Introducing balloon tamponade technology in the management of postpartum haemorrhage in Malaysia

1. Introducing balloon tamponade technology in the management of postpartum haemorrhage in Malaysia 1,2,3Associate Professor Chris Georgiou BSc (Hons) PhD MBBS MRCOG FRANZCOG, 4Professor Muhammad Abdul Jamil MohdYassinMBBCh (Cairo), MOG (UKM), FICS (USA), 5Dr Soon Ruey, FRCOG, 6Dr Mohamad Farouk Abdullah MBBS (Malaya) FRCOG (London) CRM (Malaysia) and 7Dr Harris NjooSuharjono FRCOG 1Illawarra Health and Medical Research Institute, University of Wollongong, 2Graduate School of Medicine, University of Wollongong, 3Consultant Obstetrics and Gynaecology, Wollongong Hospital, Illawarra , Australia. 4Universiti Kebangsaan Medical Centre, Kuala Lumpar, Malaysia, 5Hospital Likas, Likas, Malaysia, 6Hospital Tengku Ampuan Rahimah, Klang, Malaysia, 7Sarawak General Hospital, Sarawak, Malaysia Introduction: Worldwide postpartum haemorrhage (PPH) is the leading cause of direct maternal mortality. In recent Confidential Enquires into maternal deaths, including Malaysia, Australia and the United Kingdom, PPH is consistently in the top six causes of maternal death.1 Various methods are used in the management of PPH including rubbing up the uterus and using a range of pharmacological agents including oxytocin, ergometriene, misoprostol and prostaglandins. If these first-line approaches are unsuccessful, there are a number of second line approaches (SLA), that may be used depending on the surgical skill and local facilities available. These SLA include: hypogastric artery and uterine artery ligation, embolization of the uterine artery, compression sutures such as the B-Lynch suture, and more recently balloon tamponade technology (BTT).1,2 Although the concept of uterine tamponade in the management of postpartum haemorrhage is not new, the use of balloons such as the condom-catheter, Sengstaken-Blakemore tube, Rusch balloon and the uterine specific Bakri balloon was not widely used in Malaysia. Aim: The aim of this project was to introduce balloon tamponade technology at key conferences and meetings throughout Malaysia through a series of workshops and lectures. • Results: • Over a 2 year period 5 separate visits to Malaysia resulted in 10 presentations and 8 workshops. • An estimated 700 lecture attendees and over 300 “hands on” participants were involved. • On the 5th visit a number of workshops were organized to “accredit” the use of balloon tamponade technology to individuals working in units that transfer patients to other distant centres for the management of PPH. • On successive trips to Malaysia, an increasing number of cases were discussed in which balloon tamponade technology was used in the management of postpartum haemorrhage Methods: Through various invitations at a number of Regionaland National Meetings/Conferences a series of lectures and hands-on workshops were conducted specifically discussing the use of balloon technology in the management of PPH (Table 1: Meetings/Conferences). Each Balloon Tamponade Technology lecture (“BTT” in Table 1), consisted of various topics specifically related to the management of postpartum haemorrhage and the use of balloon tamponade technology (See “Lecture Content”). Each Workshop (“Hands on” in Table 1) was specifically related to the practical use of balloon tamponade technology in the management of PPH.3 This included making a condom-catheter as well as the principles for the use of balloon tamponade technology (See “Workshop Content”). • Conclusion: • Through the introduction of lectures/workshops the concept of balloon tamponade technology has been introduced to a wide audience of potential users. • It is anticipated that these healthcare providers will use this technology, with the appropriate evidence based data, to reducing maternal mortality and morbidity in the management of PPH in Malaysia. Table 1: Meetings/Conferences • Workshop Content: • “Having a balloon in your hand will not stop a PPH” • Methodologies for use and indication (atonic uterus) • Making a condom-catheter • Principles of usage : Placement at uterine fundus and distension of balloon (Tamponade Method) • Tamponade Test and Tamponade Method • Use of Football model for “uterus” • Insertion of Bakri balloon in “uterus” within pelvic model • Demonstration of vaginal (anterograde) insertion • Demonstration of abdominal (retrograde) insertion • Discussion re: potential complications of insertion • Use of USS to confirm location • Use of vacuum to retain balloon in the uterus Vs. vaginal pack • Resuscitation and removal based on a “24hr” plan • Encouragement to report complications • Role playing : Communication and balloon insertion • Lecture Content: • PPH as a region specific cause of maternal morbidity and mortality • Use of first line uterotonics • Second line approaches including: Hypogastric artery ligation, uterine artery ligation, embolization procedures, compression sutures and uterine tamponade • History of uterine tamponade usage and concept • Use of multiple Foley catheters before development of single balloon with 500ml capacity (Bakri) • Other non-uterine specific balloons (Rusch, Sengstaken-Blakemore, condom catheters and Foleys) • Data on usage of these various balloon • Stages in the use of balloon tamponade technology in the management of PPH • Mechanisms of action • Potential complications and guideline suggestions when using Balloon tamponade technology. References: 1Georgiou, C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009; 116:748-7572Royal College of Obstetricians and Gynaecologists. RCOG Green-top Guideline No.52. Prevention and management of postpartum haemorrhage. London RCOG, 2009 3Georgiou, C. Using the uterine-specific Bakri balloon in the management of postpartum hemorrhage: Case series and conceptual/practical guidelines. In Arulkumaran S, B-Lynch C, Keith LG, Lalonde AB, and Karoshi M, eds. A Comprehensive Textbook of Postpartum Hemorrhage , 2nd Edition.  London: Sapiens Publishing 2012 (in press) Acknowledgment: The author (CG) would like to acknowledge the patients at the Wollongong Hospital,Australia, that contributed in the development of these workshops and lecture content (Ethics approval: (HREC/09/WGONG/374). All authors would like to acknowledge the numerous participants at these workshops and the various organizing committees that facilitated these workshops and lectures.