Application of the B-Lynch brace suture with associated intrauterine balloon catheter for massive haemorrhage due to placenta accreta following a second-trimester miscarriage

A 25-year-old woman was in her fifth pregnancy. Previously, she had had two normal vaginal deliveries at term, although her second pregnancy was complicated by secondary postpartum haemorrhage, which was managed by uterine curettage with antibiotic cover. Subsequently she developed Asherman’s syndrome, which was treated by Nd:YAG-laser ablation and IUD insertion. Following this, she had two miscarriages at 7 and 20 weeks, which required uterine curettage. In her current pregnancy, she was admitted to hospital at 19 weeks’ gestation with spontaneous rupture of membranes. This was confirmed on examination and an ultrasound scan showed anhydramnios. The poor prognosis was discussed with her and a conservative management approach agreed. Five days later she became pyrexial. Her C-reactive protein level rose to 92.2 mg/l. Chorioamnionitis was diagnosed. Intravenous infusion of cefuroxime and metronidazole at 8-hourly intervals was commenced and it was decided with her consent to terminate the pregnancy. The woman was given a single dose of mifepristone, followed by five doses of misoprostol at 3-hourly intervals. Cervical dilatation of only 1 cm was achieved. She was treated with an infusion of 10 IU Syntocinon in 500 ml of 0.9% NaCl for 12 h but the fetus remained undelivered. She had a spiking temperature but was otherwise clinically stable. Although her C-reactive protein level had risen to 172 mg/l, other blood tests were normal, with haemoglobin at 12 g/ dl; white cell count 8.3610/l; platelets 153610/l; and normal coagulation. Intravenous gentamicin was added to the treatment. A further three doses of 800 mg misoprostol were given vaginally at 3-hourly intervals, followed by a further infusion of Syntocinon. Finally, a lifeless fetus was delivered more than 72 h after commencing the termination of pregnancy. However, the placenta still remained undelivered. In view of the woman’s previous history of Asherman’s syndrome, the risk of a morbidly adherent placenta was considered to be high and conservative management was planned. However, vaginal bleeding started 1 h after delivery. The woman was moved to theatre, where the placenta was removed in piecemeal fashion but not in its entirety and the bleeding continued. Laparotomy was then performed, the uterus opened and the remaining adherent placental tissue removed. The woman was resuscitated with intravenous fluids and given an infusion of Syntocinon, ergometrine and five doses of carboprost, but the bleeding rapidly become worse despite the above measures. At this stage, the total blood loss had exceeded 4,000 ml and was complicated by disseminated intravascular coagulation. At this time, her haemoglobin level was 4.1 g/dl, platelets 48610/l; activated partial thromboplastin time 54 s; activated partial thromboplastin ratio 2.07; prothrombin time 16.8 s; and fibrinogen 1.04 g/l. A transfusion of six units of blood and four units of fresh frozen plasma was given. However, diffuse bleeding continued as a result of both placenta accreta extending to the isthmus and the coagulopathy. A B-Lynch suture was applied, using a Monocryl suture on a 70 mm blunt curved Ethiguard needle, following a positive test for the potential success of this procedure, (i.e. uterus exteriorisation, bimanual compression, bleeding control). A 30 ml Foley catheter balloon was placed at the isthmus of the uterine cavity. The patient was nursed in the intensive care unit, where she received a further four units of blood. The intrauterine balloon was removed 40 h post-laparotomy and no significant bleeding was observed. The patient made a good recovery and was discharged 6 days later.