Compressive Uterine Sutures to Treat Postpartum Bleeding Secondary to Uterine Atony

doi:10.1097/01.AOG.0000168434.28222.d3

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Compressive Uterine Sutures to Treat Postpartum Bleeding Secondary to Uterine Atony

Alcides Pereira, MD, Filomena Nunes, MD, Sónia Pedroso, MD, João Saraiva, MD, Hélio Retto, MD and Manuel Meirinho, PhD

From Hospital Garcia de Orta, Almada, Portugal.

ABSTRACT

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ABSTRACT
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

Objective: To demonstrate the usefulness of a new method ofapplying compressive sutures to treat postpartum bleeding secondaryto uterine atony.

Methods: Multiple sutures were applied longitudinally and transversallyaround the uterus of 7 women with postpartum uterine atony andpostpartum bleeding.

Results: The procedure was successful in all cases.

Conclusion: Compressive sutures of the uterus were effectivein treating uterine atony with postpartum bleeding.

Level of Evidence: III

Postpartum hemorrhage is one important cause of maternal mortalityand morbidity. In developed countries, postpartum bleeding isthe third most frequent cause of maternal mortality, and inthe United Kingdom is responsible for one death for each 100,000live births. The incidence is higher in less developed countries,and in Zimbabwe postpartum bleeding is the cause of 40 maternaldeaths for each 100,000 births. It is clear that methods oftreating and preventing postpartum hemorrhage will have a significantimpact in reducing maternal mortality and morbidity.

We report a series of cases involving women with uterine atonyand actual postpartum bleeding who were successfully treatedby placing compressive sutures around the uterus.

MATERIALS AND METHODS

TOP
ABSTRACT
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

Seven women with uterine atony and postpartum hemorrhage weretreated with compressive sutures of the uterus. In all cases,the procedure was performed after failure of medical treatment.Before the procedure was attempted, all patients were treatedwith continuous oxytocin perfusion (40 U in 1,000 mL normalsaline at 200 mL/h) for 10 minutes; if they did not respondto treatment, they were given an additional continuous sulprostone(a synthetic prostaglandin estradiol analogue) infusion (500µg in 250 mL normal saline at 17 mL/min) for another 15minutes.

There were 3 cases of hemorrhage secondary to uterine atony.These patients were given packed red blood cell transfusionsand the procedure was performed to stop the hemorrhage. In theother 4 cases, the diagnosis of uterine atony with early hemorrhagewas made during cesarean delivery and more bleeding was thereforeprevented. These last cases did not require any transfusionof blood derivatives.

The patients' demographic characteristics, diagnoses, and resultsof treatment are shown in Table 1.

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Table 1. Table of Clinical Cases Submitted to Uterine Compressive Sutures

The compressive/hemostatic sutures consisted of a series oftransverse and longitudinal sutures of multifilament absorbableVicryl 1 placed around the uterus (Figure 1). Placement of thesutures involved a series of bites inserted superficially, takingonly the serous membrane and the subserous myometrium withoutpenetrating the uterine cavity (Figure 2). Two or three transversecircular sutures were placed first, starting in the anterioraspect of the uterus, crossing the broad ligament toward theposterior aspect of the uterus, then crossing the opposite broadligament toward the anterior aspect and tying the suture overthe anterior aspect of the uterus (Figure 3). The number ofbites in the uterus varied according to the size of the organ.When the suture crossed the broad ligament, it was importantto select an avascular area and to be sure that the fallopiantube, the uteroovarian ligament, and the round ligament werenot inside the suture (Figure 1). The last transverse circularsuture in the lower uterine segment served as an anchor for2 or 3 longitudinal sutures. Each longitudinal suture startedon the dorsal side of the uterus using a knot to fix it to thelowest circular suture (Figure 4) and ended on the ventral sideusing another knot attached to the lowest transverse suture(Figure 5). When each myometrial suture was placed, manual compressionwas applied to the uterus to achieve maximum reduction of uterinevolume before tying the suture. The final result of the methodis shown in Figure 6.

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Fig. 1. Method of applying transversal sutures. Needle passing the broad ligament. The needle is passing through avascular area of broad ligament (1), uterus (2), ovary (3), tube (4), and round ligament (5).