European Journal of Obstetrics & Gynecology and Reproductive Biology
Full length articleHemostatic effect of intrauterine balloon for postpartum hemorrhage with special reference to concomitant use of “holding the cervix” procedure (Matsubara)
Introduction
The intrauterine balloon (Balloon) has recently been widely used to achieve hemostasis for postpartum hemorrhage (PPH) mainly due to atonic bleeding and placenta previa (PP). Accumulated data suggest some pitfalls of Balloon use: 1) non-achievement of hemostasis (Balloon failure) in a significant proportion (5–35%) [1], [2], [3], [4], [5], [6], [7], [8]; although data were controversial, failure was more likely to occur in PP than in atonic bleeding [9], [10], and 2) Balloon prolapse into the vagina, which prevents hemostasis.
Since 2000, we have been using our original method, “holding the cervix” [11], for PPH: the cervix is closed by forceps. This possibly achieves hemostasis by: 1) blocking the exit of intrauterine blood, with the accumulating blood/hematoma tamponading the uterine lumen, and 2) inducing uterine contraction via a neuronal reflex. “Holding the cervix” may also prevent Balloon prolapse [12], [13], and, thus, we have been using this procedure, Balloon + holding the cervix [14].
Our clinical impression is that this procedure (Balloon + holding the cervix) achieves hemostasis for PPH effectively, especially for PPH due to PP. We aimed to clarify the following three factors: 1) hemostatic success rate of Balloon use, 2) effect of holding the cervix on Balloon prolapse, and, 3) the rate of bleeding after Balloon insertion, possibly predicting Balloon failure.
Section snippets
Materials and methods
This study was approved by the Ethics Committee of our institute. We retrieved medical charts on all deliveries in our institution from August 2013–July 2016, from which we extracted patients undergoing (attempting) Balloon application for primary PPH. Primary PPH is defined as blood loss ≥500 mL (vaginal delivery: VD) or ≥1000 mL (cesarean section: CS) within 24 h after delivery. Our department protocol for PPH is consistent with ACOG [15] and the Japanese Guidelines [16]. Briefly, genital tract
Results
In the study period, Balloon use was attempted in 80 patients, of which causal disorders are shown in Table 1. Atonic bleeding (n = 34) and PP (n = 36) were the two main causal disorders. Among the 80, Balloon was inserted and maintained an intrauterine position in 71 (71/80: 89%), whereas, in the remaining 9 (9/80: 11%) it was not. Uterine contraction prevented Balloon insertion (n = 5) or pushed the Balloon into the vagina (prolapse) (n = 4); however, in all of these 9 cases, hemostasis was achieved,
Comments
Three findings were made. The overall success rate of Balloon application for primary PPH was 93%; the success rate for PP was similarly high (94%), being higher than that previously reported [1], [2], [3], [4], [5], [6], [7], [8], but that for placenta accreta was low. Balloon prolapse occurred less frequently in patients with “holding the cervix”. All patients with failure bled after Balloon insertion, with a bleeding rate of >250 mL/h, which may enable the earlier prediction of Balloon
Conflict of interest statement
We declare that we have no conflict of interest.
Funding
We received no funding regarding this study.
Ethical approval
All procedures in this study involving human participants were in accordance with the declaration of Helsinki.
Contributions to authorship
Conception and design of this study: Ogoyama M, Takahashi H.
Acquisition of data: Ogoyama M, Usui R, Baba Y, Suzuki H.
Analysis and interpretation: Ogoyama M, Takahashi H, Ohkuchi A.
Writing and revising the manuscript: Ogoyama M, Takahashi H, Matsubara S.
Acknowledgement
None.
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These authors equally contributed to this study.