International Journal of Gynecology and Obstetrics 108 (2010) 187–190

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International Journal of Gynecology and Obstetrics

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Bilateral uterine artery ligation plus B-Lynch procedure for atonic postpartum
hemorrhage with placenta accreta
Ahmed Y. Shahin a,⁎, Tarek A. Farghaly a, Safwat A. Mohamed a, Mahmoud Shokry a,b,
Diaa-Eldeen M. Abd-El-Aal a, Mohammed A. Youssef a
a
Department of Obstetrics and Gynecology, Women's Health Centre, Assiut University, Egypt
b
Department of Obstetrics and Gynecology, Saudi-German Hospital, Abha, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression
Received 3 July 2009 suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent placenta
Received in revised form 18 August 2009 accreta. Method: This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta.
Accepted 13 October 2009 Results: Two women died from disseminated intravascular coagulopathy. In the remaining 24 women,
placental remnants completely disappeared within 8 months and ovulation resumed after a mean ± SD of
Keywords:
51.6 ± 3.2 days. Moreover, 18 women (75%) became pregnant within 12 months. Conclusion: Atonic post-
B-Lynch procedure
Cesarean delivery
partum hemorrhage and placental site bleeding due to adherent placenta accreta can be safely controlled by
Fertility bilateral uterine artery ligation followed by B-Lynch compression suturing in women who desire to remain
Postpartum hemorrhage fertile.
Uterine artery ligation © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction occlusion and/or uterine compression sutures for the management of

Recent reports have suggested that placenta increta occurs because a
dehiscent scar allows chorionic villi to penetrate so deeply into the
uterine wall that the trophoblast enters the myometrium [1]. The
process is categorized as accreta, increta, and percreta according to the
level of penetration (in the latter case, placental villous tissue has come
through the uterine wall) [2]. During the third stage of labor, the absence
of decidua prevents the noncontracting placenta from being separated
from the contracting myometrium, causing the adherent placenta to
bleed and often necessitating a hysterectomy [1].
Placenta previa, multiparity, advanced maternal age, previous cer-
vical dilation and curettage, and the increasing numbers of cesarean
deliveries worldwide are all known to be closely associated with
placenta accreta [2,3]. In women who do not wish to have more children,
hysterectomy with the placenta left in situ is the safest and therefore the
preferred treatment [4]. When the woman wishes to preserve her
fertility, however, attempts can be made to control a potentially life-
threatening postpartum hemorrhage due to placenta accreta and/or an
atonic uterus. In the latter case, leaving the adherent placenta (or
adherent portions of the placenta) in situ at the time of the cesarean
delivery lowers the risk of hysterectomy from 85% to 15% [4–8] and
lessens the need for a blood transfusion should a hysterectomy become
necessary [5]. Studies offer a wide range of techniques to perform arterial
uterine bleeding due to placenta accreta [6,9–11].
Uterine compression sutures have proved to be valuable in the
control of massive atonic postpartum hemorrhage as an alternative to
hysterectomy. B-Lynch [12], Hayman [13], and Cho [14] developed the
most famous techniques combining bilateral uterine artery ligation
(UAL) and uterine compression by suturing the anterior and posterior
uterine walls together [15]. With only 7 reported failures, which all
involved morbid placental adherence or disseminated intravascular
coagulopathy, the efficacy of the B-Lynch technique is high [16,17].
Bilateral UAL is the first step of a stepwise uterine devasculariza-
tion approach that affords good control of postpartum hemorrhage
[18,19]. Studies on heavy menstrual bleeding have suggested that the
decrease in bleeding following UAL was due to a decrease in blood
perfusion (measured as a decrease in blood volume) [20,21]. Per-
formed with or without utero-ovarian ligament ligation, UAL does not
appear to affect future fertility or obstetric outcomes [18,22]. Vascular
occlusion is only temporary, as recanalization soon ensures normal
uterine circulation [18].
The aim of the present study was to evaluate the effectiveness of
bilateral UAL followed by B-Lynch compression suturing in controlling
atonic postpartum hemorrhage in women in whom complete removal
of a placenta accreta was not possible.

2. Patients and methods

⁎ Corresponding author. Department of Obstetrics and Gynecology, Assiut Univer-
sity, 71116, Assiut, Egypt. Tel.: +20 100024322; fax: +49 1212532706248. This prospective study was approved by the review board of the
E-mail address: Ahmed.Shahin@web.de (A.Y. Shahin). Department of Obstetrics and Gynecology, Women's Health Centre,

0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2009.08.035
188 A.Y. Shahin et al. / International Journal of Gynecology and Obstetrics 108 (2010) 187–190
Assiut University, Assiut, Egypt, and took place from February 2007
through April 2009. All patients had placenta previa, with the placenta
implanted on the site of a cesarean scar. The inclusion criteria were a
gestation duration of at least 37 weeks and antepartum hemorrhage;
intraoperative atonic postpartum hemorrhage and discovery of a
placenta accreta; and an adherent placental part after piecemeal re-
moval of the placenta, with bleeding from the placental site. Ges-
tational age was determined on the basis of the last menstrual period
confirmed by an ultrasound scan taken between the 14th and 20th
week, and calculated in menstrual weeks. The exclusion criteria were
posterior placenta previa; placental implantation away from the scar;
a plane of easy cleavage between the placenta and the uterine wall;
and/or successful piecemeal removal of the placenta.
The participants provided written informed consent to undergo
any procedure deemed necessary, including bilateral UAL followed by
the B-Lynch procedure, as an attempt to avoid emergency hysterec-
tomy should they experience postpartum hemorrhage. They also
provided written informed consent to undergo hysterectomy if all
measures attempted to preserve the uterus failed.
All cesarean deliveries were performed by the first author assisted by
the second author. A dose of 1 g of first-generation cephalosporin
(Cefazolin; Bristol Mayers Squibb, Cairo, Egypt) was administered
intravenously 20 minutes prior to skin incision. The surgery was done
under general anesthesia, which was delivered by one of 4 anesthesiol-
ogists, each of whom had acquired a wide experience of obstetric
anesthesia from at least 400 interventions over a minimum of 2 years.
General anesthesia was obtained using a modified rapid sequence
induction, i.e., the administration of 4 to 6 mg/kg of thiopentone,
followed by 1 to 1.5 mg/kg of suxamethonium, followed by endotra-
cheal intubation. A urethral catheter was inserted after anesthesia was
obtained. The skin was incised in the midline and the subcutaneous
tissues were opened by blunt dissection. The anterior rectus sheath was
opened by sharp dissection. After dissecting fascia from rectus muscles,
the muscles were separated using the no-cutting technique. After the
parietal peritoneum was opened by sharp dissection and blunt
expansion, high above the bladder, a bladder flap was made and the
bladder was retracted (an assistant held the retractor). A small median
transverse hysterotomy incision was done in the lower uterine segment
using a scalpel. It was expanded on both sides using scissors, stopping
shortly before the uterine arteries. After delivery of the fetus, active
delivery of the placenta was attempted by searching manually for a
plane of cleavage between the placenta and the uterus. In patients in
whom no plane of cleavage could be identified, or in whom adherent
parts could not be removed, the study protocol was initiated. This
Fig. 1. Participant flow through the study.
protocol comprised 2 steps, bilateral UAL and B-Lynch compression
suturing.
The technique used for bilateral UAL was the following: The peri-
toneum over the vesicouterine pouch already being incised horizontally,
the peritoneum over the uterine isthmus and cervix was bluntly
dissected downwards, and this dissection was then extended laterally.
To avoid including the ureter in the ligation of the ascending branch of
the uterine artery, the peritoneum was carefully mobilized at the
uterine angles to expose both. The uterus was then retracted upwards
and laterally by the assistant. The uterine artery pulsations were
palpated digitally at the level of the internal os. A 1.0 chromic catgut
suture attached to a round-bodied needle was passed posteriorly to
anteriorly through the cervical tissues and the ligature consisted of a
simple stitch. A second stitch was done below the first, at a distance no
greater than 1 cm.
After the B-Lynch compressing sutures were performed as described
by B-Lynch et al. [12], a double-layer closure of the hysterotomy was
done without exteriorization by the continuous, nonlocking technique.
The visceral peritoneum was left open but the parietal peritoneum was
closed by the same technique using delayed-absorbable material. No
approximation of the rectus muscles was done. Closure of the subcu-
taneous tissue was done by the interrupted-sutures technique, and
closure of the skin by the same technique using absorbable sutures.
Because obstetric hemorrhage is an emergency, blood samples were
only drawn for hemoglobin concentration, cross matching, and blood gas
analysis. Following delivery, a complete blood count and another blood
gas analysis were done, and liver and renal functions were checked.
Before discharge, the patients were prescribed antibiotics for
3 weeks. After discharge, they were followed up for bleeding and in-
fection. Ovarian function and placental resorption were monitored by
transvaginal ultrasound using the Sonoline G60-S imaging system
(Siemens, Erlangen, Germany). The scans were done at monthly
postpartum visits, which began within the first week postpartum, as
soon as the patient's condition allowed. The volume of any adherent
placental remnant was calculated during the first scan, and these values,
in cubic millimeters, served as baseline values. At each visit, the patients
were also checked for puerperal fever or sepsis and questioned about
passage of tissues through the vagina, irregular bleeding, and re-
sumption of menstruation. Pregnancies were recorded.
3. Results
The patients’ exclusion, inclusion, and outcomes are shown in Fig. 1.
All had undergone 1 previous cesarean delivery, all had antepartum
 A.Y. Shahin et al. / International Journal of Gynecology and Obstetrics 108 (2010) 187–190 189

Table 1 on the first scan. Within the first 6 months, some still appeared as echo-
Demographic and preoperative characteristics.a dense shadows near the uterine fundus on ultrasound, but they had
Characteristic Value completely disappeared at 8 months. The mean time to sonographic
evidence of complete absence of placental tissue was 170.7±54.7 days.
Age, y 32.4 ± 3.6 (29–38)
BMI 28.6 ± 1.4 (28.5–30.3) After 1 year, 18 (75%) of the 24 patients became pregnant, as evidenced
Parity 2.5 ± 1.9 (0–5) by the presence of fetal heart beat on ultrasound. Of the 6 patients who
Gestational age, wk 36.3 ± 1.8 (34.1–39.0) did not become pregnant, 4 were receiving injectable contraceptives
No. of units of fresh blood transfused 2.8 ± 1.2 (1–4)
offered by a private clinic. The other 2, who had galactorrhea, had already
Hemoglobin concentration, mg/dL
Preoperatively 7.6 ± 0.9 been diagnosed as having hyperprolactinemia at an infertility clinic.
Postoperatively 10 ± –0.6

Abbreviation: BMI, body mass index (calculated as weight in kilograms divided by

height in meters squared).
a
Values are given as mean ± SD or mean ± SD (range).
hemorrhage, and all had placenta previa implanted on the uterine scar,
which was diagnosed preoperatively by ultrasound or discovered intra-
operatively. All underwent an emergency cesarean delivery under
general anesthesia. No postpartum hemorrhage occurred in the 17
patients in whom the placenta was easily removed, and hysterectomy
was performed in 8 patients who arrived at the emergency department
in a state of shock due to massive blood loss. The remaining 26 patients
had atonic postpartum hemorrhage and were also bleeding from
adherent placental remnants after piecemeal removal of the placenta.
These patients underwent the first step of the protocol. As bleeding from
the placental site did not stop following bilateral UAL, they all
underwent the B-Lynch procedure. The 2 patients who also needed
ligation of the internal iliac (or hypogastric) artery were then
transferred to the intensive care unit, where they died 34 hours later
from disseminated intravascular coagulopathy.
Age ranged from 29 to 38 years (mean± SD, 32.4 ± 3.6 years); body
mass index (calculated as weight in kilograms divided by height in
meters squared) from 28.5 to 30.3 (mean, 28.6 ± 1.4); parity from 0 to 5
(mean, 2.5 ± 1.9); and number of 500-mL units of fresh blood transfused
intraoperatively or postoperatively from 1 to 4 units (mean, 2.8 ± 1.2).
The mean hemoglobin concentration was significantly higher postop-
eratively than postoperatively (10.1 ± 8.6 mg/dL vs 7.6 ± 0.9 mg/dL;
P b 0.001 by the χ2 test) (Table 1).
The outcomes for the 24 surviving patients are outlined in Table 2.
There were no cases of puerperal sepsis. Genital tract infection was not
the cause of the puerperal fever that occurred in 6 (25%) of the 24
surviving patients. Only 6 of these 24 patients reported the passage of
necrotic tissue through the vagina, and only in the first 2 weeks.
Menstruation resumed within 3 months in 20 patients (83.3%), and
none experienced irregular bleeding. Ovulation resumed in all 24 patients
within a mean of 45.6 ± 5.2 days, as evidenced on transvaginal
ultrasound. The placental remnants measured a mean of 8.7±3.6 mm3
Table 2
Postoperative characteristics of the 24 surviving patients.a
Characteristic
Postpartum fever
Time to first menstruation postpartum, d
Regular menstruation within the first 3 months postpartum
Time to ovulation resumption, d
Evidence of ovulation on transvaginal ultrasound
Irregular bleeding
No. of patients reporting passage of tissues through the vagina
Puerperal sepsis
Size of placental remnants, mm3
Complete lysis of placental tissue 8 months postpartum
Pregnancy within 12 months
No. of patients not pregnant within 12 months
Likely cause
Use of injectable contraceptives
Hyperprolacteinemia
a
Values are given as number of cases (percentage) or mean ± SD unless otherwise
indicated.
4. Discussion
We assessed the effectiveness of bilateral UAL followed by B–Lynch
compression suturing to control bleeding and postpartum infection—
and allow for the restoration of ovulation and fertility—in women with
atonic postpartum hemorrhage who are also bleeding from adherent
placental remnants. Morbid placental adherence or disseminated intra-
vascular coagulopathy are the only causes proposed for the failure of the
B-Lynch procedure [16,17], and the 2 patients who died in our study had
disseminated intravascular coagulopathy. Our protocol seems promis-
ing as none of the other patients needed a hysterectomy, and the rates of
ovulation and fertility restoration were good.
Uterine compression sutures function in a manner similar to manual
compression [23], and there are no theoretical or technical explanations
regarding the failure of these approaches in women with placental
remnants. This may point to a need for an additional technical step to
control placental site bleeding in these women. Successful arterial
occlusion for the management of bleeding associated with an incom-
pletely delivered placenta accreta include hypogastric artery balloon
occlusion [9] or ligation [6], bilateral ligation of the hypogastric arteries,
Tsirulnikov arterial ligation [11], or uterine artery embolization [10]. Cho
et al. [14] described sequential deep circular compression sutures on the
serosal uterine surface to control bleeding from the placental site during
cesarean delivery in women with placenta previa accreta. Verspyck et al.
[24] reported the successful bilateral surgical devascularization of the
uterus and ovary, a procedure that allowed 5 of 6 women with placenta
accreta to keep their uterus. We successfully performed bilateral UAL,
which is one step of stepwise uterine devascularization process.
The technique decreases blood perfusion through a temporary
vascular occlusion [18,20,21]. This effect may combine with that of a
B-Lynch compression suture, which probably also decreases blood
flow. As recanalization occurs and normal uterine circulation resumes
[18], no interference with future reproductive performance is ex-
pected. Ovulation and fertility were restored within 12 months in
most of our patients.
Sentilhes et al. [25] were the first to report on a woman who
underwent stepwise uterine devascularization and B-Lynch com-
pression suturing, became pregnant again, and showed no marks of
the B-Lynch procedure on cesarean delivery. Verspyck et al. [24]
reported on the recurrence of placenta accreta and placental reten-
Value tion following both conservative treatment and surgical uterine and
ovarian devascularization.
6 (25.0)
37.5 ± 2.3 The main limitation of our study is its small sample size. Studies with
20 (83.3) larger samples are needed before we can recommend the protocol we
51.6 ± 3.2 followed as standard management of cases similar to those we treated.
24 (100.0) Because the situation of women with remnants of placenta accreta and
0
6 (25.0)
postpartum hemorrhage is critical, conducting studies with randomized
0 designs would be difficult. Studies comparing the arterial ligation
8.7 ± 3.6 technique we used with other techniques, including stepwise devascu-
24 (100.0) larization, are possible, however, and needed.
18 (75.0)
We conclude that, in women who desire to preserve their fertility,
6 (25.0)
bilateral UAL followed by B-Lynch compression suturing represent an
4 (16.6) effective and safe combination for controlling atonic postpartum hemor-
2 (8.3) rhage and bleeding due to adherent placental remnants. Although we
found that our protocol did not impair fertility, this needs further
assessment in studies with larger population samples.
190 A.Y. Shahin et al. / International Journal of Gynecology and Obstetrics 108 (2010) 187–190
Conflict of interest
The authors have no conflict of interest.
References
[1] Tantbirojn P, Crum CP, Parast MM. Pathophysiology of placenta creta: the role of
decidua and extravillous trophoblast. Placenta 2008;29(7):639–45.
[2] Baergen RN. Manual of Benirschke and Kaufmann's Pathology of the Human
Placenta. New York, NY, USA: Springer-Verlag; 2005.
[3] Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa–
placenta accreta. Am J Obstet Gynecol 1997;177(1):210–4.
[4] Legro RS, Price FV, Hill LM, Caritis SN. Non surgical management of placenta
accreta: a case report. Obstet Gynecol 1994;83(5 Pt 2):847–9.
[5] Komulainen MH, Varynen MA, Kauko ML, Saariskoski S. Two cases of placenta accreta
managed conservatively. Eur J Obstet Gynecol Reprod Biol 1995;62(1):135–7.
[6] Ledee N, Ville Y, Musset D, Mercier F, Frydman R, Fernandez H. Management in
intractable obstetric hemorrhage: an audit study on 61 cases. Eur J Obstet Gynecol
Reprod Biol 2001;94(2):189–96.
[7] Gibb DMF, Soothill PW, Ward KJ. Conservative management of placenta accreta. Br
J Obstet Gynaecol 1994;101(1):79–80.
[8] O'Brien JM, Barton JR, Donaldson ES. The management of placenta percreta:
conservative and operative strategies. Am J Obstet Gynecol 1996;175(6):1632–8.
[9] Levine D, Hulka CA, Ludmir J, Li W, Edelman RR. Placenta accreta: evaluation with color
Doppler US, power Doppler US, and MR imaging. Radiology 1997;205(3):773–6.
[10] Alanis M, Hurst BS, Marshburn PB, Matthews ML. Conservative management of
placenta increta with selective arterial embolization preserves future fertility and
results in a favorable outcome in subsequent pregnancies. Fertil Steril 2006;86(6):
1514.e3–7.
[11] Bretelle F, Courbière B, Mazouni C, Agostini A, Cravello L, Boubli L, et al. Management
of placenta accreta: morbidity and outcome. Eur J Obstet Gynecol Reprod Biol
2007;133(1):34–9.
[12] B-Lynch C, Coker A, Lawal A, Abu J, Cowen M. The B-Lynch surgical technique for
the control of massive postpartum hemorrhage: an alternative to hysterectomy?
five cases reported. Br J Obstet Gynaecol 1997;104(3):372–5.
[13] Hayman R, Arulkumaran S, Steer P. Uterine compression sutures: surgical man-
agement of postpartum hemorrhage. Obstet Gynecol 2002;99(3):502–6.
[14] Cho J, Jun H, Lee C. Hemostatic suturing technique for uterine bleeding during
cesarean delivery. Obstet Gynecol 2000;96(1):129–31.
[15] Tjalma WAA, Jacquemyn Y. A uterus-saving procedure for postpartum hemor-
rhage. Int J Gynecol Obstet 2004;86(3):396–7.
[16] Mousa HA, Alfirevic Z. Treatment for primary postpartum hemorrhage. Cochrane
Database Syst Rev 2003(1):CD003249.
[17] B-Lynch C. B-Lynch Brace suture: Description of technique. http://www.cbl.uk.
com/2008/02/description-of-technique [accessed September 21, 2009].
[18] AbdRabbo SA. Stepwise uterine devascularization: a novel technique for
management of uncontrolled postpartum hemorrhage with preservation of the
uterus. Am J Obstet Gynecol 1994;171(3):694–700.
[19] Tsirulnikov MS. Ligation of the uterine vessels during obstetrical hemorrhages.
Immediate and long-term results [in French]. J Gynecol Obstet Biol Reprod (Paris)
1979;8(8):751–3.
[20] Rapkin AJ. Pelvic pain and dysmenorrhea. In: Berek JS, Adashi EY, Hillard PA,
editors. Novak's Gynecology. 12th ed. Baltimore, Maryland, USA: Williams &
Wilkins; 1996. p. 410.
[21] Hurst BS, Stackhouse DJ, Matthews ML, Marshburn PB. Uterine artery emboliza-
tion for symptomatic uterine myomas. Fertil Steril 2000;74(5):855–69.
[22] Sentilhes L, Trichot C, Resch B, Sergent F, Roman H, Marpeau L, et al. Fertility and
pregnancy outcomes following uterine devascularization for postpartum haemor-
rhage. Hum Reprod 2008;23(5):1087–92.
[23] Shah Monjri, Wright Jason D. Surgical Intervention in the management of
postpartum hemorrhage. Semin Perinatol 2009;33(2):109–15.
[24] Verspyck E, Resch B, Sergent F, Marpeau L. Surgical uterine devascularization for
placenta accreta: immediate and long-term follow-up. Acta Obstet Gynecol Scand
May 2005;84(5):444–7.
[25] Sentilhes L, Gromez A, Trichot C, Ricbourg-Schneider A, Descamps P, Marpeau L.
Fertility after B-Lynch suture and stepwise uterine devascularization. Fertil Steril
2009;91(3):934.e5–9.