Synechia after uterine compression sutures
2010; Elsevier BV; Volume: 95; Issue: 1 Linguagem: Inglês
10.1016/j.fertnstert.2010.08.055
ISSN1556-5653
AutoresGauthier Rathat, Phi Do Trinh, Grégoire Mercier, L. Reyftmann, C. Dechanet, Pierre Boulot, P.L. Giacalone,
Tópico(s)Uterine Myomas and Treatments
ResumoWe present a study of 37 women who underwent uterine compression suture for postpartum hemorrhage, with 13 postoperative assessments by hysteroscopy. Synechia occurred in seven patients, of whom three had Asherman syndrome (23% of women who desired pregnancy and had hysteroscopic evaluation) that could not be corrected. We present a study of 37 women who underwent uterine compression suture for postpartum hemorrhage, with 13 postoperative assessments by hysteroscopy. Synechia occurred in seven patients, of whom three had Asherman syndrome (23% of women who desired pregnancy and had hysteroscopic evaluation) that could not be corrected. Postpartum hemorrhage (PPH) is a major cause of maternal morbidity and continues to be the most common cause of maternal mortality. Traditionally, surgical management of refractory PPH has relied on postpartum hysterectomy, although alternatives to this radical treatment have been proposed. Surgical ligation of pelvic arteries for PPH was described in the early 1960s (1Sagarra M. Glasser S.T. Stone M.L. Ligation of the internal iliac vessels in the control of postpartum hemorrhage: report of a case.Obstet Gynecol. 1960; 15: 698-701PubMed Google Scholar, 2Reich W.J. Nechtow M.J. Ligation of the internal iliac (hypogastric) arteries: a life-saving procedure for uncontrollable gynecologic and obstetric hemorrhage.J Int Coll Surg. 1961; 36: 157-168PubMed Google Scholar). Various techniques for uterine compression suturing (UCS) have been described over the past 10 years (3Mallappa Saroja C.S. Nankani A. El-Hamamy E. Uterine compression sutures, an update: review of efficacy, safety and complications of B-Lynch suture and other uterine compression techniques for postpartum haemorrhage.Arch Gynecol Obstet. 2010; 281: 581-588Crossref PubMed Scopus (56) Google Scholar). Christopher B-Lynch was the first to highlight UCS in 1997 (4B-Lynch C. Coker A. Lawal A.H. Abu J. Cowen M.J. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported.Br J Obstet Gynaecol. 1997; 104: 372-375Crossref PubMed Scopus (512) Google Scholar). Since then other techniques, such as Cho's square suture (5Cho J.H. Jun H.S. Lee C.N. Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131Crossref PubMed Scopus (268) Google Scholar) and modifications of the B-Lynch suture technique, have been added to the range of conservative surgical procedures (6El-Hamamy E. B-Lynch C. A worldwide review of the uses of the uterine compression suture techniques as alternative to hysterectomy in the management of severe post-partum haemorrhage.J Obstet Gynaecol. 2005; 25: 143-149Crossref PubMed Scopus (65) Google Scholar). Therefore, little is known about the fertility and pregnancy outcomes for women who have undergone UCS.This retrospective cohort study included all women who had undergone UCS after a cesarean section in our tertiary obstetric unit (Montpellier University Hospital) from October 2004 to July 2009. No institutional review board approval was necessary. B-Lynch's or Cho's technique was used by our team in this period. Both techniques are recent surgical treatments for PPH and are easier to perform than vascular ligations. These two methods are based on the same theory: a resorbable stitch is passed through the uterine cavity to treat uterine atony. According to literature, these are the two most often used techniques. For these reasons, we considered them as one type of surgery, which we called UCS.The aim of this study was to evaluate the effect of UCS on fertility and pregnancy outcomes, to define more accurately their place in the surgical uterine-sparing techniques to manage PPH. For this purpose, we studied the case reports with a focus on results of postcesarean hysteroscopy and subsequent pregnancy. Data concerning surgical procedures, hysteroscopic results, and pregnancy outcomes were retrieved from computerized hospital discharge summaries. When case note records were not available, we attempted to contact the women by telephone. The women were asked about their desire for subsequent pregnancies, and any attempts and results, since the day of the cesarean section. The women's characteristics were compared between groups (group A and group B, defined by result on hysteroscopy) (Table 1), using the Fisher exact test for categoric variables and the Mann–Whitney U test for nonparametric variables.Table 1Population and assessment.Surgical procedureGroupAge (y)ParityTerm pregnancy (wk of gestation)Cesarean indication1st technique2nd technique3rd techniqueHysterectomyHysteroscopySubsequent pregnancyGroup A (n = 6)34133Placenta previaCHOIAL—NoNormalToo earlyaToo early for woman to begin a new pregnancy.29140Nonprogressive laborIALCHO—NoNormalToo early24136Placenta previaCHOUVL—NoNormalToo early33127Twin pregnancy, nonprogressive labor, fetal heart abnormalityCHO——NoNormalLive birth20139Nonprogressive labor, fetal heart abnormality, feverCHOUVLIALNoNormalLive birth27140Nonprogressive laborCHO——NoNormalLive birthGroup B (n = 7)38238Placenta previaIALCHOB-LYNCHNoSevere synechiaToo early31135Twin pregnancy, breech presentationCHO——NoSevere synechiaNo38241Nonprogressive labor, fetal heart abnormalityCHO——NoSevere synechiaNo35140Nonprogressive laborCHOUVLIALNoLight synechiaToo early25140Nonprogressive laborIALCHO—NoLight synechiaNo desire28239Nonprogressive laborIALCHO—NoLight synechiaNo26140Nonprogressive labor, breech presentationUVLB-LYNCHCHONoLight synechiaMiscarriage, then new pregnancyPhone call34138Twin pregnancy, nonprogressive laborCHO——NoNoneNo desire28426Twin pregnancy, prematurityCHOUVLIALNoNoneNo desire38335Placenta previaIALCHO—NoNoneNo desire26133Prematurity and breech presentationCHO——NoNoneNo desire39330Twin pregnancy, prematurityCHOIAL—NoNoneNo desire26337Twin pregnancy, perineal diseaseB-LYNCHUVLIALNoNoneNo desire29138Twin pregnancy, gravidis cholestasis, and breech presentationCHOIAL—NoNoneNo desire24139Breech presentationCHOIAL—NoNoneNo desirePregnancy without hysteroscopy (n = 1)33140Fetal heart abnormalityUVLB-LYNCH—NoNoneLive birthHysterectomy33337Nonprogressive laborUVLB-LYNCH—Yes, delayed——42337Placenta previaCHOIAL—Yes——29339Double scarred uterusCHOIAL—Yes——36640Nonprogressive laborB-LYNCHUVL—Yes——29136Twin pregnancy, fetal heart abnormalityIALCHO—Yes——37130Prematurity and eclampsiaCHOUVLIALYes——36137Twin pregnancy, fetal heart abnormalityIALB-LYNCHCHOYes——Lost to follow-up22140Pelvic diseaseIALCHO—NoUnknownUnknown25335Twin pregnancy, double scarred uterusCHOIAL—NoUnknownUnknown32127Prematurity, chorioamnionitisCHOIAL—NoUnknownUnknown41340Double scarred uterusB-LYNCHUVLIALNoUnknownUnknown27140Nonprogressive laborCHO——NoUnknownUnknown37238Placenta previaB-LYNCH——NoUnknownUnknown27138Twin pregnancy, nonprogressive laborIALCHO—NoUnknownUnknown27136Nonprogressive laborIALUVLB-LYNCHNoUnknownUnknownNote: Group A, normal hysteroscopy; group B, pathologic hysteroscopy. CHO = surgical procedure as described by Cho et al. 5Cho J.H. Jun H.S. Lee C.N. Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131Crossref PubMed Scopus (268) Google Scholar; IAL = internal iliac artery ligation; UVL = uterine vessel ligation, as described by Tsirulnikov 7Tsirulnikov M.S. Ligation of the uterine vessels during obstetrical hemorrhages. Immediate and long-term results (author's transl).J Gynecol Obstet Biol Reprod. 1979; 8: 751-753PubMed Google Scholar; B-LYNCH = surgical procedure as described by B-Lynch et al. 4B-Lynch C. Coker A. Lawal A.H. Abu J. Cowen M.J. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported.Br J Obstet Gynaecol. 1997; 104: 372-375Crossref PubMed Scopus (512) Google Scholar.a Too early for woman to begin a new pregnancy. Open table in a new tab Between October 2004 and July 2009, 100 cases of PPH occurred in the course of 3,699 cesarean sections. In 57 of these 100 cases mechanical and uterotonic drug treatments were unable to control the bleeding, and the women were then managed surgically. Of these 57 cases, UCS was performed on 37 women (Table 1). These 37 women had a mean age of 31 years (range, 20–42), and their mean gestational age at the time of cesarean section was 37 weeks (range, 26–41 weeks). The mean number of pregnancies was 1.8 (range, 1–4). Causes of PPH were uterine atony in 31 of 37 cases (84%) and placenta accreta in 6 of 37 cases (16%). Median length of hospital stay was 8 days (range, 5–22). There was no maternal death.In our population (Table 1), UCS as described by Cho and B-Lynch were used as exclusive techniques, or used together, or performed in addition to ligation of pelvic arteries (uterine vessel ligation described by Tsirulnikov [7] and/or internal iliac artery ligation [1]). Choice and association of all these techniques depended on the surgeon and the situation. Conservative surgical management of PPH failed in six cases and led to hemostatic hysterectomy. In one other case, hysterectomy was performed 10 days later because of a subsequent myometrial infectious necrosis.In 30 cases (81%), the surgical procedures successfully stopped the bleeding and the patient's uterus was preserved. Thirteen cases were evaluated by hysteroscopy, which was performed 2 months after the procedure. The hysteroscopic results defined two groups: group A (n = 6), with normal uterine cavities, and group B (n = 7), with pathologic cavities (Table 1). Groups were comparable for patient characteristics, indications for cesarean section, and onset of labor. In group B synechiae were easily treated during the same procedure using the hysteroscope in four cases. One of these four women had a subsequent pregnancy but miscarried after 14 weeks' gestation. She is now pregnant again. In the other three cases of group B, the synechiae were so extensive that the endoscopic procedure was not effective. None of these three women have been pregnant since. In group A two women became pregnant thereafter, with live births. The two groups were comparable concerning the association of surgical procedures (Table 1). Patients with syncechia (group B) were not significantly older than patients in group A (31.4 ± 5.5 vs. 27.8 ± 5.4 years, respectively, P=.3) but had an almost significantly higher parity (1.4 ± 0.5 vs. 1 ± 0, respectively, P=.08). Other characteristics did not differ between groups.Seventeen women did not undergo hysteroscopy. Of these 17, 1 had a subsequent normal pregnancy after UCS, before a cavity control could be done. We tried to contact the remaining 16 women by telephone: 8 women had no desire for pregnancy. We could not reach the eight other women: no pregnancy or hysteroscopy occurred, as far as we know.In conclusion, for the 30 women who were able to conserve their uterus, follow-up was considered as favorable (full-term pregnancy and/or normal hysteroscopy) in seven cases (23%) and adverse in seven cases (23%). Eight women (27%) had no desire for pregnancy. Eight women (27%) were lost to follow-up. Of the 13 who had hysteroscopy, 7 (54%) had intrauterine synechia. Three (10% of 30 without hysterectomy, 23% of those who desired pregnancy and had hysteroscopic evaluation) had severe synechia (Asherman syndrome) that could not be corrected. Last, one woman underwent hysterectomy 10 days after cesarean section because of uterine necrosis after UCS (B-Lynch procedure) and artery ligation.The UCS techniques are quite simple and require less experience and skill than vascular ligation. For these reasons, UCS has become widely adopted as an emergency measure and is described in the French recommendations (8d'Ercole C. Shojai R. Desbriere R. Cravello L. Boubli L. et al.College National des Gynecologues et Obstetriciens FrancaisSurgical management of primary postpartum hemorrhage.J Gynecol Obstet Biol Reprod. 2004; 33 (4S103-19)Google Scholar). However, comparative trials have never been conducted to determine the superiority of a given surgical option, and thus precise recommendations are lacking. The fertility data after UCS techniques are very limited. All five women from B-Lynch's first study went on to have other pregnancies and deliveries (9Allam M.S. B-Lynch C. The B-Lynch and other uterine compression suture techniques.Int J Gynaecol Obstet. 2005; 89: 236-241Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar), and other cases of pregnancies after the B-Lynch procedure for PPH are reported in the literature (10Api M. Api O. Yayla M. Fertility after B-Lynch suture and hypogastric artery ligation.Fertil Steril. 2005; 84: 509Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 11Habek D. Vranjes M. Bobic Vukovic M. Valetic J. Krcmar V. Simunac J. Successful term pregnancy after B-Lynch compression suture in a previous pregnancy on account of massive primary postpartum hemorrhage.Fetal Diagn Ther. 2006; 21: 475-476Crossref PubMed Scopus (27) Google Scholar, 12Tsitlakidis C. Alalade A. Danso D. B-Lynch C. Ten year follow-up of the effect of the B-Lynch uterine compression suture for massive postpartum hemorrhage.Int J Fertil Womens Med. 2006; 51: 262-265PubMed Google Scholar). Four of 23 women had successful pregnancies after Cho's hemostatic suturing technique (5Cho J.H. Jun H.S. Lee C.N. Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131Crossref PubMed Scopus (268) Google Scholar). Six of 10 women who tried to conceive had term deliveries in the report by Ouahba et al. (13Ouahba J. Piketty M. Huel C. Azarian M. Feraud O. Luton D. et al.Uterine compression sutures for postpartum bleeding with uterine atony.BJOG. 2007; 114: 619-622Crossref PubMed Scopus (63) Google Scholar). Hackethal et al. (14Hackethal A. Tcharchian G. Ionesi-Pasacica J. Muenstedt K. Tinneberg H.R. Oehmke F. Uterine surgery in postpartum hemorrhage.Minerva Ginecol. 2009; 61: 201-213PubMed Google Scholar) could not report on fertility outcomes because no patient tried to become pregnant again. In our cohort, five women were pregnant after the UCS procedure. Seven cases of pathologic uterine cavity were diagnosed by hysteroscopy, with only one subsequent pregnancy in this group, ending in miscarriage.Cases of Asherman's syndrome after hemostatic multiple square suturing have been also described by Wu and Yeh (15Wu H.H. Yeh G.P. Uterine cavity synechiae after hemostatic square suturing technique.Obstet Gynecol. 2005; 105: 1176-1178Crossref PubMed Scopus (65) Google Scholar), Desbriere et al. (16Desbriere R. Courbiere B. Mattei S. Haumonte J.B. Shojai R. Antonini F. et al.Hemostatic multiple square suturing is an effective treatment for the surgical management of intractable obstetric hemorrhage.Eur J Obstet Gynecol Reprod Biol. 2008; 138: 244-246Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar), and Goojha et al. (17Goojha C.A. Case A. Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage.Fertil Steril. 2010; 94: 1098.e1-1098.e5Abstract Full Text Full Text PDF Scopus (36) Google Scholar). Synechiae may have occurred because of the choice of suture material. The techniques described by B-Lynch et al. (4B-Lynch C. Coker A. Lawal A.H. Abu J. Cowen M.J. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported.Br J Obstet Gynaecol. 1997; 104: 372-375Crossref PubMed Scopus (512) Google Scholar) and Cho et al. (5Cho J.H. Jun H.S. Lee C.N. Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131Crossref PubMed Scopus (268) Google Scholar) involved the use of two chromic catguts (18B-Lynch C. Partial ischemic necrosis of the uterus following a uterine brace compression suture.BJOG. 2005; 112: 126-127Crossref PubMed Scopus (23) Google Scholar). Because the production of this type of string was stopped, absorbable sutures (Vicryl 0; Ethicon, France), which last longer, are generally used. Compression suture may be the cause of local ischemia or necrosis, which could lead to synechia. Cho's square suture was also related to pyometria (19Ochoa M. Allaire A.D. Stitely M.L. Pyometria after hemostatic square suture technique.Obstet Gynecol. 2002; 99: 506-509Crossref PubMed Scopus (120) Google Scholar) (a case of uterine necrosis described by Reyftmann et al. (20Reyftmann L. Nguyen A. Ristic V. Rouleau C. Mazet N. Dechaud H. Partial uterine wall necrosis following Cho hemostatic sutures for the treatment of postpartum hemorrhage.Gynecol Obstet Fertil. 2009; 37: 579-582Crossref PubMed Scopus (27) Google Scholar) was included in our 37 patients). Cases of total or partial uterine necrosis have also been described (21Joshi V.M. Shrivastava M. Partial ischemic necrosis of the uterus following a uterine brace compression suture.BJOG. 2004; 111: 279-280Crossref PubMed Scopus (106) Google Scholar, 22Treloar E.J. Anderson R.S. Andrews H.S. Bailey J.L. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage.BJOG. 2006; 113: 486-488Crossref PubMed Scopus (85) Google Scholar). Akoury and Sherman (23Akoury 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: 421-424Crossref PubMed Scopus (47) Google Scholar) reported a case of partial uterine wall necrosis after combined B-Lynch and Cho square sutures. Pelvic adhesions after B-Lynch have been described as well (17Goojha C.A. Case A. Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage.Fertil Steril. 2010; 94: 1098.e1-1098.e5Abstract Full Text Full Text PDF Scopus (36) Google Scholar, 22Treloar E.J. Anderson R.S. Andrews H.S. Bailey J.L. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage.BJOG. 2006; 113: 486-488Crossref PubMed Scopus (85) Google Scholar, 24Hayman R.G. Arulkumaran S. Steer P.J. Uterine compression sutures: surgical management of postpartum hemorrhage.Obstet Gynecol. 2002; 99: 502-506Crossref PubMed Scopus (277) Google Scholar, 25Baskett T.F. Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy.Obstet Gynecol. 2007; 110: 68-71Crossref PubMed Scopus (78) Google Scholar).The small size of our cohort is a limitation, because the power of this study is low. Nevertheless, our series is the largest reported in the literature to date, with 37 UCS procedures associated with 14 postoperative assessments. The aim of this report is not to challenge UCS efficacy but to warn about the mid- and long-term outcomes of the uterine cavity and fertility. Our knowledge on UCS techniques is limited owing to a lack of sufficient data. Vascular ligation is a well-known surgery that, as we know, has no impact on fertility or pregnancy (7Tsirulnikov M.S. Ligation of the uterine vessels during obstetrical hemorrhages. Immediate and long-term results (author's transl).J Gynecol Obstet Biol Reprod. 1979; 8: 751-753PubMed Google Scholar, 26O'Leary J.A. Pregnancy following uterine artery ligation.Obstet Gynecol. 1980; 55: 112-113PubMed Google Scholar, 27Fahmy K. Uterine artery ligation to control postpartum hemorrhage.Int J Gynaecol Obstet. 1987; 25: 363-367Abstract Full Text PDF PubMed Scopus (41) Google Scholar, 28Sentilhes L. Trichot C. Resch B. Sergent F. Roman H. Marpeau L. et al.Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage.Hum Reprod. 2008; 23: 1087-1092Crossref PubMed Scopus (77) Google Scholar, 29Nizard J. Barrinque L. Frydman R. Fernandez H. Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum haemorrhage.Hum Reprod. 2003; 18: 844-848Crossref PubMed Scopus (89) Google Scholar). Therefore, even though ligation techniques require more surgical experience, we think that they should be the first choice for surgical management. Although UCS remains an excellent alternative to emergency hysterectomy, the simplicity of these techniques should not determine the decision to use them as a first attempt. Postpartum hemorrhage (PPH) is a major cause of maternal morbidity and continues to be the most common cause of maternal mortality. Traditionally, surgical management of refractory PPH has relied on postpartum hysterectomy, although alternatives to this radical treatment have been proposed. Surgical ligation of pelvic arteries for PPH was described in the early 1960s (1Sagarra M. Glasser S.T. Stone M.L. Ligation of the internal iliac vessels in the control of postpartum hemorrhage: report of a case.Obstet Gynecol. 1960; 15: 698-701PubMed Google Scholar, 2Reich W.J. Nechtow M.J. Ligation of the internal iliac (hypogastric) arteries: a life-saving procedure for uncontrollable gynecologic and obstetric hemorrhage.J Int Coll Surg. 1961; 36: 157-168PubMed Google Scholar). Various techniques for uterine compression suturing (UCS) have been described over the past 10 years (3Mallappa Saroja C.S. Nankani A. El-Hamamy E. Uterine compression sutures, an update: review of efficacy, safety and complications of B-Lynch suture and other uterine compression techniques for postpartum haemorrhage.Arch Gynecol Obstet. 2010; 281: 581-588Crossref PubMed Scopus (56) Google Scholar). Christopher B-Lynch was the first to highlight UCS in 1997 (4B-Lynch C. Coker A. Lawal A.H. Abu J. Cowen M.J. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported.Br J Obstet Gynaecol. 1997; 104: 372-375Crossref PubMed Scopus (512) Google Scholar). Since then other techniques, such as Cho's square suture (5Cho J.H. Jun H.S. Lee C.N. Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131Crossref PubMed Scopus (268) Google Scholar) and modifications of the B-Lynch suture technique, have been added to the range of conservative surgical procedures (6El-Hamamy E. B-Lynch C. A worldwide review of the uses of the uterine compression suture techniques as alternative to hysterectomy in the management of severe post-partum haemorrhage.J Obstet Gynaecol. 2005; 25: 143-149Crossref PubMed Scopus (65) Google Scholar). Therefore, little is known about the fertility and pregnancy outcomes for women who have undergone UCS. This retrospective cohort study included all women who had undergone UCS after a cesarean section in our tertiary obstetric unit (Montpellier University Hospital) from October 2004 to July 2009. No institutional review board approval was necessary. B-Lynch's or Cho's technique was used by our team in this period. Both techniques are recent surgical treatments for PPH and are easier to perform than vascular ligations. These two methods are based on the same theory: a resorbable stitch is passed through the uterine cavity to treat uterine atony. According to literature, these are the two most often used techniques. For these reasons, we considered them as one type of surgery, which we called UCS. The aim of this study was to evaluate the effect of UCS on fertility and pregnancy outcomes, to define more accurately their place in the surgical uterine-sparing techniques to manage PPH. For this purpose, we studied the case reports with a focus on results of postcesarean hysteroscopy and subsequent pregnancy. Data concerning surgical procedures, hysteroscopic results, and pregnancy outcomes were retrieved from computerized hospital discharge summaries. When case note records were not available, we attempted to contact the women by telephone. The women were asked about their desire for subsequent pregnancies, and any attempts and results, since the day of the cesarean section. The women's characteristics were compared between groups (group A and group B, defined by result on hysteroscopy) (Table 1), using the Fisher exact test for categoric variables and the Mann–Whitney U test for nonparametric variables. Note: Group A, normal hysteroscopy; group B, pathologic hysteroscopy. CHO = surgical procedure as described by Cho et al. 5Cho J.H. Jun H.S. Lee C.N. Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131Crossref PubMed Scopus (268) Google Scholar; IAL = internal iliac artery ligation; UVL = uterine vessel ligation, as described by Tsirulnikov 7Tsirulnikov M.S. Ligation of the uterine vessels during obstetrical hemorrhages. Immediate and long-term results (author's transl).J Gynecol Obstet Biol Reprod. 1979; 8: 751-753PubMed Google Scholar; B-LYNCH = surgical procedure as described by B-Lynch et al. 4B-Lynch C. Coker A. Lawal A.H. Abu J. Cowen M.J. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported.Br J Obstet Gynaecol. 1997; 104: 372-375Crossref PubMed Scopus (512) Google Scholar. Between October 2004 and July 2009, 100 cases of PPH occurred in the course of 3,699 cesarean sections. In 57 of these 100 cases mechanical and uterotonic drug treatments were unable to control the bleeding, and the women were then managed surgically. Of these 57 cases, UCS was performed on 37 women (Table 1). These 37 women had a mean age of 31 years (range, 20–42), and their mean gestational age at the time of cesarean section was 37 weeks (range, 26–41 weeks). The mean number of pregnancies was 1.8 (range, 1–4). Causes of PPH were uterine atony in 31 of 37 cases (84%) and placenta accreta in 6 of 37 cases (16%). Median length of hospital stay was 8 days (range, 5–22). There was no maternal death. In our population (Table 1), UCS as described by Cho and B-Lynch were used as exclusive techniques, or used together, or performed in addition to ligation of pelvic arteries (uterine vessel ligation described by Tsirulnikov [7] and/or internal iliac artery ligation [1]). Choice and association of all these techniques depended on the surgeon and the situation. Conservative surgical management of PPH failed in six cases and led to hemostatic hysterectomy. In one other case, hysterectomy was performed 10 days later because of a subsequent myometrial infectious necrosis. In 30 cases (81%), the surgical procedures successfully stopped the bleeding and the patient's uterus was preserved. Thirteen cases were evaluated by hysteroscopy, which was performed 2 months after the procedure. The hysteroscopic results defined two groups: group A (n = 6), with normal uterine cavities, and group B (n = 7), with pathologic cavities (Table 1). Groups were comparable for patient characteristics, indications for cesarean section, and onset of labor. In group B synechiae were easily treated during the same procedure using the hysteroscope in four cases. One of these four women had a subsequent pregnancy but miscarried after 14 weeks' gestation. She is now pregnant again. In the other three cases of group B, the synechiae were so extensive that the endoscopic procedure was not effective. None of these three women have been pregnant since. In group A two women became pregnant thereafter, with live births. The two groups were comparable concerning the association of surgical procedures (Table 1). Patients with syncechia (group B) were not significantly older than patients in group A (31.4 ± 5.5 vs. 27.8 ± 5.4 years, respectively, P=.3) but had an almost significantly higher parity (1.4 ± 0.5 vs. 1 ± 0, respectively, P=.08). Other characteristics did not differ between groups. Seventeen women did not undergo hysteroscopy. Of these 17, 1 had a subsequent normal pregnancy after UCS, before a cavity control could be done. We tried to contact the remaining 16 women by telephone: 8 women had no desire for pregnancy. We could not reach the eight other women: no pregnancy or hysteroscopy occurred, as far as we know. In conclusion, for the 30 women who were able to conserve their uterus, follow-up was considered as favorable (full-term pregnancy and/or normal hysteroscopy) in seven cases (23%) and adverse in seven cases (23%). Eight women (27%) had no desire for pregnancy. Eight women (27%) were lost to follow-up. Of the 13 who had hysteroscopy, 7 (54%) had intrauterine synechia. Three (10% of 30 without hysterectomy, 23% of those who desired pregnancy and had hysteroscopic evaluation) had severe synechia (Asherman syndrome) that could not be corrected. Last, one woman underwent hysterectomy 10 days after cesarean section because of uterine necrosis after UCS (B-Lynch procedure) and artery ligation. The UCS techniques are quite simple and require less experience and skill than vascular ligation. For these reasons, UCS has become widely adopted as an emergency measure and is described in the French recommendations (8d'Ercole C. Shojai R. Desbriere R. Cravello L. Boubli L. et al.College National des Gynecologues et Obstetriciens FrancaisSurgical management of primary postpartum hemorrhage.J Gynecol Obstet Biol Reprod. 2004; 33 (4S103-19)Google Scholar). However, comparative trials have never been conducted to determine the superiority of a given surgical option, and thus precise recommendations are lacking. The fertility data after UCS techniques are very limited. All five women from B-Lynch's first study went on to have other pregnancies and deliveries (9Allam M.S. B-Lynch C. The B-Lynch and other uterine compression suture techniques.Int J Gynaecol Obstet. 2005; 89: 236-241Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar), and other cases of pregnancies after the B-Lynch procedure for PPH are reported in the literature (10Api M. Api O. Yayla M. Fertility after B-Lynch suture and hypogastric artery ligation.Fertil Steril. 2005; 84: 509Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 11Habek D. Vranjes M. Bobic Vukovic M. Valetic J. Krcmar V. Simunac J. Successful term pregnancy after B-Lynch compression suture in a previous pregnancy on account of massive primary postpartum hemorrhage.Fetal Diagn Ther. 2006; 21: 475-476Crossref PubMed Scopus (27) Google Scholar, 12Tsitlakidis C. Alalade A. Danso D. B-Lynch C. Ten year follow-up of the effect of the B-Lynch uterine compression suture for massive postpartum hemorrhage.Int J Fertil Womens Med. 2006; 51: 262-265PubMed Google Scholar). Four of 23 women had successful pregnancies after Cho's hemostatic suturing technique (5Cho J.H. Jun H.S. Lee C.N. Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131Crossref PubMed Scopus (268) Google Scholar). Six of 10 women who tried to conceive had term deliveries in the report by Ouahba et al. (13Ouahba J. Piketty M. Huel C. Azarian M. Feraud O. Luton D. et al.Uterine compression sutures for postpartum bleeding with uterine atony.BJOG. 2007; 114: 619-622Crossref PubMed Scopus (63) Google Scholar). Hackethal et al. (14Hackethal A. Tcharchian G. Ionesi-Pasacica J. Muenstedt K. Tinneberg H.R. Oehmke F. Uterine surgery in postpartum hemorrhage.Minerva Ginecol. 2009; 61: 201-213PubMed Google Scholar) could not report on fertility outcomes because no patient tried to become pregnant again. In our cohort, five women were pregnant after the UCS procedure. Seven cases of pathologic uterine cavity were diagnosed by hysteroscopy, with only one subsequent pregnancy in this group, ending in miscarriage. Cases of Asherman's syndrome after hemostatic multiple square suturing have been also described by Wu and Yeh (15Wu H.H. Yeh G.P. Uterine cavity synechiae after hemostatic square suturing technique.Obstet Gynecol. 2005; 105: 1176-1178Crossref PubMed Scopus (65) Google Scholar), Desbriere et al. (16Desbriere R. Courbiere B. Mattei S. Haumonte J.B. Shojai R. Antonini F. et al.Hemostatic multiple square suturing is an effective treatment for the surgical management of intractable obstetric hemorrhage.Eur J Obstet Gynecol Reprod Biol. 2008; 138: 244-246Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar), and Goojha et al. (17Goojha C.A. Case A. Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage.Fertil Steril. 2010; 94: 1098.e1-1098.e5Abstract Full Text Full Text PDF Scopus (36) Google Scholar). Synechiae may have occurred because of the choice of suture material. The techniques described by B-Lynch et al. (4B-Lynch C. Coker A. Lawal A.H. Abu J. Cowen M.J. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported.Br J Obstet Gynaecol. 1997; 104: 372-375Crossref PubMed Scopus (512) Google Scholar) and Cho et al. (5Cho J.H. Jun H.S. Lee C.N. Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131Crossref PubMed Scopus (268) Google Scholar) involved the use of two chromic catguts (18B-Lynch C. Partial ischemic necrosis of the uterus following a uterine brace compression suture.BJOG. 2005; 112: 126-127Crossref PubMed Scopus (23) Google Scholar). Because the production of this type of string was stopped, absorbable sutures (Vicryl 0; Ethicon, France), which last longer, are generally used. Compression suture may be the cause of local ischemia or necrosis, which could lead to synechia. Cho's square suture was also related to pyometria (19Ochoa M. Allaire A.D. Stitely M.L. Pyometria after hemostatic square suture technique.Obstet Gynecol. 2002; 99: 506-509Crossref PubMed Scopus (120) Google Scholar) (a case of uterine necrosis described by Reyftmann et al. (20Reyftmann L. Nguyen A. Ristic V. Rouleau C. Mazet N. Dechaud H. Partial uterine wall necrosis following Cho hemostatic sutures for the treatment of postpartum hemorrhage.Gynecol Obstet Fertil. 2009; 37: 579-582Crossref PubMed Scopus (27) Google Scholar) was included in our 37 patients). Cases of total or partial uterine necrosis have also been described (21Joshi V.M. Shrivastava M. Partial ischemic necrosis of the uterus following a uterine brace compression suture.BJOG. 2004; 111: 279-280Crossref PubMed Scopus (106) Google Scholar, 22Treloar E.J. Anderson R.S. Andrews H.S. Bailey J.L. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage.BJOG. 2006; 113: 486-488Crossref PubMed Scopus (85) Google Scholar). Akoury and Sherman (23Akoury 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: 421-424Crossref PubMed Scopus (47) Google Scholar) reported a case of partial uterine wall necrosis after combined B-Lynch and Cho square sutures. Pelvic adhesions after B-Lynch have been described as well (17Goojha C.A. Case A. Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage.Fertil Steril. 2010; 94: 1098.e1-1098.e5Abstract Full Text Full Text PDF Scopus (36) Google Scholar, 22Treloar E.J. Anderson R.S. Andrews H.S. Bailey J.L. Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage.BJOG. 2006; 113: 486-488Crossref PubMed Scopus (85) Google Scholar, 24Hayman R.G. Arulkumaran S. Steer P.J. Uterine compression sutures: surgical management of postpartum hemorrhage.Obstet Gynecol. 2002; 99: 502-506Crossref PubMed Scopus (277) Google Scholar, 25Baskett T.F. Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy.Obstet Gynecol. 2007; 110: 68-71Crossref PubMed Scopus (78) Google Scholar). The small size of our cohort is a limitation, because the power of this study is low. Nevertheless, our series is the largest reported in the literature to date, with 37 UCS procedures associated with 14 postoperative assessments. The aim of this report is not to challenge UCS efficacy but to warn about the mid- and long-term outcomes of the uterine cavity and fertility. Our knowledge on UCS techniques is limited owing to a lack of sufficient data. Vascular ligation is a well-known surgery that, as we know, has no impact on fertility or pregnancy (7Tsirulnikov M.S. Ligation of the uterine vessels during obstetrical hemorrhages. Immediate and long-term results (author's transl).J Gynecol Obstet Biol Reprod. 1979; 8: 751-753PubMed Google Scholar, 26O'Leary J.A. Pregnancy following uterine artery ligation.Obstet Gynecol. 1980; 55: 112-113PubMed Google Scholar, 27Fahmy K. Uterine artery ligation to control postpartum hemorrhage.Int J Gynaecol Obstet. 1987; 25: 363-367Abstract Full Text PDF PubMed Scopus (41) Google Scholar, 28Sentilhes L. Trichot C. Resch B. Sergent F. Roman H. Marpeau L. et al.Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage.Hum Reprod. 2008; 23: 1087-1092Crossref PubMed Scopus (77) Google Scholar, 29Nizard J. Barrinque L. Frydman R. Fernandez H. Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum haemorrhage.Hum Reprod. 2003; 18: 844-848Crossref PubMed Scopus (89) Google Scholar). Therefore, even though ligation techniques require more surgical experience, we think that they should be the first choice for surgical management. Although UCS remains an excellent alternative to emergency hysterectomy, the simplicity of these techniques should not determine the decision to use them as a first attempt. We thank Melle Delphine Roubach and Miss Sott-Carmeni C. for their help with the English editing. Which surgery should be the first-line uterine-sparing procedure to control severe postpartum hemorrhage?Fertility and SterilityVol. 95Issue 8PreviewWe read with great interest the case series reporting by Rathat et al. (1), which highlights the risk of synechia after uterine compression suture. The investigators concluded that "even though ligation techniques require more surgical experience, we think that they should be the first choice for surgical management" (1). We could not agree more with them as we have been attempting to alert physicians to the possible hidden midterm or long-term effects of uterine compression sutures (2–6), in particular in publishing our algorithm for management of postpartum hemorrhage (2, 7, 8), while these procedures were adopted promptly throughout the world. Full-Text PDF
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