Introduction

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Bleeding more than 500 ml after third stage of labor is defined as postpartum hemorrhage (PPH).1 Postpartum hemorrhage is responsible for 25% of maternal mortalities which rise to 60% in developing countries if not managed properly.2 Postpartum hemorrhage is associated with chronic morbidities such as; chronic anemia, renal failure and respiratory tract problems.3

PPH related mortality and morbidities can be prevented with adequate and timely surgical intervention. Various surgical techniques have been described for women with PPH refractory to massage and uterotonic agents before hysterectomy such as; uterine compression sutures (B-lynch), bilateral uterine artery or Bilateral internal iliac (hypogastric artery) artery ligation (BIIAL).1

Bilateral internal iliac artery ligation procedure is a surgical approach which decreases pelvic and uterine perfusion rate by 75-80%, and also preserves fertility.4 BIIAL procedure is not used as preventive measure in obstetrics because of meticulous technical details which should be followed during BIIAL procedure such as; dissection of retro-peritoneum space, dissection of ureter passing over common iliac artery before start of ligation and ligation should be done after clear visualization of the external iliac artery. BIIAL needs surgical experience and BIIAL procedure related complications include; inadvertent suturing of external iliac artery and injury of adjacent vascular structures.5

B-lynch suture technique was first reported in 1997, is a vertical compression suture on the uterine vascular system with a reported success rate about 91.7% (95% CI 84.9%-95.5%).6 Many modifications have been added to the original B-lynch technique to achieve optimal results and fewer difficulties during surgery. This study was designed to assess effectiveness and safety of bilateral internal artery ligation compared to modified B-lynch suture technique (Ehab‘s modification) in the management of atonic post-partum hemorrhage (PPH).

Patients and Methods

This randomized controlled study was conducted at the Maternity University Hospital, which is a tertiary referral hospital for high risk obstetrical cases over one year from January 2012 to January 2013, to assess effectiveness and safety of bilateral internal artery ligation (BIIAL) compared to modified B-lynch suture technique (Ehab`s modification) in management of atonic post-partum hemorrhage.

Seventy two (72) women with intractable atonic post-partum hemorrhage after vaginal delivery or cesarean section not responding to uterine message and uterotonic agents (oxytocin, ergometrine and prostaglandins) were randomized to BIIAL group or modified B-lynch (Ehab’s Modification) group (36 women in each group) through a computer generated randomization sheet.

Coagulation studies including; Bleeding, clotting, prothrombin times and activated partial thromboplastin time (APTT) were done for women included in this study to exclude coagulopathy or bleeding disorders. Women with post-partum hemorrhage due to trauma or retained products of conception or coagulation defect were excluded from this study.

Bilateral internal iliac artery ligation (BIIAL) technique:

Under general anesthesia, while patient in semi-lithotomy position as it permits assessment of vaginal bleeding, laparotomy was done, uterus was explored and bowels were packed away. Opening of retro-peritoneal space and then using gentle dissection, the ureter was identified and retracted medially. Using a long hemostat, the loose areolar sheath around the internal iliac artery was dissected completely to free the artery from its adjacent structures. (Figure 1)

JGOM_R0002_Fig01_Identification of internal iliac artery

Fig. 1: Identification of internal iliac artery

A right – angled clamp was passed beneath the internal iliac artery from lateral to medial side about 3- 4 cm distal to its origin. (Figure 2)

JGOM_R0002_Fig02_Right angled clamp passing beneath internal iliac artery

Fig. 2: Right – angled clamp passing beneath internal iliac artery

Using a non-absorbable suture (silk 3-0), internal iliac artery was ligated at two levels 6-10 mm apart. Pulsations of the femoral artery and dorsalis pedis were identified after the ligation of internal iliac artery on both sides. Effect of IIAL was detected by the decrease amount of vaginal bleeding and improvement of vital signs of patients. If vaginal bleeding continued and vital signs of patients deteriorated in-spite of the BIIAL decision of emergency hysterectomy was taken.

Modified B- lynch suture technique

In this study, the original B-lynch suture technique was modified without opening the uterine cavity. Only half thickness of uterine wall was included with no much compression and the suture material used (catgut) is inexpensive and readily available.

The uterus is explored, exteriorized and checked to exclude traumatic PPH. Bimanual compression is first tried to assess the potential chance of success of modified B-lynch suture (Ehab’s Modification).

No 2 chromic catgut is used to take a half thickness bite of anterior uterine wall 3 cm from left lateral border and 1cm from lower edge of the uterine caesarean section incision. (Figure 3)

JGOM_R0002_Fig03_First chromic catgut bite was taken at lower cesarean section incision

Fig. 3: First chromic catgut bite was taken at lower cesarean section incision

Another half thickness bite at upper incision 4 cm from left lateral border and 2 cm from upper edge of the uterine cesarean section incision. (Figure 4)

JGOM_R0002_Fig04_Second half thickness bite at upper cesarean section incision

Fig. 4: Second half thickness bite at upper cesarean section incision

The chromic catgut passed upward vertically anteriorly to about 3 cm medial to left corneal end, then passed downward vertically posteriorly to the level between the two utero-sacral ligaments. A transverse half thickness bite is taken between the two utero-sacral ligaments. (Figure 5)

JGOM_R0002_Fig05_A transverse half thickness bite was taken between the two utero-sacral ligaments

Fig. 5: A transverse half thickness bite was taken between the two utero-sacral ligaments

Chromic catgut then passed upwards posteriorly about 3 cm medial to right corneal end, then downward anteriorly about 2 cm of upper uterine edge and 4 cm medial to right lateral uterine wall, at that level half thickness bite of the anterior uterine wall was taken, followed by another half thickness bite at the lower uterine edge, 1 cm lower and 3 cm medial to the right lateral uterine wall. (Figure 6)

JGOM_R0002_Fig06_Chromic catgut passed then upwards posteriorly to right uterine side

Fig. 6: Chromic catgut passed then upwards posteriorly to right uterine side

The two lengths of chromic catgut were pulled, assisted by bimanual compression by an experienced assistant to minimize trauma and to achieve or aid compression. (Figure 7)

JGOM_R0002_Fig07_Two lengths of chromic catgut were pulled to compress uterus assisted by assistant

Fig. 7: Two lengths of chromic catgut were pulled, to compress uterus assisted by assistant

Effect of modified B-lynch suture (Ehab’s Modification) was detected by decrease amount of vaginal bleeding and improvement of vital signs of patients. Women included in this study were given intravenous antibiotics, started intra-operative and continued for 5 days postoperative. Amount of blood loss was calculated by the difference in weight of pack gauze, packs, towels before and after delivery and the amount of blood collected in the suction bottle. Intra-operative and postoperative complications occurred during both procedures were recorded. Postoperative data such as; hemodynamic status, febrile morbidities, and surgery related morbidities were also recorded. Postoperative ultrasound was done for women included in this study at 3,7,40 days postoperative to detect the shape of the uterus and endometrial cavity. The women were followed up till end of puerperium and up to one year, to detect their menstrual pattern and menstrual associated pains.

Statistical analysis:

Data were collected, tabulated then statistically analyzed using the Statistical Package for Social Sciences (SPSS) computer software version 18. Numerical variables were presented as mean and standard deviation (±SD), while categorical variables were presented as number (n) and percentage (%). Student t-test was used for comparison between groups as regards quantitative variables and Chi-square test (χ2) was used for comparison between two studied groups as regards qualitative variables. A difference with a p value <0.05 was considered statistically significant.

Results

Mean age, parity and gestational age for BIIAL group were 28.2±3.0 years, 3.2±1.5 and 39.0±1.2 weeks; respectively, while, mean age, parity and gestational age for B-lynch group were 28.5±3.0 years, 3.3±1.5 and 39.2±1.2 weeks; respectively, with no significant difference between two studied groups. In BIIAL group; 18 cases (50%) delivered by cesarean section and 18 (50%) cases delivered vaginally were included, while in modified B-lynch group; 20 cases (55%) delivered by cesarean section and 16 cases (45%) delivered vaginally were included, with no significant difference between two studied groups. (Table 1)

Table. 01 Demographic data of the two studied groups

Variables BIIAL groupNumber = 36 cases B-lynch groupNumber = 36 cases P value (95% CI)Test used
Age (years) Mean±SD 28.2±3.0 28.5±3.0 0.5* (-1.68, -0.3, 1.08), t-test
Parity Mean±SD 3.2±1.5 3.3±1.5 0.5* (-0.79, -0.1, 0.59), t-test
Gestational age (weeks)Mean±SD 39.0±1.2 39.2±1.2 0.5* (-0.75, -0.2, 0.35), t-test
Gestational age (weeks)Mean±SD 18 (50%) 20 (55%) 0.79*, χ2
Normal Vaginal deliveryNumber (%) 18 (50%) 16 (45%) 0.77*, χ2

*: non-significant , BIIAL: Bilateral internal iliac artery ligation, t-test: student t test, χ2 : Chi-square test

There was no significant difference between two studied groups regarding, uterotonic agents received to control PPH before surgical procedures. In BIIAL group; 61.1% of cases received triple uterotonic agents (oxytocin, ergometrine and prostaglandins), 22.2% of cases received (oxytocin and ergometrine) and 16.6% of cases received (oxytocin and prostaglandins). In modified B-lynch group; 58.3% of cases received triple uterotonic agents (oxytocin, ergometrine and prostaglandins), 27.7% of cases received (oxytocin and ergometrine) and 13.7% of cases received (oxytocin and prostaglandins). (Table 2)

Table. 02 Comparison between two studied groups regarding uterotonic agents received before BIIAL or B-lynch

Variables BIIAL groupNumber = 36 cases B-lynch groupNumber = 36 cases P valueTest used
Oxytocin, ergometrine and prostaglandinsNumber (%) 22 (61.1%) 6 (16.6%) 1.0*, χ2
Oxytocin and ergometrineNumber (%) 8 (22.2%) 10 (27.75%) 0.6*, χ2
Oxytocin and prostaglandins Number (%) 6 (16.6%) 5 (13.7%) 0.7*, χ2

The preoperative blood loss (ml) was 2431±1785 ml in BIIAL group, while it was 2391±1251 ml in modified B-lynch group, with significant difference between two studied groups, while there was no significant difference between two studied groups regarding intra-operative blood loss which was 250±30 ml in BIIAL group and was 230± 40 ml in modified B-lynch group. (Table 3)

Amount of blood and plasma transfused in BIIAL group were 1800±450 and 400±250 ml; respectively, and were statistically significant compared to 1350±250 and 200±150 ml; respectively in modified B-lynch group. There was no significant difference between two studied groups regarding preoperative and postoperative hemoglobin. The number of cases admitted to the intensive care unit (ICU) was 13 cases in BIIAL group and was 3 cases in B-lynch group (statistically significant), duration of modified B-lynch procedure was significantly shorter 2-4 minutes compared to duration of BIIAL 15-35 minutes. (Table 3)

Table. 03 Preoperative, postoperative parameters, duration of surgical procedure and number of cases admitted to ICU in both studied groups

Variables BIIAL groupNumber = 36 cases B-lynch groupNumber = 36 cases P value (95% CI), test used
Preoperative blood loss ( ml )Mean±SD 2431±1785 2391±1251 0.01** (-672, 40, 752), t-test
Intra-operative blood loss ( ml )Mean±SD 250±30 230±40 0.9* (3.6, 20, 36), t-test
Amount of blood transfused (ml)Mean±SD 1800±450 1350±250 0.0003** (281, 450, 618), t-test
Amount of plasma transfused ( ml ) Mean±SD 400±250 200±150 0.001** (104, 200, 295), t-test
Pre-operative hemoglobin values (gm/dl)Mean±SD 7.3±0.2 7.4±0.3 1.0* (-1.08, -0.1, 0.8), t-test
Post-operative hemoglobin values (gm/dl)Mean±SD 11.8±0.6 11.2±0.6 0.5* (90.4, 0.7, 0.9), t-test
Number of cases admitted to intensive careNumber (%) 13 (36.1%) 3 (8.3%) 0.02**, χ2 test
Duration of procedure (min)Range 15-35 2-4 0.0002**, χ2 test

**: significant, *: non-significant, BIIAL: Bilateral Internal Iliac Ligation, t-test: student t test, χ2 : Chi-square test

In BIIAL group; injury to the internal iliac vein occurred in two women (first injury was due to perforation by hemostat during dissection of fascia around the internal iliac artery and second injury was due to dissection by tip of the right angled clamp). In this study, there were three maternal deaths unrelated directly to the procedure. Two in BIIAL group (first due to adult respiratory distress syndrome (ARDS) and the second due to fulminant hepatitis and hepatic failure). One in B–lynch group due to massive pulmonary embolism.

Also, in BIIAL studied group there was two cases of accidental unilateral ligation of the ureter, diagnosed intra-operative and managed by removal of ligature with insertion of ureteric stent for 15 days.

In this study, there was no significant difference between two studied groups regarding number of uterus saved after either BIIAL (26 cases) or modified B-lynch (32 cases) technique, also there was no significant difference between two studied groups regarding number of emergency hysterectomies done after either BIIAL (10 cases) or modified B-lynch (4 cases) technique. (Table 4)

Table. 04 Number of uterus saved and number of emergency hysterectomies done in both studied groups

Variables BIIAL groupNumber = 36 cases B-lynch groupNumber = 36 cases P value, test used
Uterus saved Number (%) 26(72.2%) 32(88.8%) 0.5*, χ2 test
Emergency hysterectomiesNumber (%) 10(27.8%) 4(11.2%) 0.1*, χ2 test

*: non-significant , BIIAL: Bilateral internal iliac artery ligation, χ2 : Chi-square test

Discussion

In this randomized controlled study, bilateral internal iliac artery ligation was effective to control intractable atonic PPH in 72% (26/36), while modified B-lynch group was effective in 88% (32/36). Also, Joshi and colleagues, studied the role of bilateral internal iliac artery ligation in the management of atonic postpartum hemorrhage, in their study 36 women with atonic postpartum hemorrhage were included, they found bilateral internal iliac ligation was effective to control PPH in 63.88% (23/36) of studied cases and 36.11% (13/36) of studied cases required emergency hysterectomy to control uterine bleeding.7

The bilateral internal iliac ligation was effective method to control post-partum hemorrhage in 87.9% of cases in Unal and colleagues 8 study (58 women were included) and it was effective to control post-partum hemorrhage in 82.45% in Chelli et al.9 study (52 women were included).

Camuzcuoglu et al.4 studied the role of internal iliac ligation to control severe post-partum hemorrhage in 33 women (uterine atony (n=22), morbid adherent placenta (n=5), uterine rupture (n=4), and placental abruption (n=2)). Twenty-four women underwent bilateral internal iliac artery ligation as the primary surgical intervention and BIIAL was effective to control PPH in 75% of cases (18/24). Nine women with persistent bleeding following hysterectomy were also treated with BIIAL after hysterectomy. In Camuzcuoglu and colleagues study, there were no intraoperative or postoperative complications related to the internal iliac artery ligation procedure.4

In the present study, the average time for BIIAL procedure was 15-35 minutes, pre-operative and intra-operative blood loss was 2431±1785 and 250±30; respectively, the amount of blood and plasma substituted was 1800±450 and 400±150; respectively. Coagulopathy developed in 6 cases out of 36 cases (16.66%). During the post-operative follow up period, 2 patients died (due to ARDS and fulminant hepatitis with hepatic failure). In modified B-lynch group, average time for this modification was 2-4 min, pre-operative and intra-operative blood loss was 2391±1251 and 230±40; respectively, blood and plasma substituted was 1350±250 and 200±150; respectively. Coagulopathy developed in 4 cases out of 36 cases (11.11%) and there was one case of maternal mortality due massive pulmonary embolism. A study was conducted by Evsen et al.,10 to evaluate the outcomes of bilateral internal iliac ligation in severe post-partum hemorrhage in 53 women with unstable vital signs. The mean shock index and transfused units of blood were 1.7±0.46 and 5.49±3.04; respectively. Coagulopathy developed in 49.1% (17 cases) during the postpartum period, Uterus was preserved in 32% (17 cases) and three women died due to morbidities associated with postpartum bleeding.10

No intra-operative complications reported in modified B-lynch studied group, while in studying internal iliac ligation group, two injuries to internal iliac vein were recorded and repaired immediately. Also, in BIIAL studied group there was two cases of accidental unilateral ligation of the ureter, diagnosed intra-operative and managed by removal of ligature with insertion of ureteric stent for 15 days.

Joshi and colleagues believe that the life-saving technique of BIIAL is underutilized in the management of post-partum hemorrhage probably due related internal iliac vein injuries. Thorough knowledge of retroperitoneal anatomy and meticulous operative technique can minimize these complications.7

Since the internal iliac veins lies directly posterior to the internal iliac artery passage of the right angled clamp in a controlled manner in close proximity to the posterior wall of the artery prevents perforating the underlying internal iliac vein. It is imperative to dissect the internal iliac artery completely from the surrounding for the passage of the right angled clamp without resistance. Some authors have advised the use of Babcock forceps to elevate the internal iliac artery to facilitate the passage of right angled clamp.7

In this study, after successful control of hemorrhage with internal iliac ligation, two women had delayed hemorrhage requiring re-laparotomy and managed by hysterectomy. While in modified B-lynch group one woman had delayed hemorrhage requiring re-laparotomy and managed by hysterectomy.

The three main factors related to complications associated with compression sutures were, type of suture material used, entering of the uterine cavity, use of multiple different types of compression sutures at the same time or the addition of vascular ligation of uterine or iliac vessels with compression suture. In this study, during the modified B-lynch suture technique, uterine cavity was not opened, only half thickness of uterine wall were included with no much compression and suture material used (catgut) is inexpensive and readily available. The modified B-lynch technique takes short time (2-4min.), it’s easy for the registrars to understand and apply. The modified B-lynch uterine compression suture was evaluated by Marasinghe et al.11 for treatment of postpartum bleeding due to uterine atony. In Marasinghe et al.11 study, modified anchored B-lynch suture was done in 17 women with postpartum hemorrhage due to atony, bleeding was controlled and uterus was saved in 76% (13/17). Four women (24%) didn’t respond to the anchored compression sutures and managed by emergency post-partum hysterectomy. This newly modified anchored B-lynch compression suture appeared effective in controlling about 75% of postpartum hemorrhage due to uterine atony, which allowed uterine conservation. This simple modification can provide first line surgical step for treatment of atonic PPH.

Despite the great benefits gained from the use of B-lynch suture in intractable atonic postpartum hemorrhage, some minor as well as serious complications were reported in the literature. However, number of the women treated efficiently with B-lynch suture and followed up to evaluate potential complications of the procedure is still limited. Accordingly, documented complications from case reports and case series are few and their true incidence is not clear.12

A case of uterine suture erosion with a subsequent small defect in the anterior uterine wall after B-lynch with delayed absorbable suture was observed by Grotegut et al.13

Although, Cho et al.14 reported an increase risk of pyometra and Asherman`s syndrome as a result of sutures going through the uterine cavity, Ouabhba et al.15 reported no complications related to their B-lynch technique. The use of multiple compression suturing techniques was associated with partial ischemic necrosis of uterine wall and erosion of suture material was reported in relation to B-lynch suture and Cho square sutures. Ischemic necrosis complicated by sepsis and subsequently hysterectomies was also recorded with B-lynch.16

In a prospective population based study of 1.2 million women delivering in the United Kingdom, the obstetric surveillance system (UKOSS), was used to identify women delivered between September 2007 & March 2009 and treated with uterine compression sutures. Two hundred and eleven women were treated with uterine compression sutures to control postpartum hemorrhage. The overall rate of failure, leading to hysterectomy was 25% (95% CI; 19-31%), and there were no significant differences in failure rates between B-lynch sutures, modified B-lynch sutures and other suture techniques. Women were more likely to have a hysterectomy if they were aged 35 years or older, multiparous, had a vaginal delivery, or a delay of between 2-6 hours from delivery to uterine suture compression (42% compared with 16% with delay less than 1 hour). The authors concluded that a prolonged delay of 2-6 hours between delivery and uterine compression suture was independently associated with a four-fold increase in the odds of hysterectomy.17

Understanding pelvic anatomy, following meticulous technique during internal iliac artery ligation can minimize its complications and should be incorporated in all training programs for obstetric hemorrhage. Long term effects of BIIAL and modified B-lynch after management of intractable atonic PPH should be studied on large number of cases.

Conclusions

Modified B–Lynch (Ehab`s modification) compression suture is simple, safe and appeared to be effective in controlling about 88% of atonic PPH, which allowed uterine conservation. This simple modification can be used as first line surgical step to control atonic PPH and training of registrars in maternity hospitals in using modified B-lynch technique is needed.