Time for global scale-up, not randomized trials, of uterine balloon tamponade for postpartum hemorrhage

Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review

Objectives

To evaluate uterine tamponade devices’ effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols.

Search strategy

PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021.

Study selection

Randomised and non‐randomised comparative studies.

Outcomes

Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy.

Results

All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom‐catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76–7.14) and hysterectomy (RR 4.14, 95% CI 0.48–35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07–15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47–41.09) with the use of the condom‐catheter or surgical glove balloon. One non‐randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11–1.03) and hysterectomy (RR 0.49, 95% CI 0.04–5.38) after the inclusion of the Bakri balloon. The second non‐randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32–2.81) and hysterectomy (RR 1.84, 95% CI 0.44–7.69) after the inclusion of Ebb or Bakri balloon.

Conclusions

The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting.

Tweetable abstract

Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

Use of Uterine Tamponade and Interventional Radiology Procedures During Delivery Hospitalizations

OBJECTIVE

To characterize use of uterine tamponade and interventional radiology procedures.

METHODS

This retrospective study analyzed uterine tamponade and interventional radiology procedures in a large administrative database. The primary outcomes were temporal trends in these procedures 1) during deliveries, 2) by hospital volume, and 3) before hysterectomy for uterine atony or delayed postpartum hemorrhage. Three 3-year periods were analyzed: 2006-2008, 2009-2011, and 2012-2014. Risk of morbidity in the setting of hysterectomy with uterine tamponade and interventional radiology procedures as the primary exposures was additionally analyzed in adjusted models.

RESULTS

The study included 5,383,486 deliveries, which involved 6,675 uterine tamponade procedures, 1,199 interventional radiology procedures, and 1,937 hysterectomies. Interventional radiology procedures increased from 16.4 to 25.7 per 100,000 delivery hospitalizations from 2006-2008 to 2012-2014 (P<.01), and uterine tamponade increased from 86.3 to 158.1 (P<.01). Interventional radiology procedures use was highest (45.0/100,000 deliveries, 95% CI 41.0-48.9) in the highest and lowest (8.9/100,000, 95% CI 7.1-10.7) in the lowest volume quintile. Uterine tamponade procedures were most common in the fourth (209.8/100,000, 95% CI 201.1-218.5) and lowest in the third quintile (59.8/100,000, 95% CI 55.1-64.4). Interventional radiology procedures occurred before 3.3% of hysterectomies from 2006 to 2008 compared with 6.3% from 2012 to 2014 (P<.05), and uterine tamponade procedures increased from 3.6% to 20.1% (P<.01). Adjusted risks for morbidity in the setting of uterine tamponade and interventional radiology before hysterectomy were significantly higher (adjusted risk ratio [aRR] 1.63, 95% CI 1.47-1.81 and aRR 1.75 95% CI 1.51-2.03, respectively) compared with when these procedures were not performed.

CONCLUSION

This analysis found that uterine tamponade and interventional radiology procedures became increasingly common over the study period, are used across obstetric volume settings, and in the setting of hysterectomy may be associated with increased risk of morbidity, although this relationship is not necessarily causal.