Keywords
hemostasis - intrapartum hemorrhage - uterine compression suture - complications -
surgical technique
Uterine compression suturing is a relatively simple and effective method used to manage
intrapartum hemorrhage during cesarean section. However, reported complications include
abdominal pain, ischemia, and necrosis.[1]
[2] Postoperatively, it can be difficult to control local pain corresponding to the
compression sutures, and general analgesics such as nonsteroidal anti-inflammatory
drugs and acetaminophen are ineffective in some cases. In such cases, postoperative
pain control via removal of the uterine compression sutures must be considered. We
previously reported the laparoscopic removal of vertical uterine compression sutures.[3] However, during the removal procedure, it is difficult to distinguish between the
threads of the cesarean section wound sutures versus the compression sutures, as the
threads are of the same color. Therefore, we changed the uterine compression suture
thread color to violet. In addition, we placed the compression sutures using a straight
needle rather than a curved one to increase the handling ease. Recently, a retrospective
study, in which novel dedicated blunt straight needle and sutures for uterine compression
were used, was reported.[4] Herein, we describe a case of laparoscopic removal of modified vertical uterine
compression sutures due to postoperative local pain, and discuss the needle type,
suturing, and focal pain control for compression sutures together with the previously
reported study.
Case Report
The patient was a gravida 1, para 0, 36-year-old Japanese woman diagnosed with total
placenta previa. An elective cesarean section was performed at 37 weeks and 3 days
of gestation. Intrapartum hemorrhage during cesarean section was treated with double
vertical uterine compression sutures and intrauterine balloon tamponade. Violet-colored
MONODIOX (Alfresa Pharma Corporation, Osaka, Japan) with a straight needle, which
is not a dedicated blunt needle, was used for the vertical uterine compression sutures
([Fig. 1a]). Vertical compression suturing was easily performed with the straight needle. Although
the bleeding lessened, it still continued, and, therefore, the right descending uterine
artery was ligated using white-colored 0 Vicryl plus (Ethicon, Somerville, New Jersey,
United States). Blood loss could be controlled by compression sutures and the ligation
of the right descending uterine artery. The cesarean section was then finished without
blood transfusion, and blood loss was ∼2,100 mL, including amniotic fluid. On postoperative
day 0, the patient experienced unbearable continuous pelvic pain with a right predominance
with a numerical rating scale (NRS) of 5 points, despite analgesic administration;
this pain prevented early postoperative ambulation. Although contrast-enhanced magnetic
resonance imaging (MRI) did not clearly reveal uterine ischemia and necrosis, but
due to the small hematoma (20 × 5 mm) surrounding the ligation of the right descending
uterine artery and/or right vertical compression suture on postoperative day 1, we
considered that the local pain was associated with uterine ischemia ([Fig. 1b–e]). Therefore, laparoscopic removal of the compression sutures and uterine artery
ligature was performed on postoperative day 2. During the laparoscopic operation,
the violet-colored compression suture threads were easily found and removed ([Fig. 2a]). In contrast, the removal of the white-colored suture thread used to ligate the
right descending uterine artery required some time. Unexpectedly, after removing both
compression sutures and the right descending artery, the color of the lower uterine
segment was almost same ([Fig. 2b–d]). However, on intraoperative visual inspection, the color of the anterior uterine
wall was pinkish-white to pinkish-red ([Fig. 2e,f]). Postoperatively, the NRS for pain improved from 5 to 2 points, and there was no
persistent hemorrhage. On day 2 after laparoscopic surgery, contrast-enhanced MRI
was performed. Contrast-enhanced MRI revealed that the size of the uterine corpus
had increased in comparison with the preoperative status ([Fig. 1f]). Although there was no clear improvement in uterine ischemia on MRI, the pain had
improved and the patient became able to ambulate ([Fig. 1b–f]). The patient had an uneventful postoperative course, and was discharged from hospital
9 days after the cesarean section.
Fig. 1 (a) MONODIOX with dull, straight needles. Needle length is 80 mm. Thread length is 70 cm.
*indicates the straight dull needles. (b–e) Contrast-enhanced magnetic resonance imaging after vertical compression sutures
and the ligation of the right descending uterine artery. (f) Contrast-enhanced magnetic resonance imaging after removing both vertical compression
sutures and the suture of the right descending uterine artery. (b) T2-weighted sagittal image obtained after vertical uterine compression suturing.
(c) T2-weighted sagittal image obtained with right side of the uterine after vertical
uterine compression suturing. Arrow indicates a small hematoma with high intensity
surrounding the ligation of the right descending uterine artery and/or right vertical
compression suture. (d) Fat-suppression T1-weighted dynamic magnetic resonance imaging. Arrow indicates
a small hematoma. (e) T2-weighted axial image obtained with right side of the uterine after vertical uterine
compression suturing. Arrow indicates a small hematoma with high intensity surrounding
the ligation of the right descending uterine artery and/or right vertical compression
suture. (f) T2-weighted sagittal image obtained after removal of vertical uterine compression
sutures.
Fig. 2 (a) Laparoscopic removal of uterine compression sutures. The right compression suture
thread (arrow) was held by laparoscopic forceps. (b–d) Photographs of the lower uterine segment during the laparoscopic surgery. (e,f) Visual inspection of the anterior uterine wall. (b,c) The lower uterine segment before removal compression sutures. Arrow indicates the
lower uterine segment. (d) The lower uterine segment after removal compression sutures. Arrow indicates the
lower uterine segment. (e) Uterine anterior wall before the removal of vertical uterine compression sutures.
Arrow indicates the color of the anterior uterine wall. (f) Uterine anterior wall after the removal of vertical uterine compression sutures.
Arrow indicates the color of the anterior uterine wall.
Discussion
We searched the PubMed database (https://www.ncbi.nlm.nih.gov/pubmed/) for associations
between compression suture, needle, and device. To the best of our knowledge, at least
four case reports described the use straight needles for uterine compression sutures,
but did not discuss the effectiveness of this method,[5]
[6]
[7]
[8] while recently one retrospective study was first reported the use of dedicated blunt
straight needles and sutures for uterine compression sutures of modified Hayman suture.[4] Matsuzaki et al used No. 2 Polydioxanone (2-Monodiox), which is novel dedicated
blunt straight needles.[4] The retrospective study was suggested that the uterine preservation rate was similar
for 2-Monodiox with modified Hayman suture and No.1 poliglecaprone 25 sutures with
B-Lynch suture without the occurrence of severe complications.[4] We modified both the needle type and the thread color. As a straight needle could
penetrate the anteroposterior uterine wall, care was taken during the needle handling.
MONODIOX, which is used for our case, is not dedicated blunt straight needles for
uterine compression sutures. Although 2-Monodiox has not been used for uterine vertical
compression sutures in previous study, our case together with previous study suggested
MONODIOX and 2-Monodiox are useful needles for various uterine and vertical compression
sutures. The violet-colored standing thread was easily identified during laparoscopic
removal. However, some time was required to identify the white thread used to ligate
the right descending uterine artery because of the color similarity of both uterus
connective tissue and myometrium suturing threads. Therefore, colors other than white
should be used for sutures that could possibly require removal, although it is difficult
to simply compare each operation time.
Aboulfalah et al suggested that removal of the uterine compression sutures 24–48 hours
after application prevents uterine infection and synechia.[9] In the present case, laparoscopic removal of compression suturing within 48 hours
postoperatively improved the pelvic pain that was unresponsive to analgesics, and
prompted early postoperative ambulation. In our case, especially, the unbearable continuous
pelvic pain with a right predominance occurred after cesarean section. We speculated
that the right uterine artery ligation with puerperal involution of the uterus might
cause severe postoperative pain. During the laparoscopic surgery, it was noted that
the anterior uterine wall had changed to a pinkish-red color. These findings suggest
that uterine ischemia was improved by the laparoscopic removal surgery, although this
was not confirmed on MRI findings.
Furthermore, Aboulfalah et al reported the removal of nonabsorbable sutures by simple
wire traction without any anesthesia after cesarean section.[9] While their method has the advantage of not requiring anesthesia, our method is
suitable for any type of uterine compression sutures.
In conclusion, the present case supports the concept that the laparoscopic removal
of uterine compression suturing is useful for controlling pain in cases where general
analgesics are ineffective. Using a straight needle made the application of compression
sutures easier, and using violet-colored thread enabled easier identification of the
compression sutures during laparoscopic removal. We recommend using different color
threads for the cesarean section wound sutures and the related compression sutures.
