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.

Balões de tamponamento intrauterino na hemorragia pós-parto ­ Atualizações / Uterine balloon tamponade in postpartum hemorrhage ­ Updates

A hemorragia pós-parto continua sendo uma condição relacionada a elevada morbimortalidade materna, sendo essenciais o diagnóstico precoce e o início do tratamento farmacológico. Em caso de falha, os balões de tamponamento uterino são uma alternativa eficiente, com aplicabilidade crescente na prática clínica. Esses dispositivos são seguros, apresentam baixa incidência de eventos adversos e reduzem as taxas de procedimentos cirúrgicos. Existe uma ampla variedade de modelos, tanto industriais quanto artesanais, com acúmulo de relatos na literatura demonstrando sua eficácia. Este artigo descreve os principais balões intrauterinos, com ênfase nos modelos mais novos, aplicabilidade, taxas de sucesso e eventos adversos.(AU)

Postpartum hemorrhage continues to be a condition related to high maternal morbimortality, early diagnosis and initiation of pharmacological treatment are essential. In case of failure, uterine balloon tamponade is an efficient alternative, with increasing applicability in clinical practice. These devices are safe, have a low incidence of adverse events and reduce the overall rates of surgical procedures. There is a wide variety of models, both industrial and artisanal, with an accumulation of reports in the literature demonstrating their effectiveness. This article describes the main intrauterine balloons, with an emphasis on newer models, applicability, success rates and adverse events.(AU)

El Balón de Bakri como herramienta en el manejo de la hemorragia post parto / THE BAKRI´S BALLOON AS AN IMPORTANT TOOL FOR THE MANAGEMENT OF POST PARTUM HEMORRHAGE

Introducción La hemorragia post parto es una de las complicaciones más graves del puerperio y una de las principales causas de mortalidad materna a nivel mundial. Dentro del esquema del manejo de la misma se encuentra el uso del balón de Bakri para evitar la histerectomía post parto. Objetivo: presentar la experiencia en la utilización del Balón de Bakri en un trabajo colaborativo entre los Servicios de Obstetricia del Hospital Nacional Posadas y de la Madre y el Niño de Formosa Capital entre enero de 2015 a junio de 2016. Método: Estudio transversal y descriptivo que incluyó a 25 pacientes con hemorragia post parto sin respuesta al tratamiento con Ocitócicos y que requirieron colocación del Balón de Bakri. Resultados: El balón de Bakri fue aplicado a 25 mujeres con hemorragia refractaria. La mediana de insuflación del Balón de Bakri fue de 300 (240/ 600 mL). La hemostasia se consiguió en 23 (92 %) de estas mujeres. Dos mujeres debieron ser histerectomizadas por continuar sangrando luego de la colocación del balón. Conclusión: El balón de Bakri es una herramienta eficaz para el manejo de la hemorragia post parto refractaria a carbetocina, evitando la histerectomía en el 92% de los casos.

Postpartum hemorrhage is one of the most serious complications of puerperium and one of the leading causes of maternal mortality worldwide. Within the framework of the management of it is the use of Bakri balloon to prevent puerperal hysterectomy. The aim of this study is to present the experience in the use of Bakri balloon in a collaborative work between the Obstetrics Departments of the Posadas National Hospital and the Madre y el Niño Hospital of Formosa Capital, Argentina, from January 2015 to June 2016. Methods: Cross-sectional descriptive study that included 25 patients with postpartum bleeding with uterine atony refractory to treatment with uterotonics and required Bakri balloon placement. Results: The Bakri ballon was applied to 25 women with refractory bleeding Oxytocics after vaginal delivery. The median Bakri balloon inflation was 300 (240/600 mL). Hemostasis was achieved in 23 (92%) of these women. Two women (8%) had to be undergone hysterectomy for bleeding continue after placement of the ball. Conclusion: The Bakri balloon is an effective tool for the management of post partum hemorrhage refractory to Carbetocin avoiding hysterectomy in 92% of cases.

Eficacia y seguridad del taponamiento uterino para control de hemorragia y disminución de histerectomía obstétrica: cohorte histórica en Nuevo León, México, 2013 / Efficacy and safety of uterine tamponade to control bleeding and reduce obstetric hysterectomy: historic cohort in Nuevo León, México, 2013

Objetivo: realizar una aproximación a la eficacia y seguridad del taponamiento uterino para el control de la hemorragia obstétrica y reducir la necesidad de histerectomía obstétrica.Materiales y métodos: cohorte histórica de mujeres mayores de edad con diagnóstico de hemorragia obstétrica secundaria a atonía que no respondían a manejo inicial, con sangrado del lecho placentario secundario a placentación anormal o secundaria a aborto incompleto, a las cuales se les realizó taponamiento uterino, en la Unidad Médica de Alta Especialidad No. 23 de Ginecología y Obstetricia de la ciudad de Monterrey, hospital de concentración de tercer nivel de atención, ubicado en el estado de Nuevo León (México), de enero a diciembre de 2013. A partir del expediente clínico se registraron las características sociodemográficas y clínicas basales, los datos de laboratorio previo al evento obstétrico y posterior al taponamiento, así como el tiempo de taponamiento en horas, cantidad de insuflación del balón uterino, indicación para el procedimiento, cantidad de sangrado estimado durante el evento obstétrico y posterior a la colocación del balón, control de la hemorragia y necesidad de histerectomía. Se utilizó estadística descriptiva, medidas de dispersión y de tendencia central.Resultados: se incluyeron 161 pacientes con diagnóstico de hemorragia obstétrica, 147 posterior a parto o cesárea y 14 posterior al aborto, entre 16 y 42 años de edad. Se documentó un resultado satisfactorio en más del 95 % posterior al parto o la cesárea, y en más del 93 % posaborto. La permanencia del taponamiento para ambos casos tuvo una media de 20 horas.Conclusiones: este estudio soporta el uso de taponamiento uterino como medida terapéutica eficaz y segura para controlar la hemorragia y evitar una laparotomía o histerectomía, con una disminución de la morbilidad.

Objective: Examine the efficacy and safety of uterine tamponade for controlling obstetric bleeding and reducing the need for obstetric hysterectomy.Materials and methods: Historic cohort of adult women diagnosed with obstetric bleeding secondary to uterine atony that did not respond to the initial management, with bleeding of the placental bed secondary to abnormal placentation or to incomplete abortion, subjected to uterine tamponade at the Highly Specialized Gynaecology and Obstetrics Medical Unit No. 23, a Level III Hospital in the city of Monterrey, state of Nuevo Leon, Mexico, between January and December 2013. Information about social, demographic and baseline clinical characteristics, laboratory values before the obstetric event and after the tamponade procedure, as well as the inflation volume of the balloon, the indication of the procedure, the estimated amount of bleeding during the event and after placement of the tamponade balloon, control of bleeding, and need for hysterectomy, was derived from the clinical record. Descriptive statistics, scatter measurements, and central trends were used.Results: Overall, 161 patients between the ages of 16 and 42 years, with a diagnosis of obstetric haemorrhage were included, 147 following delivery or caesarean section, and 14 following miscarriage. A satisfactory result was documented in more than 95 % of cases after delivery or caesarean section, and in more than 93 % post abortion cases. The mean tamponade time for both groups was 20 hours.Conclusions: This study supports the use of uterine tamponade as an effective and safe therapeutic measure to control bleeding and avoid laparotomy or hysterectomy, and to reduce morbidity.

Uso de balões intrauterinos em pacientes com hemorragia pós-parto / Use of intrauterine balloons in patients with postpartum haemorrhage

A hemorragia pós-parto é uma complicação presente em mais de 18% dos nascimentos e responsável por cerca de 25 a 30% das mortes maternas no mundo. No Brasil, apesar da ampliação do acesso aos serviços de saúde e da melhoria em praticamente todos os indicadores de saúde materna, esta etiologia continua se apresentando entre os três principais grupos de causas de morte no ciclo grávido-puerperal. Nas últimas décadas, várias técnicas conservadoras visando o controle hemorrágico no período pós-parto têm sido relatadas, com destaque para as técnicas de desvascularização uterina, suturas compressivas, embolização arterial, balões intrauterinos e a interrupção do ato operatório com laparostomia, empacotamento pélvico e posterior reabordagem cirúrgica. O presente artigo apresenta uma revisão do uso de balões intrauterinos no controle hemorrágico com destaque para os tipos, aplicabilidades e cronologia de invenção e publicações. Foram avaliados os balões de Sengstaken-Blakemore, os artesanais, as sondas de Foley, balão de Rusch, de Bakri e o BT-cath. Detalhou-se também o teste do tamponamento e a técnica do "sanduíche uterino".(AU)

Postpartum hemorrhage is present in over 18% of births and accounts for 25-30% of maternal deaths worldwide. In Brazil, despite the expansion of access to health care and the improvement of virtually all maternal health indicators, such etiology is still present among the three main causes of death during pregnancy and childbirth. In the last decades, several conservative techniques direct at controlling hemorrhage in the postpartum period have been reported, principally techniques of uterine devascularization, compression sutures, arterial embolization, intrauterine balloons and surgery interruption with laparostomy, pelvic packing and subsequent surgical intervention. This article presents a review of the use of intrauterine balloons in controlling hemorrhage especially types, applicability and chronology of invention and publications. Sengstaken-Blakemore balloons, the artisanal, Foley probes, Rusch balloon, Bakri and BT-cath were reviewed. The tamponade test and the "uterine sandwich" technique were also detailed.(AU)

Uso del balón sos bakri en atonía uterina: serie de casos en un hospital universitario de tercer nivel / SOS bakri balloon use in uterine inertia. number of cases in a university tertiary hospital

Objetivo: Describir el uso del balón SOS Bakri en el tratamiento de la hemorragia posparto vaginal por atonía uterina después de la falla del tratamiento médico. Métodos: Se presenta una serie de 15 pacientes con hemorragia posparto vaginal por atonía uterina, tratadas satisfactoriamente con taponamiento uterino con balón SOS Bakri luego de no responder a tratamiento médico ni a masaje uterino. Resultados: La edad promedio de las pacientes fue 22,7 (± 6,8) años. La edad gestacional promedio fue 36,3 (± 2,6) semanas. El balón se insertó en los primeros 30 minutos del diagnóstico de la atonía uterina. El tiempo total que permaneció el balón en útero fue de 13,6 (± 6,1) horas. La pérdida hemática posterior a la colocación del balón fue en total 265,3 (± 258,1) cm3. El balón SOS Bakri fue efectivo en 100 % de las pacientes. Ninguna de las pacientes ameritó histerectomía. Conclusiones: El balón SOS Bakri es una alternativa eficaz mínimamente invasiva, económica y de fácil acceso en la terapéutica de la AU que no responde al tratamiento médico.

Objective: To describe the use of SOS Bakri Balloon in the treatment of postpartum hemorrhage after unsuccessful medical treatment of uterine atony. Method: We describe a case series of 15 patients with severe uterine atony after vaginal delivery that were successfully managed with SOS Bakri balloon after failed uterine massage and medical treatment. Results: The mean patient age was 22.7 (± 6.8) years. The mean gestational age was 36.3 (± 2.6) weeks. The balloon was inserted within 30 minutes of diagnosis of uterine atony. The mean length of balloon placement was 13.6 (± 6.1) hours. The mean total blood loss post balloon insertion was of 265.3 (± 258.1) cm3. The SOS Bakri balloon was effective 100 % of the time. None of the patient required hysterectomy. Conclusion: Insertion of SOS Bakri balloon is a simple conservative live saving alternative in the management of postpartum uterine atony.

Diagnosis and management of postpartum hemorrhage

Postpartum hemorrhage (PPH) is an important cause of maternal mortality. There is currently no single, satisfactory definition of PPH. The various definitions of PPH may result in delayed diagnosis. Underestimated blood loss concerning PPH is considered one of the biggest problems. The diagnosis of PPH should include proper estimation of blood loss before vital signs and clinical symptoms change. Management of PPH involves early recognition, assessment and resuscitation. Careful monitoring of vital signs, laboratory tests, coagulation testing in particular, and timely diagnosis of the cause of PPH are important. The first priority in the management of PPH is the rapid correction of hypovolemia with fluid infusion and packed red blood cells transfusion, followed by blood component therapy as indicated by the hematocrit, coagulation tests, platelet count and clinical features. Pharmacological management of PPH is to contract uterus (e.g., oxytocin, methylergonovine, 15-methylprostaglandin F2alpha, misoprostol) and to aid hemostasis (e.g., tranexamic acid, recombinant factor VIIa). Surgical management (e.g., balloon tamponade, uterine compression suture, iliac artery ligation) should be considered if hemorrhage persists or vital signs is unstable.

Diagnosis and management of postpartum hemorrhage

Postpartum hemorrhage (PPH) is an important cause of maternal mortality. There is currently no single, satisfactory definition of PPH. The various definitions of PPH may result in delayed diagnosis. Underestimated blood loss concerning PPH is considered one of the biggest problems. The diagnosis of PPH should include proper estimation of blood loss before vital signs and clinical symptoms change. Management of PPH involves early recognition, assessment and resuscitation. Careful monitoring of vital signs, laboratory tests, coagulation testing in particular, and timely diagnosis of the cause of PPH are important. The first priority in the management of PPH is the rapid correction of hypovolemia with fluid infusion and packed red blood cells transfusion, followed by blood component therapy as indicated by the hematocrit, coagulation tests, platelet count and clinical features. Pharmacological management of PPH is to contract uterus (e.g., oxytocin, methylergonovine, 15-methylprostaglandin F2alpha, misoprostol) and to aid hemostasis (e.g., tranexamic acid, recombinant factor VIIa). Surgical management (e.g., balloon tamponade, uterine compression suture, iliac artery ligation) should be considered if hemorrhage persists or vital signs is unstable.

Fertility sparing surgery on placenta invasion anomalies and placenta previa

Abnormal placental invasion has increased parallel with persistent rise in Caesarean delivery. Management relies on accurate diagnosis and delivery should be planned at an institution with appropriate expertise and resources for managing this condition. We present a case of a placenta invasion anomaly which is the major risk factors of peripartum deaths. In this case we try to explain our approach which reduces unnecessary hysterectomy rates. In order to avoid postpartum hemorrhage and hysterectomy protocols, our approach which consists bilateral hypogastric arterial ligation, Bakri balloon tamponade and if necessary methotrexate therapy can be applied successfully