Severe Intrauterine Adhesions Following Modified B-Lynch Procedure
Year: 2025
Type: article
Abstract: To editor: In 1989, Christopher B-Lynch et al.1 first introduced the B-Lynch suture technique for the management of postpartum hemorrhage (PPH), which has since become the most widely utilized uterine compression suture method. The B-Lynch suture is particularly effective in controlling hemorrhage secondary to uterine atony that is refractory to conventional treatments. However, potential complications associated with this procedure include uterine necrosis, infection, Asherman’s syndrome, and intrauterine adhesions. Retrospective studies have reported that 19%–27% of women undergoing uterine compression sutures for PPH develop intrauterine adhesions.2 Conversely, other studies suggest that the B-Lynch suture does not adversely affect fertility or subsequent pregnancy outcomes.3 Nevertheless, the long-term safety profile of the B-Lynch suture remains to be fully elucidated. In recent years, several modifications of the B-Lynch suture have been proposed, though no definitive evidence supports the superiority of any single technique.2 In 2015, El-Sokkary et al.4 from Ain Shams University’s Maternity Hospital in Cairo, Egypt, introduced a modified B-Lynch procedure and conducted a prospective clinical trial. Their findings demonstrated that the modified technique was equally safe and effective as the classic B-Lynch suture for managing PPH due to uterine atony. This modified approach replaces the traditional belt-like suture with an “8”-shaped suture, offering enhanced fixation and a broader compression range. Additionally, it incorporates horizontal ligation of both uterine arteries in the lower uterine segment, which is particularly beneficial in cases of placenta previa or refractory lower segment bleeding. We present a case of a patient who underwent the modified B-Lynch procedure and subsequently experienced a significant reduction in menstrual flow one year postoperatively. Due to her desire for future fertility, the patient underwent hysteroscopy and laparoscopy, which revealed severe intrauterine adhesions in the upper uterine segment. The adhesions were challenging to dissect, and the upper endometrium exhibited necrotic changes with thinning of the uterine walls, severely compromising her fertility. This case underscores the importance of careful consideration when selecting surgical techniques for managing refractory PPH to preserve reproductive potential. This case was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Peking University First Hospital. Written informed consent was obtained from the patient for the publication of this case report. The patient was a 30-year-old primigravida (G1P0) admitted at 39+1 weeks of gestation on January 15, 2022, with a diagnosis of premature rupture of membranes. On January 16, 2022, an emergency lower segment cesarean section was performed due to persistent occiput posterior position and cephalopelvic disproportion when cervical dilation reached 5 cm. Preoperatively, the patient was afebrile. A female infant weighing 3710 g was delivered with Apgar scores of 10 at 1, 5, and 10 minutes. However, the patient developed uterine atony and significant hemorrhage following delivery. Despite administration of oxytocin, methylergometrine, carboprost, and four doses of prostaglandin F2 alpha, uterine contractions remained inadequate. Bilateral uterine artery ligation was performed, followed by the modified B-Lynch suture technique. The classic B-Lynch suture was initially applied. Then No. 1 absorbable suture was used to tightly encircle the uterine body, passing through the avascular area of the broad ligament below the round ligament and secured anteriorly. This is not the classic modified Blynch suture technique, which involves a circular suture at the level of the uterine arteries, rather than horizontally below the round ligament. Hemostasis was achieved with an estimated blood loss of 1200 mL, necessitating transfusion of 4 units of packed red blood cells and 400 mL of plasma. Placental pathology revealed chorioamnionitis. The patient resumed menstruation five months postoperatively in June 2022, but her cycles became irregular with markedly reduced flow. By January 2023, menstrual volume had decreased to approximately 10% of her pre-surgical baseline. Ultrasound findings indicated a small uterus with an endometrial thickness of 0.1 cm, while ovarian hormone levels remained within normal limits. Treatment with phenytoin failed to significantly improve menstrual flow. Pelvic magnetic resonance imaging in June 2023 demonstrated cervical canal elongation, thinning of the isthmic uterine wall, and a small upper uterine segment with indistinct anatomical features. Given the patient’s desire for fertility, hysteroscopy was performed on September 14, 2023. Severe adhesions in the upper uterine cavity precluded entry, and the procedure was aborted due to the risk of injury. Three-dimensional ultrasound suggested a T-shaped uterine cavity with adhesions. On October 23, 2023, laparoscopic exploration combined with hysteroscopic adhesiolysis was performed. Intraoperatively, portions of the small intestine were found adherent to the anterior abdominal wall (Fig. 1A). After adhesiolysis, the anterior uterine wall was noted to be completely fused with the abdominal wall. Under laparoscopic guidance, hysteroscopy revealed a uterine cavity depth of 6 cm, with access limited to the lower segment. A small gap-like opening on the left side was gently dilated, revealing extensive fibrous adhesions (Fig. 1B) and areas of yellowish necrotic tissue. The fallopian tube ostia were not visualized (Fig. 1C).Figure 1.: Intraoperative laparoscopic and hysteroscopic findings. A Laparoscopic view showing extensive adhesions between the anterior uterine wall and the abdominal wall. B Hysteroscopic image revealing severe intrauterine adhesions with fibrous bands in the upper uterine cavity, limiting cavity visualization. C Hysteroscopic image demonstrating areas of yellowish necrotic endometrial tissue and absence of visible fallopian tube ostia.In this case, uterine atony during cesarean section was refractory to uterotonic agents. Following the classic B-Lynch suture, circumferential compression sutures were applied to the uterine body, likely contributing to ischemic necrosis of the endometrium and uterine wall. We hypothesize that excessive compression of the uterine cavity led to these complications. In practice, longitudinal sutures are generally safer and easier to perform than transverse sutures. If transverse sutures are necessary, circumferential sutures should be limited to the lower uterine segment rather than the uterine body, as the lower segment undergoes postpartum involution. This approach may better preserve the uterine cavity and endometrium. While various modifications of uterine compression sutures, including the B-Lynch and Hayman techniques, have been developed, their safety and efficacy require further investigation. Obstetricians should exercise caution when selecting suture techniques for refractory PPH, avoiding excessive compression to safeguard future fertility. Acknowledgements We would like to express our gratitude to all those who helped me during the writing of this manuscript. Funding None. Author Contributions Hui Bi performed the surgery and conceived of the study. Ye Feng did literature research, design the paper structure, and wrote the article. Hui Bi edited the article. All authors read and approved the final manuscript. Conflicts of Interest None. Data Availability The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
Source: Maternal-Fetal Medicine
Authors: Ye Feng, Hui Bi
Institution: Peking University First Hospital
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4407777848