Alan K Lefor

Hironori Takahashi

Shigeki Matsubara

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Letter to the Editor
Comment on (Alternate Sequential Suture Tightening:
A Novel Technique for Uncontrolled Postpartum Hemorrhage)
Shigeki Matsubara,1 Hironori Takahashi,1 and Alan K. Lefor2
1Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi 329-0498, Japan
2Department of Surgery, Jichi Medical University, Tochigi 329-0498, Japan
Correspondence should be addressed to Shigeki Matsubara; matsushi@jichi.ac.jp
Received 12 May 2015; Accepted 5 July 2015
Academic Editor: Everett Magann
Copyright © 2015 Shigeki Matsubara et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
We read with interest the recent article “Alternate Sequential
Suture Tightening: ANovel Technique forUncontrolled Post-
partumHemorrhage” byGhosh andMala [1].They developed
a novel technique of uterine compression suture (UCS) for
atonic bleeding where a Hayman suture [2] is performed,
but importantly they sequentially tighten the knot, yielding
“very tight” compression. In 92% (11/12) of their patients, the
UCS alone stopped the bleeding. No patients had untoward
sequelae. Their data is promising; however, we have two
concerns.
First, we wonder if such a tight knot is needed. In the
Ghosh technique, the final knot was eventually tightened
compared to the initial knot by as much as 3–5 cm, meaning
tighter by 3–5 cm compared with an ordinary Hayman suture
[2]. In our opinion, the Ghosh suturemay be too tight and we
wish to describe two supporting pieces of evidence. First, we
usually use the Matsubara-Yano (MY) UCS in patients with
atonic bleeding (Figure 1(a)) [3] and sometimes even cut the
sutures because the knot looks “too tight.”We then reperform
the MY UCS, making a looser knot. A knot that is too tight
may lead to tissue damage caudal to the suture, that is, the
lower uterine segment. This portion would become thin and
weak, and a knot that is too tight would forcefully pull this
portion in the cephalad direction, easily damaging this area
(Figure 1(b)). We sometimes loosen the knot also for fear of
possible subsequent uterine ischemia. After placing the UCS
and closing the hysterotomy incision, it is our experience that
the uterus becomes, more or less, contracted even in patients
with an atonic uterus. Uterine contraction may make the
knot even tighter. Second, we are concerned about Figure 1(d)
in Ghosh and Mala’s article [1]. The uterus looks ischemic
in the area between two sutures even 1.5 years after the
Ghosh UCS, possibly indicating that the suture significantly
deprived blood flow to the uterus. Mowat et al. [4] reported
a case of uterine necrosis after B-Lynch suture, describing,
“there was central necrosis of the anterior body and fundus of
the uterus between the two limbs of the B-Lynch suture”: this
feature was similar to Ghosh and Mala’s figure (Figure 1(d))
[1].
As described previously, generally speaking, compression
force is related to the ability to induce hemostasis but is also
related to adverse events associatedwithUCS [3]. A tight knot
or tight suture, exerting excessive compression, naturallymay
lead to effective hemostasis at the time butmay lead to uterine
ischemia afterward, meaning that the hemostatic ability and
occurrence of ischemia may have a “trade-off” relationship.
Since the incidence rate of uterine ischemia is low [3, 4],
the fact that it is not reported by Ghosh and Mala does not
entirely rule out its occurrence.We proposed the concept of a
removableUCS [5] that has been used clinically [6], removing
the compression suture within two days postpartum. Strong
compression of the uterus for up to two days postpartum and
then removing the suture may be reasonable [5, 6].
Second, since the Ghosh technique is a modified Hay-
man suture [2], a drawback of Hayman suture [2] and B-
Lynch suture [7] persists, that is, “the suture sliding out”
Hindawi Publishing Corporation
Obstetrics and Gynecology International
Volume 2015, Article ID 279513, 3 pages
http://dx.doi.org/10.1155/2015/279513
2 Obstetrics and Gynecology International
(a) (c)(b)
Suture
sliding out (off)
Suture
embedded in the uterus
Suture forcefully 
pulled
Torn lower segment
Matsubara-Yano (MY) suture
Ghosh suture Ghosh suture
Hayman suture
Figure 1: Schematic presentation of the Matsubara-Yano (MY) uterine compression suture (a) and possible drawbacks of the Ghosh suture
(b, c). (a) The MY suture consists of two (or three) longitudinal transfixation sutures and two transverse sutures. Upper insets indicate how
the first longitudinal transfixation suture is placed. Then, the transverse sutures are placed lateral to the longitudinal suture (arrow), thereby
preventing the thread from sliding out (off). (b) Ghosh suture is a modification of Hayman suture (upper left insets). If the knot of a Ghosh
suture is too tight, it may destroy the caudal insertion site (arrow), or the lower uterine segment, which is thin and weak. Upper right inset
shows the sagittal view. (c) In the Ghosh suture, similar to the B-Lynch or Hayman suture, sutures may “slide out (off)” from the uterine
fundus (left), thus yielding insufficient compression. If the knot is too tight, the chance of “sliding out” may be higher, since there may be no
room for the suture to move. Even if it does not slide out, the thread may embed in the uterus (right), leading to uterine ischemia.
(Figure 1(c)). We have previously pointed this out [3] and
Hayman wrote, “the suture threatened to slide off the uterine
fundus, like braces off a round shouldered man” [2]. This
may occur more readily with a tight knot. When the uterus
temporarily contracts and the knot becomes tighter, the
possibility of “sliding out (off)” becomes higher; theremay be
no room for the suture other than “sliding out.” Sliding out of
the suture makes compression insufficient. Figures 1(b) and
1(c) in Ghosh and Mala’s article [1] lead us to consider this
possibility.
Obstetric practice has surely changed before and after the
introduction of the UCS. We have now obtained a powerful
tool, the UCS, against postpartum hemorrhage. Every effort
should bemade tomake theUCS better and, thus, we applaud
and respect Drs. Ghosh and Mala. The development of a
number of UCS techniques shows that there may be no one
best UCS. Further study of the UCS and wide discussion are
needed.
Abbreviations
MY: Matsubara-Yano
UCS: Uterine compression suture.
Consent
A consent was obtained from all patients.
Disclosure
The authors described the MY suture elsewhere, which
is appropriately cited in this paper. Patient anonymity is
preserved.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
Authors’ Contribution
It is certified that all authors have contributed to this paper:
work is original. Shigeki Matsubara, Hironori Takahashi,
and Alan K. Lefor were responsible for (1) substantial con-
tributions to the conception of the work, (2) drafting the
work for important intellectual content, (3) final approval of
Obstetrics and Gynecology International 3
the version to be published, and (4) agreement to be account-
able for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved.
References
[1] S. B. Ghosh and Y. M. Mala, “Alternate sequential suture
tightening: a novel technique for uncontrolled postpartum
hemorrhage,”Obstetrics andGynecology International, vol. 2015,
Article ID 145178, 6 pages, 2015.
[2] R. G. Hayman, S. Arulkumaran, and P. J. Steer, “Uterine com-
pression sutures: surgical management of postpartum hemor-
rhage,” Obstetrics and Gynecology, vol. 99, no. 3, pp. 502–506,
2002.
[3] S. Matsubara, H. Yano, A. Ohkuchi, T. Kuwata, R. Usui,
and M. Suzuki, “Uterine compression sutures for postpartum
hemorrhage: an overview,” Acta Obstetricia et Gynecologica
Scandinavica, vol. 92, no. 4, pp. 378–385, 2013.
[4] A. Mowat, L. Minuzzo, and J. Wilson, “A necrotic uterus after
a B-Lynch Suture: fertility sparing surgery,” Australian and New
Zealand Journal of Obstetrics and Gynaecology, vol. 53, no. 4, pp.
408–409, 2013.
[5] S. Matsubara, “New prophylaxis methods for adverse events of
uterine compression sutures: removing compression threads,”
ActaObstetricia et Gynecologica Scandinavica, vol. 93, no. 10, pp.
1069–1070, 2014.
[6] Z. W. Zhang, C. Y. Liu, N. Yu, and W. Guo, “Removable uterine
compression sutures for postpartum haemorrhage,” BJOG: An
International Journal of Obstetrics & Gynaecology, vol. 122, no.
3, pp. 429–433, 2015.
[7] C. B-Lynch, A. Coker, A. H. Lawal, J. Abu, and M. J. Cowen,
“The B-Lynch surgical technique for the control of massive
postpartum haemorrhage: an alternative to hysterectomy? Five
cases reported,” British Journal of Obstetrics and Gynaecology,
vol. 104, no. 3, pp. 372–375, 1997.
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Letter to the Editor Comment on (Alternate Sequential Suture Tightening: A Novel Technique for Uncontrolled Postpartum Hemorrhage)

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Letter to the Editor Comment on (Alternate Sequential Suture Tightening: A Novel Technique for Uncontrolled Postpartum Hemorrhage)

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