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 in the January issue of Obstetrics & Gynecology.
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, the investigators 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.
This study has important implications for practice, noted Dr. Carolyn Zelop, director of maternal-fetal medicine at Beth Israel Deaconess Medical Center in Boston. “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, she said.
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, Dr. Zelop advised.
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 one of the study authors, 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. Dr. Zelop had no conflicts to report.
Copyright (c) 2010 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
根据一项大型、前瞻性、以人群为基础的研究结果，延迟至分娩后2~6 h才实施子宫压迫缝合术，对产后出血的治疗失败率较高。
英格兰牛津大学的Gilles Kayem博士及其合作者在1月刊《妇产科学杂志》(Obstetrics & Gynecology)上报告，他们从2007年9月~2009年3月在英国分娩的120万名妇女中，纳入210例接受子宫压迫缝合术治疗且资料完整的产后出血患者。
分析结果显示，210例患者中，25%持续出血并行全子宫切除术。延误2~6 h的缝合中有42%失败，而更早进行的缝合仅16%失败。经校正多种社会经济、母体和医学因素后，研究者发现，缝合延误2~6 h与全子宫切除术风险增高3倍独立相关(Obstet. Gynecol. 2011;117:14-20)。研究还显示，35岁以上产妇的治疗失败率高于£35岁产妇[校正风险率(AOR)为2.77]；经产妇较初产妇更易发生缝合失败(AOR, 2.83)；无业、职位较低的产妇发生缝合失败的风险较管理职位产妇更高(AOR 3.54)；阴道分娩产妇的缝合失败风险高于剖宫产产妇(AOR 6.08)。不同缝合类型之间的失败率无差异。但因为这不是一项随机试验，对不同缝合方式的比较具有局限性。总体上，129例患者(61%)因子宫收缩乏力发生出血。接受不同类型子宫压迫缝合术的产妇的全子宫切除率无统计学差异。因子宫收缩乏力导致出血者的全子宫切除率为26%，其他原因(如胎盘植入、胎盘前置和子宫撕裂)导致出血者为23%。经校正多种变量后，子宫收缩乏力与其他出血原因产妇的全子宫切除风险无差异。
该研究的结论为：1）为了避免对产后出血发现和处理的延误，必须认真评估分娩后出血量；2）在阴道分娩并发产后出血的情况下，必须争分夺秒进行积极干预，因为延误2~6h的缝合与全子宫切除风险增高相关。
波士顿Beth Israel Deaconess医学中心母胎医学科主任Carolyn Zelop医生指出，该研究对临床实践具有重要意义：1）子宫压迫缝合术是治疗产后出血的可靠手段，但在胎盘植入情况下效果不佳，提示宫缩乏力患者行子宫压迫缝合术的获益最大；2）虽然医生往往不愿对阴道分娩产妇开腹，但对产后出血的干预不能因此而延误，在机械填塞止血失败的情况下，应果断开腹行子宫压迫缝合术。
该研究是英国产科监督系统(UKOSS)的一项独立研究，由妇女健康慈善组织资助，部分资金由卫生部策略研究项目提供。Kayem博士披露他是AXA研究基金会提供的一项博士后奖金的受益人。另一位作者Marian Knight接受了国立卫生研究院国家协调中心用于研究能力开发的一项个人奖金。Zelop医生报告无利益冲突。
爱思唯尔 版权所有
