A C TA Obstetricia et Gynecologica

MAIN RESEARCH ARTICLE

Efficacy of surgical techniques to control obstetric

hemorrhage: analysis of 539 cases
JOSÉ MIGUEL PALACIOS-JARAQUEMADA1,2
1
Center for Medical Education and Clinical Research (CEMIC), Buenos Aires, and 2 J.J. Naon Morphological Institute, School
of Medicine, University of Buenos Aires, Argentina

Key words Abstract

Uterine hemostatic technique, uterine bleeding
topography, severe postpartum hemorrhage, Objective. To analyze the efficacy of surgical techniques to stop excessive obstetric
placenta accreta, placenta percreta bleeding. Design. Retrospective follow up. Setting. Center for Medical Education
and Clinical Research and a total of twelve hospitals in Buenos Aires. Population.
Correspondence Five hundred and thirty-nine consecutive patients were included: 361 had placenta
Professor J. M. Palacios-Jaraquemada, accreta–percreta, 114 uterine atony, 19 cervical scar pregnancy, 21 placenta pre-
Elias Galván 4102, C1431FWO, Buenos Aires,
via and 24 uterine–cervical–vaginal tears. Three hundred and forty-seven women
Argentina.
E-mail: [email protected]
had surgery, of whom 192 were emergencies. Methods. The surgical techniques in-
cluded selective arterial ligation and compression procedures. The effectiveness of
Conflict of interest the techniques was assessed by cessation of bleeding according to source. Follow
The author has stated explicitly that there are up included hysteroscopy of 100 patients and magnetic resonance imaging of 341
no conflicts of interest in connection with this patients. Main outcome measures. Strong association between topographical uterine
article. irrigation areas and surgical hemostatic technique was established. Results. Hem-
orrhage stopped following arterial ligation or compression sutures in 499 women,
Received: 18 May 2010
but hysterectomy was needed in 40. In cervical, lower segment and upper vaginal
Accepted: 28 April 2011
bleeding, Cho’s compression sutures proved to be an efficient and simple procedure.
DOI: 10.1111/j.1600-0412.2011.01176.x Most surgical hemostatic failures that led to hysterectomy occurred in women with
severe hemodynamic deterioration and coagulopathy. Two women died due to mul-
tiorgan failure. After surgery, 116 successful pregnancies were reported. Conclusions.
Bilateral occlusions of the uterine artery or its branches were useful procedures to
stop upper uterine bleeding. Square sutures were a simple and effective procedure
to control lower genital tract bleeding.

Abbreviations: BUAL, bilateral uterine artery ligation; CEP, cervical ectopic preg-
nancy; LGT, lower genital tear; S1, sector 1; S2, sector 2; SLVL, selective lower
vascular ligature.

Technological advances have established substantial

Introduction progress in diagnostic methods and in measures to prevent
Postpartum hemorrhage is the major cause of maternal death critical hemorrhage. The addition, endovascular procedures
worldwide (1). Morbidity is unknown, under-reported, and have been proved to be of significant benefit (4). However, ra-
the cause of extensive use of resources. diologically assisted procedures are available only in techno-
The scientific community has been able to implement sig- logically developed centers. New hemostatic products, such
nificant measures for treatment or prevention of postpartum as recombinant factor VIIa, are promising but very costly,
hemorrhage, but in spite of efforts by bodies such as the In- and restricted availability prevents widespread use (5).
ternational Federation of Gynecology and Obstetrics (2), it Less complex hemostatic techniques have proved to be
has not yet been adopted in all countries. Even though num- fast, safe, economical and highly efficient (6). Obstetric skills
bers of postpartum hemorrhage are growing, new ideas are training that includes detailed knowledge of pelvic anatomy
reported, which are efficient, simple and can be universally and of hemodynamic and hemostatic management is also
endorsed and used (3). likely to improve clinical outcomes still further.


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J.M. Palacios-Jaraquemada Uterine surgical hemostatic techniques

The purpose of this study was to analyze the effective- ulopathy was controlled through myometrial compression
ness of surgical methods to control obstetric bleeding. In a procedures and at times with intracavity addition of 5ml fib-
consequtive series of 539 elective and emergency surgeries, I rin glue (Tissucol kitTM ; Immuno, Buenos Aires, Argentina).
studied the relation between the origin of hemorrhage and Bleeding from the uterine cervix and upper vagina, also re-
the effectiveness of the surgical methods used. ferred to as sector 2 (S2) was managed by Cho’s procedure
and through selective ligation of the pelvic subperitoneal
pedicles.
Material and methods Efficacy was defined as the ability to stop the bleeding after
Between August 1989 and December 2009, I was asked to the hemostatic technique had been performed, and technical
perform surgery on 541 patients. Two patients died within difficulty was defined as the number of manoeuvres and time
10minutes of my arrival at the operating theater. A total of required to perform the hemostatic technique.
539 patients had surgery which involved some type of uterine After an initial hemostatic procedure, additional tech-
hemorrhage, as follows: 361 had placenta accreta, 114 uter- niques were applied to complete the surgery, such as simple
ine atony, 19 cervical scar pregnancy, 21 placenta previa and tissue sutures or conservative reconstructive surgery for pla-
24 had uterine–cervical–vaginal tears. The diagnoses were centa accreta. In 505 cases, procedures were performed with
based on preoperative ultrasound, Doppler ultrasound and absorbable synthetic nos 1 and 2 sutures (Coated polyglactin
placental magnetic resonance imaging, as well as peroperative 910, VycrilTM Ethicon, Somerville, NJ, USA), and the re-
clinical and surgical features and postoperative histological maining 34 cases had sutures with chromic catgut. Fol-
examination. The study included 357 scheduled and 182 cases low up by hysteroscopy and T2 magnetic resonance imag-
of emergency surgery operated on in the following hospitals: ing were scheduled within 6–12months after the hemostatic
Center for Medical Education and Clinical Research, Suizo procedures.
Argentino, Otamendi, Argentine Institute of Diagnosis and
Treatment, Mater Dei, Durand, Fernández, Metropolitano,
Santojanni, Ipensa, Español, Austral and Adrogue. Patients
Results
were recruited from a population of about 11million inhabi-
tants with a live birth rate of 40 000 per year, and a cesarean Uterine bleeding was controlled in 499 cases (93%;
rate between 30 and 70%. Table 1). The techniques had a specific hemostatic efficacy
The hemostatic techniques applied included the follow- in relation to the pedicles ligated (S1 or S2) and also to
ing: (a) bilateral uterine artery ligation; (b) selective liga- the different conditions causing the hemorrhage (Table 2).
tion of the pelvic subperitoneal pedicles; (c) B-Lynch pro- Hysterectomy was performed in 40 cases; 16 due to severe co-
cedure; (d) Hayman’s procedure; (e) Cho’s procedure; and agulopathy, and 24 because of massive destruction of uterine
(f) Pereira’s procedure. Accurate hemostasis was defined tissue. Postsurgical bleeding was reported in nine patients;
as complete cessation of bleeding after the use of a spe- six of them were cases of bleeding secondary to retrovesi-
cific surgical hemostatic technique. The choice of action cal hemorrhage through newly formed venous collaterals in
was related to the vascular supply of the uterine bleeding. cases of placenta percreta. The three remaining cases were
B-Lynch, Cho’s or Pereira’s procedures, as well as bilateral examined by angiography; bleeding was confirmed through
uterine artery ligation, were applied at random for bleed- collaterals of the uterine artery in two women who were em-
ing from the uterine body, also referred to as the sector 1 bolized; in the remaining case, no arterial extravasation was
(S1). Bleeding from the uterine body associated with coag- identified.

Table 1. Efficacy to stop bleeding: techniques by topographic area.

Procedure BUAL B-Lynch Hayman Cho Pereira Selective pedicle ligature

S1 bleeding (uterine 19/23 49/52 25/26 11/11 2/2 0

atony)
S1 bleeding (placenta 18/20 32/34 9/11 26/26 9/9 0
accreta)
S2 bleeding Placenta accreta 0/11; 0 0 Placenta accreta 204/225; 0 Placenta accreta 31/36
placenta previa 0/5 placenta previa 21/21;
CEP 19/19; LGT 24/24
Total hemostasis in 499 of 539 cases; raw hemostatic efficacy 93%.

Abbreviations: BUAL, bilateral uterine artery ligation; CEP, cervical ectopic pregnancy; LGT, lower genital tears; S1, sector 1; S2, sector 2.


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Uterine surgical hemostatic techniques J.M. Palacios-Jaraquemada

Table 2. Main features of surgical hemostatic techniques.

S1 efficacy Time to perform the

S1 efficacy (placenta hemostatic technique Technical Specific
Procedure (atony) accreta) S2 efficacy (minutes) Additional maneuvers difficulty material

BUAL Excellent Good Poor or 5–10 Peritoneal Low No

ineffective vesico-uterine fold
opening
B-Lynch Excellent Good Poor or 2–5 No Mid Needle and
ineffective suture
Cho Good Excellent Excellent 5–10 Peritoneal Low in S1; Needle
vesico-uterine fold mid in S2
opening in S2
Hayman Excellent Good Poor or 2–7 No Low Needle
ineffective
Pereira Excellent Excellent Poor or 5–10 No Low to mid No
ineffective
SLVL Not applicable Not applicable Excellent 5–15 Peritoneal Mid to high No
vesico-uterine fold
opening

Abbreviations: BUAL, bilateral uterine artery ligature; S1, sector 1; S2, sector 2; SLVL, selective lower vascular ligature.

In five women, inadvertent ligation of the ureters was re- Discussion

ported; four in patients with placenta percreta and parame-
trial invasion, and one in a case of cervical–vaginal tear with In 1952, the use of hemostatic uterine techniques to control
pelvic hematoma and heavy coagulopathy. All were treated postpartum hemorrhage was described for the first time by
with transcutaneous nephrostomy followed by ureteral reim- Waters (7). Since then, different techniques have been added
plantation within 2–3months after the surgical misadven- to provide simplicity and hemostatic efficacy (8–11). How-
ture. Two patients with excessive blood loss, who sustained ever, despite their well-known efficacy, complications have
hypotension for over 120min, developed postpartum hy- also been reported (12–15). Detailed analysis of the differ-
pophysiary necrosis (Sheehan’s syndrome). Two patients died ent variables, both clinical and surgical, has revealed some
due to multiorgan failure consecutive to massive transfusion. aspects of the efficacy and safety of these uterine hemostatic
One case of uterine necrosis was reported in a patient em- procedures.
bolized and later treated with the B-Lynch procedure. Follow Knowledge of the origin, distribution and anastomosis of
up was performed within 6–12months after surgery in 404 of the genital arterial pedicles is necessary to obtain hemostasis.
501 women (80.6%) who retained the uterus. One hundred Based on vascularity, there are clearly defined topographic
of them were evaluated by hysteroscopy and the remaining areas in the uterus: one which comprises the uterine body,
304 by T2-weighted nuclear magnetic resonance imaging. referred to as S1; and the second, which includes the lower
Postoperative controls performed by hysteroscopy revealed segment, uterine cervix and upper part of the vagina, S2 (16).
endometrial adhesions in three patients who had undergone Sector 1 is supplied mainly by the uterine arteries and, to a
multiple Cho’s procedures with the use of chromic catgut in lesser extent, by branches of the ovarian arteries and collat-
S2 of the uterus. Uterine evaluation by magnetic resonance erals of the upper vesical artery. In contrast, S2 is supplied by
imaging in 304 cases showed neither adhesions nor irregular- a group of pelvic subperitoneal collaterals, originating from
ities of the endometrial cavity, and no uterine morphological the internal pudendal artery, and by accessory collateral ves-
alterations. sels from the internal iliac arteries, uterine artery and lower
Spontaneous successful pregnancies were reported in 116 vesical arteries.
women after the use of conservative surgical procedures for A very effective procedure, such as uterine artery ligation,
hemostasis. For 52 of these women, procedures had been could be inefficient if the uterine arteries do not have the usual
performed in S1 and for 66 women in S2. Regardless of the path or origin (17,18). When the uterine trunk originates
primary etiology of hemorrhage, none of them experienced from the ovarian artery, temporary clamping of the ascending
obstetric or fetal complications, such as severe growth restric- uterine pedicle, below the tubal insertion, will indicate its
tion, or severe postpartum hemorrhage. upper origin and, thus, the need to perform a high ligation


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J.M. Palacios-Jaraquemada Uterine surgical hemostatic techniques

Figure 1. Uterine artery ligature. Abbreviations: UA, uterine artery; 1,

lower uterine ligature; 2, upper uterine ligature.

instead of a ligation at the usual site in the lower part of the

uterine body (Figure 1).
Some complications during the application of uterine sur-
gical hemostatic methods can be avoided by simple mea-
sures. If the uterine fundus is compressed manually while
Figure 3. Front view of cervico-vaginal area that shows a placement of
the B-Lynch loop is tightened, surgical traction on the my-
Cho square suture in S2 area. Application of Hegar’s number 10 dilator
ometrium is increased. Also, lateral slippage of the ligature to cannulate the cervical canal avoids the possibility of hematometra
loops can be avoided by inserting a stitch through the uterine after application of this hemostatic procedure.
dome before traversing its posterior side (19; Figure 2). After

performing myometrial hemostatic procedures, it is not wise

to use oxytocics or postsurgical uterine massage. Owing to
the intense myometrial compression after hemostatic sutures,
the use of oxytocics is a habitual cause of intense afterpains.
In addition, postsurgical uterine massage may produce excess
traction on sutures and even inadvertent myometrial cutting
and cause secondary bleeding. When I applied Cho’s sutures
in the S2 area, I routinely dilated the cervix so as to avoid
hematometra (Figure 3). There was no report of ischemia
or uterine necrosis secondary to the direct and exclusive use
of compression sutures. However, one case of uterine necro-
sis secondary to the application of the B-Lynch procedure
was reported in a previously embolized patient. Inadvertent
obliteration of the compensatory anastomotic circuits should
be avoided to prevent compromise to future uterine viabil-
ity (20). Even though the uterus is a well-perfused organ,
the simultaneous obstruction of both uterine and vaginal ar-
teries is a common cause of ischemia or necrosis. In cases
of persistent bleeding, it is better to perform a compression
Figure 2. B-Lynch procedure. Arrows indicsate additional stitches to procedure first. If necessary, endovascular occlusion can be
avoid suture slippage. done subsequently, but not vice versa.


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Uterine surgical hemostatic techniques J.M. Palacios-Jaraquemada

Figure 4. Scheme of Pereira’s procedure. Black arrows indicate a possi-

ble area of ureteral damage during application technique.

B-Lynch, Hayman’s, Pereira’s and Cho’s procedures, as well

as bilateral uterine artery ligation, have an equivalent hemo-
Figure 5. Sagittal view of the uterus, vagina and bladder that shows
static potential in the treatment of uterine atony. However, the application of Cho’s hemostatic procedure in S2 area.
Cho’s and Pereira’s techniques are superior to B-Lynch’s and
Hayman’s in cases of placenta accreta located in S1, proba-
bly because they occlude the posterior uterine anastomotic washed away. Until plasma fibrinogen levels are restored, the
collaterals from rectal and upper vaginal arteries that are use of fibrin glue could, however, prevent secondary bleeding.
usually dilated in posterior abnormal placentations. Techni- Technical difficulty is a subjective variable, and in order to
cally, Pereira’s technique is a mixed procedure (Figure 4) that consider the degree of complexity shown in Table 2, it should
compresses the myometrium and constricts the uterine pedi- be noted that all procedures were performed by the same
cle bilaterally in the proximal and the distal area (transverse surgeon.
arches). Morbidly adherent placenta is one of the most common
Bilateral uterine artery ligation was ineffective in S2 hem- causes of obstetric hysterectomy. The UK Obstetric Surveil-
orrhages secondary to placenta previa or accreta; in these lance System found that morbidly adherent placenta was the
cases, bleeding needed to be controlled by a different tech- cause in 38% of obstetric hysterectomies (21). In the present
nique. This outcome is due to the fact that blood supply to report, forty cases of hysterectomy were recorded; 24 as as re-
S2 does not generally originate from the uterine arteries. Se- sult of extensive tissue destruction after S2 placental invasion,
lective arterial ligations constitute one option, because they and 16 because of inability to arrest bleeding during heavy
surgically obliterate the pedicles through direct identification coagulopathy. Fourteen cases were secondary to placental
and dissection. This implies wide mobilization of the bladder invasion in S2 and two cases after massive bleeding in S1
and identification of the ureters, because the vaginal pedicle is (uterine atony and coagulopathy). Uterine elastic hemosta-
immediately underneath. Though complex, it is an effective sis with Eschmarch’s bandage has been proposed in extreme
procedure. Cho’s procedure only requires wide vesical mo- cases of S1 bleeding (22), but this procedure was not accepted
bilization. Technically, it was the simplest, fastest and most by the obstetricians in charge. After hysterectomy because of
efficient procedure to stop bleeding in S2 (Figure 5). uncontrollable bleeding, all patients developed hypotension.
Performing hemostatic procedures may not enhance con- In two cases, refractary hypotension remained for 90min un-
trol of bleeding in the presence of established coagulopathy. til it was corrected; a few days after that, both patients died
In these cases, the association of procedures (B-Lynch–Cho due to multiple organ failure.
or Cho–Hayman) does not produce noticeable hemostatic Parametrial placental invasion and pelvic hematomas can
improvement. Stopping the bleeding and restoring adequate produce axial rotation of the uterus. The two previous condi-
clotting status is a priority to obtain satisfactory results. tions may produce axial alteration of the anatomical param-
Fibrin glue does not work as a hemostatic agent in cases eters with unexpected and dangerous medial displacement
of uterine active bleeding, because the glue is immediately of the ureters. Vesical trigone and cervical invasions were


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C 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 1036–1042
J.M. Palacios-Jaraquemada Uterine surgical hemostatic techniques

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