1. Evaluating the efficacy of the B-lynch suture and the Bakri balloon, or both, in the treatment of severe post-partum haemorrhage Dr Ashleigh Smith Junior House Officer, RBWH

2. Case 24 y/o G1P1 has a ‘PPH’ How do you know it is a PPH? Remember : – Tissue, Tone, Trauma, Thrombin What can you do about it?

3. Post Partum Haemorrhage Primary: >500mL’s EBL within the first 24 hours after delivery Secondary: >500mL’s EBL from 24hours to 6 weeks post delivery.

4. Medical Treatment of PPH Active management of the third stage IV 5 I.U. oxytocin IV/IM Ergometrine 250 microg Oxytocin infusion (40 in 1L) PR Misoprostol Intramyometrial PGF2alpha

5. What if Medical Management FAILS!?!?! Depends on the clinical situation Open or closed abdomen? Does the woman want a hysterectomy?

8. What if they Fail!? Hysterectomy? Can we try anything else???

9. Using both B-lynch and Bakri? A novel concept aka “uterine sandwich” If one fails in isolation, perhaps go on and try the combination as ‘3 rd line’ after – Medical management – Bakri OR B-kynch – Both

10. How about a “uterine sandwich?” Few trials available, some are very promising QLD guidelines for PPH management : “insufficient evidence to support use of combined balloon tamponade with the B- lynch suture.”

11. My Research…. A retrospective case study at RBWH all women who had a PPH and insertion of either – B-lynch suture or – Bakri balloon, or – both, between Jan 2009 – Dec 2013.

12. Please note…. If anyone received “both,” that means they failed the b-lynch or the bakri Therefore it is a very serious PPH and a more tenuous cohort/clinical situation

13. Cohort 97 cases of PPH occurred in which medical therapy alone failed.

14. What type of Birth?

15. Primary vs Secondary PPH

16. Results 7 emergency hysterectomies in the study No mortalities

17. Hysterectomy Patients

18. What about the “sandwich!?” 5 of the 9 patients treated with ‘the uterine sandwich’ went on to hysterectomy Is that bad??? – Bakri = 95% success – B-lynch = 100% success – Both ………….. 44% success

19. Conclusions Bakri and B-lynch suture = highly effective in terminating PPH when medical therapy alone fails. ‘Uterine sandwich’ appears to be an effective option to trial in an effort to avoid hysterectomy. Need clear stepwise PPH guidelines

20. Thank you! References: 1.Gronvall M, Tikkanen M, Tallberg E, et al. Use of Bakri balloon tamponade in the treatment of postpartum hemorrhage: a series of 50 cases from a tertiary teaching hospital. Acta Obstet Gynecol Scand. 2013; 92(4): 433-438. 2.2. Gao, Y., Wang Z., Zang J., et al. Efficacy and safety of intrauterine Bakri balloon tamponade in the treatment of postpartum hemorrhage: a multicenter analysis of 109 cases. Zhonghua Fuchanke Zazhi, 2014; 49(9): 670-675. 3. Liu S, Mathur M, Tagore S. Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience. Journal of Obstetrics and Gynaecology, 2014; 34(5): 383-386. 4. Kaya B, Tuten A, Daglar K, et al. B-Lynch uterine compression sutures in the conservative surgical management of uterine atony. Arch Gynecol Obstet, 2014; 291(5):1005-14. 5. Diemert A, Ortemeyer G., Hollwitz B, et al. The combination of the intrauterine balloon tamponade and b-lynch procedure for the treatment of severe postpartum hemorrhage, Am J Ostet Gynecol, 2012; 206(1):61-64. 6. Yoong W, Ridout A, Memtsa M, et al. Application of uterine compression suture in association with intrauterine balloon tamponade ('uterine sandwich') for postpartum hemorrhage. Acta Obstet Gynecol Scand, 2012; 91(1): 147-151. 7. Chan L, Lo T, Lau W, et. al. Use of second-line therapies for management of massive primary postpartum hemorrhage. Int J Gynecol Obstet, 2013; 122(3): 238–243.