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