A woman develops massive PPH unresponsive to oxytocin, ergometrine, carboprost, and misoprostol. B-Lynch suture is applied but bleeding persists. The NEXT step in the surgical management algorithm before proceeding to hysterectomy is:
- A Stepwise uterine devascularization (O'Leary sutures) ✓
- B Internal iliac artery ligation
- C Uterine artery embolization
- D Balloon tamponade with Bakri balloon
Correct answer: A. Stepwise uterine devascularization (O'Leary sutures)
Explanation
The WHO-endorsed stepwise surgical approach after B-Lynch suture failure includes O'Leary sutures (bilateral uterine artery ligation at the level of the lower segment) as the next step, followed by internal iliac artery ligation if required. Balloon tamponade (Bakri) is a step before compression sutures in the algorithm. Uterine artery embolization requires interventional radiology and is generally not available intraoperatively in an emergency setting.
Reference: Williams Obstetrics, 26th ed.
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Written and medically reviewed by the StethoPrep medical team.