Application of uterine compression suture in association with intrauterine balloon tamponade (‘uterine sandwich’) for postpartum hemorrhage

Procedural techniques to control postpartum hemorrhage

Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. Treatment procedures include obstetric, surgical, and radiologic techniques. In addition to availability and experience with the techniques, two important aspects must be considered in the selection process: the type of delivery and the cause of the hemorrhage. In particular, the distinction between pregnancies with or without disturbed placentation from the placenta accreta spectrum is crucial. From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.

Management of postpartum haemorrhage in a patient with Klippel-Trènaunay syndrome

Klippel-Trènaunay syndrome is a rare congenital disorder characterised by vascular malformations, which may be exacerbated during pregnancy and pose considerable thromboembolic and haemorrhagic risk for obstetric patients. We report on a patient with this syndrome who underwent elective caesarean section which was indicated due to previous obstetric anal sphincter injury. We describe her multidisciplinary preoperative planning and successful management of major postpartum haemorrhage with uterine compression sutures and intrauterine balloon tamponade ('uterine sandwich').

Hemostatic effect of combined procedures for placenta previa: cervix-holding, intrauterine balloon, and uterine compression suture

OBJECTIVES

Various procedures have been introduced to achieve hemostasis for postpartum hemorrhage (PPH) in placenta previa (PP). This study attempted to clarify the effectiveness of the combined use of three hemostatic procedures: Matsubara-Takahashi cervix-holding (MT-holding), intrauterine balloon (IUB), and uterine compression suture (UCS).

STUDY DESIGN

This was a historical cohort study on the hemostatic effect of combined procedures for patients with placenta previa (PP) undergoing cesarean section between April 2006 and December 2018. Until 2011 (2006-2011), we used MT-holding alone, whereas since 2012 we have also been using IUB and UCS: MT-holding alone was used in the former period whereas three procedures (MT-holding, IUB, UCS, and their combinations) have been used in the latter period. Perinatal outcomes were compared between 2006-2011 (before group) and 2012-2018 (after group).

RESULTS

Of 416 patients with PP, excluding 273 patients with cesarean hysterectomy or no hemostatic procedure, the remaining 143 patients were analyzed. In the after group, intraoperative blood loss, the percentage of patients with postoperative blood loss ≥ 500 ml, and incidence of autologous blood transfusion were significantly lower than in the before group. Multivariate analysis showed that postoperative blood loss ≥ 500 ml decreased in the after group (adjusted OR: 0.3, 95%CI: 0.1-0.8, compared with the before group).

CONCLUSION

PPH decreased after introducing the combination of hemostatic procedures in patients with PP. Further studies are needed to determine the best combination and optimal indication for combining hemostatic procedures for PP.

A novel low uterine segment sandwich technique (Caliskan's technique) for the management of post-cesarean hemorrhage due to placenta previa accreta

Objective:

Placenta previa (PP) and placenta accreta spectrum (PAS) disorders are major causes of postpartum hemorrhage (PPH). There is a variety of surgical management options with inexplicit reported success rates. Uterine sandwich is a combination of uterine compression sutures and intrauterine balloon placement to achieve hemostasis. The aim of this study was to present our experience of seven women managed with a novel “lower uterine sandwich” technique to control post-cesarean hemorrhage due to PP accreta.

Materials and Methods:

Seven pregnant women diagnosed as having PP totalis accreta underwent a post-cesarean procedure combining bilateral ligation of the uterine artery, utero-ovarian artery, and internal iliac artery, Pereira compression sutures implemented on the uterine isthmus, Foley catheter placement into the lower uterine segment, and transvaginal cervical cerclage application, namely “Caliskan’s uterine sandwich technique”.

Results:

All women included in this study had placental invasion abnormalities of varying degrees. Postoperative diffusion magnetic resonance imaging assessment revealed a completely normal and preserved uterine blood supply. All women menstruated regularly in their postoperative follow-up period and two women conceived again and delivered uneventfully. None of the patients experienced morbid complications nor required hysterectomy.

Conclusion:

This novel procedure appears to be a plausible fertility and organ-preserving option in cases of intractable PPH, particularly in lower uterine segment bleeding. This uterine sandwich technique may allow physicians to manage massive hemorrhage due to PAS conservatively by preserving the uterus and its functions without major complications.

Constructing a Novel 'Uterine Sandwich' with Simultaneous Intrauterine Balloon Tamponade and Uterine Compression Sutures to Manage Postpartum Bleeding

The uterine sandwich is a relatively new surgical technique for managing postpartum hemorrhage, which is the leading cause of maternal mortality worldwide. The purpose of this case series is to describe a novel method of constructing the uterine sandwich by simultaneously combining intrauterine balloon tamponade and uterine compression sutures. Six patients with postpartum bleeding refractory to medical management were successfully treated with this novel method and avoided hysterectomy. There were no additional complications. This novel method of constructing a uterine sandwich appears to be a simple, safe, and effective technique that could be considered in cases of persistent postpartum bleeding. More research is needed to compare the efficacy of various techniques.

Intrauterine Vacuum-Induced Hemorrhage-Control Device for Rapid Treatment of Postpartum Hemorrhage

Intrauterine vacuum-induced hemorrhage control may provide an effective treatment option for postpartum hemorrhage that has the potential to prevent severe maternal morbidity and mortality.

OBJECTIVE:

To evaluate the effectiveness and safety of an intrauterine vacuum-induced hemorrhage-control device for postpartum hemorrhage treatment.

METHODS:

A multicenter, prospective, single-arm treatment study of a novel intrauterine device that uses low-level vacuum to induce uterine myometrial contraction to achieve control of abnormal postpartum uterine bleeding and postpartum hemorrhage was undertaken at 12 centers in the United States. The primary effectiveness endpoint was the proportion of participants in whom use of the intrauterine vacuum-induced hemorrhage-control device controlled abnormal bleeding without requiring escalating interventions. The primary safety endpoint was the incidence, severity, and seriousness of device-related adverse events. Secondary outcomes included time to bleeding control, rate of transfusion, and device usability scored by each investigator using the device.

RESULTS:

Of 107 participants enrolled with primary postpartum hemorrhage or abnormal postpartum uterine bleeding, 106 received any study treatment with the device connected to vacuum, and successful treatment was observed in 94% (100/106, 95% CI 88–98%) of these participants. In those 100 participants, definitive control of abnormal bleeding was reported in a median of 3 minutes (interquartile range 2.0–5.0) after connection to vacuum. Eight adverse events deemed possibly related to the device or procedure were reported, all of which were outlined as risks in the study and all of which resolved with treatment without serious clinical sequelae. Transfusion of 1–3 units of red blood cells was required in 35 participants, and five participants required 4 or more units of red blood cells. The majority of investigators reported the intrauterine vacuum-induced hemorrhage-control device as easy to use (98%) and would recommend it (97%).

CONCLUSION:

Intrauterine vacuum-induced hemorrhage control may provide a new rapid and effective treatment option for abnormal postpartum uterine bleeding or postpartum hemorrhage, with the potential to prevent severe maternal morbidity and mortality.

FUNDING SOURCE:

Alydia Health, Inc.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02883673.

Obstetric outcomes in major vs minor placenta praevia: A retrospective cohort study

BACKGROUND

Placenta praevia (PP) is a rare obstetric condition associated with significant maternal and perinatal morbidity. Traditionally, the degree of PP has been classified into minor and major; however, there are very few robust studies that compare the maternal outcomes of these types of PP.

AIMS

To identify any significant differences in obstetric outcomes between major and minor PP, including antepartum, intraoperative and postpartum complications.

MATERIALS AND METHODS

A retrospective cohort study was conducted at the Royal Brisbane & Women's Hospital between 2009 and 2018; all women were diagnosed with PP.

RESULTS

Of the total of 368 women recruited, over half of the participants were diagnosed with major PP (57%), while the remaining had minor PP. Women with major PP, compared to women with minor PP, had an increased risk of antepartum haemorrhage (odds ratio (OR) 2.77, P < 0.001), delivery at an earlier gestational age (36.1 vs 37.4 weeks), general anaesthesia (OR 3.25, P < 0.001), greater proportion of emergency lower segment (51% vs 40%) and classical caesarean (7.7% vs 3.8%), increased number of uterotonics (incidence rate ratio (IRR) 1.17, P < 0.031), greater blood loss (IRR 1.32, P < 0.001) and higher frequency of blood transfusion (IRR 2.00, P < 0.027), and longer postpartum hospital stay (IRR 1.26, P < 0.001). Hysterectomy was performed for three women with major PP, compared to one with minor PP.

CONCLUSIONS

The degree of PP significantly impacts obstetric outcomes, with major PP associated with worse maternal morbidity antenatally, intraoperatively and postpartum. Therefore, to optimise patient care, this study emphasises the importance of identifying and distinguishing between different types of PP.

Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial

BACKGROUND

Placenta previa remains one of the major causes of massive postpartum hemorrhage and maternal mortality worldwide.

OBJECTIVE

To determine whether internal iliac artery balloon occlusion during cesarean delivery for placenta previa could reduce postpartum hemorrhage and other maternal complications.

STUDY DESIGN

This was a prospective randomized controlled trial conducted at a tertiary university obstetric unit in Hong Kong. Pregnant women who were diagnosed to have placenta previa at 34 weeks (defined as lower placenta edge within 2 cm from the internal os) and required cesarean delivery were invited to participate. Eligible pregnant women were randomized into internal iliac artery balloon occlusion (Occlusion) group or standard management (Control) group. Those randomized to the Occlusion group had internal iliac artery balloon catheter placement performed before cesarean delivery and then balloon inflation after delivery of the baby. The primary outcome was the reduction of postpartum hemorrhage in those with internal iliac artery balloon occlusion. Secondary outcome measures included hemoglobin drop after delivery; amount of blood product transfusion; incidence of hysterectomy; maternal complications including renal failure, ischemic liver, disseminated intravascular coagulation, and adult respiratory distress syndrome; length of stay in hospital; admission to intensive care unit; and maternal death.

RESULTS

Between May 2016 and September 2018, 40 women were randomized (20 in each group). Demographic and obstetric characteristics were similar between the 2 groups. In the Occlusion group, 3 women did not receive the scheduled procedure, as it was preceded by antepartum hemorrhage that required emergency cesarean delivery, and 1 woman had repeated scan at 36 weeks showing the placental edge was slightly more than 2 cm from the internal os. Intention-to-treat analysis found no significant differences between the Occlusion and the Control groups regarding to the median intraoperative blood loss (1451 [1024-2388] mL vs 1454 [888-2300] mL; P = .945), the median length of surgery (49 [30-62] min vs 37 [30-51] min; P = .204), or the need for blood transfusion during operation (57.9% vs 50.0%; P = .621). None of the patients had rebleeding after operation, complication related to internal iliac artery procedure, or any other maternal complications. Reanalyzing the data using on-treatment approach showed the same results.

CONCLUSION

The use of prophylactic internal iliac artery balloon occlusion in placenta previa patients undergoing cesarean delivery did not reduce postpartum hemorrhage or have any effect on maternal or neonatal morbidity.

The safety and effectiveness of Bakri balloon in the management of postpartum hemorrhage: a systematic review

Background: Postpartum hemorrhage (PPH) is a direct cause of maternal death all over the world. A Bakri balloon is recommended by American College of Obstetricians and Gynecologists (ACOG) and World Health Organization (WHO) as a treatment line for PPH unresponsive to uterotonics. We carried out a systematic review to assess the safety and effectiveness of Bakri balloon in the management of PPH.Methods: We searched PubMed, SCOPUS, central Cochrane, and Web of Science, from 2001 to 2018 for randomized controlled trials (RCTs) and observational studies to assess the safety and effectiveness of Bakri balloon on refractory PPH.Results: Twenty-eight articles were included for analysis. The primary indication for the use of a Bakri balloon tamponade was PPH. Only 67.9% (19/28) quantified the estimate blood loss necessary to use the balloon. Uterine atony was the underlying cause of PPH in 75% (21/28) of studies. Most of the studies on Bakri balloon are followed by vaginal birth (3/4). Bakri balloon displacement from the uterine cavity was reported by five publications, with the overall rate being 9% (95% CI: 5-15%). Hysterectomy was necessary for 1% (95% CI: 0-8%) of the women who required the balloon.Conclusions: Bakri balloon seems to be a less effective tool for management of PPH either after vaginal or cesarean delivery.

New dedicated blunt straight needles and sutures for uterine compression sutures: a retrospective study and literature review

Background

We developed a dedicated blunt straight needle with No. 2 polydioxanone sutures (2-Monodiox®) for uterine compression sutures (UCSs) and aimed to assess the outcomes and complication rates of UCSs for postpartum hemorrhage by comparing with commercially available needle and suture types.

Methods

A retrospective analysis was performed between January 2010 and February 2018. During the study period, two types of commercially available sutures and 2-Monodiox® were used. PubMed, MEDLINE, and Scopus databases were searched for English articles published between January 1997 and May 2017 using search terms related to the suture and needle types for UCSs to discuss the dedicated needles and sutures for UCS.

Results

The analysis included 47 cases of UCSs for the uterine body with three suture types (No. 0 polydioxanone, 7 cases; No. 1 poliglecaprone 25, 21 cases; and No. 2 polydioxanone, 19 cases). B-Lynch suture using No. 0 sutures was associated with a significantly lower uterine preservation rate than those with Nos. 1 and 2 sutures (42.9% vs. 95.2 and 89.5%, respectively; p < 0.01). A modified Hayman suture technique was performed using 2-Monodiox® sutures, which achieved a similar uterine preservation rate compared with B-Lynch suture using No. 1 poliglecaprone 25 sutures. No patients developed severe complications. The literature review showed that no dedicated sutures have developed for UCSs. Three dedicated needles for UCSs have been developed, and 2-Monodiox® is the first dedicated blunt straight needle for UCSs.

Conclusion

Our data showed that No. 0 sutures should not be used for B-Lynch suture. The uterine preservation rate is similar for 2-Monodiox® with modified Hayman suture and No. 1 poliglecaprone 25 sutures with B-Lynch suture, without the occurrence of severe complications.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0495-7) contains supplementary material, which is available to authorized users.

Maternal outcomes following massive obstetric haemorrhage in an inner-city maternity unit

This retrospective study evaluates the effects of a massive postpartum haemorrhage (PPH) on maternal outcomes in an inner-city London hospital. One hundred and eighty-four cases of a massive primary PPH (>2000 mL) were identified over a seven-year period. A sub-group analysis was performed to assess whether 2000-3000 mL blood loss (134 cases) was associated with specific maternal characteristics or reduced adverse outcomes compared with >3000 mL blood loss (50 cases). Bakri balloon tamponade (BBT) was the most frequent form of surgical management in both groups (21 vs. 46%), followed by compression sutures (16.4 vs. 24%), the 'uterine sandwich' technique (6.7 vs. 14%) and the hysterectomy (0 vs. 4%). There were significant differences between these groups in placenta praevia as the cause of blood loss (8 vs. 22%, p = .01), length of stay (4.6 vs. 5.9 d, p = .02), use of BBT (p = <.01) and hysterectomy (p = .03). PPH is associated with premature maternal morbidity and mortality. The incidence is increasing in high income countries despite various guidelines, skills training and identification of risk factors. A prediction and assessment of blood loss remain the very cornerstone for a prompt, effective management. Our study shows that the morbidity is clearly related to the amount of blood loss and highlights the existing variable practices for the management of PPH. Impact statement What is already known on this subject? A postpartum haemorrhage (PPH) remains a common cause of maternal morbidity and mortality. Massive PPH (>2000 mL) rates continue to rise in developed countries. The management of PPH includes the medical treatment followed by surgical methods including the Bakri balloon tamponade (BBT), compression sutures or a hysterectomy. What do the results of this study add? This retrospective study evaluates the effects of a massive PPH (blood loss >2000 mL) on maternal outcomes. One hundred and eighty-four cases of a massive PPH were identified over a seven-year period. Sub-group analysis was performed to assess whether a 2000-3000 mL blood loss was associated with specific maternal characteristics and differences in obstetric practice compared with a >3000 mL blood loss. There were significant differences between these groups in placenta praevia, as the cause of blood loss, the length of stay, the use of BBT and the hysterectomy rates. What are the implications of these findings for clinical practice and/or further research? An early identification of the risk factors of a massive PPH is essential to improve maternal outcomes and is an important part of the antenatal, intrapartum and postpartum period. The prediction and assessment of blood loss remain key for a prompt, effective management. The amount of blood loss is related to adverse maternal outcomes and the management techniques applied. BBT has an essential role to play and should be included as part of the core training in the management of a PPH.

Application of chitosan-covered gauze in combination with intrauterine balloon tamponade for postpartum hemorrhage treatment - Case report of a novel "uterine sandwich" approach

INTRODUCTION

Postpartum or peripartum hemorrhage (PPH) is a major cause of maternal death worldwide. Fertility preserving second stage interventions following uterotonic medications may include compression sutures, uterine balloon tamponade and ligation or embolization of arteries.

PRESENTATION OF CASE

We present a case of PPH where a novel "uterine sandwich" approach (combination of chitosan-covered gauze with intrauterine balloon tamponade) was effectively used to stop further blood loss and prevented more invasive second stage interventions. Furthermore, we present the ultrasonographic image of chitosan-covered gauze in the uterine cavity.

DISCUSSION

Chitosan-covered gauze and intrauterine balloon tamponade are complementary in their mechanism of work, the balloon reducing blood flow into the uterus and the chitosan-covered gauze enhancing the coagulation.

CONCLUSION

This novel "uterine sandwich" approach can be a useful method for fertility preserving management of PPH.

A sandwich technique (N&H variation technique) to reduce blood loss during cesarean delivery for complete placenta previa: a randomized controlled trial

Objective: To investigate the effect of A sandwich technique Nahla & Hany variation (N&H) technique versus stepwise uterine devascularization on blood loss during cesarean section (CS) in patients with complete placenta previa. Methods: The study was single-blind randomized controlled trial carried out in a tertiary University Hospital between March 2015 to March 2018. We included patients scheduled for CS due to complete placenta previa. They were randomly allocated to group (I) managed by stepwise uterine devascularization, group (II) managed by double transverse compression suture at the lower uterine segment plus intrauterine inflated Foley's catheter Balloon (H&N variation sandwich) at the lower uterine segment. The primary outcome was the amount of total estimated blood loss both intra- and post-operative. Results: One hundred and six patients were enrolled (n = 53 in each group). There was a great reduction in intraoperative blood loss in group II 570 (400-1300) compared with Group I 1030 (500-1540) (p = .0001), or blood in the intraabdominal drain in group II than group I (p = .0001) Also, there was no significant reduction in postoperative vaginal bleeding. Hence, the total estimated blood loss in group II 750 (550-1580) showed significant reduction compared with group I 1350 (780-1800) (p = .0001). Conclusions: N&H variation sandwich technique in the management of complete placenta previa is a simple technique, safe and effective to decrease blood loss.

Bakri balloon placement in the successful management of postpartum hemorrhage in a bicornuate uterus: A case report

•

This is the first reported case of successful use of Bakri balloon placement in the presence of postpartum hemorrhage in a bicornuate uterus.

•

Physicians should be aware that uterine malformation is not a contraindication to Bakri balloon placement.

•

When performing Bakri balloon placement in the presence of uterine malformation, efforts be made to precisely locate the site of bleeding.

Introduction

Postpartum hemorrhage is an obstetric emergency that accounts for 25% of maternal deaths worldwide. Initial management consists of uterotonic administration but in cases in which there is a failure of response to medication, uterine cavity tamponade can be effective. This is the first reported case of successful Bakri balloon placement in the management of postpartum hemorrhage at the time of cesarean delivery in a patient with a bicornuate uterus.

Presentation of case

The patient was a primigravid female who presented at 40 weeks and 1 day gestation with known bicornuate uterus and findings suggestive of placental abruption. Labor was subsequently induced and magnesium was administered after a diagnosis of preeclampsia with severe features was made. Cesarean delivery was then performed for category II fetal heart rate tracing remote from delivery. Intraoperative course was significant for uterine atony unresponsive to oxytocin, carboprost, methylergonovine and misoprostol administration. The right uterine horn was noted to be markedly atonic compared to the left. A Bakri balloon was then placed transvaginally and inflated with 600 mL of saline in this location. Atony then resolved.

Discussion

Although uterine malformation is not a documented contraindication to Bakri balloon placement, there is no literature on its efficacy in the treatment of hemorrhage in the presence of this anomaly.

Conclusion

In the management of postpartum hemorrhage, Bakri balloon placement is associated with success in the presence of a bicornuate uterus. Care should be taken to direct insertion of the balloon in the appropriate location.

Potentially Avoidable Peripartum Hysterectomies in Denmark: A Population Based Clinical Audit

Objective

To audit the clinical management preceding peripartum hysterectomy and evaluate if peripartum hysterectomies are potentially avoidable and by which means.

Material and Methods

We developed a structured audit form based on explicit criteria for the minimal mandatory management of the specific types of pregnancy and delivery complications leading to peripartum hysterectomy. We evaluated medical records of the 50 Danish women with peripartum hysterectomy identified in the Nordic Obstetric Surveillance Study 2009–2012 and made short narratives of all cases.

Results

The most frequent indication for hysterectomy was hemorrhage. The two main initial causes were abnormally invasive placenta (26%) and lacerations (26%). Primary atony was third and occurred in 20%. Before hysterectomy another 26% had secondary atony following complications such as lacerations, retained placental tissue or coagulation defects. Of the 50 cases, 24% were assessed to be avoidable and 30% potentially avoidable. Hysterectomy following primary and secondary atony was assessed to be avoidable in 4/10 and 4/13 cases, respectively. Early sufficient suturing of lacerations and uterine ruptures, as well as a more widespread use of intrauterine balloons alone or in combination with uterine compression sutures (the sandwich model), could presumably have prevented about one fourth of the peripartum hysterectomies.

Conclusion

More than 50% of peripartum hysterectomies seem to be avoidable by simple measures. In order to minimize the number of unnecessary peripartum hysterectomies, obstetricians and anesthesiologists should investigate individual cases by structured clinical audit, and disseminate and discuss the results for educational purposes. An international collaboration is warranted to strengthen our recommendations and reveal if they are generally applicable.

The fertility sparing management of postpartum hemorrhage: A series of 47 cases of Bakri balloon tamponade

OBJECTIVE

To evaluate the success rate of Bakri balloon tamponade (BBT) for managing postpartum hemorrhage (PPH), intractable to conservative medical treatment, as a fertility sparing intervention.

MATERIALS AND METHODS

We evaluated 47 women treated with BBT who had severe postpartum hemorrhage and uncontrollable bleeding due to failed treatment with uterotonic agents. The main outcome measure was successful management and preservation of the uterus.

RESULTS

Forty-seven women were identified for BBT treatment due to severe PPH. BBT was used to successfully manage hemorrhage in 43 patients, and there was no need for hysterectomy. Four patients required an additional surgical procedure. Of the four failures, a subtotal hysterectomy was performed in two patients, and the other two patients underwent a total hysterectomy. The overall success rate was 91.4%, which was comparable to rates reported earlier. The main cause of PPH was uterine atony (43%).

CONCLUSION

Uterine preservation is an important issue when managing PPH. BBT is an effective, easy to use, and safe procedure for massive PPH that can minimize recourse to hysterectomy after failed medical treatment.

Management of postpartum haemorrhage with uterine balloon tamponade: The way forward

Uterine balloon tamponade has rapidly gained popularity in the management of postpartum haemorrhage. It is a conservative method often utilised before embarking on advanced surgical interventions. The mechanism of action, complications and long-term outcomes are discussed.

Nonpneumatic antishock garment combined with bakri balloon as a nonoperative "uterine sandwich" for temporization of massive postpartum hemorrhage from disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is an uncommon but potentially catastrophic complication of postpartum hemorrhage. We describe two cases of massive postpartum hemorrhage complicated by DIC that were successfully temporized with combined use of the Bakri balloon and nonpneumatic antishock garment (NASG) during massive transfusion. In the first case, a healthy, term gravida underwent emergent cesarean for fetal bradycardia during labor induction. 10 minutes after completion of surgery, brisk vaginal hemorrhage of nonclotting blood from fulminant DIC resulted in maternal shock. A Bakri balloon and NASG were placed during massive transfusion, resulting in rapid maternal stabilization. In the second case, a healthy, term gravida suffered an amniotic fluid embolism during labor requiring emergent cesarean delivery and complicated by cardiac arrest with successful resuscitation. Postoperative rapid uterine bleeding from DIC was treated with a Bakri balloon and NASG, stabilizing the patient during massive transfusion. Neither patient required further surgical procedures. NASG combined with Bakri balloon may serve as a valuable nonoperative treatment or temporization option in cases of massive postpartum hemorrhage complicated by coagulopathy such as these. Further study of the utility of NASG in high-resource settings is warranted.

A novel 'uterine sandwich' for haemorrhage at caesarean section for placenta praevia

Although massive haemorrhage at caesarean section (CS) for placenta praevia is a serious concern, effective treatment is not yet determined. We performed a new uterine sandwich to achieve haemostasis at CS for total placenta praevia in five consecutive cases in whom the placenta reached up to >5 cm from the internal cervical os in all directions of an uterine wall. A Matsubara-Yano (MY) uterine compression suture was placed, followed by placement of an intrauterine balloon. Haemostasis was achieved in all five cases with median blood loss of 1618 mL. No short-term adverse events were observed. The MY sandwich can be used to achieve haemostasis at CS for placenta praevia.

Use of the Bakri postpartum balloon in a patient with intractable pelvic floor hemorrhage: when other methods failed to stop postcesarean bleeding, physicians tried something new

Massive pelvic floor hemorrhage is a potentially life-threatening condition associated with complicated obstetrical and gynecological procedures. Sometimes, the bleeding cannot be controlled by conventional methods. This report demonstrates the effectiveness of the Bakri balloon as a pelvic pressure pack for the control of intractable pelvic floor hemorrhage following cesarean section.

Postpartum hemorrhage: the role of the Maternal-Fetal Medicine specialist in enhancing quality and patient safety

Postpartum hemorrhage in excess of 1000 mL affects 2.9-4.3% of deliveries in North America and the prevalence is increasing (Calvert et al., 2012(1); Callaghan et al., 2010(2)). Given the unpredictable nature of most postpartum hemorrhages, all obstetric providers must understand the initial steps in the assessment and management of this emergency. In this monograph we will review the potential role of the Maternal-Fetal Medicine (MFM) specialist in managing this acute obstetric emergency. MFMs are uniquely positioned to develop hospital protocols, advocate for investment in resources to optimize outcomes, and utilize novel educational models, such as simulation, to educate other providers on the recognition and management of this condition. MFMs can also aid in the antepartum diagnosis of abnormal placentation, which is an increasingly common risk factor for severe hemorrhage.

The Bakri balloon for the management of postpartum hemorrhage in cases with placenta previa

OBJECTIVE

To evaluate the success rate of the Bakri balloon in the event of uncontrollable hemorrhage due to placenta previa.

STUDY DESIGN

We evaluated 25 patients who were treated with the Bakri balloon who had severe postpartum hemorrhage with placenta previa and failed medical treatment with uterotonic agents.

RESULTS

The Bakri balloon was inserted abdominally during cesarean section in 24 of 25 cases. In only one case was it inserted vaginally. The Bakri tamponade was effective in 22 cases (88%). There were three cases with failure: two patients needed an additional procedure (hypogastric artery ligation and B-Lynch suture) and one patient needed hysterectomy.

CONCLUSIONS

The Bakri balloon is the least invasive, rapid method in the management of bleeding due to placenta previa with minimal complications.

Use of Bakri balloon tamponade in the treatment of postpartum hemorrhage: a series of 50 cases from a tertiary teaching hospital

OBJECTIVE

Massive postpartum hemorrhage (PPH) is one of the most serious complications during delivery. Hysterectomy is commonly performed when other conventional treatment attempts fail. Bakri balloon tamponade (BBT) is a novel conservative management option for PPH. Little is known of the effectiveness of this procedure. We report a large case series from a tertiary teaching hospital.

DESIGN

Retrospective case series (October 2008-June 2011).

SETTING

University teaching hospital.

POPULATION

Forty-four women with massive PPH (blood loss >1000 mL) and six other women with expected high risk of PPH (blood loss <1000 mL) managed by BBT.

METHODS

Chart review.

MAIN OUTCOME MEASURES

Achievement of definitive hemostasis by BBT among the study population.

RESULTS

Among the women treated with BBT, the cause of PPH was uterine atony (16%), cervical rupture (14%), vaginal rupture and/or paravaginal hematoma (22%), placenta previa (18%) and placental retention (30%). The overall success rate was 86%. Seven of the 50 patients needed additional procedures. Of the seven failures, supravaginal uterine amputation or hysterectomy was required in four cases and embolization of the uterine arteries in three cases.

CONCLUSIONS

BBT is a simple, readily available, effective and safe procedure for the management of PPH in selective cases. BBT does not exclude the use of other procedures if necessary. Even if BBT failed, it may provide temporary tamponade and time to prepare for other interventions or transportation from local hospital to tertiary centre. We suggest that BBT should be included in the PPH protocol.