Description
his is part 3 of your evidence-based practice project.
In this assignment, you will refer back to assignment you completed in week 4, as this assignment will build upon it.
For this assignment, you will re-review your three articles selected from your week 2 and 4 assignment. Then, you’ll write a paper on the following (be sure to include the content from your previous papers in weeks 2 and 4, updating with feedback from your instructor).
For each of the three articles, please discuss the following in your paper:
Research design of the study
Threats to external/internal validity
Potential legal/ethical issues within the article
Data analysis (be sure to elaborate on this more from your paper in week 4, providing specifics about the results)
Implications for evidence-based practice and how this article could be used to make an evidence-based change
Conclusion/summary of the evidence
Remember to support your ideas with the articles you found. These articles should be less than five (5) years old. They should not be from the Web, but from the library databases, and be sure to use a narrative format.
In addition, you must follow APA guidelines, providing a title page, reference page, appendix, and in-text citations, as well as use level headings to match the assignment criteria listed above.
Please use, at minimum three scholarly references, and your paper should be 500-700 words, excluding title and reference pages.
Leila, M., Jestine, M., Dara, J., Neher, J. O., & Safranek, S. (2023). Preventing Postpartum Hemorrhage. American Family Physician, 107(5), 539. https://prx-herzing.lirn.net/login?url=https://www.proquest.com/scholarly-journals/preventing-postpartum-hemorrhage/docview/2813569590/se-2
Choi Wah Kong, & William Wing Kee To. (2021). The Discriminant Use of Intrauterine Balloon Tamponade and Compression Sutures for Management of Major Postpartum Hemorrhage: Comparison of Patient Characteristics and Clinical Outcome. BioMed Research International, 2021, 1–9. https://doi.org/10.1155/2021/6648829
Wei, L., Yang, H., & Sun, X. (2022). The Effect of Oxytocin plus Carboprost Methylate in Preventing Postpartum Hemorrhage in High-Risk Pregnancy and Its Effect on Blood Pressure. Evidence-Based Complementary and Alternative Medicine, 2022. https://doi.org/10.1155/2022/9878482
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BioMed Research International
Volume 2021, Article ID 6648829, 9 pages
https://doi.org/10.1155/2021/6648829
Research Article
The Discriminant Use of Intrauterine Balloon Tamponade and
Compression Sutures for Management of Major Postpartum
Hemorrhage: Comparison of Patient Characteristics and
Clinical Outcome
Choi Wah Kong
and William Wing Kee To
Department of Obstetrics and Gynaecology, United Christian Hospital, Hong Kong
Correspondence should be addressed to Choi Wah Kong; melizakong@gmail.com
Received 5 October 2020; Revised 11 December 2020; Accepted 15 December 2020; Published 2 January 2021
Academic Editor: Renato T Souza
Copyright © 2021 Choi Wah Kong and William Wing Kee To. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Background. Intrauterine balloon tamponade (IUBT) and compression sutures have been widely used in recent years in the
management of postpartum hemorrhage (PPH). However, there is scant literature directly comparing the clinical scenarios that
led to the discriminant selection of these management modalities and the direct clinical outcomes. The purpose of this study is
to compare the patient characteristics and clinical risk factors that led to the use of IUBT and compression sutures in the
management of major PPH as well as the immediate outcome in a retrospective cohort. Methods. Patients who had IUBT or
compression sutures applied due to major PPH (>1000 ml) from 2014 to 2018 in a single obstetric unit were recruited. The
patient characteristics and clinical outcome of the two groups were compared. Results. A total of 67 patients had IUBT and 29
patients had compression sutures applied as the first uterine sparing technique. Apart from more vaginal deliveries (25.4% vs.
3.5%) in the IUBT group compared to compression sutures, there were no significant differences between the two groups in
terms of patient characteristics. The IUBT group had a slightly higher blood loss at the start of the uterine sparing procedure
(239 ml, p = 0:049) and received more transfusions, despite no differences in the total blood loss, hemogloblin level, incidence of
coagulopathy, and intensive care unit admission between the two groups. There was no significant difference in the overall
success rate between IUBT and compression sutures to control PPH without additional surgical intervention or hysterectomy
(73.1% vs. 55.1%, p = 0:15) or the success rate for PPH due to uterine atony (32.8% vs. 20.7%), though IUBT apparently
performed better than compression sutures in cases of placenta praevia (77.3% vs. 16.7%, p = 0:01). Blood loss > 1:5 l at the start
of the procedure, presence of placenta accreta, and presence of coagulopathy were found to be significant poor prognostic
factors for both procedures to control PPH. Conclusions. There were no dominating patient characteristics that favoured the
selection of either IUBT or compression sutures in the management of severe PPH except for the mode of delivery. Both
procedures had equally high overall success rates to control PPH, but IUBT performed better in placenta praevia cases as
compared to compression sutures.
1. Introduction
Postpartum hemorrhage (PPH) is one of the leading causes
of maternal mortality. The basic treatment of PPH consists
of medical management by uterotonic drugs such as oxytocin, and prostaglandin or their analogues. Traditionally, peripartum hysterectomy would be performed in patients with
massive PPH who failed medical treatment. Various uterine
sparing procedures have been developed in recent years to
reduce the need for hysterectomy, including intrauterine balloon tamponade, uterine compression sutures, selective
devascularization by surgical ligation, or radiological embolization of the uterine and pelvic arteries [1–3]. In recent
decades, these second-line conservative surgical procedures
have been gradually incorporated into protocols for severe
PPH management [4].
2
The first case report of uterine compression sutures was
published in 1996 with a single patient from Zurich [5]. BLynch et al. published a case report of five consecutive cases
utilizing the B-Lynch suture in 1997 [6]. Various modifications of the B-Lynch suture and various other compression
suture techniques have been reported since then. However,
the B-Lynch suture remained the most widely performed
suture among all the compression sutures [7]. On the other
hand, the intrauterine balloon tamponade had been
attempted for years using Foley catheters, SengstakenBlakemore balloons, or other adaptations. Bakri advocated
the use of a uterine-specific silicone Bakri balloon since
2001. From then on, the Bakri balloon and other uterinespecific balloon tamponade systems had been widely used
as second-line management for PPH.
So far, there were no randomized control trials to directly
compare the efficacy of the two treatment modalities in the
literature. Understandably, such trials were considered
impossible or impractical under the dire circumstances of
severe postpartum hemorrhage, and the discriminant use of
either modality of management is usually dependent on the
preference and experience of the attending obstetrician. This
study is aimed at comparing the clinical characteristics and
risk factors of patients with major PPH undergoing these
two widely performed second-line procedures to delineate
any significant differences in patient selection, as well as their
immediate clinical outcome.
2. Materials and Methods
This study consisted of a retrospective cohort of all patients
with major PPH > 1000 ml from 2014 to 2018 (5-year
period) in a single obstetric-training unit. PPH was managed in accordance with a standard protocol, starting with
various oxytoxic agents including syntometrine, syntocinon
bolus and infusion, and carboprost injections. When medical treatment failed to control hemorrhage, second-line
conservative procedures by either IUBT or compression
sutures would be used depending on the clinical situation
and attending obstetrician’s preference and experience.
The amount of blood loss was quantified by measuring
the blood loss in the suction bottle and weighing the
abdominal pads and gauzes intraoperatively. The Bakri balloon was the only balloon tamponade system used in our
unit during the study period. The procedure for application
of the Bakri balloon was in accordance with that generally
described in the literature [3, 8]. The Bakri balloon can be
placed transvaginally through the cervix or transabdominally through the caesarean uterine wound depending on
the route of delivery and as decided by the attending obstetrician. The B-Lynch suture was the only compression
suture technique adopted in our unit during the study
period and was performed largely as originally described
by B-Lynch in 1997 [6]. Patients who failed medical treatment were categorized according to the first attempted
uterine sparing technique (intention to treat analysis).
Patients’ clinical risk factors, aetiology of PPH, and the
amount of blood loss at the time of utilization of these
treatment modalities were compared. Outcomes were then
BioMed Research International
categorized as successful (when no additional interventions
were required), as additional procedures (when additional
uterine sparing procedures including intrauterine balloon
tamponade, compression sutures, radiological uterine arterial embolization, or surgical pelvic devascularization were
required in addition to the primary procedure employed),
and as hysterectomy (when hysterectomy was required).
Secondary outcome parameters include total blood loss,
coagulopathy, need for blood product transfusion, intensive
care unit admission, need for relaparotomy, or other serious
maternal complications or death. Secondary analysis was
performed to evaluate the efficacy of IUBT and compression
sutures performed in accordance with the major indications
of PPH, namely, uterine atony or placenta praevia/accreta.
Those with direct hysterectomy without attempting uterine
sparing techniques were excluded from analysis. Those in
which the uterine sparing procedures were applied in a
prophylactic manner with total blood loss < 1000 ml were
excluded from analysis.
Based on our previous audit data, around 75% of all
patients with severe PPH were delivered by CS with 25% by
vaginal delivery, and the aetiology of PPH was uterine atony
in around 66.7% and nonatonic causes in the rest. Using the
mode of delivery and aetiology of PPH as the key discriminating factors and assuming the correlation between the
choice of procedure and either of these factors to be 40%, a
sample size of around 69 and 49, respectively, would be
required using a two-sided test at 5% significance level test
(α = 0:05) with power 80% (β = 0:2). Similarly, assuming
around 70% of patients would undergo IUBT and 30% would
have compression sutures, a sample size of around 90 would
be required to show a difference in success rate of around
30% between the two procedures using a two-sided test at
similar significance level and power. With an average severe
PPH rate estimated at around 1.5%, it was therefore decided
that an analysis of all patients with severe PPH over a fiveyear period should provide a sufficient sample.
The obstetric data of all the above patients with PPH were
identified from a comprehensive obstetric database. The electronic and paper records of these identified cases were then
studied in detail. The SPSS for Windows package was used
for data entry and analysis. Continuous variables were analyzed by t-test and discrete variables by chi-square test or
Fisher’s exact test when appropriate. A binary logistic regression model using the enter technique was constructed to
evaluate the prognostic factors for success by including
parameters found to be significant on univariate analysis. A
p value of less than 0.05 (p < 0:05) was considered statistically
significant. Ethical approval for this study was granted by the
Kowloon Central/Kowloon East Ethics Committee Board of
the Hospital Authority, Hong Kong. As this study was a retrospective review of patient outcome, patient consent was
waived by the Ethics Committee Board.
3. Results
There were a total of 20608 deliveries in the study period. The
incidence of PPH (>500 ml) was 1529/20608 (7.4%) while the
incidence of major PPH (>1000 ml) was 287/20608 (1.4%).
BioMed Research International
3
20608 women
(from year 2014–2018)
287 (1.4%) had major PPH
(Blood loss > 1000 ml)
189 (65.9%)
had medical treatment by
uterotonic agents only
49 (73.1%)
success
(no further
procedures)
7 (10.5%)
partial success
(had additional
uterine sparing
procedures)
4 had compression
sutures
3 had UAE
67 (23.3%)
had IUBT
11 (16.4%)
failure
(need hysterectomy)
2 had compression sutures
+hysterectomy
4 had UAE+hysterectomy
5 had hysterectomy
29 (10.1%)
had compression sutures
16 (55.1%)
success
(no further
procedures)
7 (24.1%)
partial success
(had additional
uterine sparing
procedures)
2 had IUBT
3 had UAE
2 had internal iliac
artery ligation
2 (0.7%)
had direct
hysterectomy
6 (20.7%)
failure
(need hysterectomy)
1 had IUBT+hysterectomy
1 had UAE+hysterectomy
4 had hysterectomy
Figure 1: The treatment modalities that were adopted for the women with major postpartum hemorrhage in this cohort. PPH: postpartum
hemorrhage; IUBT: intrauterine balloon tamponade; UAE: uterine artery embolization.
Among those with major PPH, 189 (65.9%) were successfully
managed by medical treatment alone, 67 (23.3%) had IUBT
as the first uterine sparing technique after failed medical
treatment, and 29 (10.1%) had compression sutures as the
first uterine sparing technique while 2 (0.7%) had direct hysterectomy performed without attempting any uterine sparing
procedures. The results are shown in Figure 1.
Comparing patient characteristics, there were no differences in the maternal demographic data such as maternal
age, parity, and gestation at delivery between the IUBT
group and the compression suture group. There was also
no difference in the aetiology of PPH in the start of the
uterine sparing procedure between the two groups. There
were more vaginal deliveries in the IUBT group while there
were more CS deliveries in the compression suture group.
As the use of compression sutures would require additional
laparotomy in these patients after vaginal deliveries, IUBT
would logically be preferred as the first uterine sparing
technique instead of laparotomy. There were more twin
pregnancies in the IUBT group, despite the fact that all
were delivered by CS, but the difference was not statistically
significant. The blood loss at the start of the uterine sparing
procedure was higher in the IUBT group compared with
the compression suture group (1305 vs. 1117 ml, mean difference 239 ml, p = 0:049), while the rate of transfusion of
blood products in the IUBT group was also higher than
that in the compression suture group, despite there being
no differences in the total blood loss, lowest hemogloblin
level, incidence of coagulopathy, and intensive care unit
admission between the two groups (Table 1).
For the group having IUBT as the first uterine sparing
technique, the success rate was 73.1% (49/67) with the bleeding controlled without further surgical intervention, while
10.5% (7/67) required additional uterine sparing procedures,
and 16.4% (11/67) required hysterectomy. For the group
having compression sutures as the first uterine sparing technique, the success rate was 55.1% (16/29), additional procedures were required in 24.1% (7/29), and hysterectomy was
required in 20.7% (6/29). Specifically, in the IUBT group,
concurrent compression sutures were applied in 3 cases,
and similarly, in the compression suture group, IUBT was
also applied simultaneously in 3 cases, so that in total, 6 cases
underwent the “sandwich” procedure. There were no statistically significant differences between the success rate, need for
additional procedures, and hysterectomy between the two
groups (p = 0:15) for all severe PPH cases, as well as for
PPH due to uterine atony (p = 0:09). However, IUBT apparently performed better than compression sutures for placenta
praevia/accreta cases when analyzing the overall success rate
(17/22, 77.3% vs. 1/6, 16.7%, p = 0:01) (Table 2).
Within the cohort, five women were diagnosed with placenta accreta prenatally while one had placenta accreta diagnosed intraoperatively during CS. All of them had a balloon
tamponade inserted, but only one of them was successfully
managed with the balloon tamponade; the other five women
finally required hysterectomy (including the woman having
placenta accreta diagnosed intraoperatively). Placenta
accreta was confirmed in all five women who underwent hysterectomy on subsequent histopathological examination of
the uterus.
Evaluating the risk factors for need for additional procedures and hysterectomy after use of either IUBT or compression sutures, blood loss > 1:5 l at the start of the procedure,
presence of placenta accreta, and presence of coagulopathy
were found to be significant in univariate analysis as well as
after logistic regression analysis (Tables 3 and 4).
4
BioMed Research International
Table 1: Comparison of the characteristics between women treated with IUBT and those treated with compression sutures.
IUBT (n = 67)
Compression sutures (n = 29)
Age
33.3 (SD 4.3)
33.2 (SD 4.7)
Advanced maternal age (age ≥ 35)
Parity
Nulliparous
Multiparous
29 (43.2%)
11 (37.9%)
33 (49.2%)
34 (50.8%)
13 (44.8%)
16 (55.2%)
Gestation at delivery
38.2 (SD 1.7)
38.07 (SD 1.7)
p value
0.92; MD 0.09
(CI -1.87 to 2.05)
0.39
0.43
0.74; MD 0.12
(CI -0.64 to 0.88)
Preterm delivery < 37 weeks
3 (4.5%)
3 (10.3%)
0.25
Multiple pregnancy
Previous CS
One previous CS
Two previous CS
Mode of delivery
9 (13.4%)
2 (6.9%)
0.59
7 (10.4%)
3 (4.5%)
5 (17.2%)
1 (3.5%)
0.64
Normal vaginal
17 (25.4%)
1 (3.5%)
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