Uterine Balloon Tamponade - An Overview

Introduction:

Bleeding after pregnancy is a severe complication. It occurs in around 5 % of cases globally. 25 % of women lost their lives after the delivery due to the complications caused by the blood loss after delivery. In the United States of America alone, around 18 % of women lost their lives because of this. The number is even higher in developing countries. In such cases, proper surgical and pharmacological treatment is often difficult in remote areas. Uterine balloon tamponade can be a useful option to prevent the loss of lives.

What Is Postpartum Hemorrhage?

Abnormal bleeding after delivery is known as postpartum hemorrhage. Over 500 milliliters of blood loss after vaginal delivery and 100 milliliters of blood loss after cesarean delivery is known as postpartum hemorrhage. According to the American college of obstetrics and gynecology, a total of 1000 milliliters of blood loss within 24 hours of delivery is postpartum hemorrhage. This type of bleeding post-delivery is known as primary postpartum hemorrhage. Bleeding, 24 hours to 12 weeks post-delivery, is secondary postpartum hemorrhage. The causes of postpartum hemorrhage are:

1. Uterine Atony - Failure of the contraction of the uterus after delivery.

2. Genital Tract Lacerations - This is the injury of the lower genital tract during birth. In this condition, tearing of the tissue and muscle around the vagina occurs.

3. Retained Placenta - This occurs when the placenta does not come out after delivery. This occurs if the placenta is strongly attached to the uterine wall or the placental contraction is not strong enough.

4. Uterine Inversion - The most serious complication is characterized by the collapse of the fundus in the uterine cavity. Excessive traction of the umbilical cord (attached to the baby with the mother) and pressure in the fundus is responsible for this.

5. Abnormal Placentation - In this condition, the placenta is attached deep into the uterine wall and fails to separate after delivery.

6. Coagulation Disorders - Bleeding and coagulation disorders are responsible for excessive bleeding after pregnancy. Disorders like Von Willebrands disease, and hemophilia A and B are responsible for this.

What Is a Ballon Temponad?

Temponad word originates from the word tampon. Tampons are short plug-like devices inserted into the wound to stop bleeding. Ballon tamponades are balloon-like structures inflated to stop bleeding after insertion into the uterine cavity. This non-surgical technique causes an enlargement in the uterine cavity and occupies the entire space. As a result, intrauterine pressure increases as the opposite pressure is applied to the blood vessels. As the applied pressure exceeds systemic arterial pressure, the bleeding from the blood vessels is stopped.

When Is It Done?

As discussed, it is done to stop post-deliver bleeding. But World Health Organization has created a guideline for this procedure. These are:

1) Failure in the first line of treatment, which includes:

• Use of Uterotonics - These pharmacological agents, like Oxytocin, cause the contraction of the uterus muscles and increase their tone.

• Use of Tranexamic Acid - This medication is used to stop bleeding.

• Use of Intravenous Fluid - Administration of intravenous fluid prevents any sort of hypovolemia.

2) Access to immediate surgical intervention and blood products is available.

3) Properly trained healthcare personnel is available.

4) Regular monitoring of the maternal condition is possible.

What Is the Procedure?

The balloon is placed via the transvaginal route. The patient is positioned in a dorsal lithotomy position. The balloon is held by the operator in the palm and gradually inserted into the uterine cavity through the dilated cervix. The balloon is manually held in the uterine cavity and gradually filled with saline water. Approximately around 300 milliliters or more of saline is injected into the balloon. Care must not create twists or sharp bends at the short end of the connecting tubing or stopcock to the main balloon catheter. After filling the balloon, gentle traction should be given at the stem to push and place the balloon properly. The following things should keep in mind:

• The amount of blood loss should be taken into account.

• The operator must fill the urinary toner while inserting the balloon.

• Tight vaginal packing is needed to retain the balloon in the position. It should be tied to the balloon so that packing comes out during the balloon removal.

• A catheter should be attached to the balloon bag.

What Are the Different Types of Balloons?

Different types of components can be used for balloon tamponade. These are:

• Sengstaken–Blakemore Tube - This esophageal catheter treats esophageal variceal bleeding. This a three-way catheter with stomach and esophageal balloon components and several internal channels. The balloon's capacity is more than 500 millimeters, and easy to insert. But these tubes are difficult to adapt in the uterine cavity.

• Rusch Hydrostatic Urological Balloon - This is a type of two-way Foley catheter. The capacity of this tube is greater than 500 milliliters. Before inserting the tube, the distal end of the catheter is cut, and a 60-milliliters bladder syringe is used to inflate the balloon with warm saline via the drainage port.

• Foley Catheter - This is one of the most commonly used devices to drain urine. It is most commonly and easily found and is very cost-effective. More than one catheter can also be inserted at a time. One drawback of this system is that the volume is less, around 80 to 100 milliliters, so multiple catheters must be inserted to stop bleeding simultaneously.

• Bakri Balloon - This was invented in 1910, and it is free from latex. The volume of such a balloon is 500 milliliters. Even after cesarean section, this balloon can pass into the uterine cavity, with the inflation port passing into the vagina via the cervix. Better adaptability in the uterine cavity due to the shape is another advantage of this device. The main drawback of these devices is the high cost.

• Hydrostatic Condom Catheter - This is another cost-effective way to build an intrauterine balloon tamponade. In this process, a rubber catheter is fitted with a condom. The sterile catheter is inserted within the condom and tied near the mouth of the condom with the help of silk thread. The condom is inflated with the help of saline water, and the volume of such tamponade is 250 to 500 milliliters.

What Are the After Care?

After placing the balloon tamponade, care for the patient is necessary. These procedures are:

1. Continuous Oxytocin infusion to maintain the uterine cavity's contraction for the next 12 to 24 hours.

2. Broad-spectrum antibiotic therapy must be continued.

3. The tamponade can be placed for 8 to 48 hours.

4. During removal, gradual deflection of the balloon is necessary to reduce the risk of further bleeding.

Conclusion:

Postpartum hemorrhage is one of the most common and fatal problems. In developing countries, surgical and pharmacological management of such cases is expensive. Intrauterine balloon tamponade, in such cases, can be a useful and economical option. Moreover, the placement can be done with the help of junior medical professionals also.