Evaluating the efficacy of the B-lynch suture and the Bakri balloon, or both, in the treatment of severe post-partum haemorrhage

Dr Ashleigh Smith Junior House Officer, RBWH

Case

• 24 y/o G1P1 has a ‘PPH’ • How do you know it is a PPH? • Remember :

– Tissue, Tone, Trauma, Thrombin• What can you do about it?

Post Partum Haemorrhage

• Primary: >500mL’s EBL within the first 24 hours after delivery

• Secondary: >500mL’s EBL from 24hours to 6 weeks post delivery.

Medical Treatment of PPH

• Active management of the third stage • IV 5 I.U. oxytocin • IV/IM Ergometrine 250 microg• Oxytocin infusion (40 in 1L) • PR Misoprostol • Intramyometrial PGF2alpha

What if Medical Management FAILS!?!?!

• Depends on the clinical situation • Open or closed abdomen? • Does the woman want a hysterectomy?

What if they Fail!?

• Hysterectomy? • Can we try anything else???

Using both B-lynch and Bakri?

• A novel concept aka “uterine sandwich”• If one fails in isolation, perhaps go on and try

the combination as ‘3rd line’ after – Medical management – Bakri OR B-kynch– Both

How about a “uterine sandwich?”

• Few trials available, some are very promising • QLD guidelines for PPH management :

“insufficient evidence to support use of combined balloon tamponade with the B-lynch suture.”

My Research….

• A retrospective case study at RBWH • all women who had a PPH and insertion of

either– B-lynch suture or – Bakri balloon, or – both,

• between Jan 2009 – Dec 2013.

Please note….

• If anyone received “both,” that means they failed the b-lynch or the bakri

• Therefore it is a very serious PPH and a more tenuous cohort/clinical situation

Cohort

• 97 cases of PPH occurred in which medical therapy alone failed.

40

48

9

BakriB-lynchBoth

What type of Birth?

5

25

67

VaginalElective CEmergency C

Primary vs Secondary PPH

89

8

Primary Secondary

Results

• 7 emergency hysterectomies in the study • No mortalities

Bakri B-lynch Both0

10

20

30

40

50

60

38

48

42 05

SuccessHysterectomy

Hysterectomy Patients

What about the “sandwich!?”

• 5 of the 9 patients treated with ‘the uterine sandwich’ went on to hysterectomy

• Is that bad??? – Bakri = 95% success– B-lynch = 100% success– Both ………….. 44% success

Conclusions

• Bakri and B-lynch suture = highly effective in terminating PPH when medical therapy alone fails.

• ‘Uterine sandwich’ appears to be an effective option to trial in an effort to avoid hysterectomy.

• Need clear stepwise PPH guidelines

Thank you!• References: 1. Gronvall M, Tikkanen M, Tallberg E, et al. Use of Bakri balloon tamponade in the treatment of postpartum hemorrhage: a

series of 50 cases from a tertiary teaching hospital. Acta Obstet Gynecol Scand. 2013; 92(4): 433-438.

2. 2. Gao, Y., Wang Z., Zang J., et al. Efficacy and safety of intrauterine Bakri balloon tamponade in the treatment of postpartum hemorrhage: a multicenter analysis of 109 cases. Zhonghua Fuchanke Zazhi, 2014; 49(9): 670-675.

3. Liu S, Mathur M, Tagore S. Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience. Journal of Obstetrics and Gynaecology, 2014; 34(5): 383-386.

4. Kaya B, Tuten A, Daglar K, et al. B-Lynch uterine compression sutures in the conservative surgical management of uterine atony. Arch Gynecol Obstet, 2014; 291(5):1005-14.

5. Diemert A, Ortemeyer G., Hollwitz B, et al. The combination of the intrauterine balloon tamponade and b-lynch procedure for the treatment of severe postpartum hemorrhage, Am J Ostet Gynecol, 2012; 206(1):61-64.

6. 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(1): 147-151.

7. Chan L, Lo T, Lau W, et. al. Use of second-line therapies for management of massive primary postpartum hemorrhage. Int J Gynecol Obstet, 2013; 122(3): 238–243.