Uterine necrosis following B-Lynch suture for primary postpartum haemorrhage

Authors


Sir,

In their case report Treloar et al.1 describe the occurrence of a rare complication, uterine necrosis, following the use of B-Lynch suture for treatment of postpartum haemorrhage (PPH). However, we suggest that the authors may not have satisfactorily shown the cause of this necrosis and would like to offer our advice on correct application of the B-Lynch suture.

Firstly, in this report the description of intraoperative events is not entirely clear. The authors state that the PPH ‘did not respond to systemic treatment with syntocinon, syntometrine and haemobate’, and that a ‘decision was made to place the (B-Lynch) suture prophylactically as the uterus was flaccid, despite the above management and the uterus was continuing to bleed’. These statements appear somewhat confusing and contradictory. It is not clear in what order the various measures to control haemorrhage were undertaken and whether haemostasis was achieved after application of the compression suture.

Secondly, it is not at all clear what caused the ischaemic necrosis of the uterus, since the patient made good recovery during the immediate postpartum period and presented 3 weeks later with an enlarged uterus and retained products of conception, as shown by ultrasound scan. Is it not possible that an underlying infection, or perforation of the uterus during evacuation of the retained products, were the primary causative factors?

The authors do not report whether exteriorisation of the uterus and a compression test were performed prior to application of the B-Lynch suture. This is a vital starting point for the procedure.2 If the bleeding stops when applying manual compression of the uterus, it is probable that any subsequent application of a B-Lynch suture will be successful.

It is also not clear whether in this case the authors employed the original B-Lynch suturing technique or one of the various reported modifications of this technique.3 The potential danger of these modifications is that occlusion of the uterine cavity and retention of blood clots can interfere with physiological involution of the uterus postpartum. Development of pyometra after the use of these modified techniques has been reported.3

When correctly applied the B-Lynch suture maintains longitudinal compression, even when the pelvic pulse pressure returns to normal. It is important to facilitate drainage of blood from the uterine cavity, to prevent retained blood from developing undue pressure on the suture lines. It is not reported whether such drainage was provided in this case.

The authors do not describe what suture material they used, although in the discussion ‘Vicryl’ is mentioned as a ‘commonly used’ suturing material. We would like to emphasise that a new soluble suture has been developed and is produced by Ethicon specifically for the B-Lynch procedure.4 This is a no.1 Monocryl (polyglecaprone 25) monofilament with an absorption profile of 60% of original strength at 7 days, 20% at 14 days and 0% at 21 days. Mass absorption is complete at 90 to 120 days. For this application, a 90-cm soluble Monocryl suture (code W3709) is attached to a 70-mm long blunt semicircular handheld needle. The suture is user and tissue friendly, easy to handle and of sufficient length.

A recently published review and update on the use of B-Lynch suture4 includes 17 published reports, involving a total of 46 published case histories of patients with severe life-threatening PPH who were successfully treated using the B-Lynch suture. From personal communications to Mr B-Lynch it is estimated that around 1800 cases have so far been successfully performed worldwide, including Asia, Africa, North and South America and Europe. To our knowledge, only nine failures have occurred, of which two are reported in the literature. These few cases of failure have been attributed variously to delay in application, defibrillation syndrome, lack of tightness or improper suture application, but postpartum necrosis is not a common feature.

Unfortunately, this case illustrates an imperfect understanding of the B-Lynch compression suturing technique and emphasises the need for training in its application as part of the management of major PPH. A detailed step-by-step description of application of the B-Lynch suture and a video demonstration of the procedure are available on www.cblynch.com.

Ancillary