Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage
We are pleased that our report has generated debate and are pleased to respond to Price and B-Lynch.
The B-Lynch procedure was introduced rapidly into emergency obstetric practice throughout the world after a very small case series had been published. The benefits of this novel procedure for the majority of patients treated, usually in perilous circumstances, are clear. However, it is inevitable that complications will occur with any new procedure. Only with the performance of the procedure by multiple surgeons in different institutions with good outcome reporting will their frequency and importance be better understood.
Professor B-Lynch is to be commended in setting up his own outcome registry for the procedure and asking for outcome data to be reported to him1. However, as the existence of the register is not widely known and reporting is voluntary (it was indeed unknown to us at the time of writing our case report), there will inevitably be significant under-reporting of both procedures and complications.
Our short report concentrated on the clinical outcome and the imaging techniques used and for the sake of brevity only summarised the initial events.
As the total (possibly under-) measured blood loss over approximately 2 hours was 800 ml, there was clearly not catastrophic haemorrhage, but there was continuous bleeding and a totally flaccid uterus despite the drugs administered—shown below.
The drugs administered prior to/during placement of the suture were (delivery = time zero)
Haemostasis was achieved after exteriorisation of the uterus with compression and maintained with application of a 1 Vicryl® suture using the original technique.2
We dispute the statement that it was not clear what caused the necrosis as it exactly matched the suture placement position (pathological photographs available).
The patient presented at 3 weeks postpartum, but she had been symptomatic with low abdominal pain and malaise for 10 days beforehand and had not sought earlier advice. The team who admitted her at that time believed that she had retained products of conception, but as stated in the text almost no tissue was removed and in retrospect that diagnosis was not correct.
|02||Syntocinon infusion||60 IU/litre||i.v. infusion 5–10 ml/minute for following 3 hours|
|26||Syntometrine||5 IU/500 mcg||i.m.|
There was no evidence of infection in the removed tissue and no suggestion of uterine perforation. Her symptoms were neither improved nor worsened by the evacuation procedure.
We do not agree with Price and B-Lynch’s final statement that we have an imperfect understanding of the technique.