Intrauterine balloon tamponade for uncontrollable bleeding during first trimester surgical termination of pregnancy

Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.

Therapeutic anticoagulation for pulmonary embolism during first-trimester surgical abortion: two case reports

We report two patients with bilateral pulmonary embolism who presented to our county hospital reproductive health services clinic. Both patients underwent an uncomplicated first-trimester aspiration abortion while on therapeutic unfractionated heparin therapy. Anticoagulation therapy may be modified to safely perform first-trimester surgical termination without significant blood loss.

A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy

BACKGROUND

Cesarean scar pregnancy and cervical pregnancy are unrelated forms of pathological pregnancies carrying significant diagnostic and treatment challenges, with a wide range of treatment effectiveness and complication rates ranging from 10% to 62%. At times, life-saving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single-balloon catheter for the treatment of cesarean scar pregnancy after local injection of methotrexate, we evaluated the use of a double-balloon catheter to terminate the pregnancy while preventing bleeding without any additive treatment. This was a retrospective study.

OBJECTIVES

The objective of the study was to describe the placement of a cervical ripening double-balloon catheter as a novel, minimally invasive treatment in patients with cesarean scar and cervical pregnancies to terminate the pregnancy and at the same time prevent bleeding by compressing the blood supply of the gestational sac.

STUDY DESIGN

Patients with diagnosed, live cervical pregnancy and cesarean scar pregnancy between 6 and 8 weeks' gestation were considered for the office-based treatment. Paracervical block with 1% lidocaine was administered in 3 patients for pain control. Insertion of the catheter and inflation of the upper balloon were done under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated opposite the gestational sac under transvaginal ultrasound guidance. After an hour, the area of the sac was scanned. When fetal cardiac activity was absent and no bleeding was noted, patients were discharged. After 2-3 days, a follow-up appointment was scheduled for possible catheter removal. Serial ultrasound (US) and serum human chorionic gonadotropin were followed weekly or as needed.

RESULTS

Three live cervical pregnancies and 7 live cesarean scar pregnancies were successfully treated. Median gestational age at treatment was 6 6/7 weeks (range 6 1/7 through 7 4/7 weeks). Patients' acceptance for the double-balloon treatment was high in spite of the initial low abdominal pressure felt at the inflation of the balloons. All but 1 patient noted vaginal spotting at the follow-up appointment. Only 1 patient experienced bleeding of dark blood. The balloons were in place for a median of 3 days (range, 1-5 days). Median time from treatment to the total drop of human chorionic gonadotropin was 49 days (range, 28-97 days).

CONCLUSION

The double balloon is a successful, minimally invasive and well-tolerated single treatment for cervical pregnancy and cesarean scar pregnancy. This simple treatment method has 4 main advantages: it effectively stops embryonic cardiac activity, prevents bleeding complications, does not require any additional invasive therapies, and is familiar to obstetricians-gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population.

Foley balloon catheter to prevent or manage bleeding during treatment for cervical and Cesarean scar pregnancy

OBJECTIVE

To demonstrate the efficacy of placement and inflation of Foley balloon catheters prophylactically to prevent, or as an adjuvant therapy to control, bleeding in women undergoing treatment for Cesarean scar pregnancy (CSP) or cervical pregnancy (CxP).

METHODS

This was a retrospective study of 18 women with either CSP (n = 16) or CxP (n = 2), who underwent Foley balloon catheter placement under continuous transvaginal or transabdominal ultrasound guidance to prevent or manage bleeding following treatment, which in most cases comprised local (intragestational sac) and intramuscular (IM) methotrexate (MTX) injections. In eight cases, the balloon catheter was placed immediately following local and/or IM MTX treatment, either because of bleeding or prophylactically; in eight cases, the catheter was placed as part of a two-step protocol, with patients first treated with local and IM MTX injection, then suction aspiration on Day 4 or 5, followed by planned insertion of a balloon catheter; in one patient the balloon was placed on Day 21 after local and IM MTX treatment, due to sudden bleeding; and in one case of a heterotopic pregnancy, one intrauterine and one cervical, the balloon was placed due to severe bleeding. Human chorionic gonadotropin (hCG) levels were evaluated weekly following MTX injection.

RESULTS

Gestational ages at balloon placement ranged between 5 and 12 + 2 weeks. All embryos/fetuses, with the exception of the cervical heterotopic one, had heart activity and catheter placement was well-tolerated by all women. The balloon tamponade effectively reduced or prevented maternal vaginal bleeding in all except one patient; this woman had a heterotopic CxP and required abdominal robotic cerclage to control the bleeding. Catheters were kept in place for a mean of 3.6 (range, 1-6) days. hCG levels returned to low or zero levels within 19-82 days following MTX injection. Fifteen women required antibiotic treatment following the procedure. One woman with CSP developed an arteriovenous malformation requiring uterine artery embolization.

CONCLUSION

Ultrasound-guided placement and inflation of Foley balloon catheters was easy to perform and well-tolerated by patients undergoing treatment for CSP or CxP, and successfully prevented or helped in the management of bleeding complications. Based on our experience and previous publications we suggest having the option of balloon catheter insertion available when local treatment of CSP or CxP is undertaken.