Transverse annular compression sutures in the lower uterine segment to control postpartum hemorrhage at cesarean delivery for complete placenta previa

Abstract

Complete placenta previa (CPP) is an important cause of life threatening postpartum hemorrhage (PPH) [1]. Bleeding can be severe and uncontrollable because there is less musculature in the lower uterine segment. The aim of the present study was to retrospectively evaluate the efficacy of transverse annular compression sutures (TACS) in achieving hemostasis after traditional conservative methods had failed to control bleeding during cesarean delivery in women with CPP. A total of 41 pregnant women with CPP were included in the study. Eligibility criteria were: (1) persistent bleeding from the separated placental surface of the lower uterine segment at cesarean delivery after successive use of uterotonics, local suturing, and ligation of uterine arteries; and (2) subsequent administration of either uterine packing (UP) or TACS (Fig. 1). There were 24 patients in the UP group and 17 patients in the TACS group. Primary outcome was blood loss reported at the different phases of the cesarean delivery procedure. Pb0.05 was considered statistically significant. Differences between the 2 groups were assessed using the t test, χ or Fisher exact tests. The Institutional Ethical Committee approved the study. There was no significant difference at baseline in age, body mass index (calculated as weight in kilograms divided by height in meters squared), gravidity, parity, gestational age at delivery, birth weight, doses of uterotonics, and incidence of placenta accreta (Table 1). Overall, there was greater blood loss throughout the cesarean delivery procedure in the UP group compared with the TACS group (1670.0±447.7 mL vs 978.2±142.9 mL; Pb0.05). No difference in blood loss was found between the groups both before and after the intervention (The intervention was defined as either uterine packing or TACS in the study). The difference in blood loss occurred during the intervention, with 845.8±311.3 mL of blood loss in the UP group compared with 142.9±64.5 mL in the TACS group (Pb0.05). Interestingly, the time taken to perform uterine packing was significantly longer than the time taken to perform TACS (22.0± 5.6 min vs 2.9±1.0 min; Pb0.05). The quantity of blood transfused was also significantly higher in the UP group than in the TACS group (1541.7±792.3 mL vs 1008.3±516.0 mL; Pb0.05). Hysterectomy was unavoidable in 2 (8.3%) patients in the UP group because of intractable bleeding. TACS failed to stop bleeding in 1 (5.9%) patient in the TACS group and the patient's uterus was preserved using multiple uterine compression sutures. Ultrasound results showed no uterine abnormalities on day 42 post delivery in the TACS group. No difference was found in the incidence of complications between the 2 groups. Normal menstruation resumed for all women, except for those who underwent hysterectomy. It is difficult to control the bleeding from the separated placental surface during cesarean delivery inwomenwith CPP [2,3]. The present study indicates that both UP and TACS were effective in controlling bleeding. The success rates (i.e., achievement of hemostasis) were 91.7% and 94.1% for UP and TACS, respectively. However, the mean blood loss during cesarean delivery and the quantity of blood transfused were higher in the UP group than in the TACS group. A partial explanation might be that the greater blood loss was related to the longer time taken to complete the intervention since it took more time to performuterine packing than to performTACS. Furthermore, in the only participant for whom TACS failed to control bleeding, the uterus was successfully preserved using another technique. Hysterectomy was required for the 2 patients in whom uterine packing was ineffective. TACS may be particularly useful in low-resource areas because it is technically less challenging and requiresminimal training and equipment. In 1997, B-Lynch et al. [4] first described the use of uterine compression sutures to treat PPH, primarily for uterine atony. In placenta previa cases, B-Lynch suturingwas described following afigure-of-eight suture in the lower uterine segment. Hwu et al. [3] andHayman et al. [5] International Journal of Gynecology and Obstetrics 108 (2010) 247–257BRIEF COMMUNICATIONS