Postpartum or peripartum hemorrhage (PPH) is a major cause of maternal death in Western industrialized countries. Fertility preserving second stage interventions following uterotonic drugs include embolization or ligation of relevant arteries, uterine tamponade or compression sutures. Little is known about the complications due to uterine compression sutures. We describe a case report in association with uterine compression sutures and provide a systematic review on necrosis due to compression sutures (CSU).
A PubMed database search was done up to October 1, 2016 without any restrictions of publication date or journal, using the following key words: “compression suture” and “postpartum hemorrhage” or “peripartum hemorrhage”. Reported cases were considered eligible when reason for postpartum hemorrhage (PPH), type of compression suture, suture material and type of complication were described.
Among 199 publications a total of 11 reported on uterus necrosis after CSU applied for PPH. B-Lynch and modifications were applied in seven cases, Cho compression sutures in three cases and in one case B-Lynch and Cho techniques were combined. In six cases no additional measures were applied, in two cases vessel ligation, in one case embolization and in one case intrauterine balloon application were applied. In one case of partial necrosis it is not reported if additional measures were applied.
Discussion and conclusion
Uterine compression sutures are a useful method for fertility preserving management of postpartum hemorrhage. The risk of serious complications demands the careful consideration of its use. More research is necessary to improve the technique.
Postpartum hemorrhage (PPH) is a major cause of maternal death in Western industrialized countries , . The main reason for PPH is atony followed by placenta retention or abnormally invasive placenta, trauma of birth canal or coagulopathy , , , , , . After the administration of uterotonic drugs there are different second line strategies to control blood loss without performing hysterectomy as a last resort to rescue the patient such as embolization, uterine tamponade, arterial ligation or compression sutures (CSU) , , . A recent review summarizing the evidence about efficacy and harms of embolization of uterine arteries or uterine tamponade, uterine-sparing surgeries, i.e. arterial ligation or uterine compression sutures, for managing PPH concludes that it is insufficient to low (efficacy rates ranging immensely from 36 to 98%). There are too few systematic studies evaluating the harms of the respective procedures .
The first compression suture was proposed by B-Lynch in 1997 . Modified techniques were proposed subsequently , , , , all basically leading to vertical compression of the uterus mostly suited for control of uterine blood supply and atony. Cho et al. proposed a technique of square sutures best suited for bleeding from the placenta bed in cases of abnormally invasive placenta (AIP) . Depending on the cause of PPH the efficacy of surgical management varies. In a retrospective cohort study of 56 patients with PPH the failure of uterine artery ligation possibly complemented with compression sutures was significantly higher if PPH was due to AIP . For a detailed overview of all modified suture techniques for PPH see Fotopoulou and Dudenhausen  or Matsubara et al. .
In this article a rare complication of compression sutures is presented in the highlight of a review of the evidence on complications due to compression sutures, with a special focus on uterine necrosis.
We present a case of a 39-year-old 5 gravida, 5 para with a vaginal prolapse of a necrotic omentum majus due to anterior uterine wall necrosis, 6 weeks postpartum after modified Pereira sutures performed to prevent upcoming PPH.
After four spontaneous vaginal deliveries the patient had a non-reassuring fetal heart rate during her fifth pregnancy in the first stage of labor so that a crash cesarean was performed in 38 weeks plus 6 days of gestation under general anesthesia with intubation. The operation was performed by a senior consultant with extensive surgical experience in gynecological-oncological operations. Intraoperatively a prophylactic antibiotic treatment with cefuroxime and metronidazole was started, which was continued for 3 days postoperatively. The uterotomy was closed with a double-layered suture. The uterus appeared not sufficiently contracted in spite of application of oxytocin-infusion. Cytotec® (Misoprostol, Pfizer GmbH) (1 mg) was administered rectally. Three modified Pereira sutures with horizontal intramuscular stitches in the lower uterine segment were combined with three vertical compression sutures in a rucksack manner as described by B-Lynch. Two vicryl absorbable sutures (2 MO-75 Vicryl Plus – poliglactin 910, Johnson and Johnson Medical GmbH, Ethicon Germany, Norderstedt, Germany) were used. Furthermore, a TABOTAMP-patch (Johnson and Johnson Medical GmbH, Ethicon Germany, Norderstedt, Germany) was applied on the uterotomy. Eventually sufficient contraction of the uterus and stop of bleeding were achieved. Total intraoperative blood loss was estimated as 700 mL. The postoperative hemoglobin value was 11.9 g/dL on the following day, underlining the absence of PPH and the prophylactic nature of the measure. The patient recovered quickly and was discharged on the fourth day postpartum.
Six weeks postpartum the patient presented in our emergency ward with the vaginal prolapse of a fetid, necrotic structure (Figure 1). Due to serious pain a thorough vaginal examination was not tolerated by the patient. The patient reported prolapse of the structure after defecation in the early morning hours. Minor lower abdomen pain had prevailed for the last days, but no fever. The infection parameters were only mildly elevated (C-reactive protein: 7.6 mg/L and leucocytes: 11.94/nL).
Transabdominal ultrasonography revealed a hypoechogenic structure of approximately 0.7 cm thickness and 5.0 cm length between the uterus and the bladder (Figure 2). The structure seemed to prolapse through the cervix into the vagina (Figure 3).
The patient was taken to the operation theatre for a laparotomy. The structure between the bladder and the uterus was identified as omentum adherent to the anterior uterine wall. The prolapsing structure was as well identified as omentum. Histologic examination confirmed this. Detaching the omentum from the uterine anterior wall revealed a necrotic anterior wall of the uterus expanding from the uterotomy cranially but not going further down to the cervix (Figure 4). A restitution of the uterus was impossible and a total hysterectomy was performed with patient’s consent given before surgery. Adhesions to the bowel were covered by omentoplastic. Incision of one Pereira suture was visible in the posterior wall of the uterus (Figure 5).
The intraabdominal easy flow drainage could be removed on the 4th postoperative day. The patient received antibiotic therapy with piperacillin/tazobactam for 8 days and could be discharged on the 10th postoperative day.
A PubMed database was performed on October 1, 2016 without any restrictions of publication date or journal, using the following key words: “compression suture” and “postpartum hemorrhage” or “peripartum hemorrhage”. Abstracts were scanned and complete articles retrieved if cases of partial or complete uterus necrosis after compression suture were reported. We also searched the reference lists of relevant articles and recent review articles to identify potentially relevant articles. Cases reported more than once by the same team in different publications were counted only once. For each reported case we focused on the following criteria: reason for PPH, type of CSU, additional measures to control PPH, suture material and type of complication (Table 1).
|Author||Type of study||n||Details about delivery||Indication for CSU||CSU||Other measures||Suture material||Absorption type||Type of complication|
|||Case report||1||Primipara with PIH, emergency cesarean due to unreassuring fetal status in the first stage of labor||Atony + DIC||B-Lynch||None||No 1 polyglactin||Delayed absorbable||12 h after compression sutures congested and distended uterus, sutures cut through and intervening portions of the uterine wall distended with blood. HE was necessary.|
|||Case report||1||Gravida 3, obstructed labor due to face presentation > cesarean||800 mL blood loss||B-Lynch (prophylactic)||None||Unknown||Unknown||Uterine necrosis 8 weeks post delivery. HE was necessary.|
|||Case report||1||Gravida 3, para 0 with known ITP, induction of labor in 41+5 weeks of gestation with dinoprostone 10 mg intravaginally, subsequently amniotomy and oxytocin-infusion > no progess at 6 cm dilation of cervix > cesarean||Atony + ITP||B-Lynch + Cho||None||Unknown||Delayed absorbable||3 months later synechiae at the fundus During subsequent pregnancy: triangular defect 12 × 5 cm in the anterior wall and two smaller defects in the posterior wall|
|||Case report||1||Induction of labor in 34+0 weeks of gestation after PPROM in 31+4 weeks of gestation with vaginal misoprostol and oxytocin > cesarean due to nonreassuring fetal heart rate||Atony||B-Lynch + fundal brace stitch||None||1–0 monofilament delayed absorbable||Rapidly absorbable||Day 8 postpartum ischemic necrosis in the fundal area. HE was necessary|
|||Cohort study||1 (in a total of 15 cases)||Primigravida spontaneous onset of labor at 41 weeks of gestation. Arrest of dilation at 5 cm > cesarean||Atony||B-Lynch||Bilateral uterine artery ligation + bilateral uteroovarian ligament ligation||No 1/0 Vicryl||Delayed absorbable||Ischemic uterus with pyometra 6 weeks after delivery. HE was necessary.|
|||Case report||1||Gravida 2, para 1 with spontaneous onset of labor in 41+4 weeks of gestation. Arrest of dilation and nonreassuring fetal heart rate at 6 cm > cesarean||Atony||Cho||None||Vicryl||Delayed absorbable||6 months postpartum: triangular necrotic area in the fundus|
|||Case series||4 (in a total of 539 cases)||Unknown||Not defined per case||1) B-Lynch 2–4) Cho||1) Embolization||1) No 1 or 2 Vicryl 2–4) Chromic catguta||1) Delayed absorbable 2–4) Rapidly absorbable||1) Uterine necrosis. HE was necessary. 2–4) endometrial adhesions|
|||Case report||1||Induction of labor at 38+5 weeks of gestation for GDM. Deep transverse arrest. Cesarean was necessary.||Atony||B-Lynch||Intrauterine balloon tamponade||No 1 Vicryl||Delayed absorbable||Sepsis with myonecrosis and pyometra 10 weeks later. HE was necessary|
|||Case report||1||Primigravida, cesarean probably due to nonreassuring fetal status in the second stage of labor||Atony||Cho||Bilateral uterus artery ligation||Unknown||Delayed absorbable||Anterior uterine wall necrosis and uteroumbilical fistula. HE was necessary.|
|||Cohort study||2 (in a total of 23 cases)||1) Unknown 2) cesarean for cephalo-pelvic disproportion||1) not known 2) Atony||B-Lynch||None||No 1 Vicryl||Delayed absorbable||1) 2 months’ postpartum pyometra. HE was necessary. 2) in subsequent pregnancy anatomical distortion of the fundus, anterior uterine wall and anterior abdominal wall adherent, omental adhesions|
|||Cohort study||2 (in a total of 40 cases)||Unknown||Not defined per case||Cho||Unknown||Unknown||Unknown||1) 23 days postpartum partial necrosis 2) 4 weeks postpartum endomyometritis|
ITP = immune thrombocytopenic purpura; DIC = diffuse intravascular coagulation; PIH = pregnancy induced hypertension; PPROM = preterm premature rupture of membranes; GDM = gestational diabetes mellitus; HE = hysterectomy.
The absorption rate is indicated according to Greenberg and Clark . Rapidly absorbable suture material defined as time to 50% loss of tensile strength 7–10 days, complete loss of tensile strength 14–21 days and complete mass absorption 90–120 days. Delayed absorbable suture material defined as 50% loss of tensile strength within 21 days, complete loss of tensile strength within 28 days and complete mass absorption within 56–70 days.
aExtreme variability based on tissue type, infection and other biologic conditions. Now unavailable due to risk of prion transmission.
The suture material was classified as rapidly absorbable when time to 50% loss of tensile strength was 7 to 10 days, complete loss of tensile strength was 14 to 21 days and complete mass absorption was 90 to 120 days. Suture material with 50% loss of tensile strength within 21 days, complete loss of tensile strength within 28 days and complete mass absorption within 56 to 70 days was classified as delayed absorbable. Absorption rates for each suture material were taken from a review article by Greenberg and Clark .
After reviewing of 199 abstracts, 11 publications from 2004 to 2015 were identified reporting on a total of 11 cases of partial or complete uterus necrosis after CSU were applied due to PPH. Among these 11 cases, three cases of complete necrosis were reported in larger cohort studies/case series and one case of partial necrosis in a cohort study. These bigger studies also reported on cases of other complications due to CSU, namely three cases of endometrial adhesions, one case of anatomical distortion of the fundus, anterior uterine wall and intraabdominal adhesions in subsequent pregnancy and one case of endomyometritis 4 weeks postpartum. The remaining seven cases of uterus necrosis after CSU were each published as an individual case report.
The cases were analyzed regarding the delivery mode, reason for PPH, the type of CSU, the application of additional measures, the suture material and the type of complication. All 11 cases for which information is given were cesarean sections, four due to unreassuring fetal heart beat, one due to obstructed labor, and four due to arrest of dilatation in the first stage of labor. In three cases labor was induced. The localization of the placenta was not given for any of the cases, nor was there any report about abnormally invasive placentation. The reason for PPH was only given in eight cases. Atony was the reason in five cases. In two cases atony was complicated by diffuse intravascular coagulation or immune thrombocytopenic purpura. In one case the CSU were only prophylactically applied as blood loss was only 800 mL. The most frequently reported CSU was B-Lynch and modifications thereof (seven cases). Only in three cases were Cho compression sutures used alone. In one case the B-Lynch and the Cho techniques were combined. In six cases of necrosis no additional measures were applied. In two cases vessel ligation was applied, in one case the embolization was performed and in one case the B-Lynch CSU was combined with an intrauterine balloon. Only in one case of necrosis rapidly absorbed suture material was used, in eight cases delayed absorbable suture material was used and in two cases information on the suture material was not given.
Uterine necrosis could be grouped in minor necrosis being treated preserving fertility (n=3) and major necrosis resulting in hysterectomy (HE) (n=8). The cases of major necrosis occurred in a time window from 12 h to 10 weeks after the procedure.
Compression sutures are part of the the second line management of PPH in many guidelines , , , . According to the review by Sathe et al. ligation and embolization have higher success rates in controlling PPH and a higher strength of evidence for efficacy than uterine compression sutures with median success rate for embolization of 89% and 91–92% success rate for ligation . The authors classify the evidence on compression sutures as insufficient and summarize the success rate as 60–70% . Compression sutures are incorporated in many guidelines none the less as they need fewer skills than arterial uterine ligation with visualization of the ureters and thus can be performed by less experienced surgeons. In addition, CSU can be performed in the absence of an intervention radiologist. This is probably the reason why compression sutures with a rate of 73% are the most frequently used second-line therapy for PPH in the UK in comparison with pelvic vessel ligation (7%), the interventional radiological technique (8%) or recombinant factor VII (11%) .
Necrosis due to compression sutures
There are several case series  but also big population-based cohort studies  reporting no immediate necrosis due to application of compression sutures alone or in combination with other second stage techniques such as intrauterine balloon. However, the follow-up period in these studies is mostly limited to the immediate hospitalization period postpartum, while complications may appear with a delay of several weeks .
Case reports though highlight necrosis as one main complication of compression sutures, either of the entire uterus , ,  or of certain areas , , , . Cases of necrosis are also reported in combination with other second stage interventions, such as vessel ligation , , embolization  or intrauterine balloon . A rare complication only reported once so far is the anterior uterine wall necrosis and utero-umbilical fistula . For an overview of the reported cases of uterus necrosis in the literature so far see the Table 1. Our case is the first report of a complication due uterine compression suture: the vaginal prolapse of omentum through the necrotic anterior uterine wall. In most published cases of uterus necrosis B-Lynch sutures are applied (Table 1).
Etiology of necrosis
Some argue necrosis after CSU is due to wrong application of the suture technique. Especially the case report of Joshi and Shrivastava is criticized for wrong application of the technique, namely non-performance of compression test before administration of the suture  and no treatment of DIC . Uterine necrosis even occurs in a case series of a very experienced surgeon though . In one case report necrosis was substantial, but arterial perfusion was detectable. This hints at a venous infarction as the reason for necrosis .
The risk of potential complications appears to be higher when slowly or non-absorbable sutures are used . Non-absorbable sutures pose the risk of adhesions and ileus . Too thin suture material could cut through the uterine wall , . B-Lynch himself advocates for the use of monofilaments suture with absorption profile of 60% of original strength at 7 days, 20% of original strength at 14 days and 0% of original strength at 21 days . Tissue material with such qualities are, e.g. Caprosyn or Monocryl . Surgical gut also has such qualities, but is also subject to a great variability and no longer use due to risk of infections. Most cases of necrosis reported in the literature, including our case, occurred after suture with delayed absorbable suture material (Table 1). But there is no data on the frequency of use of more rapidly absorbable suture material, which might simply not be so widely used. Zhang et al. proposed the use of removable uterine compression sutures for prevention of necrosis due to late absorption. Modified B-Lynch sutures are applied with a 2-polyglactin suture that is removed after a medium time interval of 21.6 h via a vaginal canal. So far this technique has only been used in five cases and follow-up for 2 months’ postpartum showed no complications . Another group proposes a similar approach with removal of suture material 1 or 2 days after application and 15 cases of successful application so far .
Mahajan argues that suture material probably has no effect, as damage would occur in the immediate postoperative period . This argumentation is supported by a case report in which postpartum hemorrhage due to placenta increta was controlled with recombinant activated factor VII, modified B-Lynch compression and reversible embolization of the uterine arteries. A laparoscopic check 2 days after the PPH revealed additional transversal compression sutures as loose due to postpartum involution of the uterus, so that they were removed .
There is also the discussion of the suture technique contributing to risk of necrosis. A French study of 40 cases of CSU for PPH differentiates between sutures transfixing the uterine wall such as Cho and Hackethal vs. non-transfixing sutures such as Pereira . Of 40 cases in total 15 were transfixing, 12 non-transfixing and 13 not specified. The two complications postpartum of partial necrosis and endomyometritis occurred in the cases of transfixing sutures with the Cho technique . Unfortunately the cause of PPH was not specified of the complicated cases. The Cho technique is especially appropriate for lower uterine segment bleeding due to placenta praevia. The authors suggested, that it is possible, that the thinner lower uterine segment is more susceptible to ischemic necrosis due to compression than the thick muscle tissue in the fundus compressed with other techniques. Regarding the categorization in transfixing and non-transfixing various cases of the B-Lynch technique in Table 1 as well as our case of modified Pereira sutures are examples of non-transfixing compression sutures leading none the less to necrosis of the uterus.
An et al. suspected that compression sutures induce some kind of inflammation of the serosa. In a case control study including 42 cases of pregnancies after uterine compression sutures the rate of pelvic adhesions on repeat cesarean delivery was significantly higher in the compression suture group (34.3%) than in the control group (17.5%). In our case broad adhesion of omentum to the anterior uterine wall supports the hypothesis of inflammation due to suture material on the outside of the serosa of the uterus. It can be discussed though that extensive manipulation of the uterus when applying compression sutures such as exteriosation of the uterus and enveloping it with tissues could also induce adhesions.
In summary we believe, that a combination of ischemia and inflammation caused by the suture material and the intensive “handling” of the uterus probably lead to necrosis as a complication due to compression sutures involved in second line PPH management.
Compression sutures are an important fertility preserving measure in cases of PPH, but they bear the risk of subsequent necrosis of the uterus. We presented a case of a unique, serious complication after prophylactic use of modified Pereira compression sutures. This is the second case in the literature were necrosis occurred after prophylactic application of compression suture . Hence, we advise the careful consideration before application of compression sutures. In light of the risk of complete necrosis of the uterus prophylactic use of compression sutures as proposed by some authors  should not be recommended. As all reported cases of necrosis happened within the first 10 weeks after application of compression sutures, we advise a tight sonographic follow-up within this interval. Furthermore due to the serious risk of uterine rupture in the subsequent pregnancy we recommend the delivery via repeat C-section.
Bigger prospective studies are needed to answer the questions about the best suture material and suture technique discussed above. A proposed solution is the establishment of a national registry to document both successful and unsuccessful applications of compression sutures and prospectively monitor short- and long-term maternal morbidity . We strongly support this endeavor and recommend a broadening to an international registry enabling the investigation of bigger numbers in shorter course of time.
As some of the reported cases of uterine necrosis are criticized for misapplication of the respective technique, we strongly encourage systematic training for residents in the management of PPH .
The patient whose case is presented in this case report has provided signed consent for its publication. Dr. Seidel is a participant in the BIH-Charité Clinical Scientist Program funded by the Charité-Universitätsmedizin Berlin and the Berlin Institute of Health.
Conflict of interest: Authors state no conflict of interest.
Material and methods
Informed consent: Informed consent has been obtained from all individuals included in this study.
Ethical approval: The research related to human subject use has complied with all the relevant national regulations, and institutional policies, and is in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.
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