Objective
The purpose of this study was to evaluate the efficiency and morbidity of multiple square sutures in severe postpartum hemorrhage.
Study Design
A retrospective study encompassed 30 multiple square sutures that were performed for severe postpartum hemorrhage in 26,605 deliveries in a tertiary maternity center. The main outcome measures were the ability to stop hemorrhage and the assessment of the uterine cavity by hysteroscopy at 3 months.
Results
Multiple square sutures stopped postpartum hemorrhage in 28 of 30 cases (93%). Twenty women underwent hysteroscopy after multiple square sutures. Eight women (40%) did not have intrauterine adhesions. Nine women (45%) had thin and localized intrauterine adhesions that were removed easily by the tip of the hysteroscope; 2 women had moderate intrauterine adhesions that were resected. One patient had endometritis followed by severe intrauterine adhesions.
Conclusion
Multiple square sutures are effective and safe for the control of severe postpartum hemorrhage and for uterine conservation in most cases. Although some patients had moderate or severe adhesions, a normal uterine cavity or minimal intrauterine adhesions that were removed easily were the most frequent findings at hysteroscopy. A prospective study may be helpful to compare the safety and efficiency of square and brace sutures.
Postpartum hemorrhage (PPH) is a high-risk obstetric situation for obstetrics and anesthetics teams as it can rapidly evolve into major and uncontrolled blood loss that can jeopardize the mother’s life. Obstetric hemorrhage is a major cause of maternal death and morbidity worldwide. It is the primary cause of maternal death in developing countries and among the leading causes of maternal death in developed countries.
Although many therapies are effective in controlling PPH (such as oxytocin and prostaglandins), in some cases, it remains a dramatic problem that requires hysterectomy before irreversible coagulation problems arise that could lead to maternal death. Numerous therapies and surgical techniques have been developed to conserve the uterus because, in many cases, this is the first delivery for the patient.
Different forms of vascular ligations (iliac, uterine, ovarian) that have been designed to interrupt the blood flow in the uterus have been practiced with variable rates of success. Uterine embolization is particularly useful in PPH after vaginal delivery ; however, the patient must be hemodynamically stable with a radiology team available and near the delivery room.
More recently, uterine compression sutures have been used to stop PPH. Two such techniques are the B-Lynch sutures (brace sutures) and multiple squares sutures that have been described by Cho et al. Although there are few data concerning uterine compression sutures, they seem to give good results for controlling PPH. In the study published by Cho et al, the technique of multiple square sutures was easy to perform and allowed for the control of severe PPH and uterine conservation. However, there are few data concerning the long-term outcomes of multiple square sutures.
Multiple square sutures to stop PPH were introduced in our maternity ward in 2004. We aimed to evaluate the efficiency of multiple square sutures on the control of PPH and their impact on the uterine cavity of our patients.
Materials and Methods
The cases of women with PPH who underwent uterine square suture procedures between 2004 and 2010 were reviewed retrospectively. All procedures were performed in the Regional Hospital Centre of Orléans.
Our maternity ward is a tertiary center (with a neonatal unit) and performs approximately 4200 deliveries each year. The rate of cesarean section delivery varies between 18% and 19.6%. Hemostatic uterine square sutures were performed for major and uncontrolled PPH (defined as >1 L of blood loss) after the failure of medical treatment (oxytocin, prostaglandin, uterine massage). Hemostatic square sutures were applied during a cesarean section delivery or after vaginal deliveries and the suturing of cervicovaginal tears.
We used a 70-mm–long semicurved needle with 1 vicryl. As described by Cho et al, 4 squares sutures usually were performed to approximate the anterior and posterior uterine walls. However, in some cases, 2 square sutures were enough. In other cases, 6 square sutures were necessary to stop the hemorrhage. For vaginal deliveries, a laparotomy was carried out when PPH was too severe and extensive or because hemodynamic instability did not allow for embolization.
A hysteroscopy at 3 months was proposed for all patients who underwent hemostatic uterine square sutures to assess the uterine cavity and the cervical channel and to look for eventual uterine complications. A 5-mm diameter hysteroscope (Karl Storz GmbH & Co, Tuttlingen, Germany) was used with saline solution. In cases in which endoscopic surgery was needed, the operative hysteroscope was a 9-mm diameter (Karl Storz GmbH & Co) with a glycocoll or saline solution. The instruments that were used were monopolar hooks and scissors.
Hysteroscopies were performed with local anesthesia (paracervical block), except for 1 patient in whom operative hysteroscopy was difficult and who then required general anesthesia.
We examined the tubal ostium, the uterine cavity, and the cervical channel. This retrospective study was approved by the Institutional Review Board of Ile de France II. Data were entered into and analyzed with Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA).
Results
Thirty patients underwent uterine square suture for major or severe PPH between January 2004 and June 2010; 26,605 deliveries were performed in this period, for a rate of 1.1 uterine square sutures per 1000 deliveries.
The mean age of the patients was 30 ± 6 years (mean ± SD). Two-thirds of PPHs occurred in the interval age of 20-35 years. Of 30 women, 23 were from French origin (white). Nineteen women were multiparous, and 11 women were primiparous. Eight women had had a previous cesarean section delivery, and 1 woman had had 3 previous cesarean section deliveries. PPH occurred during a cesarean section delivery in 25 of 30 cases (83%) and after a vaginal delivery in 5 cases. Fourteen cesarean section deliveries were performed before labor, and 11 were performed during labor. The mean birthweight was 3.031 ± 0.934 kg. Five newborn infants had a birthweight of >4 kg.
Table 1 shows the general characteristics of women who received uterine square sutures. Cesarean section deliveries were performed because of the cessation of cervix dilation in 5 cases, because of abnormalities of fetal heart rate in 5 cases, because of preeclampsia with intrauterine growth restriction in 4 cases, because of breech presentation in 5 cases (alone in 1 case, with a uterine scar in 2 cases, with a large myoma in 1 case, and with a first twin in 1 case), because of placenta previa in 2 cases, because of gestational diabetes mellitus with uterine scar in 2 cases, and because of suspected macrosomia in 2 cases ( Figure ).
| n = 30 | No. of women who underwent uterine square sutures | % of women |
|---|---|---|
| Maternal characteristics | ||
| Age, y | ||
| <20 | 2 | 7 |
| 20-24 | 2 | 7 |
| 25-29 | 10 | 33 |
| 30-35 | 10 | 33 |
| 36-40 | 6 | 20 |
| Origin | ||
| French | 23 | 77 |
| Sub-Saharan Africa | 5 | 17 |
| North Africa | 2 | 7 |
| Clinical risk factors | ||
| Parity | ||
| Primiparous | 11 | 37 |
| Mutiparous without previous cesarean | 10 | 33 |
| Multiparous with previous cesarean | 9 | 30 |
| Gestational age, wks | ||
| ≥35 | 22 | 73 |
| 30-34 +6 | 6 | 20 |
| <30 | 2 | 7 |
| Circumstances of hemorrhage | ||
| Cesarean delivery | 25 | 83 |
| Fetal heart rate anomalies | 5 | 17 |
| Cervical dystocia | 5 | 17 |
| Breech | 5 | 17 |
| Preeclampsia and IUGR | 4 | 13 |
| Placenta previa | 2 | 7 |
| Gestational diabetes and previous cesarean | 2 | 7 |
| Macrosomia | 2 | 7 |
| Vaginal delivery | 5 | 17 |
| Birthweight | ||
| <2500 g | 10 | 33 |
| 2600-3900 g | 15 | 50 |
| >4000 g | 5 | 17 |
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