EBRU ÇELİK KAVAK, Melike BAŞPINAR, REMZİ ATILGAN, ŞEHMUS PALA, ŞEYDA YAVUZKIR, Emre YALÇIN

Postpartum Uterin Atonide İntrauterin Balon Tamponad ile Konservatif Yaklaşım

Postpartum Uterin Atonide İntrauterin Balon Tamponad ile Konservatif Yaklaşım Amaç: Uterin atoni doğumun ciddi bir komplikasyonudur. Akut olgularda çoğunlukla histerektomi yapılır. B-Lynch sütürü ile birlikte veya tek başına intrauterin balon uygulanması konservatif yaklaşımı ise bir diğer alternatiftir. Bölge hastanesinden olgu serisi sunulmuştur. Gereç ve Yöntem: Bu çalışmada uterotonik tedaviye cevapsız ve B-Lynch sütürü ile birlikte veya tek başına intra uterin balon tamponad ile tedavi edilen otuz postpartum uterin atoni olgusu retrospektif olarak analiz edilmiştir. Bulgular: Otuz olguya B-Lynch kompresyon sütürü ile veya tek başına bakri balon tamponad (BBT ) uygulandı. Başarı oranı % 86, ortalama kan kaybı 1850 ml, intraoperatif ortalama hemoglobin değeri 6,6 mg/dl, ortalama kan transfüzyonu 4 ünite, ortalama ameliyat süresi 70 dakika, balona verilen ortalama sıvı 250 ml, balonun çıkarılma süresi ortalama 30 saat idi. Dört olgu kanamanın durmaması sebebiyle histerek tomiye alındı. Bir olguda Asherman sendromuna bağlı infertilite oluştu. BBT 'ın başarılı olduğu olgularda bilateral uterin arter doppler PI değeri, kontrol grubuyla benzerdi. Maternal mortalite olmadı. Sonuç: B-lynch sütürüyle beraber veya tek başına uygulanan balon tamponad, postpartum atoni kanamasında etkili, hızlı, basit, ve fertilite koruyucu bir tekniktir. Kanama kontrolünde başarısızlık durumunda daha ileri müdahaleler için ilave zaman sağlamaktadır.

Conservative Management of Postpartum Uterine Atony with Intrauterine Balloon Tamponade

O bje ctive: Uterine atony is one of the serious complications of labour. Hysterectomy is mostly required in acute cases. Conservative ma nagement with intrauterine balloon insertion alone or in combination with B-Lynch suture might be an alternative. We report a case series from a referral hospital. Mate rial and Method: T his was a retrospective analysis of 30 postpartum uterine atony cases refractory to uterotonic treatment and managed with intrauterine balloon tamponade with or without B-Lynch suture. Re sults: Thirty cases managed with intrauterine Bakri balloon tamponade (BBT) with or without B-Lynch compression suture. Our success rate was 86 %. Median estimated blood loss was 1850 ml, intraoperative median hemoglobin was 6.6 mg/dl, median amount of blood transfused was four units, median operation duration was 70 minutes, median volume infused into balloon was 250 ml, balloon was in pla ce for a median duration of 30 hours. In 4 cases Bakri balloon tamponade with or without B-Lynch compression sutures failed to stop hemorrhage and hysterectomy required. In one patient Asherman's syndrome and infertility developed. In cases which BBT was successful PI values of bilateral uterine artery doppler was similar to control group. T here wasn't maternal mortality. C onclusion: Balloon tamponade of uterus with or without compression sutures is an effective, quick, simple and fertility preserving techn ique in the management of postpartum uterine atony bleeding. It further provides time for more complicated interventions in case of failure to control hemorrhage.

PDF

___

1. Tindell K, Garfinkel R, Abu-Haydar E, et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage in resource-poor settings: a systematic review. BJOG 2013; 120: 5- 14.
2. Ahonen J, Stefanovic V, Lassila R. Management of postpartum haemorrhage. Acta Anaesthesiol Scand 2010; 54: 1164-78.
3. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv 2007; 62: 540-7.
4. Mousa HA, Walkinshaw S. Major postpartum haemorrhage. Curr Opin Obstet Gynecol 2001; 13: 595-603.
5. Chandraharan E, Arulkumaran S. Surgical aspects of postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol 2008; 22: 1089-102.
6. Vitthala S, Tsoumpou I, Anjum ZK, Aziz NA. Use of Bakri balloon in postpartum haemorrhage: A series of 15 cases. Aust NZJ Obstet Gynaecol 2009; 49: 191-4.
7. Diemert A, Ortmeyer G, Hollwitz B et al. The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage. Am J Obstet Gynecol 2012; 206: 65.
8. McDonald S. Management of the third stage of labour. Journal of Midwifery & Women's Health. 2007; 52: 254-61.
9. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG 1997; 104: 372-5.
10. Bakri YN, Amri A, Abdul Jabbar F. Tamponade balloon for obstetrical bleeding. Int J Gynaecol Obstet 2001; 74: 139-42.
11. Nelson WL, O'Brien JM. The uterine sandwich for persistent uterine atony: combining the BLynch compression suture and an intrauterine Bakri balloon. Am J Obstet Gynaecol 2007; 196: 9-10.
12. Cho Y, Rizvi C, Uppal T, Condous G. Ultrasonographic visualization of balloon placement for uterine tamponade in massive primary postpartum hemorrhage. Ultrasound Obstet Gynecol 2008; 32: 711-3.
13. Varatharajan L, Chandraharan E, Sutton J, Lowe V, Arulkumaran S. Outcome of the management of massive postpartum hemorrhage using the algorithm "HEMOSTASIS". Int J Gynaecol Obstet. 2011; 113: 152-4.
14. Rath W, Hackethal A, Bohlmann MK. Secondline treatment of postpartum haemorrhage (PPH). Arch Gynecol Obstet 2012; 286: 549-61.
15. Royal College of Obstetricians and Gynaecologists. RCOG Draft Guideline. Prevention and management of postpartum haemorrhage, 2008.
16. Kong MC, To WW. Balloon tamponade for postpartum haemorrhage: case series and literature review. Hong Kong Med J 2013; 19: 484- 90.
17. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. Br J Obstet Gynaecol 2009; 116: 748-57.
18. Condous GS, Arkulkumaran S, Symonds I, Chapman R, Sinha A, Razvi K. The 'tamponade test' in the management of massive postpartum hemorrhage. Obstet Gynecol 2003; 101: 767- 72.
19. Dabelea V, Schultze PM, McDuffie RS. Intrauterine balloon tamponade in the management of postpartum hemorrhage. Am J Perinatol 2007; 24: 359-64.
20. Yoong W, Ridout A, Memtsa M, et al. Application of uterine compression suture in association with intrauterine balloon tamponade ('uterine sandwich') for postpartum hemorrhage. Acta Obstet Gynecol Scand 2012; 91: 147-51.
21. Aibar L, Aguilar MT, Puertas A, Valverde M. Bakri balloon for the management of postpartum hemorrhage. Acta Obstet Gynecol Scand 2013; 92: 465-7.
22. Doumouchtsis SK, Papageorghiou AT, Vernier C, Arulkumaran S. Management of postpartum hemorrhage by uterine balloon tamponade: prospective evaluation of effectiveness. Acta Obstet Gynecol Scand 2008; 87: 849-55.
23. 23.Nagai S, Kobayashi H, Nagata T, Hiwatashi S, Kawamura T, Yokomine D, Orita Y, Oki T, Yoshinaga M, Douchi T. Clinical Usefulness of Bakri Balloon Tamponade in the Treatment of Massive Postpartum Uterine Hemorrhage. Kurume Med J 2016; 62: 17-21.
24. Pendleton AA, Natarajan A, Ahn R, Nelson BD, Eckardt MJ, Burke TF. Emergency hysterectomy for uncontrolled postpartum hemorrhage may be averted through uterine balloon tamponade in Kenya and Senegal. Int J Gynaecol Obstet 2016; 133: 124.
25. Hayman RG, Arulkumaran S, Steer P. Uterine compressions sutures: surgical management of postpartum haemorrhage. Obstet Gynecol 2002; 99: 502-6.
26. Danso D, Reginald P. Combined B-Lynch suture with intrauterine balloon catheter triumphs over massive postpartum haemorrhage. BJOG 2002; 109: 963.
27. Price N, Whitelaw N, B-Lynch C. Application of the B-Lynch brace suture with associated intrauterine balloon catheter for massive haemorrhage due to placenta accreta following a second trimester miscarriage. J Obstet Gynaecol 2006; 26: 267-8.
28. Diemert A, Ortmeyer G, Hollwitz B, et al. The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage. Am J Obstet Gynecol 2012; 206: 65.
29. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization. Acta Obstet Gynecol Scand 2008; 87: 1020-6.
30. Gezginç K, Yazici F, Koyuncu T. Results of hysterosalpingogram in women with previous B-Lynch suture. Int J Gynaecol Obstet 2011; 115: 68-9.
31. Sugawara J, Saito M, Nishigori H, et al. Fertility and pregnancy outcomes following B-Lynch sutures for post-partum hemorrhage. J Obstet Gynaecol Res 2015; 41: 559-64.
32. Goojha CA, Case A, Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartumhemorrhage. Fertil Steril 2010; 94: 1098.
33. Begum J, Pallave P, Ghose S. B-lynch: A technique for uterine conservation or deformation? A case report with literature review. J Clin Diagn Res 2014; 8: OD01-OD03.
34. Liu S, Mathur M, Tagore S. Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience. J Obstet Gynaecol 2014; 34: 383-6.
35. Rasheed SM, Amin MM, Abd Ellah AH, Abo Elhassan AM, El Zahry MA, Wahab HA. Reproductive performance after conservative surgical treatment of postpartum hemorrhage. Int J Gynaecol Obstet 2014; 124: 248-52.