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Hum. Reprod. Advance Access originally published online on November 17, 2007
Human Reproduction 2008 23(1):74-79; doi:10.1093/humrep/dem364
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© The Author 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Uterine compression U-sutures in primary postpartum hemorrhage after Cesarean section: fertility preservation with a simple and effective technique

A. Hackethal1,*, D. Brueggmann1, F. Oehmke1, H.-R. Tinneberg1, M.T. Zygmunt2 and K. Muenstedt1

1 Department of Obstetrics and Gynecology, Justus-Liebig-University of Giessen, Klinikstrasse 32, 35385 Giessen, Germany 2 Department of Obstetrics and Gynecology, Ernst-Moritz-Arndt-University of Greifswald, Wollweberstraße 1,17475 Greifswald, Germany

3 Correspondence address. Tel: +49-641-9945200; Fax: +49-641-9945139; E-mail: andreas.hackethal{at}gyn.med.uni-giessen.de


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Acknowledgements
 References
 
BACKGROUND: Transmural uterine compression suturing methods are a fertility-preserving alternative in patients with atonic primary postpartum hemorrhage (PPPH), which does not respond to manual compression or drugs. This study evaluated the effectiveness of a modified U-suturing technique in effecting uterine compression in patients with PPPH after Cesarean section.

METHODS: U-suture uterine compression was introduced at our hospital at the beginning of 2005. The medical records of patients with PPPH after Cesarean section who had undergone this treatment, and results of a follow-up and questionnaire were evaluated and our experience with this method was reviewed.

RESULTS: Between January 2005 and September 2007, seven patients underwent uterine compression with U-sutures after PPPH. In all cases, treatment was successful, the hemorrhage was controlled and the uterus preserved. Normal menstruation patterns returned in the five patients who returned the questionnaire and no surgery related morbidities were noted at the follow-up examinations of six patients. The technique was simple to perform in an emergency situation.

CONCLUSIONS: Uterine compression with U-sutures is a highly effective and straightforward emergency procedure which conserves the uterus in these patients.

Key words: atonic bleeding/postpartum hemorrhage/fertility preservation/U-sutures/uterine compression


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Acknowledgements
 References
 
Primary postpartum hemorrhage (PPPH) occurs within 24 hours of delivery. It is defined as a reduction in the patient's hematocrit level of more than 10% of the prenatal value or blood loss causing hemodynamic instability of sufficient seriousness to require blood transfusion. PPPH is a serious obstetric problem which is associated with conditions such as acute renal failure and necrosis of the anterior pituitary gland, appreciable morbidity and even maternal death (ACOG, 1998Go).

Prophylactic strategies, including the injection of oxytocin after delivery, have been shown to reduce the incidence of PPPH from as much as 18% to around 5–8% (Prendiville and Elbourne, 1998Go). Treatment of PPPH comprises bi-manual or mechanical compression of the uterus, uterotonic drugs and surgical methods, combined with resuscitative measures. Drug treatment fails to work in fewer than 1% of patients (Prendiville et al., 2000Go). The incidence of emergency postpartum hysterectomy, the final option when all conservative treatments fail, is 1–3 per 1000 deliveries (Engelsen et al., 2001Go; Francois et al., 2005Go; Wingprawat et al., 2005Go). However, hysterectomy after PPPH has appreciable drawbacks – not only does it result in infertility, there are technical difficulties in removing the lower uterine segment and these increase the likelihood of injury to the bladder or ureter.

Surgical techniques offering conservative management of PPPH have developed over the past 10 years (Table I).


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  		Table I. Overview of different published compression sutures techniques; patient number treated, penetration of uterine cavity, associated complications and further pregnancies.

 
Some procedures involve compression by brace-like suturing to preserve the uterus after atonic bleeding (B-Lynch et al., 1997Go; Hayman et al., 2002Go; Bhal et al., 2005Go; Nelson and Birch, 2006Go), also in combination with intrauterine balloon catheter (Nelson et al., 2007Go). Other workers have described multiple square sutures and vertical penetrating sutures within the lower uterine segment combined with oblique penetrating corpus sutures or multiple vertical sutures (Cho et al., 2000Go; Tjalma and Jacquemyn, 2004Go; Hwu et al., 2005Go; Ouahba et al., 2007Go). In the present study, we describe our experience over the past 32 months in using modified U-suturing methods to treat primary PPPH after Cesarean section.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Acknowledgements
 References
 
Subjects
In 2005 we began to use a modified U-suturing technique to treat patients, with primary PPPH after Cesarean section, who did not respond to mechanical/drug treatments at our institution. We reviewed all cases of Cesarean section performed between January 2005 and September 2007 and identified those patients with PPPH in whom uterine atony persisted even after our standard treatment protocol comprising:

  1. manual compression and uterine massage;
  2. oxytocin treatment (10 u after delivery and 30 u in 500 ml of 0.9% sodium chloride solution infused at a rate of 124 ml/h);
  3. continuous administration of 500 µg sulproston (diluted in 500 ml of 0.9% sodium chloride solution infused at a rate of 84 up to 102 ml/h).

In all patients identified, we had undertaken organ preserving surgical management using uterine compression suturing with U-sutures to preserve their fertility.

Record review
We examined the patients' medical records to evaluate the effectiveness of the U-suturing technique and outcomes. We collected data on the patients' age, number of previous pregnancies, multiple births, other relevant medical conditions, reasons for Cesarean section, blood loss, blood tests, duration of surgical and suturing procedures, and findings at follow-up.

Follow-up procedures and questionnaire
The patients were informed about the PPPH and seen by the colleagues from the psychological department for trauma counseling. They were advised to have close gynecological follow-up including ultrasonography and a control hysteroscopy after 6 months. During follow-up, patients were sent a detailed questionnaire including questions about their postpartum period, breastfeeding practice, the return of normal menstruation, potential lower abdominal complaints and plans for further pregnancies. A telephone survey updated the follow-up data prior to publication.

U-suturing technique
An absorbable Vicryl 0 thread and an XLH needle whose curve had been straightened manually were used for suturing. To perform an interrupted single U-suture, the needle was inserted at the ventral uterine wall, led through the posterior wall and then passed back to the ventral wall where the thread was joined with a flat double knot (Fig. 1a and b). While the lead surgeon was tying the suture, the assisting surgeon performed bi-manual uterine compression. The number of sutures required depended on the size of the uterus and the persistence of bleeding. In general, we inserted 6–16 U-sutures in horizontal rows along the uterus (Fig. 2), starting at the fundus and ending at the cervix. Thus, approximately 2–4 cm of tissue was compressed within each suture. Antibiotics were given during Cesarean section in all cases. These were continued postoperatively for at least 5 days.


Figure 1
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  		Figure 1: (a) Posterior view of the uterus showing the U-suturing technique. (b) Anterior view of the uterus showing the U-suturing technique

 

Figure 2
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  		Figure 2: Intra-operative position showing the uterus after U-suturing

 
Ethical approval
The approval of the hospital's ethics committee was not required for this study as all the patients were treated under emergency conditions after all existing uterus-conserving methods had failed.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Acknowledgements
 References
 
Number of patients
Over the study period of 32 months, 14 cases of PPPH occurred in the course of 1057 Cesarean sections. In seven of these cases, mechanical and uterotonic drug treatments were unable to control the bleeding and patients were treated with compressive uterine U-sutures.

Patient characteristics and treatment
The patients' medical history, treatment, and clinical outcomes as well as fetal characteristics are summarized in Table II. These seven patients had a mean age of 32.1 (range 25–40) years and their mean number of pregnancies was 2.4 (range 1–4). Patient records showed that only one patient had had any gynecological pathology. This was a case of early cervical cancer (patient 5) which had been treated with trachelectomy 13 months before the Cesarean. There were twin pregnancies in four of the seven cases. Problems during pregnancy in the seven patients comprised premature labor in five and cervical insufficiency in four. If the patient of case number five, whose fetus died intrauterine in week 19, is excluded, the mean gestational age at the time of Cesarean section was 35.4 weeks.


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  		Table II. Patients' demographic information, details of Cesarean section and postpartum hemorrhage, infants' characteristics, and follow-up, in seven patients who underwent uterine compression by U-suture.

 
Table II provides details of the various reasons for the Cesarean sections. In one patient, the U-sutures were performed because of uterine atony 2 h after initial Cesarean section (patient 4). A rupture of the liver was diagnosed during the second surgery. The mean estimated blood loss was 2507.1 ml (range: 2000–3500 ml) and the average time taken for the Cesarean section was 158.7 min (range 60–294 min). Preoperative and postoperative hemoglobin and leukocyte counts are shown in Table II. The mean time to complete the U-suturing procedure was 8.4 min (range 4–15 min) and depended mainly on the number of sutures needed. Six of seven patients received multiple blood transfusions and were admitted to the intensive care unit postoperatively.

Outcome and follow-up
In all cases, treatment successfully stopped the bleeding and the patient's uterus was preserved. No problems occurred during the procedure. The questionnaire was returned in five cases after a mean follow-up of 14.7 months (range 1–31 months). In these cases, the postpartal period was normal, two out of five patients did breast feeding and regular menstruation started 5–6 weeks after delivery. Six patients had follow-up which included gynecological examination, vaginal and abdominal ultrasound, and one patient had a hysteroscopy. No postoperative anatomical or physiological abnormalities were seen. Up to the date of the last follow-up, no patient had been trying to become pregnant again. One patient suffered from post-traumatic depression. One patient was lost to follow-up after 4 months since she moved to a different country.

Surgeons' evaluation of procedure
Surgeons' evaluation of experience with the U-suturing technique showed that the procedure was easy to recall and simple to perform during emergency conditions at Cesarean section. Furthermore, it was effective and safe in all cases.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Acknowledgements
 References
 
PPPH is a common obstetric emergency which can lead to emergency hysterectomy in patients with treatment-resistant, life-threatening bleeding. Surgical methods of controlling uterine bleeding by inserting compression sutures have been developed to reduce the incidence of emergency hysterectomy and to preserve fertility in these patients. In this study, we have evaluated a U-suture technique for achieving uterine compression in PPH during Cesarean section. The U-sutures were easy to perform during emergency conditions at Cesarean section; they are a safe and relatively inexpensive procedure. Furthermore, the technique enabled us to avoid emergency peripartum hysterectomy in all seven patients and thus preserve their fertility and obviate any other surgical complications of hysterectomy in these circumstances.

The shortcomings of this study are the limited number of patients and the short follow-up. Within this period, none of the patients desired further pregnancies and therefore no pregnancies occurred. This might limit the result concerning the preserved fertility. Furthermore not every patient approved invasive diagnostics to control the post U-suture situation of the uterus. Future examinations will help to evaluate the uterine cavity after U-sutures.

Since we introduced the U-suture method of uterine compression in 2005, we have not had to perform any emergency hysterectomies because of primary PPH, nor have we encountered any complications related to compression suturing. Furthermore, clinical, ultrasound and, in one case, hysteroscopic follow-up excluded possible complications such as intrauterine synechia, adhesions, irregular menstruation or menstruation-associated pain symptoms and reduced fertility. These results confirm those in a case report describing a 12-suture, uterus penetrating technique and also the work of Ferguson et al., who followed up two patients who had undergone the B-Lynch suturing procedure and found no defects of the uterine cavity after performing magnetic resonance imaging and hysterosalpingography (Ferguson et al., 2000Go; Tjalma and Jacquemyn, 2004Go). At follow-up in our patients, none had any symptoms that might have been linked to the procedure and there were no clinical symptoms or signs suggesting intra-abdominal adhesions. Therefore we did not undertake control laparoscopies to rule out adhesions on the anterior wall of the uterus where multiple knots had been placed.

Compared to other described compression sutures we postulate that, the interrupted single U-sutures (from 6 to 16 in number) provide more effective compression during uterine involution because several areas are compacted and if one suture fails, the remainder is not affected. (Fig. 2). Further investigations will provide information on the rate of vascular ligations, hysterectomies and other complications. In treating the women describe here, we experienced a learning curve. After standard treatment for uterine atony had failed, the time span we allowed for trying conservative treatments such as manual compression and drugs before applying the U-sutures decreased, and therefore the surgical operation time and blood loss decreased consecutively.

The prognosis for these patients depends on a number of factors, but prompt diagnosis and speedy treatment are essential. Compared with the technique described by Pereira et al. (2005)Go, our procedure for inserting U-sutures is fast and very easy to remember and to perform in an emergency situation. We do not believe that complicated instructions for uterus cavity sparing sutures are feasible or essential in an emergency setting, if we compare the follow-up data of all penetrating sutures as in Table I. The largest number of reported patients has been treated with the B-Lynch technique (88 patients). The B-Lynch, Hayman, Bhal, Nelson and Malibary sutures described earlier compress the uterus like a brace; failure to preserve the uterus, suture erosion, and partial and total uterine necrosis have been reported after these methods (Grotegut et al., 2004Go; Joshi and Shrivastava, 2004Go; Habek et al., 2006Go; Treloar et al., 2006Go). In addition, Cho's square suture was related to pyometria, synechia and Ashermann's syndrome (Ochoa et al., 2002Go; Wu and Yeh, 2005Go). Since all described compression sutures, except the one described by Pereira et al., penetrate the uterine cavity, the Ashermann's syndrome may be linked to the square dead space in the uterine cavity where endometrial necrosis may occur.

The U-suture technique we describe here was developed for use in emergency situations. This review of seven cases demonstrates the effectiveness of the technique over the past 32 months in controlling the atonic bleeding and its safety is shown by the absence of any associated complications. After this positive experience, we will continue to carry out uterine compression via U-suturing.


   Acknowledgements
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Acknowledgements
References
 
We thank Mrs. Adina Stephan, Giessen School of Endoscopic Surgery, for her illustration of the U-suturing technique.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Acknowledgements
 References
 
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Submitted on July 30, 2007; resubmitted on October 10, 2007; accepted on October 18, 2007.


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