Successful use of a Sengstaken-Blakemore tube to control massive postpartum haemorrhage

Introduction of the Ellavi uterine balloon tamponade into the Kenyan and Ghanaian maternal healthcare package for improved postpartum haemorrhage management: an implementation research study

OBJECTIVES

Use of intrauterine balloon tamponades for refractory postpartum haemorrhage (PPH) management has triggered recent debate since effectiveness studies have yielded conflicting results. Implementation research is needed to identify factors influencing successful integration into maternal healthcare packages. The Ellavi uterine balloon tamponade (UBT) (Ellavi) is a new low-cost, preassembled device for treating refractory PPH.

DESIGN

A mixed-methods, prospective, implementation research study examining the adoption, sustainability, fidelity, acceptability and feasibility of introducing a newly registered UBT. Cross-sectional surveys were administered post-training and post-use over 10 months.

SETTING

Three Ghanaian (district, regional) and three Kenyan (levels 4-6) healthcare facilities.

PARTICIPANTS

Obstetric staff (n=451) working within participating facilities.

INTERVENTION

PPH management training courses were conducted with obstetric staff.

PRIMARY AND SECONDARY OUTCOME MEASURES

Facility measures of adoption, sustainability and fidelity and individual measures of acceptability and feasibility.

RESULTS

All participating hospitals adopted the device during the study period and the majority (52%-62%) of the employed obstetric staff were trained on the Ellavi; sustainability and fidelity to training content were moderate. The Ellavi was suited for this context due to high delivery and PPH burden. Dynamic training curriculums led by local UBT champions and clear instructions on the packaging yielded positive attitudes and perceptions, and high user confidence, resulting in overall high acceptability. Post-training and post-use, ≥79% of the trainees reported that the Ellavi was easy to use. Potential barriers to use included the lack of adjustable drip stands and difficulties calculating bag height according to blood pressure. Overall, the Ellavi can be feasibly integrated into PPH care and was preferred over condom catheters.

CONCLUSIONS

The training package and time saving Ellavi design facilitated its adoption, acceptability and feasibility. The Ellavi is appropriate and feasible for use among obstetric staff and can be successfully integrated into the Kenyan and Ghanaian maternal healthcare package.

TRIAL REGISTRATION NUMBERS

NCT04502173; NCT05340777.

Efficacy of Intra-Uterine Tamponade Balloon in Post-Partum Hemorrhage after Cesarean Delivery: An Impact Study

Invasive therapies (surgery or radiological embolization) are used to control severe post-partum hemorrhage. The intra-uterine tamponade balloon is a potential alternative, well documented after vaginal delivery. However, available data on its use after cesarean delivery remain scarce. This study assessed the efficacy of the intra-uterine tamponade balloon during post-partum hemorrhage in a cesarean delivery setting. Using a retrospective impact design, post-partum hemorrhage-related outcomes before (“pre-balloon” period) versus after implementation of intra-uterine tamponade balloon (“post-balloon” period) were compared. All women with post-partum hemorrhage requiring potent uterotonic treatment with prostaglandins after cesarean delivery over a 9-year period were eligible. The primary outcome was the rate of invasive procedure (conservative surgery, radiological embolization and/or hysterectomy). p < 0.05 was considered statistically significant. A total of 279 patients were included (140 vs. 139). Most baseline characteristics were comparable between the two studied periods. The success rate of the intra-uterine tamponade balloon was 82%, and no related complications occurred. Rates of invasive procedures and transfusion were significantly reduced (28.6% vs. 11.5%, p < 0.001 and 44.3% vs. 28.1%, p = 0.006 respectively) during the “post-balloon” period, and length of hospital stay was shorter (p < 0.001). Implementation of intra-uterine tamponade balloon during post-partum hemorrhage after cesarean delivery appears to be safe and effective, with a decrease in both invasive procedures and transfusion rates.

Efficacy of Prophylactic Antibiotics in Bakri Intrauterine Balloon Placement: A Single-Center Retrospective Analysis and Literature Review

Objective  Bakri intrauterine balloon (BIUB) placement is an effective treatment for postpartum hemorrhage (PPH). This study aims to evaluate the risk of infection during BIUB placement. Study Design  Data for all deliveries ( n  = 2,144) at our institution between January 2014 and March 2018 were retrospectively reviewed. Patients diagnosed with PPH ( n  = 758) were included in our analysis, further divided into BIUB ( n  = 80) and non-BIUB groups ( n  = 678), and subdivided into vaginal delivery (VD), elective cesarean delivery (CD), and emergency CD groups. Postpartum endometritis rate was compared in each group. A single dose of prophylactic antibiotics was administered for BIUB placement in the VD group. In the CD groups, antibiotics were administered preoperatively once, and no additional antibiotics for BIUB placement were administered. To obtain an antibiotics administration protocol to be applied during BIUB placement, we electronically searched the PubMed and Scopus databases. Results  No significant differences were observed in endometritis rates between BIUB and non-BIUB groups of all groups. In the literature review, of 27 suitable publications identified, multiple doses of antibiotics were administered in 17 (62.9%) studies and none investigated the efficacy of a protocol for antibiotic. Conclusion  Our protocol might be effective and sufficient in preventing postpartum BIUB placement-related endometritis.

Successful use of balloon tamponade in the management of postpartum hemorrhage in a case of bicornuate uterus

Worldwide 50%-70% of all cases of maternal morbidity have been attributed to postpartum hemorrhage. This report discusses a case of bicornuate uterus in a term pregnancy. The delivery was by cesarean section, which was followed by massive postpartum hemorrhage, managed successfully with balloon tamponade. This is the second reported case of successful management of post partum hemorrhage in a bicornuate uterus with balloon tamponade. A 22-year-old primigravida at 39 weeks of gestational age presented with vaginal leaking of clear fluid. Cesarean section was done due to meconium stained liquor in early labor; with an incidental finding of bicornuate uterus followed by massive postpartum hemorrhage managed successfully with balloon tamponade. The use of uterine balloon tamponade as an effective method to control postpartum hemorrhage has been studied extensively, but use in cases of hemorrhage associated with uterine malformations has not been reported much in literature. Use of uterine balloon tamponade in case of uterine malformations has been highlighted in our case as an effective non-surgical method to control hemorrhage.

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.

Initial experience with a dual-balloon catheter for the management of postpartum hemorrhage

OBJECTIVE

When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after delivery, tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony.

STUDY DESIGN

These data are from a postmarketing surveillance study of a novel dual-balloon catheter tamponade device, the Belfort-Dildy Obstetrical Tamponade System (ebb).

RESULTS

A total of 57 women were enrolled: 55 women had the diagnosis of postpartum hemorrhage, and 51 women had uterine balloon placement within the uterine cavity. This study reports the outcomes in the 51 women who had uterine balloon placement within the uterine cavity for treatment of postpartum hemorrhage, as defined by the "Instructions for Use." We further assessed 4 subgroups: uterine atony only (n = 28 women), placentation abnormalities (n = 8 women), both uterine atony and placentation abnormalities (n = 9 women), and neither uterine atony nor placentation abnormalities (n = 6 women). The median (range) time interval between delivery and balloon placement was 2.2 hours (0.3-210 hours) for the entire cohort (n = 51 women) and 1.3 hours (0.5-7.0 hours) for the uterine atony only group (n = 28 women). Bleeding decreased in 22/51 of cases (43%), stopped in 28/51 of cases (55%), thus decreased or stopped in 50/51 of the cases (98%) after balloon placement. Nearly one-half (23/51) of all women required uterine balloon volumes of >500 mL to control bleeding.

CONCLUSION

We conclude that uterine/vaginal balloon tamponade is very useful in the management of postpartum hemorrhage because of uterine atony and abnormal placentation.

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.

CEU: Prevention and Treatment of Postpartum Hemorrhage: New Advances for Low-Resource Settings

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

Ectopic placement of Sengstaken-Blakemore device to correct outflow obstruction in liver transplantation: case reports

Liver transplantation is a complex procedure that has become the treatment for some end-stage liver diseases. Some technical features are important for the success of the transplantation, including the patency of the vascular anastomoses. In cadaveric whole organ liver transplantation, a large right subphrenic space may contribute to a twist of the inferior vena cava, leading to outflow obstruction, simulating an acute Budd-Chiari syndrome. Some devices can be used to correct this drainage problem. Herein, we have described 2 cases in which the Sengstaken-Blakemore balloon was safely used, in an ectopic position, to fix drainage complications in whole liver orthotopic transplantation.

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.

Surgical intervention in the management of postpartum hemorrhage

Obstetric hemorrhage is often a sudden, life-threatening event. Successful management hinges on both preoperative preparation if hemorrhage is anticipated as well as knowledge of interventions. Uterine-sparing techniques, such as aggressive and early use of uterotonics, balloon tamponade, uterine compression sutures, arterial ligation, and selective arterial embolization, may be used to control hemorrhage. If these techniques are not adequate, the decision must be made to proceed with hysterectomy. The type of hysterectomy (subtotal vs. total) must be individualized to each patient. Hemostatic agents may be particularly useful in patients who have excessive blood loss from raw tissue surfaces.

Mechanisms of hemostasis at cesarean delivery

Postpartum hemorrhage is an obstetric emergency that represents a major cause of maternal morbidity and mortality. With the recent rise in the cesarean delivery rate, prompt recognition and proper management at the time of cesarean delivery are becoming increasingly important for providers of obstetrics. Preparedness for hemorrhage can be achieved by recognition of prior risk factors and implementation of specific hemorrhage protocols. Medical and surgical therapies are available to treat obstetric hemorrhage after cesarean delivery.

The use of the condom-catheter for the treatment of postpartum haemorrhage – the Sokoto experience

SUMMARY

Postpartum haemorrhage (PPH) is the most common cause of maternal mortality globally. In about 50% of cases PPH is due to uterine atony. When conservative and medical methods of treating PPH due to uterine atony fail, surgical intervention is required to save the woman's life. As an alternative in such cases, intrauterine tamponade has been used successfully to stop bleeding, thus avoiding surgery. We report four cases of PPH due to uterine atony in which intrauterine tamponade with an inflated condom was effective in arresting haemorrhage. We advocate the use of a similar device in carefully selected cases, especially in low-resource settings.

Peripartum hysterectomies at the korle-bu teaching hospital: a review of 182 consecutive cases

SUMMARY OBJECTIVES

The main objectives of this study were to determine the incidence, maternal characteristics, indications, the maternal and perinatal outcomes and the complications of emergency peripartum hysterectomies done at the Korle-Bu Teaching Hospital.

STUDY DESIGN

This is a retrospective descriptive study covering the period January 1, 2000 to June 30, 2003.

SETTING

Maternity Unit of the Korle-Bu Teaching Hospital

RESULTS

The incidence of peripartum hysterectomy during the study period was 4.34/1000 deliveries. The main indication was severe uterine bleeding from uterine rupture 89 (48.9%), uterine atony 60 (33%), placenta accreta 20 (11%) and post caesarean uterine wound sepsis and necrosis 11 (6%). The average blood loss was 2.02 (SD 0.86) L and all patients received blood transfusion. The mean age of the patients was 31.6 (SD 5.3) years and the mean parity was 2.7 (SD 1.7). Complications occurred in 28 (19.8%) patients. The stillbirth rate was 483.5/1000 deliveries and the maternal mortality was 12.9%. The average duration of hospital stay was 11 (SD 8) days.

CONCLUSIONS

The incidence of emergency peripartum hysterectomy is high. It is performed for young nulliparous women through to elderly grand-multiparous women. The surgery is associated with significant maternal and perinatal morbidity and mortality. Timely expert management in a well resourced centre is advocated.

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is the most important single cause of maternal death in both developing and developed countries. It arises from abnormalities in one of four basic processes, with uterine atony being the most common. A multidisciplinary approach to management is important. The value of oxytocin and prostaglandins, including misoprostol, in treatment is discussed. Recently developed, less invasive treatment options, namely uterine tamponade and compression sutures, are fast becoming valuable alternatives to the traditional options of pelvic devascularization and hysterectomy. With a stark contrast in maternal mortality from PPH between the developing and developed countries, public health strategies and medical interventions intended to minimize this are further discussed.

Successful Treatment of Post-Cesarean Hemorrhage Related to Placenta Praevia Using an Intrauterine Balloon

The authors report a positive experience in controlling severe postpartum hemorrhage after cesarean section performed for placenta praevia by using an inflated intrauterine balloon and avoiding any further invasive surgery.

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.

Emergency peripartum hysterectomy in a tertiary London hospital

OBJECTIVE

The objective was to review all emergency peripartum hysterectomies performed at a tertiary hospital in London, UK, and to identify the risk factors for emergency peripartum hysterectomy.

METHOD

A retrospective case control study. The cases consisted of all women who had emergency peripartum hysterectomy between 1 January 1993 and 31 December 2003. Controls were women who delivered immediately before and after the indexed case. Demographic data, medical and surgical histories, pregnancy, intrapartum and postpartum data were collected. Differences between cases and controls were compared with chi2, Fisher exact and Student t tests. Multiple logistic regression analysis was performed to identify independent risk factors for emergency peripartum hysterectomy.

RESULTS

There were 15 cases of emergency peripartum hysterectomy in 31,079 deliveries, giving a rate of 0.48 per 1,000. Women who had emergency peripartum hysterectomy were significantly older (mean age 37 years vs. 29 years, P<0.001) and multiparous (P=0.02). More of the cases had a history of uterine surgery (67 vs. 30%, P=0.01), placenta praevia (60 vs. 3%, P<0.0001) and were delivered by caesarean section (86.7 vs. 30%, P=0.003). Eighty percent of the hysterectomies were performed in the daytime and all were done by consultants. Haemorrhage due to placenta praevia was the main indication for emergency peripartum hysterectomy (47%). Independent risk factors for emergency peripartum hysterectomy were older age (odds ratios [OR] 1.2, 95% confidence interval [95% CI] 1.2-1.6), multiparity (OR 2.6, 95% CI 1.3-10.2), history of previous caesarean section (OR 13.5, 95% CI 2.7-65.4), caesarean delivery in index pregnancy (OR 11.6, 95% CI 2.1-68.6) and caesarean delivery in index pregnancy for placenta praevia (OR 18, 95% CI 3.6-69).

CONCLUSION

Caesarean deliveries, especially repeat caesareans in women with placenta praevia, significantly increase the risk of emergency peripartum hysterectomy.

[Intractable postpartum haemorrhages: where is the place of vascular ligations, emergency peripartum hysterectomy or arterial embolization?]

OBJECTIVE

Update of knowledge on the various methods of management of intractable postpartum haemorrhage.

METHOD

PubMed, MEDLINE were the electronic sources, in English and French languages, used for data retrieval. Uterine atony and abnormal placental insertions (placenta praevia or accreta) are the major causes of primary postpartum haemorrhages. To preserve fertility, we dispose of angiographic selective embolization or surgical vascular ligations. Embolization is a non-invasive method practicable by simple catheterization under local anesthesia. Vascular ligations of the uterine vessels or internal iliac arteries require mostly laparotomy. New and easier surgical methods, such as uterine compression or hemostatic suturing techniques have been described for which we lack experience.

RESULTS

For uterine atony, the success rate of arterial embolization and uterine artery ligations is close to 100%. Ligation of internal iliac arteries is a little less effective and technically more difficult to carry out. It remains interesting in obstetrical traumatic hurts, which do not concern the uterus. If bleeding from the lower segment occurs during caesarean section, low uterine artery ligatures are necessary. These methods are all the more effective than they are prematurely implemented before the rise of major coagulopathy. In this case, uterine devascularization has also to be applied to ovarian vessels. With placenta accreta, accreta portion of the placenta can be left in place and arterial embolization or vascular ligations can be done. Nevertheless the main cause of failure with conservative treatments is placenta accreta.

CONCLUSION

The simplest and the least morbid methods must be retained. After vaginal birth, arterial embolization can be done, if there is no maternal haemodynamic disorder nor interventional vascular radiology unit nearby. During caesarean section, progressive uterine artery ligation can be done adapted to the bleeding cause. In case of failure of a conservative treatment, it would be dangerous to multiply techniques. Emergency peripartum then should remain the choice procedure.

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.

Planning for hemorrhage. Steps an anesthesiologist can take to limit and treat hemorrhage in the obstetric patient

Obstetric hemorrhage continues to be a significant cause of maternal mortality and morbidity. Blood transfusion in such circumstances may be life saving but involves exposing the patient to additional risks. Limiting blood transfusion and using autologous blood when possible may reduce some of these risks. This article outlines the techniques that may be used to limit and more effectively treat hemorrhage in the obstetric patient, with particular attention paid to reducing the use of allogeneic blood transfusion.

Uterine compression sutures as an alternative to hysterectomy for severe postpartum hemorrhage

OBJECTIVE

To assess the use of B-Lynch type uterine compression sutures as an alternative to hysterectomy for severe postpartum hemorrhage (PPH) due to uterine atony.

METHODS

The use of uterine compression sutures for severe postpartum hemorrhage was reviewed over a 30-month period (January 2000 June 2002) in a tertiary obstetric unit.

RESULTS

In 7 cases of uterine atony at the time of Caesarean section, which were unresponsive to all oxytocic agents, a B-Lynch type compression suture was used before resorting to hysterectomy. In 6 of the 7 women, the bleeding was controlled with the suture, while the other required hysterectomy.

CONCLUSION

At the time of writing there were 6 reports in the literature involving a total of 20 women who were successfully treated with this type of compression suture for severe atonic PPH. Our review adds 7 cases and found that the B-Lynch compression suture is easy to apply and should be considered in cases of severe atonic PPH when oxytocic agents fail, and before resorting to hysterectomy.

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.

Major postpartum haemorrhage

Postpartum haemorrhage remains in the top five causes of maternal deaths in both developed and developing countries. Persistent blood loss of more than 1000 ml should prompt predetermined measures to achieve resuscitation and haemostasis. A protocol including guidelines is given and volume replacement is discussed. The range of medical and surgical interventions that may be considered for the modern management of major haemorrhage unresponsive to oxytocin and ergometrine are presented. The review discusses in depth the use of misoprostol, recombinant activated factor VII, the uterine tamponade procedures, artery ligation, and uterine haemostatic suturing techniques. It also evaluates the place of interventional radiology and hysterectomy in modern obstetrics.

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.

Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy

Postpartum haemorrhage remains a significant complication of childbirth in the UK and worldwide. The most common cause of postpartum haemorrhage is uterine atony, but placent accreta is becoming more frequent. In these situations tamponade may be required. The successful use of the inflated stomach balloon (300ml) of a Sengstaken-Blakemore tube has been reported previously. We describe an innovative method of 'tamponade' which is simple and effective, using the Rüsch urological hydrostatic balloon catheter. In two cases of failed medical therapy for PPH, where the catheter has been tried, further surgical interventions have been avoided.

Postpartum haemorrhage

Postpartum haemorrhage can be either primary (within 24 hours of delivery) or secondary (within the following weeks). This article reviews the factors that may help anticipation of postpartum haemorrhage, and looks at issues involved in the management and treatment of women with this condition.