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Indian Journal of Medical Sciences, Vol. 61, No. 3, March, 2007, pp. 157-160 Letter To Editor Postpartum hemorrhage in two women with impaired coagulation successfully managed with condom catheter tamponade Bagga Rashmi, Jain Vanita, Sharma Sushmita, Suri Vanita Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh Code Number: ms07026 Sir, Uterine tamponade can be lifesaving in postpartum hemorrhage (PPH) associated with deranged coagulation; as such women are at high risk for surgical intervention or angiographic embolization. Successful tamponade with Rusch balloon catheter, Sengstaken-Blakemore tube, rolled gauze and recently with condom catheter are reported.[1],[2],[3],[4],[5] A primigravida with eclampsia, HELLP syndrome and deranged coagulation was admitted in labor. She was sedated, icteric, had hematuria and prolonged bleeding from venipunctures. Her blood pressure was 160/116, pulse 100/min and cervix was fully dilated. Investigations revealed hemoglobin 5.7 g/dl, platelets 51,000/mm 3sub , prothrombin time index (PTI) 68%, hyperbilirubinemia (11.4 mg/dl) and elevated transaminases. Anti-HAV, anti-HEV and HbS antigen were negative. She had metabolic acidosis. Sodium bicarbonate and 3 units of fresh frozen plasma (FFP) were given. She delivered one hour later (baby weight 2.26 kg, Apgar 6,9). Oxytocin was initiated and placenta delivered by controlled-cord traction. There was a 300 g retro-placental clot. She had PPH (~ 1,000 ml). Misoprostol (800 µg, rectally), prostaglandinF2a (i/m, 250 µg, three doses), blood (4 units) and FFP (2 units) were administered. A cervical and vaginal tear were repaired after giving injection pethidine (50 mg). The uterus relaxed intermittently, hemorrhage continued and she developed tachycardia (128/min) but no hypotension (BP 130/80). Uterine tamponade with condom catheter was applied. Other tamponade methods (Rusch-catheter) are not readily available, whereas packing with rolled gauze needs anesthesia for proper placement.[4] We used a G16 Foley catheter, though a simple rubber catheter is cheaper.[1] A condom tied with silk to the tip (3-4 cm) of the Foley was placed in the uterus and inflated using gravity method by connecting an intravenous set and saline bottle to the catheter. The condom was inflated till bleeding reduced. (Two hundred fifty milliliters saline was needed.) The proximal end of the catheter was ligated to prevent backflow of saline. Vagina was packed with rolled gauze to prevent the condom catheter from slipping out. The urinary bladder was drained continuously. Oxytocin was continued for 12 h. The bleeding stopped in the next 4 h; condom was deflated and removed after 32 h. She had fever, which responded to broad-spectrum antibiotics. Platelets, liver functions and PTI returned to normal (hemoglobin 9.1 g/dl) and she recovered. Labor was induced with oxytocin at 31 weeks in a 3rd gravida with abruptio, fetal death and PTI 50%. She delivered 6 h later (stillbirth, 1,400 g), followed by PPH (~ 1,000 ml). Oxytocin, methylergometrine and prostaglandinF2a were administered. Examination under anesthesia detected a cervical tear, which was sutured. The bleeding continued, so condom catheter tamponade was applied. Three units FFP, 3 units platelet concentrate and 3 units blood were transfused over 4 h. The PTI improved (75%) and bleeding stopped. A subsequent ultrasound showed the inflated condom to uniformly occupy the uterine cavity with no concealed hemorrhage [Figure - 1]. The condom catheter was removed after 24 h and she recovered. After genital tract trauma is excluded and PPH is not controlled by oxytocics, attempts to compress the uterine sinuses with tamponade is an option before proceeding to surgical intervention. Condom catheter is an inexpensive and readily available method. It is simple to use and in developing countries with a low institutional delivery rate, can be practiced by trained birth attendants while they make arrangements for transportation to a hospital. The inflated condom conforms naturally to the uterine contour and exerts uniform pressure on the sinuses, which stops the bleeding. It is inflated until the bleeding is controlled and usually 250-300 ml suffices. The saline flows freely initially and later slows down. This coincides with reduction in bleeding. An anesthetic is not required but analgesia (pethidine) may be used. Tamponade procedures are temporary methods to reduce bleeding due to atonicity, adherent placenta or coagulation disorders while stabilizing the patient (correcting coagulation) and preparing for surgery or embolization. These methods carry risk of infection and concealing continuing hemorrhage. If bleeding continues, it is likely that some of the blood may trickle over the surface of the balloon into the vagina. If the condom is not inflated with adequate amount of fluid, and hence is not applying adequate pressure, there might be a risk of concealed bleeding and failure of the procedure. A vaginal pack is needed to prevent the balloon from slipping out of the uterus, unless the cervix becomes retracted, or after an elective cesarean. Occasionally, tamponade may be sufficient to control PPH and obviate the need for another procedure. Tamponade may be appropriate for PPH with impaired coagulation (HELLP syndrome, abruptio, hepatitis, thrombocytopenia) where surgery or embolization carry more morbidity. In deranged coagulation, replacement of blood components to correct coagulation parameters takes some time. If hemorrhage continues unchecked, it may further deplete the clotting factors. Tamponade may stem the continuous blood loss while the coagulation parameters are being corrected. If PPH continues thereafter, other interventions are needed; but occasionally the bleeding may stop with tamponade alone, as observed in these two cases. References
Copyright 2007 - Indian Journal of Medical Sciences The following images related to this document are available:Photo images[ms07026f1.jpg] |
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