Keywords
postpartum hemorrhage - uterine atony - suture techniques - maternal mortality - surgical
hemostasis
Palavras-chave
hemorragia pós-parto - atonia uterina - técnicas de sutura - mortalidade materna -
hemostasia cirúrgica
Introduction
Maternal mortality (MM) is a tragic event of worldwide proportions. Worldwide, it
is estimated that 300,000 maternal deaths occur every year according to the World
Health Organization (WHO), 94% of which occur in poor or developing countries. Note
that the majority could have been avoided.[1]
Maternal mortality has been declining globally, with significant differences among
several countries. Effective compliance with strategies for its reduction provided
a greater understanding of the social causes of MM, such as the role of education,
income distribution, and place of birth.[2]
[3]
In Brazil, according to the WHO, the national MM ratio (MMR) was 60 deaths in 2017.
Compared to the year 1990, which had a MMR of 104 deaths, a significant reduction
of 42.3% occurred in this period. However, when we analyze countries such as Japan
and the United States of America, which presented, respectively, MMRs of 5 and 19
deaths in the same period, it is clear how much progress needs to be made so that
women's health can reach acceptable coefficients in our country.[2]
Postpartum hemorrhage (PPH) is responsible for 25 to 30% of MM worldwide. In Brazil,
13.3% of MM is due to antepartum and PPH. It is the second most important direct obstetric
cause, and, unfortunately, it remains one of the most important causes of preventable
MM.[1]
[4]
Uterine atony (UA) is the most common cause of PPH, and it is responsible for ∼ 80%
of all cases of this concerning pathology.[5] The traditional treatment of UA is established by a sequence of actions well defined
by global protocols. In the case of therapeutic failure with the initial clinical
pharmacological measures, other methods must be promptly applied to control uterine
hemorrhage. Surgical methods such as selective arterial embolization, internal iliac
or uterine artery ligation, and total or subtotal hysterectomy are presented as effective
treatment options.[6]
[7] However, they show an excessively invasive nature, requiring longer execution time,
and a long learning curve; consequently, they are associated with more comorbidities,
such as greater volume of hemorrhage and risk of injury to adjacent structures, such
as the ureter, intestines, and bladder.[7]
The search for less invasive techniques easily reproducible and aiming at the possible
preservation of fertility to avoid hysterectomies has brought about the so-called
hemostatic suture techniques for the correction of atony conditions refractory to
the initial measures.[8]
[9]
[10]
[11]
[12]
[13]
[14]
Hemostatic sutures have been part of the therapy to control PPH for at least two decades.
Several techniques have emerged over the years with the same purpose of controlling
PPH after non-surgical therapeutic failure and preserving the patient from more complex
surgeries with greater comorbidities, such as hysterectomy.[7]
[8]
[9]
In Oxford, Christopher B-Lynch described a hemostatic compression suture technique,
in 1997, in five cases of PPH secondary to UA which did not respond to the initial
clinical-pharmacological treatment, thus introducing a new conservative alternative
to surgeries with greater morbidity.[8] The application of the technique has been recommended worldwide, being included
in the routine clinical practice for PPH in several protocols around the world. A
systematic review showed 91.7% of success rate in controlling PPH.[9]
[10]
[14]
[15]
It is important to document this experience in a clinical study aimed at analyzing
the clinical experience with the B-Lynch compression suture technique in the management
of PPH at the Hospital Maternidade Escola Vila Nova Cachoeirinha (HMEVNC) over 15
years, in addition to identifying the factors related to the indication for use of
the technique. The success rates of the B-Lynch compression suture technique in controlling
PPH were also analyzed.
Methods
This is an observational, retrospective, cross-sectional, and analytical study. The
study population consisted of patients who underwent uterine compression suture using
the B-Lynch technique at HMEVNC within the period from January 1, 2005, to December
31, 2019. The number of patients included was defined by a convenience sample of 104
patients.
Regarding the use of the method, we state that the B-Lynch hemostatic suture was included
in the clinical practice protocol of the HMEVNC as of 2005. This pioneering experience
in Brazil was recorded in a national publication reporting a series of four cases
of successfully controled PPH using the B-Lynch suture technique.[16] Since then, this experience was expanded to be incorporated into their routine clinical
practices.
In our center, the indication for applying the B-lynch suture was exclusively due
to UA related to several risk factors and management of UA is established by a sequence
of actions. These actions initiated immediately after the diagnosis of PPH due to
UA initially include bimanual uterine compression, described as the Hamilton maneuver
concomitant with the use of uterotonics, with intravenous oxytocin being the first
option. The ergot alkaloids should be applied if the initial therapy with oxytocin
fails, observing the contraindication for hypertensive patients. Misoprostol, an analogue
of type E1 prostaglandin, is the third drug in the therapeutic sequence. Intrauterine
balloon tamponade is not available at our center. Therefore, if after pharmacological
treatment fails to control PPH, we immediately apply the B-lynch suture, regardless
of the parity or severity of uterine bleeding.
The document analysis to obtain the patient's data was performed on the study of medical
records. These records were selected from a notebook available at the obstetric center
for exclusive use to write down the full names and medical record of the patients
who underwent the B-Lynch suture technique. Data was collected exclusively by the
main researcher using a spreadsheet created with the software Microsoft Excel, version
for Office 365 (Microsoft Corp., Redmond, WA, USA).
The selected analysis variables were grouped and defined as follows:
Pregnancy and childbirth variables:
-
Gestational age: defined in complete weeks at the time of delivery, counting by the
date of the last menstrual period (LMP), if reliable, or by ultrasound, if LMP w unknown
or unreliable.
-
Number of pregnancies: considered the sum of current and previous pregnancies, regardless
of gestational age, vitality, or location.
-
Parity: defined as the number of deliveries whose newborn weighed ≥ 500 g or reached
gestational age ≥ 20 weeks, regardless of the number of fetuses or outcomes.
-
Antenatal care: considered performed only for patients who attended six or more appointments.[17]
-
Use of oxytocin to induce or conduct labor;
-
Previous cesarean section: 1 or more;
-
Preeclampsia: manifestation of hypertension after the 20th week of pregnancy associated
with significant proteinuria or associated with systemic impairment or damage to the
target organs (thrombocytopenia, liver dysfunction, renal failure, pulmonary edema,
impending eclampsia, or eclampsia)[18];
-
Polyhydramnios: defined as an increase in the amount of amniotic fluid[19];
-
Placental abruption: defined as the premature separation of the normal-sited placenta
from the uterus[20];
-
Fetal macrosomia: defined as birthweight greater than 4,000 g[21];
-
Grand multiparity: defined as five deliveries or more[22];
Postpartum variables
-
Blood transfusion: the process of transferring blood components, such as red blood
cells, plasma, clotting factors, and platelets was based on hemodynamic instability
with hemoglobin lower than 7 g/dL or coagulopathy.
-
Postpartum infection: defined as reproductive tract infection occurring after delivery.[23]
-
Complications of the surgical wound: defined as an abnormality in the evolution of
healing, such as dehiscence and surgical site infection.
-
Failure of the method: defined as the need for puerperal hysterectomy after application
of the B-Lynch technique.
-
Puerperal hysterectomy: defined as a surgical procedure for removing the uterus by
laparotomy when hemodynamic instability persists after failure of conservative hemostatic
methods.[7]
It is important to note that the data collected from the postpartum variables was
restricted only to the patients' hospitalization period, considered a short period
of observation.
The data was analyzed using descriptive methods to characterize the variables collected
during the study. Categorical variables were analyzed using absolute and relative
frequencies. Continuous variables were analyzed using medians. For qualitative variables,
the ratios were also estimated with their respective 95% confidence intervals. The
data was analyzed using the software R, v. 3.4.1.
The present study was approved by the ethics in research committee of the Universidade
Federal de São Paulo and HEMVNC, with due authorization to waive the informed consent
form of all patients.
Results
Regarding the obstetric conditions at hospitalization, [Table 1] illustrates the mean gestational age–which was 38 weeks–while the mean number of
pregnancies and deliveries was 2.4 and 1.01, respectively. The median was 39 weeks
regarding the gestational age, with the highest age being 41 weeks, and the lowest
being 22. Among the patients, 48.1% were nulliparous, and 30.8% of pregnant women
had already had at least one previous cesarean section. At least 6 antenatal care
visits were performed by 89.4% of patients.
Table 1
Obstetric conditions at hospitalization of patients who underwent the B-Lynch technique
|
Condition
|
n
|
%
|
Average
|
95% CI
|
Median
|
Minimum value
|
Maximum value
|
|
Gestational age
|
|
|
38.0
|
37.4–38.6
|
39.0
|
22.0
|
41.0
|
|
≥ 37
|
86
|
82.7%
|
|
|
|
|
|
|
34–36
|
11
|
10.6%
|
|
|
|
|
|
|
≤ 33
|
7
|
6.7%
|
|
|
|
|
|
|
TOTAL
|
104
|
100.0%
|
|
|
|
|
|
|
Number of pregnancies*
|
|
|
2.4
|
2.0–2.7
|
2
|
1
|
9
|
|
1
|
44
|
42.3%
|
|
|
|
|
|
|
2–4
|
48
|
46.2%
|
|
|
|
|
|
|
≥ 5
|
12
|
11.5%
|
|
|
|
|
|
|
TOTAL
|
104
|
100.0%
|
|
|
|
|
|
|
Parity**
|
|
|
1.01
|
0.80–1.4
|
1
|
zero
|
6
|
|
Nulliparous
|
50
|
48.1%
|
|
|
|
|
|
|
1–2
|
40
|
38.4%
|
|
|
|
|
|
|
3–4
|
9
|
8.7%
|
|
|
|
|
|
|
≥ 5
|
5
|
4.8%
|
|
|
|
|
|
|
TOTAL
|
104
|
100.0%
|
|
|
|
|
|
|
Previous cesarean section (n = 104)
|
32
|
30.8%
|
|
|
|
|
|
|
Antenatal care (≥ 6 visits) (n = 104)
|
93
|
89.4%
|
|
|
|
|
|
* Number of pregnancies: considered the sum of current and previous pregnancies, regardless
of gestational age, vitality, or location.
** Parity: defined as the number of previous deliveries whose newborn weighed ≥ 500 g
or reached gestational age ≥ 20 weeks, regardless of the number of fetuses or outcomes.
The perinatal characteristics of the patients are shown in [Table 2], with 96.2% having a cesarean delivery, with 93.3% of these having cephalic presentation.
Regarding birth weight, 13% were underweight, and 9.2% were macrosomal. [Table 2] also shows that 100% of patients received oxytocin and misoprostol in the pharmacological
treatment for atony, and 86.5% also used ergometrine.
Table 2
Perinatal characteristics of patients who underwent the B-Lynch technique
|
Condition
|
n
|
%
|
|
Type of delivery
|
|
|
|
Cesarean section
|
100
|
96.2
|
|
Vaginal
|
4
|
3.8
|
|
TOTAL
|
104
|
100.0
|
|
Presentation
|
|
|
|
Cephalic
|
97
|
93.3
|
|
Pelvic
|
7
|
6.7
|
|
TOTAL
|
104
|
100.0
|
|
Birth weight (g)
|
|
|
|
< 2,500
|
14
|
13.0
|
|
2,500–3,999
|
84
|
77.8
|
|
≥ 4,000
|
10
|
9.2
|
|
TOTAL
|
108
|
100.0
|
|
Use of oxytocin to treat PPH
|
|
|
|
Yes
|
104
|
100.0
|
|
No
|
0
|
0.00
|
|
TOTAL
|
104
|
100.0
|
|
Use of ergomethrin
|
|
|
|
Yes
|
90
|
86.5
|
|
No
|
14
|
13.5
|
|
TOTAL
|
104
|
100.0
|
|
Use of misoprostol
|
|
|
|
Yes
|
104
|
100
|
|
No
|
0
|
0.00
|
|
TOTAL
|
104
|
100
|
|
Days of postpartum hospitalization
|
|
|
|
≤ 3
|
88
|
84.6
|
|
4–7
|
15
|
14.4
|
|
≥ 8
|
1
|
1.0
|
|
TOTAL
|
104
|
100.0
|
[Table 3] shows the percentage of patients who presented some risk factor for UA.
Table 3
Risk factors for uterine atony identified in patients who underwent the B-Lynch technique
|
Risk factor
|
n
|
%
|
|
NONE (n = 104)
|
38
|
36.5
|
|
Previous cesarean section (n = 104)
|
32
|
30.8
|
|
Use of oxytocin for induction/conduction of labor (n = 104)
|
17
|
16.3
|
|
Preeclampsia (n = 104)
|
12
|
11.6
|
|
Fetal macrosomia (n = 104)
|
9
|
8.7
|
|
Placental abruption (n = 104)
|
9
|
8.7
|
|
Twinning (n = 104)
|
4
|
3.8
|
|
Grand multiparity (n = 104)
|
5
|
4.8
|
|
Polyhydramnios (n = 104)
|
2
|
1.9
|
The frequency of complications after the surgery is analyzed and shown in [Table 4], and 77.9% had no complications related to B-Lynch suture or PPH. Regarding hospitalization,
most patients remained hospitalized for up to 3 days, and 15.4% required intensive
care unit (ICU) care. The same table also shows that the frequency of puerperal infection
was 1%, and there were five hysterectomies due to failure of hemostasis with the use
of the B-Lynch technique representing 4.8% of patients.
Table 4
Puerperal complications in patients who underwent the B-Lynch technique
|
Complications
|
n
|
%
|
|
One or more complications (n = 104)
|
23
|
22.1
|
|
Blood transfusion (n = 104)
|
14
|
13.5
|
|
ICU admission (n = 104)
|
16
|
15.4
|
|
Puerperal infection (n = 104)
|
1
|
1.0
|
|
Surgical site infection (n = 104)
|
1
|
1.0
|
|
Puerperal hysterectomy (n = 104)
|
5
|
4.8
|
Discussion
The B-Lynch hemostatic suture was included in the clinical practice protocol of the
HMEVNC in 2005. Since then, the clinical experience at this Maternity Hospital School
has only improved.[16]
A limitation of the present study should be noted. The patients were observed in a
short period, which makes it impossible to assess late complications. A total of 104
patients were divided into groups of pregnancy-puerperium cycle variables. Regarding
gestational age, we had 82.7% of full-term births, and 17.3% of prematurity, with
61.2% of these being late preterm babies. Prematurity is often associated with indications
intended to safeguard the mother-fetus binomial.[24] The premature interruption of high-risk pregnancies often has the cesarean section
as the mode of delivery, and this association implies a greater hemorrhagic risk.
The lower uterine segment becomes thicker, and has a larger surface area of the myometrium,
which would lead to greater blood loss.[25]
Among the patients, 48.1% were nulliparous, and only 5.8% were considered grand multiparous
women. There is a direct relation between socioeconomic conditions and parity, as
this condition is implicit in the access to information, as well as in the various
methods for adequate family planning. Grand multiparity is an additional risk factor
for worse mother-fetus outcomes, regardless of other factors.[22]
At least 30.8% of pregnant women in our study had previously had a cesarean section.
In 2016, we had 55% of cesarean deliveries in Brazil, whereas the rate was 40% in
Brazil's unified health system (SUS), which is still far from the WHO recommendations.
The main objective of the cesarean section is to safeguard the mother-fetus well-being
in risk situation for this binomial. However, it is currently an iatrogenic epidemic
in our country, with this important surgery included in the category of risk factor,
among which we include the puerperal hemorrhages.[26]
Regarding antenatal care, 89.4% had at least 6 visits. According to the Ministry of
Health of Brazil, this number of appointments in a well-qualified manner and with
professional training could be sufficient to identify risks and take preventive actions,
or even to refer the patient to more complex services, thereby reducing the mother-fetus
morbidity and mortality.[27]
Concerning the clinical and obstetric conditions of patients at the time of admission,
we found 36.5% of them had no risk factor for UA. Many cases do not present any identifiable
risk factor in the antepartum nor in the intrapartum, which justifies a careful observation
of the risk signs of hemodynamic instability so that the hemorrhagic control actions
can be performed immediately.[28]
In relation to the perinatal characteristics of the patients studied, 96.2% had a
cesarean delivery with precise obstetric indications, and this type of operative delivery
represents an increased hemorrhagic risk.[26]
[29]
Still regarding the perinatal characteristics, we show that 100% of the patients received
oxytocin and misoprostol in the pharmacological treatment for atony, and 86.5% also
used ergometrine, showing that all patients received the appropriate pharmacological
treatment to correct UA, and that 13.5% did not receive ergometrine because they had
chronic hypertension or preeclampsia, which contraindicates the use of ergotamine
derivatives.[7]
Among the various risk factors for PPH, previous cesarean section stood out in the
present study, representing 30.8% of patients, followed by the use of oxytocin, which
corresponded to 16.3%, and 11.6% were diagnosed with preeclampsia. The alarming rates
of cesarean sections are going up worldwide, and the increase in hemorrhagic risk
is well established both in patients with a previous cesarean section who underwent
a new cesarean section and in patients who are undergoing cesarean delivery for the
first time.[26] The use of oxytocin may pose greater risks for the development of UA. In 2010, Balki
et al. demonstrated that there would be a desensitization of specific uterine oxytocin
receptors for patients who were exposed to high doses of oxytocin for a long period,
which would justify its refractoriness in previously exposed patients.[30]
I emphasize that 15.4% needed ICU hospitalization, and 13.5% were transfused with
blood products. It would be reasonable to assume that even though the percentage of
patients in the ICU and transfused is high, it could have been even higher if the
patients had not undergone the B-Lynch technique. It is still valid to state that
the obstetric emergency related to hemorrhage itself poses a risk for transfusion.
It is noteworthy that the uterine blood flow is ∼ 600 ml/minute in a term pregnancy,
which can lead to a very considerable blood loss in a short period.[31]
The frequency of puerperal infection and surgical wound was only 1%. Puerperal hysterectomy
is considered a failure of the method, and it occurred in 4.8% of patients, showing
that the vast majority was preserved from a procedure with greater comorbidity in
addition to having their uterus preserved. In addition to the B-Lynch technique being
simple and of lower risk for comorbidities, the preservation of the uterus as a way
of preserving fertility had a great impact on patients and family members. It is noteworthy
that, in this study, 95.2% of the patients had their uterus preserved, escaping the
possibility of having a more aggressive procedure and with a greater comorbidity such
as hysterectomy.
However, it should be noted that individual training to perform the B-Lynch technique
and the preparation of multiprofessional teams for immediate intervention in the control
of PPH are mandatory for the results to be satisfactory.
Although our results were very satisfactory to recommend its practice, we understand
that there is room for assessing the possible long-term impacts, and that they were
not included in the objectives of the present study.
More studies are necessary in our country to clarify the role of B-Lynch in the women's
reproductive health including fertility, chronic pelvic pain, dyspareunia, and menstruation.
Conclusion
The clinical experience with the B-Lynch technique was satisfactory since it presented
few complications, with excellent results in hemorrhagic control. Previous cesarean
section, the use of oxytocin and preeclampsia stood out as factors related to the
indication of the application of the technique, and the success rate in controlling
PPH was 95.2%.
