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Maintaining the position of a Bakri balloon after caesarean section for placenta previa using an abdominal traction stitch
G Model
EURO 9267 1–2 European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb 1 2 3 4 5
LETTER TO THE EDITOR—BRIEF COMMUNICATION Maintaining the position of a Bakri balloon after caesarean section for placenta previa using an Q1 abdominal traction stitch
6 7 8 9 10
Dear Editors, Q3
The Bakri intrauterine balloon can achieve haemostasis in cases of postpartum haemorrhage, including haemorrhage associated with placenta previa (PP) [1,2], by compressing the lower uterine segment [1,2]. However, strong contraction of the
uterine body can eject the balloon into the vagina (balloon prolapse) [3,4]. In order to prevent this, we devised ‘fishing for the balloon shaft’ [4], in which both cervices are held with sponge forceps, closing the ostium (‘holding the cervix’). Closing the cervices transvaginally by holding the cervix can be difficult for less-experienced doctors, or if the patient cannot open their legs adequately. However, pulling the uterine-side end of the balloon with an abdominal traction stitch overcomes this difficulty. We have used this approach successfully in two patients.
Fig. 1. Abdominal traction stitch to prevent prolapse of the Bakri balloon. (a) The placenta has reached the middle of the anterior uterine body, and a uterine incision is made transversely in the mid anterior uterine body to avoid a transplacental approach. A suture is tied through the uterine-end shaft hole of the Bakri balloon (single arrow). The other end of the suture is placed through the uterine wall (double arrow). The balloon is positioned in the lower segment. (b) The abdominal traction stitch is held by forceps and fixed, with cephalad traction applied continuously to the balloon (uterine fundal side) (small arrows), preventing balloon prolapse. (c) The abdominal traction stitch is fixed by an umbilical cord clamp on the abdominal wall, preventing the suture from receding into the abdominal cavity, and, thus, maintaining the correct position of the balloon and preventing prolapse. Removal of the balloon is easy, with no resistance; the suture does not hinder balloon removal. At the time of balloon removal, the suture that was placed through the abdominal wall will traverse the intra-abdominal and intrauterine cavities, and should be kept clean. Theoretically, an intra-abdominal suture may cause intestinal obstruction; this was previously of concern [3]. However, the typical midline uterus is located just beneath the abdominal wall, with no room for the intestine to position itself. The suture is usually removed within 24 h, and there should be little danger of associated complications. (d) Schematic presentation of the abdominal traction stitch. In this diagram, the placenta accreta remains undelivered, and is compressed by the balloon. http://dx.doi.org/10.1016/j.ejogrb.2016.01.021 0301-2115/ß 2016 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Matsubara S, et al. Maintaining the position of a Bakri balloon after caesarean section for placenta previa using an abdominal traction stitch
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EURO 9267 1–2 2
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LETTER TO THE EDITOR—BRIEF COMMUNICATION / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2016) xxx–xxx
Patient 1 had previously undergone dilatation and curettage. Imaging in her first pregnancy suggested a partial abnormal invasive placenta. Caesarean section was performed at 37 weeks of gestation with placement of a temporary intra-common-iliac arterial balloon. The placenta was removed almost entirely without manual assistance; however, a small area (2 2 cm in the lower segment) remained undelivered, bleeding continued and placement of a Bakri balloon was required. Opening the legs may cause displacement of an intra-arterial balloon, but it is difficult to hold the cervix without open legs. Fig. 1 shows the abdominal traction stitch. The Bakri balloon was first inflated with 50 ml saline and then a further 50 ml (total 100 ml), which achieved haemostasis. Bakri balloons can be inflated with up to 500 ml, but inflation was stopped at 100 ml in this case as haemostasis was achieved. The balloon was fixed with a monofilament suture through the uterine-side shaft hole. The suture was passed through the uterine wall to the anterior abdominal wall, and fixed. Total blood loss was 2600 ml. Four units of red blood cells and eight units of fresh frozen plasma were transfused. Inflation of the temporary intra-arterial balloon was not necessary. After 24 h, the balloon was deflated by 50 ml, haemostasis was confirmed, and the balloon was deflated by another 50 ml. After confirmation of haemostasis, the balloon was removed without resistance. In Patient 2, massive bleeding occurred from the placental separation site at caesarean section at 37 weeks of gestation. The attending physicians performed the abdominal procedure when the resident could not grasp the anterior and posterior lips of the ectocervix adequately. The abdominal traction stitch technique held the balloon in place, allowing adequate haemostasis. Total blood loss was 2250 ml, and eight units of red blood cells were transfused. In both cases, the mother and infant had uneventful postpartum courses. In patients with PP, contraction of the uterine body causes balloon prolapse perhaps more frequently than uterine atony. A technique to prevent prolapse is necessary. We previously reported the combined use of an abdominal traction stitch and holding the cervix through the fundal incision [4]. However, it appears that an abdominal stitch alone may be effective. Bleeding sometimes occurs with balloon deflation, when the balloon may prolapse, and re-insertion may be difficult. With an abdominal traction stitch, the balloon is easily removed cephalad. If further bleeding occurs upon balloon deflation, the balloon can be reinflated to achieve haemostasis without concern regarding balloon prolapse. The suture should not be pulled too tightly due to the possibility of uterine involution. We devised this technique independently, but subsequently noted that Khalil et al. [5] had described it in ‘A method to improve the effectiveness of the Bakri balloon for management of postpartum haemorrhage at cesarean’. Their target was uterine (body) atony rather than PP, and they excluded patients with PP. However, an abdominal traction stitch may yield greater importance in cases of PP than uterine (body) atony. If the title of their paper had specified ‘abdominal traction stitch’, awareness of this technique may have been greater. Experience may lead obstetricians to a similar concept, resulting in others describing their technique as the first, being unaware of this existing article.
Many procedures other than intrauterine balloons have been reported for haemostasis of peri-/post-partum haemorrhage, especially that associated with PP, and various uterine compression sutures have been devised [6]. For haemostasis in cases of PP, compression sutures should be placed in the lower uterine segment (placental separation site), which usually requires bladder separation; this procedure can be difficult for lessexperienced surgeons [6]. We do not claim that intrauterine balloons are superior to uterine compression sutures; however, the use of an intrauterine balloon with concomitant use of an abdominal traction stitch is one option for haemostasis at caesarean section for PP.
77 78 79 80 81 82 83 84 85 86 87 88
Conflict of interest statement
89
None declared.
90
Financial disclosure
91
None.
92
References
93
[1] Kumru P, Demirci O, Erdogdu E, et al. The Bakri balloon for the management of postpartum hemorrhage in cases with placenta previa. Eur J Obstet Gynecol Reprod Biol 2013;167:167–70. [2] Matsubara S. A new approach for the Bakri balloon for placenta previa. Eur J Obstet Gynecol Reprod Biol 2014;182:262–3. [3] Matsubara S. Re: The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?: The treatment of postpartum haemorrhage: holding the intrauterine balloon ‘there’. BJOG 2015;122:1846–56. [4] Matsubara S, Baba Y, Takahashi H. Preventing a Bakri balloon from sliding out during ‘holding the cervix’: ‘fishing for the balloon shaft’ technique (Matsubara). Acta Obstet Gynecol Scand 2015;94:910–1. [5] Khalil MI, Al-Dohami H, Aldahish MM. A method to improve the effectiveness of the Bakri balloon for management of postpartum hemorrhage at cesarean. Int J Gynaecol Obstet 2011;115:198–200. [6] Matsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum hemorrhage: an overview. Acta Obstet Gynecol Scand 2013;92:378–85.
94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111
S. Matsubara* Q2 Y. Baba H. Morisawa H. Takahashi Department of Obstetrics and Gynaecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
112 113 114 115 116 117 118
A.K. Lefor Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
119 120 121
*Corresponding author at: Department of Obstetrics and Gynaecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan. Tel.: +81 285 58 7376; fax: +81 285 44 8505 E-mail address: [email protected] (S. Matsubara).
122 123 124 125 126 127 128
Received 30 November 2015
Please cite this article in press as: Matsubara S, et al. Maintaining the position of a Bakri balloon after caesarean section for placenta previa using an abdominal traction stitch
EURO 9267 1–2 European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb 1 2 3 4 5
LETTER TO THE EDITOR—BRIEF COMMUNICATION Maintaining the position of a Bakri balloon after caesarean section for placenta previa using an Q1 abdominal traction stitch
6 7 8 9 10
Dear Editors, Q3
The Bakri intrauterine balloon can achieve haemostasis in cases of postpartum haemorrhage, including haemorrhage associated with placenta previa (PP) [1,2], by compressing the lower uterine segment [1,2]. However, strong contraction of the
uterine body can eject the balloon into the vagina (balloon prolapse) [3,4]. In order to prevent this, we devised ‘fishing for the balloon shaft’ [4], in which both cervices are held with sponge forceps, closing the ostium (‘holding the cervix’). Closing the cervices transvaginally by holding the cervix can be difficult for less-experienced doctors, or if the patient cannot open their legs adequately. However, pulling the uterine-side end of the balloon with an abdominal traction stitch overcomes this difficulty. We have used this approach successfully in two patients.
Fig. 1. Abdominal traction stitch to prevent prolapse of the Bakri balloon. (a) The placenta has reached the middle of the anterior uterine body, and a uterine incision is made transversely in the mid anterior uterine body to avoid a transplacental approach. A suture is tied through the uterine-end shaft hole of the Bakri balloon (single arrow). The other end of the suture is placed through the uterine wall (double arrow). The balloon is positioned in the lower segment. (b) The abdominal traction stitch is held by forceps and fixed, with cephalad traction applied continuously to the balloon (uterine fundal side) (small arrows), preventing balloon prolapse. (c) The abdominal traction stitch is fixed by an umbilical cord clamp on the abdominal wall, preventing the suture from receding into the abdominal cavity, and, thus, maintaining the correct position of the balloon and preventing prolapse. Removal of the balloon is easy, with no resistance; the suture does not hinder balloon removal. At the time of balloon removal, the suture that was placed through the abdominal wall will traverse the intra-abdominal and intrauterine cavities, and should be kept clean. Theoretically, an intra-abdominal suture may cause intestinal obstruction; this was previously of concern [3]. However, the typical midline uterus is located just beneath the abdominal wall, with no room for the intestine to position itself. The suture is usually removed within 24 h, and there should be little danger of associated complications. (d) Schematic presentation of the abdominal traction stitch. In this diagram, the placenta accreta remains undelivered, and is compressed by the balloon. http://dx.doi.org/10.1016/j.ejogrb.2016.01.021 0301-2115/ß 2016 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Matsubara S, et al. Maintaining the position of a Bakri balloon after caesarean section for placenta previa using an abdominal traction stitch
11 12 13 14 15 16 17 18 19 20
G Model
EURO 9267 1–2 2
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76
LETTER TO THE EDITOR—BRIEF COMMUNICATION / European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2016) xxx–xxx
Patient 1 had previously undergone dilatation and curettage. Imaging in her first pregnancy suggested a partial abnormal invasive placenta. Caesarean section was performed at 37 weeks of gestation with placement of a temporary intra-common-iliac arterial balloon. The placenta was removed almost entirely without manual assistance; however, a small area (2 2 cm in the lower segment) remained undelivered, bleeding continued and placement of a Bakri balloon was required. Opening the legs may cause displacement of an intra-arterial balloon, but it is difficult to hold the cervix without open legs. Fig. 1 shows the abdominal traction stitch. The Bakri balloon was first inflated with 50 ml saline and then a further 50 ml (total 100 ml), which achieved haemostasis. Bakri balloons can be inflated with up to 500 ml, but inflation was stopped at 100 ml in this case as haemostasis was achieved. The balloon was fixed with a monofilament suture through the uterine-side shaft hole. The suture was passed through the uterine wall to the anterior abdominal wall, and fixed. Total blood loss was 2600 ml. Four units of red blood cells and eight units of fresh frozen plasma were transfused. Inflation of the temporary intra-arterial balloon was not necessary. After 24 h, the balloon was deflated by 50 ml, haemostasis was confirmed, and the balloon was deflated by another 50 ml. After confirmation of haemostasis, the balloon was removed without resistance. In Patient 2, massive bleeding occurred from the placental separation site at caesarean section at 37 weeks of gestation. The attending physicians performed the abdominal procedure when the resident could not grasp the anterior and posterior lips of the ectocervix adequately. The abdominal traction stitch technique held the balloon in place, allowing adequate haemostasis. Total blood loss was 2250 ml, and eight units of red blood cells were transfused. In both cases, the mother and infant had uneventful postpartum courses. In patients with PP, contraction of the uterine body causes balloon prolapse perhaps more frequently than uterine atony. A technique to prevent prolapse is necessary. We previously reported the combined use of an abdominal traction stitch and holding the cervix through the fundal incision [4]. However, it appears that an abdominal stitch alone may be effective. Bleeding sometimes occurs with balloon deflation, when the balloon may prolapse, and re-insertion may be difficult. With an abdominal traction stitch, the balloon is easily removed cephalad. If further bleeding occurs upon balloon deflation, the balloon can be reinflated to achieve haemostasis without concern regarding balloon prolapse. The suture should not be pulled too tightly due to the possibility of uterine involution. We devised this technique independently, but subsequently noted that Khalil et al. [5] had described it in ‘A method to improve the effectiveness of the Bakri balloon for management of postpartum haemorrhage at cesarean’. Their target was uterine (body) atony rather than PP, and they excluded patients with PP. However, an abdominal traction stitch may yield greater importance in cases of PP than uterine (body) atony. If the title of their paper had specified ‘abdominal traction stitch’, awareness of this technique may have been greater. Experience may lead obstetricians to a similar concept, resulting in others describing their technique as the first, being unaware of this existing article.
Many procedures other than intrauterine balloons have been reported for haemostasis of peri-/post-partum haemorrhage, especially that associated with PP, and various uterine compression sutures have been devised [6]. For haemostasis in cases of PP, compression sutures should be placed in the lower uterine segment (placental separation site), which usually requires bladder separation; this procedure can be difficult for lessexperienced surgeons [6]. We do not claim that intrauterine balloons are superior to uterine compression sutures; however, the use of an intrauterine balloon with concomitant use of an abdominal traction stitch is one option for haemostasis at caesarean section for PP.
77 78 79 80 81 82 83 84 85 86 87 88
Conflict of interest statement
89
None declared.
90
Financial disclosure
91
None.
92
References
93
[1] Kumru P, Demirci O, Erdogdu E, et al. The Bakri balloon for the management of postpartum hemorrhage in cases with placenta previa. Eur J Obstet Gynecol Reprod Biol 2013;167:167–70. [2] Matsubara S. A new approach for the Bakri balloon for placenta previa. Eur J Obstet Gynecol Reprod Biol 2014;182:262–3. [3] Matsubara S. Re: The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?: The treatment of postpartum haemorrhage: holding the intrauterine balloon ‘there’. BJOG 2015;122:1846–56. [4] Matsubara S, Baba Y, Takahashi H. Preventing a Bakri balloon from sliding out during ‘holding the cervix’: ‘fishing for the balloon shaft’ technique (Matsubara). Acta Obstet Gynecol Scand 2015;94:910–1. [5] Khalil MI, Al-Dohami H, Aldahish MM. A method to improve the effectiveness of the Bakri balloon for management of postpartum hemorrhage at cesarean. Int J Gynaecol Obstet 2011;115:198–200. [6] Matsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum hemorrhage: an overview. Acta Obstet Gynecol Scand 2013;92:378–85.
94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111
S. Matsubara* Q2 Y. Baba H. Morisawa H. Takahashi Department of Obstetrics and Gynaecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
112 113 114 115 116 117 118
A.K. Lefor Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
119 120 121
*Corresponding author at: Department of Obstetrics and Gynaecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan. Tel.: +81 285 58 7376; fax: +81 285 44 8505 E-mail address: [email protected] (S. Matsubara).
122 123 124 125 126 127 128
Received 30 November 2015
Please cite this article in press as: Matsubara S, et al. Maintaining the position of a Bakri balloon after caesarean section for placenta previa using an abdominal traction stitch