Uterine Sutures Research Articles

Preferences in cesarean delivery surgical technique: a survey of maternal–fetal medicine fellows

Objective: Our goal was to (1) describe self-reported cesarean delivery (CD) surgical techniques of Maternal–Fetal Medicine (MFM) fellows and (2) determine whether preferences were congruent with recommendations using US Preventive Services Task Force (USPSTF) criteria.Methods: MFM fellows were queried regarding their preferred CD technique via online survey. Preferences were compared to evidence-based recommendations using standard recommendation language and quality of evidence as outlined by the USPSTF. Categorical variables were compared by Chi-square analysis or Fisher’s exact test, with p < 0.05 considered statistically significant.Results: Of 233 active MFM fellows in August 2012, 167 completed the survey, resulting in a response rate of 71%. Statistically significant differences of preferences were noted when stratified by year in fellowship (blunt tip needles), gender (thromboprophylaxis, skin incision, fascial extension, uterine closure suture) and geographic region of fellowship (fascial extension, skin closure). CD techniques preferred by MFM fellows were congruent with recommendations designated as high or moderate level of certainty with regard to prophylactic antibiotics, uterine incision extension, uterine atony prevention and placenta removal, while incongruent with regards to pre-operative vaginal preparation and blunt needle preference.Conclusion: Among MFM fellow respondents, variation exists in preferred CD technique and vis-à-vis evidence-based recommendations.

Uterine sutures at prior caesarean section and placenta accreta in subsequent pregnancy: a case–control study

To clarify the effects of uterine myometrial suture techniques at prior caesarean section on the incidence of pathologically diagnosed placenta accreta in placenta praevia with prior caesarean section (PPPC). Case-control study. Eleven tertiary referral hospitals in central Japan. A total of 98 cases of placenta praevia, a history of one or more prior caesarean sections, and a history of uterine transverse incision and usage of only absorbable thread for myometrial sutures at the prior caesarean section. Exclusions were a history of myomectomy or Strassmann's operation. Cases were grouped into a pathologically diagnosed placenta accreta group (38 cases) and a no accreta group (60 cases). Clinical characteristics including uterine suture methods at prior caesarean section were compared (single-layer versus double-layer closure; continuous versus interrupted sutures in the inner myometrial layer). The incidence of placenta accreta. No difference was found comparing single-layer with double-layer closure in the incidence of placenta accreta (37.1 versus 39.7%, P = 0.805); however, a significant difference was found comparing continuous with interrupted sutures (58.1 versus 29.9%, P = 0.008). Multivariable logistic regression analysis with stepwise selection for the eight factors meeting the criterion of P < 0.10 in univariate analysis was used, and four independent factors were selected, as follows: gravidity ≥ 3 (adjusted odds ratio, aOR, 3.4, 95% confidence interval, 95% CI, 0.99-11.6, P = 0.050); total praevia (versus non-total, aOR 18.4, 95% CI 3.2-107.0, P = 0.001); anterior/centre placenta (versus posterior, aOR 16.4, 95% CI 3.7-72.2, P < 0.001); and continuous sutures (versus interrupted, aOR 6.0, 95% CI 1.4-25.2, P = 0.015). In this limited study, a history of continuous sutures on the inner side of the uterine wall showed potential to influence the development of placenta accreta in PPPC patients.

Temporal Trends in Postpartum Hemorrhage and Severe Postpartum Hemorrhage in Canada From 2003 to 2010

ObjectiveIncreases in postpartum hemorrhage have been reported from several countries. We assessed temporal trends in postpartum hemorrhage and severe postpartum hemorrhage in Canada between 2003 and 2010. MethodsWe carried out a population-based cohort study of all hospital deliveries in Canada (excluding Quebec) from 2003 to 2010 (n=2 193 425), using data from the Canadian Institute for Health Information. Postpartum hemorrhage was defined as a blood loss of ≥ 500mL following vaginal delivery or ≥ 1000mL following Caesarean section, or as noted by the care provider. Severe postpartum hemorrhage was defined as postpartum hemorrhage plus blood transfusion, hysterectomy, or other procedures to control bleeding (including uterine suturing or ligation/embolization of pelvic arteries). Temporal trends were assessed using the chi-square test for trend, relative risks, and logistic regression. ResultsPostpartum hemorrhage increased by 22% (95% CI 20% to 25%) from 5.1% in 2003 to 6.2% in 2010 (P < 0.001), driven by a 29% increase (95% CI 26% to 33%) in atonic postpartum hemorrhage (3.9% in 2003 vs. 5.0% in 2010, P < 0.001). Postpartum hemorrhage with blood transfusion increased from 36.7 to 50.4 per 10 000 deliveries (P < 0.001), while postpartum hemorrhage with hysterectomy increased from 4.9 to 5.8 per 10 000 deliveries (P < 0.01). Postpartum hemorrhage with uterine suturing, or ligation/embolization of pelvic arteries, increased from 4.1 to 10.7 per 10 000 deliveries (P < 0.001). These increases occurred in most provinces and territories, and could not be explained by changes in maternal, fetal, and obstetric factors. ConclusionRates of postpartum hemorrhage and severe postpartum hemorrhage continued to increase in Canada between 2003 and 2010.

Crush-like syndrome after applying the Pereira compressive uterine suture (a case report)

Crush-like syndrome after applying the Pereira compressive uterine suture (a case report)

Hour Glass Compression Suture in the Management of Primary PPH

Objective: The present study was planned to access the efficacy of Hour Glass compression suture which is easy, can be applied faster and avoids the need of hysterectomy in patients with atonic postpartum hemorrhage. Materials and methods: This observational study was carried out from Jan 2010 to October 2012 at Gynaecology and Obstetrics Departments, Bankura Sammilani Medical College &Hospitals, West Bengal, India. All patients included in this study with primary PPH, hour-glass suture were given using No. 1 Chromic Cat gut with a straight needle. Two suture in a shape of hour glass( figure of 8) on either side of uterus were given, 10 patients presented by severe atonic PPH. In all 10 patient, routine initial measures (uterine massage, oxytocin infusion, methergine, carboprost ,if not contraindicated, and misoprostol) were done and when failed, compressing uterine suture was performed. Results: All 10 cases had an uneventful postoperative recovery. All the cases had evidence of uterine atony which was not responded to conventional uterotonics. The estimated blood loss ranged from 1000 ml to 2,000 ml. In all cases this technique successfully stopped the bleeding and the patient’s uterus was preserved. No complication like pyometra, amenorrahoea/oligomenorrahoea, suture cut down through myometrium was faced during the procedure. Regular menstruation returned within 3-4 months follow up after operation, except in one case where the patients conceived during the period of lactational amenorrhoea. Later she opted for medical termination of pregnancy.None of them require hysterectomy. Conclusion: The technique is easy, rapid and requires less skill and this simple procedure be tried first before other complex measures like uterine artery ,ovarian artery ligations are undertaken particularly for those obstetricians who lack sufficient training and skill.

Laparoscopic Ultrasound-Guided Radiofrequency Volumetric Thermal Ablation (RFVTA) of Deep Intramural Fibroids

Current uterine-sparing fibroid treatment options commonly leave many untreated fibroids in the uterus and are associated with a high risk of fibroid recurrence and high re-intervention rates. Laparoscopic ultrasound-guided RFVTA is a uterine-sparing method for ablation of virtually all uterine fibroids, including deep intramurals which account for >50% of fibroids; the method is presented in this procedural video and is targeted at gynecologic surgeons. No uterine incisions or uterine suturing are required. Demonstration of both the use and advantages of laparoscopic ultrasound—as well as of the RFVTA technique—are shown.

Comparison of the initial surgical experience with robotic and laparoscopic myomectomy

To compare the initial surgical outcomes of robotic and laparoscopic myomectomy in patients with symptomatic uterine myomas. Retrospective chart review of 86 patients undergoing robotic (RM) (n = 43) or laparoscopic (LM) (n = 43) myomectomy. Data included fibroid characteristics (number, weight, location) layers of uterine reconstruction, operating time, blood loss, complications, and postoperative hospital stay. No significant differences were noted between RM and LM for fibroid number and weight and mean operating time, although the number of patients receiving at least a double-layer uterine reconstruction was higher in RM than LM. Blood loss was higher after LM, while no differences resulted in hospital stay. RM may have some additional advantages compared with LM in terms of bleeding and uterine suturing without compromising operation duration, at least when surgeons were at the beginning of their experience of endoscopic treatment of symptomatic uterine myomas.

Uterine Artery Suture: A Preventive Approach for Pernicious Placenta Previa

Pernicious placenta previa is an obstetric complication that results in a crisis situation for many patients. Most existing options deal with the problems after delivery leading to unfavorable outcomes. To circumvent this situation, a few preventive simple surgical options have been discussed in this paper. The highlight of the approach is the application of ascending uterine artery suture that drastically reduced the amount of bleeding as compared to that observed in regular surgeries. Combined with the placenta accrete location, wedge resection and 'patch' homeostasis of the serous membrane, the surgical modifications adopted effectively reduced the need for hysterectomy thus preserving the fertility of the patients for the future. Since fetuses were safely removed within 1-2 min, the Apgar scores of the neonates were also largely unaffected.

Robotic-assisted laparoscopic surgery in uterine pathology

ObjectiveThe feasibility and safety of robotic surgery have been demonstrated by numerous comparative studies. The aim of our study was to compare several parameters related to robotic surgical procedures in uterine pathology, and to analyse clinico-biological parameters that may influence the post-operative evolution of the patients. Study designRetrospective analysis of 100 patients with uterine pathology who had undergone robotic-assisted laparoscopic surgery at the Santa Chiara Hospital, Pisa, Italy, between 2008 and 2010. ResultsDuration of surgery, docking, hysterectomy, uterine suture, blood loss, and days of hospitalisation significantly improved in parallel with the increasing experience of the surgical team. Paradoxically, the length of myomectomy increased in the same time interval, probably due to operating on more complex clinical cases with this procedure as the surgical team's experience grew. None of the robotic surgeries was converted to laparotomy. No intra- or post-operative complications were noted. ConclusionSince robotic-assisted laparoscopic surgery is becoming the preferred surgical technique for uterine pathology treatment, more clinical studies and development of protocols are essential to increase the quality of surgical treatment.

The Misgav-Ladach Method of Cesarean Section

Cesarean section (CS) is the most common intraperitoneal surgical procedure in obstetric and gynecologic practice. The most common method during the late 20th century was the Pfannenstiel-Kerr (PK) method, which uses a curved transverse suprapubic incision in the abdominal skin, a transverse lower uterine segment incision, including a double-layer uterine suture, and peritoneal closure. In the 1970s, the Joel-Cohen technique was developed to cause the least damage to tissues, avoid superfluous steps, and make the intervention the simplest possible. This technique was adopted at the Misgav-Ladach hospital in Jerusalem and underwent further changes to become the modified Misgav-Ladach (MML) technique, which was believed to make the procedure more acceptable to clinicians and patients. This 9-year prospective study was performed to compare the MML with the classic PK technique for intraoperative and short-term postoperative outcomes. Women undergoing an elective or emergent CS were selected for either the MML or PK technique according to surgeons’ preferences; patients were not randomized. All CSs were performed under general anesthesia. Intravenous analgesics were administered to all patients on postoperative day 1 (POD 1), and anticoagulant therapy was administered to all patients for 10 days after the CS. Main outcome measures were the duration of surgery, analgesic requirements, febrile morbidity, postoperative antibiotic use, postpartum endometriosis, wound complications, and hospitalization time. Wound complications were evaluated on POD 3. The outcomes for the techniques were compared using the χ2 test for proportions and Student t test for continuous variables. In a secondary analysis, outcomes were compared between women who delivered in 2003–2004, the first 2 years of the study, and women who delivered in 2010–2011, the last 2 years, when the MML technique had become the method of choice for all primary CSs. In the PK procedure, the uterine incision was closed in 2 layers (endometrium and myometrium separated) with a continuous suture. Visceral and parietal peritoneum was closed with a continuous suture and the rectus muscles with 3 to 5 interrupted approximating sutures. The transversely incised fascia was closed with a continuous suture, and the subcutis was sutured in interrupted stitches. For the MML procedure, the uterine incision was closed in 1 layer with continuous suture reapproximating the full thickness of the myometrium, with additional hemostatic stitches if required. The suture was usually unlocked. The skin was closed with widely spaced sutures. Postpartum care for both procedures were similar with intravenous hydration on the day of the surgery, catheter removal on POD 1 or 2, drinking 12 to 24 hours postoperatively, and regular diet from POD 2 or 3. Stitches were removed on POD 7. A total of 4336 women underwent the MML technique, and 608 underwent the PK technique. The obstetric characteristics and indications for CS did not differ significantly between the 2 groups. Compared with the PK technique, the MML technique was associated with a shorter operative time (13.4 ± 7.4 vs 19.1 ± 6.8 minutes), less surgical material (3.5 ± 2.5 vs 7.9 ± 2.1), lower requirements for postoperative analgesics (5.01 ± 4.7 vs 8.9 ± 1.4 doses), and lower rates of febrile morbidity (1.27% vs 6.6%) and wound infections (1.64% vs 4.9%). By the end of the study period, nearly all CSs were performed using the MML technique. Analysis of outcomes comparing 2003–2004 with 2010–2011 showed shorter operative times (17.9 ± 1.3 vs 14.2 ± 6.3 minutes), less surgical material (6.3 ± 4.7 vs 3.7 ± 2.1), lower requirements for postoperative analgesics (9.1 ± 4.7 vs 6.6 ± 2.2 doses), and lower rates of febrile morbidity (5.4% vs 1.2%), wound infections (6.8% vs 1.6%), and dehiscence (3.1% vs 1.4%) in 2010–2011. Because of the many technical differences between these 2 methods, the differences in outcomes may be secondary to specific steps of the procedures instead of the overall technique. The MML technique seems to be the least traumatic surgical procedure. Controversy still exists over the impact of the single- versus double-layer closure of the uterus on the risk of uterine rupture at the next pregnancy and on the choice between parietal and visceral closure of the peritoneum. The results suggest that the MML technique might lead to better short-term postoperative outcomes, especially in reduction of pain and postoperative complications compared with the PK technique.

Postmyomectomy Uterocutaneous Fistula

Abstract Background: Uterocutaneous fistula, although not exceptional, is a very rare clinical entity. Approximately 120 cases of uterocutaneous fistula have been reported in the world literature in its entirety over the past 200 years. It occurs most often after uterine or pelvic surgery but also can complicate the postpartum period. This article reports the first documented case of postmyomectomy uterocutaneous fistula observed in this department. Case: The patient, a 30-year-old black African woman, primigravida and nulliparous, had a history of a difficult myomectomy performed June 9, 2011 by a general surgeon. She consulted the authors' department on November 4, 2011, 5 months after myomectomy for bleeding at the surgical scar. The bleeding had been present for 5 months cyclically and at the same time period as her menstruations. Physical examination and the results of exploration revealed an uterocutaneous fistula. At laparotomy, the fistula was excised followed by a uterine suture. Results: The pos...

Total Laparoscopic Hysterectomy – New Endoneedle for Ligation of Uterine Vessels and Vault Closure

To show that two challenges in TLH - uterine vessel haemostasis and vault closure - can be overcome by the use of a new laparoscopic endoneedle. This paper uses slides and videos of operations to present the results of the study. Operations were performed in a major private teaching hospital in Perth, Australia. 20 private patients who underwent TLH had their uterine arteries ligated with the endoneedle using 1 vicryl suture before bipolar and division. The vaginal vault was closed with the endoneedle using 1 monocryl suture. 20 private patients with fully informed financial and operative consent. There were no interventions. The study revealed that the uterine suture provided better haemostasis than when only an energy-sealing device was used. The suture on the uterine pedicle provided a clear lateral landmark for ureteric safety. The vaginal vault was closed with single bite or figure of 8 sutures. No vault dehiscence was encountered. The use of the new laparoscopic endoneedle provides the GYN performing TLH with a new tool to tackle the uterine pedicle and vault suturing. Numerous laparoscopic workshops have a suturing component, as this is a challenging task for GYNs. It is hoped that this new tool will lead to more GYNs undertaking TLH, thereby spreading the benefits of MIS.

A curriculum to teach and evaluate resident skills in the management of postpartum hemorrhage

The aim of this study was the development of a curriculum for the management of postpartum hemorrhage and an objective assessment of technical skills (OSATS) for uterine compression sutures. Twenty-two residents participated in the study. Evaluations included the global rating scale, task-specific checklist, and pass/fail rating for the OSATS and task-specific checklist for the hemorrhage drill. The reliability and validity of the evaluation tools were calculated. The inter-rater reliability was 0.98 for the hemorrhage drill checklist, 0.77 for the global rating scale, and 0.93 for the uterine suture checklist. Construct validity evaluation revealed senior residents performed superiorly to junior residents on the global rating scale (P=0.006) and on the uterine suture checklist (P=0.04). There was an improvement in performance on the post-test in comparison to the pretest (P=0.001). We present an inexpensive, reliable, and valid curriculum to teach and evaluate the medical and surgical management of postpartum hemorrhage.

PP022 The haemostatic suture (technique of B-Lynch) may be an alternative to control uterine hemorrhage associated with hypertensive disorders

Postpartum haemorrhage is an important cause of maternal morbidity and mortality, uterine atony being responsible for most of the cases. Hypertensive disorders are supposed to increase the possibility of such complications, mainly when complicated by "abruptio placentae". The classical treatments for postpartum haemorrhage have been based on medications like oxytocin and misoprostol, but more recently a haemostatic uterine suture developed by Christopher B-Lynch has been indicated. Here, we describe our experience of performing such technique and investigate its results in patients complicated by hypertensive disorders. Reporting a series of cases of postpartum haemorrhage treated with the B-Lynch suture. This is a descriptive study including 39 patients treated with the B-Lynch suture after postpartum haemorrhage related to uterine atony. The period evaluated was between January 2005 and February 2012. Intravascular oxytocin was routinely used in all cases, with doses changing from 20 to 60 IU. The suture material used was chromed catgut 1.0mm. The mode of delivery was cesarean-section in all cases. Five patients (12.8%) had hypertensive disorder as additional complication and one of these patients had abruptio placentae followed by development of Couvelaire uterus. Overall, the B-Lynch technique helped to control haemorrhage in all cases evaluated. We believe that the B-Lynch technique appears as an important procedure to be indicated in cases of postpartum haemorrhage. Therefore, we recommend that this technique should be tried to control such complications before deciding for other more aggressive procedures like hysterectomy. It seems that this treatment may be used in patients complicated by hypertensive disorders.

A new type of absorbable barbed suture for use in laparoscopic myomectomy

ObjectiveTo compare effectiveness, feasibility, and suturing time required between an absorbable barbed wire (V-Loc) uterine suture and a classic continuous suture with intracorporeal knots among women undergoing laparoscopic myomectomy. MethodsFrom January 2010 to February 2011, women with single symptomatic intramural myoma were prospectively enrolled in a single-center study at a university hospital in Rome, Italy. A control group with characteristics meeting the criteria for study inclusion was retrospectively identified from the hospital databases. In the prospective group uterine wall defects were closed with V-Loc suture, whereas in the control group they were closed by classical continuous suture with intracorporeal knots. Data were analyzed via Student t test, Mann–Whitney U test, and Fisher exact test. ResultsThe mean operative time was shorter in the V-Loc (51±18.1min) than in the control (58±17.8min) group. Suturing time was significantly lower in the V-Loc than in the control (9.9±4.3 versus 15.8±4.7min; P=0.0004) group. Both intraoperative bleeding and drop in hemoglobin were significantly lower in the V-Loc group (P=0.0076 and P=0.0176, respectively). ConclusionUse of a barbed suture may aid surgeons during laparoscopic suturing by reducing operative time, suturing time, and blood loss.

“Quilting” sutures to prevent hysterectomy in patients with postpartum hemorrhage

⁎ Frauenklinik, Klinikum Fulda, D 36043 Fulda, Germany. Tel.: +49 661 845900. E-mail address: ludwig@spaetling.net. Postpartum hemorrhage (PPH) is the primary cause of maternal mortality. All obstetricians should know a safe, easy to perform method of uterine suturing in patients with PPH. The methods of B-Lynch et al. [1] and Pereira et al. [2] are relatively complicated. Ligation of the uterine artery is not sufficient as the only method to stop bleeding. A back stitch “quilting” technique was therefore developed by obstetricians at Klinikum Fulda in Germany. Quilting sutures have been used in patients with PPH at Klinikum Fulda to avoid hysterectomy after unsuccessful application of uterotonic agents. The technique places U-sutures to fix the anterior to the posterior wall starting at the top of the fundus down to the cervical segment. Up to 12 sutures are needed to compress the uterus completely (Fig. 1). The technique employed curved sharp needles, which were bent from 7.5 cm to 9 cm (DS95; Serag-Wiessner, Germany). A size 1 absorbable suture was used (Vicryl; Ethicon, USA). Between November 2006 and December 2011, 8 patients were treated using the quilting technique. Cesarean delivery was performed between 35+2 and 41+6 weeks of pregnancy. Gravidity ranged from 1–4 and parity ranged from 0–2. Delivery was induced by misoprostol in 2 patients. In 6 patients up to 6 units of blood and 4 units of fresh frozen plasma were transfused. All patients stayed in the intensive care unit for 1–2 days. Hysterectomy was avoided in all cases. All patients left hospital at between 6 and 12 days. No patient complained of any disturbance at follow up. One subsequent pregnancy has been reported. The back stitch technique is safe and is easy to perform and remember. This quilting technique could be practiced in small obstetric units that do not have operative facilities to perform postpartum hysterectomy. Compared with the B-Lynch suture, the back stitch technique results in greater compression and better hemostasis. The method of Ouahba et al. [3], published after the present study had begun, uses fewer stitches resulting in less compression. It is hoped that the contribution of the quilting technique may help to reduce maternal morbidity and mortality caused by PPH.

The use of novel hemostatic sealant (Tisseel®) in laparoscopic myomectomy: a case–control study

This is the first case-control study on the use of a fibrin sealant (Tisseel) on uterine suture during laparoscopic myomectomy (LM), with the primary endpoint to evaluate the intraoperative bleeding and postoperative blood loss. In addition, we evaluated the time required to achieve hemostasis using Tisseel and how much it can influence operative time. From December 2009 to January 2011, consecutive patients older than 18 years with symptomatic isolate intramural myoma with maximal diameter B6 cm and ≥ 4 cm and with a sonographically diagnosed free myometrium margin ≥ 0.5 cm were included in the study. We selected from our institute's database a group of consecutive patients with homogeneous features of the study group, who underwent laparoscopic myomectomy without Tisseel application. Fifteen women with symptomatic myoma were enrolled in the study (group A). Regarding the control group (group B), we selected a homogenous group of 15 patients with the same preoperative characteristics of the study group. Mean operative time was 47.7 min and 62.1 min, for groups A and B respectively (p < 0.05). Mean time required to achieve complete haemostasis was 195.5 s in group A and 361.8 in control group B (p < 0.0001). Mean estimated blood loss was 111.3 mL and 230 mL in groups A and B, respectively (p < 0.05). Mean hemoglobin decrease was 1.36 g/dL and 2.04 g/dL in groups A and B, respectively (p < 0.05). The use of Tisseel during LM may represent a valid alternative solution for obtaining hemostasis, reducing intra- and postoperative bleeding. Furthermore, it may help the surgeon to obtain a rapid healing of the injured surfaces, probably reducing the use of electrocoagulationand traumatisms.

99: Comparison of management for pregnant women with Delta Storage Pool Deficiency during labor and delivery: a pilot study

women with Delta Storage Pool Deficiency during labor and delivery: a pilot study Chao Li, Lanissa Pappas University of Toledo and University of Iowa Hospitals and Clinics, OB/GYN, Iowa City, IA, The Toledo Hospital, Ob/Gyn, Toledo, OH OBJECTIVE: To compare different management of pregnant women with Delta Storage Pool Deficiency ( -SPD)during labor and delivery . STUDY DESIGN: In platelet -granules, small molecules such as ADP, ATP, and serotonin are concentrated. These molecules play an important role in hemostasis. On the floor of labor and delivery, different managements, including hemorrhaging prophylaxis, whether applying epidural and spinal anesthesia were provided to patients in labor with -SPD by different providers. There is no study so far to compare the outcome of different management. In last 5 years, about 30 patients with -SPD were delivered. After chart review, 25 were recruited in this study. The 25 patients all had clear documented diagnosis. Patients’ age, race, gravity, parity, gestational age, pregnancy complications, blood loss, anesthesia, delivery mode and neonatal outcomes were all documented. Different managements and complications were compared. Statistic method: Student T test. Interventional factors applied before regional anesthesia and delivery included platelet transfusion, DDAVP, DDAVP plus Amicar or no intervention. RESULTS: 1. Different interventional factors applied before anesthesia. No complications developed in all the regional anesthesia applied. 2. Different interventional factors applied before spontaneous vaginal delivery in multiparity patients. No difference in estimated blood loss (EBL) was detected. 3. Different interventional factors applied before cesarean section. No difference in EBL was detected. CONCLUSION: With limited data, SPD is not a major bleeding disorder for labor patients. Safety profiles of different managements are all acceptable. It seems DDAVP plus Amicar is an effective treatment during c-section. But further studies with higher power need to be carried out to draw definitive conclusion. 100 Evolution of the invasive procedures rate after the addition of Bakri Balloon as the first second-line therapy in a protocol of severe PPH management Charles Bui, Enora Laas, Thomas Popowski, Patrick Rozenberg Poissy Saint-Germain Hospital, Obstetrics and Gynecology, Poissy, France OBJECTIVE: Postpartum hemorrhage (PPH) is among the most common causes of pregnancy-related death. When uterotonic drugs fail, second-line therapies including artery ligations, compressive uterine sutures or arterial embolization may be performed. Recently, intrauterine balloon tamponade has been proposed as a second-line procedure. Our objective was to study the evolution of the invasive procedures rate after the addition of Bakri Balloon as the first second-line therapy to our protocol of severe PPH management. STUDY DESIGN: We carried out a before and after cohort study in Poissy Saint-Germain Hospital. We compared the outcomes of all patients delivered vaginally with a PPH unresponsive to sulprostone during two equal periods. Medical management of PPH was similar during the 2 periods. However, from September 2006 to March 2008, if bleeding was still not controlled in spite of an infusion of sulprostone, an invasive procedure was at once performed. From April 2008 to December 2010, the intrauterine balloon tamponade was attempted in order to avoid an invasive procedure. RESULTS: The general and obstetrical characteristics of the patients delivered vaginally with a PPH unresponsive to Sulprostone were similar between the 2 periods. Among these, 13.4% (26/194) and 16.0% (35/218, p 0.45) required a second-line therapy during the first and the second period, respectively. During the second period, the Bakri balloon was used in 31 patients delivered vaginally with a success rate of 84% (26/31). The rates of arterial embolizations and conservative surgical procedures (artery ligations, compressive uterine sutures) were significantly reduced in the second period (8.2% vs 2.3%, p 0.006 ; OR 0.26, 95% CI 0.09-0.72 and 5.1% vs 1.4%, p 0.029 ; OR 0.26, 95% CI 0.07-0.95, respectively). No differences were observed in the rate of hysterectomy between the 2 periods. CONCLUSION: In the setting of intractable hemorrhage, balloon tamponade may avoid the need for embolization or conservative surgical procedure with their related risk.

Uterine Compression Sutures for the Management of Severe Postpartum Hemorrhage

To assess maternal outcomes after uterine compression suture use and to characterize the risk factors for failure, defined as cases that proceeded to hysterectomy. A prospective population-based study of 1.2 million women delivering was conducted using the U.K. Obstetric Surveillance System to identify all women in the United Kingdom delivering between September 2007 and March 2009 and treated with uterine compression sutures. Two hundred eleven women were treated with a uterine compression suture to control postpartum hemorrhage. The overall rate of failure, leading to hysterectomy, was 25% (95% confidence interval, 19–31%); there were no significant differences in failure rates among B-Lynch sutures, modified B-Lynch sutures, and other suture techniques. Women were more likely to have a hysterectomy if they were aged 35 years or older (33% compared with 20% aged younger than 35 years), multiparous (33% compared with 14% in nulliparous), in unemployed and routine or manual occupational groups (28% compared with 17% in managerial or professional groups), had a vaginal delivery (47% compared with 22% in the cesarean delivery group), or a delay of between 2 and 6 hours from delivery to uterine suture compression (42% compared with 16% with delay less than 1 hour). A prolonged delay of 2–6 hours between delivery and uterine compression suture was independently associated with a fourfold increase in the odds of hysterectomy. These data emphasize the need for a careful evaluation of blood loss after delivery to avoid any prolonged delay in recognition of hemorrhage. III

Evaluation of factors contributing to uterine scar formation after laparoscopic myomectomy

To evaluate factors contributing to uterine scar formation after laparoscopic myomectomy (LM) and to estimate whether uterine scarring indicated risk of uterine rupture. Retrospective study. University-affiliated hospital. A total of 692 patients who underwent second-look laparoscopy (SLL) after LM. Video-tape recording during SLL to evaluate the conditions of uterine suture wound healing, with univariate and logistic regression analysis. Correlation between scar formation and operative findings at LM. Factors influencing scar formation in 305 patients with an enucleated solitary myoma. SLL revealed that 628 patients (90.8%) had a normal uterus and 64 patients (9.2%) had a scarred uterus. Deformation of the endometrium found by preoperative imaging and complete myometrial penetration during LM had a positive correlation and the number of enucleated myomas a negative correlation with scar formation. Significant factors associated with scar formation were complete myometrial penetration (odds ratio, 2.53; 95% confidence interval, 1.30-4.93; p = 0.006) and enucleation of a subserosal myoma (odds ratio, 0.23; 95% confidence interval, 0.08-0.70; p = 0.009). Of the 98 patients who delivered, none suffered a uterine rupture regardless of the presence of a uterine scar. Uterine scar formation after LM correlated with the degree of myometrial penetration. However, the presence of a uterine scar did not appear to influence the delivery outcome.