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Piaggio D, Hyland S, Maccaro A, Iadanza E, Pecchia L. A 3D-printed condom intrauterine balloon tamponade: Design, prototyping, and technical validation. PLoS One 2024; 19:e0303844. [PMID: 38861495 PMCID: PMC11166290 DOI: 10.1371/journal.pone.0303844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/01/2024] [Indexed: 06/13/2024] Open
Abstract
Post-partum haemorrhage is among the main causes of (preventable) mortality for women in low-resource settings (LRSs), where, in 2017, the mortality ratio was 462 out of every 100 000 live births, over 10 times higher than for high-resource settings. There are different treatments available for post-partum haemorrhage. The intrauterine balloon tamponade is a medical device that proved to be a simple and cost-effective approach. Currently, there are several balloon tamponades available, with different design and working principles. However, all these devices were designed for high-resource settings, presenting several aspects that could be inappropriate for many lower-income countries. This paper presents the results of a preclinical study aiming at informing the design, prototyping and validation of a 3D-printed intrauterine balloon tamponade concept, contributing towards the United Nation's Sustainable Development Goal 3: Good health and Well-being. Frugal engineering concepts and contextualised design techniques were applied throughout, to define the design requirements and specifications. The performance of the final prototype was validated against the requirements of the UK National Health System (NHS) technical guidelines and relevant literature, measuring the water leak and pressure drop over time, both open air and in a approximate uterus model. The resulting prototype is made up of six components, some of which are easy to retrieve, namely a water bottle, a silicone tube and an ordinary condom, while others can be manufactured locally using 3D printers, namely a modified bottle cap, a flow stopper and a valve for holding the condom in place. Validation testing bore promising results with no water or pressure leak open air, and minimal leaks in the approximate uterus model. This demonstrates that the 3D printed condom-based intrauterine balloon tamponade is performing well against the requirements and, when compared to the state of the art, it could be a more appropriate and more resilient solution to low-resource settings, as it bypasses the challenges in the supply of consumables and presents a greener option based on circular economy.
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Affiliation(s)
- Davide Piaggio
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Scott Hyland
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Alessia Maccaro
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Ernesto Iadanza
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Leandro Pecchia
- School of Engineering, University of Warwick, Coventry, United Kingdom
- School of Engineering, Campus Biomedico of Rome, Rome, Italy
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Joshi BN, Shetty SS, Moray KV, Chaurasia H, Sachin O. Cost-effectiveness and budget impact of adding tranexamic acid for management of post-partum hemorrhage in the Indian public health system. BMC Pregnancy Childbirth 2023; 23:9. [PMID: 36609241 PMCID: PMC9817327 DOI: 10.1186/s12884-022-05308-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the global leading cause of maternal mortality, affecting nearly 3 to 6 percent of all women giving birth in India. The World Health Organization (WHO) has updated its guidelines to recommend the early use of intravenous (IV) tranexamic acid (TXA) in addition to standard care for all diagnosed PPH cases. This study aimed to assess the cost-effectiveness of introducing TXA for PPH management in the Indian public health system. METHODS A decision analytic model was built using a decision tree to determine the cost-effectiveness of administering IV TXA to women experiencing PPH within 3 h of birth to existing management with uterotonics and supportive care. Using a disaggregated societal perspective, the costs and consequences for a hypothetical cohort of women experiencing PPH in public health facilities was estimated. The model was populated using probabilities, clinical parameters, and utilities from published literature, while cost parameters were largely derived from a primary economic costing study. The primary outcome of interest was the incremental cost-utility ratio (ICUR). Associated clinical events and net benefits were estimated. One-way and probabilistic sensitivity analysis (PSA) was undertaken. The budget impact was estimated for a national-level introduction. RESULTS For an estimated annual cohort of 510,915 PPH cases in India, the addition of IV TXA would result in a per-patient disaggregated societal cost of INR 6607 (USD 95.15) with a discounted gain of 20.25 QALYs, as compared to a cost of INR 6486 (USD 93.41) with a discounted gain of 20.17 QALYs with standard care PPH management. At an ICUR value of INR 1470 per QALY gained (USD 21), the addition of IV TXA is cost-effective in Indian public health settings. The intervention is likely to prevent 389 maternal deaths, 177 surgeries, and 128 ICU admissions per 100,000 PPH cases. The findings are robust under uncertainty, with 94.5% of PSA simulations remaining cost-effective. A cumulative increase of 2.3% financial allocation for PPH management over five years will be incurred for TXA introduction. CONCLUSIONS Addition of tranexamic acid for primary PPH management, as recommended by WHO, is cost-effective in Indian public health settings. Policy guidelines, training manuals, and facility checklists should be updated to reflect this recommendation.
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Affiliation(s)
- Beena Nitin Joshi
- grid.19096.370000 0004 1767 225XDepartment of Operational Research, Indian Council of Medical Research - National Institute for Research in Reproductive and Child Health, Mumbai, Maharashtra India
| | - Siddesh Sitaram Shetty
- grid.19096.370000 0004 1767 225XDepartment of Population Health Sciences, King’s College London, Ex-Regional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive and Child Health, Mumbai, Maharashtra India
| | - Kusum Venkobrao Moray
- grid.19096.370000 0004 1767 225XAshwini Rural Medical College Hospital and Research Institute, Kumbhari, Solapur, Ex - Regional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive and Child Health, Mumbai, Maharashtra India
| | - Himanshu Chaurasia
- grid.19096.370000 0004 1767 225XRegional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive and Child Health, Mumbai, Maharashtra India
| | - Oshima Sachin
- grid.415820.aDepartment of Health Research, Ministry of Health and Family Welfare, New Delhi, India
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Arresting post-partum hemorrhage using the novel trans-vaginal uterine artery clamp. Eur J Obstet Gynecol Reprod Biol 2022; 272:6-15. [PMID: 35276445 DOI: 10.1016/j.ejogrb.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/28/2022] [Accepted: 03/01/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Post-partum hemorrhage (PPH) continues to be the leading cause of maternal mortality in low-resource settings. The commonest variant - Atonic PPH, is managed by additional pharmacological measures which may fail. Additional surgical interventions for hemostasis take time and are not universally available. Immediate arrest of bleeding was deemed essential and a novel Transvaginal Uterine Artery Clamp (TVUAC) was explored for its effectiveness in achieving immediate hemostasis in atonic and mixed post-partum hemorrhage. STUDY DESIGN A retrospective chart review was performed for all patients, who underwent vaginal delivery and developed immediate post-partum atonic PPH, in a tertiary care center in South India, between 1st April 2015 and 31st December 2020. As soon as excess bleeding was observed, two TVUACs were applied trans-vaginally at 3' and 9'o clock position of the cervix to occlude the uterine arteries where it joins the isthmus of the uterus. RESULTS Of 3999 vaginal deliveries, there were 251 patients who developed primary atonic PPH during the study period, of which 89 were managed by medical measures alone. Out of the remaining 162 patients, in 153 (94.4%) TVUAC helped to achieve hemostasis; with TVUAC alone in 120 patients (78.43%) and with an additional second line surgical intervention in 33 patients. In nine patients, TVUAC was not readily available and hence second line interventions alone were used. None required any third line surgical interventions (laparotomies) for hemostasis nor were there any incident of maternal mortality or consumptive coagulopathy. TVUAC was applied for a mean duration of 25 ± 10 min. Only 11.6% (29/251, 95% C.I 7.9-16.1%) of the patients required a blood transfusion with a median of 2 (1-4) units of packed RBC. No procedure related complications were reported up to a scheduled 6th week in-person follow-up. CONCLUSION The novel TVUAC shows potential in limiting third line interventions, maternal morbidity and mortality. Its effectiveness and safety may be further explored as a first line surgical adjunct to medical measures, in PPH protocols in low-resource settings.
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Joshi BN, Shetty SS, Moray KV, Sachin O, Chaurasia H. Cost-effectiveness of uterine balloon tamponade devices in managing atonic post-partum hemorrhage at public health facilities in India. PLoS One 2021; 16:e0256271. [PMID: 34407132 PMCID: PMC8372914 DOI: 10.1371/journal.pone.0256271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 08/03/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Post-partum hemorrhage (PPH) is the leading direct cause of maternal mortality in India. Uterine balloon tamponade (UBT) is recommended for atonic PPH cases not responding to uterotonics. This study assessed cost-effectiveness of three UBT devices used in Indian public health settings. Methods A decision tree model was built to assess cost-effectiveness of Bakri-UBT and low-cost ESM-UBT alternatives as compared to the recommended standard of care i.e. condom-UBT intervention. A hypothetical annual cohort of women eligible for UBT intervention after experiencing atonic PPH in Indian public health facilities were evaluated for associated costs and outcomes over life-time horizon using a disaggregated societal perspective. Costs by undertaking primary costing and clinical parameters from published literature were used. Incremental cost per Disability Adjusted Life Years (DALY) averted, number of surgeries and maternal deaths with the interventions were estimated. An India specific willingness to pay threshold of INR 24,211 (USD 375) was used to evaluate cost-effectiveness. Detailed sensitivity analysis and expected value of information analysis was undertaken. Results ESM-UBT at base-case Incremental Cost-Effectiveness Ratio (ICER) of INR -2,412 (USD 37) per DALY averted is a cost-saving intervention i.e. is less expensive and more effective as compared to condom-UBT. Probabilistic sensitivity analysis however shows an error probability of 0.36, indicating a degree of uncertainty around model results. Bakri-UBT at an ICER value of INR -126,219 (USD -1,957) per DALY averted incurs higher incremental societal costs and is less effective as compared to condom-UBT. Hence, Bakri-UBT is not cost-effective. Conclusion For atonic PPH management in India, condom-UBT offers better value as compared to Bakri-UBT. Given the limited clinical effectiveness evidence and uncertainty in sensitivity analysis, cost-saving result for ESM-UBT must be considered with caution. Future research may focus on generating high quality comparative clinical evidence for UBT devices to facilitate policy decision making.
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Affiliation(s)
- Beena Nitin Joshi
- Department of Operational Research, Indian Council of Medical Research - National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
| | - Siddesh Sitaram Shetty
- Regional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
| | - Kusum Venkobrao Moray
- Regional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
| | - Oshima Sachin
- Department of Health Research, Ministry of Health and Family Welfare, New Delhi, India
| | - Himanshu Chaurasia
- Regional Resource Hub for Health Technology Assessment, Indian Council of Medical Research - National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
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Shetty SS, Moray KV, Chaurasia H, Joshi BN. Cost of managing atonic postpartum haemorrhage with uterine balloon tamponade devices in public health settings of Maharashtra, India: an economic microcosting study. BMJ Open 2021; 11:e042389. [PMID: 33653747 PMCID: PMC7929829 DOI: 10.1136/bmjopen-2020-042389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Postpartum haemorrhage (PPH) is the worldwide leading cause of preventable maternal mortality. India offers free treatment for pregnancy and related complications in its public health facilities. Management with uterine balloon tamponade (UBT) is recommended for refractory atonic PPH cases. As part of health technology assessment to determine the most cost-effective UBT device, this study estimated costs of atonic PPH management with condom-UBT, Every Second Matters (ESM) UBT and Bakri balloon UBT in public health system of Maharashtra, India. DESIGN Health system cost was estimated using primary economic microcosting, data from Health Management Information System and published literature for event probabilities. SETTINGS Four public health facilities from the state of Maharashtra, India representing primary, secondary and tertiary level care were chosen for primary costing. OUTCOME MEASURES Unit, package and annual cost of atonic PPH management with three UBT devices were measured. This included cost of medical treatment, UBT intervention and PPH related surgeries undertaken in public health system of Maharashtra for year 2017-2018. RESULTS Medical management of atonic PPH cost the health system US$37 (95% CI 29 to 45) per case, increasing to US$44 (95% CI 36 to 53) with condom-UBT and surgical interventions for uncontrolled cases. Similar cost was estimated for ESM-UBT. Bakri-UBT reported a higher cost of US$59 (95% CI 46 to 73) per case. Overall annual cost of managing 27 915 atonic PPH cases with condom-UBT intervention in Maharashtra was US$1 226 610 (95% CI 870 250 to 1 581 596). CONCLUSIONS Atonic PPH management in public health facilities of Maharashtra with condom-UBT, ESM-UBT or Bakri-UBT accounts to 3.8%, 3.8% or 5.2% of the state's annual spending on reproductive and child health services. These findings can guide policy-makers to include PPH complication management in publicly financed health schemes. Economic evaluation studies can use this evidence to determine cost effectiveness of UBT in Indian settings.
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Affiliation(s)
- Siddesh Sitaram Shetty
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Kusum Venkobrao Moray
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Himanshu Chaurasia
- Regional Resource Hub for Health Technology Assessment in India, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
| | - Beena Nitin Joshi
- Department of Operational Research, Indian Council of Medical Research-National Institute for Research in Reproductive Health, Mumbai, India
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Alves ÁLL, Senra JC, Gonçalves CR, Ribeiro BR, São José CN, Candido EB, Silva LB, Silva‐Filho AL. Uterine tamponade in postpartum hemorrhage: A new handmade intrauterine balloon. Int J Gynaecol Obstet 2020; 149:248-250. [DOI: 10.1002/ijgo.13105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/23/2019] [Accepted: 01/27/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Álvaro Luiz Lage Alves
- Department of Obstetrics and Gynecology Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brazil
- Department of Obstetrics and Gynecology Sofia Feldman Hospital Belo Horizonte Brazil
- Department of Obstetrics and Gynecology Faculdade de Ciências Médicas de Minas Gerais Belo Horizonte Brazil
| | - Janaína Campos Senra
- Department of Obstetrics and Gynecology Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | | | - Bruna Roque Ribeiro
- Department of Obstetrics and Gynecology Faculdade de Ciências Médicas de Minas Gerais Belo Horizonte Brazil
| | - Carolina Nogueira São José
- Department of Obstetrics and Gynecology Faculdade de Ciências Médicas de Minas Gerais Belo Horizonte Brazil
| | - Eduardo Batista Candido
- Department of Obstetrics and Gynecology Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Lucas Barbosa Silva
- Department of Obstetrics and Gynecology Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brazil
- Department of Obstetrics and Gynecology Sofia Feldman Hospital Belo Horizonte Brazil
| | - Agnaldo Lopes Silva‐Filho
- Department of Obstetrics and Gynecology Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brazil
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Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, Suarez-Rebling D, Eckardt M, Theron G, Burke TF. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 222:293.e1-293.e52. [PMID: 31917139 DOI: 10.1016/j.ajog.2019.11.1287] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/12/2019] [Accepted: 11/18/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the efficacy, effectiveness, and safety of uterine balloon tamponade for treating postpartum hemorrhage. STUDY DESIGN We searched electronic databases (from their inception to August 2019) and bibliographies. We included randomized controlled trials, nonrandomized studies, and case series that reported on the efficacy, effectiveness, and/or safety of uterine balloon tamponade in women with postpartum hemorrhage. The primary outcome was the success rate of uterine balloon tamponade for treating postpartum hemorrhage (number of uterine balloon tamponade success cases/total number of women treated with uterine balloon tamponade). For meta-analyses, we calculated pooled success rate for all studies, and relative risk with 95% confidence intervals for studies that included a comparative arm. RESULTS Ninety-one studies, including 4729 women, met inclusion criteria (6 randomized trials, 1 cluster randomized trial, 15 nonrandomized studies, and 69 case series). The overall pooled uterine balloon tamponade success rate was 85.9% (95% confidence interval, 83.9-87.9%). The highest success rates corresponded to uterine atony (87.1%) and placenta previa (86.8%), and the lowest to placenta accreta spectrum (66.7%) and retained products of conception (76.8%). The uterine balloon tamponade success rate was lower in cesarean deliveries (81.7%) than in vaginal deliveries (87.0%). A meta-analysis of 2 randomized trials that compared uterine balloon tamponade vs no uterine balloon tamponade in postpartum hemorrhage due to uterine atony after vaginal delivery showed no significant differences between the study groups in the risk of surgical interventions or maternal death (relative risk, 0.59; 95% confidence interval, 0.02-16.69). A meta-analysis of 2 nonrandomized before-and-after studies showed that introduction of uterine balloon tamponade in protocols for managing severe postpartum hemorrhage significantly decreased the use of arterial embolization (relative risk, 0.29; 95% confidence interval, 0.14-0.63). A nonrandomized cluster study reported that use of invasive procedures was significantly lower in the perinatal network that routinely used uterine balloon tamponade than that which did not use uterine balloon tamponade (3.0/1000 vs 5.1/1000; P < .01). A cluster randomized trial reported that the frequency of postpartum hemorrhage-related invasive procedures and/or maternal death was significantly higher after uterine balloon tamponade introduction than before uterine balloon tamponade introduction (11.6/10,000 vs 6.7/10,000; P = .04). Overall, the frequency of complications attributed to uterine balloon tamponade use was low (≤6.5%). CONCLUSION Uterine balloon tamponade has a high success rate for treating severe postpartum hemorrhage and appears to be safe. The evidence on uterine balloon tamponade efficacy and effectiveness from randomized and nonrandomized studies is conflicting, with experimental studies suggesting no beneficial effect, in contrast with observational studies. Further research is needed to determine the most effective programmatic and healthcare delivery strategies on uterine balloon tamponade introduction and use.
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Affiliation(s)
- Sebastian Suarez
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts.
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan
| | - Anderson Borovac-Pinheiro
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas (SP), Brazil
| | - Daniela Suarez-Rebling
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Melody Eckardt
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Thomas F Burke
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Hu K, Lapinski MM, Mischler G, Allen RH, Manbachi A, Seay RC. Improved Treatment of Postpartum Hemorrhage: Design, Development, and Bench-Top Validation of a Reusable Intrauterine Tamponade Device for Low-Resource Settings. J Med Device 2020. [DOI: 10.1115/1.4045965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
AbstractPostpartum 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.
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Affiliation(s)
- Katherine Hu
- Department of Biomedical Engineering, The Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218
| | - Maya M. Lapinski
- Department of Biomedical Engineering, The Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218
| | - Gavin Mischler
- Department of Biomedical Engineering, The Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218
| | - Robert H. Allen
- Albert Einstein College of Medicine, Yeshiva University, Jack and Pearl Resnick Campus, 1300 Morris Park Avenue, Belfer Building, Room 512, Bronx, NY 10461
| | - Amir Manbachi
- Department of Neurosurgery, The Johns Hopkins University, Meyer Building, Room 8-181C, 600 N Wolfe Street, Baltimore, MD 21287; Department of Biomedical Engineering, The Johns Hopkins University, Clark Hall, Room 208F, 3400 N Charles Street, Baltimore, MD 21218
| | - Rachel Chan Seay
- Department of Gynecology and Obstetrics, School of Medicine, Johns Hopkins Bayview Medical Center, The Johns Hopkins University, A Building, Room 121, 4940 Eastern Avenue, Baltimore, MD 21224
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Mollazadeh-Moghaddam K, Dundek M, Bellare A, Borovac-Pinheiro A, Won A, Burke TF. Mechanical Properties of the Every Second Matters for Mothers-Uterine Balloon Tamponade (ESM-UBT) Device: In Vitro Tests. AJP Rep 2019; 9:e376-e383. [PMID: 31815053 PMCID: PMC6894953 DOI: 10.1055/s-0039-1697653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022] Open
Abstract
Objective Postpartum hemorrhage (PPH) is the most common cause of maternal mortality and morbidity worldwide, most of which occurs in resource-poor settings. Placement of a uterine balloon may be life-saving in uncontrolled PPH. The Every Second Matters for Mothers-Uterine Balloon Tamponade (ESM-UBT) device is an ultra-low-cost uterine balloon designed for global access. The purpose of this study was to evaluate the mechanical properties of the ESM-UBT device. Study design Intraluminal pressures, diameters, and burst volumes of condom uterine balloons and Foley catheter balloons of ESM-UBT devices were measured in open air and inside uterus models. Condom uterine balloons were tested with uterus model sizes of 100, 250, and 500mL. The condom-catheter O-ring attachment tensile strength was also evaluated. Results All 28 samples of ESM-UBT condom uterine balloons maintained their integrity for at least 3 hours when subjected to pressures of 200 mm Hg or greater across each of the tested uterine volumes. No Foley catheter balloons burst after instillation of 30mL, O-rings withstood forces of 15.4 ± 2.1 N, and condom uterine balloons stretched to 35.8 ± 2.1 cm without loss of integrity. Conclusion The mechanical properties of the ESM-UBT device make it attractive for scale across resource-poor settings.
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Affiliation(s)
- Kamyar Mollazadeh-Moghaddam
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michelle Dundek
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anuj Bellare
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anderson Borovac-Pinheiro
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Alice Won
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas F Burke
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Perrin C, Hounga L, Geissbuhler A. Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus. BMJ Open 2018; 8:e022262. [PMID: 30121608 PMCID: PMC6104789 DOI: 10.1136/bmjopen-2018-022262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/18/2018] [Accepted: 07/26/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes. DESIGN Systematic review and Delphi study. METHODS We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists. RESULTS We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators. CONCLUSIONS The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable. PROSPERO REGISTRATION NUMBER CRD42015027351.
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Affiliation(s)
- Caroline Perrin
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lothaire Hounga
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Antoine Geissbuhler
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Henriquez DDCA, Bloemenkamp KWM, van der Bom JG. Management of postpartum hemorrhage: how to improve maternal outcomes? J Thromb Haemost 2018; 16:S1538-7836(22)02220-6. [PMID: 29883040 DOI: 10.1111/jth.14200] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Indexed: 01/18/2023]
Abstract
Postpartum hemorrhage is the leading cause of maternal mortality and severe morbidity. Despite efforts to improve maternal outcomes, management of postpartum hemorrhage still faces at least four challenges, discussed in this review. First, current definitions for severe postpartum hemorrhage hamper early identification of women with a high risk of adverse outcomes. Adaptations to the definitions and the use of clinical tools such as shock index and early warning systems may facilitate this early identification. Second, surgical and radiological interventions to prevent hysterectomy are not always successful. More knowledge on the influence of patient and bleeding characteristics on the success rates of these interventions is necessary. Scarce data suggest that early timing of intrauterine balloon tamponade may improve maternal outcomes, whereas early timing of arterial embolization seems to be unrelated to maternal outcomes. Third, fluid resuscitation with crystalloids and colloids is unavoidable in the early phases of postpartum hemorrhage but may result in dilutional coagulopathy. Effects of different volumes of clear fluids on the occurrence of dilutional coagulopathy and maternal outcomes is unknown. Fourth, a better understanding of diagnosis and correction of coagulopathy during postpartum hemorrhage is needed. Low plasma fibrinogen levels at the start of postpartum hemorrhage predict progression to severe hemorrhage, but standard coagulation screens are time consuming. A solution may be point-of-care coagulation testing; however, clinical usefulness during postpartum hemorrhage has not been demonstrated. To date, early administration of tranexamic acid is the only hemostatic intervention that was proven to improve outcomes in women with postpartum hemorrhage.
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Affiliation(s)
- D D C A Henriquez
- Center for Clinical Transfusion Research, Sanquin Research and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics, Birth Center, Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Dumont A, Bodin C, Hounkpatin B, Popowski T, Traoré M, Perrin R, Rozenberg P. Uterine balloon tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage: a randomised controlled trial in Benin and Mali. BMJ Open 2017; 7:e016590. [PMID: 28864699 PMCID: PMC5589006 DOI: 10.1136/bmjopen-2017-016590] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of low-cost uterine tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage (PPH) in low-resource settings. DESIGN Randomised controlled trial. SETTING Seven healthcare facilities in Cotonou, Benin and Bamako, Mali. POPULATION Women delivering vaginally who had clinically diagnosed PPH that was suspected to be due to uterine atony, who were unresponsive to oxytocin and who needed additional uterotonics. METHODS Women were randomly assigned to receive uterine balloon tamponade with a condom-catheter device or no tamponade; both groups were also given intrarectal or sublingual misoprostol. MAIN OUTCOME MEASURE Proportion of women with invasive surgery or who died before hospital discharge. RESULTS The proportion of primary composite outcome did not differ significantly between the tamponade arm (16%; 9/57) and the standard second line treatment arm (7%; 4/59): relative risk 2.33 (95% CI 0.76 to 7.14, p=0.238). A significantly increased proportion of women with tamponade and misoprostol versus misoprostol alone had total blood loss more than 1000 mL: relative risk 1.52 (95% CI 1.15 to 2.00, p=0.01). Case fatality rate was higher in the tamponade group (10%; 6/57) than in the control group (2%; 1/59) (p=0.059). TRIAL REGISTRATION NUMBER ISRCT Registry Number 01202389; Post-results.
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Affiliation(s)
- Alexandre Dumont
- Research Institute for Development, Université Paris Descartes, Paris, France
| | - Cécile Bodin
- Research Institute for Development, Université Paris Descartes, Paris, France
- Community of Practice QUAHOR, Quality of Care in Referral Hospitals, Paris, France
| | - Benjamin Hounkpatin
- Department of Obstetrics and Gynaecology, CHU-MEL, University Hospital for Mother and Child of Lagune, Cotonou, Benin
| | - Thomas Popowski
- Department of Obstetrics and Gynaecology, Poissy Saint Germain Hospital, Poissy, France
| | - Mamadou Traoré
- Department of Obstetrics and Gynaecology, Referral Health Center of the Commune V, Bamako, Mali
| | - René Perrin
- Department of Obstetrics and Gynaecology, CHU-MEL, University Hospital for Mother and Child of Lagune, Cotonou, Benin
| | - Patrick Rozenberg
- Department of Obstetric and Gynecology, Poissy Saint Germain Hospital, Poissy, France
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