Transcript role of modified b-lynch suture in atonic pph

ROLE OF MODIFIED B-LYNCH
SUTURE IN ATONIC PPH IN
CESAREAN SECTION
DR.NEENA AGRAWAL
M.S., F.I.C.O.G.
CONSULTANT
CHL APOLLO HOSPITAL
INDORE (M.P.)
INTRODUCTION:
• Worldwide over 125,000 women die of PPH
every year; hence it is a significant cause of
maternal morbidity and mortality both in
developed as well as developing countries.
• In the recent triennial confidential enquiry into
maternal deaths in UK (2003-2005), PPH
remained one of the top 3 causes of direct
maternal deaths.
• Atonic uterus accounts for 75-90% of primary
PPH.
The traditional management begins with
conservative methods like bimanual
uterine compression, use of uterotonics,
uterine tamponade with balloons, rarely
arterial embolisation, the failure of which
mandates surgical intervention.
Internal iliac artery ligation requires skill and
practice and when all these measures fail
hysterectomy is the last resort.
In 1997 Christopher B Lynch devised an innovative
technique to treat uterine atony where a continuous
suture was used to envelope and mechanically
compress the uterus in an attempt to avoid
hysterectomy. Since then this technique has been
widely used around the world. Later Dr Richard
Hayman and Prof. Arulkumaran in Derby modified
this procedure of B Lynch suture independently.
Here there is no need to open the uterine cavity
and the suture on straight needle is used to transfix
uterus from front to back just above reflection of
bladder and tied at fundus of uterus.
AIMS AND OBJECTIVES:
To evaluate efficacy of modified B-Lynch
suture in atonic PPH encountered during
cesarean section.
METHODS:
• A prospective study was conducted in CHL
Apollo hospital, Indore which is a tertiary referral
centre.
• We evaluated 30 patients of atonic PPH during
LSCS, where routine uterotonics did not work.
• This study included patients from 1st January
2009 till 31st December 2009. In all these
patients we used modified B-Lynch suture to
control hemorrhage.
EXCLUSION CRITERIA:
1. Patients with atonic PPH following vaginal
delivery.
2. Patients with PPH where the cause was
not uterine atony.
PROCEDURE:
• While performing cesarean section, in all
patients we follow AMTL as per the protocol.
With the delivery of vertex, 10 unit inj. Pitocin is
given i/m and 20 units is added to the drip;
following which inj. Carboprost 250 µgm i/m is
given if the contraction is not satisfactory.
• After expulsion of placenta, if the uterus is
flabby, inj. Ergometrine i/m and 800mgm
misoprostol is given sublingually with continuous
bimanual uterine compression.
• In spite of doing all this there was a situation in
30 patients where the uterus was still flabby and
continued to bleed. At this hour we applied
modified B-Lynch suture using chromic no.1 and
a straight cutting needle and hemorrhage was
controlled in 29 patients showing an efficacy of
97%.
• Only 1 patient of massive abruptio placentae
required a cesarean hysterectomy
Anterior view of uterus
showing modified BLynch Technique
posterior view of uterus
showing modified B-Lynch
Technique
Anterior view of uterus showing modified B-Lynch
Technique with 4 embracing compressing sutures.
OBSERVATIONS:
Patient profile-
Number of
patients
Severe PIH
5
Abruptio placentae
2
Placenta previa
3
Previous 2 LSCS
5
Previous 1 LSCS
4
Breech
2
Transverse lie
1
PROM
2
Prolonged 1st stage with fetal distress
5
Prolonged 2nd stage
1
5
5
Severe PIH
5
5
Abruptio placentae
4
Placenta previa
4
Previous 2 LSCS
3
3
Previous 1 LSCS
2
2
2
Breech
2
1
1
0
1
Transverse lie
PROM
Prolonged 1st stage with fetal distress
Prolonged 2nd stage
Age distribution: all patients were ranging
from 20-35 yrs of age.
Age in
years
Number of
patients
AGE WISE DISTRIBUTION
18
20-25 yrs
25-30 yrs
9
18
16
14
12
10
NUMBER OF
PATIENTS
8
6
4
2
0
30-35 yrs
20-25
3
25-30
30-35
AGE OF PATIENTS
Parity wise distribution
Gravida
Number of
patients
8
I
II
7
III
9
IV
4
PARITY WISE DISTRIBUTION
9
8
7
6
5
4
3
2
1
0
NUMBER OF
PATIENTS
I
II
III
IV
GRAVIDA
V
2
V
Gestational Age wise distribution:
Gestational Number
age
of
patients
34-36
4
weeks
36-38
weeks
38-40
weeks
> 40
weeks
16
GESTATIONAL AGE WISE DISTRIBUTION
16
14
12
10
8
NUMBER OF
PATIENTS
6
9
4
2
0
1
34-36 36-38 38-40 > 40
GESTATIONAL AGE
Type of surgery:
Type of
surgery
Number of
patients
20
18
16
14
12
Emergency 19
NUMBER OF
PATIENTS
10
8
6
Elective
11
4
2
0
EMERGENCY
ELECTIVE
Effective blood loss varied from
800 ml – 1.5 litre.
Packed cell transfusion varied from
3-5 units. FFP used in 2 patients of
abruptio.
Post operative period in all these
patients was uneventful except for
fever and wound sepsis in 3 patients.
1 patient of massive abruption
needed a cesarean hysterectomy.
DISCUSSION:
Although uterine atony is the indication for use
of modified B-Lynch suture, but it has been
shown in many case reports that this suture is
also useful in controlling bleeding in cases of
placenta previa and placenta accreta.
It has also been used in controlling massive
bleeding after mid trimester miscarriages. It
has been used in patients who are at high risk
of PPH and where blood transfusion facilities
are not available.
DISCUSSION:
• In our series none of the patients had any
adverse outcome; on the contrary the success of
the procedure cause to be 97%.
• This procedure is easy and quick to perform,
there is no cervical stenosis, no hematometra
formation and no bleeding from lower uterine
segment.
• It doesn’t require any extra training and skill to
learn the procedure and is a life saving
measure.
CONCLUSION:
• Modified B-Lynch suture was successful in
controlling atonic PPH during LSCS and
obstetric hysterectomy could be avoided in
97% cases.
• Only 1 patient needed hysterectomy after
application of this suture.
• There were no major postoperative
complications.
REFERENCES:
•
•
•
•
Obstetric hemorrhages Williams obst.22nd
edition 2005; 823-24.
Review of B-Lynch brace suture, British journal
of obst. and gynae 2004; 111(3) 279-80.
B-Lynch brace suture a technique for atonic
PPH, Journal of Reproductive medicine 2004;
49(10) 849-52.
Harme M.Gungen N., B-Lynch suture for PPH
due to placenta previa and accrete, Australia
Nz J of obst. and gynae. 2005; 45, 93-5.
THANK YOU