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Vacuum Induced Management of Hemorrhage Using Intrauterine Foley Catheter: A Report of Two Cases
Abstract
Hemorrhage is a common complication in both abortion and postpartum care. While most cases can be managed with uterine evacuation and uterotonic agents, some cases require additional surgical procedures. We present two cases, one of hemorrhage following dilation and evacuation, and the other of delayed postpartum hemorrhage, where a Foley catheter was used for vacuum-induced hemorrhage control.
Keywords: dilation and evacuation, case report, foley catheter, postpartum hemorrhage, vacuum-induced hemorrhage control
Introduction
Intrauterine devices for managing postpartum hemorrhage include tamponade and vacuum techniques. Hemorrhage is the most common complication from medication abortions, and one of the most common complications of procedural abortions. [1,2] The only FDA-approved vacuum device, Jada®, was studied in the setting of vaginal and cesarean births for immediate postpartum hemorrhage in patients who are at least 3cm dilated. [3] There is a need for easily accessible hemorrhage control techniques in both hospital and outpatient clinical settings for patients with lower gestational age. We describe two cases where a Foley catheter attached to suction provide vacuum-induced hemorrhage control during a second-trimester dilation and evacuation, and a delayed postpartum hemorrhage. Informed consent was obtained from both patients. This case series follows the CARE Guidelines.[4]
Case Reports
Case 1
A 34-year-old G7P1051 presented to the complex family planning office at 18 weeks 6 days by embryo transfer date, with a fetal demise measuring 15 weeks 4 days. The patient requested surgical management. Medical history included dysfibrinogenemia and a prior cesarean delivery. A hematology evaluation occurred on the day of presentation. The hemoglobin was 13.9 g/dL, platelets 203 K/uL, and fibrinogen 62 mg/dL. On the day of admission, the patient received 10 units of cryoprecipitate preoperatively. A dilation and evacuation was performed under ultrasound guidance with a 15 mm suction curette, removing the products of conception. Methylergonovine and carboprost were administered, but bleeding persisted due to coagulopathy. A 16 French Foley catheter (Bard, Covington, GA USA) was inserted into the uterine cavity and inflated with 35 mL of sterile saline (Image 1). It was then connected to 80 mmHg suction for vacuum-induced hemorrhage control. At that time, hemoglobin was 12.2 g/dL and fibrinogen was <35 mg/dL. The patient received 10 units of cryoprecipitate and 2 units of fresh frozen plasma. Once the bleeding was controlled, the patient was transferred to the postoperative area with the suction tubing clamped. The Foley catheter remained on suction for 15 hours with minimal bleeding and was then removed. The patient was discharged in stable condition on postoperative day 2.
Image 1: Placement of Foley catheter for intrauterine vacuum-induced hemorrhage control.
Case 2
A 33-year-old G2P2002 presented on postoperative day 6 following an uncomplicated term repeat cesarean delivery, reporting bright red vaginal bleeding and significant abdominal pain. The postpartum course had been unremarkable until then. Medical history included antepartum iron deficiency anemia, treated with iron and B12 supplementation and blood transfusions at 33 weeks gestation. The patient was followed by a hematologist during pregnancy for anemia. At presentation, the patient was hypertensive with a hemoglobin of 7.8 g/dL, platelets at 155K/uL, fibrinogen at 68 mg/dL. A repeat fibrinogen was 55 mg/dL. Maternal Fetal Medicine (MFM) was consulted and recommended administration of 10 units of cryoprecipitate. A CT scan and ultrasound revealed concern for an enlarged uterus with retained contents. Repeat labs showed hemoglobin 5.8 mg/dL, platelets 112 K/uL, and fibrinogen 193 mg/dL. The patient was taken to the operating room for a suction dilation and curettage under ultrasound guidance. The cervix was closed, and the uterus was 2 cm above the umbilicus. The cervix was dilated, and an 8mm suction curette was used to remove approximately 1500 mL of blood from the uterine cavity. Active bleeding persisted and atony was noted on ultrasound despite treatment with carboprost, misoprostol, and oxytocin. A 16 French Foley catheter was inserted into the uterine cavity, inflated with 35 ml of sterile saline, and connected to 80 mmHg suction for vacuum-induced hemorrhage control. Once stable, the patient was transferred to the interventional radiology suite for uterine artery embolization with the suction tubing attached to a bulb suction. In total 4 units of red blood cells, 4 units of fresh frozen plasma, and 1 pack of platelets, 10 units of cryoprecipitate were administered for resuscitation. The foley was removed 12 hours post-procedure, with remaining atony of the lower segment which was treated with uterotonic agents. The bleeding was stable on postoperative day 0, following dilation and curettage and uterine artery embolization. The patient was admitted 4 additional days for management of severe preeclampsia.
Comment
Current interventions for managing hemorrhage at early gestational ages or with delayed postpartum hemorrhage beyond uterotonics are limited. Previous studies have shown that vacuum-induced hemorrhage control with devices like the Jada® and Bakri® can be beneficial [2,3,5]. Vacuum-induced hemorrhage control devices have been associated with fewer blood transfusions and massive transfusion protocol activation[6]. However, these devices are not always available and may not be suitable for abortions, early preterm deliveries, or delayed hemorrhages. Recommendations for managing hemorrhage during abortion include tamponade techniques using a Foley balloon or Bakri®, but do not mention vacuum-induced hemorrhage control methods.[2] A recent review highlighted only the suction tube uterine tamponade as a readily available option for such hemorrhages, though it requires manual stabilization.[7]
In our case series, we used a Foley catheter, suction tubing, a connector, and suction to create an intrauterine vacuum for hemorrhage control (Image 2). This approach demonstrates the effectiveness of using commonly available equipment in both surgical and clinic settings to manage hemorrhage at early gestational ages and in the delayed postpartum period when uterotonics are ineffective.
Image 2: Supplies required to use foley for vacuum-induced hemorrhage control: Cardinal HealthTM Non-conductive suction tubing (connector included), and Bard 16 French 30cc Foley Catheter
References
[1] Spingler T, Sonek J, Hoopmann M, Prodan N, Abele H, Kagan KO. Complication rate after termination of pregnancy for fetal defects. Ultrasound in Obstetrics & Gynecology 2023;62:88–93. https://doi.org/10.1002/uog.26157.
[2] Kerns JL, Brown K, Nippita S, Steinauer J. Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion. Contraception 2024;129. https://doi.org/10.1016/j.contraception.2023.110292.
[3] Goffman D, Rood KM, Bianco A, Biggio JR, Dietz P, Drake K, et al. Real-World Utilization of an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device. Obstetrics & Gynecology 2023;142:1006. https://doi.org/10.1097/AOG.0000000000005366.
[4] Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: explanation and elaboration document. Journal of Clinical Epidemiology 2017;89:218–35. https://doi.org/10.1016/j.jclinepi.2017.04.026.
[5] Haslinger C, Weber K, Zimmermann R. Vacuum-Induced Tamponade for Treatment of Postpartum Hemorrhage. Obstetrics & Gynecology 2021;138:361. https://doi.org/10.1097/AOG.0000000000004510.
[6] Gulersen M, Gerber RP, Rochelson B, Nimaroff M, Jones MDF. Vacuum-Induced Hemorrhage Control versus Uterine Balloon Tamponade for Postpartum Hemorrhage. Journal of Obstetrics and Gynaecology Canada 2023;45:267–72. https://doi.org/10.1016/j.jogc.2023.02.017.
[7] Overton E, D’Alton M, Goffman D. Intrauterine devices in the management of postpartum hemorrhage. American Journal of Obstetrics and Gynecology 2024;230:S1076–88. https://doi.org/10.1016/j.ajog.2023.08.015.