Use of intrauterine application of chitosan-coated tape in the management of postpartum hemorrhage

Maternal mortality remains a pressing global health issue that requires comprehensive solutions, as confirmed by the World Health Organization (WHO) [1]. Every year, thousands of women worldwide experience severe complications during pregnancy, childbirth, and the postpartum period, making this problem a top priority in healthcare [2, 3]. The leading causes of maternal death in the postpartum period include massive hemorrhage (particularly postpartum hemorrhage), infectious complications leading to septic shock, hypertensive disorders of pregnancy (preeclampsia and eclampsia), and the consequences of unsafe abortions. Statistical data indicate that postpartum hemorrhage is the most frequent cause of maternal mortality [4]. Therefore, prevention and timely management are key priorities in modern obstetric practice [5].

Notably, hypotonic uterine bleeding accounts for up to 70% of all cases of postpartum hemorrhage. This type of bleeding develops due to inadequate uterine contractions, which disrupts physiological hemostasis. The primary mechanism for arresting postpartum hemorrhage is uterine contraction, which compresses the blood vessels at the placental site [6–9].

In contemporary obstetrics, uterotonic agents and procoagulant therapy are widely used to control postpartum bleeding. However, in cases of massive hemorrhage, conservative management may be insufficient [10]. Additional interventions include intrauterine balloon tamponade and external elastic compression of the uterus [11].

According to the current WHO clinical recommendations, uterine balloon tamponade should be applied when first-line measures fail to achieve hemostasis. Timely diagnosis and selection of the most effective method for hemorrhage control in individual cases remain critical [12].

A comparative study by Chinese investigators evaluating the efficacy of intrauterine balloon tamponade versus surgical hemostasis (B-Lynch compression sutures and uterine artery ligation) revealed no significant differences in total blood loss or the frequency of blood transfusions [13]. Nonetheless, despite the effectiveness of these interventions, certain clinical situations necessitate more innovative approaches to manage massive postpartum hemorrhage [14–16].

As noted by Kurtser M.A. et al., when conservative measures fail, it is necessary to escalate to more invasive procedures, such as compression sutures, ligation of major pelvic arteries, or embolization of uterine vessels. If these methods are unsuccessful, hysterectomy is performed as a life-saving measure [17–19].

In the search for more effective and minimally invasive techniques to control postpartum hemorrhage, researchers have explored the use of chitosan-impregnated gauze tamponades [20–22]. This method achieves hemostasis through a combined mechanism involving both mechanical compression and biochemical interactions between chitosan molecules and blood cells [23].

Chitosan, derived from the shells of marine crustaceans or the cell walls of certain fungi, possesses pronounced hemostatic properties [24]. It is obtained through the partial deacetylation of chitin, enabling interactions with blood components and promoting the formation of pseudoclot. As a natural biopolymer, chitosan can function as a coagulating agent owing to its structural characteristics [25]. Furthermore, chitosan is biocompatible, safe for human use, and exhibits moderate antimicrobial activity. The hemostatic mechanism is based on several effects: absorption of plasma fluid, erythrocyte aggregation, platelet adhesion, aggregation, and activation.

Chitosan can absorb 50–300% of its initial mass in liquid, depending on its molecular weight and the degree of deacetylation. In the presence of chitosan, erythrocytes lose their biconcave shape, thereby reducing the intercellular distance. Plasma absorption increases the local concentrations of erythrocytes and platelets at the site of vessel injury. Blood coagulation in the presence of chitosan is attributed to the “cross-linking” of erythrocytes by polymer chains, which form a reticular structure that entraps cellular elements. This process is driven by the positive charge of chitosan molecules, which attract negatively charged erythrocyte membranes (electrostatic effect). The additional hemostatic effect of chitosan is mediated by platelet adhesion, aggregation, and activation owing to its specific surface characteristics [26].

Mikhailov A.V. et al. reported that a nonwoven bandage coated with chitosan fibers exhibits a unique mechanism of action: the nanofiber layer on its surface absorbs the liquid portion of blood, resulting in the formation of a dense gel-like erythrocyte clot that adheres firmly to damaged vessels, mechanically occluding their lumens at the bleeding site. An additional hemostatic effect arises from the electrostatic attraction between erythrocytes and positively charged chitosan molecules, ensuring rapid hemostasis [27].

The use of chitosan-based tamponade in obstetrics was first described in 2012 by Schmid et al. in a clinical case involving a 32-year-old woman with massive hypotonic postpartum hemorrhage refractory to standard uterotonic therapy and surgical interventions. In this case, the application of chitosan tamponade successfully achieved hemostasis. Subsequent clinical studies by Carles G. and Dueckelmann A.M. (2017) confirmed the efficacy of this method [28]. A retrospective study conducted at Charité University Hospital (Berlin) demonstrated a substantial reduction in the rate of postpartum hysterectomies when chitosan tamponade was used compared to balloon tamponade [29].

This study aimed to evaluate the outcomes of intrauterine application of chitosan-coated tape in the treatment of postpartum hemorrhage.

Materials and methods

This study, conducted from November 2024 to February 2025 at the Perinatal Center of St. Petersburg State Pediatric Medical University represents a consecutive case series involving 21 women with postpartum hemorrhage refractory to uterotonic therapy.

The exclusion criteria included controlled intrauterine balloon tamponade, birth canal soft tissue trauma, placenta accreta, congenital coagulation disorders, and known allergies to seafood.

The inclusion criterion was ongoing bleeding exceeding 500 mL after vaginal delivery or 1000 mL after cesarean section despite the administration of oxytocin, misoprostol, and tranexamic acid.

Uterine atony was the primary cause of postpartum hemorrhage despite standard uterotonic therapy. In four out of 21 patients (19%) who delivered vaginally, a hemostatic chitosan-coated tape was applied to the uterine cavity through the cervical canal after confirming the integrity of the uterus and soft tissues of the birth canal in cases of atonic postpartum hemorrhage.

During cesarean section, 17 out of 21 patients (81%) received intrauterine application of the distal end of the hemostatic chitosan-coated tape through the uterine incision up to the fundus, following fetal and placental extraction. The proximal end of the chitosan-coated tape was exteriorized through the cervical canal and vagina beyond the vulvar cleft using a clamp to facilitate subsequent removal. After application, bimanual compression of the uterine body and lower uterine segment was performed for five minutes to ensure hemostasis, followed by suturing of the uterine incision. The hemostatic chitosan-coated tape was removed after 18–24 hours using ultrasound guidance. Patients with moderate postpartum anemia were administered oral iron supplementation.

Statistical analysis

Statistical analysis was performed using the SPSS software package. Quantitative variables were summarized as mean values, and qualitative variables were presented as frequencies and percentages.

Results

Our prospective study, conducted from November 2024 to February 2025, included 21 patients who developed postpartum hemorrhage. Of these, 4/21 (19%) delivered vaginally, while 17/21 (81%) underwent cesarean sections. In all patients, the application of chitosan-coated hemostatic tape successfully achieved complete hemostasis without the need for invasive interventions such as hemostatic sutures, arterial ligation, or hysterectomy, and none required blood transfusion.

In cases of atonic postpartum hemorrhage following vaginal delivery, blood loss ranged from 650 to 1,700 mL prior to intervention. Blood loss during the application of the chitosan-coated hemostatic tape was 50–200 mL, resulting in a total blood loss of 700–1,750 mL.

In cases of atonic postpartum hemorrhage following cesarean section, pre-intervention blood loss ranged from 1,090 to 1,400 mL, and blood loss during application of the chitosan-coated hemostatic tape was 50–100 mL, yielding a total blood loss of 1,240–1,700 mL.

Discussion

The use of hemostatic tape was initially described as a method for controlling hemorrhage in military medicine [21, 22]. Data analysis demonstrated that the intrauterine application of a chitosan-coated hemostatic tape effectively arrested postpartum hemorrhage caused by uterine atony. The rapid achievement of hemostasis helps prevent massive blood loss and, consequently, the need for blood transfusions, representing a significant advantage of this technique.

The results indicate that early intrauterine application of chitosan-coated hemostatic tape in cases of postpartum hemorrhage enables prompt cessation of atonic bleeding. This was confirmed by monitoring total blood loss and hemoglobin levels, which, after timely cessation of postpartum hemorrhage, did not fall below 90 g/L. None of the postpartum patients in this study required blood transfusion, further supporting the positive clinical impact of this method.

Particular attention was paid to ultrasound monitoring at all stages of the procedure. The insertion of the chitosan-coated hemostatic tape and verification of its position within the uterine cavity were performed strictly under ultrasound guidance. The tape was removed under ultrasound control, followed by a standard ultrasound examination of the uterus and its cavity on postpartum day 3. All women included in our study had normal ultrasound findings. The intrauterine application of the hemostatic tape under ultrasound guidance ensured procedural accuracy and safety, helping to prevent potential complications.

Conclusion

In recent years, most international and Russian authors have reached a consensus that early control of hemorrhage at the onset of bleeding prevents the development of massive blood loss, eliminates the need for surgical interventions such as uterine compression sutures, balloon tamponade, and uterine artery embolization, and significantly reduces the likelihood of subsequent hysterectomy, thereby preserving the woman’s reproductive potential. The use of chitosan-coated hemostatic tape in clinical obstetrics is a novel and promising method that warrants further investigation.