Abstract Objective A new fertility assessment after a B-Lynch suture without a concomitant uterine devascularization is proposed. Case Report The case of a 37-year-old woman who experienced postpartum hemorrhage due to uterine atony during cesarean delivery of the previous pregnancy is reported. A B-Lynch brace suturing technique, not associated to any other hemostatic surgical procedure, was carried out. One year later and after an uncomplicated pregnancy of 39 weeks, the patient delivered a healthy infant by an elective cesarean section. Only omental adhesions were found on the anterior surface of the uterus as a consequence of the previous B-Lynch suture. Conclusion The B-Lynch hemostatic surgical procedure, alone, does not seem to have a negative impact on fertility. Additional clinical evidences in a greater case-series of patients are needed to assess the value of the method for fertility preservation

Alessandro Favilli

Claudia Giordano

Elena Laurenti

Gian Carlo Di Renzo

Sandro Gerli

Silvia Pericoli

Taiwanese Journal of Obstetrics and Gynecology

English

Open Access Repository

Available online at www.sciencedirect.comTaiwanese Journal of Obstetrics & Gynecology 52 (2013) 110e112www.tjog-online.comCase ReportFertility after “only B-Lynch” suture: A case report and literature reviewSandro Gerli*, Alessandro Favilli, Claudia Giordano, Silvia Pericoli, Elena Laurenti,Gian Carlo Di RenzoDepartment of Obstetrics and Gynecology, University of Perugia, Perugia, ItalyAccepted 24 April 2012AbstractObjective: A new fertility assessment after a B-Lynch suture without a concomitant uterine devascularization is proposed.Case Report: The case of a 37-year-old woman who experienced postpartum hemorrhage due to uterine atony during cesarean delivery of theprevious pregnancy is reported. A B-Lynch brace suturing technique, not associated to any other hemostatic surgical procedure, was carried out.One year later and after an uncomplicated pregnancy of 39 weeks, the patient delivered a healthy infant by an elective cesarean section. Onlyomental adhesions were found on the anterior surface of the uterus as a consequence of the previous B-Lynch suture.Conclusion: The B-Lynch hemostatic surgical procedure, alone, does not seem to have a negative impact on fertility. Additional clinical evi-dences in a greater case-series of patients are needed to assess the value of the method for fertility preservation.Copyright  2013, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.Keywords: B-Lynch suture; fertility; postpartum hemorrhage; pregnancy; uterine atonyIntroductionAll over the world, obstetric hemorrhage is still the majorcause of maternal mortality, although about 90% of deathsafter postpartum hemorrhage (PPH) are preventable [1]. Nosignificant changes in the definitions, over the past 50 years,have been evidenced, but a classification has been recentlyproposed by Coker et al wherein the volume loss is assessed inconjunction with clinical signs and symptoms [2]. The factorsmost significantly associated with hemorrhage includeadvanced maternal age, prolonged labor, preeclampsia, obe-sity, multiple pregnancies, birth weight >4000 g, and previouspostpartum hemorrhage. Early identification and prompttreatment are key factors for an adequate management of PPH.The B-Lynch surgical technique has been used successfullysince 1989 in cases where bleeding was secondary to uterineatony, with failed conservative, pharmacological management[3]. It allows the conservation of the uterus for subsequentmenstrual function and pregnancies. The B-Lynch technique is* Corresponding author. Department of Obstetrics and Gynecology, Uni-versity of Perugia, Ospedale S.M. della Misericordia, 06156 Perugia, Italy.E-mail address: gerber@unipg.it (S. Gerli).1028-4559/$ - see front matter Copyright  2013, Taiwan Association of Obstetrihttp://dx.doi.org/10.1016/j.tjog.2013.01.014far less complicated thanmore radical surgical methods, such asinternal iliac arterial ligation or hysterectomy, not only becauseit is technically easier, but also because the application of thesuture is away from the uterine cornua, without major vessel ororgan compromise. Although several reports on fertility andpregnancy outcomes following hypogastric artery ligation, orarterial embolization [4e6] for severe postpartum hemorrhagehave been published with extensive literature review [7e10], nodefinitive clinical evidence is present related to a B-Lynch su-turing technique and subsequent reproductive outcome, notassociated to other hemostatic surgical interventions.We report a case of a successful pregnancy occurringspontaneously after a B-Lynch suture without concomitantdevascularization, introducing a new concept of fertilityassessment after a pure B-Lynch procedure.Case reportA 37-year-old, gravida 1, with a body mass index of 24 kg/m2, was referred to the Department of Obstetrics and Gyne-cology, University of Perugia, Italy, in January 2009. Thepatient, at 35 weeks’ gestation, had a personal history of type Ics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.111S. Gerli et al. / Taiwanese Journal of Obstetrics & Gynecology 52 (2013) 110e112diabetes mellitus, Basedow disease treated by thyroidectomy,and celiac disease. Her pregnancy was uneventful, except fora suspected fetal malformation: hyperechogenic areas werefound on the fetal heart and liver, with moderate ileal dis-tension. A bowel atresia was suspected. Levels of glycemiawere not within the normal range, although insulin wasadjusted daily. An ultrasound scan revealed a fetal macro-somia (>90th percentile), therefore a termination of pregnancywas programmed. Lung maturity was previously confirmed bydiagnostic amniocentesis with a lecithin sphingomyelin ratioof 6 and the presence of phosphatidylglycerol. After 36 weeks,a healthy newborn of 3160 g was born by cesarean section.After fetal extraction, the uterus appeared atonic and a mod-erate bleeding of 900 mL was observed. Intravenous oxytocin(5 IU followed by 20 IU in 0.9% saline) failed to arrest thebleeding. Although methylergometrine (0.25 mg i.v.) andsulprostone (0.5 mg i.v. in 0.9% saline at 250 mL/h) wereadministered, the uterus was still flabby and atonic. Thereforea hemostatic synthetic absorbable, surgical suture (poly-glactin) was carried out according to the B-Lynch procedure,to preserve the uterus. Bleeding was stopped and the abdomenwas closed. The patient did not receive any transfusion. Twohours later, blood parameters were stable: the white blood cellcount was 10,910/mL and hemoglobin was 9.2 g/dL. Duringthe following days, vaginal blood loss was regular. Histologyrevealed the presence of a placental subchorionitis. She wasdischarged from the hospital on day 4. Forty days later,a Doppler velocimetry did not reveal any abnormality inuterine vessels. In January 2010, a new unplanned pregnancywas registered. The antenatal course of the pregnancy wasuneventful. Due to the recent cesarean section, a surgical de-livery was electively performed at 39 weeks’ gestation. Duringsurgery, the potential consequences associated with the pre-viously applied B-Lynch brace suture were evaluated. Onlyomental adhesions were found on the anterior surface of theuterus. A healthy newborn of 3460 g. was delivered througha lower uterine segment incision. Delivery of the placenta wasunremarkable. Intravenous oxytocin (5 IU) was administeredand the uterine incision was closed with absorbable braidedsuture material. The total blood loss was 400 mL. After thesurgery, hemoglobin was 10.2 g/dL. No complications in thepostoperative days were observed and the patient was dis-charged 72 hours later.DiscussionPost partum hemorrhage occurs in approximately 4% ofvaginal and 6% of cesarean deliveries [11]. A new PPH top-guideline adopts a practical approach, whereby a perceivedloss of 500e1000 mL prompts basic measures of monitoringand readiness for resuscitation, whereas a perceived loss of>1000 mL or smaller, associated with clinical signs of shock,prompts a full protocol of measures to resuscitate, monitor andarrest bleeding [2]. The prevalence of severe PPH was esti-mated in 6.7 per 1000 deliveries [12], while deaths from PPHoccur in approximately 1 per 1000 deliveries [11]. Differentuterine compression sutures have recently been described tocontrol PPH, including the B-Lynch suture that runs throughthe full thickness of both the anterior and posterior uterinewalls [2]. The mechanical compression of uterine vascularsinuses prevents further engorgement with blood and con-tinued hemorrhage. The compression effect keeps thesebleeders inactive until physiological hemostasis is achieved.Since the B-Lynch technique was reported, several modi-fications have been described, with only minor variations fromthe original procedure [13]. In the Hayman procedure, forexample, hysterotomy is not performed and there are concernsabout occlusion of the uterine cavity and blood entrapment,without the possibility to exclude retained products.Among the hemostatic surgical techniques, the B-Lynchsuture gained a major popularity, mainly because many prac-titioners are less confident with more complicate surgicalprocedures, such as bilateral hypogastric artery ligation, andprefer to proceed with an easier, quicker, and effective B-Lynch suture.Almost nothing is known about fertility and pregnancyoutcomes for patients who have undergone B-Lynch suture forsevere PPH, with or without concomitant uterine devascula-rization procedures. Initial fears about possible anatomicaldamage due to extreme uterine compression have material-ized. These uterus preserving procedures are not alwayswithout complications. Ochoa et al [14] reported pyometracomplicating square suture technique and Joshi and Shriv-astava [15] reported a partial ischemic necrosis of the uterusafter a brace compression suture. Rathat et al presented a studywhere patients were assessed by hysteroscopy, after a previousuterine compression suture. Synechia occurred in seven pa-tients (out of 13 patients), three of whom had Ashermansyndrome that could not be corrected [16]. Fourteen cases ofsubsequent pregnancy after B-Lynch suture have been reportedin the literature [17], but only in four cases was a B-Lynchsuture realized without associated hemostatic surgical pro-cedures [3,18,19]. Hypogastric artery ligation or stepwiseuterine devascularizations were sometimes associated to B-Lynch suture. Thirteen pregnancies were uneventful, one wascomplicated by preeclampsia and PPH that required hyster-ectomy [16]. Sentilhes et al [20] described uneventful preg-nancy after four different uterine-sparing procedures thatincluded pelvic arterial embolization, stepwise uterine devas-cularization, hypogastric artery ligation, and B-Lynch suture.If we consider the dramatic vascular changes occurringimmediately after the hypogastric uterine arteries ligatures, orfurthermore, arterial embolization, we cannot exclude that thevascular modifications induced by the B-Lynch suture carriedout immediately after a stepwise uterine devascularization aretotally different and probably more limited than vascularchanges induced by the “only B-Lynch” case. A confirmationof this comes from Pirard et al: uterine necrosis and sepsisafter vascular embolization and uterine artery ligation forpostpartum hemorrhage due to placenta accreta were found[21]. Moreover, accidental embolization of ovarian vessels viauterineeovarian anastomoses can result in the loss of ovarianfunction, as Chrisman et al have reported in connection withfibroid embolizations [22].Table 1Characteristics of pregnancies after “only B-Lynch” procedures.First author(reference)CasenumberParity at the timeof B Lynch sutureWks ofgestationCause of PPH Mode of delivery Observations and complicationsduring subsequent cesarean sectionNeonataloutcomeB-Lynch [3] 1 1 >37 Abruptio placentae Vaginal delivery e Healthy2 1 39 Uterine atony Cesarean section None HealthyHaberk [18] 3 1 >37 Uterine atony Cesarean section Slight synechia along previousB-Lynch sutureHealthyVitthala [19] 4 1 Not specified Uterine atony Cesarean section Bands of adhesion between uterinefundus and bowels at level of previousB-LynchNot specifiedOur case 5 0 39 Uterine atony Cesarean section Omental adhesion on the anteriorsurface of the uterusHealthy112 S. Gerli et al. / Taiwanese Journal of Obstetrics & Gynecology 52 (2013) 110e112To determine the exact relation between the B-Lynch sutureand a subsequent pregnancy, in terms of conception andpregnancy outcome, it would be therefore more accurate toanalyze results deriving from “only B-Lynch” cases, with noother associated hemostatic, surgical procedure. Our case isthe fifth reported case in a recent literature of a successfulpregnancy after a previous cesarean section and a B-Lynchprocedure due to postpartum hemorrhage caused by uterineatony, not associated to any other surgical ligation.In previous reported “only B-Lynch” cases, one patientdelivered vaginally [3] while three patients had a repeatedcesarean delivery [3,18,19]. No PPH or any other complicationoccurred. Bands of adhesions were found between the uterusand the bowel only in one case [19]. Only omental adhesionswere found on the anterior surface of the uterus in our case(Table 1).The B-Lynch suture is a successful, safe, inexpensive, andsimple method for the treatment of PPH during cesareansection, which reduces the incidence of mutilating urgentperipartum hysterectomy due to uterine atony or coagulopathy,possibly preserving subsequent patient fertility.Additional clinical evidences in a greater case-series ofpatients that involves “only B-Lynch” sutures are obviouslyneeded, to assess the value of the method for fertilitypreservation.References[1] Hibbard BM, Anderson MM, Drife JO, Tighe JR, Gordon G, Willatts S,et al. Report on confidential enquiries into maternal death in the UnitedKingdom 91e93. London: Her Majesty’s Stationary Office; 1996.[2] Coker A, Oliver R. Demographic and logistical considerations. Defini-tions and classifications. In: B-Lynch C, editor. A textbook of postpartumhemorrhage. London: Sapiens Publishing; 2006. p. 11e7.[3] B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch sur-gical technique for the control of massive postpartum hemorrhage: analternative to hysterectomy? Five cases reported. Br J Obstet Gynecol1997;104:372e5.[4] Ornan D, White R, Pollak J, Tal M. Pelvic embolisation for intractablepostpartum hemorrhage: long-tem follow up and implication for fertility.Obstet Gynecol 2003;102:904e10.[5] Chauleur C, Fanget C, Tourne G, Levy R, Larchez C, Seffert P. Seriousprimary post-partum hemorrhage, arterial embolization and future fer-tility: a retrospective study of 46 cases. Hum Reprod 2008;23:1553e9.[6] Fiori O, Deux JF, Kambale JC, Uzan S, Bougdhene F, Berkane N. Impactof pelvic arterial embolization for intractable postpartum hemorrhage onfertility. Am J Obstet Gynecol 2009;200:384.e1e4.[7] Nizard J, Barrinque L, Frydman R, Fernandez H. Fertility and preg-nancies outcomes following hypogastric artery ligation for severe post-partum hemorrhage. Hum Reprod 2003;18:844e8.[8] Papp Z, Sztanyik L, Szabo I, Inovay J. Successful pregnancy afterbilateral internal iliac artery ligation monitored by color Doppler imag-ing. Ultrasound Obstet Gynecol 1996;7:211e2.[9] Wagaarachchi PT, Fernando L. Fertility following ligation of internaliliac arteries for life-threatening obstetric haemorrhage: case report. HumReprod 2000;15:1311e3.[10] Casele HL, Laifer SA. Successful pregnancy after bilateral hypogastricartery ligation. A case report. J Reprod Med 1997;42:30630e8.[11] Mousa H, Alffirevic Z. Treatment for primary postpartum haemorrhage.Cochrane Database Syst Rev 2003;1. CD003249.[12] Mousa H, Walkinshaw S. Major postpartum haemorrhage. Curr OpinObstet Gynecol 2001;13:595e603.[13] El-Hayman RG, B-Lynch C. Aworldwide review of the use of the uterinecompression suture techniques as alternative to hysterectomy in themanagement of severe post-partum hemorrhage. J Obstet Gynaecol 2005;25:143e9.[14] Ochoa M, Allaire AD, Stietly ML. Pyometra after hemostatic squaresuture technique. Obstet Gynecol 2002;99:506e9.[15] Joshi VM, Shrivastava M. Partial ischemic necrosis of the uterus fol-lowing a uterine brace compression suture. BJOG 2004;111:279e80.[16] Rathat G, Do Trinh P, Mercier G, Reyftmann L, Dechanet C, Boulot P,et al. Synechia after uterine compression sutures. Fertil Steril 2011;95:405e9.[17] Sentilhes L, Gromez A, Trichot C, Ricbourg-Schneider A, Descamps P,Marpeau L. Fertility after B-Lynch suture and stepwise uterine devas-cularization. Fertil Steril 2009;91:934.[18] Habek D, Vranjes M, Bobic Vukovic M, Valetic J, Krcmar V, Simunac J.Successful term pregnancy after B-Lynch compression suture in a pre-vious pregnancy on account of massive primary postpartum hemorrhage.Fetal Diagn Ther 2006;21:475e6.[19] Vitthala S, Misra PK. Fertility after B-Lynch suture in a patient previ-ously treated for acute myeloid leukaemia. Eur J Obstet Gynecol ReprodBiol 2008;136:133e4.[20] Sentilhes L, Gromez A, Marpeau L. Fertility after pelvic arterialembolization, stepwise uterine devascularization, hypogastric arteryligation, and B-Lynch suture to control postpartum hemorrhage. Int JGynaecol Obstet 2010;108:249.[21] Pirard C, Squifflet J, Gilles A, Donnez J. Uterine necrosis and sepsis aftervascular embolization and surgical ligation in a patient with post partumhaemorrhage. Fertil Steril 2002;78:412e3.[22] Chrisman HB, Saker MB, Ryu RK, Nemcek Jr AA, Gerbie MV,Milad MP, et al. The impact of uterine fibroid embolization onresumption of menses and ovarian function. J Vasc Interv Radiol 2000;11:699e703.

Fertility after "only B-Lynch" suture: A case report and literature review

Objective: A new fertility assessment after a B-Lynch suture without a concomitant uterine devascularization is proposed.
Case Report: The case of a 37-year-old woman who experienced postpartum hemorrhage due to uterine atony during cesarean delivery of the previous pregnancy is reported. A B-Lynch brace suturing technique, not associated to any other hemostatic surgical procedure, was carried out. One year later and after an uncomplicated pregnancy of 39 weeks, the patient delivered a healthy infant by an elective cesarean section. Only omental adhesions were found on the anterior surface of the uterus as a consequence of the previous B-Lynch suture.
Conclusion: The B-Lynch hemostatic surgical procedure, alone, does not seem to have a negative impact on fertility. Additional clinical evidences in a greater case-series of patients are needed to assess the value of the method for fertility preservation

Directory of Open Access Journals

Fertility after “only B-Lynch” suture: A case report and literature review

AbstractObjectiveA new fertility assessment after a B-Lynch suture without a concomitant uterine devascularization is proposed.Case ReportThe case of a 37-year-old woman who experienced postpartum hemorrhage due to uterine atony during cesarean delivery of the previous pregnancy is reported. A B-Lynch brace suturing technique, not associated to any other hemostatic surgical procedure, was carried out. One year later and after an uncomplicated pregnancy of 39 weeks, the patient delivered a healthy infant by an elective cesarean section. Only omental adhesions were found on the anterior surface of the uterus as a consequence of the previous B-Lynch suture.ConclusionThe B-Lynch hemostatic surgical procedure, alone, does not seem to have a negative impact on fertility. Additional clinical evidences in a greater case-series of patients are needed to assess the value of the method for fertility preservation

Gerli, Sandro

Favilli, Alessandro

Giordano, Claudia

Pericoli, Silvia

Laurenti, Elena

Di Renzo, Gian Carlo

Elsevier - Publisher Connector 

Available online at www.sciencedirect.comTaiwanese Journal of Obstetrics & Gynecology 52 (2013) 110e112
www.tjog-online.comCase Report
Fertility after “only B-Lynch” suture: A case report and literature review
Sandro Gerli*, Alessandro Favilli, Claudia Giordano, Silvia Pericoli, Elena Laurenti,
Gian Carlo Di Renzo
Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
Accepted 24 April 2012AbstractObjective: A new fertility assessment after a B-Lynch suture without a concomitant uterine devascularization is proposed.
Case Report: The case of a 37-year-old woman who experienced postpartum hemorrhage due to uterine atony during cesarean delivery of the
previous pregnancy is reported. A B-Lynch brace suturing technique, not associated to any other hemostatic surgical procedure, was carried out.
One year later and after an uncomplicated pregnancy of 39 weeks, the patient delivered a healthy infant by an elective cesarean section. Only
omental adhesions were found on the anterior surface of the uterus as a consequence of the previous B-Lynch suture.
Conclusion: The B-Lynch hemostatic surgical procedure, alone, does not seem to have a negative impact on fertility. Additional clinical evi-
dences in a greater case-series of patients are needed to assess the value of the method for fertility preservation.
Copyright  2013, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
Keywords: B-Lynch suture; fertility; postpartum hemorrhage; pregnancy; uterine atonyIntroduction
All over the world, obstetric hemorrhage is still the major
cause of maternal mortality, although about 90% of deaths
after postpartum hemorrhage (PPH) are preventable [1]. No
significant changes in the definitions, over the past 50 years,
have been evidenced, but a classification has been recently
proposed by Coker et al wherein the volume loss is assessed in
conjunction with clinical signs and symptoms [2]. The factors
most significantly associated with hemorrhage include
advanced maternal age, prolonged labor, preeclampsia, obe-
sity, multiple pregnancies, birth weight >4000 g, and previous
postpartum hemorrhage. Early identification and prompt
treatment are key factors for an adequate management of PPH.
The B-Lynch surgical technique has been used successfully
since 1989 in cases where bleeding was secondary to uterine
atony, with failed conservative, pharmacological management
[3]. It allows the conservation of the uterus for subsequent
menstrual function and pregnancies. The B-Lynch technique is* Corresponding author. Department of Obstetrics and Gynecology, Uni-
versity of Perugia, Ospedale S.M. della Misericordia, 06156 Perugia, Italy.
E-mail address: gerber@unipg.it (S. Gerli).
1028-4559/$ - see front matter Copyright  2013, Taiwan Association of Obstetri
http://dx.doi.org/10.1016/j.tjog.2013.01.014far less complicated thanmore radical surgical methods, such as
internal iliac arterial ligation or hysterectomy, not only because
it is technically easier, but also because the application of the
suture is away from the uterine cornua, without major vessel or
organ compromise. Although several reports on fertility and
pregnancy outcomes following hypogastric artery ligation, or
arterial embolization [4e6] for severe postpartum hemorrhage
have been published with extensive literature review [7e10], no
definitive clinical evidence is present related to a B-Lynch su-
turing technique and subsequent reproductive outcome, not
associated to other hemostatic surgical interventions.
We report a case of a successful pregnancy occurring
spontaneously after a B-Lynch suture without concomitant
devascularization, introducing a new concept of fertility
assessment after a pure B-Lynch procedure.Case report
A 37-year-old, gravida 1, with a body mass index of 24 kg/
m2, was referred to the Department of Obstetrics and Gyne-
cology, University of Perugia, Italy, in January 2009. The
patient, at 35 weeks’ gestation, had a personal history of type Ics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
111S. Gerli et al. / Taiwanese Journal of Obstetrics & Gynecology 52 (2013) 110e112diabetes mellitus, Basedow disease treated by thyroidectomy,
and celiac disease. Her pregnancy was uneventful, except for
a suspected fetal malformation: hyperechogenic areas were
found on the fetal heart and liver, with moderate ileal dis-
tension. A bowel atresia was suspected. Levels of glycemia
were not within the normal range, although insulin was
adjusted daily. An ultrasound scan revealed a fetal macro-
somia (>90th percentile), therefore a termination of pregnancy
was programmed. Lung maturity was previously confirmed by
diagnostic amniocentesis with a lecithin sphingomyelin ratio
of 6 and the presence of phosphatidylglycerol. After 36 weeks,
a healthy newborn of 3160 g was born by cesarean section.
After fetal extraction, the uterus appeared atonic and a mod-
erate bleeding of 900 mL was observed. Intravenous oxytocin
(5 IU followed by 20 IU in 0.9% saline) failed to arrest the
bleeding. Although methylergometrine (0.25 mg i.v.) and
sulprostone (0.5 mg i.v. in 0.9% saline at 250 mL/h) were
administered, the uterus was still flabby and atonic. Therefore
a hemostatic synthetic absorbable, surgical suture (poly-
glactin) was carried out according to the B-Lynch procedure,
to preserve the uterus. Bleeding was stopped and the abdomen
was closed. The patient did not receive any transfusion. Two
hours later, blood parameters were stable: the white blood cell
count was 10,910/mL and hemoglobin was 9.2 g/dL. During
the following days, vaginal blood loss was regular. Histology
revealed the presence of a placental subchorionitis. She was
discharged from the hospital on day 4. Forty days later,
a Doppler velocimetry did not reveal any abnormality in
uterine vessels. In January 2010, a new unplanned pregnancy
was registered. The antenatal course of the pregnancy was
uneventful. Due to the recent cesarean section, a surgical de-
livery was electively performed at 39 weeks’ gestation. During
surgery, the potential consequences associated with the pre-
viously applied B-Lynch brace suture were evaluated. Only
omental adhesions were found on the anterior surface of the
uterus. A healthy newborn of 3460 g. was delivered through
a lower uterine segment incision. Delivery of the placenta was
unremarkable. Intravenous oxytocin (5 IU) was administered
and the uterine incision was closed with absorbable braided
suture material. The total blood loss was 400 mL. After the
surgery, hemoglobin was 10.2 g/dL. No complications in the
postoperative days were observed and the patient was dis-
charged 72 hours later.
Discussion
Post partum hemorrhage occurs in approximately 4% of
vaginal and 6% of cesarean deliveries [11]. A new PPH top-
guideline adopts a practical approach, whereby a perceived
loss of 500e1000 mL prompts basic measures of monitoring
and readiness for resuscitation, whereas a perceived loss of
>1000 mL or smaller, associated with clinical signs of shock,
prompts a full protocol of measures to resuscitate, monitor and
arrest bleeding [2]. The prevalence of severe PPH was esti-
mated in 6.7 per 1000 deliveries [12], while deaths from PPH
occur in approximately 1 per 1000 deliveries [11]. Different
uterine compression sutures have recently been described tocontrol PPH, including the B-Lynch suture that runs through
the full thickness of both the anterior and posterior uterine
walls [2]. The mechanical compression of uterine vascular
sinuses prevents further engorgement with blood and con-
tinued hemorrhage. The compression effect keeps these
bleeders inactive until physiological hemostasis is achieved.
Since the B-Lynch technique was reported, several modi-
fications have been described, with only minor variations from
the original procedure [13]. In the Hayman procedure, for
example, hysterotomy is not performed and there are concerns
about occlusion of the uterine cavity and blood entrapment,
without the possibility to exclude retained products.
Among the hemostatic surgical techniques, the B-Lynch
suture gained a major popularity, mainly because many prac-
titioners are less confident with more complicate surgical
procedures, such as bilateral hypogastric artery ligation, and
prefer to proceed with an easier, quicker, and effective B-
Lynch suture.
Almost nothing is known about fertility and pregnancy
outcomes for patients who have undergone B-Lynch suture for
severe PPH, with or without concomitant uterine devascula-
rization procedures. Initial fears about possible anatomical
damage due to extreme uterine compression have material-
ized. These uterus preserving procedures are not always
without complications. Ochoa et al [14] reported pyometra
complicating square suture technique and Joshi and Shriv-
astava [15] reported a partial ischemic necrosis of the uterus
after a brace compression suture. Rathat et al presented a study
where patients were assessed by hysteroscopy, after a previous
uterine compression suture. Synechia occurred in seven pa-
tients (out of 13 patients), three of whom had Asherman
syndrome that could not be corrected [16]. Fourteen cases of
subsequent pregnancy after B-Lynch suture have been reported
in the literature [17], but only in four cases was a B-Lynch
suture realized without associated hemostatic surgical pro-
cedures [3,18,19]. Hypogastric artery ligation or stepwise
uterine devascularizations were sometimes associated to B-
Lynch suture. Thirteen pregnancies were uneventful, one was
complicated by preeclampsia and PPH that required hyster-
ectomy [16]. Sentilhes et al [20] described uneventful preg-
nancy after four different uterine-sparing procedures that
included pelvic arterial embolization, stepwise uterine devas-
cularization, hypogastric artery ligation, and B-Lynch suture.
If we consider the dramatic vascular changes occurring
immediately after the hypogastric uterine arteries ligatures, or
furthermore, arterial embolization, we cannot exclude that the
vascular modifications induced by the B-Lynch suture carried
out immediately after a stepwise uterine devascularization are
totally different and probably more limited than vascular
changes induced by the “only B-Lynch” case. A confirmation
of this comes from Pirard et al: uterine necrosis and sepsis
after vascular embolization and uterine artery ligation for
postpartum hemorrhage due to placenta accreta were found
[21]. Moreover, accidental embolization of ovarian vessels via
uterineeovarian anastomoses can result in the loss of ovarian
function, as Chrisman et al have reported in connection with
fibroid embolizations [22].
Table 1
Characteristics of pregnancies after “only B-Lynch” procedures.
First author
(reference)
Case
number
Parity at the time
of B Lynch suture
Wks of
gestation
Cause of PPH Mode of delivery Observations and complications
during subsequent cesarean section
Neonatal
outcome
B-Lynch [3] 1 1 >37 Abruptio placentae Vaginal delivery e Healthy
2 1 39 Uterine atony Cesarean section None Healthy
Haberk [18] 3 1 >37 Uterine atony Cesarean section Slight synechia along previous
B-Lynch suture
Healthy
Vitthala [19] 4 1 Not specified Uterine atony Cesarean section Bands of adhesion between uterine
fundus and bowels at level of previous
B-Lynch
Not specified
Our case 5 0 39 Uterine atony Cesarean section Omental adhesion on the anterior
surface of the uterus
Healthy
112 S. Gerli et al. / Taiwanese Journal of Obstetrics & Gynecology 52 (2013) 110e112To determine the exact relation between the B-Lynch suture
and a subsequent pregnancy, in terms of conception and
pregnancy outcome, it would be therefore more accurate to
analyze results deriving from “only B-Lynch” cases, with no
other associated hemostatic, surgical procedure. Our case is
the fifth reported case in a recent literature of a successful
pregnancy after a previous cesarean section and a B-Lynch
procedure due to postpartum hemorrhage caused by uterine
atony, not associated to any other surgical ligation.
In previous reported “only B-Lynch” cases, one patient
delivered vaginally [3] while three patients had a repeated
cesarean delivery [3,18,19]. No PPH or any other complication
occurred. Bands of adhesions were found between the uterus
and the bowel only in one case [19]. Only omental adhesions
were found on the anterior surface of the uterus in our case
(Table 1).
The B-Lynch suture is a successful, safe, inexpensive, and
simple method for the treatment of PPH during cesarean
section, which reduces the incidence of mutilating urgent
peripartum hysterectomy due to uterine atony or coagulopathy,
possibly preserving subsequent patient fertility.
Additional clinical evidences in a greater case-series of
patients that involves “only B-Lynch” sutures are obviously
needed, to assess the value of the method for fertility
preservation.
References
[1] Hibbard BM, Anderson MM, Drife JO, Tighe JR, Gordon G, Willatts S,
et al. Report on confidential enquiries into maternal death in the United
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Fertility after “only B-Lynch” suture: A case report and literature review 

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Fertility after "only B-Lynch" suture: A case report and literature review

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