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Tamponade Test’ in the Management of Massive Postpartum Hemorrhage
Abstract & Commentary
Synopsis: This diagnostic test rapidly identifies those patients with postpartum hemorrhage who will require a laparotomy. Even when results are positive, life-threatening hemorrhage is arrested and time is also allowed to correct any consumptive coagulopathy.
Source: Condous GS, et al. Obstet Gynecol. 2003; 101(4):767-772.
Although homicide surprisingly is now the leading cause of maternal mortality, postpartum hemorrhage has always remained near the top of the list. Attempts to mechanically cause uterine tamponade have been reported mainly in the Japanese and European literature, but very recently, an article appeared in Obstetrics and Gynecology that got my attention.
The paper by Condous and colleagues described a simple method of stopping intrauterine bleeding with an inflated balloon (the Sengstaken-Blalock esophageal catheter). Although somewhat similar techniques were described by other authors to quell postpartum hemorrhage in a few patients, Condous and colleagues used the method as a "tamponade test" to see which patients would require surgery (if the balloon failed to accomplish hemostasis).
Sixteen patients with intractable postpartum hemorrhage were studied. Fourteen of the 16 had uterine atony, but 5 also had retained products and 3 had DIC. There were no known cases of accreta.
The tamponade method simply consisted of gently inserting the S-B catheter into the uterus, after cutting off the protruding end of the catheter so that it was flush with the superior margin of the balloon. Between 70 and 300 cc of saline were infused into the balloon until the uterus, palpated abdominally, "felt like a well contracted uterus," and, at the same time, appeared within the cervix.
Fourteen of the 16 had complete cessation of the bleeding (a positive test) and, therefore, did not require surgery, while 2 continued to bleed and required surgery. The success rate probably might have been even better since 1 patient requiring surgery had an unrecognized cervical extension of a cesarean incision and in the other case Condous et al admitted they probably had not applied the balloon correctly.
Comment by John C. Hobbins, MD
In the overwhelming majority of cases, postpartum bleeding can be stopped with uterine massage and oxytocics (oxytocin, Methergine, and/or prostaglandins such as 15-methyl F2α). However, when hemorrhage is not countered by these methods, some patients may lose much of their blood volume while attempts are being made to establish the cause of the bleeding and to institute rescue therapy through interventional radiological techniques or surgery.
This technique, which really represents a kinder, gentler means of intrauterine packing, can either stop the bleeding by itself, or enable the operators to tread water, without disastrous interval blood loss, while preparations are being made for further interventions.
These catheters could be stocked on labor and delivery floors and brought out for occasional use immediately upon request. The expense of this esophageal catheter, compared with a Foley catheter, which has only been tried on a few occasions, could be easily justified based on the success of the above study.
Unfortunately, it seems that the most common step undertaken in the United States, after oxytocics fail to stop postpartum hemorrhage, is to take the patient "back" where she is put in stirrups and a D&C is done to determine if retained products are the cause of the bleeding. While preparing for the D&C, and during the procedure itself, the patient can lose a substantial portion of her blood volume.
Actually, this often-used step is unnecessary in the majority of cases. A simple transabdominal ultrasound examination at the bedside will tell the provider in a minute whether or not retained tissue is present. This would allow the balloon to be placed at the bedside without delay if no tissue is found or to do a gentle removal of the tissue with sponge forceps under ultrasound direction if there is retained tissue.
Various interventive methods to stem intrauterine bleeding have been described, which include embolizing the arterial circulation to the uterus, applying various stitches to compress the uterine cavity, occluding the uterine or hypogastric artery, or, the ultimate therapy, performing a hysterectomy.
This balloon method seems to represent the simplest step, as it may work by itself, as shown in the study, or can help to ameliorate blood loss (while correcting a DIC) until more drastic intervention can be arranged.
Dr. Hobbins is Professor
and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver.