RU2619404C1 - Method of arresting postpartum hemorrhage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: hemostatic exteriorly-uterine supraplacental stitch is put. For this purpose, assembly stich is put in the transverse direction with a single thread on the side of the serous membrane of the uterus in the region of the placental area by 1/3 myometrium without penetration into the uterine cavity. Then, the thread is tightened in the transverse direction as a "pouch" and the stitch is tied with a force sufficient to arrest the bleeding, without using bimanual compression of the uterus.

EFFECT: method enables to perform compression of placental area spiral arteries with minimum damage to surrounding tissues and preserve blood flow in the major branches of the uterine artery, providing the main blood supply to the uterine muscle without reducing the uterine cavity space.

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Description

The invention relates to medicine, surgery, obstetrics and can be used to stop postpartum hemorrhage.

Despite the significant achievements of obstetric science and practice, postpartum hemorrhages continue to occupy the first - second place in the structure of maternal mortality - 25% in the world, in the Russian Federation - 16% over the past 7 years with no tendency to further decrease (V. Radzinsky, Galina T.V. Kirbasov N.P., Markaryan N.M. Reserves for reducing blood loss during abdominal delivery.Results of a randomized trial.Obstetrics and gynecology. 20015; 6: 40-45). Moreover, hypo- and atonic hemorrhages account for more than 70% in the structure of all obstetric bleeding (Higgins L., Mechery J., Tomlinson AJ Does carbetocin for prevention of postpartum haemorrhage at caesarean section provide clinical or financial benefit compared with oxytocin? J. Obstet. Gynaecol. 2011; 31 (8): 732-9). Currently used for the treatment of postpartum hemorrhages caused by uterine atony are: injections of uterotonic drugs, bimanual compression of the uterus, intrauterine balloon tamponade, selective uterine devascularization by ligation of the main arteries or by angiographic embolization, uterine compression sutures and removal of the uterus.

The goal of all these therapeutic measures is: minimizing blood loss, preserving childbearing function, preventing life-threatening complications such as hemorrhagic shock, necrosis of the anterior pituitary, hypoxic encephalopathy and coagulopathy.

In about 1% of cases, medication is ineffective (Prendiville et al. Active versus expectant management in the third stage of labor. Cochrane Database of Systematic Reviews 2000, Issue 3; Elgafor el Sharkwy LA Carbetocin versus sublingual misoprostol plus oxytocin infusion for prevention of postpartum hemorrhage at cesarean section in patients with risk factors: a randomized, open trail study. Arch. Gynecol. Obstet. 2013; 288 (6): 1231-6.), and the frequency of urgent postpartum hysterectomy undertaken after the unsuccessful application of the entire arsenal of conservative measures , is 1-3 per 1000 births (Francous K. et al. Is peripartum hysterectomy more common in multiple gestations. Obstet Gynec 2005; 105: 1369-1372).

It is known that radical methods for stopping obstetric bleeding can discredit the function of the pelvic floor due to changes in the blood supply, innervation and lymphatic drainage of these organs and the development of polyglandular, polysystemic syndromes (Kozek-Langenecker SA Perioperative coagulation monitoring. Best Pract Res Clin Anaesthesiol. 2010; 24: 27 -40).

Hysterectomy for postpartum hemorrhage is currently considered an undesirable and extreme means not only because it leads to a loss of generative function, but also due to technical difficulties associated with the allocation of the lower segment of the uterus, accompanied by the risk of damage to the bladder and ureter.

In recent years, several new, simpler, and less invasive techniques have been developed to combat massive postpartum hemorrhage in an attempt to get away from major surgery and maintain child-bearing function.

The closest in technical essence and the achieved result to the present invention is a method for the treatment of postpartum hemorrhage, which consists in applying compression sutures to the uterus according to B-Lynch, first described in 1997 (B-Lynch C., Coker A. et al. The B- Lynch surgical technique for the control of massive post partum hemorrhage: an alternative to hysterectomy. Five cases reported, Br. J. Obstet Gynaecol, 1997; 104: 372-375). The known method involves the imposition on the uterus of the so-called "backpack" sutures. The uterus is belted twice with one thread in the longitudinal direction at a distance of 4 cm from each lateral edge.

There is a method of applying a compression suture to the uterus, which consists in laying two longitudinal and two transverse sutures through the entire myometrium (Matsubara S., Kuwata T., Yoshiba T., Usui R., Ohkuchi A. Uterine compression suture for cesarean hysterectomy: possible applications to conditions other than atonic bleeding. J. Clin. Case Rep 2014, 4: 5).

There is a method of applying compression hemostatic sutures to the uterus according to the type of hourglass (Debjyoti Santra, Sumanta Kumar Mondal, Debmalya Maity, Debasis Das, Utpal Ghosh. Hour Glass Compression Suture in the Management of Primary PPH. IOSR Journal of Dental and Medical Sciences. 2014; 5 (1): 35-40): consisting in the application of two eight-shaped seams in the longitudinal direction at a distance of 4 cm from each lateral edge.

There is a known hemostatic compression suture on the uterus according to the type of safety pin (Ali Abdelhamed M. Mostfa and Mostafa M. Zaitoun Safety pin suture for management of atonic postpartum hemorrhage. Obstetrics and Gynecology. 2012; Article ID 405795, doi: 10.5402 / 2012/405795 ): the first injection of the needle is carried out through the myometrium 3 cm from the right rib and 3 cm below the lower incision on the uterus, the puncture is made on the posterior wall of the uterus. The thread passes along the entire posterior surface of the uterus, is thrown through the bottom and the second injection is carried out on the front wall 4-5 cm below the bottom and approximately 4 cm from the edge of the right rib, the needle passes through the myometrium and the puncture is carried out on the posterior surface of the uterus, the thread is thrown through the bottom of the uterus. Sutures are tightened with moderate compression of the uterus and are fixed by a knot on the front wall of the uterus. The second seam is applied symmetrically to the left side.

A known method of applying hemostatic compression sutures to the uterus proposed by Shamsun Nahar (Shamsun Nahar, Shamim Fatema Nargis, Merina Khannam. Simple technique of uterine compression sutures for prevention of primary postpartum hemorrhage during caesarian secrion. Pak J. Med Sci. 2010; 26 (2 ): 319-323). The method involves the imposition of three sutures on the uterus: the uterus is thrice threaded with one thread in the longitudinal direction.

A known method for applying a compression hemostatic suture to the uterus proposed by Dusan Stanojevic (Dusan Stanojevic, Marija Stanojevic, Milena Zamurovic, Anka Cirovic, Amira Hajric, Snezana Rakic, Pavle Srbinovic. Uterine compression suture technique in the management of effective postpartum Srp. Arh. Celok. Lek. 2009; 137 (11-12): 638-640): the suture is wavy along the posterior wall of the uterus upward, starting from the right uterine-sacral ligament to the right corner of the uterus, capturing the myometrium and not touching uterine cavity. The thread is thrown across the bottom of the uterus and the wave-like suture continues along the front wall. The second suture is done symmetrically on the left side of the uterus. Then two more transverse sutures are superimposed on the central part of the uterus in order to compress it.

Known hemostatic seam according to Hyman (Anamika Majumdar, Kallol Mallick, Bipin Vasava, Kanan T. Desai, Malati Dalal. A descriptive study on Hayman suture technique to control postpartum hemorrhage. Journal of Obstetrics and Gynaecology 2012; 34: 79-83): method involves the application of мат backpack ’sutures to the uterus twice with one thread, it is girdled in the longitudinal direction at a distance of 4 cm from each lateral edge and fixing the suture in the uterine fundus.

Known compression hemostatic suture proposed by Cho JH: multiple square suture (Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol. 2000; 96: 129-31): through the anteroposterior direction through the entire thickness of the myometrium superimposed four seams in the form of a square.

There is a method of treating postpartum hemorrhage by applying plugging staple-like sutures to the uterus (RU 2394509): horizontal through sutures are applied, with which the placental site is purposefully tamped with the opposite wall of the uterine cavity. Sutures are applied mainly within the placental site. The seams are made in horizontal rows with a seam length of 2.0-2.5 cm, and the distance between the seams is selected in the transverse direction within 3.0-3.5 cm from each other, and between the rows of transverse seams vertically, one above the other - at a distance of 5.0-5.5 cm. Before tying the knots, a bimanual reception of uterine compression is performed, with which the pressure force of the opposite wall of the uterus on the placental site is selected, which is necessary to stop bleeding. Tying knots only fixes the achieved hemostasis.

The principle of operation of these sutures is "a continuous compression effect on the intraorgan vascular system of the uterus", thus it is a variant of the idea of ligation of blood vessels supplying the uterus. Only in this case, it is not the internal iliac or uterine arteries that are ligated, but the following vascular branches: arquate arteries - the largest intraorgan vessels of the first order, extending from the ascending branch of the uterine artery to the body of the uterus in a horizontal direction in the amount of 10-15 branches and arched covering the front and rear walls of the body.

Disadvantages of the above-described sutures: firstly, significant volumes of muscle tissue get into their lumen, and secondly, considerable effort is needed to ligate the intraorgan vascular system of the uterus while tightening the sutures, which inevitably leads to excessive compression and possible damage to muscle tissue, impaired blood flow to the myometrium with the transition to partial or complete uterine necrosis, thirdly, in the postpartum period as a result of uterine involution, sagging of sutures and the formation of open filament loops carrying along entsialny risk of infringement and violations of bowel obstruction. Complications such as cicatricial ischemic degeneration of the myometrium, eruption of sutures through the thickness of the uterus, pyometra, intrauterine synechia that interfere with the outflow of menstrual flow, external adhesions in the abdominal cavity, etc., which in some cases accompany the use of this method, are described.

The effectiveness of compression hemostatic joints is 90%. There are reports of the need for additional ligation of the great vessels (Nelson GS, O'Brien JM The uterine sandwich for persistent uterine atony: combining the B-Lynch compression suture and an intrauterine Bakri ball. Am. J. Obstet Gynecol 2007; 196; 9-10 )

The present invention is the development and creation of a method for stopping postpartum hemorrhage with improved characteristics, primarily in relation to maintaining the anatomical and functional integrity of the uterus.

In addition, increasing the efficiency and reducing the percentage of complications, the simplicity of instructions, the speed and safety of emergency surgery in a crisis would be very valuable characteristics of the newly developed method.

To solve this problem, a new method of stopping postpartum hemorrhage has been developed, in which another mechanism for achieving hemostasis is involved, namely, the local application of a hemostatic suture to the bleeding site - the placental site.

To stop bleeding in general surgery, firstly, the application of a tourniquet above the bleeding site is used, secondly, compression of the bleeding vessel from the outside, prolonged compression on the walls of the damaged vessel leads to their closure, and further thrombosis processes are activated, which ensures reliable stopping of bleeding .

The essence of uterine bleeding with atony and hypotension is that blood loss occurs from the gaping spiral arteries of the placental site.

In our proposed method for stopping uterine bleeding, there is no massive, longitudinal, excessive compression effect on the myometrial tissue and the entire intraorgan vascular system. The imposition of the proposed assembly external uterine supraplacental hemostatic suture is a targeted effect on the system of spiral arteries that open at the bottom of the placental bed with minimal impact on the rest of the myometrium tissue.

The proposed method for stopping postpartum hemorrhage is that from the side of the serous membrane of the uterus, the myometrium of the placental area is stitched with an assembly (pouch-type) suture that does not penetrate the uterine cavity (Figures 1, 2). Suture material is laid at 1/3 of the myometrium and is pulled in the transverse direction as a “pouch” with one thread. The stitched seam is tied with an effort sufficient to stop the bleeding.

The proposed method for stopping postpartum uterine bleeding ensures the absence of compression-ischemic damage to the myometrium, reduces intraoperative blood loss and general trauma, reduces the risk of adhesions in the uterine cavity, and also reduces the possibility of pinching of the intestine with the possible sagging of long sutures due to involution of the uterus, provides free outflow of lochia in the postpartum period.

Thus, compression of the spiral arteries of the placental site is carried out by the assembly external uterine suture through the myometrium. without penetrating the uterine cavity, with the help of which compression of the gaping vessels occurs with minimal trauma to the surrounding tissues.

An essential distinguishing feature of the proposed suture is that when it is used, preservation of blood flow in these largest branches of the uterine artery, providing the main blood supply to the muscles of the uterus (figure 3).

In contrast to the known analogues, the proposed hemostatic external uterine supraplacental assembly suture does not reduce the volume of the uterine cavity, which creates the conditions for additional installation of the uterine catheter.

In the case of postpartum hemorrhage resulting from presentation or low attachment of the placenta, with a well-contracted uterine body, the suture area with a good hemostatic effect is limited only to the lower uterine segment, mainly the area of the placental site.

As a result, a method was created to stop postpartum uterine bleeding, the mechanism of action of which is based on compression of the gaping spiral arteries of the placental bed area by applying a serous-muscular assembly suture that preserves blood flow in the rest of the vascular system that feeds the myometrium (in the arcuate and radial arteries).

An essential technical part of our method is that the sutures are tied without the use of bimanual compression of the uterus, unlike all existing analogues.

As suture material, absorbable braided multi-filament yarns (Dexon, Vicryl, Monocryl) can be used. The seam is imposed by a curved needle with a length of 70 mm (figure 4).

A clinical trial of the proposed method for stopping postpartum hemorrhage by applying a hemostatic external uterine supraplacental assembly suture was conducted. The studies were conducted on the basis of the Budgetary Healthcare Institution of the Omsk Region “Regional Clinical Hospital” (BUZOO “OKB”) “Maternity Hospital”. The study included 94 patients with bleeding after cesarean section. All women were divided into two groups depending on treatment tactics. The main group consisted of 65 women, to whom hemostatic external-uterine supraplacental assembly suture was used, the comparison group included 29 women, to whom traditional obstetric tactics were applied. The effectiveness of treatment was evaluated according to two criteria: the volume of blood loss and the number of hysterectomies.

Traditional tactics for blood loss exceeding physiological included uterine massage, manual examination of the uterine cavity, invasive and transfusion therapy using freshly frozen plasma, erythrocyte mass, platelet concentrate, protease inhibitors, as well as surgical methods of hemostasis: ligation of the uterine arteries.

Among obstetric hemorrhages, more than half of the 57 (60.6%) cases were caused by lower segment bleeding (placenta previa, inferior scar on the uterus after surgery, cesarean section, multiple pregnancy), in other cases - hypotonic bleeding (39.36%). Of the nosologies, anomalies of the placenta prevailed - placenta previa (25.50%) and anomalies of placenta attachment - placenta rotation (12.31%).

In accordance with the performance criteria used in this work, the most pronounced hemostatic effect was obtained in the main group. With standard obstetric tactics, the number of cases of hysterectomies was significantly greater than in the main group (31.03% versus 6.15%, p = 0.02).

Blood loss of 2000 ml or more was registered in 16.2% of women of the main group and in 27.6% of cases among patients of the comparison group (p = 0.03). The total volume of blood loss in women in the main group was significantly less than in the comparison group (2402 ± 203 ml versus 1926 ± 108 ml).

Clinical examples

Patient A., 28 years old, was operated on as planned for central placenta previa. After separation of the placenta, blood loss amounted to 700 ml. A hemostatic external uterine supraplacental assembly suture was applied to the area of the lower uterine segment. The bleeding was stopped. Total blood loss of 1000 ml. The postpartum period went smoothly. The patient was discharged on the 6th day.

Patient B., 24 years old. Timely delivery of a large fetus (weight 4100 g). In the early postpartum period, after 18 minutes after separation of the placenta, abundant blood discharge from the genital tract appeared in a volume of 800 ml. A manual examination of the uterus was performed. The uterus is flabby, bleeding continues, the volume of blood loss reached 1300 ml. The patient was transferred to the operating room. A lower middle laparotomy was performed, a hemostatic external uterine supraplacental assembly suture was placed on the uterus. Bleeding is stopped. Total blood loss of 1700 ml. The postpartum period went smoothly. Discharged on the 8th day.

Patient M., 28 years old, was operated on as planned for diamniotic, dichoric twins, the transverse position of both fetuses. Intraoperatively noted increased bleeding from the placental bed. Blood loss reached 1200 ml. The hemostatic external uterine supraplacental assembly suture was superimposed. The bleeding was stopped. Total blood loss of 1800 ml. The postpartum period went smoothly. The patient was discharged on the 6th day.

Claims (1)

A method of stopping postpartum hemorrhage, which consists in applying a hemostatic external uterine supraplacental suture, for which an assembly suture is applied in the transverse direction with one thread from the side of the serous membrane of the uterus in the placental area by 1/3 of the myometrium without penetrating the uterine cavity, then the thread is pulled in the transverse direction according to the "pouch" type and tie the suture with an effort sufficient to stop bleeding, without the use of bimanual compression of the uterus.

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