USE OF SAYEBAS CONDOM - CATHETER TECHNIQUE AS UTERINE TAMPONADE TO CONTROL EARLY POSTPARTUM HEMORRHAGE

20 October 2006

BACKGROUND
PPH
Major cause of maternal mortality Soetomo Hospital
1st : PE-E (39.7%)

2nd : Infection (21,55%)

3rd : PPH (17,24%)

Time related

Medical Mechanical Surgical

BACKGROUND

Timing of Obstetrical Hemorrhage

Resuscitation : IV, O2, Catheter, Monitor VS

PPH

Access etiology : explore 4T Laboratory test : CBC, Coagulation, Cross match Get help : Obstetrician,Anesthesiologist, Lab, ICU Local control : Man.comp. Ut. Pack, Embolization BP & Coagulation : Cristaloid, Blood product Tone Tissue : massage, compression, drugs : manual removal, curretage : Correct inversion, repair laceration, Ident. rupture

Direct th/

Intractable

Trauma

Thrombin : anticoagulan, replace factor Repair

Surgery

Ligate

Hysterectomy
Abdominal packing Embolization

Post Hysterectomy bleeding

Oxitocyn

Medical

Prostaglandin
Methergin Bimanual Compression

Mechanical

Tamponade

Gauze Balloon

Embolization
Ut (+) : Ligation B-Lynch

Surgical

Square Suture Ut (-) : Hysterectomy

BACKGROUND
Ideal treatment / device?
Efective Widely available Cheap Easy

Tamponade Balloon is superior than gauze

No Concealed Bleeding Better Coverage Atraumatic insertion Fast Simple to place and remove Removal does not cause bleeding Less Infection No spec. skill Ideal ?

PPH
PPH : Vag > 500 cc ; Op > 1000cc

Late >24 h

Early <24 h

Subinvolusion Rest Placentae

Tone Trauma Tissue Thrombin

Medical Mechanical Surgical

CLASS
1 2

Ammount (cc)
900 1200-1500

Loss (%)
15 20-25

Respons
Asimptomatik

3 4

1800-2100 >2400

Tachicardia,tachipneu, weak pulse, ortostatic hipotension 30-35 Tachicardia,tachipneu, hipotension, cold extr. 40 Shock, oligo-uria/anuria

Estimated blood loss is commonly only about half the actual loss ! (Cuningham,2005)

When in shock, the brain, heart, and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs.

 Unpredictable Event
Even in a mother without a single predisposing factor
Tone Tissue Trauma Thrombin

Resuscitation : IV, O2, Catheter, Monitor VS

PPH

Access etiology : explore 4T Laboratory test : CBC, Coagulation, Cross match Get help : Obstetrician,Anesthesiologist, Lab, ICU Local control : Man.comp. Ut. Pack, Embolization BP & Coagulation : Cristaloid, Blood product Tone Tissue : massage, compression, drugs : manual removal, curretage : Correct inversion, repair laceration, Ident. rupture

Direct th/

Intractable

Trauma

Thrombin : anticoagulan, replace factor Repair

Surgery

Ligate

Hysterectomy
Abdominal packing Embolization

Post Hysterectomy bleeding

Balloon Tamponade

Rusch Hydrostatic Urologic Catheter Johanson, 2001

Used in urology for stretching the bladder and for stemming mucosal hemorrhage
2 Successful case report Placentae acreta

SOS BAKRI TAMPONADE

Bakri, et al, Int J Gyne Obstet, 2001 Designed specifically for obstetrical hemorrhage Maximum capacity 800cc of balloon (recommended 250 to 500c) Wider caliber drainage shaft Article describes 5 successful cases with previas It can be placed from above at time of C/S ( not from below )

 Basket, JOGC, 2004 Technique

straight catheter and surgical glove tie at wrist with #1 vicryl insert and fill with 100cc

Shivkars -1981- India

IV set is passed through the condom and is fixed to the condom with a latex rubber band The IV set is connected to the IV bottle as usual and the bottle is hung up on the calibrated IV stand at 60 cm. Neither anesthesia nor sedation is required. The IV flow controller is now released and fluid is allowed to run fast over 1-2 minutes from a 60 cm height above the abdominal level. Usually up to 300cc Brought down to a 25 cm height from the abdomen May be lowered or raised Maintained for approximately 6-8 hours. Vagina should be packed to prevent slipping of the condom. pack is removed usually at the end of 6-8 hours, by bringing the bottle down slowly by 5 cm every 15 minutes

Sayebas - 2003 - Bangladesh

Oxytocin Drip Kept for 6 - 24/48 hrs Deflate gradually Antibiotics coverage A/G/M : 7 days

 Atonic PPH occurs due to failure of living ligatures of uterine muscles to compress the vessels.
Directly compressing the bleeding vessels by hydrostatic pressure Improving the efficiency of failed live ligature by uterine muscle contractions

Mechanism of Action

By allowing sufficient time for resuscitation of the patient, which enables the severely anoxic uterine muscle to recover from tissue anoxia and contract.
The pressure in the capillary system is 21-48 mm of Hg or 28.5-65.5 cm of water. Pressure in intervillous space is 25mm of Hg or 33.9cm of water. Hence the pack stops most of the bleeding except for arteriolar spurters wherein the pack may fail or be less effective

 Advantage over Shivkars

Mobility Less leakage

Disadvantage
Pressure Not Fully controled

Indications
Atonic PPH Coagulation failure Inversion Traumatic PPH

Contraindications
Suspected or diagnosed uterine rupture.

Tamponade Test
SengstakenBlakemore Tube Insert into uterine cavity Filled 70 -300cc NS (+) Bleeding stop and No surgery (-) Bleeding Continue, Surgery needed

Condous J, et al. 2003 16 Px : 14 (+), 2(-)

Condom can hold 7 gallons of water

Average : 3 gallons
Only < 1000 cc needed

Case I
Mrs. Y / 37 th GIIIP2-2, Aterm, PROM ANC : Suwandi Hospital Dilation 2cm, Contraction (-) Termination : Misoprostol 2 x 50 mcg 2nd Misoprostol : Contraction start 4 hrs : Delivered Rapid Labor

/3900/51/6-8

PPH of Atonic Oxytocin and Misoprostol >1500 cc loss Intractable PPH Reffered to Soetomo Hospital Hb : 2,6 g/dL, Thrombocyte : 8000, Shock Medical bleeding Intubated, Explored at the Op. Theater Laceration of labia major and cervix

 Perform Sayebas technique

NS 350 cc Cefotaxim 3 x1 g Oxytocin Drip Methergin 3 x 1

7 Wb 10 TC, Hb : 8,8 g/dL, Thrombo : 105.000 Kept for 48 hrs No sign of infection Discharge at day 5 No menstrual complain

Case II
Mrs. R / 24 th GIP0-0, 36/37 wks, Eisenmenger Syndrome ANC : Soetomo Hospital Congenital Heart Disease : VSD Termination : Elective CS + Tubectomy Hb :13 + 300 cc during operation, Misoprostol 4 tab

/2300/45/7-8

4 hrs post CS : PPH of Atonic Oxytocin and Misoprostol 800 cc loss and continued, Hb : 12,1 Under Ketamin + Dormicum Perform Sayebas technique
NS 350 cc Cefotaxim 3 x1 g Gentamycin 2 x 80 mg Oxytocin Drip Misoprostol

 No Transfusion Kept for 24 hrs

No sign of infection Discharge at day 7 No menstrual complain

Case III
Mrs. S / 39 th GIIP1-1 , Aterm, Gemelli ANC : Midwive Preeclampsia, Lung Oedem I : FE /2400/4-9/8-9 II : Version Extraction /2600/47/6-8 Hb: 11,6 g/dL

2 hrs post partum : PPH of Atonic Oxytocin and Misoprostol > 500 cc loss and continued, Hb : 9,8g/dL Perform Sayebas technique
NS 300 cc Cefotaxim 3 x1 g Oxytocin Drip Misoprostol

 No Transfusion Kept for 48 hrs

No sign of infection Discharge at day 8 No menstrual complain

CASE
Predisposing Case Rapid I Labor Misoprostol Case Eisenmenger II Syndrome Case -Gemeli III -PIH -SM

A TIMING M

CAUSE

Other

Blood Lost (cc) 2800

Hb

Trans fusion

Soon

Tone Shock Trauma Thrombin Tone Vitium cordis Lung Oedem

? - 2,6

7 WB 10 TC -

+ +

2 hr Post CS

800 500

13 -11,5 11,6 9,8

2 hr Tone Post Partum Trauma

CASE
MOD Time NS Duration Antibiotics (mnt) (cc) (hrs) 45 350 48 Cefotaxim Infection Anestesi

Spt Induction El. SC FE Extraction Version

General + intubation Ketamin Dormicum -

20 30

350 300

24 48

Cefotaxim Gentamycin Cefotaxim

Summary
PPH : Great Mother killer Use of Condom as tamponade is highly effective and avoid the surgical need 3 Cases reported with successful result in Dr. Soetomo Hospital 2005 Hopefully contribute to reduce Maternal morbidity and mortality