Uterine compression sutures: surgical management of postpartum hemorrhage.

BACKGROUND: It has been estimated that worldwide, over 125,000 women die of postpartum hemorrhage each year. The traditional management of this condition includes the use of oxytocics, such as oxytocin, ergometrine, and prostaglandins, before proceeding to ligation of the internal iliac arteries and even hysterectomy. The B-Lynch technique is a surgical procedure that may be used to arrest postpartum hemorrhage resulting from uterine atony. CASES: This paper describes simple modifications of this technique that make this procedure less complex to perform. Three clinical case scenarios illustrate the context in which the sutures may be used. CONCLUSION: Compression sutures placed into the postpartum uterus may provide a simple first surgical step to control bleeding when routine oxytocic measures have failed. We suggest that the technique we have described is a simple procedure and should be tried before more complex interventions are used.

Relationship of cell adhesion molecule expression to endothelium-dependent relaxation in normal pregnancy and pregnancies complicated with preeclampsia or fetal growth restriction.

OBJECTIVES: To determine the degree of endothelium-dependent relaxation in myometrial and omental resistance arteries from normal pregnancies and pregnancies complicated with preeclampsia or fetal growth restriction (FGR) (compromised pregnancy group), and to correlate the results with the endothelial surface expression of cell adhesion molecules (CAMs) in the same vessels. METHODS: Parallel wire myography was used to assess the relaxation of omentum or myometrial vessels obtained from nonpregnant women (n = 3), women with normal pregnancies (n = 11), and women with pregnancies complicated by preeclampsia or fetal growth restriction (n = 10). These resistance vessels were constricted with incremental concentrations of vasopressin (10(-10) mol/L to 3.3 x 10(-8) mol/L) prior to the addition of incremental concentrations of bradykinin (10(-10) mol/L to 3.3 x 10(-6) mol/L). Immunohistochemistry was used to assess the endothelial expression of the CAMs E-selectin, ICAM-1, VCAM-1, and PECAM. RESULTS: A significant reduction in endothelium-dependent relaxation of myometrial vessels was found in the compromised pregnancy group when compared with both the normotensive pregnant group and the nonpregnant group. This reduction was not noted with omental vessels. All vessels in the nonpregnant group, normal pregnant group, and compromised pregnancy group expressed PECAM and ICAM-1 on the endothelium. There was no difference in intensity of immunostaining between the groups. None of the vessels in any of the groups expressed VCAM-1 or E-selectin. CONCLUSIONS: We found no evidence that impaired relaxation responses to bradykinin are linked to altered expression of CAMs in preeclampsia and FGR. These results suggest that increased CAM expression occurs in a vascular bed separate from those investigated in the present study. Possible sites for this would be in the microcirculation of organs such as the kidney.

Fowler's syndrome and pregnancy.

We present a favourable outcome of a pregnant woman with underlying Fowler's syndrome. This is a rare disorder affecting young women with painless urinary retention, and as there is no known cure, the main concern is to ensure adequate bladder emptying. Our patient went through self-catheterisation and suprapubic catheters after which she was finally successfully managed on a sacral nerve stimulator (SNS). Upon getting pregnant the stimulator was switched off due to safety concerns, and from then on, bladder emptying was managed with a suprapubic catheter (which was regularly changed over the gestation). The main concern thereafter was recurrent hospital admissions with urinary tract infections and pelvic pain requiring parenteral antibiotics and analgesia. She underwent an uncomplicated elective caesarean section at 36 weeks and delivered a healthy female infant. The SNS was successfully reactivated in the postnatal phase, and the suprapubic catheter was removed upon achieving adequate urethral output.

The role of the endogenous anti-inflammatory compound gravidin in pre-eclampsia.

OBJECTIVES: The study's aims were to investigate the levels of gravidin, an endogenous phospholipase A2 inhibitor, in pregnancy and pre-eclampsia and to establish its effects on neutrophil function. STUDY DESIGN: Serum samples were collected from 9 nonpregnant, 15 preeclamptic, and 10 healthy pregnant women and assayed for free gravidin by enzyme-linked immunosorbent assay. Neutrophil phospholipase A2 and respiratory burst activities were determined in the presence of isolated free gravidin by cellular arachidonic acid release and superoxide anion production. RESULTS: Levels of free gravidin were higher in the healthy pregnant (36.1 +/- 5.5 ng/mL) and preeclamptic (17.8 +/- 2.8 ng/mL) groups than in the nonpregnant control group (3.9 +/- 0.5 ng/mL) and were significantly different between pregnancy groups (P <.01, Mann-Whitney U test). Free gravidin caused a concentration dependent decrease in N-formyl-methionyl-leucyl-phenylalanine-stimulated neutrophil arachidonic acid release (inhibitory concentration of 50% 25 nmol/L) and superoxide anion generation (inhibitory concentration of 50% 32 nmol/L). CONCLUSIONS: Circulating levels of free gravidin are reduced in pre-eclampsia compared with normal pregnancy. This may encourage an increase in the respiratory burst of neutrophils in pre-eclampsia and could contribute to the oxidative stress and vascular damage that characterize this disease.

Relationship between myometrial resistance artery behavior and circulating lipid composition.

OBJECTIVES: The study investigated whether an inducible alteration in endothelium-dependent relaxation in myometrial vessels could be correlated with plasma lipid composition. STUDY DESIGN: Myometrial resistance vessels were obtained from 10 women with normal pregnancy undergoing elective cesarean delivery. Paired vessels were incubated with plasma samples from patients with preeclampsia or from women with normal pregnancy and mounted on a wire myograph. After contraction with vasopressin, the degree of relaxation in response to bradykinin was observed. Plasma samples were assayed for cholesterol, triglycerides, apolipoprotein A1, and apolipoprotein B. RESULTS: A significant reduction in endothelium-dependent relaxation with respect to control values was observed in vessels incubated in plasma samples from patients with preeclampsia (P =.0001). Although no significant difference was noted between the lipid profiles of the 2 subgroups, a significant correlation was found between the vessel relaxation and the plasma content of apolipoprotein A1 (R2 = 0.36, P = .025). CONCLUSION: Plasma samples from women with pregnancies complicated by preeclampsia are capable of altering endothelium-dependent myometrial vessel relaxation. A significant relationship between the apolipoprotein A1 concentration and endothelial behavior supports the suggestion that aberrant lipid metabolism may be involved in the endothelial dysfunction characteristic of preeclampsia.