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Effect of early “quilting” sutures on morbidity in postpartum hemorrhage

Abstract Objective To examine whether “quilting” sutures are safe and effective in preventing hysterectomy among women with postpartum hemorrhage (PPH) and whether early application might reduce the incidence of transfusion. Methods Data were reviewed from women treated via quilting sutures after cesarean delivery at a university hospital between 2007 and 2016. Objective and subjective data were collected by analyzing medical records and performing telephone interviews. To observe trends during the study period, data from the first 50% of women treated were compared with those from the second 50%. Results Overall, 26 cesareans with quilting sutures were performed. Two hysterectomies could not be avoided. During 2012–2106, 18 quilting sutures were performed as compared with 8 in 2007–2011, pointing to a more liberal indication. Intensive care was required twice as frequently among the first 13 procedures than among the second 13 procedures (10 vs 5, respectively). A similar observation was made for the use of blood transfusions or clotting activation (9 vs 4, respectively). Three women who desired to have a child subsequently delivered a newborn. Conclusion Quilting sutures were found to be a safe and simple technique to prevent hysterectomies in PPH. Morbidity was reduced when the decision to perform sutures was taken early.


| MATERIALS AND METHODS
The present descriptive retrospective study evaluated the medical histories and clinical records of all women treated by using quilting sutures between January 1, 2007, and December 31, 2016, at the Department of Obstetrics and Gynecology, Klinikum Fulda, Fulda, Germany. Ethics Committee approval was not needed because the retrospective study design relied on patient records. Because PPH is unpredictable, the women were not asked to give consent prior to surgery. All women who were interviewed by telephone consented to take part in the study.
Quilting sutures were used on all patients with PPH after cesarean when application of the myometrium-contracting substances oxytocin (Hexal AG, Holzkirchen, Germany) and Sulprostone (Nalador; Jenapharm, Jena, Germany). Starting at the top of the uterus continuing down to the cervical segment, horizontally placed U-sutures were used to fix the anterior to the posterior wall.
Up to 12 size-1 absorbable sutures (Vicryl; Ethicon, Bridgewater, NJ, USA) were applied to compress the uterus completely. Rapidly absorbable suture material was avoided because it has a lower tensile strength. In the absence of straight needles, the technique employed curved needles, which curved from 7.5 cm to 9 cm (DS 95; Serag Wiessner, Naila, Germany). The procedure has been demonstrated in a short film. 6 The quilting sutures procedure was initially indicated and performed by the director of the clinic. As they gained in experience, senior physicians were instructed in the technique and then also performed the procedure. As a result, the change in management policy toward a more rapid decision to use quilting sutures was a continuous process.
To distinguish trends, data were compared between the first 50% (first group) and the second 50% (second group) of women treated by quilting sutures. In the second group, quilting sutures were used more liberally, that is, immediately after failure of medical treatment and before the onset of massive loss of blood and clotting factors.
To obtain follow-up data, women were contacted by telephone and asked to participate in a short interview, including complications since hospital discharge, state of health, and desire for children. For women treated with quilting sutures within 6 months of the start of evaluation, the interviews regarding personal condition and state of health were conducted by the same obstetrician.
Data were compiled using Microsotft Excel (Microsoft, Redmond, WA, USA). The data were summarized by using simple statistics.
Because they were not normally distributed, they were presented as number, mean, and median (range).

| RESULTS
During the 10-year study period, quilting sutures were used to treat PPH among 26 women. Eight procedures were carried out in the first The biometric data, gravidity, and parity of the study women were similar between the first 13 women and the second 13 women treated ( Table 1) In the second group, two cases were complicated by further problems not related to PPH. One case involved polytrauma, including placental abruption owing to a car accident that resulted in intrauterine T A B L E 1 Characteristics of the study patients.
fetal death; the patient received a massive blood transfusion. In the second case, pulmonary embolism occurred during the cesarean and was diagnosed 1 day later.
Regarding the characteristics of the cesarean deliveries, nine women had induction of labor, mostly by misoprostol (Table 2). For 13 women, either transfusion or clotting activation was necessary ( Table 3). Most of these women were in the first group (Table 3)  In total, 14 women completed the follow-up telephone interviews ( Table 4). The responses demonstrated good recovery of the women. For women not on hormonal contraceptives, menstruation had restarted by 7 weeks postpartum. Amenorrhea and menstrual discomfort after quilting sutures was uncommon, and only one women reported a lack of vaginal discharge ( Table 4). All women reported that they were pleased to have kept their uterus even if they did not desire a child. Three (21%) of the 14 women reported having had a child since the procedure. Where their personal situation permitted, all women desiring to have a child were able to do so.

| DISCUSSION
The present study indicates that the horizontal backstitch quilting sutures method is a safe, easy-to-perform, and easy-to-remember means of avoiding hysterectomy in cases of PPH. This is reflected by the increasing number and the earlier indication of quilting sutures before the women were affected by anemia and clotting problems. The decrease in morbidity and ease of handling have contributed to a reduction of fear of PPH on the delivery ward.
Quilting sutures failed only once because of ongoing bleeding due to therapeutic anticoagulation.
Early application of quilting sutures before the onset of massive blood loss reduced the need for blood transfusion, especially the need for mass transfusion. Furthermore, the incidence of admission to the intensive care unit and prolonged hospitalization were considerably reduced.
In other techniques for treating PPH using compression sutures, infection (pyometria), 7 ischemia (necrosis), 8  Less than before (n=6); same as before (n=1); more intense than before (n=3) Discomfort 10 Less than before (n=6); same as before (n=1); more intense than before (n=3) Children since cesarean Born 3 Born 3, 4, and 7 y after the procedure (3/14; 21%) Desired 7 Desired children, but too close to last delivery (n=3); desired children, but undecided because of past delivery (n=2); desired children, but no partner (n=2) Other comments 14 All women felt lucky to have kept their uterus even if they did not desire children a Five women were not interviewed because the index cesarean was in the past 6 months; 15 women were contacted, but one (who had lung embolism and hysterectomy) declined to take part.