Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Utah Health Sciences Center, Salt Lake City, UT.
Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern Feinberg School of Medicine, Chicago, IL.
Am J Obstet Gynecol. 2017 Mar;216(3):300.e1-300.e5. doi: 10.1016/j.ajog.2016.10.040. Epub 2016 Nov 4.
Intrauterine balloon tamponade is an effective treatment for postpartum hemorrhage when first-line treatments fail. The optimal duration of intrauterine balloon tamponade for management of postpartum hemorrhage is unclear.
The objective of the study was to determine whether intrauterine balloon tamponade removal >12 hours of duration is associated with postpartum hemorrhage-related clinical outcomes.
This was a retrospective cohort study of women with postpartum hemorrhage from 2007 through 2014 who underwent intrauterine balloon tamponade. We excluded failures of intrauterine balloon tamponade (intrauterine balloon expulsion with duration <2 hours or if hysterectomy was required prior to planned intrauterine balloon removal). Patients who underwent intrauterine balloon tamponade for 2-12 hours were compared with those who underwent intrauterine balloon tamponade for >12 hours. Examined postpartum hemorrhage-related clinical outcomes included estimated blood loss after intrauterine balloon tamponade placement, blood product transfusion, use of adjuvant measures to control postpartum hemorrhage after intrauterine balloon tamponade (either uterine artery embolization or hysterectomy), and maternal intensive care unit admission. Secondary outcomes examined included postpartum fever and hospital length of stay. Multivariable logistic regression models were used to control for confounding variables.
Of 274 eligible women, 206 (75%) underwent intrauterine balloon tamponade for >12 hours and 68 (25%) underwent intrauterine balloon tamponade for 2-12 hours. The median estimated blood loss after intrauterine balloon tamponade placement (190 vs 143 mL, P = .116) as well as the frequencies of blood product transfusion (62.1% vs 51.5%, P = .120), transfusion of ≥4 U of packed red blood cells (17.0% vs 14.7%, P = .659), uterine artery embolization (15.1% vs 16.2%, P = .823), hysterectomy (0.0% vs 1.5%, P = .248), and intensive care unit admission (8.7% vs 7.4%, P = .721), was not statistically different between the groups, and this lack of association persisted in multivariable regressions. Intrauterine balloon tamponade duration >12 hours was associated with a higher frequency of postpartum fever (27% vs 15%, P = .047) and a longer mean hospital length of stay (3.7 vs 3.1 days, P = .002). After adjusting for variables that differed statistically between groups, the difference in length of stay associated with intrauterine balloon tamponade duration was no longer present, but the association between intrauterine balloon tamponade duration >12 hours and postpartum fever persisted (odds ratio, 2.33, 95% confidence interval, 1.07-5.11). Including chorioamnionitis as an independent variable in a post hoc multivariable analysis diminished the association between intrauterine balloon tamponade >12 hours and postpartum fever (adjusted odds ratio, 2.04, 95% confidence interval, 0.92-4.53).
There are no significant differences in postpartum hemorrhage-related outcomes associated with intrauterine balloon tamponade duration >12 hours compared with removal 2-12 hours. If ongoing hemorrhage has abated, it is reasonable to consider the removal of an intrauterine balloon by 12 hours after its initial placement.
宫腔球囊填塞术是治疗一线治疗失败后产后出血的有效方法。宫腔球囊填塞术治疗产后出血的最佳持续时间尚不清楚。
本研究旨在确定宫腔球囊填塞术去除>12 小时是否与产后出血相关的临床结局有关。
这是一项回顾性队列研究，纳入了 2007 年至 2014 年间接受宫腔球囊填塞术治疗产后出血的妇女。我们排除了宫腔球囊填塞术失败的患者（宫腔球囊排出<2 小时或在计划宫腔球囊取出前需要行子宫切除术）。将宫腔球囊填塞 2-12 小时的患者与宫腔球囊填塞>12 小时的患者进行比较。检查的产后出血相关临床结局包括宫腔球囊填塞放置后估计失血量、输血、使用辅助措施控制宫腔球囊填塞后产后出血（子宫动脉栓塞术或子宫切除术）以及产妇入住重症监护病房。次要结局包括产后发热和住院时间。多变量逻辑回归模型用于控制混杂变量。
在 274 名符合条件的妇女中，206 名（75%）行宫腔球囊填塞>12 小时，68 名（25%）行宫腔球囊填塞 2-12 小时。宫腔球囊填塞放置后估计失血量中位数（190 vs 143 mL，P=0.116）以及输血频率（62.1% vs 51.5%，P=0.120）、输血≥4 U 浓缩红细胞（17.0% vs 14.7%，P=0.659）、子宫动脉栓塞术（15.1% vs 16.2%，P=0.823）、子宫切除术（0.0% vs 1.5%，P=0.248）和重症监护病房入住率（8.7% vs 7.4%，P=0.721）在两组之间无统计学差异，这种无关联在多变量回归中仍然存在。宫腔球囊填塞>12 小时与产后发热频率较高相关（27% vs 15%，P=0.047）和平均住院时间较长（3.7 天 vs 3.1 天，P=0.002）。在调整组间统计学差异的变量后，与宫腔球囊填塞持续时间相关的住院时间差异不再存在，但宫腔球囊填塞持续时间>12 小时与产后发热之间的关联仍然存在（比值比，2.33，95%置信区间，1.07-5.11）。在后验多变量分析中，将绒毛膜羊膜炎作为独立变量纳入，降低了宫腔球囊填塞>12 小时与产后发热之间的关联（调整后的比值比，2.04，95%置信区间，0.92-4.53）。
与去除 2-12 小时相比，宫腔球囊填塞持续时间>12 小时与产后出血相关结局无显著差异。如果持续出血已经停止，则可考虑在初始放置宫腔球囊后 12 小时内取出。
