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Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage

Authors’ Reply

Sir,

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.

Time (minutes)Drug/actionDoseRoute
  1. i.v., intravenous; i.m., intramuscular; p.r., per rectum.

0Syntocinon5 IUi.v.
02Syntocinon infusion60 IU/litrei.v. infusion 5–10 ml/minute for following 3 hours
22Hemabate250 mcgi.m.
26Syntometrine5 IU/500 mcgi.m.
37Misoprostol800 mcgp.r.
37Hemabate250 mcgi.m.
52Hemabate250 mcgi.m.
62Intubated/general anaesthesia 
66Hemabate250 mcgi.m.
81Hemabate250 mcgi.m.
87Hemabate250 mcgi.m.
105Hemabate250 mcgi.m.
123Hemabate250 mcgi.m.
150Skin closed 
162Extubated 

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.

References

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  2. References
  • 1
    El-Hamamy E, B-Lynch C. A worldwide review of the uses of the uterine compression suture techniques as alternative to hysterectomy in the management of severe post-partum haemorrhage. J Obstet Gynaecol 2005;25:1439.
  • 2
    B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:3725.