Balloon Tamponade. Uterine packing to treat refractory uterine atony fell from favor because of concerns regarding concealed bleeding and infection (Gilstrap, 2017). Newer techniques of balloon tamponade help alleviate some of these concerns (Sentilhes, 2016; Zelop, 201l). In one technique, the tip of a 24F to 30F Foley catheter with a 30-mL balloon is guided into the uterine cavity and illed with 60 to 80 mL of saline. The open tip permits continuous drainage of blood from the uterus. We have experienced balloon rupture when more than 50 mL was instilled into the balloon, thus a 34F Foley with a 60-ml balloon can be used. If bleeding subsides, the catheter is typically removed ater 12 to 24 hours. Similar devices for tamponade include SegstakenBlakemore, Rusch, and ebb balloons and condom catheters (Antony, 2017; Georgiou, 2009).
Enthusiasm has developed for specially constructed intrauterine balloons to treat hemorrhage from uterine atony and other causes. A Bakri Pospartum Baloon or BT-Cath may be inserted and inlated to tamponade the endometrial cavity and stop bleeding (Fig. 41-5). Insertion requires two or three team members. he irst performs abdominal sonography during the procedure. The second places the delated balloon into the uterus and stabilizes it. The third member instills luid to inlate the balloon, rapidly infusing at least 150 mL followed by further instillation over a few minutes for a total of 300 to 500 mL to arrest hemorrhage. It is reasonable to remove the balloon after approximately 12 hours (Einerson, 2017).
In prospective studies, nearly 150 women have been managed for postpartum hemorrhage with these uterine balloons
FIGURE 41 -5 Intrauterine Bakri balloon for postpartum hemorrhage.
(Gronvall, 2013; Kaya, 2016; Vintejoux, 2015). Perhaps a fourth of cases were caused by uterine atony. For all causes, the success rate was noted to be approximately 85 percent. Combinations of balloon tamponade and uterine compression sutures have also been described (Diemert, 2012; Yoong, 2012). Failures for all of these require various surgical methods including hysterectomy.
These include uterine compression sutures, pelvic vessel ligation, angiographic embolization, and hysterectomy. hese are discussed on page 792.
Puerperal inversion of the uterus is one of the classic hemorrhagic disasters encountered in obstetrics. Unless promptly recognized and managed appropriately, associated bleeding often is massive. Risk factors include alone or in combination: (1) fundal placental implantation, (2) uterine atony, (3) cord traction applied bore placental separation, and (4) abnormally adhered placentation such as with the accrete syndromes (p. 777).
Depending on which of these factors are contributory, the incidence and severity of uterine inversion varies. There is progressive severity of inversion as shown in Figure 41-6. The worst scenario is complete inversion with the uterus protruding from the birth canal (Fig. 41-7).