Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 193e197

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Taiwanese Journal of Obstetrics & Gynecology

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Original Article

Longitudinal parallel compression suture to control postopartum

hemorrhage due to placenta previa and accrete
Guang-Tai Li a, 1, Xiao-Fan Li b, 1, Baoping Wu a, c, Guangrui Li b, *
a
Department of Obstetrics and Gynecology, China Meitan General Hospital, No. 29, Xibahe Nanli, Chaoyang District, Beijing, China
b
Department of Radiation Oncology, Peking University School of Oncology, Peking University Cancer Hospital, Haidian District, Beijing, China
c
Department of Obstetrics and Gynecology, Beijing Fengtai Hospital Afliated to Capital Medical University, Beijing, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To assess the efcacy and safety of longitudinal parallel compression suture to control heavy
Accepted 12 October 2015 postpartum hemorrhage (PPH) in patients with placenta previa/accreta.
Materials and Methods: Fifteen women received a longitudinal parallel compression suture to stop life-
Keywords: threatening PPH due to placenta previa with or without accreta during cesarean section. The suture
longitudinal parallel compression suture apposed the anterior and posterior walls of the lower uterine segment together using an absorbable
lower uterine segment
thread A 70-mm round needle with a Number-1 absorbable thread was used. The point of needle entry
placenta previa accreta
was 1 cm above the upper margin of the cervix and 1 cm from the right lateral border of the lower
postpartum hemorrhage
segment of the anterior wall. The suture was threaded through the uterine cavity to the serosa of the
posterior wall. Then, it was directed upward and threaded from the posterior to the anterior wall at ~1
e2 cm above the upper boundary of the lower uterine segment and 3-cm medial to the right margin of
the uterus. Both ends of the suture were tied on the anterior aspect of uterus. The left side was sutured in
the same way.
Results: The success rate of the procedure was 86.7% (13/15). Two of 15 cases were concurrently
administered gauze packing and achieved satisfactory hemostasis. All patients resumed a normal
menstrual ow, and no postoperative anatomical or physiological abnormalities related to the suture
were observed. Three women achieved further pregnancies after the procedure.
Conclusion: Longitudinal parallel compression suture is a safe, easy, effective, practical, and conservative
surgical technique to stop intractable PPH from the lower uterine segment, particularly in women who
have a cesarean scar and placenta previa/accreta.
Copyright 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This
is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).

Introduction increta, or percreta) and retained placenta. Placenta previa occurs

Postpartum hemorrhage (PPH) is a leading cause of maternal
mortality worldwide and is responsible for approximately 25% of all
maternal deaths [1]. It is estimated that more than 127,000 women
worldwide die annually from obstetric hemorrhage [2]; however,
90% of maternal deaths due to PPH are preventable [3].
Placental abnormalities are a major contributor to obstetric
hemorrhage. The most common placental abnormalities are
placental abruption, placenta previa, and an adherent (accreta,
* Corresponding author. Wangjing Hospital, China Academy of Chinese Medical
Science, Huajiadi Jie, Chaoyang District, Beijing 100102, China.
E-mail address: wjyylgr@yeah.net (G. Li).
1
Joint rst authors.
in approximately four of every 1000 pregnancies beyond the 20th
week of gestation. Bleeding due to placenta previa can occur
throughout the peripartum period (e.g., antepartum hemorrhage,
intrapartum hemorrhage, and PPH) and increase the risk for pre-
term premature rupture of membranes, leading to premature labor.
Placenta accreta is one of the most serious complications of
placenta previa and is frequently associated with severe obstetric
hemorrhage usually necessitating hysterectomy [4,5].
Primary management for PPH involves the use of uterotonic
agents, bimanual uterine massage, and laceration suturing. If
these approaches are ineffective, other uterine-sparing surgical
management procedures, including uterine compression sutures,
uterine arterial embolization, and ligation of the uterine or hypo-
gastric artery, are required [6,7].

http://dx.doi.org/10.1016/j.tjog.2016.02.008
1028-4559/Copyright 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
194 G.-T. Li et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 193e197

However, these methods can be insufcient for some cases of

bleeding from the lower uterine segment. Some authors have
devised various compression sutures to stop bleeding and achieve
hemostasis [8e11]. Of these sutures, the multiple square sutures
and the circular isthmic-cervical sutures have the risk of uterine
cavity occlusion because bloods clot and debris entrapment are
more likely to occur. The parallel vertical penetrating sutures re-
Figure 1. Sagittal section of the longitudinal parallel compression suture. Arrows
ported in the literature may prevent cervical canal closure, but the indicate the direction and line of the suture. Numbers represent the puncture point
suture does not include the whole length and the whole thickness and the pierce sequence.
of the lower uterine wall. Therefore, it may not facilitate complete
hemostasis. Here, we report a new conservative surgical method,
called the longitudinal parallel compression suture, to control
bleeding from the lower uterine segment due to uterine atony,
cesarean scar, or placenta previa. We sutured the whole length and
thickness of the bilateral lower uterine segment, apposed both
walls together, and provided an almost immediate hemostatic ef-
fect. The efcacy and the safety of the suture were also evaluated
retrospectively.

Materials and methods

From January 2003 to December 2012, 15 women with PPH from

the lower uterine segment due to placenta previa and accreta
received a longitudinal parallel compression suture at China Meitan
General Hospital and Beijing Fengtai Hospital in Beijing, China. This
study was approved by the Ethics Committees of both hospitals,
and a written informed consent form was signed by the women
and/or their nearest relatives before the operation.
Conservative treatments such as manual massage, uterotonic
agents (oxytocin and/or prostaglandin analogs), pressure with
warm gauze packs, and under-sewing the bleeding points with a
gure-eight suture were performed when PPH of the lower uterine
segment occurred. If these procedures were ineffective, a longitu-
dinal parallel compression suture was added immediately to con-
trol bleeding due to uterine atony or diffuse multiple oozing points
from the lower uterine segment.
After the placenta was removed, the bladder was separated from
the lower uterine segment and cervix and reected downward
behind a retractor to expose the entire uterine lower segment.
Vicryl Number 1 absorbable thread (Ethicon Inc., Somerville, NJ,
USA) and a 70-mm round needle were used for suturing. To add a
longitudinal parallel compression suture, the rst puncture point
was selected at the ventral uterine wall, which was approximately
1 cm above the upper end of the cervix and 1 cm from the right
lateral margin of the lower segment. The needle was inserted
vertically from the anterior wall into the uterus and threaded
through to the posterior wall serosa of the lower uterine segment.
After pulling the needle out from the posterior wall, it was threaded
up to the second puncture point approximately 1e2 cm above the
upper boundary of the lower uterine segment and 3-cm medial to
the right lateral border of the uterus, and the needle was pene-
trated through the uterine cavity again and out of the anterior wall.
Then the needle spanned over the transverse cesarean section
incision site at the front of the anterior uterine wall and was tied as
tightly as possible as a four-fold at knot together with the initial
end of the thread (Figures 1e3). An identical suture was added on
the contralateral side.
In addition to this technique, concurrent therapy, including
blood transfusion, plasma expanders, antishock measures, and
brinogen, were also administered depending on the patient's
needs. Postoperative patient management and length of hospital
stay were similar to those in patients who underwent ordinary
cesarean sections. Antibiotics were administered to all women who
underwent a cesarean section and were continued postoperatively
for at least 5 days.
Figure 2. Anterior view of the longitudinal parallel compression suture. Arrows
indicate the direction and line of the suture. Numbers represent the puncture point
and the pierce sequence.
Figure 3. Posterior view of the longitudinal parallel compression suture. Arrows
indicate the direction and line of the suture. Numbers represent the puncture point
and the pierce sequence.
A 6-week follow-up exam was conducted for all patients.
Additional follow-ups were carried out every 3 months for the 1st
year and then annually. Each patient's medical records were
reviewed to evaluate the effectiveness of the suturing technique.
The patients were informed about PPH and advised to have close
gynecological follow-up examinations, including ultrasonography
and a control hysteroscopy, after 6 months.
Results
The 15 patients who received longitudinal parallel compression
suture were followed for age, gravidity number, parturition,
gestational age, delivery conditions, reason for cesarean section,
cause of PPH, volume of blood loss and blood transfusions, post-
operative complications, hospital stay, recovery of normal men-
strual ow, imaging, and endoscopy. The data of the 15 patients
were analyzed for efcacy and safety of the longitudinal parallel
compression suture. The mean follow-up time was
60.2 23.6 months and the patient age range was 23e42 years
(median, 29 years).
Nine women were nulliparous, and six women were multipa-
rous. The mean gestational age was 37 weeks. The indication for
cesarean section was placenta previa. Bleeding causation of the
lower uterine segment included placenta previa in eight patients,
 G.-T. Li et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 193e197 195

placenta previa accreta in four patients, and uterine atony with
placenta previa accreta in three patients. The total blood loss vol-
ume was 2000e3600 mL (mean, 2586 495 mL), and the blood
transfusion volume was 600e2000 mL (mean, 1160 429 mL).
All 15 cases had undergone conservative management (i.e.,
uterotonic drugs such as oxytocin and/or prostaglandin analogs,
manual massage, and gauze packing) but did not respond until they
received longitudinal parallel suture. Bleeding was obviously
improved in all cases after suturing. The success rate for the
cessation of bleeding was 86.7% (13/15). Overall, two of 15 cases
(13.3%) required concurrent use of gauze packing. Additional sur-
gical treatments such as ligation of the internal iliac arteries,
embolization of uterine arteries, and a hysterectomy were avoided.
No postoperative anatomical or physiological abnormalities
were seen. Postpartum menstrual ow and breastfeeding were
normal. No postoperative symptoms, including lower abdominal
complaints, were reported. Ultrasonography conrmed normal
endometria and ureters in all patients. Hysteroscopy showed
normal uterine cavities in all 15 patients.
Five patients planned future pregnancies, and three had suc-
cessful pregnancies within 5 years after the operation. The char-
acteristics of the patient population and the ndings are shown in
Table 1.
Discussion
PPH remains one of the most challenging problems facing mid-
wives and obstetricians today. The development of conservative
surgical methods such as B-Lynch suture and its modications has
improved the outcome of PPH in most patients. However, bleeding
from the lower uterine segment during a caesarian section remains
a life-threatening problem, particularly in women with placenta
previa or partial placenta increta in the lower uterine segment and/
or those with a history of cesarean section. The latter has been called
pernicious placenta previa because the lower segment has less
musculature and is poorly retractable. B-Lynch suture and Hayman's
suture [8] are generally effective for treating PPH due to uterine
atony but may not stop bleeding from the lower uterine segment.
Further surgical treatment such as ligation of the internal iliac
arteries, embolization of the uterine arteries, or hysterectomy is
traditionally employed when conservative management, including
conservatively applied surgical sutures, fails to control bleeding
from the lower uterine segment. However, these treatments often
cause complications and adverse events. For example, hysterec-
tomy after PPH has appreciable drawbacks, which can result in
infertility. It can be technically difcult to remove the lower uterine
segment, and the risk of bladder or ureter injury increases.
Some authors have reported multiple square sutures and par-
allel vertical penetrating sutures at the lower uterine segment
combined with oblique penetrating corpus sutures or multiple
vertical sutures [9e15]. Hackethal et al [16] described a modied U-
suturing method to treat primary PPH after cesarean section and
achieved satisfactory results. In 2008, Dedes and Ziogas [17] re-
ported circular isthmic-cervical suturing to control peripartum
hemorrhage from the lower segment during cesarean section in
patients with placenta previa accreta. All of these suturing tech-
niques have advantages and disadvantages. No high-level evidence
has demonstrated whether compression sutures achieve better and
safer hemostasis for PPH than other methods, or whether one su-
turing technique is more efcient and safer than another [18,19].

Table 1
Characteristics of patients with severe postpartum hemorrhage treated with longitudinal parallel compression suture.

Case Age Gravidity Term Presenting Concurrent Estimated Blood Operation time/new Adjunctive Resumed Follow-up
no. (y) & parity (wk of gestation) diagnosis causes blood loss transfusion suture time (min) hemostatic menstruation/achieved (mo)
(mL) (unit) procedures gestation
(mo)

1 23 G1P0 37 1 Placental previa 2500 5 units PRBC 80/8 4/30 68

200 mL FFP
2 29 G2P0 36 3 Placental previa 2400 5 units PRBC 65/8 3 50
400 mL FFP
3 38 G3P1 37 1 Placental previa Uterine 3600 10units PRBC 145/13 Gauze 3 42
accreta atony 800 mL FFP packing
2 units platelets
4 25 G1P0 37 1 Placental previa 2000 4 units PRBC 100/10 3 102
accreta 200 mL FFP
5 23 G2P0 37 1 Placental previa 2500 6 units PRBC 90/9 2/39 63
400 mL FFP
6 42 G4P1 36 6 Placental previa Uterine 3200 9 units PRBC 95/10 Gauze 4 46
accreta atony 600 mL FFP packing
1 units platelets
7 32 G3P1 36 5 Placental previa 2800 6 units PRBC 65/7 3 54
400 mL FFP
8 31 G3P0 36 2 Placental previa 2500 6 units PRBC 60/8 3 37
200 mL FFP
9 36 G4P1 37 2 Placental previa 2800 7 units PRBC 80/7 3 25
accreta 400 mL FFP
10 26 G2P1 37 Placental previa 2000 3 units PRBC 60/6 4 88
11 23 G1P0 36 6 Placental previa 2500 5 units PRBC 55/6 2 66
300 mL FFP
12 32 G2P0 38 1 Placental previa 2200 4 units PRBC 70/6 3 46
accreta 400 mL FFP
13 27 G2P0 36 4 Placental previa 2000 3 units PRBC 70/7 3 38
200 mL FFP
14 24 G2P0 36 6 Placental previa 2400 5 units PRBC 80/7 4/28 102
accreta 400 mL FFP
15 35 G2P1 37 3 Placental previa Uterine 3400 9 units PRBC 90/9 5 76
accreta atony 600 mL FFP

FFP fresh-frozen plasma;;PRBC packed red blood cells.

196 G.-T. Li et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 193e197
Nevertheless, the issue of restricted drainage of the uterine
cavity after applying these sutures, resulting in possible occlusion
of the uterine cavity and infection, pyometra, synechiae, or infer-
tility, has attracted the attention of obstetricians [20e22]. Poujade
et al [23] reported a retrospective observational study of four of 33
patients managed with surgical uterine compression suturing (the
Hackethal technique) who developed uterine synechiae, suggesting
the potential risk for subsequent intrauterine synechiae following
the use of compression sutures and that the occurrence of post-
operative uterine synechiae may be underestimated. Although no
denite data are available, the Cho suture appears to be associated
with more frequent complications than other suturing techniques.
This is reasonable because complications can be associated with
compression tightness and uterine penetration. As described,
the needle transxes the anterior and posterior walls 16e20 times
when applying Cho suture, which may lead to tight compression
and deprive the site of a blood supply. The tight compression of Cho
suture may provide good hemostasis, but, in turn, may also lead to
complications associated with compression [18]. Uterine cavity
synechiae and uterine wall partial thickness necrosis have been
reported in some patients after receiving multiple square sutures
[19e21,24]. Therefore, it is important to keep the lower uterine
cavity and the cervical canal patent to allow drainage of blood or
debris from the cavity while adding a compression suture to the
lower segment. In this regard, the longitudinal vertical suture may
be a better choice, as it does not distort the shape of the uterus and
does not form a closed space inside the uterus.
We used a hemostatic longitudinal parallel compression suture
to control refractory PPH of the lower segment in women with a
hypotonic uterus and particularly for those with placenta previa
accreta. The theory behind this technique is mechanical compres-
sion of the uterine vascular sinuses and an endometrial laceration
that prevents further engorgement with blood and continued
hemorrhaging. These sutures also twist and close the uterine vessel
beds and branches of the bilateral uterine arteries (e.g., arcuate,
radial, basal, and spiral arteries and their anastomoses) to reduce
blood ow to the lower uterine segment from its lateral margins
and occlude the placental bed vessels by tightly apposing the
anterior and posterior uterine walls. In other words, our longitudi-
nal parallel suture may have dual actions of hemostatic compression
of the bleeding surface and reduced uterine blood ow.
There are some differences between other parallel vertical sutures
and our longitudinal parallel suture. The advantage of Hwu's et al's
[11] suture is that it might avoid injuring the adjacent organs such as
the bowel, vessels, and ureters because the stitch is placed 3-cm
medial to the ipsilateral margin of the lower segment and does not
penetrate through the whole posterior wall. However, this suture
augments suturing difculty because Hwu's suture requires sewing
inside the lower uterine cavity and inserting a needle directed
vertically upward 3e4 cm within the middle layer of the posterior
wall, but the thinness and friability of the lower uterine segment
tissue and the narrowed section of the cervical canal often cause
difculty, particularly when the entire cavity is perfused with blood.
Hence, full-thickness sutures work best as it is simple to do. More-
over, Hwu's suture is only 3e4 cm long, which is not apt to arrest a
large area of bleeding in the lower segment; thus, several sutures are
required. Because the suturing range of our procedure includes the
full length rather than a partial length of the lower uterine segment, it
is better able to stop bleeding in most patients. The other advantages
of this procedure are that it is simple, easy, safe, effective, and prac-
tical, as it requires less experience than other conservative devas-
cularization methods, including hypogastric artery ligation. This is
because its sutures are placed directly into the lower uterine segment
wall and not into the periphery of the uterus, and no important
structures such as greater vessels or a ureter occur in this area.
The success rate for stopping hemorrhage using our procedure
was 86.7% (13/15), and only two cases required gauze packing to
stop bleeding in extenso. No complications or potential adverse
events were detected in these patients. In addition, no uterine
cavity abnormalities have been found, and the menstrual ow
recovered normally. These results are due to the longitudinal di-
rection of the suture, which allows space in the uterine cavity for
free drainage of blood, debris, and inammatory material. Our
success rate (86.7%) for controlling bleeding from the lower uterine
segment using this procedure was slightly lower than that of the
sutures described by Hwu et al [11] (14/14) and Dedes and Ziogas
[17] (6/6), but the complication rate (0%) was equivalent to those
studies (0/14 and 0/6). Therefore, the longitudinal parallel
compression suture was easy and can be used in cases of uterine
atony and placenta previa accreta/increta/percreta. A junior sur-
geon with less experience and skill in emergency conditions can
apply this technique, or it can be used in hospitals with limited
techniques and equipment. The drawbacks of this suturing tech-
nique are the limited number of patients who have received the
suture and the lack of long-term comparison with other suturing
methods. We are collecting additional patients to compare this
procedure with other compression uterine suturing techniques.
In summary, the longitudinal parallel compression suture is a
simple, swift, safe, effective, inexpensive, practical, and conserva-
tive surgical treatment to treat intractable PPH in the lower uterine
segment during cesarean section, particularly in women with a
cesarean scar and placenta previa accreta.
Conicts of interest
The authors have no conicts of interest relevant this article.
Acknowledgments
The authors acknowledge the academic support of the Scientic
Research Project of Meitan General Hospital. No funding source was
used for this study.
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