Use of a Condom to Control Massive Postpartum Hemorrhage

Sayeba Akhter, FCPS, DRH, FICMCH, Mosammat Rashida Begum, FCPS, MS, Zakia Kabir, Maliha Rashid, FCPS, Tarafder Runa Laila, FCPS, Fahmida Zabeen, FCPS

Disclosures

Medscape General Medicine. 2003;5(3) 

In This Article

Abstract and Introduction

Abstract

Objectives: To evaluate the efficacy of a condom as a tamponade for intrauterine pressure to stop massive postpartum hemorrhage (PPH).
Design and Setting: This prospective study was done in the Obstetrics and Gynecology Department of Dhaka Medical College and Hospital, Bangladesh, between July 2001 and December 2002.
Patients: During the study period, 152 cases of PPH were identified; 109 were managed medically; 20 were managed using the B-Lynch procedure, and 23 were managed using the condom catheter. Patients were selected for intervention with the condom catheter when PPH that occurred as a result of atonicity or morbid adhesion (accreta) could not be controlled by uterotonics or a surgical procedure. In patients who were in shock due to massive hemorrhage, a condom catheter was introduced immediately without prior medical management.
Intervention: With aseptic precautions, a sterile rubber catheter fitted with a condom was introduced into the uterus. The condom was inflated with 250-500 mL normal saline, according to need. The condom catheter was kept for 24-48 hours, depending upon the initial intensity of blood loss, and gradually deflated when bleeding ceased.
Main outcome measures: (1) Ability of condom catheter to stop bleeding; (2) time required to stop bleeding after the tamponade was applied; (3) subsequent morbidity in terms of severe infection, despite use of prophylactic antibiotics.
Results: In all 23 cases in which the condom catheter was used, bleeding stopped within 15 minutes. No patient needed further intervention. No patient went into irreversible shock. There was no intrauterine infection as documented by clinical signs and symptoms and culture and sensitivity of high vaginal swab.
Conclusion: The hydrostatic condom catheter can control PPH quickly and effectively. It is simple to use, inexpensive, and safe. In developing countries where PPH remains a primary cause of maternal mortality, any healthcare provider involved in delivery may use this procedure for controlling massive PPH to save the lives of patients.

Introduction

Postpartum hemorrhage (PPH) is a leading cause of maternal death all over the world.[1] In developing countries, it is responsible for an annual mortality of approximately 150,000 women per year. It remains a serious complication of childbirth in both developed and developing countries. From 2% to 5% of deliveries may lead to PPH with a blood loss of > 1000 mL within the first 24 hours.[2] The most common cause of PPH is uterine atony. A delay in correction of hypovolumia and delay in the control of bleeding are the main avoidable factors in most maternal deaths caused by hemorrhage. A population-based study has shown that PPH accounts for 28% of all maternal deaths in 8 developing countries.[3] In Bangladesh, PPH remains the number 1 killer of mothers, and PPH contributes to 26% of all maternal deaths.[4]

Whatever the cause of PPH, death should be preventable, and outcome is largely dependent upon timely interference and efficiency and vigor of medical practitioners. Active management of the third stage of labor reduces uterine atony and is the mainstay of prevention of hemorrhage.[5] The rapid correction of hypovolumia with crystalloid and red cells is the first priority of management of PPH. Uterotonic drugs, such as oxytocin or ergometrine, are used as prophylaxis and for controlling PPH. Modern management of atonic PPH entails the use of prostaglandins administered parenterally, orally, rectally, or vaginally.[6,7,8] Each has advantages and disadvantages in terms of efficiency, availability, cost, stability, and ease of administration. Bimanual compression, uterine packing, and such surgical interventions as B-Lynch suture,[2,9] ligation of uterine artery, ovarian artery, and internal iliac artery, and embolization are effective methods for controlling intractable hemorrhage. Hysterectomy is the procedure of last resort, and a few patients really need it to save their lives (Rouf S et al, unpublished data).[10,11,12]

After failed medical treatment, and before proceeding to surgical intervention and possible hysterectomy, attempting to compress the uterine sinuses and to stop bleeding via uterine packing is a reasonable option for management of PPH. Successful results have been shown by many researchers by using a Sengstaken-Blakemore tube and a Rusch urologic hydrostatic balloon catheter.[13,14] In light of these results, we tried an inflated condom as a tamponade for control of massive PPH after failure of medical treatment. Condoms are inexpensive and widely available throughout the world. Our aim in this trial was to establish the efficacy of this inexpensive device to control massive PPH and to evaluate postpartum morbidity related to this intervention.

Design and Setting

A prospective study was done in the Obstetrics and Gynecology Department of Dhaka Medical College and Hospital, Bangladesh, between July 2001 and December 2002. Data were collected continuously from patients in 2 obstetric units. The study was approved by an institutional review board, which was constituted by the head of the department and other professors of the department. Written consent was obtained from the patient or from her attendant if the patient's condition was poor.

Patient Characteristics

During the study period, 152 cases of PPH were identified; 109 were managed medically, 20 were managed using the B-Lynch suture (named after its innovator[2,9]) during cesarean section, and 23 were managed using the condom catheter. Patients in whom PPH due to atonicity or morbid adhesion (accreta) could not be controlled by medical treatment or the surgical approach were selected for intervention with the condom catheter. Bimanual compression was given, but aortic compression was not attempted.

Primary and secondary PPH were diagnosed according to standard textbook definitions (bleeding within 24 hours of delivery and between 24 hours and 6 weeks of delivery, respectively). Of the 23 patients managed with the condom catheter, 19 (82%) had primary PPH and 4 (17%) had secondary PPH; 12 (52%) patients were in shock due to massive hemorrhage. In these latter cases, a condom catheter was introduced immediately without prior medical management. In the other cases, uterine massage and uterotonics (oxytocin or ergometrine; misoprostol is not used for PPH at our institution) had been administered without success in 10 patients, and in 1 patient a B-Lynch suture applied during cesarean section did not stop the bleeding.

The characteristics of patients selected for the condom catheter intervention are summarized in Table 1 . The patients were between the ages of 19 and 40 years, and the mean age was 26.8 years. Parity ranged from 1-6, with a median of 2. (In our experience, multiparous women are more prone to develop PPH.) The majority of the 23 cases had spontaneous vaginal delivery (61%) and developed PPH immediately after delivery (48%). In 17% (4/23) of the cases, bleeding occurred outside the hospital, and these patients were admitted to the hospital. None of the 23 cases had antenatal care, and all had some form of predisposing factors for developing PPH; 48% had active management of the third stage, 26% had hepatitis, and 17% had had a history of previous lower segment cesarean section ( Table 2 ).

Intervention

With aseptic precautions, a sterile rubber catheter fitted with a condom was introduced into the uterus. The condom was inflated with 250-500 mL normal saline according to need. Vaginal bleeding was observed and further inflation was stopped when bleeding ceased. To keep the balloon in situ, the vaginal cavity was filled with roller gauze and finally a sanitary pad. If bleeding continues, this vaginal pack will usually become soaked with blood, and if profuse it will trickle through the introitus to soak the outside pad and undergarments. This did not happen in any of our cases. Removal of a pack did reveal that it was soaked with blood, but no profuse bleeding occurred, so no blood came through introitus. Uterine contractility was maintained by oxytocin drip for at least 6 hours after the procedure. As mentioned, the condom catheter was used in those cases in which oxytocin and other drugs were not effective for management of PPH. However, as it maintains the tone of uterus, oxytocin was administered along with introduction of the condom catheter.

Figure 1.

Inflated condom in a kidney tray.

Figure 2.

Tying the condom to the catheter.

Figure 3.

Introducing the catheter in the uterus.

Figure 4.

After introduction of the catheter, a tight vaginal pack is applied and then saline is administered into the catheter.

Antibiotics were also administered prophylactically because of the presence of a foreign body inside the uterus. The triple antibiotic regimen used was amoxicillin (500 mg every 6 hrs) plus metronidazole (500 mg every 8 hrs) plus gentamicin (80 mg every 8 hrs) administered intravenously for 7 days. High vaginal culture swab was done to determine whether there was any invading organism even after giving antibiotics, as some organisms may be resistant to this triple antibiotic regimen.

The condom catheter was kept for 24-48 hours, depending upon the initial intensity of blood loss ( Table 3 ). For those who had severe bleeding, the catheter was kept for the longer duration. Bleeding did not resume in any patient, and the condom was deflated slowly over 10 to 15 minutes during the same sitting.

The steps are summarized as follows:

  1. Under aseptic precautions a sterile rubber catheter was inserted within the condom and tied near the mouth of the condom by a silk thread.

  2. Urinary bladder was kept empty by indwelling Foley's catheter.

  3. After putting the patient in the lithotomy position, the condom was inserted within the uterine cavity.

  4. Inner end of the catheter remained within the condom.

  5. Outer end of the catheter was connected with a saline set and the condom was inflated with 25-500 mL of running normal saline.

  6. Bleeding was observed, and when it was reduced considerably, further inflation was stopped and the outer end of the catheter was folded and tied with thread.

  7. Uterine contraction was maintained by oxytocin drip for at least 6 hours after the procedure.

  8. The uterine condom was kept tight in position by ribbon gauze pack or another inflated condom placed in the vagina.

  9. The condom catheter was kept for 24-48 hours and then was deflated gradually over (10-15 minutes) and removed.

  10. Patient was kept under triple antibiotic coverage (amoxicillin [500 mg every 6 hrs] + metronidazole [500 mg every 8 hrs] + gentamicin [80 mg every 8 hrs]) administered intravenously for 7 days.

Main Outcome Measures

The main outcomes evaluated in this study were the ability of the condom catheter to stop bleeding, the time required to stop bleeding after the tamponade was applied, and any subsequent morbidity in terms of severe infection, despite the use of prophylactic antibiotics.

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