multiple square sutures. Eight women (40%) did not have intrauterine adhesions. Nine women (45%) had thin and localized intrauterine adhe-
sions that were removed easily by the tip of the hysteroscope; 2 women had moderate intrauterine adhesions that were resected. One patient had endometritis followed by severe intrauterine adhesions. CONCLUSION: Multiple square sutures are effective and safe for the
control of severe postpartum hemorrhage and for uterine conservation in most cases. Although some patients had moderate or severe adhesions, a normal uterine cavity or minimal intrauterine adhesions that were removed easily were the most frequent findings at hysteroscopy. A prospective study may be helpful to compare the safety and efficiency of square and brace sutures. Key words: fertility, hysteroscopy, intrauterine adhesion, multiple square sutures, postpartum hemorrhage, uterine conservation
Cite this article as: Alouini S, Coly S, Mégier P, et al. Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment. Am J Obstet Gynecol 2011;205:335.e1-6.
P
ostpartum hemorrhage (PPH) is a high-risk obstetric situation for obstetrics and anesthetics teams as it can rapidly evolve into major and uncontrolled blood loss that can jeopardize the mother’s life. Obstetric hemorrhage is a major cause of maternal death and morbidity worldwide. It is the primary cause of maternal death in developing countries and among the leading causes of maternal death in developed countries.1,2 Although many therapies are effective in controlling PPH (such as oxytocin and prostaglandins),3 in some cases, it remains a dramatic problem that requires hysterectomy before irreversible
From the Department of Obstetrics and Gynecology, Centre Hospitalier Régional d’Orléans, Orléans, France. Received Jan. 15, 2011; revised March 12, 2011; accepted May 3, 2011. Reprints: Souhail Alouini, MD, PhD, Regional Hospital Center of Orléans, Obstetrics and Gynecology, 1 porte Madeleine, Orléans 45000, France. [email protected]. 0002-9378/$36.00 © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.05.006
coagulation problems arise that could lead to maternal death. Numerous therapies and surgical techniques have been developed to conserve the uterus because, in many cases, this is the first delivery for the patient. Different forms of vascular ligations (iliac, uterine, ovarian) that have been designed to interrupt the blood flow in the uterus have been practiced with variable rates of success.4,5 Uterine embolization is particularly useful in PPH after vaginal delivery6; however, the patient must be hemodynamically stable with a radiology team available and near the delivery room. More recently, uterine compression sutures have been used to stop PPH. Two such techniques are the B-Lynch sutures (brace sutures)7 and multiple squares sutures that have been described by Cho et al.8 Although there are few data concerning uterine compression sutures, they seem to give good results for controlling PPH. In the study published by Cho et al, the technique of multiple square sutures was easy to perform and allowed for the control of severe PPH and uterine conservation. However, there are few data con-
cerning the long-term outcomes of multiple square sutures. Multiple square sutures to stop PPH were introduced in our maternity ward in 2004. We aimed to evaluate the efficiency of multiple square sutures on the control of PPH and their impact on the uterine cavity of our patients.
M ATERIALS AND M ETHODS The cases of women with PPH who underwent uterine square suture procedures between 2004 and 2010 were reviewed retrospectively. All procedures were performed in the Regional Hospital Centre of Orléans. Our maternity ward is a tertiary center (with a neonatal unit) and performs approximately 4200 deliveries each year. The rate of cesarean section delivery varies between 18% and 19.6%. Hemostatic uterine square sutures were performed for major and uncontrolled PPH (defined as ⬎1 L of blood loss) after the failure of medical treatment (oxytocin, prostaglandin, uterine massage). Hemostatic square sutures were applied during a cesarean section delivery or after vaginal deliv-
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TABLE 1
Maternal characteristics for uterine square sutures and risk factors No. of women who underwent % of uterine square sutures women
n ⴝ 30 Maternal characteristics
.....................................................................................................................................................................................................................................
Age, y
............................................................................................................................................................................................................................
⬍20
2
7
............................................................................................................................................................................................................................
20-24
2
7
25-29
10
33
30-35
10
33
36-40
6
20
............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ .....................................................................................................................................................................................................................................
Origin
............................................................................................................................................................................................................................
French
23
77
Sub-Saharan Africa
5
17
North Africa
2
7
............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ..............................................................................................................................................................................................................................................
Clinical risk factors
.....................................................................................................................................................................................................................................
Parity
............................................................................................................................................................................................................................
Primiparous
11
37
Mutiparous without previous cesarean
10
33
9
30
............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................
Multiparous with previous cesarean
..............................................................................................................................................................................................................................................
Gestational age, wks
.....................................................................................................................................................................................................................................
ⱖ35
22
73
30-34 ⫹6
6
20
⬍30
2
7
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
deliveries, a laparotomy was carried out when PPH was too severe and extensive or because hemodynamic instability did not allow for embolization. A hysteroscopy at 3 months was proposed for all patients who underwent hemostatic uterine square sutures to assess the uterine cavity and the cervical channel and to look for eventual uterine complications. A 5-mm diameter hysteroscope (Karl Storz GmbH & Co, Tuttlingen, Germany) was used with saline solution. In cases in which endoscopic surgery was needed, the operative hysteroscope was a 9-mm diameter (Karl Storz GmbH & Co) with a glycocoll or saline solution. The instruments that were used were monopolar hooks and scissors. Hysteroscopies were performed with local anesthesia (paracervical block), except for 1 patient in whom operative hysteroscopy was difficult and who then required general anesthesia. We examined the tubal ostium, the uterine cavity, and the cervical channel. This retrospective study was approved by the Institutional Review Board of Ile de France II. Data were entered into and analyzed with Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA).
Circumstances of hemorrhage
.....................................................................................................................................................................................................................................
Cesarean delivery
25
83
Fetal heart rate anomalies
5
17
Cervical dystocia
5
17
Breech
5
17
Preeclampsia and IUGR
4
13
Placenta previa
2
7
Gestational diabetes and previous cesarean
2
7
Macrosomia
2
7
Vaginal delivery
5
17
............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................
..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Birthweight
.....................................................................................................................................................................................................................................
⬍2500 g
10
33
2600-3900 g
15
50
5
17
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
⬎4000 g
..............................................................................................................................................................................................................................................
IUGR, intrauterine growth restriction. Alouini. Multiple square sutures for postpartum hemorrhage. Am J Obstet Gynecol 2011.
eries and the suturing of cervicovaginal tears. We used a 70-mm–long semicurved needle with 1 vicryl. As described by Cho et al,8 4 squares sutures usually were per335.e2
formed to approximate the anterior and posterior uterine walls. However, in some cases, 2 square sutures were enough. In other cases, 6 square sutures were necessary to stop the hemorrhage. For vaginal
American Journal of Obstetrics & Gynecology OCTOBER 2011
R ESULTS Thirty patients underwent uterine square suture for major or severe PPH between January 2004 and June 2010; 26,605 deliveries were performed in this period, for a rate of 1.1 uterine square sutures per 1000 deliveries. The mean age of the patients was 30 ⫾ 6 years (mean ⫾ SD). Two-thirds of PPHs occurred in the interval age of 20-35 years. Of 30 women, 23 were from French origin (white). Nineteen women were multiparous, and 11 women were primiparous. Eight women had had a previous cesarean section delivery, and 1 woman had had 3 previous cesarean section deliveries. PPH occurred during a cesarean section delivery in 25 of 30 cases (83%) and after a vaginal delivery in 5 cases. Fourteen cesarean section deliveries were performed before labor, and 11 were performed during labor. The mean birthweight was 3.031 ⫾ 0.934 kg. Five newborn infants had a birthweight of ⬎4 kg.
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TABLE 2
Amount of blood loss and number of square sutures applied for severe hemorrhage n ⴝ 30
Age, y
W.G.
Birthweight, kg
Blood loss, L
Hb before PPH g/dL
Hb post PPH
Hb loss
Transfusions PRBC
Square sutures, n
Mean
30
37
3.051
2.5
12.1
8.2
3.8
5
4
6
2
0.934
1.8
1.0
1.2
1.5
2
1
................................................................................................................................................................................................................................................................................................................................................................................
SD
................................................................................................................................................................................................................................................................................................................................................................................
Hb, hemoglobin; PPH, postpartum hemorrhage; PRBC, packed red blood cells; W.G., weeks of gestation. Alouini. Multiple square sutures for postpartum hemorrhage. Am J Obstet Gynecol 2011.
Table 1 shows the general characteristics of women who received uterine square sutures. Cesarean section deliveries were performed because of the cessation of cervix dilation in 5 cases, because of abnormalities of fetal heart rate in 5 cases, because of preeclampsia with intrauterine growth restriction in 4 cases, because of breech presentation in 5 cases (alone in 1 case, with a uterine scar in 2 cases, with a large myoma in 1 case, and with a first twin in 1 case), because of placenta previa in 2 cases, because of gestational diabetes mellitus with uterine scar in 2 cases, and because of suspected macrosomia in 2 cases (Figure). The first 10 patients had vascular ligations (of uterine arteries and of uteroovarian and round vessels) before the square sutures; however, vascular ligations were completely ineffective. For the other 20 patients, square sutures were performed first.
Results of hemostatic uterine square sutures Twenty-five uterine square sutures were performed during a cesarean section delivery, and 5 were performed after a vaginal delivery. Uterine square sutures were performed for uterine atony in 27 cases, for placenta previa in 2 cases, and for placenta accreta in 1 case. Hemorrhage was stopped in 28 of 30 cases (93%) by the uterine square sutures (Table 2). The mean number of square sutures to stop the hemorrhage was 4 ⫾ 1. The mean blood loss that was quantified for 20 patients was 2.5 ⫾ 1.7 L. The mean level of hemoglobin before PPH for the 30 patients was 12.1 ⫾ 1 g/dL and was 8.2 ⫾ 1.2 g/dL after the hemorrhage was stopped and after transfusions. The mean drop in hemoglobin level was 3.8 g/dL. Eighteen women received transfusion (60%); the mean number of units of packed red blood cells that were trans-
fused was 5 ⫾ 2 (Table 2). Two patients who delivered vaginally underwent hysterectomy after failure of hemostatic sutures and vascular ligations. In one case, a suspected placenta accreta was confirmed by the histologic examination; in another case, uterine atony was confirmed.
Results of hysteroscopy at 3 months after square uterine sutures Uterine square sutures allowed uterine conservation in 28 of 30 women. Of 28 patients, 20 women had hysteroscopy 3 months after square hemostatic uterine sutures. One patient did not want to have hysteroscopy but became pregnant 1 year after receiving multiple square sutures and delivered vaginally. Seven patients did not come for the hysteroscopy. Among them, 6 women had changed their address and phone number; therefore, it was not possible to contact them after the postnatal consultation. Twenty patients had a normal menstrual period after uterine square sutures, and 1 patient who had endometritis after delivery had amenorrhea. In 8 of 20 patients (40%), the uterine cavity and the cervix channel were normal. Nine patients (47%) had thin and localized synechiae that were easily removed by the tip of the hysteroscope or by the pressure of the fluid (physiologic solution) delivered by the hysteroscope (Table 3). The uterine cavity was completely normal after this simple procedure. In 2 cases of moderate intrauterine adhesions, hysteroscopic resection was necessary and allowed us to divide the intrauterine adhesions. In 1 case (0.05%), there were severe intrauterine adhesions, and repeated resections of synechiae by hysteroscopy were ineffective at restoring a normal uterine cavity. In this case, the uterine square sutures were complicated early by endometritis.
Eleven patients with intrauterine adhesions had a cesarean section delivery, and 1 patient had an operative vaginal delivery. The 8 women without intrauterine adhesions were all delivered by cesarean section. The mean number of uterine square sutures was similar in women with adhesions and in women without adhesions (4 in each group). The mean hemoglobin losses were equivalent between the group with intrauterine adhesions and the group without intrauterine adhesions (4.45 ⫾ 1.45 vs 4.08 ⫾ 0.91 g/dL). Among the 28 patients who underwent square uterine sutures with success, 3 patients had a new pregnancy respectively after 1, 2, and 3 years and gave birth. Among the 3 patients who became pregnant after Cho sutures, 2 women had a minor synechiae at the hysteroscopic control, and 1 woman did not have hysteroscopy. In total, according to the classification by March et al,9 there were 9 patients with stage I (minimal) adhesions, 2 patients with stage II (moderate) adhesions, and 1 patient with stage III (severe) adhesions. Eight patients did not have intrauterine adhesions (Figure). According to the American Fertility Society Classification,10 there were 9 patients with score 1 fertility, 2 patients with score 2 fertility, and 1 patient with score 4 (amenorrhea) fertility.
C OMMENT In our study, uterine square sutures stopped PPH in the most cases and allowed for uterine conservation without any maternal death. Forty percent of patients avoided transfusions. In 2 cases, multiple uterine square sutures were ineffective, and a hysterectomy was necessary to save the mother’s life.
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FIGURE
Hysteroscopy results for uterine square sutures (n ⴝ 20)
No IUAD Minimal IUAD removed Moderate IUAD removed Severe adhesion 0
2
4
6
8
10
Number of paents IUAD, intrauterine adhesion. Alouini. Multiple square sutures for postpartum hemorrhage. Am J Obstet Gynecol 2011.
Cho et al8 published the first study using multiple uterine square sutures for PPH and found an efficiency of 100% in approximately 23 cases. Multiple square sutures are a relatively easy technique to learn. However, it is necessary to have a long needle with short-lasting resorbable sutures to transfix the entire uterine wall. Although there are few data concerning uterine compression sutures, many authors have noted the efficiency of square sutures or B-Lynch sutures to stop severe PPH. Wu and Yeh11 reported that multiple square sutures through the uterus were effective to control PPH in 1 case. Fotopoulou and Dudenhausen12 also found a high efficiency of uterine compression sutures against PPH. For Hackethal et al,13 uterine compression sutures were a highly effective and easy emergency procedure that conserved fertility. For Baskett,14 uterine compression sutures (B-Lynch, square and vertical sutures) permitted the avoidance of hysterectomy in 23 of 28 women. In our study, uterine square sutures were effective in PPH from placenta previa, enlarged uterus (macrosomia, twin pregnancy), scarred uterus, uterine atony, and in the uterus of women who were delivered before term. Cho et al8 335.e4
also showed that square sutures were effective on PPH from placenta previa and uterine atony during cesarean section delivery that was complicated by PPH. In our study, uterine square sutures were performed for severe PPH in most cases after both cesarean section and vaginal deliveries when the embolization was not possible. In the study of Cho et al,8 all square sutures were performed during a cesarean delivery. Uterine square sutures could be performed with some success after vaginal delivery in cases of major PPH when embolization was not possible or not available and after the failure of medical treatment or balloon tamponade that required an emergency laparotomy. Four square sutures usually were placed in our patients. However, in our experience, when the area of bleeding was localized, we applied only 2 squares, and the bleeding stopped. In other cases, 6 square sutures were necessary to stop PPH. There was no correlation between the number of square sutures and adhesions. For placenta previa, the square sutures were applied to the inferior segment of the uterus on the placental site insertion to stop the hemorrhage.
American Journal of Obstetrics & Gynecology OCTOBER 2011
In our study, for most women (85%) in whom hemorrhage was controlled by uterine square sutures, hysteroscopy revealed that the uterine cavity was normal or had minimal synechiae that were removed easily, which makes the uterine cavity completely permeable and restored ad integrum. Fifteen percent of the women had moderate or severe adhesions. In only 1 case (5%), an endometritis and major intrauterine adhesion complicated the square sutures. Three patients had a new pregnancy and gave birth. However, a new pregnancy was not necessarily an objective for our patients. A long-term follow-up evaluation will allow us to know whether these patients wished to have other pregnancies. In most cases, multiple square sutures do not damage the uterine cavity, and multiple square sutures preserve fertility. Some authors have described complications after uterine square sutures. Ochoa et al15 described 1 case of pyometra after the hemostatic square sutures technique that was associated with vascular ligation. However, we know that the combination of uterine compression sutures and vascular ligations are more ischemic and therefore had a higher risk of uterine infection and necrosis.12 Wu and Yeh11 reported uterine synechiae after 1 case of hemostatic square sutures. However, they performed 6 square sutures, whereas Cho et al8 performed 4 square sutures with long-lasting suture material, which is not advised. Akoury and Sherman16 reported a case of partial uterine necrosis after the combination of B-Lynch and Cho square sutures for PPH. However, similar complications after other uterine compression sutures, such as B-Lynch sutures, are related. Indeed, Treloar et al17 reported a case of uterine necrosis after B-Lynch sutures for PPH. Goojha et al18 described a case of Asherman syndrome with complete obliteration of the uterine cavity after the use of the B-Lynch suture. Sentilhes et al19 reported a pyometra after B-Lynch sutures that required hysterectomy. Grotegut et al20 reported 1 case of a defect in the anterior wall of the lower uterine segment after B-Lynch sutures, probably because of an erosion of these sutures. Follow-up
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TABLE 3
Hysteroscopic findings after hemostatic uterine square sutures (20 patients) Variable
Previous deliveries, n
Squares, n
Hysteroscopic finding
March classification
Management of lesions
Total restoration of uterine cavity
Age, y
................................................................................................................................................................................................................................................................................................................................................................................
28
0
4
Filmy adhesion
I (minimal IUAD)
Lysis with the tip of the hysteroscope
Yes
Lysis with the tip of the hysteroscope
Yes
Lysis with the tip of the hysteroscope
Yes
Lysis with the tip of the hysteroscope
Yes
Failure of hysteroscopic resections
No
Lysis with the tip of the hysteroscope
Yes
Lysis with the tip of the hysteroscope
Yes
Hysteroscopic resection with scissors
Yes
Lysis with the tip of the hysteroscope
Yes
Divided using fluid distension of uterine cavity
Yes
Hysteroscopic resection
Yes
.......................................................................................................................................................................................................................................................................................................................................................................
38
0
2
Filmy adhesion
I
.......................................................................................................................................................................................................................................................................................................................................................................
38
0
4
Thin IUAD of the left ostial area
I
2 thin adhesions
I
....................................................................................................................................................................................................................................................................................................................................................................... a
28
1
4
....................................................................................................................................................................................................................................................................................................................................................................... 34
22
0
4
Severe IUAD, ⁄ of uterine cavities involved
III (severe)
Filmy adhesion of the left edge of the uterus
I
Intracervical adhesion
I
.......................................................................................................................................................................................................................................................................................................................................................................
26
0
4
.......................................................................................................................................................................................................................................................................................................................................................................
34
0
2
.......................................................................................................................................................................................................................................................................................................................................................................
35
0
4
Not completely resorbed, hyperplasic area
II (moderate)
Filmy IUAD on the left edge of the uterus
I
1 thin adhesion
I
....................................................................................................................................................................................................................................................................................................................................................................... b
35
1
4
.......................................................................................................................................................................................................................................................................................................................................................................
29
0
4
....................................................................................................................................................................................................................................................................................................................................................................... a
25
1
3
2 dense IUADs of the left ostial area
II
1 central filmy adhesion
I
.......................................................................................................................................................................................................................................................................................................................................................................
17
0
4
Lysis with the tip of the hysteroscope
Yes
.......................................................................................................................................................................................................................................................................................................................................................................
36
0
4
No IUAD
No IUAD
No surgery
Yes
32
0
4
No IUAD
No IUAD
No surgery
Yes
27
0
4
No IUAD
No IUAD
No surgery
Yes
25
0
4
No IUAD
No IUAD
No surgery
Yes
36
1
4
No IUAD
No IUAD
No surgery
Yes
31
1
4
No IUAD
No IUAD
No surgery
Yes
26
1
6
No IUAD
No IUAD
No surgery
Yes
0
4
No IUAD
No IUAD
No surgery
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... b ....................................................................................................................................................................................................................................................................................................................................................................... a ....................................................................................................................................................................................................................................................................................................................................................................... a .......................................................................................................................................................................................................................................................................................................................................................................
33
Yes
................................................................................................................................................................................................................................................................................................................................................................................
Total
6/20
19/20
................................................................................................................................................................................................................................................................................................................................................................................
Mean
31
4
6
1
................................................................................................................................................................................................................................................................................................................................................................................
SD
................................................................................................................................................................................................................................................................................................................................................................................
IUAD, intrauterine adhesion; SD, standard deviation. a
Cesarean delivery; b Vaginal delivery.
Alouini. Multiple square sutures for postpartum hemorrhage. Am J Obstet Gynecol 2011.
evaluation is necessary after all types of uterine compression sutures, especially when vascular ligations are involved.12 In our survey, the number of women who benefited from hemostatic square sutures was not very high because these situations are rare and extreme. Indeed, severe
PPHs are rare, and failure of all medical means to stop PPH is not a frequent event. However, this was the largest study of the efficiency of uterine square sutures and hysteroscopic evaluation. It included 30 patients and confirmed the efficiency and the safety of uterine square suturing. The
square sutures were as effective as other uterine compression sutures and were associated with only a few complications, which included uterine infections, uterine ischemia, and intrauterine adhesions. In our study, multiple square sutures stopped major PPH and allowed uterine
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conservation in most cases. For most patients, hysteroscopy after uterine square sutures showed the uterine cavity to be normal or with minimal and easily removed synechiae, which makes the uterine cavity totally permeable and restores ad integrum. A prospective study may be helpful to compare the efficiency and safety of multiple square, brace, and other hemostatic sutures. Multiple square sutures are a conservative, safe, and efficient technique to control PPH and preserve fertility. Hysteroscopy after multiple square sutures is recommended because intrauterine adhesions may appear, but they are removed easily in most cases. f REFERENCES 1. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank.Geneva:WorldHealthOrganization;2007. 2. Knight M, Callaghan WM, Berg C, et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 2009;9:55. 3. Mercier FJ, Van de Velde M. Major obstetric hemorrhage. Anesthesiol Clin 2008;26:53-66. 4. Chattopadhyay SK, Deb Roy B, Edrees YB. Surgical control of obstetric hemorrhage: hypo-
335.e6
www.AJOG.org gastric artery ligation or hysterectomy? Int J Gynaecol Obstet 1990;32:345-51. 5. Abdrabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994;171:694-700. 6. Pelage JP, Le Dref O, Mateo J, et al. Lifethreatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 1998;208:359-62. 7. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG 1997;104:372-5. 8. Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000;96:129-31. 9. March CM, Israel R, March AD. Hysteroscopic management of intrauterine adhesions. Am J Obstet Gynecol 1978;130:653-7. 10. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Müllerian anomalies and intrauterine adhesions. Fertil Steril 1988;49: 944-55. 11. Wu HH, Yeh GP. Uterine cavity synechiae after hemostatic square suturing technique. Obstet Gynecol 2005;105:1176-8. 12. Fotopoulou C, Dudenhausen JW. Uterine compression sutures for preserving fertility in severe postpartum haemorrhage: an overview 13 years after the first description. J Obstet Gynaecol 2010;30:339-49.
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13. Hackethal A, Tcharchian G, Ionesi-Pasacica J, Muenstedt K, Tinneberg HR, Oehmke F. Uterine surgery in postpartum hemorrhage. Minerva Ginecol 2009;61:201-13. 14. Baskett TF. Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy. Obstet Gynecol 2007;110:68-71. 15. Ochoa M, Allaire AD, Stitely ML. Pyometria after hemostatic square suture technique. Obstet Gynecol 2002;99:506-9. 16. Akoury H, Sherman C. Uterine wall partial thickness necrosis following combined B-Lynch and Cho square sutures for the treatment of primary postpartum hemorrhage. J Obstet Gynaecol Can 2008;30:421-4. 17. Treloar EJ, Anderson RS, Andrews HS, Bailey JL. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage. BJOG 2006;113:486-8. 18. Goojha CA, Case A, Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage. Fertil Steril 2010;94:1098.e1-5. 19. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization. Acta Obstet Gynecol Scand 2008;87:1020-6. 20. Grotegut CA, Larsen FW, Jones MR, Livingston E. Erosion of a B-Lynch suture through the uterine wall: a case report. J Reprod Med 2004;49:849-52.
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OBSTETRICS
Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment Souhail Alouini, MD, PhD; Sekou Coly, MD; Pascal Mégier, MD; Bruno Lemaire, MD; Louis Mesnard, MD; Alain Desroches, MD OBJECTIVE: The purpose of this study was to evaluate the efficiency
and morbidity of multiple square sutures in severe postpartum hemorrhage. STUDY DESIGN: A retrospective study encompassed 30 multiple square sutures that were performed for severe postpartum hemorrhage in 26,605 deliveries in a tertiary maternity center. The main outcome measures were the ability to stop hemorrhage and the assessment of the uterine cavity by hysteroscopy at 3 months. RESULTS: Multiple square sutures stopped postpartum hemorrhage in
28 of 30 cases (93%). Twenty women underwent hysteroscopy after multiple square sutures. Eight women (40%) did not have intrauterine adhesions. Nine women (45%) had thin and localized intrauterine adhe-
sions that were removed easily by the tip of the hysteroscope; 2 women had moderate intrauterine adhesions that were resected. One patient had endometritis followed by severe intrauterine adhesions. CONCLUSION: Multiple square sutures are effective and safe for the
control of severe postpartum hemorrhage and for uterine conservation in most cases. Although some patients had moderate or severe adhesions, a normal uterine cavity or minimal intrauterine adhesions that were removed easily were the most frequent findings at hysteroscopy. A prospective study may be helpful to compare the safety and efficiency of square and brace sutures. Key words: fertility, hysteroscopy, intrauterine adhesion, multiple square sutures, postpartum hemorrhage, uterine conservation
Cite this article as: Alouini S, Coly S, Mégier P, et al. Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment. Am J Obstet Gynecol 2011;205:335.e1-6.
P
ostpartum hemorrhage (PPH) is a high-risk obstetric situation for obstetrics and anesthetics teams as it can rapidly evolve into major and uncontrolled blood loss that can jeopardize the mother’s life. Obstetric hemorrhage is a major cause of maternal death and morbidity worldwide. It is the primary cause of maternal death in developing countries and among the leading causes of maternal death in developed countries.1,2 Although many therapies are effective in controlling PPH (such as oxytocin and prostaglandins),3 in some cases, it remains a dramatic problem that requires hysterectomy before irreversible
From the Department of Obstetrics and Gynecology, Centre Hospitalier Régional d’Orléans, Orléans, France. Received Jan. 15, 2011; revised March 12, 2011; accepted May 3, 2011. Reprints: Souhail Alouini, MD, PhD, Regional Hospital Center of Orléans, Obstetrics and Gynecology, 1 porte Madeleine, Orléans 45000, France. [email protected]. 0002-9378/$36.00 © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.05.006
coagulation problems arise that could lead to maternal death. Numerous therapies and surgical techniques have been developed to conserve the uterus because, in many cases, this is the first delivery for the patient. Different forms of vascular ligations (iliac, uterine, ovarian) that have been designed to interrupt the blood flow in the uterus have been practiced with variable rates of success.4,5 Uterine embolization is particularly useful in PPH after vaginal delivery6; however, the patient must be hemodynamically stable with a radiology team available and near the delivery room. More recently, uterine compression sutures have been used to stop PPH. Two such techniques are the B-Lynch sutures (brace sutures)7 and multiple squares sutures that have been described by Cho et al.8 Although there are few data concerning uterine compression sutures, they seem to give good results for controlling PPH. In the study published by Cho et al, the technique of multiple square sutures was easy to perform and allowed for the control of severe PPH and uterine conservation. However, there are few data con-
cerning the long-term outcomes of multiple square sutures. Multiple square sutures to stop PPH were introduced in our maternity ward in 2004. We aimed to evaluate the efficiency of multiple square sutures on the control of PPH and their impact on the uterine cavity of our patients.
M ATERIALS AND M ETHODS The cases of women with PPH who underwent uterine square suture procedures between 2004 and 2010 were reviewed retrospectively. All procedures were performed in the Regional Hospital Centre of Orléans. Our maternity ward is a tertiary center (with a neonatal unit) and performs approximately 4200 deliveries each year. The rate of cesarean section delivery varies between 18% and 19.6%. Hemostatic uterine square sutures were performed for major and uncontrolled PPH (defined as ⬎1 L of blood loss) after the failure of medical treatment (oxytocin, prostaglandin, uterine massage). Hemostatic square sutures were applied during a cesarean section delivery or after vaginal deliv-
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TABLE 1
Maternal characteristics for uterine square sutures and risk factors No. of women who underwent % of uterine square sutures women
n ⴝ 30 Maternal characteristics
.....................................................................................................................................................................................................................................
Age, y
............................................................................................................................................................................................................................
⬍20
2
7
............................................................................................................................................................................................................................
20-24
2
7
25-29
10
33
30-35
10
33
36-40
6
20
............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ .....................................................................................................................................................................................................................................
Origin
............................................................................................................................................................................................................................
French
23
77
Sub-Saharan Africa
5
17
North Africa
2
7
............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ..............................................................................................................................................................................................................................................
Clinical risk factors
.....................................................................................................................................................................................................................................
Parity
............................................................................................................................................................................................................................
Primiparous
11
37
Mutiparous without previous cesarean
10
33
9
30
............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................
Multiparous with previous cesarean
..............................................................................................................................................................................................................................................
Gestational age, wks
.....................................................................................................................................................................................................................................
ⱖ35
22
73
30-34 ⫹6
6
20
⬍30
2
7
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
deliveries, a laparotomy was carried out when PPH was too severe and extensive or because hemodynamic instability did not allow for embolization. A hysteroscopy at 3 months was proposed for all patients who underwent hemostatic uterine square sutures to assess the uterine cavity and the cervical channel and to look for eventual uterine complications. A 5-mm diameter hysteroscope (Karl Storz GmbH & Co, Tuttlingen, Germany) was used with saline solution. In cases in which endoscopic surgery was needed, the operative hysteroscope was a 9-mm diameter (Karl Storz GmbH & Co) with a glycocoll or saline solution. The instruments that were used were monopolar hooks and scissors. Hysteroscopies were performed with local anesthesia (paracervical block), except for 1 patient in whom operative hysteroscopy was difficult and who then required general anesthesia. We examined the tubal ostium, the uterine cavity, and the cervical channel. This retrospective study was approved by the Institutional Review Board of Ile de France II. Data were entered into and analyzed with Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA).
Circumstances of hemorrhage
.....................................................................................................................................................................................................................................
Cesarean delivery
25
83
Fetal heart rate anomalies
5
17
Cervical dystocia
5
17
Breech
5
17
Preeclampsia and IUGR
4
13
Placenta previa
2
7
Gestational diabetes and previous cesarean
2
7
Macrosomia
2
7
Vaginal delivery
5
17
............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................
..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Birthweight
.....................................................................................................................................................................................................................................
⬍2500 g
10
33
2600-3900 g
15
50
5
17
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
⬎4000 g
..............................................................................................................................................................................................................................................
IUGR, intrauterine growth restriction. Alouini. Multiple square sutures for postpartum hemorrhage. Am J Obstet Gynecol 2011.
eries and the suturing of cervicovaginal tears. We used a 70-mm–long semicurved needle with 1 vicryl. As described by Cho et al,8 4 squares sutures usually were per335.e2
formed to approximate the anterior and posterior uterine walls. However, in some cases, 2 square sutures were enough. In other cases, 6 square sutures were necessary to stop the hemorrhage. For vaginal
American Journal of Obstetrics & Gynecology OCTOBER 2011
R ESULTS Thirty patients underwent uterine square suture for major or severe PPH between January 2004 and June 2010; 26,605 deliveries were performed in this period, for a rate of 1.1 uterine square sutures per 1000 deliveries. The mean age of the patients was 30 ⫾ 6 years (mean ⫾ SD). Two-thirds of PPHs occurred in the interval age of 20-35 years. Of 30 women, 23 were from French origin (white). Nineteen women were multiparous, and 11 women were primiparous. Eight women had had a previous cesarean section delivery, and 1 woman had had 3 previous cesarean section deliveries. PPH occurred during a cesarean section delivery in 25 of 30 cases (83%) and after a vaginal delivery in 5 cases. Fourteen cesarean section deliveries were performed before labor, and 11 were performed during labor. The mean birthweight was 3.031 ⫾ 0.934 kg. Five newborn infants had a birthweight of ⬎4 kg.
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TABLE 2
Amount of blood loss and number of square sutures applied for severe hemorrhage n ⴝ 30
Age, y
W.G.
Birthweight, kg
Blood loss, L
Hb before PPH g/dL
Hb post PPH
Hb loss
Transfusions PRBC
Square sutures, n
Mean
30
37
3.051
2.5
12.1
8.2
3.8
5
4
6
2
0.934
1.8
1.0
1.2
1.5
2
1
................................................................................................................................................................................................................................................................................................................................................................................
SD
................................................................................................................................................................................................................................................................................................................................................................................
Hb, hemoglobin; PPH, postpartum hemorrhage; PRBC, packed red blood cells; W.G., weeks of gestation. Alouini. Multiple square sutures for postpartum hemorrhage. Am J Obstet Gynecol 2011.
Table 1 shows the general characteristics of women who received uterine square sutures. Cesarean section deliveries were performed because of the cessation of cervix dilation in 5 cases, because of abnormalities of fetal heart rate in 5 cases, because of preeclampsia with intrauterine growth restriction in 4 cases, because of breech presentation in 5 cases (alone in 1 case, with a uterine scar in 2 cases, with a large myoma in 1 case, and with a first twin in 1 case), because of placenta previa in 2 cases, because of gestational diabetes mellitus with uterine scar in 2 cases, and because of suspected macrosomia in 2 cases (Figure). The first 10 patients had vascular ligations (of uterine arteries and of uteroovarian and round vessels) before the square sutures; however, vascular ligations were completely ineffective. For the other 20 patients, square sutures were performed first.
Results of hemostatic uterine square sutures Twenty-five uterine square sutures were performed during a cesarean section delivery, and 5 were performed after a vaginal delivery. Uterine square sutures were performed for uterine atony in 27 cases, for placenta previa in 2 cases, and for placenta accreta in 1 case. Hemorrhage was stopped in 28 of 30 cases (93%) by the uterine square sutures (Table 2). The mean number of square sutures to stop the hemorrhage was 4 ⫾ 1. The mean blood loss that was quantified for 20 patients was 2.5 ⫾ 1.7 L. The mean level of hemoglobin before PPH for the 30 patients was 12.1 ⫾ 1 g/dL and was 8.2 ⫾ 1.2 g/dL after the hemorrhage was stopped and after transfusions. The mean drop in hemoglobin level was 3.8 g/dL. Eighteen women received transfusion (60%); the mean number of units of packed red blood cells that were trans-
fused was 5 ⫾ 2 (Table 2). Two patients who delivered vaginally underwent hysterectomy after failure of hemostatic sutures and vascular ligations. In one case, a suspected placenta accreta was confirmed by the histologic examination; in another case, uterine atony was confirmed.
Results of hysteroscopy at 3 months after square uterine sutures Uterine square sutures allowed uterine conservation in 28 of 30 women. Of 28 patients, 20 women had hysteroscopy 3 months after square hemostatic uterine sutures. One patient did not want to have hysteroscopy but became pregnant 1 year after receiving multiple square sutures and delivered vaginally. Seven patients did not come for the hysteroscopy. Among them, 6 women had changed their address and phone number; therefore, it was not possible to contact them after the postnatal consultation. Twenty patients had a normal menstrual period after uterine square sutures, and 1 patient who had endometritis after delivery had amenorrhea. In 8 of 20 patients (40%), the uterine cavity and the cervix channel were normal. Nine patients (47%) had thin and localized synechiae that were easily removed by the tip of the hysteroscope or by the pressure of the fluid (physiologic solution) delivered by the hysteroscope (Table 3). The uterine cavity was completely normal after this simple procedure. In 2 cases of moderate intrauterine adhesions, hysteroscopic resection was necessary and allowed us to divide the intrauterine adhesions. In 1 case (0.05%), there were severe intrauterine adhesions, and repeated resections of synechiae by hysteroscopy were ineffective at restoring a normal uterine cavity. In this case, the uterine square sutures were complicated early by endometritis.
Eleven patients with intrauterine adhesions had a cesarean section delivery, and 1 patient had an operative vaginal delivery. The 8 women without intrauterine adhesions were all delivered by cesarean section. The mean number of uterine square sutures was similar in women with adhesions and in women without adhesions (4 in each group). The mean hemoglobin losses were equivalent between the group with intrauterine adhesions and the group without intrauterine adhesions (4.45 ⫾ 1.45 vs 4.08 ⫾ 0.91 g/dL). Among the 28 patients who underwent square uterine sutures with success, 3 patients had a new pregnancy respectively after 1, 2, and 3 years and gave birth. Among the 3 patients who became pregnant after Cho sutures, 2 women had a minor synechiae at the hysteroscopic control, and 1 woman did not have hysteroscopy. In total, according to the classification by March et al,9 there were 9 patients with stage I (minimal) adhesions, 2 patients with stage II (moderate) adhesions, and 1 patient with stage III (severe) adhesions. Eight patients did not have intrauterine adhesions (Figure). According to the American Fertility Society Classification,10 there were 9 patients with score 1 fertility, 2 patients with score 2 fertility, and 1 patient with score 4 (amenorrhea) fertility.
C OMMENT In our study, uterine square sutures stopped PPH in the most cases and allowed for uterine conservation without any maternal death. Forty percent of patients avoided transfusions. In 2 cases, multiple uterine square sutures were ineffective, and a hysterectomy was necessary to save the mother’s life.
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FIGURE
Hysteroscopy results for uterine square sutures (n ⴝ 20)
No IUAD Minimal IUAD removed Moderate IUAD removed Severe adhesion 0
2
4
6
8
10
Number of paents IUAD, intrauterine adhesion. Alouini. Multiple square sutures for postpartum hemorrhage. Am J Obstet Gynecol 2011.
Cho et al8 published the first study using multiple uterine square sutures for PPH and found an efficiency of 100% in approximately 23 cases. Multiple square sutures are a relatively easy technique to learn. However, it is necessary to have a long needle with short-lasting resorbable sutures to transfix the entire uterine wall. Although there are few data concerning uterine compression sutures, many authors have noted the efficiency of square sutures or B-Lynch sutures to stop severe PPH. Wu and Yeh11 reported that multiple square sutures through the uterus were effective to control PPH in 1 case. Fotopoulou and Dudenhausen12 also found a high efficiency of uterine compression sutures against PPH. For Hackethal et al,13 uterine compression sutures were a highly effective and easy emergency procedure that conserved fertility. For Baskett,14 uterine compression sutures (B-Lynch, square and vertical sutures) permitted the avoidance of hysterectomy in 23 of 28 women. In our study, uterine square sutures were effective in PPH from placenta previa, enlarged uterus (macrosomia, twin pregnancy), scarred uterus, uterine atony, and in the uterus of women who were delivered before term. Cho et al8 335.e4
also showed that square sutures were effective on PPH from placenta previa and uterine atony during cesarean section delivery that was complicated by PPH. In our study, uterine square sutures were performed for severe PPH in most cases after both cesarean section and vaginal deliveries when the embolization was not possible. In the study of Cho et al,8 all square sutures were performed during a cesarean delivery. Uterine square sutures could be performed with some success after vaginal delivery in cases of major PPH when embolization was not possible or not available and after the failure of medical treatment or balloon tamponade that required an emergency laparotomy. Four square sutures usually were placed in our patients. However, in our experience, when the area of bleeding was localized, we applied only 2 squares, and the bleeding stopped. In other cases, 6 square sutures were necessary to stop PPH. There was no correlation between the number of square sutures and adhesions. For placenta previa, the square sutures were applied to the inferior segment of the uterus on the placental site insertion to stop the hemorrhage.
American Journal of Obstetrics & Gynecology OCTOBER 2011
In our study, for most women (85%) in whom hemorrhage was controlled by uterine square sutures, hysteroscopy revealed that the uterine cavity was normal or had minimal synechiae that were removed easily, which makes the uterine cavity completely permeable and restored ad integrum. Fifteen percent of the women had moderate or severe adhesions. In only 1 case (5%), an endometritis and major intrauterine adhesion complicated the square sutures. Three patients had a new pregnancy and gave birth. However, a new pregnancy was not necessarily an objective for our patients. A long-term follow-up evaluation will allow us to know whether these patients wished to have other pregnancies. In most cases, multiple square sutures do not damage the uterine cavity, and multiple square sutures preserve fertility. Some authors have described complications after uterine square sutures. Ochoa et al15 described 1 case of pyometra after the hemostatic square sutures technique that was associated with vascular ligation. However, we know that the combination of uterine compression sutures and vascular ligations are more ischemic and therefore had a higher risk of uterine infection and necrosis.12 Wu and Yeh11 reported uterine synechiae after 1 case of hemostatic square sutures. However, they performed 6 square sutures, whereas Cho et al8 performed 4 square sutures with long-lasting suture material, which is not advised. Akoury and Sherman16 reported a case of partial uterine necrosis after the combination of B-Lynch and Cho square sutures for PPH. However, similar complications after other uterine compression sutures, such as B-Lynch sutures, are related. Indeed, Treloar et al17 reported a case of uterine necrosis after B-Lynch sutures for PPH. Goojha et al18 described a case of Asherman syndrome with complete obliteration of the uterine cavity after the use of the B-Lynch suture. Sentilhes et al19 reported a pyometra after B-Lynch sutures that required hysterectomy. Grotegut et al20 reported 1 case of a defect in the anterior wall of the lower uterine segment after B-Lynch sutures, probably because of an erosion of these sutures. Follow-up
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TABLE 3
Hysteroscopic findings after hemostatic uterine square sutures (20 patients) Variable
Previous deliveries, n
Squares, n
Hysteroscopic finding
March classification
Management of lesions
Total restoration of uterine cavity
Age, y
................................................................................................................................................................................................................................................................................................................................................................................
28
0
4
Filmy adhesion
I (minimal IUAD)
Lysis with the tip of the hysteroscope
Yes
Lysis with the tip of the hysteroscope
Yes
Lysis with the tip of the hysteroscope
Yes
Lysis with the tip of the hysteroscope
Yes
Failure of hysteroscopic resections
No
Lysis with the tip of the hysteroscope
Yes
Lysis with the tip of the hysteroscope
Yes
Hysteroscopic resection with scissors
Yes
Lysis with the tip of the hysteroscope
Yes
Divided using fluid distension of uterine cavity
Yes
Hysteroscopic resection
Yes
.......................................................................................................................................................................................................................................................................................................................................................................
38
0
2
Filmy adhesion
I
.......................................................................................................................................................................................................................................................................................................................................................................
38
0
4
Thin IUAD of the left ostial area
I
2 thin adhesions
I
....................................................................................................................................................................................................................................................................................................................................................................... a
28
1
4
....................................................................................................................................................................................................................................................................................................................................................................... 34
22
0
4
Severe IUAD, ⁄ of uterine cavities involved
III (severe)
Filmy adhesion of the left edge of the uterus
I
Intracervical adhesion
I
.......................................................................................................................................................................................................................................................................................................................................................................
26
0
4
.......................................................................................................................................................................................................................................................................................................................................................................
34
0
2
.......................................................................................................................................................................................................................................................................................................................................................................
35
0
4
Not completely resorbed, hyperplasic area
II (moderate)
Filmy IUAD on the left edge of the uterus
I
1 thin adhesion
I
....................................................................................................................................................................................................................................................................................................................................................................... b
35
1
4
.......................................................................................................................................................................................................................................................................................................................................................................
29
0
4
....................................................................................................................................................................................................................................................................................................................................................................... a
25
1
3
2 dense IUADs of the left ostial area
II
1 central filmy adhesion
I
.......................................................................................................................................................................................................................................................................................................................................................................
17
0
4
Lysis with the tip of the hysteroscope
Yes
.......................................................................................................................................................................................................................................................................................................................................................................
36
0
4
No IUAD
No IUAD
No surgery
Yes
32
0
4
No IUAD
No IUAD
No surgery
Yes
27
0
4
No IUAD
No IUAD
No surgery
Yes
25
0
4
No IUAD
No IUAD
No surgery
Yes
36
1
4
No IUAD
No IUAD
No surgery
Yes
31
1
4
No IUAD
No IUAD
No surgery
Yes
26
1
6
No IUAD
No IUAD
No surgery
Yes
0
4
No IUAD
No IUAD
No surgery
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... b ....................................................................................................................................................................................................................................................................................................................................................................... a ....................................................................................................................................................................................................................................................................................................................................................................... a .......................................................................................................................................................................................................................................................................................................................................................................
33
Yes
................................................................................................................................................................................................................................................................................................................................................................................
Total
6/20
19/20
................................................................................................................................................................................................................................................................................................................................................................................
Mean
31
4
6
1
................................................................................................................................................................................................................................................................................................................................................................................
SD
................................................................................................................................................................................................................................................................................................................................................................................
IUAD, intrauterine adhesion; SD, standard deviation. a
Cesarean delivery; b Vaginal delivery.
Alouini. Multiple square sutures for postpartum hemorrhage. Am J Obstet Gynecol 2011.
evaluation is necessary after all types of uterine compression sutures, especially when vascular ligations are involved.12 In our survey, the number of women who benefited from hemostatic square sutures was not very high because these situations are rare and extreme. Indeed, severe
PPHs are rare, and failure of all medical means to stop PPH is not a frequent event. However, this was the largest study of the efficiency of uterine square sutures and hysteroscopic evaluation. It included 30 patients and confirmed the efficiency and the safety of uterine square suturing. The
square sutures were as effective as other uterine compression sutures and were associated with only a few complications, which included uterine infections, uterine ischemia, and intrauterine adhesions. In our study, multiple square sutures stopped major PPH and allowed uterine
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conservation in most cases. For most patients, hysteroscopy after uterine square sutures showed the uterine cavity to be normal or with minimal and easily removed synechiae, which makes the uterine cavity totally permeable and restores ad integrum. A prospective study may be helpful to compare the efficiency and safety of multiple square, brace, and other hemostatic sutures. Multiple square sutures are a conservative, safe, and efficient technique to control PPH and preserve fertility. Hysteroscopy after multiple square sutures is recommended because intrauterine adhesions may appear, but they are removed easily in most cases. f REFERENCES 1. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank.Geneva:WorldHealthOrganization;2007. 2. Knight M, Callaghan WM, Berg C, et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 2009;9:55. 3. Mercier FJ, Van de Velde M. Major obstetric hemorrhage. Anesthesiol Clin 2008;26:53-66. 4. Chattopadhyay SK, Deb Roy B, Edrees YB. Surgical control of obstetric hemorrhage: hypo-
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www.AJOG.org gastric artery ligation or hysterectomy? Int J Gynaecol Obstet 1990;32:345-51. 5. Abdrabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994;171:694-700. 6. Pelage JP, Le Dref O, Mateo J, et al. Lifethreatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 1998;208:359-62. 7. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG 1997;104:372-5. 8. Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000;96:129-31. 9. March CM, Israel R, March AD. Hysteroscopic management of intrauterine adhesions. Am J Obstet Gynecol 1978;130:653-7. 10. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Müllerian anomalies and intrauterine adhesions. Fertil Steril 1988;49: 944-55. 11. Wu HH, Yeh GP. Uterine cavity synechiae after hemostatic square suturing technique. Obstet Gynecol 2005;105:1176-8. 12. Fotopoulou C, Dudenhausen JW. Uterine compression sutures for preserving fertility in severe postpartum haemorrhage: an overview 13 years after the first description. J Obstet Gynaecol 2010;30:339-49.
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13. Hackethal A, Tcharchian G, Ionesi-Pasacica J, Muenstedt K, Tinneberg HR, Oehmke F. Uterine surgery in postpartum hemorrhage. Minerva Ginecol 2009;61:201-13. 14. Baskett TF. Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy. Obstet Gynecol 2007;110:68-71. 15. Ochoa M, Allaire AD, Stitely ML. Pyometria after hemostatic square suture technique. Obstet Gynecol 2002;99:506-9. 16. Akoury H, Sherman C. Uterine wall partial thickness necrosis following combined B-Lynch and Cho square sutures for the treatment of primary postpartum hemorrhage. J Obstet Gynaecol Can 2008;30:421-4. 17. Treloar EJ, Anderson RS, Andrews HS, Bailey JL. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage. BJOG 2006;113:486-8. 18. Goojha CA, Case A, Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage. Fertil Steril 2010;94:1098.e1-5. 19. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization. Acta Obstet Gynecol Scand 2008;87:1020-6. 20. Grotegut CA, Larsen FW, Jones MR, Livingston E. Erosion of a B-Lynch suture through the uterine wall: a case report. J Reprod Med 2004;49:849-52.