While you establish an IV, resuscitate her, and wait for the gynaecology team to arrive, is there any trick you can use to stem the bleeding?
The obstetricians sometimes use a Bakri balloon (Bakri postpartum balloon, Cook Medical) for postpartum bleeding. This balloon will take 250-500 cc of fluid. In the ED, a regular Foley catheter can be used.
Reference Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(6):748–757.
Trick of the trade:
Foley catheter insertion into the uterus for DUB
Foley catheter insertion into the uterus for DUB
The obstetricians sometimes use a Bakri balloon (Bakri postpartum balloon, Cook Medical) for postpartum bleeding. This balloon will take 250-500 cc of fluid. In the ED, a regular Foley catheter can be used.
Step 1:
Regular speculum exam. Remove clots.
Regular speculum exam. Remove clots.
Step 2:
Feed Foley catheter through the os by curved or straight forceps held close to the os.
Feed Foley catheter through the os by curved or straight forceps held close to the os.
Step 3:
When the catheter is in a few centimetres through the os (endometrial cavity is usually 6 - 8 cm deep), inflate the Foley balloon with 30-80 cc of water.
When the catheter is in a few centimetres through the os (endometrial cavity is usually 6 - 8 cm deep), inflate the Foley balloon with 30-80 cc of water.
The balloon will hopefully tamponade the endometrium that it contacts and prevent further blood loss.
Illustration by Simon Yiu
Thanks to Dr. Jamie Kroft for this great tip!
Great trick, Stella. I also saw a case report of 2 foleys being placed to get a more snug tamponade fit in case of extra leakage. Sometimes foleys can only hold up to 30 cc of fluid. Will have to remember this trick.
ReplyDeleteOh, and nice drawing by your brother! Talented family.
ReplyDelete@Michelle: Thanks, it was a really practical tip from an OB staff. There was another case series that use the Blakemore tube as well. I guess any balloon would work in a pinch.
ReplyDeleteDo u think this will help too for active per rectal bleeding from haemorrhoids ?
ReplyDelete@Smith: Hmm, fascinating idea. I suppose foley tamponading will work for that as well, since it's been documented for posterior nasal bleeds and GSWs to the heart. Would recommend gently inflation of balloon though!
ReplyDeleteI used this trick for a rectal bleeding after trans rectal biopsy of the prostate. it worked, while waiting for the endoscopic team to arrive.. elisabeth
ReplyDelete@Elisabeth: I have 3 words for you. A-- MAAAA-- ZING. Thanks for letting us know.
ReplyDelete@ Elisabeth: Wow! A humble device, so many uses!
ReplyDeleteHi Stella and Michelle. As the postpartum anatomy of uterus is quite different from non pregnant one, I'm just curious that are there any reports using this on non-pregnant females? Thanks!
ReplyDelete@ Bow: Great point! All but one study are on postpartum patients, and the one study is on a cervical ectopic pregnancy.
ReplyDeleteAccording to one OB, this Foley method works since we are not putting in very much fluid in the balloon compared to the Bakri balloon.
Would love to hear anyone else's experience.
@Bow: I agree with Stella. Foley balloons are nowhere as big as the Bakri balloons. I would say, just inflate the balloon carefully until bleeding significantly slows, and stop the procedure if the patient experiences pain. Good question.
ReplyDeleteThanks for the reply michelle
ReplyDeleteStella, Michell, Thanks!
ReplyDeleteHaving just pulled this trick in the ED for spontaneous abortion in patient who did not know they were pregnant let me briefly add: a foley will tamponade at the level of the os, so active uterine bleeding (as in the case of postpartum hemorrhage) could potentially back up in the uterus and enter the abdominal cavity. My understanding from the referenced article is that this trick is to follow the administration of pharmacological agents. Retained products, continued bleeding, risk of uterine perforation, and inability to maintain sterility are all factors that need to be part of your thought process.
ReplyDeleteBasically, if I'm working in the middle of Bumbum Nowhere, I'm likely to move to this earlier, but the patient is also more likely to go to the OR. Here at my level 1 trauma center, OB (finally) came down, took out my bulb, told me it was clever, did a bedside D&C, and wanted me to send the patient home with doxy and methergine.
HI Gabriel: Wow, thanks for your sharing your experience with this trick with us. You make an excellent point about using this trick as one of the options of last resort after you try medications and supportive care. It's a truly is just a temporizing measure until more definitive care is available. Thanks for your comments.
ReplyDelete