Baloon tamponade in management of postpartum haemorrhage


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Baloon tamponade in management of postpartum hemorrhage

Published in: Health & Medicine

Baloon tamponade in management of postpartum haemorrhage

  1. 1. Balloon tamponade in the management of postpartum haemorrhage Aboubakr Elnashar Benha university Hospital, Egypt Aboubakr Elnashar
  2. 2. Management of PPH 1. Exclusion: retained products genital tract trauma. 2. Uterin atony: a. Uterine massage b. Uterotonic agents: oxytocin, ergometrine, misoprostol and prostaglandin 3. If these unsuccessful: laparotomy. a. Uterine artery ligation b. Uterine compression sutures c. Internal iliac artery ligation d. Hysterectomy Recently, uterine balloon tamponade has been added to this armamentarium Aboubakr Elnashar
  3. 3. Uterine tamponade Packing or Balloon Indications 1. Uterotonics fail to cause sustained uterine contractions& satisfactory control of hge after vaginal delivery 2. Surgical treatment is unavailable at the current site 3. Woman is too unstable to undergo surgery at that time. No prompt response: exploratory laparotomy.Aboubakr Elnashar
  4. 4. A. Uterine packing Steps: •4 inch gauze from one cornu to the other using a sponge stick, packing back& forth, and ending with extension of the gauze through the cervical os. •Antibiotics •Pack is left 24 h •Fluid and blood component replacement. Aboubakr Elnashar
  5. 5. Aboubakr Elnashar
  6. 6. Complications: Trauma Infection Ineffective packing concealed bleeding increasing need for uterotonics Effectiveness: 97% ‘immediate control of bleeding’. Aboubakr Elnashar
  7. 7. B. Uterine Balloon tamponade What? inserting a rubber or silicone balloon into the uterine cavity and inflating the balloon with normal saline. Mechanism of action 1. Exerting in inward-to-outward pressure > systemic arterial pressure: prevent continual bleeding. 2. Hydrostatic pressure effect of the balloon on the uterine arteries. Aboubakr Elnashar
  8. 8. Uses I. Hge at other anatomical sites: Bladder Oesophagus II. PPH from vaginal lacerations. III. Gynaecological bleeding 1. First- and second-trimester termination of pregnancy 2. Cervical pregnancy 3. knife cone biopsy 4. Laser ablation of the endometrium 5. Dysfunctional uterine bleeding, 6. Multiple vaginal lacerations 7. Bleeding from a cervical stump following a post-CS subtotal hysterectomy. Aboubakr Elnashar
  9. 9. Types 1. Condom catheter 2. Rusch catheter 3. Balloon tamponade catheter 4. Foley catheter 5. SOS Bakri tamponade balloon 6. Sengstaken-Blakemore tube Bakri balloon Balloon tamponade catheter specifically designed for control of pph’ If unavailable, or considered expensive: other balloons Aboubakr Elnashar
  10. 10. Effectiveness: •Balloon catheter has superseded uterine packing •An appropriate intervention for most women where uterine atony is the only or main cause of PPH •Hysterectomy was averted in 78%. Aboubakr Elnashar
  11. 11. Distal component of tamponade balloons. Asterisk: position of suture to attach condom to Foley catheter. Also represents distal point of measurement of balloon shaft lengthAboubakr Elnashar
  12. 12. Proximal component of tamponade balloons. Asterisk: proximal point of measurement of balloon shaft b, d, e, f, i, j, k and m: insufflation portion of balloon a, c, g and h: drainage portion of uterine cavity. l and n do not contribute to balloon tamponade or drainage. They inflate a balloon within the actual tamponade balloon. No drainage of the uterine cavity when using the Rusch and condom catheter Aboubakr Elnashar
  13. 13. 1. Condom catheters • Sterile rubber catheter is inserted within the condom and tied near the mouth of the condom by a silk thread. Aboubakr Elnashar
  14. 14. • Urinary bladder was kept empty by indwelling Foley's catheter. • After putting the patient in the lithotomy position, the condom is inserted within the uterine cavity. • Inner end of the catheter remained within the condom. • Outer end of the catheter is connected with a saline set and the condom is inflated with 250-500 mL of running normal saline. Aboubakr Elnashar
  15. 15. • Bleeding is observed, and when it is reduced considerably, further inflation is stopped and the outer end of the catheter is folded and tied with thread. • Oxytocin drip for at least 6 h after the procedure. • The uterine condom is kept tight in position by ribbon gauze pack or another inflated condom placed in the vagina. • The condom catheter is kept for 24-48 h and then is deflated gradually over (10-15 m) and removed. • Triple antibiotic coverage (amoxicillin [500 mg/6 h] + metronidazole [500 mg/8 h] + gentamicin [80 mg/8 hrs]) for 7 d. Aboubakr Elnashar
  16. 16. Aboubakr Elnashar
  17. 17. 23 women with PPH due to uterine atony with uncontrolled bleeding following administration of uterotonics had the condom catheter placed. •Bleeding stopped within 15 m, and no further intervention or treatment Management of PPH in women with impaired coagulation, as after placental abruption 2 cases were successfully treated Aboubakr Elnashar
  18. 18. 2. Rusch balloon Rusch balloon and the condom catheter conforming naturally to the contour of the uterus do not allow drainage of the uterine cavity. Insufflation capacity of 1500 ml ease of use low cost The Sheffield guidelines suggest the use of the Rusch balloon as a prophylactic method in cases of women who are at increased risk of PPH and when PPH would jeopardise the pre-existing maternal condition’. balloon was inflated with 400–500 ml of warm saline removed after 24 h following deflation at a rate of 20 ml/h Aboubakr Elnashar
  19. 19. 3. Balloon tamponade catheter Contours to uterine shape provides drainage at the fundus Dual lumen catheter that allows infusion of saline to expand the balloon while providing uterine drainage to monitor the progression of hemostasis Aboubakr Elnashar
  20. 20. 4. Multiple urinary Foley catheters •inserted together with a ‘haemostatic substance’ applied to the oozing inner surface of the lower uterine segment •The uterine incision site was then closed, and each of the balloons was inflated with 35–75 cm3 of saline or water. •Gentle traction was then applied to obtain a continuous tamponade effect, and the vagina was packed. •The catheters were then tied together, and an examination glove or plastic bag was used for the collection and measurement of blood loss: prevent blood collection inside the uterine cavity and provide an accurate estimation of bleeding. Aboubakr Elnashar
  21. 21. 5. Bakri ‘SOS’ (Surgical Obstetric Silicone) balloon Aboubakr Elnashar
  22. 22. Capacity: up to 500 ml of saline Drainage channel: large bore Use: PPH resulting from a low-lying placenta/placenta praevia Under US guidance, the balloon portion of the catheter is inserted into the uterus, making certain that the entire balloon is inserted past the cervical canal and internal ostium Aboubakr Elnashar
  23. 23. 6. Sengstaken–Blakemore tube The volume of a postpartum uterus was considered too large for an effective tamponade to be achieved by using a 30-ml Foley catheter balloon as used in gynaecological procedures. Therefore, the Sengstaken–Blakemore two-balloon tube, originally designed for the management of bleeding oesophageal varices, was used. The distal, gastric balloon was filled with 300 ml of normal saline to control uterine atony following vaginal delivery and manual removal of the placenta Subsequently, the proximal oesophageal balloon of the Sengstaken–Blakemore tube was used The greater cost of the Sengstaken–Blakemore tube in comparison to the Bakri balloon and the premise that the uterine cavity requires a balloon capable of being insufflated to a large volume resulted in the use of the urological Rusch balloon In Sengstaken–Blakemore balloon, the tip is usually cut to allow a better fit between the balloon and the uterine fundus. In other studies, the distal gastric balloon is folded back when the oesophageal balloon is insufflated Users of the Sengstaken–Blakemore balloon suggest that ‘the tubular oesophageal balloon of the tube would conform more to the shape of the uterine cavity to achieve a haemostatic effect compared to the stomach balloon or a Foley catheter’. In the case of the Sengstaken–Blakemore tube when the distal tip is folded, the previously available drainage channel is potentially eliminated, whereas cutting the distal tip creates a single wide bore channel for drainage. Aboubakr Elnashar
  24. 24. Indications •After pharmacological methods (oxytocin, ergometrine and misoprostol) have proven to be ineffective for uterine atony. •Can be used alone or in combination with other surgical interventions, such as internal iliac artery ligation and the B- Lynch suture. Aboubakr Elnashar
  25. 25. Contraindications 1. Uterine infection 2. Allergy to rubber/latex products, such as the Rusch balloon and the condom catheter Aboubakr Elnashar
  26. 26. Timing •Early intervention of a balloon device: less maternal morbidity {reduced blood loss}. allow time for resuscitation of the women, obtaining cross-matched blood and arrival of senior help 1. Prior to laparotomy following a vaginal delivery: Successful: negate the need for a laparotomy. Unsuccessful: no significant delay {insertion is easily achieved}. reduce continuing bleeding prior to transfer to the operating theatre 2. At laparotomy or at CS Close the uterus first and then insert the balloon from the vagina, applying the tamponade test before closing the laparotomy site: allow visualisation of the uterus following insufflation. Aboubakr Elnashar
  27. 27. Inflation minimal amount of uterine distension to accomplish haemostasis over-inflating’ the balloon: distension of the uterus: significant pain. theoretical concern of uterine rupture Aboubakr Elnashar
  28. 28. Use of a vaginal pack Recommended for •Condom catheters(or second inflated condom in the vagina) •Bakri balloon •Sengstaken–Blakemore tube. •PPH involving a dilated cervix {balloon is insufflated, it will expand to fit the least resistant space the vagina). Positive tamponade test needs to be demonstrated prior to placement of the vaginal pack. Otherwise, there is a danger that the pack will obscure any continuing bleeding leading to a delayed diagnosis of ineffective tamponade. Aboubakr Elnashar
  29. 29. Tamponade test Positive: control of PPH following inflation of the balloon: laparotomy is not required Negative: continued PPH following inflation of the balloon: proceed to laparotomy. Aboubakr Elnashar
  30. 30. Removal After In most cases: 4–6 h of tamponade should be adequate to achieve haemostasis Most papers have removed the balloon within 48 hours. When: during daytime hours, in the presence of appropriate senior staff Before its complete removal the balloon could be deflated but left in place to ensure that bleeding does not reoccur. Rate of deflation vary from 20 ml/hour to half the volume in the balloon at 12 hours. Aboubakr Elnashar
  31. 31. Oxytocin infusion No evidence that an oxytocin infusion is obligatory for all causes of PPH. If the syntocinon is continued for the duration of balloon placement, this can range from 2 to 82 hours . Prolonged: hyponatraemia {cross-reactivity of the oxytocin with antidiuretic hormone receptors. Aboubakr Elnashar
  32. 32. Carbetocin, a synthetic analogue of oxytocin, with a halflife of 4–10 times that of oxytocin is available. There were no significant changes in sodium, potassium or chloride values from predrug levels after a single dose of carbetocin when measured at 6, 24 and 72 hours after intravenous injection in nonpregnant women. Therefore, this may be a preferred drug in the presence of a uterine balloon for prolonged uterine contraction. Although not specifically mentioned, another means of increasing uterine tone is to encourage breastfeeding. However, this may be impractical or declined by the mother. Aboubakr Elnashar
  33. 33. Antibiotic •Objective: to reduce the risk of iatrogenic infection caused by contamination of the uterine environment by the balloon from the vaginal environment. •E.g: cephalosporin. •Duration: ± prophylactic (single dose), continued for 24–48 hours or recommended for the duration of balloon usage Aboubakr Elnashar
  34. 34. Pain relief During insertion: Following a vaginal delivery: No anaesthetic analgesia (pethidine) may be used’. After insertion: no pain relief Aboubakr Elnashar
  35. 35. Failures and complications Few •obstruction by uterine leiomyomata • inadvertent damage to the balloon during preparation of Sengstaken–Blakemore tube while cutting off the tip •inability to place the balloon due to the presence of a B- Lynch suture • insufficient insufflation requiring two balloons. •air emboli if air is used as the distension medium for the balloon. •uterine rupture from uterine overdistension •uterine perforation during insertion. Aboubakr Elnashar
  36. 36. Future pregnancies At present, single pregnancy reported following the use of the Rusch balloon 2 pregnancies following the use of a Bakri balloon in combination with a B-Lynch suture. Aboubakr Elnashar
  37. 37. Summary •PPH is a potentially life-threatening event. •In the majority of cases, relatively simple methods are used to avert a disaster, although these are not always employed. •Uterine tamponade using intrauterine balloons is an effective tool in the management of PPH {90% cases were successful} •Balloon tamponade is simple to arrange and with minimal adverse effects: a familiar component for the management of PPH Aboubakr Elnashar
  38. 38. Thanks Aboubakr Elnashar