Managing massive postpartum haemorrhage



We read with interest the review article by Georgiou on balloon tamponade for the management of postpartum haemorrhage (PPH).1 Whether using a balloon is better or worse than other methods in arresting PPH is a crucial issue. In a systematic review, we have previously shown that success rates of balloon tamponade, arterial embolisation, pelvic devascularisation and different forms of brace sutures are similar.2 The choice of the technique will therefore depend on the setting (e.g. is it at laparotomy or not? what is the experience of the operator?). It appears from most papers that there is no specific hierarchy in the sequence of the surgical measures for managing PPH after medical management has failed, and in some centres the use of balloon tamponade does not feature in treatment algorithms at all. Using a balloon has many potential advantages: success rates are similar to other methods, it is simple and easy to use, can be deployed rapidly avoiding laparotomy or need for specialised radiological input, is associated with low complication rates and allows the option of being used alongside other methods. We believe these are sufficient reasons to make it a first line of treatment after failure of medical management.

We agree that the volume used depends on the presumed capacity of the uterine cavity and the tamponade achieved. Grand multiparous women or those with uterine overdistention (e.g. multiple pregnancy or polyhydramnios) may require higher volumes to achieve tamponade. In a prospective series of 27 cases, the median volume required to achieve haemostasis was 300 ml (interquartile range 200–400 ml). Of the 22 successful placements, additional inflation was required in only one woman. Clinical judgment will dictate the actions if haemostasis is not achieved; either to abandon the failed ‘tamponade test’ and proceed to other measures, or further inflation of the balloon.3

The method used to treat PPH should depend on the degree of continuous bleeding, estimated blood loss, haemodynamic status of the woman and availability of facilities. However, attempts to control haemorrhage with uterotonic agents and conservative surgical measures should not result in undue delay in proceeding to hysterectomy when they are not effective. Obstetricians may have a feeling of reluctance to resort to difficult surgery with high risks of severe morbidity and mortality. The probability of survival decreases sharply after the first, ‘golden’, hour if the patient is not successfully resuscitated. When conservative measures fail to control haemorrhage surgery should be undertaken sooner rather than later, and it is estimated that for each woman who dies following peripartum hysterectomy more than 150 survive. Of the 318 women undergoing peripartum hysterectomy in the UKOSS study, 50 were unsuccessfully managed with compression sutures, 28 had activated factor VII and nine underwent arterial embolisation. The authors called for further research on innovative therapies for control of haemorrhage.4 In the meantime, all women should have documented attempts at fertility sparing measures of managing PPH prior to timely hysterectomy.