Disseminated intravascular coagulation (DIC) is an uncommon but potentially catastrophic complication of postpartum hemorrhage. We describe two cases of massive postpartum hemorrhage complicated by DIC that were successfully temporized with combined use of the Bakri balloon and nonpneumatic antishock garment (NASG) during massive transfusion. In the first case, a healthy, term gravida underwent emergent cesarean for fetal bradycardia during labor induction. 10 minutes after completion of surgery, brisk vaginal hemorrhage of nonclotting blood from fulminant DIC resulted in maternal shock. A Bakri balloon and NASG were placed during massive transfusion, resulting in rapid maternal stabilization. In the second case, a healthy, term gravida suffered an amniotic fluid embolism during labor requiring emergent cesarean delivery and complicated by cardiac arrest with successful resuscitation. Postoperative rapid uterine bleeding from DIC was treated with a Bakri balloon and NASG, stabilizing the patient during massive transfusion. Neither patient required further surgical procedures. NASG combined with Bakri balloon may serve as a valuable nonoperative treatment or temporization option in cases of massive postpartum hemorrhage complicated by coagulopathy such as these. Further study of the utility of NASG in high-resource settings is warranted.
Disseminated intravascular coagulation (DIC) is an uncommon but potentially catastrophic complication of postpartum hemorrhage. Operative interventions, such as laparotomy for uterine compression suture placement or for hysterectomy, may increase blood loss in an already unstable patient if not preceded by rapid whole blood, platelet, and clotting factor replacement.
We describe here two cases of massive postpartum hemorrhage complicated by DIC diagnosed after completion of cesarean delivery that were successfully temporized nonsurgically with combined use of the Bakri balloon (Cook Medical, Bloomington, IN) and nonpneumatic antishock garment (NASG) (Zoex NIASG, Coloma, CA).
DIC is an uncommon but potentially lethal complication of massive postpartum hemorrhage characterized by widespread activation of procoagulant activity, fibrinolysis, depletion of clotting factors, and end-organ damage. In obstetrics, inciting causes include placental abruption, postpartum hemorrhage, preeclampsia, acute fatty liver of pregnancy, sepsis, and amniotic fluid embolism [
In the current case report, we describe combined use of the nonpneumatic antishock garment (NASG) and the Bakri postpartum balloon in two cases of massive postpartum hemorrhage with shock from fulminant DIC. We attribute the successful outcomes without need for further operative interventions to the combined effects of recentralization of circulating volume to treat shock and external and internal uterine compression which slowed uterine blood loss sufficiently to allow definitive treatment with fluid, blood, and clotting factor transfusion. Importantly, the combination of NASG and Bakri balloon was relatively low cost, nonoperative, and nonpharmaceutical and allowed ongoing close monitoring of maternal bleeding and hemodynamic status, without precluding the options for additional operative or medical interventions, such as recombinant factor VII, hysterectomy, or uterine artery embolization, had they been deemed necessary.
Numerous case series and several quasirandomized trials have described use of the NASG for treatment of hemorrhagic shock from massive postpartum hemorrhage, where its use in developing countries was associated with a 38% reduction in odds of maternal death from hemorrhage [
Nonpneumatic antishock garment worn in demonstration by the author (MB).
Several prior reports have described successful use of the Bakri balloon together with uterine compression sutures in the so-called “uterine sandwich” [
Reports of NASG use in high-resource settings, where transfusion, medical and surgical treatments are generally widely available, are virtually nonexistent. Larger case series and five recent quasirandomized trials were conducted in low resource care settings in Pakistan, Nigeria, Egypt, Zambia, Zimbabwe, and India (notably without concomitant use of a Bakri balloon), where blood transfusion is either not available or significantly delayed [
In contrast to a pneumatic inflatable antishock garment, which may risk complications from overinflation, adverse outcomes reported with the use of NASG are infrequent and were found to be similar before and after NASG usage [
Published reports as well as the author’s personal experience do not indicate that wearing the NASG is painful for the patient. In the current cases, pain management was not complicated by use of the Bakri and NASG together, although, in both cases, the patients were not ambulatory during this interval and had bladder catheters in place. In both cases, intrauterine location of the Bakri balloon was confirmed by ultrasound after placement of the NASG to ensure it had not been expulsed by application of the NASG; in the second case, the Bakri had to be deflated and replaced. Both devices were removed in the current cases after approximately 24 hours, which corresponded to confirmed hemodynamic stability and normalization of clotting status. In both cases, the NASG was removed first, although it seems unlikely that the order of removal would affect success rates. Removal of the NASG was performed per manufacturer’s recommendations: progressively beginning with the feet sections, waiting 15 minutes for equilibration between sections, and monitoring pulse and blood pressure closely.
In summary, NASG combined with Bakri balloon was successfully employed in two cases of massive postpartum hemorrhage complicated by DIC. Further study of the utility of NASG in high-resource settings is warranted.
The authors declare that there is no conflict of interests regarding the publication of this paper.