A stroke of brilliance: a faster and simpler non-surgical intervention to tamponade uterine bleeding in postpartum complications.
Background
When a new life comes into this world, the delivery involves uterine contraction. It pushes out the placenta, which exerts pressure onto the bleeding vessels attached to the placenta. If the uterine contraction is restricted or obstructed for any reason, or there is residual attachment of placenta, these blood vessels bleed freely. The result is excessive placental bleeding (compared to normal conditions), causing a postpartum hemorrhage. Postpartum hemorrhages are one of the most significant causes of mortality due to childbirth worldwide, creating a demand for effective solutions as incidence rates rise. In most cases, postpartum hemorrhage is caused by atony – the failure of the uterus to contract after delivery. Atony is regularly prevented through use of oxytocic drugs that induce uterine contraction. When prevention fails, the uterus must be mechanically stimulated to contract. The most common solution used in developing countries is the balloon system which exerts outward hydrostatic pressure on the uterus.
Intrauterine balloon systems with applications of an intrauterine vacuum are a promising new method. It aims to reduce uterine size for the control of a postpartum hemorrhage with no additional intervention required thereafter. With advancing technology the vacuum induced uterine tamponade (VIUT) has come into play. It was created through a device inserted transvaginally into the uterine cavity. An occlusion balloon built into the device shaft was inflated to the level of the external cervical os (the junction between the cervix and the vagina) to create a uterine seal.
Internal mechanics of VIUTS
The process consists of applying low level intrauterine vacuum to facilitate physiologic forces of uterine contractions to constrict myometrial blood vessels and achieve homeostasis.
The tamponade itself is made of medical grade silicon, of which the distal end (placed in the uterus) is an elliptical loop, containing 20 vacuum pores on its inner surface. The proximal end of the tamponade has a vacuum connector.
Prior to the beginning of the process of placing the device, a manual sweep of the uterine cavity is performed. After this, a Bakri balloon is inserted into the uterus, given that either a postpartum hemorrhage has occurred (and treatment consists of oxytocin followed by prostaglandins), or when uterine bleeding has continued despite removal of placenta or retained placental tissue.
The procedure¹ further includes inflation of the balloon with 50-100 ml of physiologic saline solution. The catheter is then connected to a non sterile tube, which is in turn connected to a vacuum device, at which point an intrauterine vacuum is applied with 60-70kPa. The tube positioning and uterine cavity condition must be monitored through ultrasonography to detect an unwanted accumulation of blood. If no bleeding is visible then the patient is stable and the balloon should be deflated completely and removed.
In very rare cases, this process requires additional antibiotics or analgesia administration.
The time taken for uterine collapse and hemorrhagic control is relatively short. In the prospective study² carried out, the initial collapse of the uterus took a median of one to two minutes from the time of vacuum connection. Bleeding came into control within 5 minutes for 82 percent of women. The median overall duration of the vacuum treatment was 144 minutes (median being 85-295 minutes), which includes the required 60 minutes of vacuum treatment time and 30 minutes of observation without any vacuum connected, but with the device still in place.
Fig 2: Vacuum induced uterine tamponade in vitro observed in ultrasonography
Conclusion
The above study, as well as an FDA review³ that followed, deemed the device to be safe. Some possible adverse effects were found, such as endometriosis, laceration, and vaginal infection. However, these were resolved in further trials without any serious clinical consequences.
Although the method has yielded confidence from its success rates, VIUTs must undergo periodic evaluations. Further investigation should be undertaken to determine whether the success rates found so far were solely due to vacuum induced uterine tamponade methods or proper management of postpartum hemorrhage patients. The majority of clinicians (according to this poll²) reported that the vacuum induced hemorrhagic control device was easy to use and recommended it for future patients.
Pratiksha Baliga, Youth Medical Journal 2022
References
1. Haslinger, C., Weber, K. and Zimmermann, R., 2022. Vacuum-Induced Tamponade for Treatment of Postpartum Hemorrhage. [online] National Center for Biotechnology Information. Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8366764/>
2. D’Alton ME, Rood KM, Smid MC, Simhan HN, Skupski DW, Subramaniam A, Gibson KS, Rosen T, Clark SM, Dudley D, Iqbal SN, Paglia MJ, Duzyj CM, Chien EK, Gibbins KJ, Wine KD, Bentum NAA, Kominiarek MA, Tuuli MG, Goffman D, M., 2020. National Library of Medicine: National Centre for Biotechnology Information. 2022. Intrauterine Vacuum-Induced Hemorrhage-Control Device for Rapid Treatment of Postpartum Hemorrhage. [online] Available at:
<https://pubmed.ncbi.nlm.nih.gov/32909970/>
3. D’Alton, M., Rood, K., Simhan, H. and Goffman, D., 2022. Profile of the Jada® System: the vacuum-induced hemorrhage control device for treating abnormal postpartum uterine bleeding and postpartum hemorrhage. [online] Taylor & Francis. Available at: <https://www.tandfonline.com/doi/full/10.1080/17434440.2021.1962288>
Youth Medical Journal 