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Don't delay suturing for postpartum hemorrhage.

Uterine compression sutures for postpartum hemorrhage are more likely to fail when there is a delay of 2-6 hours between delivery and placement of the sutures, according to a large prospective population-based study.

Of 1.2 million women who delivered in the United Kingdom between September 2007 and March 2009, 210 who were treated with a uterine compression suture to control postpartum hemorrhage had adequate information for analysis. Of those, 25% continued to bleed and underwent hysterectomy, Dr. Gilles Kayem of the University of Oxford (England) and his colleagues reported.

Suture failure occurred in 42% of those with a 2- to 6-hour delay in suture placement, compared with only 16% of those with earlier suture placement. After adjustment for numerous socioeconomic, maternal, and medical factors, a 2- to 6-hour delay in suture placement was found to be independently associated with a fourfold increase in the odds of hysterectomy, the investigators found (Obstet. Gynecol. 2011;117:14-20).

"One possible explanation may be that unrecognized bleeding that prolongs the delay between the delivery and the treatment increases the risk of hysterectomy," they wrote, explaining that "a higher blood loss and disseminated intravascular coagulation would lead to clinical conditions that render hysterectomy almost inevitable."

Failure in this study was also more likely in women older than age 35 years, compared with younger women (adjusted odds ratio, 2.77); those who were multiparous, compared with nulliparous women (AOR, 2.83); those who were unemployed or employed in routine or manual occupations, compared with those in managerial positions (AOR, 3.54); and those who had a vaginal delivery, compared with those who had a cesarean delivery (AOR, 6.08), the researchers found.

It is interesting, they noted, that vaginal delivery was the factor associated with the highest odds of hysterectomy in this study.

"It is possible that the obstetrician is more reluctant to perform a laparotomy to insert a compression suture after excessive bleeding after a vaginal delivery than after a cesarean delivery and that, therefore, only the women with the most severe hemorrhage were selected by the obstetrician to have a uterine compression suture after a vaginal delivery," they speculated.

Another possible explanation is that other methods - such as intrauterine balloon or uterine packing - were used successfully in some cases of hemorrhage after vaginal delivery, and thus were not identified in this study, suggesting that cases involving uterine compression sutures after a vaginal delivery may be the most serious, and no other treatment modalities were available to treat the affected patients, they noted.

No differences in failure rates were seen among suture types (B-Lynch, modified B-Lynch, and 32 other techniques such as figure-of-eight, multiple compression, or square sutures).

However, because this was not a randomized study, comparisons among the suture methods were limited, as the baseline populations treated may have differed.

In all, 129 women (61%) had a hemorrhage resulting from atony. Hysterectomy rates according to the different types of uterine compression suture also were not significantly different. The hysterectomy rate was 26%) in cases with atony and 23% in cases with other causes, such as placenta accreta, placenta previa, and uterine tear. After adjustment for a number of variables, the risk of hysterectomy was no different in women with atony compared with other causes of hemorrhage.

Patients included in the study were women identified via the U.K. Obstetric Surveillance System (UKOSS). Case patients were those giving birth who were treated with a uterine compression suture to treat postpartum hemorrhage.

Strengths of the study include the collection of comprehensive population-based national information about women who were treated with compression sutures for postpartum hemorrhage, they said. The findings emphasize the need for careful evaluation of blood loss following delivery so that delays in recognizing and managing hemorrhage can be avoided, they concluded.

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Technique Often Useful

Dr. Carolyn Zelop said that this study has important implications for practice. "I think the take-home message ... is that [the use of compression sutures] is a very reliable technique, but that it's probably less useful in the setting of placenta accreta," explaining that uterine atony appears to be the indication that leads to the most success with this technique.

Another important point made by the authors is that in the setting of vaginal delivery that is complicated by postpartum hemorrhage, it is important to "be on the clock and ready to move to the next intervention," since a delay of 2-6 hours in suture placement was associated with increased risk of hysterectomy.

Although it seems logical that a clinician might be reluctant to proceed with laparotomy after vaginal delivery, a prolonged delay could predispose a patient to unrecognized blood loss, and increase the risk of compression suture failure. If mechanical tamponade techniques fail to control hemorrhaging, the clinician should proceed with laparotomy and uterine compression suture placement, she advised.

DR. ZELOP is director of maternal-fetal medicine at Beth Israel Deaconess Medical Center in Boston. She said she had no relevant financial disclosures.

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Major Finding: A 2- to 6-hour delay in suture placement was found to be independently associated with a fourfold increase in the odds of hysterectomy.

Data Source: A prospective population-based study of 1.2 million women, 210 of whom were treated with a uterine compression suture to control postpartum hemorrhage.

Disclosures: This study was funded by the charity Wellbeing of Women. Dr. Kayem disclosed that he is the beneficiary of a postdoctoral grant from the AXA Research Fund. Another study author, Marian Knight, is funded by a personal fellowship from the National Coordinating Centre for Research Capacity Development of the National Institute for Health Research. This was an independent study from UKOSS, which is partially funded by the Policy Research Programme in the Department of Health.

SHARON WORCESTER

FROM OBSTETRICS & GYNECOLOGY
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Title Annotation:OBSTETRICS
Author:Worcester, Sharon
Publication:OB GYN News
Article Type:Clinical report
Date:Mar 1, 2011
Words:963
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