The Mumbai Obstetric & Gynecological Society

The Mumbai Obstetric and Gynaecological Society www.mogsonline.org mogs

Obstetrics

Websites

www.rcog.org.uk

The website of the Royal College of Obstetricians and Gynecologists has plenty of useful features for students and to clinicians looking for guidelines on specific topics. There are about 75 Green Top Guidelines, Working Party Reports and Opinion papers giving detailed evidence based literature on topics in obstetrics and gynecology. They are downloadable at no cost.


www.ranzcog.edu.au

This is the website of the Royal Australian and New Zealand College of Obstetricians and Gynecologists. It has a number of articles, statements and guidelines on a variety of OBGYN topics. The site features RANZCOG material as well as material from other bodies that have been endorsed by this College.


www.thefetus.net

This is probably the most comprehensive source on fetal medicine. It literally has thousands of sonography images and interesting cases which can be downloaded. The site also features videos of procedures. There are articles on fetal medicine and guidelines.


Abstracts

Progesterone for preterm birth prevention: an evolving intervention

Am J Obstet Gynecol. 2009 Mar;200(3):219-24.

Tita AT, Rouse DJ.

Center for Women's Reproductive Health, Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA.

We sought to review emerging data on the use of progesterone to prevent preterm birth (PTB). Using the terms "preterm or premature" and "progesterone" we queried the PubMed database, restricting our search to January 1, 2000, forward and selected randomized clinical trials (RCTs) and metaanalyses of RCTs that evaluated the use of progesterone for the prevention of PTB. We reviewed 238 abstracts and supplemented our review by a bibliographic search of selected reports. We focused on the pharmacologic aspects of progesterone and risk factor-specific outcomes. We identified a total of 17 relevant reports: 8 individual RCTs, 6 metaanalyses, and 3 national guidelines. Individual trials and metaanalyses support that synthetic intramuscular 17-alpha-hydroxyprogesterone effectively reduces the incidence of recurrent PTB in women with a history of spontaneous PTB. One trial found that vaginally administered natural progesterone reduced the risk of early PTB in women with a foreshortened cervix. The data are suggestive but inconclusive about: (1) the benefits of progesterone in the setting of arrested preterm labor; and (2) whether progesterone lowers perinatal morbidity or mortality. In some women, progesterone reduces the risk of PTB. Further study is required to identify appropriate candidates and optimal formulations.


A randomized trial of cerclage vs. 17 alpha-hydroxyprogesterone caproate for treatment of short cervix.

J Perinat Med. 2009 Jun 3.

Keeler SM, Kiefer D, Rochon M, Quinones JN, Novetsky AP, Rust O.

Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA, USA.

Abstract Objective: To determine pregnancy outcome in patients with short cervix on transvaginal ultrasound between 16 and 24 weeks' gestation treated with McDonald cerclage compared to weekly intramuscular injections of 17 alpha-hydroxyprogesterone caproate (17OHP-C). Methods: From November 2003 through December 2006, asymptomatic, singleton pregnancies were screened with transvaginal ultrasound between 16-24 weeks' gestation. Patients with a cervical length (CL)

Placenta Accreta in a Woman with Escherichia coli Chorioamnionitis with Intact Membranes

Emma M. Montelongo, * Nathan R. Blue, and Richard H. Lee

Abstract : Background. Escherichia coli (E. coli) associated intrauterine infections with intact membranes are extremely rare. Case. A 30-year-old multiparous female presented at 26 weeks' gestation with clinical signs of chorioamnionitis but physical examination suggested intact membranes. Her dietary history was concerned with Listeriosis. An amniocentesis was performed. Shortly thereafter, the mother developed septic shock and an urgent Cesarean delivery was performed. The patient required a peripartum hysterectomy for placenta accreta. Amniotic fluid cultures grew E. coli.

Introduction : Chorioamnionitis can be caused by a variety of bacterial species and few viruses, and it is rarely associated with intact membranes [1]. We report a case of chorioamnionitis due to E. coli in a woman with intact membranes and who also required a peripartum hysterectomy for placenta accreta.

Case : A 30-year-old gravida 4 para 3 presented to our hospital at 26 0/7 weeks' gestation with a 10-hour history of lower abdominal pain, vaginal discharge, dysuria, and complaints of subjective fever. She described the vaginal discharge as mucoid and blood-tinged. She denied any history of invasive procedures (i.e., amniocentesis) or leakage of fluid from her vagina prior to having the vaginal discharge. Her obstetrical history was significant for two prior term Cesarean deliveries. Upon presentation, she was afebrile and normotensive with a pulse of 106 beats per minute (bpm), no uterine contractions, and a nonreactive fetal heart tracing. Her maximum temperature was 100.0°F. Her abdominal exam revealed generalized tenderness. Speculum examination showed copious yellow mucopurulent discharge in the vaginal vault and the cervical os was closed. There was no pooling of amniotic fluid and testing for amniotic fluid ferning was negative. Nitrazine testing was mildly positive but was attributed to the mucopurulent discharge. Her white blood cell count was elevated at 17.9 [103/μL]. Ultrasound revealed a singleton fetus in breech presentation with an amniotic fluid index of 18.6 cm. The placenta was posterior fundal with no placenta previa. The placenta did demonstrate placental lacunae.

When interviewed, the patient acknowledged having consumed “queso fresco” throughout her pregnancy. Queso fresco is a Mexican cheese often made with raw, unpasteurized cow milk and is associated with Listeriosis when consumed in pregnancy. Because of this concern, an amniocentesis was performed with the plan to provide Listeria specific antimicrobial treatment if confirmed. When the amniocentesis was performed, it yielded yellow-opaque colored fluid, which was sent for Gram stain, culture, and glucose concentration and white blood cell count. Following the procedure, treatment with intravenous ampicillin and gentamicin was initiated. A few minutes later, the patient became tachycardic and tachypnic with rigors and chills, while complaining of extreme thirst. Fetal tachycardia was also observed. Given the concern for maternal sepsis due to chorioamnionitis, a Cesarean delivery was performed. A viable female infant was delivered weighing 790 grams with APGAR scores of 5 at 1 minute and 6 at 5 minutes. The placenta did not deliver with external uterine massage and was therefore removed manually. The placenta was removed with difficulty and extracted in segments. The placental bed was inspected and appeared hemostatic. The uterine incision was closed. Subsequently, the patient developed uterine atony which was treated with uterine massage and uterotonics. After closure of the laparotomy, the patient continued to have uterine atony. Bimanual compression and additional uterotonics were administered, and an intrauterine BAKRI balloon was placed. Her vital signs were stable, and she was extubated and transferred to the surgical intensive care unit. The total estimated blood loss was 1500 cc and her postoperative hemoglobin decreased from 9.6 [g/dL] to 7.5 [g/dL].

Despite these measures, the patient's uterus had intermittent atony. Her vital signs decompensated with a heart rate of 140 bpm and blood pressure of approximately 60/40 mmHg. Because of the lack of response to uterotonics and uterine compression, a peripartum hysterectomy was performed. The total estimated blood loss was 5000 cc, and the patient was transfused eleven units of packed red blood cells, three units of platelets, ten units of cryoprecipitate, and eight units of FFP. The intraoperative hemoglobin was 3.8 [g/dL] and postoperatively it was 13.3 [g/dL].

The amniotic fluid studies resulted in 4+ Gram-negative rods, which were later confirmed to be Escherichia coli by culture. Urine culture also grew E. coli but blood cultures resulted negative. Pathologic examination of the uterus identified placenta accreta. Examination of the umbilical cord and placenta revealed acute funisitis, meconium staining, and chorioamnionitis.

The patient continued to receive intravenous ampicillin and gentamicin for twenty-four hours following the operation. Her hospital course was complicated by an ileus, an acute rise in bilirubin that was attributed to sepsis, and a urinary tract infection that was treated with ceftriaxone. She was discharged on postoperative day ten. Immediately after birth, the neonate was found to have an elevated white blood cell count of 50 [103/μL] and was treated for presumed sepsis with intravenous ampicillin and gentamycin for fourteen days. She remained hospitalized for approximately three months in the neonatal intensive care requiring two months of intubation, closure of a patent ductus arteriosus, and total parenteral nutrition. At one year, she has had multiple hospitalizations for chronic lung disease and has been observed to have some developmental delays.

Discussion : Chorioamnionitis most commonly results from migration of cervicovaginal flora through the cervical canal to cause intra-amniotic infection, though transplacental infection can also occur through hematogenous spread or from direct inoculation during an invasive procedure. In this case, the presence of intact membranes initially lowered the concern for an ascending intra-amniotic infection from ruptured membranes.

There are numerous reports of intrauterine infection with intact membranes caused by a variety of agents, including Listeria monocytogenes, Candida, Capnocytophaga sputigena, Fusobacterium nucleatum, Staphylococcus aureus, Streptococcus agalactiae, Eikenella corrodens, Streptococcus viridans, Haemophilus influenzae, and some species of Ureaplasma. Transplacental infection with Listeria has been previously associated with unpasteurized “queso fresco” [2]. A comprehensive EMBASE and PubMed search using the search terms “chorioamnionitis, Escherichia coli, intact, membranes, pregnancy” yielded only one case report that E. coli related chorioamnionitis in a patient with intact membranes. In contrast to our case, the report described a patient who underwent placement of two cerclages. The authors report that the resulting infection was likely secondary to hematogenous spread from repeated instrumentation with the suture serving as a nidus for infection [3]. Besides this single report, it has been widely observed that intrauterine E. coli infection portends a poor prognosis to the fetus and has been associated with midtrimester fetal demise [4–7].

While there has been an observed association between placental lacunae and pathologic conditions such as placenta previa and accreta [8, 9], several large-scale studies have failed to demonstrate a significant association between this ultrasound finding and any adverse pregnancy outcome [10, 11]. The lack of consensus on the topic suggests that lacunae observed by ultrasound should not be interpreted as a diagnostic finding. What is unusual about this case is the location of the placental location and the accreta. Although the patient had a history of two previous Caesarian sections, the placenta was located on the posterior-fundal uterine wall and away from the anterior lower uterine segment, the area where both prior uterine incisions would be located. Given the unlikely event of de novo abnormal placentation remote from the uterine scar, our suspicion for placenta accreta prior to surgery was low.

The placenta accreta in this case is unlikely to have been caused by the chorioamnionitis. Distortion of the placental attachment to the uterus would have been expected to occur much earlier in the pregnancy. A recent population-based study of placenta accreta did not demonstrate any association between chorioamnionitis and abnormal placentation; however, the study was likely underpowered to detect a significant relationship as only three cases of chorioamnionitis were identified among 128 patients with placenta accreta (OR 0.88 CI (0.28–2.78) P value 0.83) [12]. In addition, there is some evidence to suggest that intra-amniotic inflammation may be associated with certain placental abnormalities, such as a placental edema and terminal villous immaturity [13]. Although the cause of her accreta is unknown, we speculate that the direct attachment of the placenta to the myometrium, rather than the decidua, might have facilitated the transmission of E. coli by the absence of the decidual layer that normally separates the myometrium from the placenta.

In conclusion, E. coli may now be included as a bacterium that can also cause chorioamnionitis in the setting of intact membranes. Although rare, E. coli associated chorioamnionitis can cause severe, life-threatening complications for both mother and fetus.

References

  1. Tita A. T. N., Andrews W. W. Diagnosis and management of clinical chorioamnionitis. Clinics in Perinatology. 2010;37(2):339–354. doi: 10.1016/j.clp.2010.02.003. [PMC free article] [PubMed] [Cross Ref]
  2. Linnan M. J., Mascola L., Lou X. D., et al. Epidemic listeriosis associated with Mexican-style cheese. The New England Journal of Medicine. 1988;319(13):823–828. doi: 10.1056/nejm198809293191303. [PubMed] [Cross Ref]
  3. Winer N., David A., Leconte P., et al. Amniocentesis and amnioinfusion during pregnancy: report of four complicated cases. European Journal of Obstetrics Gynecology and Reproductive Biology. 2001;100(1):108–111. doi: 10.1016/s0301-2115(01)00442-0. [PubMed] [Cross Ref]
  4. McDonald H. M., Chambers H. M. Intrauterine infection and spontaneous midgestation abortion: is the spectrum of microorganisms similar to that in preterm labor? Infectious Diseases in Obstetrics and Gynecology. 2000;8(5-6):220–227. doi: 10.1155/S1064744900000314. [PMC free article] [PubMed] [Cross Ref]
  5. Maleckiene L., Nadisauskiene R., Stankeviciene I., Cizauskas A., Bergström S. A case-referent study on fetal bacteremia and late fetal death of unknown etiology in Lithuania. Acta Obstetricia et Gynecologica Scandinavica. 2000;79(12):1069–1074. doi: 10.1034/j.1600-0412.2000.0790121069.x. [PubMed] [Cross Ref]
  6. Moyo S. R., Hägerstrand I., Nyström L., et al. Stillbirths and intrauterine infection, histologic chorioamnionitis and microbiological findings. International Journal of Gynecology and Obstetrics. 1996;54(2):115–123. doi: 10.1016/0020-7292(96)02705-1. [PubMed] [Cross Ref]
  7. Tolockiene E., Morsing E., Holst E., et al. Intrauterine infection may be a major cause of stillbirth in Sweden. Acta Obstetricia et Gynecologica Scandinavica. 2001;80(6):511–518. doi: 10.1034/j.1600-0412.2001.080006511.x. [PubMed] [Cross Ref]
  8. Hamada S., Hasegawa J., Nakamura M., et al. Ultrasonographic findings of placenta lacunae and a lack of a clear zone in cases with placenta previa and normal placenta. Prenatal Diagnosis. 2011;31(11):1062–1065. doi: 10.1002/pd.2833. [PubMed] [Cross Ref]
  9. Woodring T. C., Klauser C. K., Bofill J. A., Martin R. W., Morrison J. C. Prediction of placenta accreta by ultrasonography and color doppler imaging. Journal of Maternal-Fetal and Neonatal Medicine. 2011;24(1):118–121. doi: 10.3109/14767058.2010.483523. [PubMed] [Cross Ref]
  10. Thompson M. O., Vines S. K., Aquilina J., Wathen N. C., Harrington K. Are placental lakes of any clinical significance? Placenta. 2002;23(8-9):685–690. doi: 10.1053/plac.2002.0837. [PubMed] [Cross Ref]
  11. Reis N. S. V., Brizot M. L., Schultz R., Nomura R. M. Y., Zugaib M. Placental lakes on sonographic examination: correlation with obstetric outcome and pathologic findings. Journal of Clinical Ultrasound. 2005;33(2):67–71. doi: 10.1002/jcu.20086. [PubMed] [Cross Ref]
  12. Eshkoli T., Weintraub A. Y., Sergienko R., Sheiner E. Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births. American Journal of Obstetrics and Gynecology. 2013;208(3):219.e1–219.e7. doi: 10.1016/j.ajog.2012.12.037. [PubMed] [Cross Ref]
  13. Pinar H., Goldenberg R. L., Koch M. A., et al. Placental findings in singleton stillbirths. Obstetrics and Gynecology. 2014;123(2, part 1):325–336. doi: 10.1097/aog.0000000000000100. [PMC free article] [PubMed] [Cross Ref]

 

Uterus Wrapping: A Novel Concept in the Management of Uterine Atony during Cesarean Delivery

N. Kimmich, * W. Engel, M. Kreft, and R. Zimmermann

Abstract : Uterine atony during cesarean delivery is a serious cause of maternal morbidity and mortality. Management strategies include medical treatment with uterotonic agents, manual compression of the uterus, and interventional or surgical procedures. A novel technique to compress the uterus by wrapping it with an elastic bandage and its outcome in 3 cases of uterine atony during cesarean section are presented. Our novel method of intermittent wrapping of the uterus during cesarean delivery seems to be a successful additional approach in the management of uterine atony during cesarean delivery and may be an alternative treatment option to other compressing procedures in order to avoid high blood loss and last but not least postpartum hysterectomy.

Introduction : Uterine atony with severe hemorrhage is a serious cause of maternal morbidity and mortality. Different methods in the management of uterine atony during cesarean delivery are well established. In addition to medical treatment by uterotonic agents, manual compression/massage of the uterus and interventional or surgical procedures are performed [1]. Those procedures include embolization of the uterine artery, uterine packing with gauze [2], uterine compression sutures [3–7], tamponade of the uterus by application of a balloon [8], bilateral arcuate artery suture [9], and ligation of the uterine artery. The aim of all these treatment options is to reduce blood loss and to avoid hysterectomy in order to sustain maternal fertility.

We developed a novel technique to compress the uterus in case of uterine atony during cesarean delivery by wrapping the uterus.

Case Presentation : We present three cases of uterine atony during cesarean delivery, which were treated with our novel technique of uterus wrapping intraoperatively. An overview of the three cases with maternal and obstetrical data is shown in Table 1. Every cesarean delivery was performed according to standard protocol in our hospital via Pfannenstiel laparotomy and transverse hysterotomy. Intraoperatively, all patients were routinely administered 10 IU of oxytocin intramyometrially to encourage uterine contraction. As uterine atony appeared, contractile agents and blood coagulation drugs were administered according to standard protocol and uterus wrapping was performed additionally in replacement for manual compression. If the uterus was considered well contracted by clinical evaluation, the bandage was removed and the surgical procedure completed. The course of every patient was uneventful and they could leave our hospital three, four, and seven days after cesarean delivery, respectively, in good shape. The length of stay of seven days for one patient was because of nonobstetrical but neonatal reasons. Follow-up until the postpartum control six weeks after cesarean was uneventful in every case.

Technique of Uterus Wrapping : Uterus wrapping was performed in replacement for manual compression. For this purpose, the uterus was exteriorized and wrapped with a white, sterile bandage (pro-IDEAL, Promedical AG, Glarus, Switzerland; size 10 centimeters × 5 meters) concentrically from the fundus to the isthmocervical segment. In cases with long ovarian ligaments, the ovary was put aside and was not included into the wrapping. If inclusion of the ovary could not be avoided, slightly less wrapping was performed in the region of the ovary and the ovarian ligaments in order to maintain ovarian blood supply. This was also important with intention to preserve blood flow of the fallopian tubes and the infundibulopelvic ligaments. The total wrapping procedures took about 30 seconds each. If the uterus was considered well contracted by clinical evaluation (palpation of a good uterus tone and less bleeding observable), the bandage was removed and the surgical procedure completed. In case of persisting atony after removal of the bandage, the bandage was installed again until the uterine tone was assessed to be well contracted. As long as the bandage was installed, the uterus was kept exteriorized, but without tension on the parametria and adnexa. Before ending the surgical procedure of cesarean, the bandage had to be removed totally.

Case 1 : A 39-year-old nulliparous woman with an uncomplicated dichorionic-diamniotic twin pregnancy was hospitalized at 40 1/7 weeks of gestation for labor induction because of the twin and postterm pregnancy. Labor was induced by insertion of a cervical ripening balloon (Cook Cervical Ripening Balloon, Cook Medical) for 24 hours, followed by 6 cycles of continuous drip of oxytocin intravenously. Each oxytocin cycle lasted for six hours and was followed by a break of two hours before starting the next cycle. Because of failure to progress in first stage of labor with a maximal cervical dilatation of 5 centimeters (cm) and insufficient contractions in the absence of oxytocin infusion, we decided to perform a cesarean delivery under spinal anesthesia at 40 5/7 weeks of gestation. Extraction of the first twin in vertex presentation was difficult because of a trapped head in the pelvis, so that the fetus had to be extracted in an inverse breech position by enlarging the hysterotomy by a T-shaped cut in caudal direction. The second fetus could easily be extracted in breech position. Each placenta was removed manually in toto. The vertical T-shaped cut of the hysterotomy was closed by single sutures and the transverse hysterotomy by continuous suturing. Because of uterine atony, uterotonic agents were administered as described in Table 1 and the uterus was exteriorized and first compressed manually. As uterotonic management by manual compression and uterotonic agents was insufficient in termination of bleeding, the uterus was wrapped as described above. The wrapping did not include the fimbriae, which allowed checking the circulation of the fallopian tubes. Uterine tone was checked regularly by palpation. After 35 minutes and 55 minutes, respectively, the bandage was removed in presumption of a good uterine tone but had to be installed again because of persistence or recurrence of atony. After a total wrapping time of 75 minutes, the bandage was finally removed. Then, the surgical procedure could be completed. Total blood loss was 2000 mL.

Case 2 : A 40-year-old nulliparous woman with a singleton pregnancy in vertex presentation presented herself to our obstetrical ward at 38 4/7 weeks of gestation for elective cesarean delivery because of a sonographically verified fetal malformation. Additional risk factors included gestational diabetes, treated with insulin, and a history of lumbar disc herniation. Hence, cesarean delivery was performed in general anesthesia. Because of uterine atony despite application of uterotonics as described in Table 1 and manual uterine compression, the uterus was exteriorized and wrapped as described above (Figure 1). After 18 minutes, the uterine bandage was removed, as the uterus seemed to be well contracted and really was. Then, the surgical procedure was completed. Total blood loss was 1100 mL.

Case 3 : A 30-year-old nulliparous woman with a singleton pregnancy in vertex presentation presented herself to our obstetrical ward at 41 3/7 weeks of gestation for labor induction because of postterm pregnancy. A cesarean delivery under spinal anesthesia was performed at 42 1/7 weeks of gestation after failed induction of labor over a period of five days, including multiple oral doses of misoprostol and a cervical ripening balloon (Cook Cervical Ripening Balloon, Cook Medical) for 24 hours. Again, manual compression and uterotonics were insufficient in treatment of uterine atony. Therefore, the uterus was exteriorized and wrapped as described above (Figure 2). After 12 minutes, the uterine bandage was removed, as the uterus was well contracted. Then, the surgical procedure was completed. Total blood loss was 800 mL.

Discussion : Manual uterine compression is well established in first-line management of uterine atony, before any further procedures follow. The disadvantage of manual compression is the fact that pressure cannot be distributed equally over the whole uterus and cannot be maintained effectively and constantly over a longer period of time. Other mechanical compression procedures, as packing the uterus with gauze or tamponade of the uterus by application of a balloon, might also be less successful because of lacking counterforce from the outer face of the uterus or balloon displacement.

For this, uterus wrapping is an alternative technique for compressing the uterus. By wrapping the uterus a constant pressure can be applied to the uterus and can equally be distributed, even over a longer period of time, without causing harm to the uterus itself. As no difficult interventional or surgical procedure is necessary, it can easily and rapidly be performed when uterus atony appears, even by inexperienced surgeons. It is cheap, as only a sterile elastic bandage is needed.

Traditional interventional and surgical procedures as mentioned above could possibly cause adverse effects, such as ureteral or vascular injury, uterine synechia, myometrial necrosis, and endomyometritis [1]. But little information is given regarding subsequent fertility and pregnancy outcomes after those interventions [1].

The disadvantage of our novel method is the fact that it is sometimes difficult to decide for how long the compression by uterus wrapping has to be maintained, since a sufficient tone after removal of the bandage can worsen again. A critical point might be the problem of finding the correct amount of wrapping intensity, as the adnexa might be embedded in the wrapping and in case of too tight wrapping the blood circulation to and from the adnexa can be compromised, especially when the wrapping persists too long. In our three cases, no adverse effects appeared, even with a wrapping time of 75 minutes in one case. In one case, the bandage did not include the fimbriae, which allowed checking the circulation of the fallopian tubes.

We conclude that our novel method of wrapping the uterus seems to be a successful way of continuously compressing the uterus over a longer time during cesarean delivery in case of uterine atony. We speculate that it is able to minimize blood loss during cesarean delivery, if applied early, and may substitute more invasive operative procedures.

References

  1. Akbayir O., Corbacioglu Esmer A., Cilesiz Goksedef P., et al. Single square hemostatic suture for postpartum hemorrhage secondary to uterine atony. Archives of Gynecology and Obstetrics. 2013;287(1):25–29. doi: 10.1007/s00404-012-2509-x. [PubMed] [Cross Ref]
  2. Schmid B. C., Rezniczek G. A., Rolf N., Saade G., Gebauer G., Maul H. Uterine packing with chitosan-covered gauze for control of postpartum hemorrhage. American Journal of Obstetrics and Gynecology. 2013;209(3):225.e1–225.e5. doi: 10.1016/j.ajog.2013.05.055. [PubMed] [Cross Ref]
  3. B-Lynch C., Coker A., Lawal A. H., Abu J., Cowen M. J. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. British Journal of Obstetrics and Gynaecology. 1997;104(3):372–375. doi: 10.1111/j.1471-0528.1997.tb11471.x. [PubMed] [Cross Ref]
  4. Pereira A., Nunes F., Pedroso S., Saraiva J., Retto H., Meirinho M. Compressive uterine sutures to treat postpartum bleeding secondary to uterine atony. Obstetrics and Gynecology. 2005;106(3):569–572. doi: 10.1097/01.AOG.0000168434.28222.d3. [PubMed] [Cross Ref]
  5. Spätling L. ‘Quilting’ sutures to prevent hysterectomy in patients with postpartum hemorrhage. International Journal of Gynecology and Obstetrics. 2012;117(3, article 291) doi: 10.1016/j.ijgo.2012.01.006. [PubMed] [Cross Ref]
  6. Hayman R. G., Arulkumaran S., Steer P. J. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstetrics and Gynecology. 2002;99(3):502–506. doi: 10.1016/s0029-7844(01)01643-x. [PubMed] [Cross Ref]
  7. Cho J. H., Jun H. S., Lee C. N. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstetrics & Gynecology. 2000;96(1):129–131. doi: 10.1016/s0029-7844(00)00852-8. [PubMed] [Cross Ref]
  8. Wright C. E., Chauhan S. P., Abuhamad A. Z. Bakri balloon in the management of postpartum hemorrhage: a review. American Journal of Perinatology. 2014;31(11):957–964. doi: 10.1055/s-0034-1372422. [PubMed] [Cross Ref]
  9. Li J., Yu Y.-X., Zheng L.-Y., Yang L.-N., Sun C.-Y., Chen Z.-Y. Clinical research on bilateral arcuate artery suture hemostasis of corpus uteri for postpartum hemorrhage due to uterine inertia during caesarean section. Zhonghua fu chan ke za zhi. 2013;48(3):165–170. [PubMed]

 

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