Evidence Gaps in the Management of Intrauterine Hemorrhage-Control Device Failure for Atonic Postpartum Hemorrhage.

IMPORTANCE

Intrauterine hemorrhage-control devices are key second-line therapeutic interventions for refractory postpartum hemorrhage (PPH) due to uterine atony. Less is known about the detection and clinical management of failure of 2 commonly used devices: intrauterine balloon tamponade, in particular the Bakri device, and the Jada device (a vacuum-induced hemorrhage control device).

OBJECTIVE

This narrative review describes the epidemiology and management challenges of the failure of intrauterine balloon tamponade and the Jada device.

EVIDENCE ACQUISITION: Original research, review articles, and PPH guidelines.

RESULTS

Unsuccessful arrest of bleeding requiring invasive intervention is 11-12% for intrauterine balloon tamponade, and 7.5% among vaginal deliveries using the Jada device, and 16.3% among cesarean deliveries using the Jada device. Rates of transfusion and hysterectomy in patients who receive intrauterine balloon tamponade are 36% and 6%, respectively. Patients' risk of intrauterine hemorrhage-control device failure may not be easily determined prior to device placement. There is a paucity of information in national and international PPH guidelines for the detection and management of intrauterine hemorrhage-control device failure. For intrauterine balloon tamponade, caudal prolapse or balloon sliding into the vagina can occur in 10-15% of cases, and the risk of hemorrhage-related morbidity is associated with balloon volume >350 mL. Point-of-care hemodynamic and hemostatic monitors can provide early warning signs of ongoing hemorrhage and maternal compromise when a diagnosis of intrauterine hemorrhage control device failure is delayed or missed.

CONCLUSIONS AND RELEVANCE: Expert consensus is needed to develop device-specific criteria for the diagnosis and early management of intrauterine hemorrhage-control device failure.