Fertility after B-Lynch suture and hypogastric artery ligation

Obstetrical outcome after B-Lynch sutures and ligation of uterine arteries: A case report

Objective

To illustrate the obstetrical outcome after B-Lynch sutures and ligation of the uterine arteries.

Case

A 26-year-old nulliparous woman. A caesarean section performed for obstructed labour was complicated by uterine atony. A B-Lynch uterine compression suture technique was used combined with ligation of the ascending branches of the uterine arteries. Before the subsequent fertility treatment, gel instillation sonography and power Doppler imaging showed a normal uterine cavity and restored myometrial vascularization. Subsequent caesarean section showed external adhesions on the anterior uterine serosa. A healthy baby of normal weight was delivered. There was focal placenta accreta; the underlying myometrium was strikingly thinner and prone to inversion.

Discussion

After B-Lynch sutures and ligation of the ascending branches of the uterine arteries, the pregnancy was subsequently uncomplicated. The potential association between B-Lynch sutures and placenta accreta or uterine inversion in a subsequent pregnancy has to be assessed in further studies. This case report illustrates how 3D gel instillation sonography is a valuable tool to evaluate the integrity of the uterine cavity.

•

3D gel instillation sonography gives the best evaluation of the uterus after B-Lynch sutures have been used.

•

Normal fertility and pregnancy are possible after B-Lynch sutures have been used.

•

Normal fertility and pregnancy are possible after ligation of the uterine arteries.

•

B-Lynch sutures and ligation of the uterine arteries are useful in postpartum haemorrhage.

[Which surgical strategy to adopt for the management of postpartum haemorrhage and how to improve the effects of hypogastric arteries ligation?]

L'objectif était d'identifier les facteurs de succès de la ligature bilatérale des artères hypogastriques et évaluer sa place dans le traitement chirurgical des hémorragies du post-partum. Nous avons réalisé une étude rétrospective regroupant tous les cas d'hémorragie du post-partum ayant nécessité un traitement chirurgical entre Janvier 2008 et Décembre 2011. L'étude a concerné 88 patientes (0,47% du total des accouchements). L'atonie utérine était l'étiologie la plus fréquente (64,8 % des patientes). La ligature bilatérale des artères hypogastriques a été réalisée chez 81,8% des patientes. Quand elle était le premier geste chirurgical réalisé, son taux de succès était de 66%. Ce taux était variable en fonction de l'étiologie de l'hémorragie, de la présence ou non de troubles de l'hémostase et du temps écoulé entre le diagnostic et la réalisation du geste chirurgical. En cas atonie utérine, l'association d'une deuxième technique conservatrice lorsque la première était insuffisante, a permis d'arrêter le saignement dans 98% des cas. La ligature des artères hypogastriques est une technique chirurgicale efficace pour le traitement de l'hémorragie du post-partum. Son taux de succès est augmenté par sa réalisation précoce ainsi que son association à d'autres techniques conservatrices.

[Risk of uterine synechiae following uterine compression sutures during postpartum haemorrhage]

OBJECTIVES

Uterine compression sutures are highly successful conservative surgical techniques used to treat severe postpartum haemorrhage. These methods can induce subsequent uterine synechiae. To determine this risk of synechiae after conservative uterine compression sutures, which may induce further fertility problems.

PATIENTS AND METHODS

We retrospectively reviewed the medical and pathological records of the patients who underwent uterine compression sutures for severe postpartum haemorrhage between January 2003 and March 2013 in a French University Hospital. The Cho's, the B-Lynch's and the Hayman's techniques have been used. The results of the hysteroscopies were detailed.

RESULTS

Among the 25 patients included, the B-Lynch or the Hayman's techniques have been used in 13 cases (52%). The Cho's technique has been performed alone for 5 patients (20%) and both techniques have been practiced in 7 situations (28%). In 17 cases (68%), some vascular sutures have been associated and, for 7 patients (28%), a vascular embolisation had been performed before the uterine compressive sutures. Only 19 patients underwent a diagnostic hysteroscopy and among them 13 had a normal uterine cavity (68%), 3 of them had uterine synechiae (16%) and 3 had placental retention (16%). Synechiae and retention have all been successfully removed by operative hysteroscopy.

DISCUSSION AND CONCLUSION

The compressive techniques can induce uterine synechiae, which may impair subsequent fertility.

Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature

OBJECTIVE

To investigate the most appropriate surgical technique for optimizing hemostasis and preservation of subsequent fertility after postpartum hemorrhage (PPH).

DESIGN

Systematic review of the literature.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTION(S)

Review of MEDLINE, EMBASE, ScienceDirect, and the Cochrane Library.

MAIN OUTCOME MEASURE(S)

Comparison of the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus), fertility rate (subsequent pregnancies or the return of regular menstrual cycles), complication rate of the procedure, and the outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications.

RESULT(S)

Compressive sutures and vessel embolization may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation.

CONCLUSION(S)

Pelvic vessel embolization and compressive sutures are associated with high rates of restoration of regular menses and successive pregnancies, even if the former is burdened by an increased rate of placental disorders and fetal growth restriction and the latter by an increased risk of cesarean deliveries and PPH recurrence. Randomized trials would be desirable to define the best management of PPH.

B-Lynch suture technique to control postpartum hemorrhage in a patient with mullerian anomaly

Congenital anomalies of the uterus may cause gynecologic, obstetric and fertility problems. Obstetrical complications are reported to occur more commonly with mullerian duct anomalies, such as postpartum hemorrhage (PPH). Uterine compression sutures may be effective in controlling PPH in these conditions as an alternative to hysterectomy, especially if the patient has a desire to conceive. As the shape of the uterus is changed in congenital malformation, the usage of compression sutures such as B-Lynch can be more difficult. In this study we report a case of PPH accompanying a large septae, treated with B-Lynch suture. A 24 year old, multigravid and nulliparous patient (G:3) was admitted to our clinic with vaginal bleeding and abdominal pain at 31 weeks of gestation. Emergency cesarean section was performed for abruptio placenta and PPH occurred subsequently. A deep uterine septum was revealed during operation. Intermittent fundal massage and intravenous uterotonics were used to improve uterine tonicity without any improvement. After the B-Lynch suture was performed, the bleeding diminished dramatically. As the shape of the uterus is changed in congenital malformation, the application of secondary interventions in postpartum hemorrhage can be more difficult. There can be slippage or overlapping of the suture while using a B-Lynch suture. Because the uterine shape is not completely distorted, patients with septate uterus can be candidates for a B-Lynch suture. There is no such reported case from the literature regarding efficacy of B-Lynch suture in mullerian anomalies. his case illustrates the potential benefits of B-Lynch compression suture in an uterus with mullerian anomalies.

Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage

OBJECTIVE

Describe a case of secondary infertility due to the development of severe Asherman Syndrome after the B-Lynch compression suture and uterine artery ligation, and to review the B-Lynch technique and documented complications.

DESIGN

Case report.

SETTING

Tertiary care hospital.

PATIENT(S)

A 29-year-old primigravida patient.

INTERVENTION(S)

B-Lynch suture and uterine artery ligation.

MAIN OUTCOME MEASURE(S)

Development of Asherman syndrome.

RESULT(S)

Development of secondary infertility due to Asherman syndrome after the B-Lynch suture.

CONCLUSION(S)

The B-Lynch suture is a highly successful conservative surgical technique used to treat this condition. There is little information regarding any potential for compromised future fertility, although there have been several reports of successful pregnancy after the use of the B-Lynch compression suture. In this report, we present a case of Asherman syndrome with complete obliteration of the uterine cavity after the B-Lynch suture.

Hypogastric artery ligation for severe hemorrhage in obstetric patients

Ligation of the hypogastric arteries (HAL) was first introduced into surgery by the end of the 19(th) century to control intractable hemorrhage from the uterus of women with advanced cervical cancer. At present, HAL is one in a spectrum of operative methods to control life-threatening postpartum hemorrhage before hysterectomy. Bilateral ligation of the internal iliac artery does not result in complete blockage of but to a significant decrease in blood supply to the female pelvic organs. Soon after ligation three previously existent collateral circulations will develop. Due to the smaller caliber of these arteries, the arterial pulse and pulse pressure are virtually eliminated. The effectiveness of HAL in avoiding hysterectomy for postpartum hemorrhage has been reported in up to 50% of cases. HAL has no adverse effect on subsequent fertility or pregnancy outcome, however, assessment for intrauterine fetal growth restriction is recommended. This safe and effective procedure should be taught during obstetric and gynecologic training.

Postpartum hemorrhage: a recurring pregnancy complication

Postpartum hemorrhage (PPH) is a potentially life-threatening complication of both vaginal and cesarean deliveries. Although many variables increase the chance for bleeding, a PPH in a previous pregnancy is one of the greatest risk factors for recurrent PPH. A physiologic explanation for this association is not known, but recurrent risk factors such as a retained placenta or underlying medical disorders may account for the majority of recurrent PPH cases. To reduce maternal morbidity and mortality, prevention of PPH in these patients is critical. Steps to minimize hemorrhagic complications include the identification of high-risk patients through a complete history, vigilant management of the third stage of labor, and having uterotonic medications readily available in the delivery room. Patients with inherited coagulopathies require individualized treatment, and their risks for bleeding extend beyond the first 24 hours after delivery. Further studies are needed to determine whether the administration of prophylactic measures such as prostaglandins decrease the PPH occurrence in high-risk patients.

Successful Term Pregnancy after B-Lynch Compression Suture in a Previous Pregnancy on Account of Massive Primary Postpartum Hemorrhage

A case is presented of a successful term pregnancy in a 28-year-old secundipara after previous Misgav-Ladach cesarean section and B-Lynch compression suture on account of massive postpartal hemorrhage caused by uterine atony. On account of dystocia and relative cephalopelvic disproportion, secondary repeated cesarean section was performed; she gave birth to a live child 3,900 g/52 cm, Apgar score 9/10, with a regular neonatal course. During the repeated cesarean section, thin laces of connective tissue were found along the sutures placed on the uterus during the previous B-Lynch operation. Pelvic and intrauterine adhesions were not found.