Professional Documents
Culture Documents
102..107
Takako Ishii1, Kenjiro Sawada1, Shunsuke Koyama1, Aki Isobe1, Atsuko Wakabayashi1,
Tsuyoshi Takiuchi1, Takeshi Kanagawa1, Takuji Tomimatsu1, Kazuhide Ogita2 and
Tadashi Kimura1
1
Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, and 2Department of
Obstetrics and Gynecology, Rinku General Medical Center, Izuminsano, Osaka, Japan
Abstract
Aim: Severe post-partum hemorrhage during cesarean section due to placenta previa is still one of the leading
causes of maternal mortality. The aim of this study was to evaluate the efficiency of intrauterine tamponade
with a Sengstaken-Blakemore tube (SB-tube) for the treatment of severe post-partum hemorrhage in cases of
placenta previa.
Material and Methods: Data were collected from our departmental clinical records on all patients who
underwent caesarian section due to placenta previa between 2007 and 2009.
Results: During the period analyzed, 37 patients underwent caesarian section due to placenta previa/lowlying placenta. Four (11%) underwent hysterectomy due to placenta accreta and 33 (89%) were treated
conservatively. Of the 33 patients with conserved uterus, 10 (28%) patients required a SB-tube during the
cesarean section because of continuous post-partum hemorrhage despite appropriate medical treatment. The
median bleeding during the operation was 2030 860 mL in the patients who used SB-tube. None of them
presented severe complications related to these procedures or required any further invasive surgery.
Conclusion: Intrauterine balloon-tamponade could successfully control severe hemorrhage from a lower
uterine segment of a patient with placenta previa. This technique is simple to use, scarcely invasive, and
available at a low cost to all maternity wards, and should be considered as one of the first management options
to reduce the risk of undesirable hysterectomy.
Key words: balloon-tamponade, cesarean section, placenta previa, post-partum hemorrhage, SengstakenBlakemore tube.
Introduction
The incidence of placenta previa at the time of birth
varies widely in published series, but on average it
occurs once in every 150250 live births. Obstetrical
bleeding (intrapartum/post-partum) secondary to placenta previa with variable degrees of accretion is not
uncommon. Post-partum bleeding is usually from the
placental bed at the lower uterine segment and occurs
immediately after the placenta is delivered. Although
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Methods
Between January 2007 and December 2009, there were
1731 deliveries in the Perinatal Medical Center of
Osaka University Hospital (Osaka, Japan). Of these, 37
(2.1%) underwent caesarian section due to placenta
previa/low-lying placenta. All were Asian, aged
2741 years and from a middle-class community in
Osaka or Hyogo prefecture in Japan. Since our unit
accepts high-risk pregnant women who can not be
treated in usual neighborhood hospitals, the percentage of placenta previa/low-lying placenta was relatively high. Placenta previa was diagnosed by
transvaginal ultrasonography in late pregnancy and it
was confirmed that the placental edge overlapped the
internal cervical os just before the operation. Low-lying
placenta was diagnosed when the distance of the pla-
103
104
No
No
No
No
Yes
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
No
Yes
Yes
RCC 8U
None
RCC 6U
None
None
None
None
None
None
None
120
56
121
40
170
40
320
140
125
125
3160
1000
3220
1300
1500
1700
1360
1450
2830
2780
5 min
1 min
2 min
4 min
4 min
8 min
5 min
4 min
6 min
2 min
Previa totalis
Previa totalis
Previa totalis
Previa totalis
Previa totalis
Low lying placenta
Previa totalis
Previa totalis
Low lying placenta
Previa totalis
RCC, red cell concentrate.
G4P0
G2P1
G5P4
G2P0
G2P0
G1P0
G2P0
G2P1
G1P0
G2P1
37
30
34
34
35
29
37
37
36
34
1
2
3
4
5
6
7
8
9
10
37w0d
36w1d
36w3d
34w6d
36w3d
37w3d
36w5d
36w6d
37w0d
36w0d
Antibiotics
after operation
Transfusion
Drainage
blood
loss (mL)
Estimated
blood
loss (mL)
Duration between
baby delivery and
placenta delivery
Position of
placenta
Gestation
Gravidity
and parity
Age
(y)
Case
No.
Result
Table 1 Summary of clinical outcomes of the patients who used Sengstaken-Blakemore tube
Postoperative
fever
T. Ishii et al.
Table 2 The summary of clinical outcomes of the cases of cesarean section due to placenta previa
Number
Age (y)
Previous cesarean section
Previous myomectomy
Estimated blood loss (mL)
Uterine artery embolization required
Transfusion
Postoperative fever
SengstakenBlakemore tube
Rolled
gauze
No
treatment
Hysterectomy
required
10
34.3 2.8
0/10
1/10
2030 860
0/10
2/10
2/10
17
33.7 5.2
2/17
1/17
2241 1378
1/17
3/17
8/17
6
35.0 2.4
1/6
0/6
935 271
0/6
0/6
1/6
4
35.3 4.0
4/4
0/4
3300 1764
N.A.
3/4
2/4
Age
(y)
Gravity and
parity
Previous
CS
Gestation
Prenatal
diagnosis
Estimated
blood loss (mL)
Transfusion
required
Pathological
diagnosis
1
2
3
4
31
37
40
33
G2P1
G4P3
G4P2
G3P1
1
2
2
1
35w2d
35w4d
36w0d
35w3d
Yes
No
Yes
Yes
2900
5000
4300
1000
RCC 4U
RCC 8U FFP 8U
RCC 8U
None
Placenta percreta
Placenta accreta
Placenta accreta
Placenta increta
Estimated blood loss during the initial cesarean section. CS, cesarean section; FFP, fresh frozen plasma; RCC, red cell concentrate.
operation day, transcatheter angiographic uterine arterial embolization was conducted with gelatin sponge
particles and platinum coils; one week later, total hysterectomy was carried out. In Table 3, the blood loss
during the initial cesarean section was shown. In case 2,
although the placenta was partially separated spontaneously, the other part of placenta was tightly attached to
the uterine wall and massive bleeding occurred. Since
the operator considered it was not possible to control
bleeding, the hysterectomy was emergently performed.
Discussion
Post-partum hemorrhage in cases of placenta previa
remains a serious obstetric complication. Successful
control of bleeding can often be achieved medically
using uterotonics including oxytocin, ergometrine,
15-methyl prostaglandin F2a and misoprostol.9
However, once these medical treatments fail, it is often
necessary to intervene surgically with uterine or internal iliac ligation, uterine compression sutures or hysterectomy. When dealing with young women who may
wish to have more children, the cesarean-hysterectomy
without delay, resulting in devastating emotional
and/or cultural consequences, should be avoided
wherever possible.12 Actually, in our reports, six
women were nulliparas and all 10 cases who used
SB-tube strongly wished to preserve fertility.
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T. Ishii et al.
While a variety of surgical techniques have been proposed to avoid hysterectomy, a suitable conservative
technique is still lacking in the literature and all the
advantages shown by the proposed options are counterbalanced by some risks.2 Herein, we described that
not only uterine gauze packing but uterine balloon
tamponade with a SB-tube showed similarly high efficacy in controlling PPH originating from the placental
site of the lower uterine segment during caesarian sections. Historically, the use of uterine gauze packing in
the management of PPH fell into disfavor after the
1960s, following concerns of concealing ongoing hemorrhage, development of infection and its nonphysiological approach.13 Condous et al. commented,
based on their experiences, that uterine packing with
gauze packs is outdated and should only be reserved in
cases when a balloon catheter is unavailable.10 Control
of PPH by uterine balloon packing itself is not a new
idea. Although some of the balloons, such as the Rusch
balloon and the condom catheter, are reported to be
effective,14 they do not allow blood drainage from the
uterine cavity. On the contrary, in SB-tube system, the
blood drainage is collected through the distal end of
the shaft by attaching a collection bag. This drainage
system helps prevent blood collection inside the
uterine cavity and provide an accurate estimation of
bleeding. Besides, if the procedure fails to stop the
bleeding, the failure is immediately visible, as opposed
to the use of the conventional balloons as tamponade.
With these reasons, we consider SB-tube system to be
superior to the other treatment options such as rolled
gauze or the conventional balloon.
Reports are accumulating suggesting that methods
of uterine tamponade are effective to avoid hysterectomy in frequently unstable patients and can preserve
fertility, especially in the case of severe PPH secondary
to uterine atony.15 A recent American College of Obstetricians and Gynecologists practice bulletin suggests
that tamponade of the uterus can be an effective way to
decrease hemorrhage secondary to uterine atony, and
procedures such as uterine artery ligation or B-Lynch
suture may be used to obviate the need for hysterectomy. Furthermore, it is suggested that if hysterectomy
is performed for uterine atony, there should be documentation of these therapies attempts.16 On the other
hand, the use of a balloon tamponade in severe PPH
due to placenta previa has been reported only in a
small series of a few cases. Bowen et al. reported the
first attempt to archive hemostasis in case of PPH complicated by placenta previa by compression using a
Foley catheter.17 Bakri et al. used a self-made original
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Acknowledgments
This work was supported in part by a Grant-in-Aid for
scientific research from the Ministry of Education,
Science, Sports and Culture of Japan. The authors are
grateful to Remina Emoto and Ayako Okamura for
their secretarial assistance.
References
1. Maier RC. Control of postpartum hemorrhage with uterine
packing. Am J Obstet Gynecol 1993; 169: 317321; discussion
2123.
2. Zaki ZM, Bahar AM, Ali ME, Albar HA, Gerais MA. Risk
factors and morbidity in patients with placenta previa accreta
compared to placenta previa non-accreta. Acta Obstet Gynecol
Scand 1998; 77: 391394.
3. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum
hemorrhage: What to do when medical treatment fails. Obstet
Gynecol Surv 2007; 62: 540547.
4. Condie RG, Buxton EJ, Payne ES. Successful use of
Sengstaken-Blakemore tube to control massive postpartum
haemorrhage. Br J Obstet Gynaecol 1994; 101: 10231024.
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