Innovative hemostasis technique for cesarean section in placenta previa: A retrospective study.

OBJECTIVE: To evaluate hemostatic efficacy, complications, and subsequent pregnancy outcomes in women with placenta previa who underwent combined vertical compression sutures in the lower uterine segment and intrauterine balloon tamponade (Hot-Dog method) to achieve hemostasis after cesarean section. METHODS: We retrospectively reviewed data for 117 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between 29 and 38 weeks' gestation. Treatments were as follows: (1) conventional-intravenous oxytocin administration after placental detachment and suturing of bleeding points at the detachment site as needed (conventional group) (n = 47). (2) Intrauterine balloon tamponade alone (balloon group) (n = 41). (3) Vertical compression sutures + intrauterine balloon tamponade (Hot-Dog group) (n = 29). RESULTS: The placenta accreta spectrum prevalence was significantly higher in the balloon and Hot-Dog groups versus the conventional group. The prevalence of anteriorly located placenta was significantly higher in the Hot-Dog versus balloon groups. Intraoperative and total blood loss were significantly higher in the Hot-Dog versus conventional groups. Postoperative blood loss was significantly lower in the Hot-Dog versus balloon groups. Fewer additional procedures for managing postoperative hemorrhage were required in the Hot-Dog versus conventional and balloon groups. The number of subsequent pregnancies in the conventional, balloon, and Hot-Dog groups was 11 (23.4%), 8 (19.5%), and 4 (13.8%), respectively; all resulted in live births at term without serious obstetric complications. CONCLUSION: The Hot-Dog method is a straightforward and safe hemostasis technique for placenta previa that preserves fertility and controls severe bleeding.

Short and long-term menstrual, reproductive, and mental health outcomes after the intrauterine use of chitosan tamponade or the Bakri balloon for severe postpartum hemorrhage: an observational study.

OBJECTIVE: This retrospective follow-up study analyzes the effect of intrauterine postpartum hemorrhage (PPH) therapy on menstrual, reproductive, and mental health outcomes. METHODS: All women who delivered at a university hospital between 2016 and 2021 with PPH and who needed intrauterine therapy were included. A questionnaire on well-being, menses, fertility, and reproductive outcomes was mailed to the patients. Those who did not reply were surveyed by telephone. RESULTS: A total of 214 women treated with chitosan-covered gauze (group A) and 46 women treated with a balloon tamponade (group B) were recruited, and their short-term courses were analyzed. For long-term follow-up, 71 women of group A (33%) and 21 women of group B (46%) could be reached. A total of 89% of group A and 95% of group B had regular menstrual bleeding in the most recent 12 months; 27% (group A) and 29% (group B) were trying to conceive again, and all of them did so successfully. There were 12 deliveries, 3 ongoing pregnancies, 3 miscarriages, and 2 terminations of pregnancies (TOP) in group A and 4 deliveries, 1 miscarriage, and 2 TOPs in group B. More than half of our study participants was sorted into grade II or III of the Impact of Events Scale, indicating they experienced clinical impacts in the form of psychological sequelae. One-quarter of patients had symptoms of post-traumatic stress disorder. CONCLUSION: Chitosan gauze as well as balloon tamponade appear to have few adverse effects on subsequent menstrual and reproductive function. Women after PPH are at increased risk of long-term adverse psychological outcomes.

Uterine Balloon Tamponade under Ultrasound Guidance in Women with Postpartum Hemorrhage: A Retrospective Cohort Study.

Background: Postpartum hemorrhage (PPH) represents one of the principal causes of maternal mortality and morbidity worldwide. Uterine balloon tamponade (UBT) is recommended for the treatment of postpartum hemorrhage due to uterine atony in women who do not respond to pharmacological first-line treatment. The success of UBT in bleeding control is related to the correct positioning of the device, since incorrect insertion can be associated with ineffectiveness and requires time-consuming repositioning maneuvers, with a further increase in blood loss. The use of ultrasound (US) during UBT may increase the success rate by preventing wrong positioning. This study aims to demonstrate the role of US guidance during UBT and to assess whether US guidance can ease positioning and reduce insertion times, preventing additional repositioning maneuvers, in comparison with a US check carried out after balloon insertion. Methods: This was a retrospective study including 370 women who underwent vaginal delivery, had PPH caused by uterine atony and required UBT at Sant'Anna Hospital from 2015 to 2019. The exclusion criteria were an abnormal placental site, vaginal or cervical trauma, coagulation defects, uterine anomalies, previous postpartum hemorrhage and previous caesarean section. Included subjects were divided into two groups: the US-guided group (n = 200) underwent Bakri balloon positioning under US guidance, and the non-guided group (n = 170) received a US check only after balloon insertion. The primary outcome was the success rate of the procedure, expressed as the percentage of cases with bleeding control without the need for balloon repositioning; the secondary outcomes were the length of the procedure and some parameters related to blood loss. Results: The success rate was 99% for the US-guided group vs. 86% for the non-guided group. None of the patients required hysterectomy. In the US-guided group with respect to the non-guided group, we observed a significant reduction in blood loss (1100 ± 450 vs. 1500 ± 600 mL; p < 0.001), Δhemoglobin level (1.8 ± 1.1 vs. 2.7 ± 2.0 g/dL, p < 0.001) and time required for the procedure (8 vs. 13 min, p < 0.001). Conclusions: Our data suggest that the use of US guidance for placement of UBT was associated with reduced need for balloon repositioning, lower blood loss, and faster resolution of postpartum hemorrhage.

Management of an Iatrogenic Pulmonary Artery Rupture via Balloon Tamponade.

Pulmonary artery rupture is a rare complication of right heart catheterization characterized by a rapid clinical deterioration and high mortality rate. We present the case of an 89-year-old woman with severe symptomatic aortic stenosis who underwent cardiac catheterization prior to aortic valve replacement. The patient had acute cardiopulmonary deterioration due to pulmonary artery rupture at the time of right heart catheterization, that was successfully sealed by balloon tamponade.

The virtual reality classroom: a randomized control trial of medical student knowledge of postpartum hemorrhage emergency management.

Objective: To investigate the use of a virtual reality learning environment (VRLE) to enhance medical student knowledge of postpartum hemorrhage (PPH) emergency management and insertion of a postpartum balloon. Methods: A randomized control trial involving medical students from University College Dublin, Ireland. Participants were randomly allocated to the intervention group (VRLE tutorial) or control group (PowerPoint tutorial on the same topic). All participants completed pre-learning experience and post-learning experience surveys. Both groups were timed and assessed on postpartum balloon insertion technique on a model pelvis. The primary outcome was assessment of student knowledge. Secondary outcomes included confidence levels, time taken to complete the task, technique assessment, satisfaction with the learning environment, and side effects of VR. Results: Both learning experiences significantly (p < 0.001) enhanced student performance on the post-learning experience multiple choice questionnaire, with no difference between the intervention and control groups. In the intervention group, time for task completion was significantly less compared to the control group (1-2 min vs. 2-3 min, p = 0.039). Both learning experiences significantly (p < 0.001) enhanced student confidence, with no significant difference between intervention and control groups. 100% of the students using the VRLE enjoyed the experience, and 82.4% were very likely to recommend use of VRLE in medical education. 94.1% of the students felt the VRLE was beneficial over didactic teaching. Conclusion: Receiving formal instruction, regardless of format, enhances students' knowledge and confidence of the topic covered. Students who received instruction via the VRLE assembled the postpartum balloon faster than students who received didactic teaching. VR may be beneficial in teaching hands-on procedural skills in obstetrics and gynecology education.

Timely use of Bakri intrauterine balloon tamponade contributes to the effectiveness in controlling severe postpartum hemorrhage.

The aim of the present study was to explore the effectiveness of Bakri intrauterine balloon tamponade (IUBT) in treating severe postpartum hemorrhage (SPPH). A cohort of 198 women with SPPH using IUBT were retrospectively selected. The baseline and maternal outcome characteristics were examined. The results demonstrated that women with SPPH had a high proportion of placenta accrete (53.0%). Bakri IUBT demonstrated a global effectiveness of 84.5% in SPPH treatment, accounting for 82.9% in women with placenta accrete. Compared with women with Bakri failure, women who experienced Bakri success had reduced rates of less use of pre-/post-IUBT intervention, blood transfusion, lower genital tract trauma, estimated blood loss (EBL), and a longer indwelling duration (P<0.05). Logistic regression revealed that the pre-IUBT intervention (OR=3.910; 95% CI: 1.684-9.079; P=0.002) was positively associated with hemostasis success, while lower genital tract trauma was negatively associated with Bakri success (OR=0.091; 95% CI: 0.009-0.894; P=0.040). Moreover, women diagnosed with placenta accrete underwent a greater number of transabdominal placed Bakri IUBT and pre-IUBT interventions than those without placenta accrete (P<0.05). No significant differences were observed in Bakri success, total EBL, pre-/post-IUBT EBL, infused volume of IUBT, IUBT indwelling duration, even the rate of hemostasis, lower genital tract trauma, blood transfusion, post-IUBT intervention, and puerperal fever between women with and without placenta accrete (P>0.05). In conclusion, placenta accrete may be the leading cause of SPPH. Bakri IUBT is an effective and safe measure for SPPH. Pre-IUBT intervention may be predictive of Bakri's success. The timely use of IUBT during labor may mitigate the impact of risk factors identified on PPH.

Improving maternal safety: Usability and performance assessment of a new medical device for the treatment of postpartum haemorrhage.

Postpartum haemorrhage (PPH) is an obstetric emergency causing nearly one-quarter of maternal deaths worldwide, 99% of these in low-resource settings (LRSs). Uterine balloon tamponade (UBT) devices are a non-surgical treatment to stop PPH. In LRSs, low-cost versions of UBT devices are based on the condom balloon tamponade (CBT) technique, but their effectiveness is limited. This paper discusses the experimental study to assess the usability and performance of a medical device, BAMBI, designed as an alternative to current CBT devices. The testing phase involved medical and non-medical personnel and was focused on testing BAMBI's usability and effectiveness compared to a standard CBT solution. We collected measures of the execution time and the procedure outcome. Different training procedures were also compared. Results show a significant preference for the BAMBI device. Besides, medical and non-medical subjects reached comparable outcomes. This aspect is highly relevant in LRSs where the availability of medical personnel could be limited.

Intrauterine devices in the management of postpartum hemorrhage.

Obstetrical hemorrhage is a relatively frequent obstetrical complication and a common cause of maternal morbidity and mortality worldwide. The majority of maternal deaths attributable to hemorrhage are preventable, thus, developing rapid and effective means of treating postpartum hemorrhage is of critical public health importance. Intrauterine devices are one option for managing refractory hemorrhage, with rapid expansion of available devices in recent years. Intrauterine packing was historically used for this purpose, with historical cohorts documenting high rates of success. Modern packing materials, including chitosan-covered gauze, have recently been explored with success rates comparable to uterine balloon tamponade in small trials. There are a variety of balloon tamponade devices, both commercial and improvised, available for use. Efficacy of 85.9% was cited in a recent meta-analysis in resolution of hemorrhage with the use of uterine balloon devices, with greatest success in the setting of atony. However, recent randomized trials have demonstrated potential harm associated with improvised balloon tamponade use In low resource settings and the World Health Organization recommends use be restricted to settings where monitoring is available and care escalation is possible. Recently, intrauterine vacuum devices have been introduced, which offer a new mechanism for achieving hemorrhage control by mechanically restoring uterine tone via vacuum suction. The Jada device, which is is FDA-cleared and commercially available in the US, found successful bleeding control in 94% of cases in an initial single-arm trial, with recent post marketing registry study described treatment success following hemorrhage in 95.8% of vaginal and 88.2% of cesarean births. Successful use of improvised vacuum devices has been described in several studies, including suction tube uterine tamponade via Levin tubing, and use of a modified Bakri balloon. Further research is needed with head-to-head comparisons of efficacy of devices and assessment of cost within the context of both device pricing and overall healthcare resource utilization.

A new technique to preserve the uterus in patients with placenta accreta spectrum disorders.

BACKGROUND: Placenta accreta spectrum disorders are associated with substantial maternal morbidity and mortality. Despite a preoperative diagnosis, the rate of complications remains high, and the condition is generally associated with the need for a hysterectomy. OBJECTIVE: This study aimed to evaluate the outcomes of a new uterine-preserving technique (called the combined approach, including surgical hemostasis, bilateral ligation of the descending branches of the uterine arteries, and hemostatic external supraplacental stitch with the use of the Zhukovsky double-balloon tamponade in patients with placenta accreta spectrum disorders) during cesarean delivery in women with placenta accreta spectrum disorders vs the surgical technique used until 2014. STUDY DESIGN: This retrospective cohort study included 147 patients with placenta accreta spectrum disorders who were divided into 2 groups: the study group (n=95) is to undergo cesarean delivery using the combined approach, and the control group (n=52) is to undergo the surgical technique used until 2014, which included bilateral uterine artery ligation, which is the transfusion of plasma, red blood cells, platelets, and protease inhibitors. RESULTS: The volume of blood loss was 1.5-fold lower (P=.0010), the number of blood transfusions was 5.1-fold lower (P=.026), and the rate of bladder injuries was 19-fold lower (P=.012) in the study group than that in the control group. The duration of hospital stay after delivery was 4 days lesser (P=.001) and the number of hysterectomies was 4.5-fold lower in the study group than in the control group (P=.023). The study groups did not differ in terms of placenta accreta spectrum type. CONCLUSION: The combined approach during cesarean delivery proved to be more effective than the surgical technique used until 2014 in reducing the number of hysterectomies, blood loss volume, number of blood transfusions, and duration of hospital stay in patients with placenta accreta spectrum disorders.

Rescue Strategy for Hemorrhagic Complication During Mechanical Thrombectomy and the Clinical Outcome.

PURPOSE: Hemorrhagic complications occasionally occur during mechanical thrombectomy and may lead to catastrophic outcomes. Therefore, remedial strategies require careful investigation. Herein, we aimed to evaluate a cohort of patients who experienced hemorrhage during endovascular procedures, the rescue methods used, and outcomes observed. METHOD: This prospective study included patients who had hemorrhagic complications observed on digital subtraction angiography (DSA) during mechanical thrombectomy, between October 2017 and October 2022, at a high-volume stroke center. Functional outcomes were assessed using the modified Rankin scale (mRS) score at a 90-day follow-up. The primary outcomes were favorable outcomes (mRS score: 0-2 points) and mortality rates. The secondary outcomes were rescue therapy success rates, according to extravasation observed on the final DSA, recanalization status, and causes of hemorrhage. RESULTS: From October 2017 to October 2022, 1537 patients with stroke received emergency endovascular therapy, and 1147 patients completed a 90-day follow-up. Hemorrhage was observed in 33 (2.1%) patients in the process of endovascular interventions. Eighteen (54.5%) cases of hemorrhage were caused by microwire or microcatheter perforation. Mechanical stretching of the vessel during stent retriever withdrawal resulted in 8 (24.2%) cases of hemorrhage. Nine (27.3%) instances of hemorrhage stopped after the reversal of heparin administration and introduction of blood pressure control measures. Further endovascular rescue treatment was performed in 11 patients. Intracranial inflation of the balloon for tamponade stopped 10 hemorrhages, and 1 patient underwent additional coil embolization. Fifteen (45.5%) patients died within 90 days after the procedure. Three (9.1%) patients recovered functional independence (mRS score: 0-2 points) within 90 days. CONCLUSION: Hemorrhage during mechanical thrombectomy is a rare but severe complication of acute ischemic stroke with high mortality and disability rates. Intracranial inflation of a balloon for tamponade can effectively stop extravasation. CLINICAL IMPACT: This paper described haemorrhagic events characterised by contrast extravasation in the procedure of mechanical thrombectomy due to various causes. Although this complication is rare, patients showed a high mortality and disability rate. There are limited reports available. We found self-limiting haemorrhage had a rather benign prognosis and balloon tamponade could effectively stop the extravasation and might reduce the death rate within 90d. The methods we adopted could be applied in the clinical practice and help neuro-interventionist cope with this complication more promptly and effectively.

Viable invasive cervical pregnancy treated with minimally invasive procedures.

With an incidence of 1% of all ectopic pregnancies, cervical ectopic pregnancy (CEP) is due to possible early misdiagnosis or bleeding and rupture can become a life-threatening condition with the need for urgent hysterectomy, which has been seen in clinical practice recently. We present a case of early diagnosed invasive CEP treated with combined minimally invasive procedure (MIP) due to acute pelvic pain and bleeding. In our case, we applied several of these methods to a primigravida with early invasive CEP with fertility preservation. By combining the self-described local medications with uterotonics and cervical anaemia treatment, intravenous tranexamic acid and MIP, we were able to preserve the uterus with minimal blood loss and the possibility of future conception.

An alternative method of Bakri balloon placement for postpartum hemorrhage after vaginal delivery.

OBJECTIVES: We developed a new Bakri balloon tamponade (BBT) placement technique after vaginal delivery, which aimed to be faster without balloon slippage. This study compared the new method with standard placement of BBT in women with postpartum hemorrhage (PPH) after vaginal delivery. MATERIAL AND METHODS: This study was undertaken of women who underwent vaginal delivery at the obstetrics and gynecology departments of the Hospital of Chengdu University of Traditional Chinese Medicine, Sichuan Provincial Hospital for Women and Children, and Si Chuan JINXIN Women and Children Hospital between January 2014 and December 2020. Women who underwent BBT for PPH were grouped according to placement method into the old-BBT group and the new-BBT group. RESULTS: Of 20487 childbirths by vaginal delivery, 512 (2.50%) had PPH, 77 women underwent BBT (old-BBT n = 28, new-BBT n = 49). Background characteristics were similar except prothrombin time (PT, p < 0.01) and activated partial thromboplastin time (APTT, p < 0.004) were lower in the new-BBT group than the old-BBT group. The operation time was shorter in the new-BBT group (p < 0.001) with less bleeding (p < 0.003) and saline injection (p < 0.001). A balloon slippage was less likely (p < 0.008) and postoperative bleeding (p < 0.01), transfusion rate (p < 0.03), transfusion volume (p < 0.002), and hospital stay was lower in the new-BBT group (p < 0.015). Multivariate analysis suggested PT (OR = 0.039, 95% CI: 0.002-0.730, p < 0.030), international normalized ratio (OR = 8.244, 95% CI: 3.807-17.850, p < 0.009), and BBT method (OR = 5.200, 95% CI: 1.745-15.493, p < 0.003), were associated with requiring a blood transfusion. CONCLUSIONS: This method of BBT placement reduced operation time, balloon slippage, bleeding, and hospital stay in women with PPH after vaginal delivery.

Especificidades técnicas no tamponamento uterino com balões e algumas dificuldades técnicas / Technical specificities in uterine tamponade with balloons and some technical difficulties

A mortalidade materna é inaceitavelmente alta. A hemorragia pós-parto encontra- se na primeira posição no mundo, tendo como principal causa específica a atonia uterina. Eventualmente, as medidas iniciais e a terapia farmacológica não são efetivas no controle do sangramento, impondo a necessidade de tratamentos invasivos, cirúrgicos ou não. Entre esses, o tamponamento uterino com balão requer recursos locais mínimos e não exige treinamento extensivo ou equipamento muito complexo. Entretanto, algumas dificuldades podem ocorrer durante a inserção, infusão ou manutenção do balão na cavidade uterina, com especificidades relacionadas à via de parto. Após o parto vaginal, a dificuldade mais prevalente é o prolapso vaginal do balão. Na cesárea, as principais dificuldades são a inserção e o posicionamento do balão na cavidade uterina, principalmente nas cesáreas eletivas. Este artigo revisa e ilustra as principais dificuldades e especificidades relacionadas ao tamponamento uterino com balões.

Maternal mortality is unacceptably high. Postpartum hemorrhage is ranked first in the world, with the main specific cause being uterine atony. Eventually, initial measures and pharmacological therapy are not effective in controlling bleeding, imposing the need for invasive treatments, surgical or not. Among these, uterine balloon tamponade requires minimal local resources and does not require extensive training or very complex equipment. However, some difficulties may occur during insertion, infusion, or maintenance of the balloon in the uterine cavity, with specificities related to the mode of delivery. After vaginal delivery, the most prevalent difficulty is vaginal balloon prolapse. In cesarean section, the main difficulty is the insertion and positioning of the balloon in the uterine cavity, especially in elective cesarean sections. This article reviews and illustrates the main difficulties and specificities related to uterine balloon tamponade.

Efficacy of early intrauterine balloon tamponade for immediate postpartum hemorrhage after vaginal delivery: a randomized clinical trial.

BACKGROUND: Many questions remain about the appropriate use of intrauterine balloon devices in postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. Available data suggest that early use of intrauterine balloon tamponade might be beneficial. OBJECTIVE: This study aimed to compare the effect of intrauterine balloon tamponade used in combination with second-line uterotonics vs intrauterine balloon tamponade used after the failure of second-line uterotonic treatment on the rate of severe postpartum hemorrhage in women with postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. STUDY DESIGN: This multicenter, randomized, controlled, parallel-group, nonblinded trial was conducted at 18 hospitals and enrolled 403 women who had just given birth vaginally at 35 to 42 weeks of gestation. The inclusion criteria were a postpartum hemorrhage refractory to first-line uterotonics (oxytocin) and requiring a second-line uterotonic treatment with sulprostone (E1 prostaglandin). In the study group, the sulprostone infusion was combined with intrauterine tamponade by an ebb balloon performed within 15 minutes of randomization. In the control group, the sulprostone infusion was started alone within 15 minutes of randomization, and if bleeding persisted 30 minutes after the start of sulprostone infusion, intrauterine tamponade using the ebb balloon was performed. In both groups, if the bleeding persisted 30 minutes after the insertion of the balloon, an emergency radiological or surgical invasive procedure was performed. The primary outcome was the proportion of women who either received ≥3 units of packed red blood cells or had a calculated peripartum blood loss of >1000 mL. The prespecified secondary outcomes were the proportions of women who had a calculated blood loss of ≥1500 mL, any transfusion, an invasive procedure and women who were transferred to the intensive care unit. The analysis of the primary outcome with the triangular test was performed sequentially throughout the trial period. RESULTS: At the eighth interim analysis, the independent data monitoring committee concluded that the incidence of the primary outcome did not differ between the 2 groups and stopped inclusions. After 11 women were excluded because they met an exclusion criterion or withdrew their consent, 199 and 193 women remained in the study and control groups, respectively, for the intention-to-treat analysis. The women's baseline characteristics were similar in both groups. Peripartum hematocrit level change, which was needed for the calculation of the primary outcome, was missing for 4 women in the study group and 2 women in the control group. The primary outcome occurred in 131 of 195 women (67.2%) in the study group and 142 of 191 women (74.3%) in the control group (risk ratio, 0.90; 95% confidence interval, 0.79-1.03). The groups did not differ substantially for rates of calculated peripartum blood loss pf ≥1500 mL, any transfusion, invasive procedure, and admission to an intensive care unit. Endometritis occurred in 5 women (2.7%) in the study group and none in the control group (P=.06). CONCLUSION: The early use of intrauterine balloon tamponade did not reduce the incidence of severe postpartum hemorrhage compared with its use after the failure of second-line uterotonic treatment and before recourse to invasive procedures.

Novel Use of a Minnesota Tube for Enteral Feeding in a Critically Ill Patient With Gastroesophageal Bleeding.

Balloon tamponade of bleeding varices is a temporizing measure acting as a bridge for the treatment of massive gastrointestinal (GI) hemorrhage. After treatment, utilization of a gastric tube for feeding is challenging due to the risk of variceal rebleeding during placement. No literature to date has explored the use of the suction ports of a tamponade device as an alternative form of enteral access for medication and feeding administration in critically ill patients. We report a case of the novel use of a Minnesota tube for enteral feeds and medication administration in a critically ill patient awaiting liver transplantation after massive upper GI bleeding.

Bougie-Facilitated Tamponade Balloon Placement for Massive Esophagogastric Variceal Hemorrhage: A Case Series and Novel Procedural Technique Description.

BACKGROUND: Balloon tamponade of esophagogastric variceal hemorrhage is a lifesaving but challenging procedure. One difficulty that often arises is coiling of the tube in the oropharynx. We describe a novel use of the bougie as an external stylet to help guide placement of the balloon to help overcome this challenge. DISCUSSION: We describe four cases in which the bougie was successfully utilized as an external stylet to place a tamponade balloon (3 Minnesota tubes, 1 Sengstaken-Blakemore tube) without any apparent complication. The straight end of the bougie is inserted approximately 0.5 cm into the most proximal of the gastric aspiration ports. The tube is then inserted into the esophagus under direct or video laryngoscopic visualization using the bougie to help "push" the tube into place as an external stylet. Once the gastric balloon is fully inflated and withdrawn to the gastroesophageal junction, the bougie is gently removed. CONCLUSION: The bougie may be considered as an adjunct for placement of tamponade balloons for massive esophagogastric variceal hemorrhage when placement proves refractory to traditional techniques. We think this can be a valuable tool in the emergency physician's procedural repertoire.

Cervical Cerclage to Prevent Intrauterine Balloon Prolapse.

Intrauterine balloon prolapse sometimes occurs, and the intrauterine balloon must be reinserted. Furthermore, intrauterine balloon tamponade (IBT) failure can necessitate additional invasive procedures. We report a case of cervical cerclage with IBT for placenta previa with a cervical dilation. In our case, emergency cesarean section was performed at 35 + 4 weeks of gestation because of persistent hemorrhage. During the operation, we performed IBT to prevent further postpartum hemorrhage. However, immediately after the operation, uterine cervical dilatation was 6 cm, which resulted in cervical dilation and prolapse of the intrauterine balloon. Therefore, we performed cervical cerclage using absorbable sutures with IBT and blood transfusion. We speculated that the intrauterine balloon might have induced cervical canal ripening during the operation. Our case suggested that cervical cerclage with IBT is a useful method to prevent intrauterine balloon prolapse in cases with cervical dilation.

Uterine tamponade in postpartum hemorrhage with handmade balloons: Comparison of manufacturing, infusion, and total times.

OBJECTIVE: To compare the manufacturing, infusion, and total times of handmade balloons for uterine tamponade using the El Hennawy and Alves techniques, given the failure of initial measures and uterotonic therapy to control postpartum hemorrhage. METHODS: An open clinical trial (clinical article) was conducted among 30 physicians, residents, and assistants in an Obstetrics Department. Each participant manufactured and infused one of two different balloons compared in the study, in a randomly predefined sequence. The manufacturing and infusion times were timed by the researchers and their medians were compared using the t test or Mann-Whitney U test. RESULTS: The manufacturing time of the El Hennawy balloon was 72 s lower in relation to the Alves balloon (P < 0.010). Regarding the infusion time, the Alves balloon was filled faster than the El Hennawy balloon (P < 0.010). The total time (manufacturing and infusion) of Alves balloon was also lower than the El Hennawy device (P < 0.010). CONCLUSIONS: Although the El Hennawy balloon was manufactured more quickly, the total time of manufacturing and infusing the Alves balloon was much faster, which makes it the most suitable device to be used in critical situations of postpartum hemorrhage.

Gastroesophageal Balloon Tamponade Simulation Training with 3D Printed Model Improves Knowledge, Skill, and Confidence.

BACKGROUND: Gastroesophageal balloon tamponade (BT) tube placement is a life-saving procedure for refractory bleeding from gastroesophageal varices performed by gastroenterologists, intensivists, internists, and emergency medicine physicians. Despite a recognized need for procedural training, no standard curriculum or assessment tools exist. Given the infrequent performance of this procedure, the development of a representative and accessible simulation model would permit hands-on training to practice and maintain proficiency with BT tube placement. AIMS: To assess BT tube placement performance before and after a novel simulation-based learning module in gastroenterology fellows and faculty. METHODS: A 16-item knowledge questionnaire and 22-item procedural skill checklist utilizing a novel 3D printed esophagus model were developed to assess participant knowledge, procedural skills, and confidence prior to our simulation-based intervention and again 8-12 weeks after. Performance metrics were compared pre- and post-intervention within groups and between participant groups. RESULTS: Fifteen gastroenterology fellows (of 15 eligible; 100%) and 14 gastroenterology faculty (of 29 eligible; 48%) completed training. Fellows demonstrated improvement in knowledge (55% to 79%, p < 0.001) and procedural skill (35% to 57%, p < 0.001) following training. Baseline faculty performance did not differ from fellows' performance and post-intervention showed similar improvement in knowledge (61% to 77%, p = 0.001) and procedural skill (40% to 49%, p = 0.147). Overall satisfaction with training was high in both groups post-intervention and faculty felt more confident teaching fellows. CONCLUSION: The presented learning module offers a unique, low stakes opportunity for learners to improve skills, gain knowledge, and build confidence in placing BT tubes using a realistic simulation model.

Glove Balloon in Postpartum Hemorrhage: A Case Report.

Postpartum hemorrhage is a long-running and frequent cause of maternal death in most developing countries and is associated with uterine atony. Nowadays, balloon tamponade has gained popularity due to its advantages. It is a technically simple, safely applied, time saver, and easily removed in a low-risk method and also needs less expertise and no special equipment. Despite all advantages, the Bakri balloon is very expensive in less developed countries and not available everywhere, especially in limited resource settings. Such disadvantages prompted us to perform an innovative, cost-effective, and practical method relying on low-resource equipment and named it "Glove Balloon." A 26-year-old woman presented in her third pregnancy underwent an elective cesarean section. Following the surgeon's mention of low segment atony, the patient returned to the operating room quickly. The bleeding continued despite the administration of uterotonic drugs, and because of active bleeding, the decision was made to apply a glove balloon. After gently inserting the glove balloon into the uterus, 500 ccs of saline was inflated into the balloon, and the bleeding stopped shortly afterward. The patient was discharged on the third postoperative day and remained well after. We believe that junior obstetricians and midwives should consider all options, even new strategies, to stop hemorrhages before considering invasive surgical procedures. The "Glove Balloon" is an innovative, practical uterine tamponade balloon that can make the difference between life and death in treating postpartum hemorrhage cases and should be considered a life-saver tool in all settings.