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The association between intrauterine balloon tamponade duration and postpartum hemorrhage outcomes

Published:November 04, 2016DOI:https://doi.org/10.1016/j.ajog.2016.10.040

      Background

      Intrauterine balloon tamponade is an effective treatment for postpartum hemorrhage when first-line treatments fail. The optimal duration of intrauterine balloon tamponade for management of postpartum hemorrhage is unclear.

      Objective

      The objective of the study was to determine whether intrauterine balloon tamponade removal >12 hours of duration is associated with postpartum hemorrhage–related clinical outcomes.

      Study Design

      This was a retrospective cohort study of women with postpartum hemorrhage from 2007 through 2014 who underwent intrauterine balloon tamponade. We excluded failures of intrauterine balloon tamponade (intrauterine balloon expulsion with duration <2 hours or if hysterectomy was required prior to planned intrauterine balloon removal). Patients who underwent intrauterine balloon tamponade for 2–12 hours were compared with those who underwent intrauterine balloon tamponade for >12 hours. Examined postpartum hemorrhage–related clinical outcomes included estimated blood loss after intrauterine balloon tamponade placement, blood product transfusion, use of adjuvant measures to control postpartum hemorrhage after intrauterine balloon tamponade (either uterine artery embolization or hysterectomy), and maternal intensive care unit admission. Secondary outcomes examined included postpartum fever and hospital length of stay. Multivariable logistic regression models were used to control for confounding variables.

      Results

      Of 274 eligible women, 206 (75%) underwent intrauterine balloon tamponade for >12 hours and 68 (25%) underwent intrauterine balloon tamponade for 2–12 hours. The median estimated blood loss after intrauterine balloon tamponade placement (190 vs 143 mL, P = .116) as well as the frequencies of blood product transfusion (62.1% vs 51.5%, P = .120), transfusion of ≥4 U of packed red blood cells (17.0% vs 14.7%, P = .659), uterine artery embolization (15.1% vs 16.2%, P = .823), hysterectomy (0.0% vs 1.5%, P = .248), and intensive care unit admission (8.7% vs 7.4%, P = .721), was not statistically different between the groups, and this lack of association persisted in multivariable regressions. Intrauterine balloon tamponade duration >12 hours was associated with a higher frequency of postpartum fever (27% vs 15%, P = .047) and a longer mean hospital length of stay (3.7 vs 3.1 days, P = .002). After adjusting for variables that differed statistically between groups, the difference in length of stay associated with intrauterine balloon tamponade duration was no longer present, but the association between intrauterine balloon tamponade duration >12 hours and postpartum fever persisted (odds ratio, 2.33, 95% confidence interval, 1.07–5.11). Including chorioamnionitis as an independent variable in a post hoc multivariable analysis diminished the association between intrauterine balloon tamponade >12 hours and postpartum fever (adjusted odds ratio, 2.04, 95% confidence interval, 0.92–4.53).

      Conclusion

      There are no significant differences in postpartum hemorrhage–related outcomes associated with intrauterine balloon tamponade duration >12 hours compared with removal 2–12 hours. If ongoing hemorrhage has abated, it is reasonable to consider the removal of an intrauterine balloon by 12 hours after its initial placement.

      Key words

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      Linked Article

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        American Journal of Obstetrics & GynecologyVol. 216Issue 5
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          We commend Einerson et al1 for answering a very important unsolved question: whether the Bakri balloon can be removed <12 hours after placement. Their retrospective observational study showed that Bakri balloon removal before or after 12 hours does not affect outcomes, and thus concluded “if ongoing hemorrhage has abated, it is reasonable to consider removal of an intrauterine balloon by 12 hours after its initial placement.” We have a concern and an addition.
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      • Excessive duration of intrauterine balloon placement
        American Journal of Obstetrics & GynecologyVol. 217Issue 2
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          Einerson et al1 reported that there were no significant differences in postpartum hemorrhage (PPH) outcomes when the Bakri balloon was removed after 12 hours or before 12 hours. In the group of 206 patients, the intrauterine balloon was removed after 21 hours (range, 17–24 hours).
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