The use of a Sengstaken-Blakemore tube to control post-partum hemorrhage

Mechanical and surgical interventions for treating primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions.

OBJECTIVES

To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review's important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter ('condom catheter'), an air-filled latex balloon-loaded catheter ('latex balloon catheter'), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean 'intraoperative' blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.

Improved Treatment of Postpartum Hemorrhage: Design, Development, and Bench-Top Validation of a Reusable Intrauterine Tamponade Device for Low-Resource Settings

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide, and effective interventions for addressing PPH are urgently needed. Uterine balloon tamponade (UBT) is a technique to control PPH. Commercially available UBT devices are expensive and frequently require imaging technology to ensure placement. Condom-catheter uterine tamponade (C-UBT) is a technique appropriate for low-resource settings. Testing of the C-UBT is needed to better understand and optimize this technique for use in a variety of clinical settings including low-resource contexts. We describe here the design, development, and bench-top validation of a reusable C-UBT device optimized for low-resource settings. The device was tested in three differently sized uterine models using a variety of condom balloon configurations. Intrauterine wall pressure application was measured to evaluate the device capacity to apply pressure of at least 90 mmHg, estimating the mean arterial pressure within the uterine vasculature. Bench-top experimental validation of pressure exerted in uterine models demonstrated the device's capability of reaching hemostatic pressure in uterine volumes ranging from 170 to 1740 mL. Device adaptability and versatility were shown through its ability to reach the target pressure of 90 mmHg in different uterine sizes by varying balloon parameters, including condom thickness and condom configuration. The results of this study show the potential of a low-cost, reusable C-UBT device optimized to treat PPH in a variety of clinical settings, including low-resource contexts.

Under Pressure: Intraluminal Filling Pressures of Postpartum Hemorrhage Tamponade Balloons

Objective Uterine tamponade by fluid-filled balloons is now an accepted method of controlling postpartum hemorrhage. Available tamponade balloons vary in design and material, which affects the filling attributes and volume at which they rupture. We aimed to characterize the filling capacity and pressure-volume relationship of various tamponade balloons. Study Design Balloons were filled with water ex vivo. Intraluminal pressure was measured incrementally (every 10 mL for the Foley balloons and every 50 mL for all other balloons). Balloons were filled until they ruptured or until 5,000 mL was reached. Results The Foley balloons had higher intraluminal pressures than the larger-volume balloons. The intraluminal pressure of the Sengstaken-Blakemore tube (gastric balloon) was initially high, but it decreased until shortly before rupture occurred. The Bakri intraluminal pressure steadily increased until rupture occurred at 2,850 mL. The condom catheter, BT-Cath, and ebb all had low intraluminal pressures. Both the BT-Cath and the ebb remained unruptured at 5,000 mL. Conclusion In the setting of acute hemorrhage, expeditious management is critical. Balloons that have a low intraluminal pressure-volume ratio may fill more rapidly, more easily, and to greater volumes. We found that the BT-Cath, the ebb, and the condom catheter all had low intraluminal pressures throughout filling.

Intrauterine balloon tamponade for management of severe postpartum haemorrhage in a perinatal network: a prospective cohort study

OBJECTIVE

To evaluate the effectiveness of intrauterine balloon tamponade (IUBT) for management of severe postpartum haemorrhage (PPH). To identify the factors predicting IUBT failure.

DESIGN

Prospective cohort study.

SETTING

Ten maternity units in a perinatal network.

POPULATION

Women treated by IUBT from July 2010 to March 2013.

METHODS

The global IUBT success rate was expressed as the number of women with severe PPH who were successfully treated by IUBT divided by the total number treated by IUBT. IUBT failure was defined as the need for arterial embolisation or surgery. Logistic regression analysis was used to estimate factors predicting IUBT failure.

MAIN OUTCOME MEASURES

Global IUBT success rate. Factors associated with IUBT failure.

RESULTS

Intrauterine balloon tamponade was attempted in 226 women: 171 after vaginal delivery (VD) (75.7%) and 55 during or after caesarean delivery (CD) (24.3%). The global success rate was 83.2% (188/226) and was significantly higher after VD (152/171, 88.9%) than CD (36/55, 65.5%, P < 0.01). The percentage of CD was significantly higher in the failure group (50.0 versus 19.1%, P < 0.01), as was mean (SD) estimated blood loss before IUBT: 1508 ± 675 ml versus 1064 ± 476, P < 0.01. Coagulopathy was significantly more frequent in the failure group (50.0% versus 17.2%, P < 0.01). CD [Odds ratio (OR) 3.5; 95% CI 1.6-7.6], estimated blood loss before IUBT (OR 3.2; 95% CI 1.5-6.8) and coagulopathy (OR 5.6; 95% CI 2.5-13.0) were predictive of IUBT failure.

CONCLUSION

Intrauterine balloon tamponade is an effective method for treating severe PPH. Early balloon deployment before the development of coagulopathy increases its success rate.

TWEETABLE ABSTRACT

Intrauterine balloon tamponade is effective for achieving haemostasis in intractable postpartum haemorrhages.

The use of a Rusch intrauterine balloon to cause tamponade on a severe hemorrhage in a case of endometrial cancer

Intractable vaginal bleeding is a complication of gynecological tumors of the cervix and endometrium. The management of torrential bleeding usually requires laparotomy or laparoscopy, or less invasive techniques such as uterine artery embolization. This case report describes the use of an intrauterine Rusch balloon catheter, previously only used in the obstetric setting. This is a safe and inexpensive method of management, which does not need specific training. We also review all the current options for the management of severe bleeding as a complication of gynecological cancers.

Treatment for primary postpartum haemorrhage

BACKGROUND

Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries.

OBJECTIVES

To assess the effectiveness and safety of any intervention used for the treatment of primary PPH.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013).

SELECTION CRITERIA

Randomised controlled trials comparing any interventions for the treatment of primary PPH.

DATA COLLECTION AND ANALYSIS

We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information.

MAIN RESULTS

Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review.Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41).  Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering.Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre-specified outcomes.One study compared lower segment compression but was too small to assess impact on primary outcomes.We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics.

AUTHORS' CONCLUSIONS

Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first-line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit.The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy.

Trends in the rate of invasive procedures after the addition of the intrauterine tamponade test to a protocol for management of severe postpartum hemorrhage

OBJECTIVE

The purpose of this study was to investigate changes in invasive procedure rates after the addition of intrauterine balloon tamponade as an initial second-line therapy to our protocol for the management of severe postpartum hemorrhage.

STUDY DESIGN

We compared the outcomes of all patients with postpartum hemorrhage that was unresponsive to prostaglandin during 2 equal periods, before (first period) and after (second period) the introduction of a balloon tamponade protocol.

RESULTS

During the second period, 43 women had uterine tamponade with a Bakri balloon as their initial second-line therapy (after vaginal delivery, 31; after caesarean delivery, 12). The global success rate was 86% (37/43 women). Among patients who delivered vaginally, the rates of arterial embolization (8.2% vs 2.3% in the first and second period; P = .006; odds ratio, 0.26; 95% confidence interval, 0.09-0.72) and conservative surgical procedures (5.1% vs 1.4%, in the first and second period; P = .029; odds ratio, 0.26; 95% confidence interval, 0.07-0.95) were significantly lower after the uterine tamponade test was added to our protocol.

CONCLUSION

Intrauterine balloon tamponade is an attractive adjunctive strategy for the achievement of hemostasis in intractable hemorrhages and prevention of the need for invasive procedures.

[Obstetric bleeding: an update]

Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.

Emergent management of postpartum hemorrhage for the general and acute care surgeon

BACKGROUND

Postpartum hemorrhage is one of the rare occasions when a general or acute care surgeon may be emergently called to labor and delivery, a situation in which time is limited and the stakes high. Unfortunately, there is generally a paucity of exposure and information available to surgeons regarding this topic: obstetric training is rarely found in contemporary surgical residency curricula and is omitted nearly completely from general and acute care surgery literature and continuing medical education.

METHODS

The purpose of this manuscript is to serve as a topic specific review for surgeons and to present a surgeon oriented management algorithm. Medline and Ovid databases were utilized in a comprehensive literature review regarding the management of postpartum hemorrhage and a management algorithm for surgeons developed based upon a collaborative panel of general, acute care, trauma and obstetrical surgeons' review of the literature and expert opinion.

RESULTS

A stepwise approach for surgeons of the medical and surgical interventions utilized to manage and treat postpartum hemorrhage is presented and organized into a basic algorithm.

CONCLUSION

The manuscript should promote and facilitate a more educated, systematic and effective surgeon response and participation in the management of postpartum hemorrhage.

The use of the Rusch balloon for management of severe postpartum haemorrhage

Tamponade techniques using a uterine balloon in management of postpartum haemorrhage has been reported increasingly in recent years. The aim of this retrospective study is to evaluate the use of the Rusch hydrostatic balloon in the management of severe postpartum haemorrhage not controlled by medical measures. All women had risk factors for PPH. The Rusch balloon was used in all cases of PPH apart from traumatic PPH, which is considered as a contraindication for its use. The Rusch balloon was successful in seven out of the eight cases treated. We have introduced guidelines for using the Rusch balloon and they are provided in this paper.

Hemorrhagic shock in obstetrics

Acute postpartum hemorrhage is the leading worldwide cause of maternal mortality, such deaths being usually related to the development of hemorrhagic shock and its consequences, especially the multiple organ dysfunction syndrome. Obstetricians should be aware of the clinical manifestations and principles of management of hemorrhagic shock. Initial assessment of the bleeding patient requires monitoring blood pressure, pulse, capillary refill, mental status and urinary output. This allows estimation of the amount and the rate of blood loss and helps direct treatment. Hemorrhagic shock is a condition in which inadequate perfusion of organs results in insufficient availability of oxygen to satisfy the metabolic needs of the tissues. A catabolic state develops. The consequences of these changes are inflammation, endothelial dysfunction, and disruption of normal metabolic processes in vital organs. Once these events become established, the process of shock is often irreversible, even if volume and red cell deficits are corrected. The principal goals of management are controlling the source of the blood loss; restoring adequate oxygen carrying capacity; and maintaining adequate tissue perfusion. Patients with severe postpartum hemorrhage are at risk of developing hypothermia, an insidious complication that contributes substantially to morbidity and mortality. It must be prevented or treated promptly. Successful treatment of exsanguinating postpartum hemorrhage depends on efficient collaboration among all members of the patient care team, and a management plan based on an understanding of the pathophysiology of shock and tailored to the individual patient's situation.

Use of Sengstaken-Blakemore tube in massive postpartum hemorrhage: a series of 17 cases

BACKGROUND

To evaluate the efficacy and identify the indications of intrauterine tamponade with a Sengstaken-Blakemore tube in acute postpartum hemorrhage.

METHODS

Retrospective study was performed in 17 female patients with massive postpartum hemorrhage despite appropriate medical treatment, and requiring surgery (embolization techniques were not available in our hospital). Patients were treated by inserting a Sengstaken-Blakemore tube in the uterus through the vagina in case of vaginal delivery or through the hysterotomy incision in case of cesarean section. The esophageal balloon was inflated with 250 ml of isotonic saline solution. Patients underwent regional or general anesthesia. A preventive treatment with broad-spectrum antibiotics was systematically administered.

RESULTS

Tamponade treatment prevented surgery in 88% of patients, hemorrhage was controlled in 71% of cases (reducing the need for embolization by 80%), and waiting for a transfer for embolization was made possible for 18% of patients.

CONCLUSION

Intrauterine tamponade with a Sengstaken-Blakemore tube appears as a simple, low-cost, readily available and effective means of treating life-threatening postpartum hemorrhage. The only apparent contraindication is the discovery of an infection during delivery.

Use of Sengstaken-Blakemore tube to stop massive upper gastrointestinal bleeding from Dieulafoy's lesion in the lower oesophagus

Massive upper gastrointestinal bleeding from Dieulafoy's lesion in the gastrointestinal tract is uncommon. The use of the Sengstaken-Blakemore tube in acute gastrointestinal bleeding has become less common since endoscopic sclerotherapy and banding procedures have become widely available. The successful use of a Sengstaken-Blakemore tube to control acute massive upper gastrointestinal bleeding from a Dieulafoy's lesion in the lower oesophagus in an elderly man with severe coronary artery disease and heart failure is described.

Surgical Management of Severe Obstetric Hemorrhage: Experience with an Obstetric Hemorrhage Equipment Tray

BACKGROUND

Hemorrhage remains a leading cause of severe maternal morbidity and death. In addition to the appropriate use of oxytocic agents for uterine atony, surgical techniques, including uterine tamponade, major vessel ligation, compression sutures, and hysterectomy, may be required. On the rare occasions they are needed, the instruments and equipment required for these surgical techniques may not be readily available.

OBJECTIVE

To record our experience with an obstetric hemorrhage equipment tray for surgical management of severe obstetric hemorrhage.

METHODS

A severe obstetric hemorrhage equipment tray was established and included packing (5-yard roll) and balloon device for uterine tamponade, straight (10 cm) eyed-needles and large curved eyed-needles for use with No. 1 suture, 3 Heaney vaginal retractors, 4 sponge forceps, and diagrams and instructions for the various types of compression sutures and tamponade techniques.

RESULTS

Of the 4400 deliveries that occurred at 1 tertiary maternity hospital during 2002, the obstetric hemorrhage tray was used on 9 occasions: 3 Caesarean sections with placenta previa (uterine tamponade used in 2 cases, compression sutures in 1); 2 Caesarean sections with uterine atony (compression sutures); 1 Caesarean section with placenta previa accreta (major vessel ligation and compression sutures); and 3 vaginal deliveries (suturing of cervical and vaginal lacerations in 2 of the cases, uterine tamponade used in the third case). In all cases, hysterectomy was avoided.

CONCLUSION

The ready availability of an obstetric hemorrhage equipment tray on the labour ward facilitates prompt surgical management of severe obstetric hemorrhage, and may reduce the need for blood transfusion and hysterectomy.

Medical and Conservative Surgical Management of Postpartum Hemorrhage

Massive postpartum hemorrhage (PPH) is a major cause of maternal mortality in the United Kingdom and worldwide. Life-threatening PPH occurs with a frequency of 1 in 1000 deliveries in the developed world. In the latest triennial Why Mothers Die: Confidential Enquiries into Maternal Deaths in the United Kingdom (1997-1999), PPH was the fifth most common cause of maternal mortality. In this review, we discuss the role of medical management in primary PPH and the use of the "tamponade test" when such management fails. The less radical surgical options discussed include uterine compression sutures, uterine or internal iliac artery ligation, and arterial embolization, all of which have the advantage of potentially preserving reproductive function. Radical surgical options, including subtotal or total hysterectomy, are not discussed in this review. A systematic or algorithmic method of tackling the problem is described. The suggested management approach is likely to reduce maternal morbidity from bleeding, hysterectomies, and maternal deaths.

The surgical management of post-partum haemorrhage

Life-threatening post-partum haemorrhage (PPH) occurs with a frequency of 1 per 1000 deliveries in the developed world. In the 1994-1996 Triennial Confidential Enquiry into Maternal Deaths in the United Kingdom primary PPH was responsible for five deaths. In this chapter we discuss briefly the assessment and initial medical management of the patient with primary PPH but concentrate on the surgical management where medical treatment has failed. The surgical management discussed includes both traditional or long-established management strategies together with newer, less radical surgical options, such as embolization techniques, uterine compression sutures and methods involving uterine tamponade, which are less hazardous to perform and have the advantage of preserving reproductive function. The recommendations of the reports from the Confidential Enquiries into Maternal Deaths in the UK are summarized at the end of the chapter.

The surgical management of postpartum haemorrhage

This review summarizes the options available for the management of postpartum haemorrhage when ecbolic agents have failed to control the bleeding and an obvious rectifiable problem such as retained placental fragments, lower genital tract trauma, uterine inversion or uterine rupture have been excluded or dealt with. The review covers the range of surgical options but gives an in-depth explanation of the more recent developments such as uterine brace sutures, the use of the Sengstaken-Blakemore tube and embolization procedures.