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BackTable / OBGYN / Article
Postpartum Hemorrhage Management Guide
Taylor Spurgeon-Hess • Updated Aug 27, 2023 • 109 hits
Postpartum hemorrhage management varies based on the underlying cause, patient risk factors, and condition severity. There are medications for postpartum hemorrhage, balloon tamponade (Bakri), Jada system, interventional radiology referrals, and invasive operations. Maternal Fetal Medicine (MFM) specialists, Drs. Roxane Rampersad and Tony Shanks, explain how they work through their process for postpartum hemorrhage management without compromising a patient's fertility when possible.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable OBGYN Brief
• To manage postpartum hemorrhage conservatively with medication, oxytocin can be administered to promote uterine contraction. Other medications for postpartum hemorrhage options include misoprostol, methylergonovine, carboprost, or TXA (if bleeding persists).
• The Bakri balloon is a balloon tamponade device designed for use in the uterus to manage postpartum hemorrhage. After insertion, the Bakri is inflated with 300 to 500 ccs of saline which helps to tamponade the uterus and prevent blood loss while still preserving a woman’s fertility.
• If other interventions fail, hemodynamically stable patients may be sent to the interventional radiology suite for further treatment. IR doctors should take caution if the patient was recently given TXA, as it can create issues with thrombus induction.
• Hemodynamically unstable patients who are hypotensive or have abnormal vitals will likely be sent to the operating room for further treatment. Operative procedures may include a hysterectomy or a B-Lynch suture with hypogastric vessel ligation.
Table of Contents
(1) Conservative Postpartum Hemorrhage Management
(2) Utilizing the Bakri Balloon For Postpartum Hemorrhage
(3) Triaging Postpartum Hemorrhage Patients to Interventional Radiology or the Operating Room
Conservative Postpartum Hemorrhage Management
When possible, postpartum hemorrhage management should remain conservative as more intensive management strategies often come with increased risk to the mother. While a number of events can result in postpartum hemorrhage, an atonic uterus most commonly causes this condition. The first-line medication for postpartum hemorrhage is oxytocin, which helps to prevent bleeding by contracting the uterus. Other medications for postpartum hemorrhage include misoprostol, methylergonovine, and carboprost. After three hours of ongoing bleeding, tranexamic acid (TXA), a fibrinolytic inhibitor, may be administered in an attempt to promote coagulation.
[Dr. Christopher Beck]
Once you know you have postpartum hemorrhage, you're working through your differential. I think it's easiest to talk about an atomic uterus. By far and away, the most common. We talked about starting oxytocin. We talked about the other medications that you have potentially at your disposal. Can you talk about what other options that you have, or at least let's talk about first, the conservative side like what you're doing for conservative management, and then what you're thinking of in terms of getting this patient ready for escalated level of, I don't know, care or treatment. Do you know what I mean by this?
[Dr. Anthony Shanks]
I'd love to hear your opinions on this, Roxane. We're blowing past the atonic uterus. We've gone through our medication algorithms. What are you guys doing next?
[Dr. Roxane Rampersad]
In my mind, the things I'm thinking about is what stage of hemorrhage I am and what the medications I'm going to need, and potentially what other, I think, actions I need to get done. If we start with the medications like you mentioned, Tony, and I'm not getting any response and I have ongoing bleeding, then I'm going down in my head, "What else am I supposed to do?"
The next thing for me to do in addition to the medications that we use to make the uterus more contractile that I'm thinking about TXA, the addition of TXA to help. Then if TXA is not helping, I'm thinking about tamponade, so introducing balloon tamponade, the uterus. Tamponade, the sites that are bleeding inside the uterus. For us, that's a Bakri balloon.
[Dr. Christopher Beck]
Roxane, I'm sorry to interrupt, but I don't know what TXA is. I suspect a couple of other people don't.
[Dr. Roxane Rampersad]
Yes, so that's tranexamic acid.
[Dr. Christopher Beck]
Okay, got you.
[Dr. Roxane Rampersad]
We use it not only in the OB world but also in the GYN world. When a hysterectomy is with ongoing bleeding, we can use TXA. GYN is not my world anymore. Tony, remind me. I think people also use TXA for heavy menstrual bleeding, don't they?
[Dr. Anthony Shanks]
Yes. In terms of how it actually works, it prevents that fibrinogen getting broken down by plasminogen. It works on that coagulation pathway. Technically, you can make these people hypercoagulable with that. There is a lot of studies that come out with TXA. I think people use it for the postpartum hemorrhage after three hours if you're still having ongoing bleeding.
I have come across in preparing for this talk. They have had some studies where they've done it prophylactically as part of bundles for people that they're anticipating being at risk and that they may show some potential benefits. I suspect that we'll continue to see more studies with TXA. I wanted to hear, Roxane, about the Bakri balloon because I mentioned to her. We're doing something called Jada at our institution. Tell us what the Bakri is, Roxane.
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Utilizing the Bakri Balloon For Postpartum Hemorrhage
If medications fail to stop the bleeding in postpartum hemorrhage, obstetricians often turn to balloon tamponade for treatment. Generally, balloon tamponade offers patients a minimally invasive option to control their bleeding and can be applied in a variety of cases bodywide. The Bakri balloon is specifically designed for the uterus and for postpartum hemorrhage management. The balloon is introduced into the uterus and inflated with 300 to 500 ccs of saline. After sitting for 12-24 hours, the Bakri should have helped to tamponade the bleeding sites and achieve homeostasis to decrease blood loss. Unlike other invasive options, this technique preserves fertility in patients.
[Dr. Roxane Rampersad]
Bakri is essentially a balloon. Think about it as a big Foley catheter, but larger, and we can instill 300 to 500 ccs in that Bakri balloon. We introduce it into the uterus and then we instill fluids to inflate that balloon. It sits there for somewhere between 12 and 24 hours tamponading those sites, trying to achieve hemostasis and to decrease blood loss. This is great because the Jada is something new and it's a little bit different in terms of mechanism. We don't actually use it yet at our institution, but we're waiting.
We're waiting to introduce it and to potentially study it because I think one of the things is that it was recently FDA-approved, but we don't really have any studies in terms of comparison. Does it work better than the Bakri? Is the Bakri better? Because I think the Bakri is more cost-effective in terms of price. I think we don't have those studies yet. We are going to introduce that. Tony, do you have it at your institution?
[Dr. Anthony Shanks]
Yes, we do. We've done training with it. The difference is with a Bakri, it's just a balloon that you put in and fill up with saline. Again, like we're always thinking about, we want to minimize going back to these complicated surgeries if you can avoid it. Certainly, we always think about people preserving their fertility. Bakri is just a bigger balloon that goes inside the uterus. You blow it up.
It's nice because you can watch the amount of blood that's coming through to know if you're still having ongoing bleeding. Eventually, after a certain amount of time, 24 hours what I've done in the past, you deflate and you can take it out. The concept of the Jada is if you're thinking about an atonic uterus, you're placing in something, a foreign body, and blowing it up.
It sounds maybe a little counterintuitive. If you're going to explain something to an engineer and say, "What would you actually do to get a uterus to clamp down? Would blowing it up be the way to do it?" That was the concept of the Jada, which is, essentially, it's going to use pressure suction to keep things down. You have to insert this device. I don't really have anything around here on my desk that looks like it, but it's a small--
[Dr. Christopher Beck]
Most people won't be able to see the desk anyway.
[Dr. Anthony Shanks]
Well, a prepared obstetrician would have had something, but you can place it into the uterus and you actually have to hook it up to wall suction. There's metrics that they use to do that. It's been successful when we've done it, but Roxane's right. It's newer, so it doesn't have the studies behind it. Personally, I think it makes intuitive sense. I think just having more options for things that can work would be good because you want to try to avoid some of these certainly hysterectomies and other invasive things.
[Dr. Roxane Rampersad]
Right, because that's where we're going, right? If the medications don't work and tamponade doesn't work is we're taking the patient either to the interventional radiology suite or we're going to the operating room. That's our next big, I think, decision is where we're going.
Triaging Postpartum Hemorrhage Patients to Interventional Radiology or the Operating Room
When physicians exhaust all conservative options for postpartum hemorrhage management, the decision must be made to send the patient to either the interventional radiology suite or the operating room. Hemodynamically stable patients can often be sent to the interventional radiology suite. Interventional radiologists should be aware of their institution's management algorithms as previous administration of TXA can create issues with thrombus induction. For hemodynamically unstable patients with increased blood loss or abnormal vital signs, obstetricians often choose the operating room. Operative maneuvers include performing a hysterectomy or a B-Lynch suture with hypogastric ligation. The latter involves compressing the uterus on itself and ligating the uterine arteries. Ultimately, different institutions have varying resources when it comes to IR suites and operating rooms, so patient care will reflect each physician’s comfort and access level.
[Dr. Christopher Beck]
Sure. One of the things I want to talk about with TXA just for some of the IR listeners, TXA is something to keep on your radar if your institution uses it or it's part of their algorithm. If you do end up taking a patient back and you're going to be working in the blood vessels knowing the patient is on TXA can create issues with basically inducing thrombus in areas that we don't want to put it there, so we go in femoral access or radial access. TXA makes people hypercoagulable.
You can have more clot formation in areas you do not want the clot. Now, we're getting to the point where either the balloons aren't working, the meds aren't working, and you're now at a point where you either have to take them back to the OR or you take them back to the IR suite. What's going on in your head as to how patients get triaged to different spots? Just because you're going to the operating room doesn't mean it's hysterectomy, right? There are some other maneuvers you can do, but will you talk about how that decision tree happens?
[Dr. Roxane Rampersad]
I'll tell you, for me, what allows me to decide whether the patients go into the IR or the operating suite is really the amount of blood. Persistent bleeding in someone that's hemodynamically stable, I'm going to take that patient to the interventional radiology suite. If that patient is not hemodynamically stable, they're unstable and they have more brisk bleeding, their vital signs are abnormal, they're hypotensive, then I'm going to the operating room and I'm going to think about more operative maneuvers.
You mentioned there are other things besides hysterectomy. A B-Lynch suture is one of those things that we can do. Essentially, we're compressing the uterus on itself to try to stop the bleeding. We can sometimes ligate the vessels, the uterine arteries going to the uterus, or we can ligate a little bit higher. A hypogastric ligation is the next thing. Then if those things are not working and bleeding ensues and that patient becomes unstable and it's becoming coagulopathic from that blood loss, then we're thinking about hysterectomy is my mind. Tony, what do you think?
[Dr. Anthony Shanks]
I think the word that you mentioned about stability is the big one. We would never want to send a hemodynamically unstable patient off the floor to interventional radiology where they cannot be surgically reopened quickly. I think that would probably be the unsafe thing to do. That's reserved for the person that has maybe that persistent low-level bleed. If you have a Bakri balloon and you continue to see blood come out, the patient's vital signs are otherwise stable, but you're not really addressing the bleeding.
That's a good person for that. I also think certainly C-sections. If you have a complicated C-section and they're hemodynamically unstable, going back in, seeing where you actually closed off your hysterotomy, that makes sense because sometimes you can have those extensions and that's where you're bleeding from. Not necessarily hysterectomy, but just reapproximating those areas first.
[Dr. Christopher Beck]
One of the things I want to dig in on though is you guys are super high-level operators at big institutions, do a lot of those work, but not every OBGYN is created equal or not all resources available. Just not every IR is created equal, not every OBGYN is created equal. Can you speak to that a little bit? Are there some operators who would feel uncomfortable with unstable patients? Sometimes I'll hear from OBGYN colleagues like they're very nervous about taking a patient back because they're like, "Oh, I just feel like it's going to be a hostile pelvis." Things like this come up into, I think, people's decision tree. Can different obstetricians end up in different places?
[Dr. Anthony Shanks]
Yes, I would never want an obstetrician or really any physician do something that they're uncomfortable with. I was specifically thinking about hysterectomies, a cesarean hysterectomy. I think the planning stages are very important because, at our institution, we actually have GYN oncologists. Those are the people that do the most surgery. Typical day for Roxane and myself, we are not in the OR all day.
We're seeing patients. We're doing ultrasound. We like having people that are really good at knowing surgical planes and distorted anatomy because that's what it is at the time of a c-hyst. Planning is great. Certainly, there are going to be times when the instability happens and they're not there like it happens. You want to make sure your labor and delivery is covered by staff that is capable of doing that. What do you think, Roxane?
[Dr. Roxane Rampersad]
We take a lot of transfers, and so this comes up definitely. For most obstetricians out in smaller areas and small institutions, I think the thing that they worry about mostly is their blood bank, is that they are not equipped to transfuse someone sometimes more than six units. It's really unfathomable to me because we have this big blood bank and we have massive transfusion protocols. I think that's what most of those obstetricians are thinking about.
[Dr. Anthony Shanks]
Sure.
[Dr. Roxane Rampersad]
They may have the balloon tamponades, but they may not have interventional radiology also. For them, hysterectomy is the-- The end-point is removing that. Then we often get a lot of those patients transferred to us because they can still have ongoing bleeding even after hysterectomy, and so they need to come to these quaternary centers like what we have. It's definitely something to think about when you're in a smaller area and a smaller hospital.
Podcast Contributors
Dr. Roxane Rampersad
Dr. Roxane Rampersad is a professor and practicing OBGYN with Washington University School of Medicine in St. Louis.
Dr. Anthony Shanks
Dr. Anthony Shanks is a professor of clinical obstetrics and gynecology with the Indiana University School of Medicine.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2022, November 15). Ep. 4 – IR/OB Collaboration in Treating Postpartum Hemorrhage [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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