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Rozenberg P, Sentilhes L, Goffinet F, Vayssiere C, Senat MV, Haddad B, Morel O, Garabedian C, Vivanti A, Perrotin F, Kayem G, Azria E, Raynal P, Verspyck E, Sananes N, Gallot D, Bretelle F, Seco A, Winer N, Deneux-Tharaux C. Efficacy of early intrauterine balloon tamponade for immediate postpartum hemorrhage after vaginal delivery: a randomized clinical trial. Am J Obstet Gynecol 2023; 229:542.e1-542.e14. [PMID: 37209893 DOI: 10.1016/j.ajog.2023.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/08/2023] [Accepted: 05/14/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Many questions remain about the appropriate use of intrauterine balloon devices in postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. Available data suggest that early use of intrauterine balloon tamponade might be beneficial. OBJECTIVE This study aimed to compare the effect of intrauterine balloon tamponade used in combination with second-line uterotonics vs intrauterine balloon tamponade used after the failure of second-line uterotonic treatment on the rate of severe postpartum hemorrhage in women with postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. STUDY DESIGN This multicenter, randomized, controlled, parallel-group, nonblinded trial was conducted at 18 hospitals and enrolled 403 women who had just given birth vaginally at 35 to 42 weeks of gestation. The inclusion criteria were a postpartum hemorrhage refractory to first-line uterotonics (oxytocin) and requiring a second-line uterotonic treatment with sulprostone (E1 prostaglandin). In the study group, the sulprostone infusion was combined with intrauterine tamponade by an ebb balloon performed within 15 minutes of randomization. In the control group, the sulprostone infusion was started alone within 15 minutes of randomization, and if bleeding persisted 30 minutes after the start of sulprostone infusion, intrauterine tamponade using the ebb balloon was performed. In both groups, if the bleeding persisted 30 minutes after the insertion of the balloon, an emergency radiological or surgical invasive procedure was performed. The primary outcome was the proportion of women who either received ≥3 units of packed red blood cells or had a calculated peripartum blood loss of >1000 mL. The prespecified secondary outcomes were the proportions of women who had a calculated blood loss of ≥1500 mL, any transfusion, an invasive procedure and women who were transferred to the intensive care unit. The analysis of the primary outcome with the triangular test was performed sequentially throughout the trial period. RESULTS At the eighth interim analysis, the independent data monitoring committee concluded that the incidence of the primary outcome did not differ between the 2 groups and stopped inclusions. After 11 women were excluded because they met an exclusion criterion or withdrew their consent, 199 and 193 women remained in the study and control groups, respectively, for the intention-to-treat analysis. The women's baseline characteristics were similar in both groups. Peripartum hematocrit level change, which was needed for the calculation of the primary outcome, was missing for 4 women in the study group and 2 women in the control group. The primary outcome occurred in 131 of 195 women (67.2%) in the study group and 142 of 191 women (74.3%) in the control group (risk ratio, 0.90; 95% confidence interval, 0.79-1.03). The groups did not differ substantially for rates of calculated peripartum blood loss pf ≥1500 mL, any transfusion, invasive procedure, and admission to an intensive care unit. Endometritis occurred in 5 women (2.7%) in the study group and none in the control group (P=.06). CONCLUSION The early use of intrauterine balloon tamponade did not reduce the incidence of severe postpartum hemorrhage compared with its use after the failure of second-line uterotonic treatment and before recourse to invasive procedures.
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Affiliation(s)
- Patrick Rozenberg
- Department of Obstetrics and Gynecology, American Hospital of Paris, Neuilly-sur-Seine, France; Université Paris-Saclay, UVSQ, Inserm, Equipe U1018, Epidémiologie clinique, CESP, Montigny-le-Bretonneux, France.
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - François Goffinet
- Department of Obstetrics and Gynecology, Hôpital Cochin-Port Royal, AP-HP, Paris, France
| | - Christophe Vayssiere
- Department of Obstetrics and Gynecology, Hôpital Paule de Viguier, CHU, Toulouse, France
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Hôpital Bicêtre AP-HP, Le Kremlin-Bicêtre, France
| | - Bassam Haddad
- Department of Obstetrics and Gynecology, Hôpital Intercommunal de Créteil, Créteil, France
| | - Olivier Morel
- Department of Obstetrics and Gynecology, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Charles Garabedian
- Department of Obstetrics and Gynecology, Hôpital Jeanne de Flandre, Lille, France
| | - Alexandre Vivanti
- Department of Obstetrics and Gynecology, Hôpital Antoine-Béclère AP-HP, Clamart, France
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Hôpital Bretonneau, Tours, France
| | - Gilles Kayem
- Department of Obstetrics and Gynecology, Hôpital Armand Trousseau AP-HP, Paris, France
| | - Elie Azria
- Department of Obstetrics and Gynecology, Hôpital Saint Joseph, Paris, France
| | - Pierre Raynal
- Department of Obstetrics and Gynecology, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Eric Verspyck
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Nicolas Sananes
- Department of Obstetrics and Gynecology, Centre Médico-Chirurgical et Obstétrical, Schiltigheim, France
| | - Denis Gallot
- Department of Obstetrics and Gynecology, CHU Clermont-Ferrand Site Estaing, Clermont Ferrand, France
| | - Florence Bretelle
- Department of Obstetrics and Gynecology, Hôpital Nord, Marseille, France
| | - Aurélien Seco
- Clinical Research Unit Necker Cochin, APHP, Paris, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology, Hôpital Mère-Enfant, Nantes, France; NUN INRAE UMR 1280, PhAN Nantes University, Nantes, France
| | - Catherine Deneux-Tharaux
- Obstetrical Perinatal and Paediatric Epidemiology Research Team, Université de Paris Cité, CRESS, INSERM, INRA, Paris, France
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Kern-Goldberger AR, Howell EA, Srinivas SK, Levine LD. What we talk about when we talk about severe maternal morbidity: a call to action to critically review severe maternal morbidity as an outcome measure. Am J Obstet Gynecol MFM 2023; 5:100882. [PMID: 36736823 PMCID: PMC10121757 DOI: 10.1016/j.ajogmf.2023.100882] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023]
Abstract
Severe maternal morbidity has historically functioned as an umbrella term to define major, potentially life-threatening obstetrical, medical, and surgical complications of pregnancy. There is no overarching or consensus definition of the constellation of conditions that have been used variably to define severe maternal morbidity, although it is clear that having a well-honed definition of severe maternal morbidity is important for research, quality improvement, and health policy purposes. Although severe maternal morbidity may ultimately elude a single unifying definition because different features may be relevant depending on context and modality of data acquisition, it is valuable to explore the intellectual frameworks and various applications of severe maternal morbidity in current practice, and to consider the potential benefit of more consolidated terminology for maternal morbidity.
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Affiliation(s)
- Adina R Kern-Goldberger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Elizabeth A Howell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sindhu K Srinivas
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lisa D Levine
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tam Tam H, Putterman D, Sinha R, Woods Ludwig J, Gulersen M. Computed tomography-guided injection for management of caesarean scar pregnancy. Clin Radiol 2021; 76:696-700. [PMID: 34154834 DOI: 10.1016/j.crad.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 11/28/2022]
Affiliation(s)
- H Tam Tam
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - D Putterman
- Division of Vascular and Interventional Radiology, Department of Radiology, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - R Sinha
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - J Woods Ludwig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - M Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.
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