O & G Forum | Volume 29 | Issue 1 | 2019

O&G Forum 2019; 29:1 EDITORIAL OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 1 | 1 Uterine Balloon Tamponade In sub-Saharan Africa postpartum haemorrhage (PPH) is the leading direct cause of maternal deaths. 1 Of all maternal deaths 17% are due to PPH. In the 2014 to 2016 triennium, as reported by the National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD) in South Africa, haemorrhage caused 624 maternal deaths (16.9% of all deaths) and was the second most common direct cause of maternal deaths. 2 Of the maternal deaths due to haemorrhage 128 were referred to higher levels of care. 3 Of these women 21% died while waiting for ambulance transfer and 14% during transfer. A uterine balloon tamponade (UBT) method should be attempted in the event that emergency measures and medical treatment for PPH, due to an atonic uterus, have failed. 4,5,6 Balloon tamponade of the uterus can be done at low cost by using a condom or a surgical glove balloon. 5,6 If the “tamponade” test with a UBT method is unsuccessful to control the bleeding, bimanual compression of the uterus and a laparotomy, with the patient draped in the modified Lloyd Davis position, must follow as quick as possible. At laparotomy the surgeon can observe whether bimanual compression of the uterus results in a reduction of the blood loss. If yes, compression sutures should be inserted to maintain the compression. Hayman compression sutures will be used with an intact uterus and B-lynch sutures if a Caesarean section (C/S) was done. 7 If bleeding continues following insertion of compression sutures, UBT can now be used combining external compression with internal tamponade to arrest the bleeding. 8.9 A last resort in women of low parity would be systematic devascularisation of the uterus prior to proceeding with a hysterectomy. 6,7 A laparotomy and total or subtotal hysterectomy should be the procedure of choice for patients of higher parity if a skilled physician is available. The blood spaces (lacunae) within the placenta are filled with maternal blood. The chorionic villi float in these spaces. The blood spaces are supplied with maternal arterial blood through low resistance sinusoids that pass through the myometrium. 10 Following delivery of the placenta the myometrium with muscle fibres, arranged in the format of a matrix, contracts and retracts. The sinusoids are closed off and the blood loss limited. The aim with the management of a PPH, due to an atonic uterus, is to facilitate the process of contraction and retraction of the myometrium by rubbing or compressing the uterus and administering addition oxytocic drugs. The surgical glove balloon is a UBT device that is an open system and allows water to be expelled from the balloon to reduce the volume and allow the physiological process of contraction and retraction of the myometrium to occur. 6 Using UBT once compression sutures have been inserted to keep the uterus contracted, requires control of the amount of pressure exerted in the uterus to prevent uterine necrosis. Although uterine necrosis is possible following the insertion of compression sutures without using UBT, the risk understandably would increase with pressure exerted from inside the uterus when UBT is used additionally. Cases with uterine necrosis following insertion of compression sutures have been reported with and without UBT. 11,12 The surgical glove balloon is an open system UBT device that allows the intra-uterine pressure to be controlled by adjusting the height of the supply bag above the patient. If the pressure inside the uterus corresponds to the patient’s systolic blood pressure, arterial bleeding from the placental implantation site will be stopped.With a systolic blood pressure of 100 mmHg the giving set needs to be 1.3 meters above the patient. The specific gravity of mercury is 13 times more than water. In addition, the device used for the balloon has to be large enough to be inflated with water without taking up any expansion pressure. This was achieved by using a surgical glove. During workshops on the assembly of makeshift devices, using a condom or surgical glove, the problem of leaking water when inflated is apparent. Given an emergency situation, with limited time, physicians often rather resort to a commercially available uterine balloon. The need for an affordable pre-assembled single unit ready for use was evident. A South African company, Sinapi biomedical (Pty) Ltd, took up the challenge to develop an easy to use pre-assembled uterine balloon tamponade unit that contains the unique features of the surgical glove balloon. The Ellavi uterine balloon, with a capacity of 750 ml, can be filled within 45 seconds without any expansion pressure. The tubing of the balloon contains a t-valve and the cap can be screwed onto a supply bag or spiked into a one litre intravenous fluid bag. The Ellavi uterine balloon is easier and faster to use in comparison to a surgical glove balloon. A prospective case series with the Ellavi uterine balloon was conducted to assess feasibility and acceptance by physicians and recently published. 13 In addition, the device is affordable for use in lesser resourced countries. Doctors working in obstetrics across all levels of care and midwives working in midwife obstetric units and district hospitals need to be skilled in UBT. The NCCEMD guidelines for the management of postpartum haemorrhage include UBT as one of the steps in the management of PPH. Essential skills in the management of obstetric emergencies (ESMOE) training also include UBT. 14 A skills workshop including a DVD on the use of the Ellavi uterine balloon is available on line. 15 Gerhard B Theron Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa References 1. www.countdown2015mnch.org/2014report 2. Saving Mothers 2014 – 2016: Seventh triennial report on confidential enquiries into maternal deaths in South Africa. http://www.sasog.co.za/ Content/Docs/Saving_Mothers.pdf 3. Fawcus S.A focus on referral problems in women who died from obstetric haemorrhage in South Africa (2016-2016). O&G Forum 2018; 28: 23-27. 4. Doumouchtsis SK, Papageorghiou AT,Arulkumaran S. Systematic review of conservative management of postpartum haemorrhage:What to do when medical treatment fails. Obstet Gynaecol Survey 2007; 62: 540-547. 5. Georgiou C. Uterine tamponade in the management of postpartum haemorrhage: a review. BJOG 2009; 116:748-757. 6. A Monograph of the Management of Postpartum Haemorrhage. National Committee for the Confidential Enquiries into Maternal Deaths in South Africa (Chapter 6). National Department of Health, South Africa and the United Nations Population fund, 2010. ISBN 978-1-86840-4. 7. B-Lynch C, Keith LG, Lalonde AB, Karoshi M in: A textbook of postpartum haemorrhage. Chapters 21&31. Sapiens Publishing 2006. 8. Danso D, Reginald P. Combined B-lynch suture with intraunterine balloon catheter triumphs over massive postpartum haemorrhage. BJOG 2002; 109:693 9. Diemert A, Ortmeyer G, Hollwitz B, Lotz M, Somville T, Glosemeyer P, Diehl W, Hecher K.The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage. Am J Gynecol 2012; 206: 65e1-4 10. Cronje HS, Cilliers JBF, Du Toit MA. Clinical Obstetrics – a Southern African perspective, Fourth Edition. Chapters 2 and 26.Van Schaik Publishers. 11. Treloar EJ,Anderson RS,Andrews HS, Bailey JL. Uterine necrosis following B-Lynch sutures for primary postpartum haemorrhage. BJOG 2006; 113: 486-488. 12. Lodhi W, Golara M, Karagoakar V,YoongW. Uterine necrosis flowing application of combined uterine compression suture with intrauterine balloon tamponade. J Obstet Gynaecol 2012; 32: 30-31. 13. Theron GB. Management of postpartum haemorrhage with free-flow pressure controlled uterine balloon. Int J Gynecol Obstet 2018; 142: 371- 373. 14. http://www.esmoe.co.za 15. www.bettercare.co.za/intrapartum-care/0-3-contetns.htmal (5A Skills: Inserting and using intra-uterine balloon tamponade to treat postpartum haemorrhage).