Stepwise Uterine Devascularization Research Articles

A sandwich technique (N&H variation technique) to reduce blood loss during cesarean delivery for complete placenta previa: a randomized controlled trial

Objective: To investigate the effect of A sandwich technique Nahla & Hany variation (N&H) technique versus stepwise uterine devascularization on blood loss during cesarean section (CS) in patients with complete placenta previa.Methods: The study was single-blind randomized controlled trial carried out in a tertiary University Hospital between March 2015 to March 2018. We included patients scheduled for CS due to complete placenta previa. They were randomly allocated to group (I) managed by stepwise uterine devascularization, group (II) managed by double transverse compression suture at the lower uterine segment plus intrauterine inflated Foley’s catheter Balloon (H&N variation sandwich) at the lower uterine segment. The primary outcome was the amount of total estimated blood loss both intra- and post-operative.Results: One hundred and six patients were enrolled (n = 53 in each group). There was a great reduction in intraoperative blood loss in group II 570 (400–1300) compared with Group I 1030 (500–1540) (p = .0001), or blood in the intraabdominal drain in group II than group I (p = .0001) Also, there was no significant reduction in postoperative vaginal bleeding. Hence, the total estimated blood loss in group II 750 (550–1580) showed significant reduction compared with group I 1350 (780–1800) (p = .0001).Conclusions: N&H variation sandwich technique in the management of complete placenta previa is a simple technique, safe and effective to decrease blood loss.

Maternal Outcomes After Uterine Balloon Tamponade for Postpartum Hemorrhage

(Acta Obstet Gynecol Scand. 2015;94(4):399–404) Two recent reviews have suggested that uterine balloon tamponade most quickly treats and is the least invasive method available for treating postpartum hemorrhage (PPH). Although this procedure is frequently used and has a success rate similar to uterine artery embolization, B-Lynch suture, and stepwise uterine devascularization, its utility is unclear. The authors of this study examined its use in 2 French health centers to determine what factors might serve as reliable indicators for its failure.

Reproductive performance after conservative surgical treatment of postpartum hemorrhage

ObjectiveTo evaluate the impact of bilateral internal iliac artery ligation (BIL), bilateral uterine artery ligation (BUAL), step-wise uterine devascularization (SWUD), and B-Lynch on infertility, ovarian reserve, and pregnancy outcome. MethodsThe study included 168 infertile or pregnant patients—recruited at outpatient clinics in Egypt—who had previously undergone uterine-sparing surgery (BIL [group I], n=59; SWUD [group II], n=65); BUAL [group III], n=2; and B-Lynch [group IV], n=42). One-way analysis of variance was used to compare the prevalence of infertility, the status of ovarian reserve, and the prevalence and type of relevant maternal and/or fetal obstetric complications between the groups. ResultsGroups II and IV had the highest prevalences of infertility. The ovarian reserve was significantly lower in group II. Unexplained infertility was the predominant cause of infertility in group I, anovulation and premature ovarian failure in group II, and endometriosis and intrauterine adhesions in group IV. The frequency of obstetric complications, particularly placenta previa and preterm labor, was high in group IV. ConclusionOf the 4 procedures, BIL had the least deleterious effect on reproductive performance; SWUD increased the risk of premature ovarian failure, and B-Lynch increased the risks of endometriosis, intrauterine adhesions, placenta previa, and preterm labor.

Fertility after pelvic arterial embolization, stepwise uterine devascularization, hypogastric artery ligation, and B-Lynch suture to control postpartum hemorrhage

0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2009.10.003 A 28-year-old primiparous womanwas referred to our center with secondary postpartum hemorrhage (PPH). The patient had a previous history of two curettages. Secondary PPH occurred 10 days after an uneventful vaginal delivery of a healthy neonate. Ultrasound examination showed a poorly-defined, hyperechogenic intrauterine mass measuring 54 mm at its greatest diameter, which was consistent with a diagnosis of retained placenta. Emergency curettage performed under ultrasound guidance was not successful in removing the retained placenta or in stopping the hemorrhage. Sulprostone administrationwas started because of persistent bleeding unresponsive to oxytocics. Owing to stable hemodynamics the patient was transferred for pelvic arterial embolization that was performed successfully using pledgets of absorbable gelatin sponge and 900 to 1200-μm inert microparticles. PPH had stopped by completion of the procedure. However, recurrent bleeding occurred 3 hours later. Because the patient was primiparous and hemodynamically stable, subsequent uterine-sparing surgical procedures were undertaken according to our protocol for the management of PPH, as reported previously [1,2]. Our protocol outlines vessel ligation and B-Lynch suture as firstand second-line procedures, respectively, for the management of severe PPH [1,2] because there is no evidence to suggest that any one method is better than the other and because reassuring data regarding subsequent fertility are currently more numerous for vessel ligation than B-Lynch suture [3]. A stepwise uterine devascularization was performedfirst, without success. Therefore, hypogastric artery ligation was performed and, because the bleeding continued, a B-Lynch suture was placed prior to considering hysterectomy [1,2]. PPH stopped after B-Lynch suture. The postoperative period was uneventful. The patient had an unplanned pregnancy 4 months following the previous delivery. The pregnancy proceeded unremarkably. Labor was spontaneous at 41 weeks of pregnancy and a healthy female neonate weighing 3350 g was delivered vaginally. The third stage of labor was uneventful and no recurrent abnormal placentation was observed. Some authors have proposed that a second (or even a third) uterine-sparing procedure should be performed in case of a failed first (or second) procedure before considering peripartum hysterectomy in a hemodynamically stable patient with a desire for subsequent pregnancy [1–4]. Nevertheless, one can speculate that using multiple uterine-sparing procedures increases the risk of impairing the subsequent fertility and pregnancy outcomes, which would render this strategy unwarranted. The present case describes how 4 different uterine-sparing procedures to control PPH resulted in an uneventful postoperative period and a subsequent uncomplicated full-term pregnancy and vaginal delivery.

Why stepwise uterine devascularization should be the first‐line conservative surgical treatment to control severe postpartum hemorrhage?

Sir, We thank Dr. Doumouchtsis and colleagues for their interest in our study, and for pursuing the debate regarding what to do when medical treatment fails 1. The main message of our work was that...

B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

Fertility after B-Lynch suture and stepwise uterine devascularization

To report the obstetric outcome in a patient who had previously undergone a stepwise uterine devascularization followed by a B-Lynch suture for severe postpartum hemorrhage (PPH). Case report. University hospital. A 29-year-old woman whose first pregnancy was complicated by severe PPH due to uterine atony. Stepwise uterine devascularization followed by a B-Lynch suture because of persistent PPH. Preservation of reproductive capacity. Two years later, the patient conceived spontaneously and delivered a healthy infant by caesarean section after an uneventful pregnancy. During the operation, the uterus showed no marks of the former B-Lynch suture. This is the first reported case of obstetric outcome after stepwise uterine devascularization and B-Lynch suture. Further case series with mid- and long-term follow-up are required to determine whether the B-Lynch suture has an impact on the patient's subsequent fertility and pregnancies and to establish its place in the PPH surgical management algorithm.

B‐Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

To estimate the effectiveness and safety of the B-Lynch suture for severe persistent postpartum hemorrhage (PPH) following vessel ligation before considering hysterectomy and its impact on menstruation and uterine cavity. Cohort study. University-affiliated tertiary referral center. Population. Fifteen consecutive women who underwent B-Lynch suture for persistent PPH despite vessel ligation. Data were retrieved from medical files and telephone interviews. Hysterectomy, infection, hysteroscopy, future menstruations. In 13 of the 15 cases (86.7%), PPH occurred after cesarean deliveries. B-Lynch sutures controlled the hemorrhage and resulted in an avoidance of immediate hysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for 14 of 15 women (93.3%). In one case hysterectomy was required due to pyometra in an ischemic uterus. In the remaining 11 women where the uterus was preserved, ambulatory hysteroscopy was normal. No women reported any differences in menses or pain compared to that they experienced before pregnancy, or any clinical symptoms of early menopause. One woman reported a subsequent pregnancy with normal conception delay, whereas the ten remaining women had no desired pregnancy due to, in each case, the fear of PPH recurrence. B-Lynch technique appears to be an effective procedure with a relatively low morbidity to control persistent severe PPH following a failure of vessel ligation before considering hysterectomy.

Hematometra following uterine compression sutures

Postpartum hemorrhage (PPH) occurs in nearly 4% to 6% of deliveries and accounts for 25% of all maternal deaths. Hysterectomy has been the management option for PPH resistant to oxytocics and stepwise uterine devascularization. Uterine compression sutures namely the B-Lynch Hayman and Cho sutures are newer conservative procedures that require less time and expertise. Though reported successful problems following use are emerging. We report a case of PPH managed successfully with uterine compression sutures that later presented with hematometra. (excerpt)

Postpartum haemorrhage

Most cases of postpartum haemorrhage are caused by uterine atony, maternal soft-tissue trauma, retained placenta or its parts, and obstetric coagulopathy. The factors most significantly associated with haemorrhage include advanced maternal age, prolonged labour, pre-eclampsia, obesity of mother, multiple pregnancy, a birth weight of more than 4000g, and previous postpartum haemorrhage. It seems that multiparity itself is only a weakly associated factor. The prophylactic use of oxytocic drugs (oxytocin or its combination with ergometrine at the third stage of labour is always recommended for decreasing the bleeding. Prostaglandins should be used as a second line treatment if uterine atony cannot be abolished by uterine massage and oxytocin infusion. In the surgical management, the role of hypogastric artery ligation is decreasing. The stepwise uterine devascularization may be a reasonable method in the most severe uncontrollable postpartum bleeding. The uterine tamponade with gauze or specific tubes may also be a useful alternative in some cases. Selective arterial embolization is a promising new method that seems to have success in controlling the heavy postpartum bleeding unresponsive to more usual measures. However, the value of this method should be evaluated in bigger series.

Stepwise uterine devascularization: A novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus

The objective of this study was to test the efficacy of a novel stepwise technique of uterine devascularization for management of uncontrollable postpartum hemorrhage. Stepwise uterine devascularization was performed for 103 patients to control intractable postpartum hemorrhage not responding to classic management. This technique entails five successive steps, so if bleeding is not controlled by one step the next step is taken until bleeding stops. The steps were (1) unilateral uterine vessel ligation, (2) bilateral uterine vessel ligation, (3) low uterine vessel ligation, (4) unilateral ovarian vessel ligation and (5) bilateral ovarian vessel ligation. The procedure was effective in all cases (100%), and hysterectomy was not needed in any case. No complications occurred, and the survival rate was 100%. Among the patients followed up normal menstruation and pregnancy occurred. Stepwise uterine devascularization is an effective and safe alternative to hysterectomy for management of uncontrollable postpartum hemorrhage.