Comparison of Outcome Between Intrauterine Balloon Tamponade and Uterine Artery Embolization in the Management of Persistent Postpartum Hemorrhage: A Propensity Score–matched Cohort Study

study aimed to evaluate TEG parameters for accuracy in the diagnosis of coagulopathy during PPH and accuracy in the prediction of severe hemorrhage > 2500mL. This was a retrospective observational study conducted to investigate the performance of a TEG, which was used alongside standard biological assays at Trousseau Hospital, Paris, France. The cohort included women at 24 weeks gestation or greater who had ongoing PPH within 24 hours following delivery between January 2012 and July 2015. PPH was defined as blood loss > 500mL measured by calibrated drapes for vaginal delivery or >1000mL for intraoperative blood loss for cesarean delivery. Once the decision to assess coagulation was made by the anesthesiologist, TEG assays were drawn and biological assays were collected. Samples were tested for full blood count, Clauss fibrinogen, prothrombin ratio, activated partial thromboplastin time ratio, and a TEG analysis. A TEG 5000 was used for TEG analysis, which included Kaolin-maximum amplitude (K-MA), Kaolinmaximum rate of thrombus generation using G (K-MRTGG), functional fibrinogen-maximum amplitude (FF-MA), and functional fibrinogen-maximum rate of thrombus generation using G (FF-MRTGG). Patient management was based on standard laboratory results according to local guidelines. The accuracy of TEG parameters to predict hypofibrinogenemia ≤2 g/L and/or thrombocytopenia ≤80,000/mm2 was the primary outcome. A total of 98 patients were included in the analysis and of those, 89 patients had a 24-hour blood loss calculation. There was no significant difference between K-MA and K-MRTGG in terms of predicting hypofibrinogenemia ≤2 g/L and/or thrombocytopenia ≤80,000/mm2 for the Kaolin assay (area under the curve=0.970 and 0.981, respectively). There was no significant difference for the functional fibrinogen assay for detecting hypofibrinogenemia ≤2 g/L between FF-MA and FF-MRTGG (area under the curve=0.988 vs. 0.974, respectively). Both velocity-derived parameters had shorter times to obtain results than the classic parameters (FF-MRTGG: 2.7min vs. FF-MA: 14.0min; P<0.001; K-MRTGG: 7.7min vs. K-MA: 24.7min; P<0.001). The velocity-derived parameters were not significantly different in predictive performance than the classic parameters, but required a shorter time to obtain results. The use of this assessment may enable the diagnosis of clotting disorders and therefore proper treatment.

management and improve outcomes in PPH patients. This study aimed to evaluate TEG parameters for accuracy in the diagnosis of coagulopathy during PPH and accuracy in the prediction of severe hemorrhage > 2500 mL.
This was a retrospective observational study conducted to investigate the performance of a TEG, which was used alongside standard biological assays at Trousseau Hospital, Paris, France. The cohort included women at 24 weeks gestation or greater who had ongoing PPH within 24 hours following delivery between January 2012 and July 2015. PPH was defined as blood loss > 500 mL measured by calibrated drapes for vaginal delivery or > 1000 mL for intraoperative blood loss for cesarean delivery. Once the decision to assess coagulation was made by the anesthesiologist, TEG assays were drawn and biological assays were collected. Samples were tested for full blood count, Clauss fibrinogen, prothrombin ratio, activated partial thromboplastin time ratio, and a TEG analysis. A TEG 5000 was used for TEG analysis, which included Kaolin-maximum amplitude (K-MA), Kaolinmaximum rate of thrombus generation using G (K-MRTGG), functional fibrinogen-maximum amplitude (FF-MA), and functional fibrinogen-maximum rate of thrombus generation using G (FF-MRTGG). Patient management was based on standard laboratory results according to local guidelines. The accuracy of TEG parameters to predict hypofibrinogenemia ≤ 2 g/L and/or thrombocytopenia ≤ 80,000/mm 2 was the primary outcome.
A total of 98 patients were included in the analysis and of those, 89 patients had a 24-hour blood loss calculation. There was no significant difference between K-MA and K-MRTGG in terms of predicting hypofibrinogenemia ≤ 2 g/L and/or thrombocytopenia ≤ 80,000/mm 2 for the Kaolin assay (area under the curve = 0.970 and 0.981, respectively). There was no significant difference for the functional fibrinogen assay for detecting hypofibrinogenemia ≤ 2 g/L between FF-MA and FF-MRTGG (area under the curve = 0.988 vs. 0.974, respectively). Both velocity-derived parameters had shorter times to obtain results than the classic parameters (FF-MRTGG: 2.7 min vs. FF-MA: 14.0 min; P < 0.001; K-MRTGG: 7.7 min vs. K-MA: 24.7 min; P < 0.001).
The velocity-derived parameters were not significantly different in predictive performance than the classic parameters, but required a shorter time to obtain results. The use of this assessment may enable the diagnosis of clotting disorders and therefore proper treatment.

COMMENT
This manuscript demonstrated that the TEG can consistently detect hypofibrinogenemia and thrombocytopenia during PPH. What was more interesting was their use of velocity-based parameters, the maximum rate of thrombus generation. A thrombus velocity curve or V curve can be obtained from the TEG waveform by taking the first derivative of changes in clot resistance. Parameters obtained are total thrombus generation, maximum rate of thrombin generation, and time to maximum rate of thrombus generation. For those who are not familiar with these parameters, they can be seen by clicking on the V curve icon at the top right of their TEG software. These parameters give the user a more rapid way of identifying hypofibrinogenemia and thrombocytopenia when compared with assessing the maximum amplitude. Topics: Obstetric Hemorrhage, Maternal Morbidity and Mortality P eripartum hysterectomy can be life-saving in the setting of postpartum hemorrhage (PPH). However, it produces infertility and is therefore considered a treatment of last resort. Many other procedures are first attempted to control PPH in an effort to avoid peripartum hysterectomy, such as intrauterine balloon tamponade, uterine compression sutures, and uterine artery ligation or embolization. Uterine artery embolization and intrauterine balloon tamponade have not previously been compared in terms of their effectiveness in preventing maternal death or near miss in women experiencing PPH. Uterine artery embolization is costly and may lead to thromboembolic events and other complications. Intrauterine balloon tamponade has more recently emerged as a more inexpensive strategy for managing PPH. This study aimed to compare the effectiveness of these 2 techniques for the management of persistent PPH.
This study utilized a propensity score-matching method to correct for confounders, as intrauterine balloon tamponade is less invasive, and therefore may be more likely to be used for women with less severe bleeding. A study cohort was developed that included patients with similar clinically relevant characteristics, but who received different management strategies for their PPH. Data were obtained from the Transfusion strategies in women during Major Obstetric Hemorrhage (TeMpOH-1) study, a retrospective cohort study that was performed at 61 hospitals in the Netherlands and included patients who received at least 4 U of packed red blood cells (PRBCs) or fresh frozen plasma or platelets in addition to PRBCs. For the current study, women from the TeMpOH-1 study who underwent intrauterine balloon tamponade or uterine artery embolization for persistent PPH were included. Persistent hemorrhage was defined as continued bleeding during the first 24 hours after delivery that was unresponsive to first-line therapy, including the administration of at least 1 uterotonic drug. The cohort was also limited to patients that had an estimated blood loss (EBL) of 1000 to 7000 mL. The primary outcome measure was a composite of maternal death or maternal near miss averted by peripartum hysterectomy. Total EBL and total number of PRBCs transfused were secondary outcomes of the study. A logistic regression model was used for statistical analysis.
There were 373 women with EBL of 1000 to 7000 mL identified from the TeMpOH-1 database who were initially managed by intrauterine balloon tamponade and 82 initially treated with uterine artery embolization. Propensity scorematching was performed to include 50 women from each management group. For the propensity-matched cohort, the risk of the composite primary outcome was was not significantly different between the intrauterine balloon tamponade and uterine artery embolization groups with 6 (12%) in each group undergoing hysterectomy (odds ratio = 1.00; 95% confidence interval: 0.30-3.34). There were no maternal deaths in either treatment group. The median blood loss (4500 mL for balloon tamponade vs. 4000 mL for embolization, P = 0.382) and units of PRBCs transfused (median = 7 for balloon tamponade vs. 6 for embolization, P = 0.319) also did not differ significantly between groups. Of note, uterine artery embolization was ultimately performed in nearly a third (n = 15, 30%) of patients who were initially managed by intrauterine balloon tamponade.
In conclusion, this propensity-matched retrospective cohort study found that EBL, transfusion requirements and the need for hysterectomy were similar for women initially treated with intrauterine balloon tamponade or uterine artery embolization for persistent PPH. Since balloon tamponade is easier and less invasive, these investigators suggested that it should be considered as a viable first option in the management of persistent PPH. However, they pointed out that the small sample size did not allow equivalence of the 2 procedures to be demonstrated, and therefore, larger studies are needed comparing balloon tamponade with other management strategies.
T he World Health Organization has recommended uterine balloon tamponade (UBT) as one intervention for postpartum hemorrhage (PPH), a leading cause of maternal mortality worldwide. This is important for low-and middle-income countries (LMICs), where uterotonics, blood products, and skilled surgical teams may not be readily available. A few studies have reviewed the use of condom-catheter UBT in LMICs, but they have demonstrated conflicting findings or lacked robust evidence on its effectiveness. The aim of this study was to examine if condom-catheter UBT reduced maternal morbidity and mortality associated with PPH in LMICs.
This was a stepped-wedge, cluster-randomized trial conducted from October 2016 to March 2018 at 18 secondary-level public hospitals in Senegal, Egypt, and Uganda. The study population included women having a vaginal delivery who were treated for PPH at these hospitals or were referred to these hospitals for PPH after delivery elsewhere. Patients were excluded if they had a cesarean delivery or died before arrival to the study hospital. Data on PPH practices were collected in 3 consecutive phases during the trial: the baseline phase, to collect data on existing practices; the first intervention phase, where 9 sites began using condom-catheter UBT with the remaining sites serving as the control; and the second intervention phase, in which all 18 sites used UBT. Data collection each week included number of vaginal deliveries, number of women treated for PPH, blood transfusions, hysterectomies for PPH, and maternal deaths related to PPH. The primary composite outcome was PPHrelated maternal death and/or the need for invasive procedures.
There were 28,183 deliveries in the control group and 31,928 deliveries in the intervention group. Of these, 1357 (4.8%) women in the control group and 1037 (3.3%) women in the intervention group had PPH. Maternal death or the need for invasive procedures occurred in 19 cases in the control group and 37 in the intervention group (6.7/10,000 deliveries vs. 11.6/10,000 delivers, respectively; unadjusted incident rate ratio = 1.72, 95% confidence interval: 0.99-2.99). In the intervention group, UBT was used on 55 (5.3%) women-all of whom received uterotonics before UBT. In 25 of 48 (52.1%) cases with documentation, providers reported needing > 1 attempt before successful insertion (n = 15) and problems with balloon displacement (n = 10). Bleeding was controlled with UBT in 44 of all 55 cases in the intervention group.
In conclusion, there was an increase in PPH-related maternal deaths and/or use of invasive procedures associated with the introduction of UBT in LMICs. Caution should be exercised in determining the role of UBT in LMICs.

How Women Are Treated During Facility-Based Childbirth in Four Countries: A Cross-Sectional Study
With Labor Observations and Community-based Surveys