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

Assessment of Structural and Process Readiness for Postpartum Haemorrhage Care in Uganda and Ghana: A Mixed Methods Study

OBJECTIVE

To determine structural and process readiness for postpartum haemorrhage (PPH) care at referral-level facilities in Ghana and Uganda to identify opportunities for strengthening.

DESIGN

Mixed-methods cross-sectional study.

SETTING

Three districts in Ghana and two in Uganda.

POPULATION OR SAMPLE

Nine hospitals in Ghana and seven in Uganda; all hospitals had theoretical capacity for caesarean section and blood transfusion.

METHODS

We deployed a modular quantitative health facility assessment to explore structural readiness (drugs, equipment, staff) complemented by in-depth interviews with maternity health service providers to understand process readiness (knowledge, attitudes, and practices as related to World Health Organization [WHO] guidance on PPH care).

MAIN OUTCOME MEASURES

Availability of essential structural components needed to support key PPH processes of care.

RESULTS

In both countries, there was generally good structural readiness for PPH care. However, key common gaps included inadequate staffing (especially specialist physicians), and unavailability of blood for transfusion. Interviews highlighted particularly good process readiness in the provision of uterotonics, recognising and responding to retained placenta, and repairing tears. However, there were clear gaps in the utilisation of tranexamic acid and uterine balloon tamponade.

CONCLUSIONS

We have identified good structural and process readiness across both Ghanaian and Ugandan health facilities to support PPH responses. However, some key missed opportunities-to align with current WHO guidance on providing bundles of interventions for PPH care-could be strengthened with minimal investment but promising impact.

Prevention of intrauterine balloon displacement in patients with postpartum hemorrhage: A narrative review

Postpartum hemorrhage (PPH) remains a significant complication of pregnancy globally, with uterine atony accounting for the great majority of cases. Second-line hemostatic strategies such as uterine balloon tamponade play a crucial role in managing refractory hemorrhage. Despite its effectiveness, the phenomenon of balloon displacement poses a challenge to PPH management, often leading to treatment failure. Various techniques have been proposed to address this issue, including vaginal packing, cervical cerclage, fixation to the abdominal wall, holding the cervix with ring forceps, and suspending the balloon with cervical sutures. Each method has its advantages and limitations, influencing its suitability in different clinical scenarios. Understanding these techniques may be useful to optimize and improve the management of PPH and maternal outcomes. This review provides a comprehensive summary of these strategies, their mechanisms, and their clinical implications, aiming to guide healthcare providers in choosing the most appropriate approach for individual cases of PPH.

Chitosan-covered tamponade for the treatment of postpartum hemorrhage: a registry-based cohort study assessing outcomes and risk factors for treatment failure

BACKGROUND

Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide. Intrauterine hemostatic devices are recommended when PPH does not respond to medical treatment. The objective of this study was to assess the factors leading to unsuccessful intrauterine therapy with a chitosan-covered tamponade (CT) for the treatment of PPH and to evaluate clinical outcomes based on real-world data.

METHODS

This registry-based cohort study included all women treated with CT for PPH between January 2017 and June 2022 at a university clinic's perinatal department. The endpoint was defined as the failure of CT, indicated by the requirement of further invasive procedures for ongoing hemorrhage after CT application. Medical records were reviewed and binary logistic regressions used to evaluate delivery mode, placenta previa, and placenta accreta spectrum as potential risk factors for CT treatment failure.

RESULTS

The cohort consisted of 230 women, with successful CT treatment in 91.3%. The success rate for mild PPH was 100.0%, for moderate 95.5%, and for severe 84.2%. Five hysterectomies were performed in total. Placenta previa in cesarean sections was identified as the primary risk factor for CT treatment failure, increasing the odds about 7.5-fold (Odds Ratio: 7.48; 95% CI: 1.87-33.15) compared to cesarean sections without placenta previa. Furthermore, delays in CT insertion may also contribute to treatment failure.

CONCLUSION

CT serves as an intrauterine treatment for medically intractable PPH. Placenta previa significantly increases the risk of CT treatment failure in cesarean sections. Obstetricians should be particularly vigilant in managing patients with placenta previa and consider early use of CT or a combination of procedures.

TRIAL REGISTRATION

This study was approved by the local Ethics Committee on 11/10/2021 (EA4/231/21).

Red Blood Cell Transfusion after Postpartum Hemorrhage: Clinical Variables Associated with Lack of Postpartum Hemorrhage Etiology Identification

Postpartum hemorrhage (PPH) remains a significant obstetric emergency worldwide and a leading cause of maternal death. However, it is commonly underreported, which can represent a major concern for maternal morbidity and mortality. This retrospective case series study analyzed patients with red blood cell transfusion (RBCt) in the postpartum period over a four-year interval at a specific center. A total of 18,674 patients delivered between January 2018 and December 2021. Patients with postpartum RBCt were classified into two groups: those with identified PPH (i-PPH) and those without (non-i-PPH). Clinical variables, delivery details, blood loss data, and treatment information were collected. Statistical analysis involved a comparison of variables between the i-PPH and non-i-PPH groups. Univariate and multivariate analyses were performed, aiming to identify significant associations between the clinical variables and a lack of PPH identification. The incidence of RBCt was 1.26% (236 cases). Patients receiving RBCt had higher rates of cesarean delivery, twin pregnancy, labor induction, and previous cesarean section. Among patients with postpartum RBCt, 34.3% lacked an identified PPH. The rarity of postpartum RBCt contrasts with the increasing rates of PPH, highlighting the importance of diagnosing PPH and postpartum anemia. A strategy of systematic quantification of blood loss during delivery could help detect PPH and anemia before adverse consequences occur.

Is it worth to insert uterine pack instead of Bakri balloon to control postpartum hemorrhage after vaginal delivery in hypertensive patients?

OBJECTIVE

To assess the safety and effectiveness of uterine packing with gauze compared to Bakri balloon to control postpartum hemorrhage (PPH) after vaginal delivery in patients with hypertensive disorders with pregnancy (HDP).

METHODS

This was a prospective observational study conducted on 142 patients with HDP who suffered atonic PPH following vaginal delivery and were allocated either to insert uterine packing with gauze (n = 68) or insertion of Bakri balloon (n = 74). Success of the tamponade to arrest bleeding was the primary outcome measure. Data was collected and analyzed.

RESULTS

Most of the included patients experienced spontaneous onset of labour (69%), had not receive I.V. antihypertensive drugs (83.1%) or magnesium sulphate (94.4%), or calcium channel blocker (95.7%), underwent spontaneous vaginal delivery (85.9%), received Pethidine by IMI for pain relief during labour (67.6%), did not need an episiotomy (59.2%), with spontaneous delivery of the placenta (95.77%). Bakri balloon was associated with a shorter duration to insert (p < 0.001), a higher failure rate with the need for laparotomy (p < 0.05) and more post-delivery hospital stay compared to uterine packing (p < 0.001).

CONCLUSION

Although uterine packing with gauze to control PPH after vaginal delivery in patients with HDP requires a longer time to insert compared to Bakri balloon yet associated with a lesser need for laparotomy and shorter hospital stay. Larger trials are warranted to confirm or refute these findings.

Uterine Artery Embolization of Uterine Arteriovenous Malformation: A Systematic Review of Success Rate, Complications, and Posterior Pregnancy Outcomes

Uterine Arteriovenous Malformation (UAVM) is a rare but life-threating cause of uterine bleeding. The clinical management of this condition is challenging, and there is a need to describe the most adequate approach for these patients. Uterine artery embolization (UAE) is the most widely-published treatment in the literature in recent years, although there is a need to update the evidence on this treatment and to compare it with other available therapies. Thus, the objective of this systematic review is to quantify the efficacy of UAE of UAVM. In addition, we evaluated the clinical context of the patients included, the treatment complications, and the pregnancy outcomes after UAE. With this goal in mind, we finally included 371 patients spread over all continents who were included in 95 studies. Our results show that, similar to other medical therapies, the global success rate after embolization treatment was 88.4%, presenting a low risk of adverse outcomes (1.8%), even in women with later pregnancy (77% had no complications). To date, this is the largest systematic review conducted in this field, although there are still some points to address in future studies. The results obtained in our study should be outlined in UAE protocols and guidelines to aid in clinical decision-making in patients with UAVM.

Workshop on Blood Loss Quantification in Obstetrics: Improving Medical Student Learning through Clinical Simulation

PURPOSE

To assess whether a clinical simulation-based obstetric blood loss quantification workshop for medical undergraduate trainees improves theoretical-practical knowledge, along with self-assurance and self-confidence.

METHODS

This was a quasi-experimental pre-post learning study conducted at the Gynaecology and Obstetrics Unit of the Hospital Gregorio Marañón, Madrid, Spain. Participants were volunteer students in their fourth year of a 6-year degree course in Medicine. The study period was divided into the stages: pre-workshop, intra-workshop, 2 weeks post-workshop and 6 months post-workshop. In the pre-workshop stage, students completed a brief online course in preparation for the workshop. The effectiveness of the workshop was assessed through multiple choice tests and self-administered questionnaires. Data were compared between time-points using statistical tests for paired samples.

RESULTS

Of the 142 students invited (age 21.94 ± 3.12 years), 138 accepted the offer of the workshop (97.2%), and 85.4% had no experience in managing blood loss. Between the stages pre- and 2 weeks post-workshop, significant improvements were observed in theoretical-practical knowledge (μ = 1.109), self-assurance and self-confidence. At the 6 months post-workshop stage, theoretical-practical knowledge diminished compared with 2 weeks post-workshop, returning to pre-workshop levels, while self-assurance and confidence failed to vary significantly in the longer term.

CONCLUSIONS

The obstetric workshop improved theoretical-practical knowledge and the self-assurance and confidence of the medical students. Results 2 weeks post-workshop were maintained up until 6 months after the training intervention. The clinical simulation-based workshop was perceived by the students as useful and necessary.

Tamponamento por balão intrauterino no tratamento da hemorragia pós-parto

Resumo Introdução: A hemorragia pós-parto trata-se de uma emergência obstétrica com elevada prevalência e morbimortalidade significativa, sobretudo em contextos de baixa acessibilidade a serviços especializados de saúde. Objetivo: Avaliar a efetividade do tamponamento por balão intrauterino no controle da hemorragia pós-parto, redução da necessidade de intervenções cirúrgicas de emergência e redução da mortalidade materna. Métodos: Revisão sistemática de ensaios clínicos randomizados, orientada pelo Cochrane Handbook for Systematic Reviews of Interventions e relatada através do Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Foram considerados como critérios de elegibilidade ensaios clínicos randomizados que avaliaram o uso de diferentes tipos de balão para tamponamento intrauterino enquanto estratégia para a redução ou cessação da hemorragia pós-parto quando comparados a outras intervenções (farmacológicas ou cirúrgicas). Resultados: Quatro estudos avaliaram 498 pacientes para os desfechos preconizados. Em 80% dos casos relatados observou-se a cessação da hemorragia em um intervalo médio de 15 minutos, após a inserção dos dispositivos. O tempo de permanência dos dispositivos foi de 24 horas. Não foram relatados eventos adversos graves. Devido à heterogeneidade clínica entre os estudos, não foi possível realizar síntese quantitativa. Conclusão: Os achados obtidos não fornecem evidências suficientes para sustentar a utilização rotineira dos dispositivos de tamponamento uterino enquanto prática protocolar no controle da hemorragia pós-parto refratária. A utilização destes dispositivos, no entanto, parece ser promissora diante da falha das intervenções de primeira linha, podendo desempenhar um importante papel em termos de redução de morbimortalidade materna e preservação uterina.

Intrauterine balloon tamponade for postpartum hemorrhage

Abstract Introduction: Postpartum hemorrhage is an obstetric emergency with high prevalence and significant morbidity and mortality, especially in areas with reduced access to specialized health services. Objective: To evaluate the effectiveness of intrauterine balloon tamponade in controlling postpartum hemorrhage, with the aim to reduce the need for emergency surgical interventions and decrease maternal mortality. Methods: A systematic review of randomized clinical trials, guided by the Cochrane Handbook for Systematic Reviews of Interventions and reported through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomized clinical trials that evaluated the use of different types of balloons for intrauterine tamponade as a strategy for reducing or stopping postpartum hemorrhage compared to other interventions (pharmacological or surgical) were considered for inclusion. Results: Four studies evaluated 498 patients. In 80% of the reported cases, hemorrhage cessation was observed within a mean interval of 15 min after device insertion. The device permanence time was 24 h. No serious adverse events were reported. Due to clinical heterogeneity between studies, it was not possible to perform a quantitative synthesis. Conclusion: We did not find enough evidence to support the routine use of uterine tamponade devices as a protocol practice in the control of refractory postpartum hemorrhage. However, the use of these devices seems to be promising in cases where first line interventions fail and may play an important role in decreasing maternal morbidity and mortality and in uterine preservation.