World Health Organization Recommendation for Using Uterine Balloon Tamponade to Treat Postpartum Hemorrhage.

The World Health Organization (WHO) recently published a new recommendation on the use of the uterine balloon tamponade for the treatment of postpartum hemorrhage. The recommendation that uterine balloon tamponade should be used only where there is already access to other postpartum hemorrhage treatments (including immediate recourse to surgery) has proved controversial. It is especially problematic for those working in low-level health care facilities in under-resourced settings, where there are already programs that have introduced low-cost uterine balloon tamponade devices for use, even in settings where recourse to surgical interventions is not possible. However, there are now two separate randomized trials that both unexpectedly show unfavorable outcomes in these settings when a condom catheter uterine balloon tamponade device was introduced. Considering the balance of potential benefits and these safety concerns, the WHO postpartum hemorrhage guideline panel therefore recommends that uterine balloon tamponade should be used only in contexts where other supportive postpartum hemorrhage interventions are available if needed.

WHO recommendation on uterine balloon tamponade for the treatment of postpartum haemorrhage

Postpartum haemorrhage (PPH) is commonly defined as a blood loss of at least 500 mL within 24 hours after birth and affects about 5% of all women giving birth around the world. Globally, nearly one quarter of all maternal deaths are associated with PPH and, in most low-income countries, it is the main cause of maternal mortality. Improving care duringchildbirth to prevent PPH is a necessary step towards achievement of the health targets of the third Sustainable Development Goal (SDG 3), particularly target 3.1: reduce the global maternal mortality ratio to less than 70 per 100 000 live births by 2030. Efforts to prevent and reduce morbidity and mortality due to PPH can help to address the profound inequities in maternal and perinatal health globally. To achieve this, skilled health personnel, health managers, policy-makers and other stakeholders need up-to-date and evidence-informed recommendations to guide clinical policies and practices. In 2019, the Executive Guideline Steering Group (GSG) for the World Health Organization (WHO) maternal and perinatal health recommendation prioritized updating of the existing WHO recommendations on uterine balloon tamponade for treating PPH, in response to the availability of new evidence. The recommendation in this document thus supersedes the previous WHO recommendations on this intervention as published in the 2012 guideline, WHO recommendations for the prevention and treatment of postpartum haemorrhage.

Hemorragia obstétrica manejada con balón de Bakri / Obstetric hemorrhage management with the Bakri SOS balloon

Antecedentes: La Organización Mundial de la Salud reporta que existen en el mundo 536.000 muertes maternas al año, de las cuales 140.000 son originadas por hemorragia obstétrica, representando el 25% del total de dichas muertes. En México, se considera la segunda causa de muerte materna, con una tasa de mortalidad de 14,3 por 100.000 nacidos vivos. Objetivo: Conocer el porcentaje de éxitos de las pacientes con hemorragia obstétrica tratadas con balón de Bakri en el Instituto Nacional de Perinatología. Material y métodos: Se analizó una serie de casos, durante 2 años (2009-2011) en pacientes complicadas con hemorragia obstétrica, las cuales recibieron manejo conservador con balón de Bakri. Se encontró a 19 pacientes y se describieron los antecedentes obstétricos, personales, control prenatal, atención obstétrica, parámetros de laboratorios y desenlace perinatal. Resultados: El porcentaje de éxito con el balón de Bakri fue del 95% y solo el 5% se consideró fallido, ameritando histerectomía obstétrica. La pérdida hemática promedio fue 1.290 cc, con diferencia de 4 g/dl en los controles de hemoglobina pre- y posquirúrgicos. Dos días promedio de estancia en unidad de cuidados intensivos. El peso promedio de los recién nacidos fue 2.580 g y el 63% fue de sexo femenino. No se reportaron complicaciones por el uso del balón de Bakri. Se realizó una fórmula para estimar el llenado de balón en cc = 41 + (11 × semanas de gestación). Conclusión: El uso del balón de Bakri puede ser útil en el manejo conservador ante una hemorragia obstétrica con una tasa considerable de éxito y sin reportes de complicación debida al uso

Background: The World Health Organization reports that 536,000 maternal deaths occur per year, of which 140,000 are caused by obstetric hemorrhage, representing 25% of all maternal deaths. In Mexico, obstetric hemorrhage is the second cause of maternal death, with a mortality rate of 14.3/100,000 newborns. Objective: To describe the success rate in obstetric hemorrhage patients treated with the Bakri SOS balloon in the National Institute of Perinatology. Material and methods: From 2009- 2011, data were collected from obstetric hemorrhage patients (n = 19) who were treated conservatively with the Bakri SOS balloon in the Institute. Data on obstetric and personal history, prenatal care, obstetric care, laboratory values and perinatal outcomes were obtained. Results: The success rate with the Bakri SOS balloon was 95%, with a failure rate of only 5%; these patients required further hysterectomy. The mean blood loss was 1,290 cc, with a difference of 4 g of hemoglobin before and after surgery. The mean length of stay in the intensive care unit was 2 days. The mean birth weight was 2,580 g, and 63% of the neonates were females. There were no incidents or complications with the use of the Bakri SOS balloon. The formula to estimate balloon filling was cc = 41 + (11 × gestational age). Conclusion: The Bakri SOS balloon can be helpful to treat obstetric hemorrhage and has high success rates and no complications

[Management of severe or persistent postpartum hemorrhage after vaginal delivery]. / Prise en charge obstétricale en cas d'hémorragie du post-partum qui persiste malgré les mesures initiales ou qui est sévère d'emblée, après accouchement par voie basse.

INTRODUCTION: This chapter is an update of the 2004 recommendations for the management of persistent or severe postpartum hemorrhage (PPH) after natural childbirth. Severe PPH is defined by estimated blood loss greater than 1000mL (gradeC). Persistent bleeding within 15 to 30minutes after diagnosis and initial treatment (gradeC) or abundant immediately (professional consensus) should lead to a further management. MATERIALS AND METHODS: A systematic review of the literature concerning the management of persistent or severe PPH was conducted on Medline and Cochrane Database, with no specified time period. RESULTS AND DISCUSSION: The initial clinical evaluation is the same whatever initial severity. Each possible cause of bleeding must be evaluated: uterine vacuity must be checked and birth canal lesions must be researched and repaired (gradeC). Sulprostone is effective for the treatment of severe or persistent PPH (EL4) and its use is recommended for the management of PPH resistant to oxytocin administration (grade B). In the current state of the literature, there is no argument for replacing sulprostone in France by dinoprostone or prostaglandins F2α (professional consensus). If oxytocin has been administered, it is not recommended to use misoprostol (EL1) as adjuvant treatment because there is no evidence of benefit in this indication (grade A). Balloon intra-uterine tamponade appears to be an efficient mechanical treatment of uterine atony in case of failure of the initial management by sulprostone. Tamponade allows avoiding the need for further interventional radiology or surgery in most cases (EL4). Intra-uterine tamponade may be offered in case of failure of sulprostone and prior to surgical management or interventional radiology (professional consensus). Its use is left to the discretion of the practitioner. Tamponade should not delay the implementation of further invasive procedures.