Balloon Tamponade in the Management of Postpartum Haemorrhage: a Review

DOI: 10.1111/j.1471-0528.2009.02113.x Review article www.blackwellpublishing.com/bjog Balloon tamponade in the management of postpartum haemorrhage: a review C Georgioua,b a Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia b Wollongong Hospital, Department of Obstetrics and Gynaecology, Illawarra, New South Wales, Australia Correspondence: Dr C Georgiou, The Wollongong Hospital Academic Suite, Wollongong Hospital, Block C, Level 8, Crown Street, Wollongong, NSW 2500, Australia. Email [email protected] Accepted 31 December 2008. Obstetric haemorrhage is a significant contributor to worldwide available including the Bakri, Foley, Sengstaken–Blakemore, Rusch maternal morbidity and mortality. Guidelines for the management and condom catheter. This paper reviews these uterine tamponade of postpartum haemorrhage (PPH) involve a stepwise escalation of technologies in the management of PPH. pharmacological and eventual surgical approaches. The method of Keywords Balloon tamponade, intrauterine, management, post- uterine tamponade using balloons has recently been added to the partum haemorrhage, review. armamentarium for managing PPH. There are various balloons Please cite this paper as: Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009;116:748–757. Background Uterine tamponade Obstetric haemorrhage is a significant contributor to world- One of the earliest methods of achieving a tamponade effect wide maternal morbidity and mortality.1,2 In Australia and to control PPH was by uterine packing.15 the UK, haemorrhage features within the top four causes of The possibilities of trauma, infection and ineffective pack- direct maternal death as reported in the latest triennial ing resulting in concealed bleeding together with the reports.3,4 increasing effective pharmacological agents to treat uterine Guidelines for the management of postpartum haemor- atony such as ergometrine and syntocinon resulted in a grad- rhage (PPH) involve a stepwise approach including the exclu- ual reluctance in use.16 Despite the declining popularity, in sion of retained products and genital tract trauma. Uterine units where uterine packing was commonly employed, data atony, which is the most common cause,5 is dealt with uterine suggested that it was effective.17,18 In one series of 163 cases, rubbing and various uterotonic agents such as oxytocin, ergo- 158 (97%) of these resulted in ‘immediate control of metrine, misoprostol and prostaglandin F2a (PGF2a).3,6–8 bleeding’.19 If these attempts prove to be unsuccessful and the woman is Sterile gauze was invariably used for uterine packing, but not already having a caesarean section, a laparotomy is con- more recently, balloon technology has been used to tampo- sidered. During this time, various surgical interventions may nade the postpartum uterus to control haemorrhage. This be used. These include internal iliac artery ligation, uterine involves inserting a rubber or silicone balloon into the uterine compression sutures and peripartum hysterectomy to control cavity and inflating the balloon with normal saline. The the life-threatening haemorrhage.9–11 balloons in descending order of relative cost include the Recently, uterine balloon tamponade has been added to Sengstaken–Blakemore tube, the Bakri balloon, the Rusch this armamentarium in the management of PPH.7,12–14 The balloon, Foley catheters and the condom catheter balloon purpose of this paper was to review the various uterine tam- (Tables 1 and 2, Figures 1 and 2). ponade technologies currently available for the management Currently, the intrauterine balloon is believed to act by of PPH. exerting in inward-to-outward pressure ‘that is greater than 748 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology Balloon tamponade in the management of postpartum haemorrhage the systemic arterial pressure’ to prevent continual bleeding.35 Foley catheters, filled to 30–50, 80 and 110 ml, respectively, More recently, an alternative mechanism of action has been were used in postpartum haemorrhage following unsuccessful proposed, which involves the hydrostatic pressure effect of the use of pharmacological agents and despite uterine curette.34 balloon on the uterine arteries.28 Many of these balloons have previously been used to con- Sengstaken–Blakemore tube trol haemorrhage at other anatomical sites, including the bladder36 and oesophagus,37 as well as to control PPH from The volume of a postpartum uterus was considered too large vaginal lacerations.38 for an effective tamponade to be achieved by using a 30-ml 45 Furthermore, these same technologies have been used in Foley catheter balloon as used in gynaecological procedures. gynaecological conditions in which bleeding is problematic, for Therefore, the Sengstaken–Blakemore two-balloon tube, orig- example following first- and second-trimester termination of inally designed for the management of bleeding oesophageal 37 pregnancy,20,39 cervical pregnancy,40–44 knifeconebiopsy,33 laser varices, was used. The distal, gastric balloon was filled with ablation of the endometrium, dysfunctional uterine bleeding,45 300 ml of normal saline to control uterine atony following 23 multiple vaginal lacerations46 and bleeding from a cervical stump vaginal delivery and manual removal of the placenta following a post-caesarean section subtotal hysterectomy.47 (Table 1, Figures 1 and 2). Subsequently, the proximal oesophageal balloon of the Seng- staken–Blakemore tube was used24 (Table 1, Figures 1 and 2). Bakri balloon Bakri first published the concept of intrauterine balloon tech- Rusch balloon nology in the management of haemorrhage secondary to pla- The greater cost of the Sengstaken–Blakemore tube in com- centa praevia–accreta during caesarean section with or parison to the Bakri balloon and the premise that the uterine 48 without bilateral hypogastric arterial ligation. Multiple uri- cavity requires a balloon capable of being insufflated to a large nary Foley catheters were inserted together with a ‘haemostatic volume resulted in the use of the urological Rusch balloon29 substance’ applied to the oozing inner surface of the lower (Figures 1 and 2). This balloon is reported having an insuf- uterine segment to function as a ‘haemostatic cushion’. The flation capacity of 1500 ml.30 uterine incision site was then closed, and each of the balloons The Rusch balloon was first used for continual uterine 3 was inflated with 35–75 cm of saline or water. Gentle traction bleeding after removal of a morbidly adherent placenta and was then applied to obtain a continuous tamponade effect, an adherent succenturiate lobe. In the former case, balloon and the vagina was packed. application followed a failed Sengstaken–Blakemore tube The catheters were then tied together, and an examination application and unilateral uterine artery embolisation. The glove or plastic bag was used for the collection and measure- other uterine artery being inaccessible for embolisation. In ment of blood loss. This was suggested to help prevent blood both cases, the Rusch urological balloon was inflated with collection inside the uterine cavity and provide an accurate 400–500 ml of warm saline and removed after 24 hours fol- estimation of bleeding. lowing deflation at a rate of 20 ml/hour29 (Table 1). Later, a ‘balloon device for controlling capillary/venous bleeding and surface oozing’ in cases of ‘placenta praevia with variable Condom catheters degrees of accretism’ was described49 (Figures 1 and 2). The now termed Bakri ‘SOS’ (Surgical Obstetric Silicone) balloon was The principle of a fluid-filled structure exerting a tamponade described with a capacity of up to 500 ml of saline achieving a effect to stop bleeding36,37 has also been exemplified by the use ‘pressure and tamponade effect to control the bleeding state’. of condom catheters in the management of PPH. This ‘Sayeba’s A subsequent article described the successful use of the method of PPH control’ was used in a prospective study of 23 Bakri (SOS) balloon in four women with PPH resulting from cases31,32,50 (Figures 1 and 2). A latex condom was inserted into a low-lying placenta/placenta praevia20 (Table 1). the uterus by means of a size 16 rubber catheter and inflated with 250–300 ml of isotonic saline until the bleeding was con- Foley catheters trolled. The condom catheter was then removed after 24–48 hours (Table 1). Both single and multiple Foley catheters have been used in the Two further cases using this condom catheter were management of PPH48 (Table 1, Figures 1 and 2). In one case, described in the management of PPH in women with despite uterine curette and failed uterine packing using dry impaired coagulation32 (Table 1). In the first case, a condom sterile gauze, five Foley catheters were inserted into the uter- tied with silk to the tip 3–4 cm of the Foley catheter was ine cavity.33 They were inflated with 80 ml normal saline to placed in uterus. The condom was inflated (250 ml saline) achieve haemostasis and subsequently removed after 36 hours until bleeding was reduced. The proximal end of catheter was without further bleeding (Table 1). Three other cases of single ligated to prevent backflow, and the vagina was packed with ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 749 Georgiou Table 1. Balloon tamponade devices Balloon Number Timing of use Cause of PPH Use of Failed surgical Additional surgical

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