Baloon tamponade in management of postpartum hemorrhage

1. Balloon tamponade in the
management of
postpartum haemorrhage
Aboubakr Elnashar
Benha university Hospital, Egypt
Aboubakr Elnashar

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. 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. 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. Aboubakr Elnashar

6. Complications:
Trauma
Infection
Ineffective packing
concealed bleeding
increasing need for uterotonics
Effectiveness:
97%
‘immediate control of bleeding’.
Aboubakr Elnashar

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. 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. 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. 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. 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. 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. 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. • 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. • 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. Aboubakr Elnashar

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. 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. 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. 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. 5. Bakri ‘SOS’ (Surgical Obstetric Silicone) balloon
Aboubakr Elnashar

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. 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. 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. Contraindications
1. Uterine infection
2. Allergy to rubber/latex products, such as the
Rusch balloon and the condom catheter
Aboubakr Elnashar

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. 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. 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. 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. 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. 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. 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. 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. Pain relief
During insertion:
Following a vaginal delivery:
No anaesthetic
analgesia (pethidine) may be used’.
After insertion:
no pain relief
Aboubakr Elnashar

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. 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. 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. Thanks
Aboubakr Elnashar