Women with postpartum hemorrhage (PPH) associated with cesarean section are 4 times more likely to have failure of intrauterine tamponade used to control the bleeding, according to a recent study of nearly 40,000 women published in the journal Obstetrics & Gynecology.¹

The effectiveness of intrauterine tamponade after vaginal or caesarean delivery was examined in this population-based cohort study, involving 39,193 French women with PPH, conducted in the year 2019. Data for the study was sourced from the national hospital database “Programme de Médicalisation des Systèmes dInformation”. Failure of intrauterine tamponade, as indicated by the use of a second-line method such as uterine artery embolization, surgery or mortality within 7 days of its use was the primary outcome.

A total of 1761 (4.5%) women with continuous bleeding received intrauterine tamponade. The tamponade effectively controlled bleeding in 88.9% patients, while a second-line method was required in the remaining 11.1%. On univariate analysis, the factors associated with failure of intrauterine tamponade were identified as advanced maternal age and lower mean gestational age. Tamponade failure was more common in the presence of conditions such as preeclampsia, cesarean birth, placental abnormalities and uterine rupture. However, on multivariate analysis, only cesarean birth, preeclampsia and uterine rupture remained significant for intrauterine tamponade failure. The risk of intrauterine tamponade failure was increased 4-folds with cesarean birth with adjusted odds ratio (aOR) of 4.2. Pre-eclampsia doubled the risk with aOR of 2.3. Expectedly, the odds of tamponade failure increased 14 times with uterine rupture (aOR 14.1).

PPH remains an important cause of maternal death globally, particularly in developing countries. Management involves use of less invasive and conservative methods such as compression, intrauterine balloon tamponade to the more invasive intervention like hysterectomy when other options fail. This study which set out to examine the factors predisposing to failure of intrauterine tamponade in the management of PPH has identified cesarean delivery, preeclampsia and uterine rupture as independent risk factors for tamponade failure. In such situations, treating clinicians should anticipate and be prepared for second-line methods like uterine artery embolization, pelvic vessel ligation and surgery when attempting to control the hemorrhage with intrauterine balloon tamponade. Early recognition of these factors is important.

Reference

1. Mathilde Gibier, et al. Risk factors for intrauterine tamponade failure in postpartum hemorrhage. Obstet Gynecol. 2022 Aug 3. doi: 10.1097/AOG.0000000000004888.