OBSTETRICS AND GYNECOLOGY/CASE REPORT

Balloon Compression as Treatment for Refractory Vaginal Hemorrhage

Nathaniel Ryan Schlicher, MD, JD
From Wright State University, Emergency Medicine, Kettering, OH.

Severe vaginal hemorrhage is a rare presenting condition but serious life threat in the emergency department (ED). Initial management has historically been limited to vaginal packing, uid resuscitation, and emergency surgical intervention. An alternative approach to therapy is presented that can be effectively deployed in the ED. In the present case, balloon compression of the vaginal mucosa was successful in arresting life-threatening hemorrhage. The patient survived subsequent hemodynamic stabilization and surgical intervention and was ultimately discharged home. [Ann Emerg Med. 2008;52: 148-150.]
0196-0644/$-see front matter Copyright 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2008.04.001

INTRODUCTION
Severe vaginal hemorrhage is a potentially life-threatening condition. Denitive control of severe hemorrhage is difcult to perform in the emergency department (ED). Vaginal packing with gauze or sterile towels has been the standard approach to hemorrhage control. When packing fails, however, there is little more that can be performed by the emergency physician. We present a case of severe vaginal hemorrhage that was controlled with balloon compression.

CASE REPORT
A 62-year-old white woman presented to the ED at a large regional medical center with 5 days of vaginal bleeding. She had been diagnosed with ovarian cancer 17 years earlier. She was status post complete hysterectomy, pelvic radiation, and multiple rounds of chemotherapy since her initial diagnosis. She presented with vaginal spotting for 4 days that had increased to the point of changing a pad hourly for the 12 hours before admission. Results of a review of systems on presentation were positive for difculty standing and feelings of lightheadedness but negative for easy bruising or bleeding from any other site. Additional medical history included hypertension, deep venous thrombosis, and pulmonary embolism. Surgical history included cesarean section, complete hysterectomy with bilateral salpingo-oophorectomy, bilateral nephrostomy, thoracostomy, pleurodesis, and bilateral ureteral stents. Her medications included vitamin B6, triamterene, metoclopramide hydrochloride, and allopurinol. Her social history included a supportive husband who had been caring for her at home. The patient denied tobacco, alcohol, or drug use. In the ED, initial vital signs included blood pressure 128/74 mm Hg, pulse rate of 130 beats/min, and respiratory rate 24 148 Annals of Emergency Medicine

breaths/min, reecting compensated hemorrhagic shock. Initial evaluation showed a tachycardic, pale, but alert woman. There was no abdominal tenderness. Vaginal examination revealed a steady stream of hemorrhage from the vaginal canal near the level of the vaginal cuff. A friable mass was observed on the anterior vaginal wall on palpation that could not be visualized directly. Her gynecologist was consulted by the emergency physician. The gynecologist repeated the physical examination and replaced the vaginal packing after the original packing placed by the emergency physician did not achieve hemostasis. However, the patient continued to bleed, resulting in tachycardia, profound hypotension (systolic blood pressure in the fties), and mental status decrease during the ensuing hour, consistent with decompensated hemorrhagic shock. Initial hemoglobin level tested on arrival in the ED was 13.2 g/dL. While in the ED, she was resuscitated with 3 L of isotonic crystalloid, 6 units of packed RBCs, 6 units of fresh frozen plasma, and a 10-pack of platelets through an introducer placed in the right femoral vein. A left femoral arterial catheter was placed for continuous hemodynamic monitoring. She was temporarily stabilized with resolution of the hypotension (systolic pressures between 110 and 119 mm Hg) and improvement in mentation. The general surgeon and gynecologist both stated that surgical intervention was unlikely to be successful, given the patients critical condition and the friable nature of the bleeding site. She was transported to the interventional radiology suite for internal iliac artery embolization. While in the suite, she received an additional 2 units of packed RBCs and 4 more units of fresh frozen plasma. Minimal blush was observed on initial uoroscopy with contrast, but given the patients critical condition, the
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Schlicher

Balloon Compression for Refractory Vaginal Hemorrhage The Zassi tube was deated 12 hours later and left in the vaginal vault for 1 hour, and when no further bleeding was observed, it was removed. Hemoglobin level at that time was 9.5 g/dL. The patients vital signs remained stable. No further life-threatening vaginal hemorrhage was observed on her hospitalization. An enterovaginal stula was discovered on hospital day 6 and a diverting colostomy was performed on ICU day 11. She was discharged from the hospital on ICU day 20 in good clinical condition to independent care.

DISCUSSION
Cases of severe hemorrhage requiring hemodynamic stabilization and resuscitation are relatively rare and account for less than 1% of all gynecologic consultations from the ED.1 The treatment options for signicant vaginal hemorrhage are limited in the ED. In the setting of large-volume bleeding without pregnancy, the approach is limited to hemodynamic stabilization and rapid referral to gynecology. Vaginal packing with gauze and other absorptive material has been the hallmark of emergency management of profuse vaginal hemorrhage. However, there have been no studies that document the effectiveness of this approach. Although the concept is sound from the emergency treatment of hemorrhage in other locations, there are serious issues about effectiveness, given the dynamic muscular tone of the vaginal vault. Gauze packing has been extended to other gynecologic conditions, including intra-abdominal pelvic packing associated with surgical procedures intraoperatively,2 intrauterine packing for postpartum hemorrhage3 and vaginal lacerations from trauma.4 During the past 3 decades, with the expansion of interventional radiology, the option for embolization of the internal iliac artery has been used for profuse vaginal bleeding in a variety of settings.5-8 However, as in this case, embolization can be effective only when the source of the bleeding can be identied and reached intravascularly. When there is an aberrant bleeding source, such as in the case of pelvic tumors, the efcacy of arterial embolization has not been demonstrated. Surgical exploration and intervention is an alternative to obtain direct control of bleeding in the pelvis in some cases. This approach results in the standard operative risks, including anesthesia-associated complications and risks of an open laparotomy. In the patient with hemorrhagic shock, this may not be safe. The surgeon and gynecologist involved in the case both thought that surgical intervention was unlikely to be successful, given that the patient was receiving chemotherapy and had a high risk of disseminated intravascular coagulation from the large-volume transfusions. Furthermore, given the likelihood that the site had extensive tumor burden, it was thought that surgical control would not be possible because of the large mucosal area of bleeding observed in the vaginal vault and associated with the mass. The use of alternative compression devices has not been explored extensively in the patient with vaginal bleeding. The literature does include case reports of use of a variety of measures for compression in postpartum uterine hemorrhage,
Annals of Emergency Medicine 149

Figure. Zassi Bowel Management system with cuff inated with 25 cc of air.

embolization of bilateral internal iliac arteries was performed. She remained transiently stable throughout the procedure and was transported to the ICU for medical management. Five hours after her arrival in the ED and 1 hour after her admission to the ICU, she experienced another episode of hypotension associated with continued vaginal hemorrhage, consistent with refractory hemorrhagic shock. A quadruplelumen catheter was placed and 3 additional units of packed RBCs and 2 L of isotonic crystalloid were given. Total resuscitation efforts since arrival 6 hours before included 5 L of isotonic crystalloid, 11 units of packed RBCs, 10 units of fresh frozen plasma, and a 10-pack of platelets. At that time, the vaginal packing remained ineffective in controlling the hemorrhage, as indicated by the persistent hypotension and continued bleeding from the vaginal vault through and around the packing material. A deated Zassi Bowel Management System (Zassi Medical Evolutions, Fernandina Beach, FL) (rectal tube), shown in the Figure, was placed intravaginally. Approximately 25 mL of saline solution were infused into the balloon to achieve rm pressure on the vaginal walls at the site of the friable mass previously palpated. Hemorrhage ceased immediately. The patient remained stable throughout the night, having no additional hypotensive episodes. She continued receiving her maintenance uids at 150 mL per hour, received a dose of cryoprecipitate, and received 4 additional units of fresh frozen plasma for a small increase in her prothrombin time and partial thromboplastin time that developed at her last hypotensive episode when the rectal tube was placed. The coagulopathy resolved 6 hours later on repeated laboratory testing after the fresh frozen plasma and cessation of vaginal hemorrhage. Two units of packed RBCs were given to correct a hemoglobin level of 8.5 g/dL tested 1 hour after placement of the rectal tube. Repeated abdominal examinations did not show any increase in tenderness or evidence of peritonitis from bleeding into the abdomen.
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Balloon Compression for Refractory Vaginal Hemorrhage including the Sengstaken-Blakemore tube,9 a rubber catheter tted with a condom for uterine compression,10 balloon compression,11 and Foley catheter.12 There is a case report out of the United Kingdom that describes balloon tamponade for vaginal lacerations with severe hemorrhage as a result of postpartum hemorrhage.13 In this case we used a Zassi rectal tube off label for vaginal hemorrhage tamponade. The Zassi Bowel Management System is used in the setting of severe diarrhea and rectal incontinence for bowel management (Figure). Similar in function to a Foley catheter, the rectal tube is placed into the rectal vault, with a balloon on the distal insertion end to seal the rectal vault. There is a central opening in the balloon that allows for drainage of the fecal material. In the present case, the balloon meant to seal the rectal vault has a generous reservoir that created an effective tamponade with the vaginal wall but was not large enough to cause redundancies in the balloon that might make for less effective deployment. The surface of the balloon is a nonadherent polymer that we hypothesized would not create strong attachments to formed clots on removal of the tube. The balloon could be palpated as it was inated to ensure that there was not excessive pressure on the vaginal mucosa. With the transparent central tube, we were able to monitor for bleeding around the balloon and detect whether deployment in a different position would be necessary. Given the abrupt improvement in patient condition observed after the deployment of the balloon, it was the teams belief that this was the cause of her stabilization. The development of the enterovaginal stula could be considered a complication, given its physical and temporal proximity, but given its well-formed tract discovered in surgery, it is more likely that it existed before the balloon ination. Given the brisk bleeding and presence of the stula, it is reasonable to hypothesize that a marginal branch of the colon may have been the cause of the vaginal bleeding. In that case, it would account for the failure of the internal iliac embolization and success of direct compression on the bleeding artery. The present case of extreme vaginal hemorrhage from an aberrant bleeding source is a rare occurrence in the presentation of the ED patient. In this case, vaginal packing was not successful in controlling the hemorrhage. Vaginal tamponade with deployment of a rectal tube balloon provided an effective alternative in this case of bleeding below the uterus. Further research and development of targeted mucosal compression devices should be considered as an alternative for primary hemorrhage control.
Supervising editor: Judd E. Hollander, MD

Schlicher
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, nancial, and other relationships in any way related to the subject of this article that might create any potential conict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specic conicts covered by this statement. Publication dates: Received for publication February 28, 2008. Revision received March 28, 2008. Accepted for publication April 2, 2008. Available online May 12, 2008. Reprints not available from the author. Address for correspondence: Nathaniel Schlicher, MD, JD, 3525 Southern Blvd, Kettering, OH 45429; 937-395-8839, fax 937-395-8387; E-mail schlicnr@yahoo.com.

REFERENCES
1. Sau AK, Dhar KK, Dhall GI. Nonobstetric lower genital tract trauma. Aust N Z J Obstet Gynaecol. 1993;33:433-435. 2. Ramsewak S, Sohan K, Ramdass MJ, et al. Gauze packing for aspirin-induced hemorrhage in vaginal hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15:59-60. 3. Hsu S, Rodgers B, Lele A, et al. Use of packing in obstetric hemorrhage of uterine origin. Reprod Med. 2003;48:69-71. 4. Lacy J, Brennand E, Ornstein M, et al. Vaginal laceration from a high-pressure water jet in a prepubescent girl. Pediatr Emerg Care. 2007;23:112-114. 5. Rosenthal DM, Harkins JL, Garzo G, et al. Management of postoperative vaginal hemorrhage. Obstet Gynecol. 1983;61(3 suppl):42S-46S. 6. Villella J, Garry D, Levine G, et al. Postpartum angiographic embolization for vulvovaginal hematoma. A report of two cases. J Reprod Med. 2001;46:65-67. 7. Chin HG, Scott DR, Resnik R, et al. Angiographic embolization of intractable puerperal hematomas. Am J Obstet Gynecol. 1989; 160:434-438. 8. Pelage JP, Le Dref O, Mateo J, et al. Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology. 1998;208:359-362. 9. Seror J, Allouche C, Elhaik S. Use of Sengstaken-Blakemore tube in massive postpartum hemorrhage: a series of 17 cases. Acta Obstet Gynecol Scand. 2005;84:660-664. 10. Akhter S, Begum MR, Kabir Z, et al. Use of a condom to control massive postpartum hemorrhage. Med Gen Med. 2003;5:38. 11. Dabelea V, Schultze PM, McDufe RS. Intrauterine balloon tamponade in the management of postpartum hemorrhage. Am J Perinatol. 2007;24:359-364. 12. Marcovici I, Scoccia B. Postpartum hemorrhage and intrauterine balloon tamponade. A report of three cases. J Reprod Med. 1999;44:122-126. 13. Tattersall M, Braithwaite W. Balloon tamponade for vaginal lacerations causing severe postpartum hemorrhage. BJOG. 2007; 114:647-648.

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