Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review.

OBJECTIVES: To evaluate uterine tamponade devices' effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols. SEARCH STRATEGY: PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021. STUDY SELECTION: Randomised and non-randomised comparative studies. OUTCOMES: Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy. RESULTS: All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom-catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76-7.14) and hysterectomy (RR 4.14, 95% CI 0.48-35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07-15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11-1.03) and hysterectomy (RR 0.49, 95% CI 0.04-5.38) after the inclusion of the Bakri balloon. The second non-randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32-2.81) and hysterectomy (RR 1.84, 95% CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon. CONCLUSIONS: The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting. TWEETABLE ABSTRACT: Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

Postpartum Hemorrhage.

Interventional radiologists are often called for emergent control of abnormal uterine bleeding. Bleeding, even heavy bleeding as a result of uterine fibroids is not a common emergent procedure; instead, pregnancy and pregnancy related conditions, trauma and malignancy associated with bleeding can be the source of many interventional radiology on call events or procedures. Postpartum hemorrhage (PPH) is the most common cause, and is defined as blood loss of 500mL after vaginal delivery or 1000mL after cesarean section. Several authors have suggested a simpler definition of any amount of blood loss that creates hemodynamic instability in the mother. Regardless, PPH can be a life-threatening emergency and is a leading cause of maternal mortality requiring prompt action. Primary PPH is bleeding within the first 24 hour of delivery and secondary PPH is hemorrhage that occurs more than 24 hour after delivery. In addition to death, other serious morbidity resulting from postpartum bleeding includes shock, adult respiratory distress syndrome, coagulopathy, and loss of fertility due to hysterectomy. Transcatheter uterine artery embolization was first introduced as a treatment for PPH in 1979. It is a nonsurgical, minimally invasive, extremely safe and effective treatment for controlling excessive bleeding of the female reproductive track usually after conservative measures have failed, yet somewhat underused. Referring providers have limited awareness of the procedure. In hospitals where interventional radiologists have the experience and technical expertise to perform pelvic arteriography and embolization, this therapeutic option can play a pivotal role in the management of emergent obstetric hemorrhage.

The role of interventional radiology in obstetric hemorrhage.

Obstetric hemorrhage remains a major cause of maternal morbidity and mortality worldwide. Traditionally, in cases of obstetric hemorrhage refractory to conservative treatment, obstetricians have resorted to major surgery with the associated risks of general anesthesia, laparotomy, and, in the case of hysterectomy, loss of fertility. Over the past two decades, the role of pelvic arterial embolization has evolved from a novel treatment option to playing a key role in the management of obstetric hemorrhage. To date, interventional radiology offers a minimally invasive, fertility-preserving alternative to conventional surgical treatment. We review current literature regarding the role of interventional radiology in postpartum hemorrhage, abnormal placentation, abortion, and cervical ectopic pregnancy. We discuss techniques, success rates, and complications.

Fertility after embolization of the uterine arteries to treat obstetrical hemorrhage: a review of 53 cases.

OBJECTIVE: To study subsequent fertility of patients who underwent embolization of the uterine arteries to treat postpartum hemorrhage. DESIGN: Retrospective cohort study between January 2000 and June 2006 with two patient groups: exposed and nonexposed to embolization for postpartum hemorrhage. SETTING: Level 3 maternity unit. PATIENT(S): Fifty-three patients exposed to embolization and 106 nonexposed patients were included and paired according to several criteria: date of delivery, age, parity, whether the pregnancy was spontaneous or with fertility assistance, and mode of delivery. INTERVENTION(S): None. MAIN OUTCOMES MEASURE(S): Occurence of pregnancy. RESULT(S): Among patients exposed to embolization, 14 had been exposed to pregnancy and 12 had been pregnant. There was no statistically significant difference of occurrence of pregnancy between the nonembolized and embolized groups (P=.30). CONCLUSION(S): According to the results, it seems that embolization does not alter subsequent fertility. This study nevertheless suggests a trend toward fewer pregnancies in the embolization group and reports three severe complications in that group. This trend deserves to be explored by further studies with higher statistical power. However, even if it would be difficult to provide complete reassurance to patients who have undergone embolization, better information regarding their subsequent fertility and potential risks could relieve them of their worries regarding a new pregnancy.