Partial ischemic necrosis of the uterus following a uterine brace compression suture

Authors


Sir,

We wish to comment on the case report of “Partial ischemic necrosis of the uterus following a uterine brace compression suture.”1 The authors assume that haemorrhage was controlled by the brace suture, although clearly the patient was in a state of coagulation failure. The treatment of this is by correcting the coagulation failure and blood transfusion not by inserting a B-Lynch suture. Histopathology details were not available to support the diagnosis of ischaemic necrosis of the uterus.

The orientation of the photograph is unclear but there appears to be both a vertical suture and a horizontal one. This is more like a Square suture rather than a B-Lynch, as in the B-Lynch procedure there is no horizontal suture. The B-Lynch suturing technique involves an insertion of a continuous suture which will compress the uterus with uniform tension. I think the authors have confused the B-Lynch (Brace) suture technique and the Square suture, which does not open the uterus to insert multiple square sutures to appose the anterior and posterior uterine wall. Occlusion of the cavity and development of pyometra have been reported after this technique.2

The authors state that the most important mechanism of action of the Brace suture is by direct application of pressure on the placental bed bleeding and by reducing blood flow to the uterus. This is not true. The Brace suture exerts direct uterine compression without interfering with the uterine blood supply. Atony is unlikely to recur after successful application as the suture will maintain uterine tone till involution starts.

The B-Lynch technique has been used worldwide since the original report in 1997. In a recent worldwide review, there were no reports of complications in over 46 published cases. It is used for cases of postpartum haemorrhage secondary to atony. Prior compression is needed to predict successful application. The whole uterus is compressed longitudinally and left to right using absorbable stitches fixed at the anterior and posterior lower uterine segment. Integrity and haemostasis are maintained as evidenced by laparoscopic follow up, hysterosalpingography, USS and MRI and direct visualisation of the uterus at the time of subsequent elective caesarean section.3

One of the most important reasons for the lack of complications from the B-Lynch suture is the rapid involution of the uterus during the first postpartum week. This physiological process protects against continued undue tension of the suture on the uterus.

This case illustrates a misunderstanding and misinterpretation of the original B-Lynch technique, and indicates the need for training and ‘fire drills’.

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