Discussion :
Postpartum Bleeding is defined as an estimated blood loss greater than
500 ml within 24 hours after vaginal birth and more than 1000 ml after a caesarean section [2]. Post partum haemorrhage remains an obstetrical emergency which requires rapid treatment. This treatment is based on medical treatment (oxytocin, methyl-ergometrine, misoprostol), non-medical treatment (uterine massage, bimanual uterine compression then compression of the abdominal aorta), repair of vaginal or cervical lacerations and manual uterine revision if necessary [3].
If these measures fail, and/or if the patient’s condition is unstable, surgical treatment is required. There are many surgical techniques for the management of post-partum haemorrhage and hysterectomy remains the reference solution.
in this context. However, new conservative surgical techniques that
are easier to execute and are less aggressive have emerged and are
becoming more commonly used. [4]
Uterine preservation surgery has been defined as any surgery consisting of pelvic artery ligation or application of uterine compression sutures to achieve haemostasis while preserving the uterus, e.g. Bilateral hypogastric artery ligation, uterine artery ligation, B-Lynch uterine compression suture, Tsirulnikov triple ligation…
Tsirulnikov’s Triple Ligation is a simple surgical technique for the preservation of the uterus consisting of bilateral ligation of round ligaments, uteroovarian ligaments and uterine arteries [5].
The B-Lynch technique: first practised in 1989 by Christopher B-Lynch in a woman who refused hysterectomy haemostasis, during a caesarean section, with a resorbable suture resistance 1 or 2 and for as long as possible, which is applied around the uterus like the straps of a backpack [6].
- Cho suture (square sutures): Korean This technique was introduced by Cho JH, which consists of applying the anterior and posterior walls of the uterus together using multipoint sutures with transfixing frames.
- The often cited Pereira stitch combines several sutures, vertical and transfixion under horizontal serosa [7].
Although these uterine compression and ligation techniques have been poorly evaluated, the ease of implementation has allowed their rapid diffusion throughout the world. As a result, some complications occurred: pyrometry, erosion of the strap through the uterine wall, uterine ischaemia, uterine necrosis, synechia. Nevertheless the frequency of such complications remains uncertain given the lack of major reports in the literature on these procedures, but could be as high as 5-7% [8].
The nature of the sutures used (duration of resorption) and the degree of initial tension in the stitches are two elements which may explain the difference in terms of ischaemia. The technique itself could have an effect on the occurrence of necrosis: a uniform compression which does not interrupt the parietal vascularisation in its entirety (in particular by avoiding sutures in the horizontal direction and only performing them in the vertical direction) could reduce this risk [9]. Correct placement of the compression points (alone or in combination with other haemostatic procedures) so that reperfusion of the myometrium through the collateral anastomotic network is preserved may reduce the risk of necrosis [10]. finally, combination with other haemostatic procedures leading to total interruption of the anastomotic network of the uterus, as was the case with our patient [11].
The combination of conservative surgical techniques remains to be assessed. Preference is given to the Tsirulnikov type distal triple ligature, supplemented if necessary by a B-Lynch, modified according to Hayman (closed uterus) [12]. Imaging plays an important role in the diagnosis. Ultrasound is the first line because it shows a large uterus with a redrawn wall and a heterogeneous image is associated with the presence of air in the uterus. The use of CT scan is also often useful, as in our case it revealed uterine necrosis with the presence of gas bubbles in the myometrium and endometrium and a lack of myometrial elevation.