Placement of a cervical cerclage postpartum allows retention of a uterine tamponade balloon in women with a dilated cervix. This novel indication for a cervical cerclage may be a useful adjunct to intrauterine balloon catheter in management of postpartum uterine hemorrhage.
In cases of postpartum hemorrhage, first-line treatment includes uterotonic agents with or without procedures aimed at achieving uterine tamponade. The importance of this approach lies in potentially avoiding more radical surgical procedures such as uterine/hypogastric artery ligation or hysterectomy that are associated with a higher risk of surgical and hematological complications.
A 32 year old gravida 2 para 1 at 32 weeks’ gestation, with antenatal diagnosis of multiple fetal anomalies including bilateral renal agenesis, omphalocele, and an imperforate anus, underwent induction of labor for termination of pregnancy.
After delivery of the baby, with a retained placenta for around 5 hours, the patient was taken to the operating room for manual removal under general anesthesia. A partial placenta accreta was encountered, with small fragments of the placenta remaining attached to left upper uterus. Oxytocin administration led to appropriate uterine contractions. However, significant hemorrhage continued, likely as a result of an abnormal placental bed because of placenta accreta and residual placental fragments. A Bakri postpartum balloon (Cook Medical, Bloomington, IN) was placed through the cervix into the uterine cavity to arrest blood loss through tamponade. Attempts to inflate the balloon resulted in prolapse of the catheter through the dilated cervix ( Figure , A).
Because the likely cause of failure of the balloon catheter was the dilated cervix, after replacing a deflated catheter in the uterine cavity, a cervical cerclage was placed using #1 Prolene (Ethicon, Somerville, NJ) ( Figure , B). Then the balloon was gradually inflated with 300 mL of saline. The balloon remained in place and the hemorrhage abated. The patient’s hemoglobin dropped from 13.8 to 7.1 g/dL. However, she remained stable and declined a blood transfusion. The catheter and the cerclage were removed after 32 hours. The patient went on to have a vaginal delivery of a healthy girl in her next pregnancy a year later.
Despite significant advances in obstetrics over several decades, postpartum hemorrhage remains one of the leading causes of maternal morbidity and mortality. Major postpartum hemorrhage is a serious and rapidly progressive clinical condition with a high risk of adverse outcomes including maternal death if not managed in a timely and effective manner.
The technique of uterine tamponade has evolved with time. The use of uterine packing has been replaced by balloon catheters. The basic principle involves the placement of a balloon catheter in the uterine cavity and distending it with saline (or air), which serves to tamponade the bleeding surface, thereby arresting hemorrhage. This conservative approach is recommended because of the inherent risks of more radical surgical procedures such as uterine/hypogastric artery ligation and hysterectomy. In addition, if hysterectomy has to be resorted to, loss of fertility is an important issue for most of the patients.
A problem often encountered with the use of intrauterine balloon catheters is prolapse of the balloon through a dilated cervix with increasing distension of the balloon. Uterotonics or compression sutures such as B-Lynch, used to help the uterine wall provide counter pressure around the balloon, also contribute to expulsion of the balloon in the presence of any significant cervical dilation.
The use of a vaginal pack to support the balloon has been described but is usually not very effective. Cervical cerclage was successful in closing the uterine cervix and maintaining the balloon within the uterine cavity. The balloon could then be distended to an adequate pressure, allowing effective tamponade of the bleeding surface of the uterus. Ongoing postpartum hemorrhage was arrested and any other surgical procedures were avoided in this woman, who wanted to preserve future fertility.
The use of postpartum cervical cerclage is proposed in cases in which there is difficulty in correctly placing an intrauterine balloon catheter to control postpartum hemorrhage. The catheter can be left in place for up to 48 hours and antibiotic prophylaxis should be used. The stitch may be removed at the time of removal of the balloon catheter or at a later date. Although intrauterine balloon catheter with or without cervical cerclage can be used as a definitive procedure, it may also have a role as a temporizing measure pending other interventions such as uterine arterial embolization or hysterectomy. However, concealed intrauterine hemorrhage is a potential complication of all uterine tamponade procedures and must be recognized and managed in a timely fashion.
Cervical cerclage as an adjunct to intrauterine balloon catheter may also have a role in hemorrhage associated with gynecologic conditions such as hysteroscopic procedures, surgical terminations of pregnancy, and cervical pregnancy.