Balloon tamponade in the management of postpartum haemorrhage: a review

Obstetric haemorrhage is a significant contributor to worldwide maternal morbidity and mortality. Guidelines for the management of postpartum haemorrhage (PPH) involve a stepwise escalation of pharmacological and eventual surgical approaches. The method of uterine tamponade using balloons has recently been added to the armamentarium for managing PPH. There are various balloons available including the Bakri, Foley, Sengstaken–Blakemore, Rusch and condom catheter. This paper reviews these uterine tamponade technologies in the management of PPH.     

Postpartum haemorrhage and haematological management

Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality around the world. In the UK, the Centre for Maternal and Child Enquiries (CMACE) confirmed a reduction in maternal deaths due to postpartum haemorrhage during the last Triennium (2006–2008). However, substandard care continues to contribute to more than half of maternal deaths due to postpartum haemorrhage.     

The impact of post-partum haemorrhage in “near-miss” morbidity and mortality in developing countries

The global maternal mortality ratio (MMR) of 400 per 100,000 live births results in an estimated 529,000 maternal deaths annually. Most of these deaths occur in developing countries and only about 1% in developed countries. Besides mortality data, the identification and accurate documentation of “near-miss” morbidity (a more sensitive index) is extremely important to assess the quality of health care systems. It can suitably guide to adopt appropriate measures to reduce maternal mortality and morbidity. Haemorrhage remains a major cause of maternal mortality in both developing and developed countries followed by anaemia and infection, which are more common in developing countries. Post-partum haemorrhage (PPH) is a frequent complication of delivery. PPH occurred in 10.5% of all live births worldwide resulting in 13,795,000 cases in the year 2000. The case fatality rate for PPH was 1% and there were 132,000 deaths attributable to PPH. Anaemia as a consequence of PPH was estimated to occur in 1.6 million women every year. Thus, the prevention and adequate management of obstetric haemorrhage are likely to result in a significant reduction in the MMR and in the less frequently monitored “near-miss” morbidity. Strategies to be adopted with regard to PPH in developing countries may differ from those routinely available and practised in developed countries because of limited access to health care facilities and low institutional delivery rate in the former countries. Some low cost, simple techniques to prevent and manage PPH are described. These need to be tested in a wider population to determine which is most suitable for a particular area or country. The mortality and “near-miss” morbidity data should be continually assessed and only then will the impact of these strategies be known. First level midwifery care plus backup by well-equipped hospitals must be developed concomitantly. Anyone can conduct a normal delivery when all is going well but only those with good clinical judgement and the necessary skills will be able to anticipate and manage a problem. This is especially important in the context of PPH where the under-estimation of blood loss coupled with the rapidity of development of serious consequences is the key issue.     

Postpartum haemorrhage and haematological management

Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Recent report of the Centre for Maternal and Child Enquiries (CMACE) in the United Kingdom, which was previously called Confidential Enquiries into Maternal and Child Health (CEMACH), confirmed a reduction in maternal deaths during the last Triennium (2006–2008). This is attributed to improvements in timely diagnosis and prompt and aggressive treatment. PPH is now the sixth most common direct cause of maternal deaths in the U.K. World Health Organization (WHO) estimates that postpartum haemorrhage accounts for 25% of maternal deaths worldwide. Substandard care and ‘too little being done too late’ remain a significant contributor of maternal deaths.Primary PPH refers to a blood loss from the genital tract of 500 ml or more within 24 h of delivery (or >1000 ml during caesarean section). Secondary PPH refers to an excessive blood loss between 24 h and 6 weeks after birth. Massive PPH refers to a blood loss of over 2000 ml (or >30% of blood volume) and is associated with increased maternal morbidity and mortality. A timely, multi-disciplinary and systematic approach to restore the volume, clotting system and the oxygen carrying capacity of blood, whilst steps are taken to arrest bleeding, is essential to save life.Primary postpartum haemorrhage is caused by uterine atony, genital tract trauma, retained placental tissue and membranes after birth or coagulopathy. The latter may not only be a cause of PPH, but also could be an effect of massive haemorrhage due to a ‘washout phenomenon’. Rapid and profuse bleeding results in loss of platelets and clotting factors, that get ‘washed out’. This may lead to a depletion of coagulation factors and resultant bleeding.     

Risk management and medicolegal issues related to postpartum haemorrhage

Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity. Despite several local and national guidelines and recommendations, the incidence of major obstetric haemorrhage has not declined significantly over the years. A high proportion of these cases involve patient safety incidents. The major themes in such incidents are: delay in diagnosis, failure to adhere to protocols, lack of consultant supervision, communication and documentation problems, inefficient teamwork and organizational failure. This chapter deals with ways of identifying the major contributory factors for adverse events associated with PPH and suggests solutions to minimize errors.     

Management of massive postpartum haemorrhage and coagulopathy

Postpartum haemorrhage (PPH) continues to remain the leading cause of maternal morbidity and mortality worldwide. Whilst this is especially true in resource limited countries, it also remains a significant problem in developed countries. The traditional definition of primary PPH is blood loss from the genital tract of 500 ml or more within 24 h of delivery (or >1000 ml during caesarean section). Secondary PPH refers to an excessive blood loss between 24 h and 6 weeks, postnatally. Massive PPH refers to a blood loss of over 2000 ml (or >30% of blood volume) and hence, is an obstetric emergency that requires a systematic, multi-disciplinary approach to restore the volume, clotting system and the oxygen carrying capacity of blood, whilst steps are taken to arrest bleeding as quickly as possible.The last confidential enquiry into maternal deaths (CEMACH, 2003–2005) in the UK cited ‘haemorrhage’ as the third highest cause of direct maternal deaths with 6.6 deaths per million maternities. This report found that 58% of these deaths may have been preventable and ‘too little being done, too late’ (failure to appreciate clinical picture, delay in instituting appropriate treatment, delay is summoning senior help and system failures) continues to contribute to maternal morbidity and mortality, even in the developed world.Massive obstetric haemorrhage may occur in the antepartum (placenta praevia, placental abruption and placenta accreta) or postpartum period. It is has been observed that the incidence of massive PPH is likely to be increasing due to the increased incidence of risk factors such as morbidly adherent placenta secondary to previous caesarean sections and maternal obesity. However, massive obstetric haemorrhage and the resultant coagulopathy can occur in women deemed to be at ‘low risk’ and hence, all clinicians managing women during pregnancy and labour need to possess knowledge and skills to recognize symptoms, signs and complications of massive obstetric haemorrhage. This may ensure institution of timely and appropriate treatment that could save lives.     

Surgical management of postpartum hemorrhage

When medical management of PPH is unsuccessful, surgical options should be utilized in a timely fashion in order to reduce maternal morbidity and mortality. This chapter describes ways of effective preparation, mobilization of resources and an organized approach to evaluation and surgical amelioration of PPH. Multiple fertility preserving surgical techniques to control PPH are described. Although a variety of conservative surgical approaches can be used in the setting of PPH, in a hemodynamically unstable patient, readiness for definitive management with a hysterectomy is necessary in order to reduce the risk of maternal mortality.     

Management challenges in primary and secondary postpartum haemorrhage

In this review article we will cover the management of both primary and secondary postpartum haemorrhage. Detailed national guidance on the management of primary PPH has been in place since 1998. Despite this, multiple MBRRACE-UK reports have consistently found significant scope for improvement in the care delivered to women. The recurrent nature of the themes highlighted in the reports is equally sobering, which suggests a failure to learn from these tragic cases. The first part of this paper will provide practical steps that can be taken to embed the learning from successive MBRRACE-UK reports into our day-to-day clinical practice. The second part of this paper will provide an overview of the literature on secondary postpartum haemorrhage. Secondary PPH is associated with significant maternal morbidity. Despite this, there is a lack of randomised controlled trials to inform the management of these women, and the long-term sequalae associated with both the condition and its management is unknown.     

A new uterine compression suture for postpartum haemorrhage with atony

Postpartum haemorrhage (PPH) is a major cause of worldwide maternal mortality and is still associated with significant morbidity. After the B-Lynch suture was reported in 1997, several different uterine compression sutures were found to be successful in controlling PPH. In this paper, we describe another simple variation of the uterine compression suture technique, which was performed without an incision in the uterine wall, without entering the uterine cavity and without suturing the anterior and posterior walls of the uterus together, so minimising the trauma to the uterus. This new uterine compression suture is an effective and safe surgical treatment for PPH caused by atony. It has the potential to apply to intractable PPH after vaginal delivery.     

Medical and Conservative Surgical Management of Postpartum Hemorrhage

Massive postpartum hemorrhage (PPH) is a major cause of maternal mortality in the United Kingdom and worldwide. Life-threatening PPH occurs with a frequency of I in 1000 deliveries in the developed world. In the latest triennial Why Mothers Die: Confidential Enquiries into Maternal Deaths in the United Kingdom (1997–1999), PPH was the fifth most common cause of maternal mortality. In this review, we discuss the role of medical management in primary PPH and the use of the “tamponade test” when such management fails. The less radical surgical options discussed include uterine compression sutures, uterine or internal iliac artery ligation, and arterial embolization, all of which have the advantage of potentially preserving reproductive function. Radical surgical options, including subtotal or total hysterectomy, are not discussed in this review. A systematic or algorithmic method of tackling the problem is described. The suggested management approach is likely to reduce maternal morbidity from bleeding, hysterectomies, and maternal deaths.     

A worldwide review of the uses of the uterine compression suture techniques as alternative to hysterectomy in the management of severe post-partum haemorrhage.

Postpartum haemorrhage (PPH) is a worldwide problem. The historical background dates back to William Smelley's in the seventeenth century in his famous treaty of the theory and practice of midwifery in 1752. Changes in clinical factors and surgical expertise compel the modern day midwife and obstetrician to be vigilant in identifying risk factors and apply appropriate solution early. The recent confidential enquiry into maternal death (why mothers die (2000-2002)) identifies areas of substandard care. The rising caesarean section rate adds to the rising incidence of PPH. The reduction in junior doctor's hours may limit the pool of experienced obstetric surgeons available to manage severe PPH competently. There can be major complications following radical surgery for PPH. These include loss of fertility, other morbidity and even maternal death. The invention of the B-Lynch surgical technique for the conservative management of PPH was first performed and reported by a consultant obstetrician and gynaecological surgeon in Milton Keynes NHS Trust publishing the first series of cases in BJOG 1997. This has made a significant impact on the conservative surgical management of massive PPH. There are now over 1300 successful applications of this technique worldwide (CB-Lynch personal communication). Other similar or modified techniques such as Cho's Square Suture and Haymen's modification of the B-Lynch Suture Technique have been introduced adding to more available methods of conservative surgery. The current list of publications of successful application of the B-Lynch compression technique is encouraging and more outcome data can be reported by a letter or e-mail to enquiries@cblynch.com. Obstetricians and midwives both in developed and underdeveloped countries should seek training and attend fire drills in PPH control to avoid maternal morbidity and death. There should be special concentration on effective conservative surgery such as uterine compression techniques to avoid major morbidity and loss of fertility.     

Antepartum haemorrhage

Antepartum haemorrhage (APH) is defined as bleeding from, or into, the genital tract, occurring from 24⁺⁰ weeks of pregnancy and prior to delivery. It complicates 3–5% of pregnancies but is seen in up to 20% of very preterm deliveries, and an association with cerebral palsy. MBBRACE -UK 2019 reported that 8% of UK maternal deaths occurred secondary to bleeding (APH&PPH) in pregnancy during the triennium 2015–2017. The high prevalence and the associated perinatal and maternal mortality and morbidity, demands a thorough understanding of APH and this review considers the most common causes of APH (placenta praevia, placental abruption and local causes), together with their management, using a case-based approach.     

Diagnosis and treatment of peripartum bleeding

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5-5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VIIa.     

产后出血及其临床救治

产后出血是一种常见的并发症,是产妇发病率和死亡率的主要原因。产后出血有许多潜在的原因,但最常见的是子宫收缩乏力。所有产科工作人员和参与孕产妇保健的工作人员,必须有一个产后出血的预防和管理的明确计划。应当记住:一到位,两个重视,三个正确,提高产后出血救治水平。     

Postpartum hemorrhage: practical approach to a life-threatening complication

Postpartum haemorrhage (PPH) occurs in 5% of all deliveries and is responsible for a major part of maternal mortality. Adequate attendance to this complication can mean the difference between life and death. A well-trained staff together with clear and simple guidelines can make a significant difference to the patient. The aim of this article is to offer a practical guide for the management of PPH; a flowchart is presented. When faced with refractory hemorrhage, one can switch to interventional therapy or surgery. Efficiency and speed play a key part in the approach to this life threatening bleeding.     

Surgical management of severe postpartum haemorrhage

In the UK maternal deaths as a result of postpartum haemorrhage (PPH) numbered 1 in 60 000 births in the 1970s, falling to 1 in 200 000 births in the 1990s. However, in developing countries this figure may be as high as 1 in 2000–5000 births. The morbidity is 50 times more common than in developed countries. The improved figures from England and Wales are largely due to prophylactic use of oxytocics in the management of the third stage of labour and is similar to the figures of other developed countries. Confidential enquiries in the developed countries point to avoidable factors. Replacement of blood that is ‘too little and too late’ and ‘delay to initiate and perform definitive surgery’ when there is severe PPH that does not respond to medical management have been highlighted. The role of surgery and various surgical methods in the management of severe PPH is discussed.     

全球产后出血指南异同

产后出血是全球孕产妇死亡的首要原因,产后出血的诊断和治疗指南对规范产后出血的临床管理及降低孕产妇死亡率意义重大。文章对我国产后出血指南及全球其他国家主要产后出血指南的推荐进行对比,希望进一步提高产科医生对产后出血的重视程度。     

Postpartum ultrasound: postpartum assessment using ultrasonography

Postpartum haemorrhage (PPH) is a potential cause of maternal mortality, and obstetricians must be prepared to rapidly diagnose and treat this condition. Optimal treatment is dependent upon the underlying cause of haemorrhage. Ultrasonography is the most helpful tool for prompt diagnosis of PPH aetiology and obstetricians must have a strong understanding of postpartum ultrasonography. In our previous report, we demonstrated the utility of ultrasonography using the focused assessment with sonography for obstetrics (FASO) technique (a modified version of FAST) as the primary postpartum obstetric survey. In the present article, we review the ultrasonographic findings of PPH, differentiated by the underlying cause of haemorrhage, including retained placenta, morbidly adherent placenta, uterine rupture, uterine inversion and uterine artery abnormalities.     

Maternal mortality and serious maternal morbidity in Jehovah's witnesses in the Netherlands

Objective  To determine the risk of maternal mortality and serious maternal morbidity because of major obstetric haemorrhage in Jehovah's witnesses in the Netherlands.
Design  A retrospective study of case notes.
Setting  All tertiary care centres, general teaching hospitals and other general hospitals in the Netherlands.
Sample  All cases of maternal mortality in the Netherlands between 1983 and 2006 and all cases of serious maternal morbidity in the Netherlands between 2004 and 2006.
Methods  Study of case notes using two different nationwide enquiries over two different time periods.
Main outcome measures  Maternal mortality ratio (MMR) and risk of serious maternal mortality.
Results  The MMR for Jehovah's witnesses was 68 per 100 000 live births. We found a risk of 14 per 1000 for Jehovah's witnesses to experience serious maternal morbidity because of obstetric haemorrhage while the risk for the total pregnant population was 4.5 per 1000.
Conclusions  Women who are Jehovah's witnesses are at a six times increased risk for maternal death, at a 130 times increased risk for maternal death because of major obstetric haemorrhage and at a 3.1 times increased risk for serious maternal morbidity because of obstetric haemorrhage, compared to the general Dutch population.     

Post-partum haemorrhage

Obstetric haemorrhage accounts for 25% of maternal deaths in developing countries and post-partum haemorrhage (PPH) is the most common type. It accounts for 10.6% of all direct maternal deaths in the UK and, according to the recent Confidential Enquiries into Maternal and Child Health report, it is the third most common cause of maternal mortality. The enquiry concluded that a number of these deaths were avoidable and highlighted ‘doing too little too late’.Failure to assess the clinical picture, underestimating blood loss, delayed treatment, lack of multidisciplinary team work and failure to seek timely senior help are some of the issues highlighted. Clinicians should be aware of appropriate surgical measures and the timing of interventions. Effective team work, pooling of resources and the presence of a ‘rapid PPH response teams’ can improve outcome.