The Bakri balloon for the management of postpartum hemorrhage in cases

with placenta previa

Pnar Kumru
a
, Oya Demirci
a
, Emre Erdogdu
a,
*, Resul Arsoy
a
, Arif Aktug Ertekin
b
, Semih Tugrul
a
,
Oya Pekin
a
a
Zeynep Kamil Gynecologic and Pediatric Training and Research Hospital, Istanbul, Turkey
b
Uskudar University Obstetrics and Gynecology, Istanbul, Turkey
1. Introduction
Postpartum hemorrhage (PPH) is a major cause of pregnan-
cy-related death in both developed and developing countries
[1]. The incidence of atony has been reduced by intrapartum
care, but because of increasing cesarean section (CS) rates,
hemorrhage originating from the placental implantation site
due to placenta previa remains a serious obstetric complication
with maternal mortality and morbidity [24]. Patients with
placenta previa are at a signicant risk of high intraoperative
blood loss due to the possibility of the obstetrician incising
through the placenta and the increased risk of placenta accreta.
In addition, the uterine site of abnormal implantation does not
contract as effectively as a normal uterine segment. For these
reasons, we need to improve our ability to respond to this
obstetric emergency. One of those improvements in care is the
Bakri balloon, which is one of the most important recent
advances for treating serious PPH.
The aim of the present study was to evaluate the success rate of
the Bakri balloon in the event of uncontrollable hemorrhage due to
placenta previa.
2. Materials and methods
This is a retrospective study of 25 patients who were treated
with the Bakri balloon (Cook Womens Health, Spencer, IN, USA),
diagnosed to have severe PPH with placenta previa and failed
medical treatment with uterotonic agents in our unit between
February 2009 and February 2012. PPH was dened as >1000 ml
estimated blood loss after CS [5]. The cases were identied by
review of medical records. For maternal demographic data
medical records were received to assess the following: age,
parity, gestational age, previous abortions and dilatation and
curettage. Pre-operative and postoperative hemoglobin, hemato-
crit, thrombocyte count, operation length, need for and number of
transfusions, balloon tamponide time, postoperative hospitaliza-
tion time, need for high dependency unit care and complications
were detected. Risk factors for PPH; previous CS, number of
previous CS and current placenta previa were identied from the
medical records.
Balloon insertion was done transvaginally or transabdominally.
Transabdominal insertion of the balloon was performed by passing
the distal and of the balloon shaft through the cervix with an
assistant pulling vaginally. After checking the position of the
balloon, the uterine incision was closed. The balloon was lled
with an amount of saline ranging from 130 to 500 ml depending on
the size and capacity of uterus. A collection bag was used to follow
European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 167170
A R T I C L E I N F O
Article history:
Received 17 July 2012
Received in revised form 5 November 2012
Accepted 30 November 2012
Keywords:
Bakri balloon
Postpartum hemorrhage
Placenta previa
Cesarean
A B S T R A C T
Objective: To evaluate the success rate of the Bakri balloon in the event of uncontrollable hemorrhage
due to placenta previa.
Study design: We evaluated 25 patients who were treated with the Bakri balloon who had severe
postpartum hemorrhage with placenta previa and failed medical treatment with uterotonic agents.
Results: The Bakri balloon was inserted abdominally during cesarean section in 24 of 25 cases. In only
one case was it inserted vaginally. The Bakri tamponade was effective in 22 cases (88%). There were three
cases with failure: two patients needed an additional procedure (hypogastric artery ligation and B-Lynch
suture) and one patient needed hysterectomy.
Conclusions: The Bakri balloon is the least invasive, rapid method in the management of bleeding due to
placenta previa with minimal complications.
2012 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author. Tel.: +90 05053842092.
E-mail address: emreerd@yahoo.com (E. Erdogdu).
Contents lists available at SciVerse ScienceDirect
European Journal of Obstetrics & Gynecology and
Reproductive Biology
j ou r nal h o mepag e: w ww. el sevi er . co m / l ocat e/ ej o g r b
0301-2115/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejogrb.2012.11.025
the blood drainage by collecting through the distal and of the shaft
[6]. The balloon was removed after 2448 h.
The procedures were performed by one surgical team with
different surgeons in our unit. Medical treatment included
oxytocin 40 IU in 500 ml normal saline at a rate of 125 ml/h
intravenously, and ergometrine 0.250.5 mg intramuscularly.
Multiple placental bed sutures and hypogastria artery ligation
were performed in some cases when medical treatment failed. We
decided to insert the Bakri balloon when performing multiple
placental bed sutures or hypogastric artery ligation failed to
control bleeding. The procedure was considered successful if the
bleeding was stopped, and unsuccessful if additional surgical
procedures (e.g., uterine compression sutures, uterine artery or
hypogastric artery ligation, and hysterectomy) were needed to
stop bleeding after the Bakri balloon insertion.
3. Results
There were 33,195 deliveries during the study period. The Bakri
balloon was used in 30 cases (0.09% of all deliveries), of which 25
(87.5% of cases in which the Bakri balloon used) were the cases
with placenta previa.
The mean maternal age was 28.9 4.4 years. The median
number of gravidity and parity were 3 (range 19) and 1.3 (range 0
6), respectively. The mean gestational age was 37.3 1.7 weeks
(range 3340). Six (24%) patients had CS in the index pregnancy and
19 (76%) patients had one or more previous CS. The patients received
a median of 2.2 units of erythrocyte suspension (range 06) and a
median of 1.1 units fresh frozen plasma (range 04). The preoperative
and postoperative median hemoglobin levels were 11 mg/dl (range
8.613.9) and 7.8 mg/dl (range 5.311.8) (Table 1).
In our cases, we decided to insert the Bakri balloon when
performing multiple placental bed sutures or hypogastric artery
ligation failed to control bleeding. In all cases the Bakri balloon was
successfully inserted. It was inserted abdominally during CS in 24
of 25 cases, and in only one case it was inserted vaginally, 3 h after
CS. The mean insertion time of the balloon was 4.2 min (range 2
10). The median volume infused into the balloon was 320 ml
(range 130500 ml). The Bakri balloon was left in place for 24 h in
18 cases (72%), and for 48 h in ve cases (20%). The Bakri
tamponade was effective in 22 cases (88%). In these cases
endouterine hemostatic sutures were applied in the area of
bleeding site in the lower segment in 14 of 25 cases (56%) and
bilateral internal iliac artery ligation was performed in two cases
(8%) before the balloon insertion.
There were three cases with failure. The rst case had
postpartum bleeding 3 h after CS and the Bakri balloon was then
inserted vaginally. Because of continued bleeding, relaparotomy
was needed to control bleeding with hypogastric artery ligation
and B-Lynch suture. The second case had severe bleeding with the
Bakri balloon, and hypogastric artery ligation was performed to
control the bleeding. The third case was an intraoperatively
diagnosed case of placenta percreta, and the placenta could be
removed partially. Bleeding was controlled with the Bakri
tamponade and the patient was discharged with no problem.
Interestingly, however, she came to the hospital with severe
vaginal bleeding 75 days after discharge, and hysterectomy was
performed to the control bleeding.
The mean hospitalization time was 3.9 day (range 27). Four of
the 25 patients (20%) needed high dependency unit care. There was
no reported complication due to balloon insertion.
4. Comment
In this retrospective study we have conrmed that uterine
tamponade with the Bakri balloon is a useful intervention for
intractable PPH due to placental site bleeding. The mechanism of
uterine tamponade works by increasing intrauterine pressure
above systemic arterial pressure. Ramsbotham describes uterine
tamponade techniques with uterine packing as early as 1856 [7].
Despite data suggesting its effectiveness, its popularity declined
because of the risk of uterine trauma and infection [8]. Recently
resurgence in the use of uterine tamponade has occurred using
balloon technology in PPH management. Successful use of
tamponade has been reported in case reports and series, using
the SengstakenBlakemore tube [9], the Rusch balloon [10], the
condom catheter [11] and the Foley catheter [12].
Bakris rst report described how he simultaneously placed 5
10 standard Foley balloons in the lower uterine cavity to control
PPH [13]. Building on this success, he developed a single, large
balloon with a large central lumen and used it successfully in four
cases of PPH related to low-lying placenta/placenta previa [6]. The
Bakri balloon is a 24-French, 54-cm long, silicone catheter that
contains a large central lumen. The capacity of the balloon is up to
800 ml; the recommended use is 500 ml. It can be inserted
vaginally after vaginal delivery or abdominally after CS.
Table 1
Characteristics of cases treated with the Bakri balloon (n = 25).
Mean SD or n IQR or %
Age, years (median) 28.9 4.4 2138
Gravidity (n) 3 1.7 19
Parity (n) 1.36 1.2 06
Abortion (n) 0.3 0.8 04
Dilatation and curettage (n) 0.4 0.7 03
Multiparous 4 16%
Gestational age of delivery (weeks) 37.31.7 3340
Blood loss (ml) 1360 350 10001800
Erythrocyte suspension (unit) 2.2 1.9 06
Fresh frozen plasma (unit) 1.1 1 04
Preoperative hemoglobin (g/dl) 11.1 1.4 8.613.9
Preoperative hemotocrit % 32.8 3.8 25.941.4
Preoperative trombocyte (g/dl) 220,000 70,700 10000336000
Postoperative hemoglobin (g/dl) 7.8 1.6 5.311.8
Postoperative hemotocrit (%) 24.1 4.1 16.832.1
Postoperative trombocyte (g/dl) 180,000 62,000 75000130000
Duration of operation (min) 71.9 15.6 45110
The Bakri balloon insertion time (min) 4.2 1.5 210
Postoperative hospitalization (day) 3.9 1.3 27
IQR: interquartile range.
P. Kumru et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 167170 168
The present study shows that the Bakri balloon alone or with
placental bed sutures was effective in 88% of cases. All the cases
had placenta previa with no signs of uterine atony. Of the cases
with failure, one needed hysterectomy and the other two needed
additional procedures (hypogastric artery ligation and hypogastric
artery ligation with B-Lynch suture). The case which needed
hysterectomy was a multiparous woman with two previous
cesarean sections who had no antenatal care. She presented with
vaginal bleeding in the late third trimester and when ultrasonog-
raphy was performed, placenta previa totalis was detected. Color
Doppler supported the diagnosis of plasenta percreta. During
laparotomy large tortuous vessels overlying the uterosacral fold
with placental tissues invading the uterine serosa were observed.
The baby was delivered through a vertical hysterotomy incision.
Fifty percent of the placenta had abrupted spontaneously and was
taken out gently without traction. A Bakri balloon was placed in the
uterine cavity and left in place for 24 h. The patient was discharged
on the fth day and closely followed up with placental volume and
serum HCG levels. Methotrexate treatment was administered in
the third and sixth postoperative weeks. In the sixth week serum
hCG level was 0.1 IU and the placenta volume decreased. On the
75th postoperative day, the patient was admitted to our hospital
with abundant vaginal bleeding and immediate laparotomy was
performed. A diffuse tissue defect at the anterior uterine wall
where placental tissue was adherent and diffuse hemorrhage from
uterine surfaces was noted. At operation placental tissue was
invading from the right parametrium to the left obturator fossa and
the bladder anterior wall. Hysterectomy was performed. At
laparotomy, compared with the time of CS, vascularity was
remarkably decreased so it was easier to perform hysterectomy.
Placenta percreta was conrmed histopathologically.
The Bakri balloon can be applied to prevent abundant bleeding
by reducing the morbidity of early surgery on the excessively
vascularized uterus and bladder. Vitthala et al. reported 80%
success in 15 cases of PPH but all the cases who failed had placenta
previa or accreta [14]. Similarly Debelea et al. reported that balloon
tamponade was effective in 18 of 20 cases of PPH: they reported
failure in two cases, one of which was placenta percreta [15].
Although the Bakri balloon seems to be effective in the cases of
PPH with uterine atony, there are limited data its use for PPH due to
placenta previa without atony. We report the largest series on
treatment with the Bakri balloon of PPH due to placenta previa. As
mentioned above, Bakri et al. rst reported the effectiveness in 6
patients and 4 of them had placenta previa. Homeostasis was
achieved in all the cases [13]. Diemert et al. reported 20 PPH cases
treated with the Bakri balloon: in 9 cases there was bleeding from
the placental site (7 with placenta previa, 1 with placenta bipartite,
and 1 with placenta increate). The case with placenta increate
needed hysterectomy despite the combination of the Bakri balloon
and the B-Lynch procedure. The others did well with the Bakri
balloon alone or in combination with the B-Lynch procedure. The
B-Lynch procedure is added if the tamponade test fails [16].
Arduini et al. described the new technique named uterine
sandwich in which both external (B-Lynch) and internal (Bakri
balloon) uterine compression are combined. They used radiologi-
cal catheterization of the descending aorta and placement of
hemostatic square sutures in the lower uterine segment in
addition to the uterine sandwich procedure. With this technique
9 cases of placenta previa accreta, which had been diagnosed based
on ultrasound and clinical ndings, were treated successfully with
no need for hysterectomy [17]. Recently, Yoong et al. reported 10
cases with placenta previa treated with a similar uterine
sandwich procedure. Again no additional conservative surgery
or hysterectomy was needed [18].
In our study none of the cases needed compression sutures.
Endouterine hemostatic sutures were applied in the area of
bleeding site in the lower segment in 14 cases and bilateral internal
iliac artery ligation was performed before balloon insertion in two
cases. In general, we perform multiple placental bed sutures when
medical treatment fails to control bleeding in cases with placenta
previa. If these fail, the Bakri balloon can be a choice. We agree that
hypogastric artery ligation should not be a choice before Bakri
balloon insertion, but we have reported two cases in whom
hypogastric artery ligation was performed before the Bakri balloon
insertion. We are aware of this contradictory situation: a possible
reason is that different surgeons from one surgical team performed
these procedures. The Bakri balloon was successful in controlling
bleeding in these cases where hypogastric artery ligation failed
although it was performed before balloon insertion.
Failure of the PPH treatment with the Bakri balloon may be due
to damage or displacement of the balloon. When the Bakri balloon
is inserted abdominally it is insufated after the incision site is
closed. This may potentially result in balloon failure secondary to
damaging the balloon by the needle. As an alternative approach the
uterus can be closed rst, and then the balloon is inserted
vaginally. This gives the advantage of applying a tamponade test
before closing the laparotomy site, and allowing visualization of
the uterus after insufations the balloon [19]. Another problem,
displacement of the balloon, can decrease its effect in controlling
atomic PPH. Usually displacement is due to a dilated cervix. The
use of a vaginal pack can be recommended to hold the balloon in
the uterine cavity. Alternatively Khalil et al. recently recom-
mended the use of a traction stitch to keep the Bakri balloon within
the uterus [20]. In our study damage or displacement of the balloon
was reported in none of the cases.
In conclusion, our study shows that the Bakri balloon can be a
choice in the management of uncontrolled bleeding due to
placenta previa before more aggressive surgery, but there are
some limitations to advising its widespread use. Because most of
the studies are retrospective without a comparison group, there is
no proof that the intrauterine balloon is superior to other methods
of controlling PPH. Nevertheless uterine tamponade with the Bakri
balloon is the least invasive, rapid method with minimal
complications. We believe that in the near future the Bakri
balloon, which can be a life-saving device for women whose severe
PPH has not responded to rst-line measures, should be a good
choice.
Conicts of interest
The authors have stated explicitly that there are no conicts of
interest in connection with this article.
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