Managing Spontaneous Abortion Hemorrhage: An Adult Simulation Case for Emergency Medicine Residents

This simulation is intended for emergency medicine residents, PGY 1-4.

Postpartum hemorrhage (PPH) is defined as cumulative blood loss ≥1000 mL or any postpartum bleeding with signs of hypovolemia within 24 hours of delivery. Post-abortion hemorrhage (PAH) has no single universally adopted numeric definition but clinically is defined as excessive bleeding following spontaneous or induced abortion that results in hemodynamic instability, need for transfusion, hospital admission, or procedural intervention. Due to its rarity, PAH may be underrecognized and thus is the target of this simulation. The emergency department is the country's reproductive health safety net. With the decline of labor and delivery units and on-call, in-house OB/GYN consultants, emergency clinicians must be equipped to recognize and manage these cases.1 Effective management of these cases includes uterotonic medications and uterine tamponade devices like the Bakri balloon.2 There is mixed evidence on the use of Bakri balloons for post-abortion hemorrhage, with some hospitals moving towards vacuum-assisted devices (e.g. JADA).3 However, they have remained relevant in non-OB settings and institutions with limited obstetrical support.4-6 This simulation aims to address a gap in training for PAH for emergency medicine residents, focusing on the placement of the Bakri balloon.

By the end of this simulation, learners should be able to: 1) recognize signs of post-abortion hemorrhage, 2) manage hemorrhage using appropriate physical maneuvers, uterotonic medications, and specialist consultation, 3) demonstrate proper placement of a Bakri balloon.

This single-center, high-fidelity simulation was conducted at a tertiary care academic center. Simulation was chosen as the best way to teach this topic because it allows a psychologically safe environment to practice a scenario which involves high-level critical thinking and fine-motor skills that would otherwise degrade under stress during a real patient encounter.

Pre- and post-simulation surveys were administered, including Likert-scale questions on comfort with the management and procedures included, and a multiple-choice knowledge assessment. Twenty-eight individuals completed the pre-simulation learner evaluation, and 31 completed the post-simulation learner evaluation. Likert-scale data was treated as ordinal (1 = strongly disagree, 5 = strongly agree) and analyzed using the Mann-Whitney U Test. The multiple-choice knowledge assessment was analyzed using a paired T-test.

The simulation included 29 emergency medicine residents, four MS3 students, four MS4 students, and three junior EM PA fellows. This case was used eight times during the session. The simulation lasts approximately 20 minutes. There were statistically significant improvements across all measures. On a 5-point Likert scale, comfort in placing a Bakri balloon increased from 2.35 to 3.97 (U = 82, z = 5.34, P < 0.01); comfort in managing postpartum/abortion hemorrhage rose from 3.11 to 3.90 (U = 197, z = 3.59, P < 0.01), and recognition of hemorrhage signs increased from 3.96 to 4.39 (U = 278, z = 2.36, P = 0.02). Mean scores on the multiple-choice knowledge assessment improved from 55.79% to 90.52% (t(18) = -5.23, P < 0.001) pre- and post-intervention.

This simulation successfully addressed the gap in the educational materials available to address the learning of the recognition and management of PPH/PAH, including the placement of intrauterine balloon devices. The simulation increased learners' comfort in managing PAH and placing Bakri balloons. While effective for immediate skills/knowledge acquisition, this is a high-acuity, low-occurrence procedure that requires repetition and deliberate practice for more durable learning.

Postpartum hemorrhage, post-abortion hemorrhage, Bakri balloon, uterine tamponade, simulation training.