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

Authors


Sir,

I read the report of Joshi and Shivastava [Partial ischemic necrosis of the uterus following a uterine brace compression suture. Br J Obstet Gynaecol 2004;111(3):279–280 (March).] on the above subject with great concern.

The purpose of the B-Lynch surgical technique1 is not to oppose the anterior and posterior vaginal walls but to exert longitudinal compression with an even distribution of tension throughout the procedure. Joshi and Shivastava did not describe the compression tests after exteriorisation of the uterus, which is a vital starting point. The correct application of the B-Lynch suture will distribute the tension across the uterine body. The figure-of-eight suture could apply transverse compression as described in the B-Lynch original text to control bleeding from the lower uterine segment.

The potential danger of other modifications such as described by Haymen et al.2 quoted in Joshi's report runs the risk of contained blood being trapped within the uterine cavity instead of being expelled freely through the vagina. The Cho technique of multiple sutures similarly applied to oppose the anterior and posterior uterine walls have been reported to be associated with pyometris and subsequent hysterectomy.3

Joshi and Shivastava have not convincingly demonstrated the proper application of the B-Lynch suture placement. A prototype B-Lynch suture has been produced 1 as a No. 1 Monocryl (polynecaperone) Monofilaments suture with absorption profile of 60% of original strength at 7 days, 20% of original strength at 14 days and 0% of original strength at 21 days. Mass absorption is complete at 90–120 days (code W309) information obtainable from tcb@fsmail.net.

The B-Lynch suture correctly applied maintains longitudinal compression even when the pelvic pulse pressure returns to normal. Reactionary bleeding is minimised. It is important to facilitate drainage of blood from the uterine cavity. It is probable that because of retention of blood in the uterine cavity, undue pressure on the suture lines developed. Both Cho and Haymen's modifications would present these potential complications.

The current level of success of the B-Lynch suture worldwide is 948 cases. The Indian subcontinent has the largest number of reported successful applications, over 250, followed by Africa, South America, North America, Europe and less well-known countries. There have been seven reported failures because of delay in application, defibrillation syndrome and technical difficulties; a full analysis of these data is being prepared for publication. Various suture materials have been reported as used. The Monocryl Suture (code W309) is user- and tissue-friendly with uniform tension distribution and is easy to handle.

I am grateful to the authors for reporting this case. It does emphasise the importance of regular advanced life support and fire drill training to enable this technique to provide safe practice in postpartum haemorrhage control.

Ancillary