USE OF SAYEBA’S CONDOM - CATHETER TECHNIQUE AS UTERINE TAMPONADE TO

CONTROL EARLY POSTPARTUM HEMORRHAGE

20 October 2006

BACKGROUNDPPH

Major cause of maternal mortality

Soetomo Hospital 1st : PE-E (39.7%)

2nd : Infection (21,55%)

3rd : PPH (17,24%)

Time related

Medical Mechanical Surgical

BACKGROUND

Timing of Obstetrical Hemorrhage

PPH

Resuscitation : IV, O2, Catheter, Monitor VS

Access etiology : explore 4T

Laboratory test : CBC, Coagulation, Cross match

Direct th/

Tone : massage, compression, drugs

Tissue : manual removal, curretage

Trauma : Correct inversion, repair laceration, Ident. rupture

Thrombin : anticoagulan, replace factor

Intractable

Get help : Obstetrician,Anesthesiologist, Lab, ICULocal control : Man.comp. Ut. Pack, EmbolizationBP & Coagulation : Cristaloid, Blood product

Surgery

Repair

Ligate

Hysterectomy

Post Hysterectomy bleedingAbdominal packing

Embolization

Medical

Mechanical

Surgical

Oxitocyn

Prostaglandin

Methergin

Balloon

Gauze

Ut (-) :

Hysterectomy

Ut (+) :

Ligation

B-Lynch

Square Suture

Tamponade

Bimanual Compression

Embolization

BACKGROUNDIdeal treatment / device?

Efective

Widely available

Cheap

Easy

Tamponade

Balloon is superior than gauze

No Concealed Bleeding Better Coverage Atraumatic insertion Fast Simple to place and remove Removal does not cause bleeding Less Infection No spec. skill Ideal ?

PPH : Vag > 500 cc ; Op > 1000cc

Late>24 h

Subinvolusion

Rest Placentae

MedicalMechanical

Surgical

Early<24 h

ToneTraumaTissue

Thrombin

PPH

CLASS Ammount

(cc)

Loss (%)

Respons

1 900 15 Asimptomatik

2 1200-1500 20-25 Tachicardia,tachipneu, weak pulse, ortostatic

hipotension

3 1800-2100 30-35 Tachicardia,tachipneu,

hipotension, cold extr.

4 >2400 40 Shock, oligo-uria/anuria

Estimated blood loss is commonly only about half the actual loss ! (Cuningham,2005)

When in shock, the brain, heart, and lungs aredeprived of oxygen because blood accumulates

in the lower abdomen and legs.

• Unpredictable Event

Even in a mother without a single predisposing factor

–Tone–Tissue–Trauma–Thrombin

PPH

Resuscitation : IV, O2, Catheter, Monitor VS

Access etiology : explore 4T

Laboratory test : CBC, Coagulation, Cross match

Direct th/

Tone : massage, compression, drugs

Tissue : manual removal, curretage

Trauma : Correct inversion, repair laceration, Ident. rupture

Thrombin : anticoagulan, replace factor

Intractable

Get help : Obstetrician,Anesthesiologist, Lab, ICULocal control : Man.comp. Ut. Pack, EmbolizationBP & Coagulation : Cristaloid, Blood product

Surgery

Repair

Ligate

Hysterectomy

Post Hysterectomy bleedingAbdominal packing

Embolization

Balloon Tamponade

Rusch Hydrostatic Urologic Catheter

Johanson, 2001

Used in urology for stretching the bladder and for stemming mucosal hemorrhage

2 Successful case report

Placentae acreta

SOS BAKRI TAMPONADE

• Bakri, et al, Int J Gyne Obstet, 2001

• Designed specifically for obstetrical hemorrhage

• Maximum capacity 800cc of balloon (recommended 250 to 500c)

• Wider caliber drainage shaft • Article describes 5 successful

cases with previas • It can be placed from above at

time of C/S ( not from below )

• Basket, JOGC, 2004 • Technique

– straight catheter and surgical glove

– tie at wrist with #1 vicryl

– insert and fill with 100cc

Shivkar’s -1981- India• IV set is passed through the condom and is fixed to the condom with a

latex rubber band• The IV set is connected to the IV bottle as usual and the bottle is hung up

on the calibrated IV stand at 60 cm. • Neither anesthesia nor sedation is required. • The IV flow controller is now released and fluid is allowed to run fast over

1-2 minutes from a 60 cm height above the abdominal level. Usually up to 300cc

• Brought down to a 25 cm height from the abdomen• May be lowered or raised • Maintained for approximately 6-8 hours. • Vagina should be packed to prevent slipping of the condom.• pack is removed usually at the end of 6-8 hours, by bringing the bottle

down slowly by 5 cm every 15 minutes

Sayeba’s - 2003 - Bangladesh

• Oxytocin Drip• Kept for 6 - 24/48 hrs• Deflate gradually • Antibiotics coverage

– A/G/M : 7 days

• Atonic PPH occurs due to failure of ‘living ligatures’ of uterine muscles to compress the vessels.

• Directly compressing the bleeding vessels by hydrostatic pressure

• Improving the efficiency of failed live ligature by uterine muscle contractions

• By allowing sufficient time for resuscitation of the patient, which enables the severely anoxic uterine muscle to recover from tissue anoxia and contract.

• The pressure in the capillary system is 21-48 mm of Hg or 28.5-65.5 cm of water. Pressure in intervillous space is 25mm of Hg or 33.9cm of water. Hence the pack stops most of the bleeding except for arteriolar spurters wherein the pack may fail or be less effective

Mechanism of Action

• Advantage over Shivkar’s– Mobility– Less leakage

• Disadvantage– Pressure Not Fully controled

• Indications– Atonic PPH– Coagulation failure – Inversion – Traumatic PPH

• Contraindications – Suspected or diagnosed uterine rupture.

Sengstaken-Blakemore Tube

Insert into uterine cavity

Filled 70 -300cc NS

(+) Bleeding stop and No surgery

(-) Bleeding Continue, Surgery needed

Tamponade Test

Condous J, et al. 2003

16 Px : 14 (+), 2(-)

Condom can hold 7 gallons of water

Average : 3 gallons

Only < 1000 cc needed

Case I• Mrs. Y / 37 th • GIIIP2-2, Aterm, PROM• ANC : Suwandi Hospital• Dilation 2cm, Contraction (-)• Termination : Misoprostol 2 x 50 mcg• 2nd Misoprostol : Contraction start• 4 hrs : Delivered Rapid Labor

♂/3900/51/6-8

• PPH of Atonic• Oxytocin and Misoprostol• >1500 cc loss• Intractable PPH

Reffered to Soetomo Hospital• Hb : 2,6 g/dL, Thrombocyte : 8000,

Shock Medical bleeding

• Intubated, Explored at the Op. Theater• Laceration of labia major and cervix

• Perform Sayeba’s technique– NS 350 cc– Cefotaxim 3 x1 g– Oxytocin Drip– Methergin 3 x 1

• 7 Wb 10 TC, Hb : 8,8 g/dL, Thrombo : 105.000

• Kept for 48 hrs

• No sign of infection Discharge at day 5

No menstrual complain

Case II• Mrs. R / 24 th

• GIP0-0, 36/37 wks, Eisenmenger Syndrome • ANC : Soetomo Hospital• Congenital Heart Disease : VSD• Termination : Elective CS + Tubectomy• Hb :13• + 300 cc during operation, Misoprostol 4 tab

♂/2300/45/7-8

• 4 hrs post CS : PPH of Atonic

• Oxytocin and Misoprostol

• 800 cc loss and continued, Hb : 12,1

• Under Ketamin + Dormicum

• Perform Sayeba’s technique– NS 350 cc– Cefotaxim 3 x1 g– Gentamycin 2 x 80 mg– Oxytocin Drip– Misoprostol

• No Transfusion

• Kept for 24 hrs

• No sign of infection

Discharge at day 7

No menstrual complain

Case III

• Mrs. S / 39 th • GIIP1-1 , Aterm, Gemelli • ANC : Midwive• Preeclampsia, Lung Oedem • I : FE ♂/2400/4-9/8-9• II : Version Extraction ♂/2600/47/6-8 • Hb: 11,6 g/dL

• 2 hrs post partum : PPH of Atonic

• Oxytocin and Misoprostol

• > 500 cc loss and continued, Hb : 9,8g/dL

• Perform Sayeba’s technique– NS 300 cc– Cefotaxim 3 x1 g– Oxytocin Drip– Misoprostol

• No Transfusion

• Kept for 48 hrs

• No sign of infection

Discharge at day 8

No menstrual complain

Predisposing

AM

TIMING CAUSE Other Blood Lost

(cc)

Hb Transfusion

Case

I

RapidLaborMisoprostol

+ Soon ToneTraumaThrombin

Shock 2800 ? - 2,6 7 WB10 TC

Case II

EisenmengerSyndrome

+ 2 hr Post CS

Tone Vitium cordis

800 13 -11,5 -

Case III

-Gemeli-PIH-SM

+ 2 hrPost Partum

ToneTrauma

LungOedem

500 11,6 – 9,8 -

CASE

MOD Time(mnt)

NS(cc)

Duration(hrs)

Antibiotics Infection Anestesi

Spt Induction

45 350 48 Cefotaxim - General + intubation

El. SC 20 350 24 CefotaximGentamycin

- KetaminDormicum

FEExtraction Version

30 300 48 Cefotaxim - -

CASE

Summary• PPH : Great Mother killer

• Use of Condom as tamponade is highly effective and avoid the surgical need

• 3 Cases reported with successful result in Dr. Soetomo Hospital 2005

• Hopefully contribute to reduce Maternal morbidity and mortality