International Journal of Gynecology and Obstetrics 129 (2015) 26–29

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International Journal of Gynecology and Obstetrics

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CLINICAL ARTICLE

A modified suture technique for hemorrhage during cesarean deliverycomplicated by complete placenta previa

Lei Zhu, Zhenyu Zhang, Hong Wang, Jing Zhao, Xin He, Junli Lu ⁎Department of Gynecology and Obstetrics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China

⁎ Corresponding author at: Department of Gynecology aHospital, Capital Medical University, 8 Gongti Nanlu, ChChina. Tel.: +86 10 85231832; fax: +86 10 85232985.

E-mail address: lujunli200868@126.com (J. Lu).

http://dx.doi.org/10.1016/j.ijgo.2014.11.0050020-7292/© 2014 International Federation of Gynecology

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 4 June 2014Received in revised form 28 October 2014Accepted 22 December 2014

Keywords:Cesarean deliveryComplete placenta previaPlacenta accretaFoley catheterLu suturePostpartum hemorrhage

Objective: To assess the usefulness of a modified suture to treat postpartum bleeding among patients with com-plete placenta previa (CPP). Methods: An observational study was conducted at Beijing Chaoyang Hospital,Beijing, China, among patients with CPP (with or without placenta accreta) who were enrolled from January 1toMarch 31, 2014. During surgery, a Foley catheter balloon containing 60–120mLofwaterwas used to compressthe hemorrhage site and an absorbable suture was placed around the lower uterus segment to provide extrapressure on the balloon. Results: Seven women with CPP underwent the procedure. The median hemostatictime was 4.6 minutes (range 3.0–7.0). The median estimated blood loss during surgery was 480 mL (range400–600) for deliveries not complicated with placenta accreta and 1250 mL (range 1000–1500) for womenwith placenta accreta. Active bleeding was stopped after application of the modified suture; blood loss wasless than 100 mL in all cases in the 24 hours after surgery. Conclusion: The modified suture technique providedan easy and efficient surgical choice for women with CPP, especially among those with placenta accreta.

© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Postpartum hemorrhage (PPH) is the direct cause of 12%–50% of allmaternal deaths worldwide [1]. Furthermore, 0.4% of deliveries arecomplicated by placenta previa [2], and complete placenta previa(CPP) is a key contributing factor inmany cases of severe PPH.Maternaland perinatal morbidity and mortality are increased after the develop-ment of CPP [3]. The use of cesarean delivery (CD) has continued torise over the past few years [4]. An association between previous CDand the development of CPP in a subsequent pregnancy is wellestablished; consequently, CPP has become an increasingly frequentcomplication of pregnancy [5]. In addition, many women with CPPalso experience placenta accreta. Bleeding of the lower uterine segmentowing to CPP can, therefore, be difficult to control owing to the weakcontractile nature of this region of the uterus.

Women with CPP are generally treated using a conservative man-agement strategy. However, there is no gold-standard surgical approachfor this condition because each of the currently available methods hasadvantages and disadvantages. Treatments for CPP include uterotonicdrugs, selective devascularization by ligation or embolization, andmany different types of surgical procedure. Uterine sutures includeB-Lynch [6], Pereira, or Hayman [7,8]; modifications of the B-lynch

ndObstetrics, Beijing Chaoyangaoyang District, Beijing 10020,

and Obstetrics. Published by Elsevier I

suture [9]; and Cho square [10,11]. Although the use of such sutureshas markedly decreased maternal mortality associated with PPH,these methods cannot always stop bleeding within the lower uterinesegment. Therefore, various specialized folding sutures were developedto control bleeding in this anatomical region, such as circular isthmic–cervical compression sutures [12], transverse annular compressionsutures [13,14], parallel vertical compression sutures [15], and doublevertical compression sutures [16]. These folding sutures resolve mostcases of lower segment PPH. However, their use can be technically chal-lenging and the ureter is susceptible to damage if the bleeding is locatedwithin the posterior wall or sidewall of the uterus.

Even when bleeding occurs within the anterior uterine wall, thebladder must be pushed down to facilitate the procedure. Furthermore,the procedure could potentially take a long time if adhesions are pres-ent as a result of previous CD, which in turn might lead to increasedblood loss. Tamponade has been successfully performed using theSengstaken–Blakemore tube [17], Rusch balloon [18], condom catheter[19], Foley catheter balloon [20,21], and Bakri balloon [22–24]. Thesemethods can prevent profuse bleeding and reducemorbidity associatedwith damage to the excessively vascularized uterus, as well as to thebladder and ureter. Nevertheless, a limitation of these methods is thatthe balloon might not compress the hemorrhage site tightly enough.Furthermore, a risk of hemorrhage after surgery remains, especiallyamong women with placenta accreta [17].

To overcome these problems, a modification to the Foley catheterballoon was developed: the Lu suture. The aim of the present studywas to evaluate the usefulness of the Lu suture for treatment ofwomen with CPP.

reland Ltd. All rights reserved.

27L. Zhu et al. / International Journal of Gynecology and Obstetrics 129 (2015) 26–29

2. Materials and methods

An observational studywas conducted at Beijing Chaoyang Hospital,Beijing, China, among women with CPP (with or without placentaaccreta) who were enrolled between January 1 and March 31, 2014.Standard protocols for themanagement of PPH of the lower uterine seg-ment owing to CPP were in use at Beijing Chaoyang Hospital and weresuitable for both CPP alone and CPP complicated by placenta accreta. Ashort trial of uterotonic medications and uterine massage was per-formed during CD if steady bleeding of the lower section of the uterusoccurred after the placenta was removed. Women were considered eli-gible for inclusion in the present study if heavy bleeding continued fromthe lower section while the body section contracted well withouthemorrhage. Themodified suture techniquewas approved by the ethicscommittee of the present study center (No. 2013-R-135) and informedconsent was provided by each participant before undergoingthe procedure.

The modified surgical procedure was performed in eligible womenaccording to specific directions. An Fr-24 Foley catheter was preparedand 60–120 mL of water was injected into the balloon, according tothe position and area of hemorrhage. Next, the balloon was insertedby passing the distal part of the catheter through the cervix while an as-sistant pulled the tail of the catheter vaginally. Insertion of the balloondid not require downward reflection of the bladder. Bloodwas collectedin a bag as it drained through the catheter. A size-1 absorbable suturewas used to place a stitch through both sides of the avascular zonebelow the origin of round ligament from the uterus. This suture was lo-cated close to the fold of the peritoneum, according to the hemorrhagesite of the uterus and the size of the balloon. After the suture was tied, itresembled a belt around the lower uterine segment and provided extrapressure to ensure that the balloon tightly compressed the hemorrhagesite, while concurrently blocking the body branches of uterine artery(Figs. 1 and 2). The tie was tight enough to compact the balloon yetavoid blocking the drainage channel of the catheter.

Fig. 1. Schematic of the Lu suture. An Fr-24 Foley catheter with a 60–120 mL capacity balloon wportion of the balloon to provide extra pressure on the hemorrhage site; this approach also blo

The uterine incision was closed in the usual fashion after it had beenconfirmed that there was no active bleeding. The balloon remained inplace for 24 hours. Prostaglandin (one 0.4 mg dose of misoprostol)was administered to strengthen uterine contraction before the balloonwas removed. The water in the balloon was then slowly discharged.The balloon was re-expanded for a further 24 hours if active bleedingoccurred during this procedure. The use of bilateral uterine arteryembolization was advised in such cases.

Information was collected about the uterine incision, blood lossduring surgery and in the 24 hours after surgery, blood transfusions,and the hemostatic time.

3. Results

The characteristics of the seven women with CPP who underwentthe Lu suture procedure are outlined in Table 1. Themean age of the co-hort was 38± 3 years. Five women underwent elective CD at 37 weeksof pregnancy. The remaining two women underwent CD before term:one because of heart failure caused by pre-eclampsia and the other be-cause of prepartumhemorrhage (blood loss of 600mL). Six participantshad previously undergone uterine surgeries (Table 1). Two of the deliv-eries were complicated by placenta accreta.

The median hemostatic time was 4.6 minutes (range 3.0–7.0). Themedian estimated blood loss during surgery was 480 mL (range400–600) for cases not complicated with placenta accreta and1250 mL (range 1000–1500 mL) for women with placenta accreta.Active bleeding had stopped after suturing, and blood loss was lessthan 100 mL in the 24 hours after surgery among all seven women.Two of the patients with placenta accreta underwent transfusion withpacked red blood cells; the median volume transfused was 3 units.None of the other women required blood transfusion.

Fever, uterine erosion, and renal dysfunction were not experiencedby any of the participants. Similarly, none of the women had delayed

as inserted into the uterus. Subsequently, a size-1 absorbable suture was tied at the uppercked the body branches of uterine artery.

Fig. 2. Use of the Lu suture during surgery. The suture was finished and the balloon com-pressed tightly within the lower segment of uterus. A longitudinal uterine incision waschosen for this patient to avoid cutting the placenta before delivery.

28 L. Zhu et al. / International Journal of Gynecology and Obstetrics 129 (2015) 26–29

hemorrhage that required repeat laparotomy or hysterectomy, andnone was admitted to the intensive care unit.

4. Discussion

In the present study, a modification of the Foley catheter balloon(the Lu suture) was piloted for use during CD complicated by CPP. TheLu suture is an absorbable thread that is applied to tighten the balloonat the site of hemorrhage, thereby applying increased pressure toblock the body branches of uterine artery and decrease the riskof hematocele in the uterus. The procedure is both quick and simpleto perform.

Uterus-packing techniques using other sutures (e.g. B-Lynch [6],Pereira or Hayman [7], and modifications of the B-Lynch [9]) are not ef-fective for lower-segment hemorrhage. However, the Lu suture doesseem to effectively stop bleeding within the lower uterine segment.Folding sutures specialized for lower uterine segment bleeding arereported to be extremely efficient [12–16]. For example, in one study[13], the success rates of uterine packing alone or transverse annularcompression sutures alone were 91.7% and 94.1%, respectively. Never-theless, the Lu suture is likely to be easier to perform than arethese techniques when the hemorrhage site is located on the

Table 1Characteristics of patients with complete placenta previa who were managed with the Lu sutu

Patient Age,y

Gravity(parity)

Previousuterinesurgeries

Length ofpregnancy,wk

Diagnosis

1 41 2 (1) D&C N29 CPP; placenta accreta; severe pre-eclamfailure; retinal edema; IVF-ET; dizygotic

2 36 3 (2) CD; D&C 37 CPP; scarred uterus3 35 1 (1) None 37 CPP4 42 3 (2) CD; D&C 37 CPP; scarred uterus5 41 3 (2) CD; D&C 37 CPP; placenta accreta; scarred uterus6 35 2 (2) CD 33 CPP; prepartum hemorrhage; scarred ut7 36 2 (2) CD 37 CPP; scarred uterus

Abbreviations: D&C, dilatation and curettage; CPP, complete placenta previa; IVF-ET, in vitro fe

sidewall of the lower uterine section, which is hard to suture, andamong women who have undergone previous CD, and whose blad-ders are consequently hard to push downward because of thepresence of adhesions.

Unlike the different kinds of tamponades, use of the Lu suture canpotentially prevent the balloon from slipping into the cavity of the uter-us. Furthermore, the Lu suture provides additional pressure on the hem-orrhage site, which facilitates cessation of the bleed. A combination ofthe Bakri balloon tamponade and a B-lynch or Hayman suture hasbeen previously described [25]. This approach is potentially useful ifthere is hemorrhage in both the body segment and the lower segmentof the uterus. However, for many cases, only lower segment hemor-rhage develops and the use of a simple suture (such as the Lu suture)is likely to be easier to perform and could avoid the risk of hemorrhageat the suture points.

Balloon-assisted occlusion of the internal iliac arteries was devel-oped to block the uterine blood supply and so limit hemorrhage duringsurgery [26]. However, this procedure only temporarily blocked theuterine arteries and combination with another method was requiredto stop the bleeding. For women who are likely to have abundant hem-orrhage, combining balloons and other surgical techniques might mini-mize the blood loss.

Some technical points must be considered when using the Lu sutureto treat CPP during CD. First, the operator should ensure that the balloonis of sufficient volume (60–120 mL) and that the suture is above thetransverse incision. Otherwise, there is the potential risk of suturingthe bladder edge. Second, the Foley catheter should be filled beforebeing placed inside the uterus to avoid rupture once in situ. Third, theoperator should be careful not to pierce the balloon during the suture.Fourth, steps must be taken after surgery to avoid pulling the catheterto decrease the possibility of balloon rupture. Finally, if rupture doesoccur, the balloon should be checked carefully to avoid leaving frag-ments in the uterus or abdomen.

The type of balloon used during the procedure is also an importantconsideration. The present study used the Foley catheter balloon. Thisdevice carries a low risk of rupture, is cheap, and easy to use, especiallyin emergency situations. However, specialized balloons, such as theRusch [18] and Bakri [22] balloons, are available in some hospitals foruse in the uterus, although these devices were not designed specificallyfor the lower uterine segment. When contractile function of the uterusis good and there is heavy bleeding in the lower segment owing toCPP, these balloonsmight be usedwith the Lu suture, with less possibil-ity of rupture as long as the balloon is not fully filled.

Use of the Lu suture is not suitable for all cases of hemorrhage asso-ciated with CPP. When there is only limited bleeding, hemostasis bycompression or a figure-of-eight suture is a better option to solve theproblem. Similarly, the Lu suture should not be used if there is steadyhemorrhage of the body section of the uterus, or if the cervix is tooloose to hold the Foley catheter balloon when filled with 120 mL ofwater. For patientswith placenta accreta, thepossibility exists of uterinerupture because of high pressure and thinning myometrium. If themyometrium is already thin, the use of transverse annular compression

re (n = 7).

Type ofuterineincision

Blood lossduringsurgery, mL

Blood lossaftersurgery, mL

Packed red bloodcells transfused,units

Hemostatictime, min

psia; hearttwins

Transverse 1000 90 2 6

Longitudinal 600 55 0 4Transverse 500 40 0 3Longitudinal 400 45 0 4Transverse 1500 85 4 7

erus Transverse 500 25 0 4Transverse 400 80 0 4

rtilization embryo transfer; CD, cesarean delivery.

29L. Zhu et al. / International Journal of Gynecology and Obstetrics 129 (2015) 26–29

sutures [13], Cho square [11], and vertical compression sutures [15,16]should be safer than the Lu suture as these techniques would avoiddamage to the uterus.

In conclusion, use of the Lu suture might represent an easy, cheap,and efficient option for women with lower segment hemorrhage ofuterus, especially among thosewith CPP andplacenta accreta. However,the findings of the present study require confirmation in a large cohort.In addition, the efficacy of the Lu suture should be compared with otherprocedures under various conditions.

Conflict of interest

The authors have no conflicts of interest.

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