Several invasive procedures can help arrest postpartum hemorrhage. A report from the Agency for Healthcare Research and Quality concluded that most studies addressing these methods are of poor quality (Likis, 2015). In one study of 6660 women with postpartum hemorrhage, 4.4 percent underwent an invasive procedure, and 1.1 percent had a hysterectomy (Kayem, 2016). he failure rate of conservative measures was 15 percent in surgical and embolization procedures.
The technique for unilateral or bilateral uterine artery ligation is used primarily for lacerations at the lateral part of a h) ster otomy incision (Fig. 41-33). In our experiences, this procedure is less helpful for hemorrhage from uterine atony.
his surgical technique uses a no. 2 chromic suture to compress the anterior and posterior uterine walls together (B-Lynch, 1997). Because they give the appearance of suspenders, they are also called braces (Fig. 41-34). Several modiications of the B-Lynch technique have been described (Cho, 2000; Hayman, 2002; Matsubara, 2013; Nelson, 2007). Indications vary for its application, and this will afect the success rate. For example, B-Lynch (2005) cited 948 cases with only seven failures. Conversely, Kayem and associates (2011) described 211 women who had an overall failure rate of 25 percent, which did not difer between B-Lynch sutures and their modiications. In another series, the failure rate was 20 percent (Kaya, 2016). From their review, Sathe and coworkers (2016) reached similar conclusions.
FIGURE 41-33 Uterine artery ligation. The suture goes through the lateral uterine wall anteriorly, curves around posteriorly, then re-enters anteriorly. When tied, it encompasses the uterine artery.
Some unique complications can rarely follow compression sutures (Matsubara, 2013). Most involve variations of uterine ischemic necrosis with peritonitis (Gottlieb, 2008; Joshi, 2004; Ochoa, 2002; Treloar, 2006). In one case, total uterine necrosis followed B-Lynch sutures that were placed in combination with bilateral ligation of uterine, uteroovarian, and round ligament arteries (Friederich, 2007). In most cases, subsequent pregnancies are uneventful if compression sutures are used (n, 2013). A few women, however, with B-Lynch or Cho sutures developed uterine wall defects (Akoury, 2008). Another longterm complication is uterine cavity synechiae (Alouini, 2011; Ibrahim, 2013; Poujade, 2011).
For years, ligation of one or both internal iliac arteries has been used to reduce pelvic hemorrhage. Drawbacks are that the procedure may be technically diicult and is only successful half of the time (American College of Obstetricians and Gynecologists, 2017d). It is not particularly helpful for abating hemorrhage with postpartum atony (Clark, 1985).