A C TA Obstetricia et Gynecologica

MAIN RESEARCH ARTICLE

Efficacy of surgical techniques to control obstetric

hemorrhage: analysis of 539 cases
JOSÉ MIGUEL PALACIOS-JARAQUEMADA1,2
1
Center for Medical Education and Clinical Research (CEMIC), Buenos Aires, and 2 J.J. Naon Morphological Institute, School
of Medicine, University of Buenos Aires, Argentina

Key words Abstract

Uterine hemostatic technique, uterine bleeding
topography, severe postpartum hemorrhage,
placenta accreta, placenta percreta
Correspondence
Professor J. M. Palacios-Jaraquemada,
Elias Galván 4102, C1431FWO, Buenos Aires,
Argentina.
E-mail: jpalacios@fmed.uba.ar
Conflict of interest
The author has stated explicitly that there are
no conflicts of interest in connection with this
article.
Received: 18 May 2010
Accepted: 28 April 2011
DOI: 10.1111/j.1600-0412.2011.01176.x
Objective. To analyze the efficacy of surgical techniques to stop excessive obstetric
bleeding. Design. Retrospective follow up. Setting. Center for Medical Education
and Clinical Research and a total of twelve hospitals in Buenos Aires. Population.
Five hundred and thirty-nine consecutive patients were included: 361 had placenta
accreta–percreta, 114 uterine atony, 19 cervical scar pregnancy, 21 placenta pre-
via and 24 uterine–cervical–vaginal tears. Three hundred and forty-seven women
had surgery, of whom 192 were emergencies. Methods. The surgical techniques in-
cluded selective arterial ligation and compression procedures. The effectiveness of
the techniques was assessed by cessation of bleeding according to source. Follow
up included hysteroscopy of 100 patients and magnetic resonance imaging of 341
patients. Main outcome measures. Strong association between topographical uterine
irrigation areas and surgical hemostatic technique was established. Results. Hem-
orrhage stopped following arterial ligation or compression sutures in 499 women,
but hysterectomy was needed in 40. In cervical, lower segment and upper vaginal
bleeding, Cho’s compression sutures proved to be an efficient and simple procedure.
Most surgical hemostatic failures that led to hysterectomy occurred in women with
severe hemodynamic deterioration and coagulopathy. Two women died due to mul-
tiorgan failure. After surgery, 116 successful pregnancies were reported. Conclusions.
Bilateral occlusions of the uterine artery or its branches were useful procedures to
stop upper uterine bleeding. Square sutures were a simple and effective procedure
to control lower genital tract bleeding.

Abbreviations: BUAL, bilateral uterine artery ligation; CEP, cervical ectopic preg-
nancy; LGT, lower genital tear; S1, sector 1; S2, sector 2; SLVL, selective lower
vascular ligature.

Technological advances have established substantial

Introduction
Postpartum hemorrhage is the major cause of maternal death
worldwide (1). Morbidity is unknown, under-reported, and
the cause of extensive use of resources.
The scientific community has been able to implement sig-
nificant measures for treatment or prevention of postpartum
hemorrhage, but in spite of efforts by bodies such as the In-
ternational Federation of Gynecology and Obstetrics (2), it
has not yet been adopted in all countries. Even though num-
bers of postpartum hemorrhage are growing, new ideas are
reported, which are efficient, simple and can be universally
endorsed and used (3).
progress in diagnostic methods and in measures to prevent
critical hemorrhage. The addition, endovascular procedures
have been proved to be of significant benefit (4). However, ra-
diologically assisted procedures are available only in techno-
logically developed centers. New hemostatic products, such
as recombinant factor VIIa, are promising but very costly,
and restricted availability prevents widespread use (5).
Less complex hemostatic techniques have proved to be
fast, safe, economical and highly efficient (6). Obstetric skills
training that includes detailed knowledge of pelvic anatomy
and of hemodynamic and hemostatic management is also
likely to improve clinical outcomes still further.


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J.M. Palacios-Jaraquemada
The purpose of this study was to analyze the effective-
ness of surgical methods to control obstetric bleeding. In a
consequtive series of 539 elective and emergency surgeries, I
studied the relation between the origin of hemorrhage and
the effectiveness of the surgical methods used.
Material and methods
Between August 1989 and December 2009, I was asked to
perform surgery on 541 patients. Two patients died within
10minutes of my arrival at the operating theater. A total of
539 patients had surgery which involved some type of uterine
hemorrhage, as follows: 361 had placenta accreta, 114 uter-
ine atony, 19 cervical scar pregnancy, 21 placenta previa and
24 had uterine–cervical–vaginal tears. The diagnoses were
based on preoperative ultrasound, Doppler ultrasound and
placental magnetic resonance imaging, as well as peroperative
clinical and surgical features and postoperative histological
examination. The study included 357 scheduled and 182 cases
of emergency surgery operated on in the following hospitals:
Center for Medical Education and Clinical Research, Suizo
Argentino, Otamendi, Argentine Institute of Diagnosis and
Treatment, Mater Dei, Durand, Fernández, Metropolitano,
Santojanni, Ipensa, Español, Austral and Adrogue. Patients
were recruited from a population of about 11million inhabi-
tants with a live birth rate of 40 000 per year, and a cesarean
rate between 30 and 70%.
The hemostatic techniques applied included the follow-
ing: (a) bilateral uterine artery ligation; (b) selective liga-
tion of the pelvic subperitoneal pedicles; (c) B-Lynch pro-
cedure; (d) Hayman’s procedure; (e) Cho’s procedure; and
(f) Pereira’s procedure. Accurate hemostasis was defined
as complete cessation of bleeding after the use of a spe-
cific surgical hemostatic technique. The choice of action
was related to the vascular supply of the uterine bleeding.
B-Lynch, Cho’s or Pereira’s procedures, as well as bilateral
uterine artery ligation, were applied at random for bleed-
ing from the uterine body, also referred to as the sector 1
(S1). Bleeding from the uterine body associated with coag-
Table 1. Efficacy to stop bleeding: techniques by topographic area.
Procedure BUAL B-Lynch Hayman
S1 bleeding (uterine 19/23 49/52 25/26
atony)
S1 bleeding (placenta 18/20 32/34 9/11
accreta)
S2 bleeding Placenta accreta 0/11; 0 0
placenta previa 0/5
Total hemostasis in 499 of 539 cases; raw hemostatic efficacy 93%.
Abbreviations: BUAL, bilateral uterine artery ligation; CEP, cervical ectopic pregnancy; LGT, lower genital tears; S1, sector 1; S2, sector 2.

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Uterine surgical hemostatic techniques
ulopathy was controlled through myometrial compression
procedures and at times with intracavity addition of 5ml fib-
rin glue (Tissucol kitTM ; Immuno, Buenos Aires, Argentina).
Bleeding from the uterine cervix and upper vagina, also re-
ferred to as sector 2 (S2) was managed by Cho’s procedure
and through selective ligation of the pelvic subperitoneal
pedicles.
Efficacy was defined as the ability to stop the bleeding after
the hemostatic technique had been performed, and technical
difficulty was defined as the number of manoeuvres and time
required to perform the hemostatic technique.
After an initial hemostatic procedure, additional tech-
niques were applied to complete the surgery, such as simple
tissue sutures or conservative reconstructive surgery for pla-
centa accreta. In 505 cases, procedures were performed with
absorbable synthetic nos 1 and 2 sutures (Coated polyglactin
910, VycrilTM Ethicon, Somerville, NJ, USA), and the re-
maining 34 cases had sutures with chromic catgut. Fol-
low up by hysteroscopy and T2 magnetic resonance imag-
ing were scheduled within 6–12months after the hemostatic
procedures.
Results
Uterine bleeding was controlled in 499 cases (93%;
Table 1). The techniques had a specific hemostatic efficacy
in relation to the pedicles ligated (S1 or S2) and also to
the different conditions causing the hemorrhage (Table 2).
Hysterectomy was performed in 40 cases; 16 due to severe co-
agulopathy, and 24 because of massive destruction of uterine
tissue. Postsurgical bleeding was reported in nine patients;
six of them were cases of bleeding secondary to retrovesi-
cal hemorrhage through newly formed venous collaterals in
cases of placenta percreta. The three remaining cases were
examined by angiography; bleeding was confirmed through
collaterals of the uterine artery in two women who were em-
bolized; in the remaining case, no arterial extravasation was
identified.
Cho Pereira Selective pedicle ligature
11/11 2/2 0
26/26 9/9 0
Placenta accreta 204/225; 0 Placenta accreta 31/36
placenta previa 21/21;
CEP 19/19; LGT 24/24
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Uterine surgical hemostatic techniques J.M. Palacios-Jaraquemada

Table 2. Main features of surgical hemostatic techniques.

S1 efficacy Time to perform the

S1 efficacy (placenta hemostatic technique Technical Specific
Procedure (atony) accreta) S2 efficacy (minutes) Additional maneuvers difficulty material

BUAL Excellent Good Poor or 5–10 Peritoneal Low No

ineffective vesico-uterine fold
opening
B-Lynch Excellent Good Poor or 2–5 No Mid Needle and
ineffective suture
Cho Good Excellent Excellent 5–10 Peritoneal Low in S1; Needle
vesico-uterine fold mid in S2
opening in S2
Hayman Excellent Good Poor or 2–7 No Low Needle
ineffective
Pereira Excellent Excellent Poor or 5–10 No Low to mid No
ineffective
SLVL Not applicable Not applicable Excellent 5–15 Peritoneal Mid to high No
vesico-uterine fold
opening

Abbreviations: BUAL, bilateral uterine artery ligature; S1, sector 1; S2, sector 2; SLVL, selective lower vascular ligature.

In five women, inadvertent ligation of the ureters was re- Discussion

ported; four in patients with placenta percreta and parame-
trial invasion, and one in a case of cervical–vaginal tear with
pelvic hematoma and heavy coagulopathy. All were treated
with transcutaneous nephrostomy followed by ureteral reim-
plantation within 2–3months after the surgical misadven-
ture. Two patients with excessive blood loss, who sustained
hypotension for over 120min, developed postpartum hy-
pophysiary necrosis (Sheehan’s syndrome). Two patients died
due to multiorgan failure consecutive to massive transfusion.
One case of uterine necrosis was reported in a patient em-
bolized and later treated with the B-Lynch procedure. Follow
up was performed within 6–12months after surgery in 404 of
501 women (80.6%) who retained the uterus. One hundred
of them were evaluated by hysteroscopy and the remaining
304 by T2-weighted nuclear magnetic resonance imaging.
Postoperative controls performed by hysteroscopy revealed
endometrial adhesions in three patients who had undergone
multiple Cho’s procedures with the use of chromic catgut in
S2 of the uterus. Uterine evaluation by magnetic resonance
imaging in 304 cases showed neither adhesions nor irregular-
ities of the endometrial cavity, and no uterine morphological
alterations.
Spontaneous successful pregnancies were reported in 116
women after the use of conservative surgical procedures for
hemostasis. For 52 of these women, procedures had been
performed in S1 and for 66 women in S2. Regardless of the
primary etiology of hemorrhage, none of them experienced
obstetric or fetal complications, such as severe growth restric-
tion, or severe postpartum hemorrhage.
In 1952, the use of hemostatic uterine techniques to control
postpartum hemorrhage was described for the first time by
Waters (7). Since then, different techniques have been added
to provide simplicity and hemostatic efficacy (8–11). How-
ever, despite their well-known efficacy, complications have
also been reported (12–15). Detailed analysis of the differ-
ent variables, both clinical and surgical, has revealed some
aspects of the efficacy and safety of these uterine hemostatic
procedures.
Knowledge of the origin, distribution and anastomosis of
the genital arterial pedicles is necessary to obtain hemostasis.
Based on vascularity, there are clearly defined topographic
areas in the uterus: one which comprises the uterine body,
referred to as S1; and the second, which includes the lower
segment, uterine cervix and upper part of the vagina, S2 (16).
Sector 1 is supplied mainly by the uterine arteries and, to a
lesser extent, by branches of the ovarian arteries and collat-
erals of the upper vesical artery. In contrast, S2 is supplied by
a group of pelvic subperitoneal collaterals, originating from
the internal pudendal artery, and by accessory collateral ves-
sels from the internal iliac arteries, uterine artery and lower
vesical arteries.
A very effective procedure, such as uterine artery ligation,
could be inefficient if the uterine arteries do not have the usual
path or origin (17,18). When the uterine trunk originates
from the ovarian artery, temporary clamping of the ascending
uterine pedicle, below the tubal insertion, will indicate its
upper origin and, thus, the need to perform a high ligation


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J.M. Palacios-Jaraquemada
Figure 1. Uterine artery ligature. Abbreviations: UA, uterine artery; 1,
lower uterine ligature; 2, upper uterine ligature.
instead of a ligation at the usual site in the lower part of the
uterine body (Figure 1).
Some complications during the application of uterine sur-
gical hemostatic methods can be avoided by simple mea-
sures. If the uterine fundus is compressed manually while
the B-Lynch loop is tightened, surgical traction on the my-
ometrium is increased. Also, lateral slippage of the ligature
loops can be avoided by inserting a stitch through the uterine
dome before traversing its posterior side (19; Figure 2). After
Figure 2. B-Lynch procedure. Arrows indicsate additional stitches to
avoid suture slippage.

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Uterine surgical hemostatic techniques
Figure 3. Front view of cervico-vaginal area that shows a placement of
Cho square suture in S2 area. Application of Hegar’s number 10 dilator
to cannulate the cervical canal avoids the possibility of hematometra
after application of this hemostatic procedure.
performing myometrial hemostatic procedures, it is not wise
to use oxytocics or postsurgical uterine massage. Owing to
the intense myometrial compression after hemostatic sutures,
the use of oxytocics is a habitual cause of intense afterpains.
In addition, postsurgical uterine massage may produce excess
traction on sutures and even inadvertent myometrial cutting
and cause secondary bleeding. When I applied Cho’s sutures
in the S2 area, I routinely dilated the cervix so as to avoid
hematometra (Figure 3). There was no report of ischemia
or uterine necrosis secondary to the direct and exclusive use
of compression sutures. However, one case of uterine necro-
sis secondary to the application of the B-Lynch procedure
was reported in a previously embolized patient. Inadvertent
obliteration of the compensatory anastomotic circuits should
be avoided to prevent compromise to future uterine viabil-
ity (20). Even though the uterus is a well-perfused organ,
the simultaneous obstruction of both uterine and vaginal ar-
teries is a common cause of ischemia or necrosis. In cases
of persistent bleeding, it is better to perform a compression
procedure first. If necessary, endovascular occlusion can be
done subsequently, but not vice versa.
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Uterine surgical hemostatic techniques
Figure 4. Scheme of Pereira’s procedure. Black arrows indicate a possi-
ble area of ureteral damage during application technique.
B-Lynch, Hayman’s, Pereira’s and Cho’s procedures, as well
as bilateral uterine artery ligation, have an equivalent hemo-
static potential in the treatment of uterine atony. However,
Cho’s and Pereira’s techniques are superior to B-Lynch’s and
Hayman’s in cases of placenta accreta located in S1, proba-
bly because they occlude the posterior uterine anastomotic
collaterals from rectal and upper vaginal arteries that are
usually dilated in posterior abnormal placentations. Techni-
cally, Pereira’s technique is a mixed procedure (Figure 4) that
compresses the myometrium and constricts the uterine pedi-
cle bilaterally in the proximal and the distal area (transverse
arches).
Bilateral uterine artery ligation was ineffective in S2 hem-
orrhages secondary to placenta previa or accreta; in these
cases, bleeding needed to be controlled by a different tech-
nique. This outcome is due to the fact that blood supply to
S2 does not generally originate from the uterine arteries. Se-
lective arterial ligations constitute one option, because they
surgically obliterate the pedicles through direct identification
and dissection. This implies wide mobilization of the bladder
and identification of the ureters, because the vaginal pedicle is
immediately underneath. Though complex, it is an effective
procedure. Cho’s procedure only requires wide vesical mo-
bilization. Technically, it was the simplest, fastest and most
efficient procedure to stop bleeding in S2 (Figure 5).
Performing hemostatic procedures may not enhance con-
trol of bleeding in the presence of established coagulopathy.
In these cases, the association of procedures (B-Lynch–Cho
or Cho–Hayman) does not produce noticeable hemostatic
improvement. Stopping the bleeding and restoring adequate
clotting status is a priority to obtain satisfactory results.
Fibrin glue does not work as a hemostatic agent in cases
of uterine active bleeding, because the glue is immediately
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J.M. Palacios-Jaraquemada
Figure 5. Sagittal view of the uterus, vagina and bladder that shows
the application of Cho’s hemostatic procedure in S2 area.
washed away. Until plasma fibrinogen levels are restored, the
use of fibrin glue could, however, prevent secondary bleeding.
Technical difficulty is a subjective variable, and in order to
consider the degree of complexity shown in Table 2, it should
be noted that all procedures were performed by the same
surgeon.
Morbidly adherent placenta is one of the most common
causes of obstetric hysterectomy. The UK Obstetric Surveil-
lance System found that morbidly adherent placenta was the
cause in 38% of obstetric hysterectomies (21). In the present
report, forty cases of hysterectomy were recorded; 24 as as re-
sult of extensive tissue destruction after S2 placental invasion,
and 16 because of inability to arrest bleeding during heavy
coagulopathy. Fourteen cases were secondary to placental
invasion in S2 and two cases after massive bleeding in S1
(uterine atony and coagulopathy). Uterine elastic hemosta-
sis with Eschmarch’s bandage has been proposed in extreme
cases of S1 bleeding (22), but this procedure was not accepted
by the obstetricians in charge. After hysterectomy because of
uncontrollable bleeding, all patients developed hypotension.
In two cases, refractary hypotension remained for 90min un-
til it was corrected; a few days after that, both patients died
due to multiple organ failure.
Parametrial placental invasion and pelvic hematomas can
produce axial rotation of the uterus. The two previous condi-
tions may produce axial alteration of the anatomical param-
eters with unexpected and dangerous medial displacement
of the ureters. Vesical trigone and cervical invasions were

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