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.