Predictors of failed intrauterine balloon tamponade for persistent postpartum hemorrhage after vaginal delivery

Risk factors for Bakri balloon tamponade failure in the management of postpartum hemorrhage

OBJECTIVE

To predict risk factors for Bakri balloon tamponade (BBT) failure in the management of postpartum hemorrhage (PPH).

METHODS

The data of 599 patients who underwent BBT were retrospectively analyzed from January 1, 2017 to December 31, 2021 in a tertiary hospital in Shanghai, East China. The patients were divided into the failure group and the success group. Failure was defined as the inability to control bleeding, which required surgical interventions. Maternal characteristics, PPH characteristics, PPH management approaches, and maternal complications were compared between the groups. The independent predictors of BBT failure were analyzed by logistic regression analysis.

RESULTS

The overall success rate of BBT was 83.0% (497/599). The blood loss before and after balloon insertion in the failure group was significantly greater than that in the success group. Of the 102 failures, B-Lynch suture was performed in one patient, uterine artery embolization was performed in 99 patients (with one failure), and total hysterectomy was performed in three patients. Some risk factors, including twin gestation (odds ratio [OR] 9.68), placenta accreta spectrum with/without placenta previa (OR 4.45), estimated blood loss at least 1135 ml at balloon insertion (OR 3.35), multiparous (OR 2.72), and in vitro fertilization-embryo transfer (OR 2.00) were strongly associated with BBT failure.

CONCLUSION

BBT seemed to be a less effective tool in the management of PPH due to placenta accreta spectrum with/without placenta previa and twin gestation.

Risk Factors for Intrauterine Tamponade Failure in Postpartum Hemorrhage

OBJECTIVE

To identify factors associated with intrauterine tamponade failure after vaginal or cesarean delivery.

METHODS

This was a nationwide population-based cohort study that used data from the French Programme de Médicalisation des Systèmes d'Information. This study compared the failure and effectiveness of intrauterine tamponade among all women who received the procedure in France from January 1, 2019, to December 31, 2019. Failure was defined as the use of a second-line method (uterine artery embolization, conservative or radical surgery, or death) within 7 days of intrauterine tamponade. Factors associated with intrauterine tamponade failure were identified by univariate analyses and tested using multivariate generalized logistic regression models (with a random intercept on institution) to obtain adjusted odds ratio (aOR) and 95% CI statistics.

RESULTS

A total of 39,193 patients presented with postpartum hemorrhage in 474 French maternity wards. Of these patients, 1,761 (4.5%) received intrauterine tamponade for persistent bleeding. The effectiveness rate of intrauterine tamponade was 88.9%. For 195 women (11.1%), a second-line method was indicated. Patients for whom intrauterine tamponade failed had a higher maternal age, a lower mean gestational age, and more frequent instances of placental abnormalities, preeclampsia, cesarean birth, and uterine rupture. The multivariate analysis revealed that cesarean birth (aOR 4.2; 95% CI 2.9-6.0), preeclampsia (aOR 2.3; 95% CI 1.3-4.0), and uterine rupture (aOR 14.1; 95% CI 2.4-83.0) were independently associated with intrauterine tamponade failure.

CONCLUSION

Cesarean delivery, preeclampsia, and uterine rupture are associated with intrauterine tamponade failure in the management of postpartum hemorrhage.

The Impact of Obesity on the Management and Outcomes of Postpartum Hemorrhage

OBJECTIVE

The study aimed to evaluate the impact of obesity on the management and outcomes of postpartum hemorrhage.

STUDY DESIGN

We conducted a retrospective cohort study of women who delivered at a tertiary care center between February 1, 2013 and January 31, 2014 and experienced a postpartum hemorrhage. Charts were reviewed for clinical and sociodemographic data, and women were excluded if the medical record was incomplete. Hemorrhage-related severe morbidity indicators included blood transfusion, shock, renal failure, transfusion-related lung injury, cardiac arrest, and use of interventional radiology procedures. Obese (body mass index [BMI] ≥ 30 kg/m²) and nonobese women were compared. Data were analyzed using Chi-square, Student's t-test, Mann-Whitney U test, and linear regression where appropriate. The p-value <0.05 was significant.

RESULTS

Of 9,890 deliveries, 2.6% (n = 262) were complicated by hemorrhage. Obese women were more likely to deliver by cesarean section (55.5 vs. 39.8%, p = 0.016), undergo a cesarean after labor (31.1 vs. 12.2%, p = 0.001), and have a higher quantitative blood loss (1,313 vs. 1,056 mL, p = 0.003). Both groups were equally likely to receive carboprost, methylergonovine, and misoprostol, but obese women were more likely to receive any uterotonic agent (95.7 vs. 88.9%, p = 0.007) and be moved to the operating room (32.3 vs. 20.4, p = 0.04). There was no difference in the use of intrauterine pressure balloon tamponade, interventional radiology, or decision to proceed with hysterectomy. The two groups were similar in time to stabilization. There was no difference in the need for blood transfusion. Obese women required more units of blood transfused (2.2 ± 2 vs. 2 ± 5 units, p = 0.023), were more likely to have any hemorrhage-related severe morbidity (34.1 vs. 25%, p = 0.016), and more than one hemorrhage related morbidity (17.1 vs. 7.9, p = 0.02). After controlling for confounding variables, quantitative blood loss, and not BMI was predictive of the need for transfusion.

CONCLUSION

Despite similar management, obese women were more likely to have severe morbidity and need more units of blood transfused.

KEY POINTS

· Obese women were more likely to have a higher quantitative blood loss and require more units of blood transfused.. · Obese women were more likely to experience any hemorrhage-related severe morbidity.. · Although obese women were more likely to be moved to the operating room for intervention, the rates of intrauterine pressure balloon tamponade, interventional radiology or hysterectomy were the same for obese and non-obese women..

Conservative Surgical Management of Early Postpartum Hemorrhage: A 12-Year Experience in a Tertiary Care Center in the South of Thailand

Background/Purpose of the Study

To evaluate the success rate and predictive factors of success in conservative surgical management of early postpartum hemorrhage (PPH).

Methods

A retrospective study was conducted at a tertiary care hospital in the south of Thailand, from January 2006 to December 2017. PPH with conservative surgical management including Bakri balloon tamponade, B-Lynch uterine compression sutures, arterial embolization, vessel ligations, and combined surgical procedures was reviewed. The procedures were considered successful if bleeding could be controlled without subsequent hysterectomy. Multivariate logistic regression analysis was used to identify predictive factors for success of conservative surgical treatment.

Results

Among 39,327 deliveries, 1461 (3.7%) patients had early PPH, and 92 cases received conservative surgical management. Most patients (92.4%) underwent cesarean section. Median (IQR) blood loss before conservative surgery was 1800 (1100, 2575) mL, and median (IQR) time from early PPH to conservative surgical management was 41 (25.5, 60.0) minutes. The overall success rate of conservative surgical management was 80.4%, meanwhile the postoperative complication rate was 27.2%. The predictive factors significantly associated with success were maternal age < 35 years (odds ratio [OR] 4.53, 95% confidence interval [CI] 1.27-16.23; p = 0.02), blood loss before conservative surgery < 1800 mL (OR 5.82, 95% CI 1.45-23.33; p = 0.01), and time to start conservative surgery ≤ 40 min (OR 4.76, 95% CI 1.13-20.12; p = 0.03).

Conclusion

The overall success rate of conservative surgical procedures was high. Maternal age < 35 years, blood loss before conservative management < 1800 mL, and time to conservative surgery ≤ 40 min were predictive factors of success.

Profile of the Jada® System: the vacuum-induced hemorrhage control device for treating abnormal postpartum uterine bleeding and postpartum hemorrhage

INTRODUCTION

Abnormal postpartum uterine bleeding occurs commonly after birth and can quickly become an obstetric emergency. With postpartum hemorrhage representing the leading cause of maternal mortality, accounting for 25% of maternal deaths due to obstetric complications, there is a critical need for effective and easy to use treatment options.

AREAS COVERED

This profile describes the Jada System, a novel intrauterine vacuum-induced hemorrhage control device that provides a rapid and effective treatment option for abnormal postpartum uterine bleeding and postpartum hemorrhage. In addition to explaining the mechanism of action of vacuum-induced hemorrhage control and reviewing the device's safety and effectiveness, this profile elucidates how the Jada System compares to currently available medications and devices for treatment of this obstetric emergency.

EXPERT OPINION

New therapies to address this life-threatening condition are needed to reduce the risk of maternal mortality and severe maternal morbidity. Data demonstrate that the Jada System provides rapid, effective control of abnormal postpartum uterine bleeding and postpartum hemorrhage, while offering reported ease of use and short treatment duration. These results suggest that use of the Jada System in treatment algorithms may improve outcomes.

Predictors of Failed Intrauterine Balloon Tamponade in the Management of Severe Postpartum Hemorrhage

To identify the factors predicting intrauterine balloon tamponade (IUBT) failure for severe postpartum hemorrhage (PPH) after delivery, we conducted a retrospective cohort study of women who underwent IUBT for severe PPH after delivery from October 1, 2016 until September 30, 2017. The failure of IUBT was defined as the need of additional surgical procedures or uterine embolization. A total of 99,650 deliveries occurred during the study period. Among the patients, 106 cases of severe PPH were managed with IUBT, and the global success rate was 70.8% (75/106). Least absolute shrinkage and selection operator (LASSO) regression was performed to select the potential risk factors predicting IUBT failure. The associated risk factors-obesity, multiple gestation, cesarean delivery, estimated blood loss (EBL), and placenta accreta spectrum (PAS)-were included in multivariate logistic models. Ultimately, these models identified multiple gestation, EBL, and PAS as independent risk factors for IUBT failure. In conclusion, IUBT is an effective method for severe PPH. The presence of factors affecting IUBT failure should be recognized early, and other modalities of management should be anticipated.

Factors Associated with Failure of Bakri Balloon Tamponade for the Management of Postpartum Haemorrhage. Case Series Study and Systematic Review

Background: Postpartum haemorrhage (PPH) is an unpredictable obstetric emergency that requires a multidisciplinary approach. Bakri balloon tamponade (BBT) is recommended when PPH does not respond to medical treatment. Nowadays few published studies have performed a multivariate analysis to determine the variables independently associated with BBT failure. Methods: Our study purpose was to determine the variables independently associated with BBT failure: first, in a large single-centre cohort study between 2010 and 2020, and second, in a systematic literature review using Medline and the Cochrane Library. Maternal and perinatal variables, PPH characteristics, technique-related variables and complications were recorded in the case series study, comparing between successful and failed BBT patients. Study characteristic and variables significantly associated with BBT failure were recorded in the systematic review. All studies used a logistic regression test. Results: The case series included 123 patients. The profile of these patients were primiparous, with vaginal delivery and a full-term new-born. BBT was successful in 81.3% of cases. Five studies were included in the systematic review, providing data from 551 patients. BBT was successful in 79.5% of cases. Conclusions: Maternal age, caesarean delivery, ≥7 red blood cells units (RBCU) transfused and curettage before BBT insertion, history of caesarean section, pre-pregnancy obesity, anteriorly placed placenta, placenta accreta, caesarean delivery, estimated blood loss before insertion of BBT, long operation duration, and coagulopathy were independent factors for BBT failure.

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.

Postpartum hemorrhage with uterine artery embolization: the risk of complications of uterine artery embolization

INTRODUCTION

The purpose of this study was to evaluate the efficacy and adverse effects of uterine artery embolization (UAE) to treat postpartum hemorrhage (PPH) and determine the factors associated with clinical outcomes.

MATERIAL AND METHODS

This study included 117 patients who underwent UAE for PPH between January 2010 and November 2018. Their medical records were retrospectively reviewed to assess the mode of delivery, causes of bleeding, detailed laboratory results, clinical outcomes, time from delivery to UAE, and embolizing material used.

RESULTS

The clinical UAE success rate was 99.1%. Late complications were found in 11 patients. Two total hysterectomies were performed. Most PPH cases treated with UAE had early-onset PPH caused by uterine atony. Late-onset PPH was caused by placenta-related problems (remnant placenta, placenta accreta). Body mass index, cesarean section, the use of mixed embolizing materials, placenta abruption as the cause of PPH, and transferred patients were associated with uterine necrosis. Age, re-embolization, and the use of mixed embolizing materials were associated with adverse complications.

CONCLUSIONS

Although UAE is a safe and effective way to manage PPH, a long-term follow-up is needed to determine the complications of UAE. When uterine necrosis is suspected, prompt and adequate treatment should be performed due to the effects of necrosis on menstrual cycles, fertility, and subsequent pregnancies.

Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis

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.