International Journal of Gynecology and Obstetrics 108 (2010) 191–193

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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 ev i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

B-Lynch suture, intrauterine balloon, and endouterine hemostatic suture for the
management of postpartum hemorrhage due to placenta previa accreta
Maurizio Arduini ⁎, Giorgio Epicoco, Graziano Clerici, Elvira Bottaccioli, Saverio Arena, Giuseppe Affronti
S.C. Ostetricia e Ginecologia, Azienda Ospedaliera S. Maria della Misericordia, Perugia, Italy

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

Article history: Objective: To report our experience with a new conservative management approach to treat postpartum
Received 8 September 2009 hemorrhage (PPH) due to placenta previa accreta. Methods: A retrospective study of 9 patients with placenta
Received in revised form 20 October 2009 previa accreta who underwent a conservative management protocol. The protocol consists of preventive
Accepted 2 November 2009 radiological catheterization of the descending aorta, cesarean delivery, use of Affronti endouterine square
hemostatic sutures, and placement of an intrauterine Bakri balloon in conjunction with B-Lynch suture. In
Keywords:
the event of failure of the protocol, subsequent management employs ligation and/or reversible embolization
Affronti endouterine square hemostatic suture
Bakri balloon
of the uterine arteries followed by hysterectomy if unsuccessful. Results: Conservative management of PPH
B-Lynch suture was successful in all 9 patients evaluated and avoided the need for ligation and/or reversible embolization
Conservative management of the uterine arteries. Conclusion: Management of PPH is dictated by several considerations including
Placenta previa accreta hemodynamic status and desire to preserve fertility. The initial results of this conservative protocol for
Postpartum hemorrhage treatment of PPH in high-risk patients with placenta previa accreta are encouraging.
© 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction 2. Materials and methods

Postpartum hemorrhage (PPH) is the leading cause of maternal
death worldwide, with an estimated mortality rate of 140 000 deaths
per year, or 1 maternal death every 4 minutes. The complication occurs
in 5% of all deliveries [1]. It is commonly defined as an estimated blood
loss of more than 500 mL after vaginal delivery or more than 1000 mL
after cesarean delivery; however, assessment of blood loss is often
inaccurate. A 10% decrease in hematocrit value is also used to define
PPH [1], but evaluation of hemoglobin or hematocrit concentrations
may not reflect the patient's current hematologic status.
Treatment options for PPH include conservative management with
uterotonic drugs, selective devascularization by ligation or emboliza-
tion of the uterine artery, external compression with uterine sutures
(B-Lynch, Hayman, Cho), and intrauterine packing [2–6].
Failure of conservative treatment options often necessitates hyster-
ectomy, a radical intervention that remains the most common surgical
procedure [7]. Despite medical and surgical options for management of
PPH, about 60% of maternal deaths are due to substandard care [8].
The aim of the present study was to evaluate the effectiveness of a new
conservative management protocol for the prevention and treatment of
PPH in high-risk patients diagnosed with placenta previa accreta.
⁎ Corresponding author. Via Tagliapietra N°3, 06132 Perugia, Italy. Tel.: +39 34 7604 5328.
E-mail address: maoard@libero.it (M. Arduini).
We retrospectively reviewed the records of 9 women with PPH due
to placenta previa accreta at the Hospital of Perugia between October
2007 and January 2009. The diagnosis of placenta previa accreta was
based on ultrasound and clinical findings. The study was approved by
the institutional review board and all patients gave informed consent.
The protocol for management of PPH used in our institution is
shown in Fig. 1 and described in the following steps: (1) preventive
catheterization of the descending aorta is performed via transhumeral
access to allow the simultaneous embolization of pelvic vessels by a
medical radiologist without interfering with the surgical team [6];
(2) cesarean delivery using the Stark technique is performed; (3) the
Affronti technique is used to apply endouterine square hemostatic
sutures using 1.0 vicryl in the area of bleeding at the site of the
placental bed. The sutures are square in shape measuring approxi-
mately 2 cm and penetrate from the endometrium to the myometrium
without extending beyond the uterine serosa. Between 4 and 6
Affronti sutures are used depending on the severity of bleeding
(Fig. 2); (4) a B-Lynch compression suture is prepared (2.0 coated
vicryl); (5) a Bakri balloon (Cook Medical, Bloomington, IN, USA) is
inserted into the uterus through the hysterotomy site and is filled with
100 mL of normal saline; (6) the B-Lynch suture is performed, the
hysterotomy site is closed, and the uterus is placed into the abdomen;
the Bakri balloon is filled with up to 500 mL of normal saline while the
uterine response to increasing tamponade is visualized. Finally, the
abdomen is closed using a regular technique.

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.2009.10.007
192 M. Arduini et al. / International Journal of Gynecology and Obstetrics 108 (2010) 191–193

Fig. 1. Protocol for the management of postpartum hemorrhage.

If this conservative protocol fails then the next step is ligation and/
or reversible embolization of the uterine arteries followed by radical
hysterectomy if unsuccessful. Monitoring of maternal hematologic
parameters 24 hours before cesarean delivery and 2 hours after the
procedure is a requirement of the protocol. Blood transfusion was
performed if the hemoglobin level was less than 7 g/dL and the
hematocrit value was less than 21%. The Bakri balloon was removed
24 hours after delivery.
3. Results
Nine patients underwent conservative management using the
protocol described. The average age of the patients was 36.5 years,
mean gestational age was 35.3 weeks, and mean gravidity and parity
were 2.4 and 1.1, respectively. Eight patients had had previous uterine
surgery (cesarean delivery, n = 3; dilatation and curettage [D&C],
n = 4; cesarean delivery and D&C, n = 1). During each cesarean
delivery procedure, spontaneous placental extraction failed, placenta
previa accreta was suspected, and manual removal was performed.
Bleeding persisted from the placental bed site and our protocol for
conservative management of PPH was performed. Bleeding stopped
following placement of Affronti sutures combined with external
(B-Lynch suture) and internal (Bakri balloon) uterine compression.
On average, 5 Affronti sutures were used in the area of bleeding at
the site of the placental bed. None of the patients required ligation
or embolization of the uterine arteries.
The mean surgical time was 44 minutes. All patients received a high
dose of oxytocin (more than 20 U/L) and prostaglandin E2. Decreases
in hematologic parameters were seen postoperatively (Table 1). The
mean estimated blood loss was 1620 mL (range, 1100–2340 mL). Five
patients underwent intraoperative or postoperative blood transfusion
and the mean transfused volume was 700 mL.
One of the patients was admitted to the general intensive care unit
owing to postoperative hemodynamic instability caused by severe
intrapartum bleeding. Invasive blood pressure and blood-gas analysis
were monitored over the first 24 hours. The patient was discharged
from the unit the following day.

Table 1
Preoperative versus postoperative hematologic values among the 9 patients.

Value Preoperative Postoperative Δ Mean Δ Range

HCT, % 34.3 29.8 −4.5 − 10.5 to − 0.2

HGB, g/dL 11.1 8.7 − 2.4 − 4.1 to − 0.70
Fig. 2. Affronti endouterine square hemostatic sutures in the lower uterine segment.
RBC, 106 g/dL 3.94 3.51 − 0.43 − 1.34 to − 0.1
Between 4 and 6 Affronti sutures are placed in the area of bleeding (anterior/posterior
PLT, 103 g/dL 177.6 138.3 39.3 − 98 to 18
uterine wall) at the placental bed. The myometrial fibers are retracted when the ends of
the suture are tied, causing subsequent reduction of bleeding. Key: (e) endometrium; Abbreviations: HCT, hematocrit; HGB, hemoglobin; RBC, red blood cells; PLT, platelets;
(m) myometrium; (s) serosa. Δ, delta (preoperative versus postoperative).
 M. Arduini et al. / International Journal of Gynecology and Obstetrics 108 (2010) 191–193
Fig. 3. Uterine compression using B-Lynch suture and an intrauterine balloon. Two-dimensional (1) and three-dimensional (2) transvaginal ultrasound images showing that the
B-Lynch suture and Bakri balloon (“uterine sandwich” technique) were effective at the site of placental insertion in the lower uterine segment.
None of the patients experienced complications of fever, anuria,
uterine erosion, or abdominal pain. All patients were administered
prophylactic intravenous antibiotic therapy with 3 g of ampicillin/
sulbactam every 12 hours.
4. Discussion
The management of PPH is dictated by several considerations,
including hemodynamic status and the desire to preserve fertility. The
last possible treatment option for severe PPH is hysterectomy, but
conservative interventions are recommended primarily [9–12].
A recent review by Doumouchtsis et al. [13] evaluated the different
methods—surgical and radiological—for conservative treatment of
PPH after failure of medical therapy. There was no statistical dif-
ference in success rates for arresting PPH using balloon tamponade,
arterial embolization, iliac artery ligation or uterine devascularization,
and uterine compression sutures. These options appear to be safe
procedures that do not impair subsequent fertility and pregnancy
outcomes [13].
In the present study, two surgical treatments were combined using
external (B-Lynch suture) and internal (Bakri balloon) uterine com-
pression for treatment of PPH due to placenta previa accreta. With this
new technique, termed the “uterine sandwich,” we can simultaneously
apply pressure to both surfaces of the myometrium. We theorize that
the uterine sandwich technique, combined with Affronti endouterine
sutures, achieves hemostasis at the site of placental insertion in the
lower uterine segment (Fig. 3).
The rationale for using Affronti sutures arises from the lack of
musculature in the lower uterine cavity that inhibits its ability to
contract and assert hemostatic action at the placental insertion site.
Tying the two ends of the Affronti suture retracts the myometrial
fibers, which causes a reduction in bleeding. These sutures represent a
variation of the Cho square suture that penetrates from the anterior to
posterior uterine walls. This compression technique reduces the size
of the uterine cavity space, thereby controlling bleeding [14].
The technique for conservative management of PPH described
here, avoiding the need for ligation and/or reversible embolization
of the uterine arteries, was successful in all 9 patients. The potential
complications of combined interventions, such as uterine necrosis
resulting from poor perfusion, uterine lacerations, or endomyometritis
were not seen. Furthermore, average surgical times (44 minutes) and
postoperative hospital stay (5 days) were slightly higher compared
with cesarean delivery performed for other complications.
Using a standard protocol for the management of PPH in high-risk
patients with placenta previa accreta is vital. Such a stepwise approach
193
can minimize confusion in the operating room and the need for
hysterectomy. Although our small sample size makes it impossible to
draw definitive conclusions, the encouraging results suggest this
treatment protocol may be used for the management of PPH. A
limitation of the protocol is that it can only be performed in a fully-
equipped X-ray department with radiologists trained in embolization
techniques. Further studies are required to determine whether this
conservative management technique has an impact on the subsequent
fertility of patients.
Conflict of interest
The authors have no conflict of interest to disclose.
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