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 B-Lynch 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 Previous 1 LSCS 4 Breech Transverse lie 1 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 20-25 yrs 9 25-30 yrs 18 30-35 yrs 3

Parity wise distribution Gravida Number of patients I 8 II 7 III 9 IV 4 V 2

Gestational Age wise distribution: Number of patients 34-36 weeks 4 36-38 weeks 16 38-40 weeks 9 > 40 weeks 1

Type of surgery: Type of surgery Number of patients Emergency 19 Elective 11

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.

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