Comment on “Alternate Sequential Suture Tightening: A Novel Technique for Uncontrolled Postpartum Hemorrhage”

We read with interest the recent article " Alternate Sequential Suture Tightening: A Novel Technique for Uncontrolled Post-partum Hemorrhage " by Ghosh and Mala [1]. They developed a novel technique of uterine compression suture (UCS) for atonic bleeding where a Hayman suture [2] is performed, but importantly they sequentially tighten the knot, yielding " very tight " compression. In 92% (11/12) of their patients, the UCS alone stopped the bleeding. No patients had untoward sequelae. Their data is promising; however, we have two concerns. First, we wonder if such a tight knot is needed. In the Ghosh technique, the final knot was eventually tightened compared to the initial knot by as much as 3–5 cm, meaning tighter by 3–5 cm compared with an ordinary Hayman suture [2]. In our opinion, the Ghosh suture may be too tight and we wish to describe two supporting pieces of evidence. First, we usually use the Matsubara-Yano (MY) UCS in patients with atonic bleeding (Figure 1(a)) [3] and sometimes even cut the sutures because the knot looks " too tight. " We then reperform the MY UCS, making a looser knot. A knot that is too tight may lead to tissue damage caudal to the suture, that is, the lower uterine segment. This portion would become thin and weak, and a knot that is too tight would forcefully pull this portion in the cephalad direction, easily damaging this area (Figure 1(b)). We sometimes loosen the knot also for fear of possible subsequent uterine ischemia. After placing the UCS and closing the hysterotomy incision, it is our experience that the uterus becomes, more or less, contracted even in patients with an atonic uterus. Uterine contraction may make the knot even tighter. Second, we are concerned about Figure 1(d) in Ghosh and Mala's article [1]. The uterus looks ischemic in the area between two sutures even 1.5 years after the Ghosh UCS, possibly indicating that the suture significantly deprived blood flow to the uterus. Mowat et al. [4] reported a case of uterine necrosis after B-Lynch suture, describing, " there was central necrosis of the anterior body and fundus of the uterus between the two limbs of the B-Lynch suture " : this feature was similar to Ghosh and Mala's figure (Figure 1(d)) [1]. As described previously, generally speaking, compression force is related to the ability to induce hemostasis but is also related to adverse events …