Evidence Gaps in the Management of Intrauterine Hemorrhage-Control Device Failure for Atonic Postpartum Hemorrhage

Intrauterine hemorrhage-control devices are key second-line therapeutic interventions for refractory postpartum hemorrhage (PPH) due to uterine atony. Less is known about the detection and clinical management of failure of 2 commonly used devices: intrauterine balloon tamponade, in particular the Bakri device, and the Jada device (a vacuum-induced hemorrhage control device).

This narrative review describes the epidemiology and management challenges of the failure of intrauterine balloon tamponade and the Jada device.

Original research, review articles, and PPH guidelines.

Unsuccessful arrest of bleeding requiring invasive intervention is 11-12% for intrauterine balloon tamponade, and 7.5% among vaginal deliveries using the Jada device, and 16.3% among cesarean deliveries using the Jada device. Rates of transfusion and hysterectomy in patients who receive intrauterine balloon tamponade are 36% and 6%, respectively. Patients' risk of intrauterine hemorrhage-control device failure may not be easily determined prior to device placement. There is a paucity of information in national and international PPH guidelines for the detection and management of intrauterine hemorrhage-control device failure. For intrauterine balloon tamponade, caudal prolapse or balloon sliding into the vagina can occur in 10-15% of cases, and the risk of hemorrhage-related morbidity is associated with balloon volume >350 mL. Point-of-care hemodynamic and hemostatic monitors can provide early warning signs of ongoing hemorrhage and maternal compromise when a diagnosis of intrauterine hemorrhage control device failure is delayed or missed.

Expert consensus is needed to develop device-specific criteria for the diagnosis and early management of intrauterine hemorrhage-control device failure.