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This document summarizes a study evaluating the effectiveness of the Bakri balloon in managing postpartum hemorrhage due to placenta previa. The study reviewed 25 cases where the Bakri balloon was used after failed medical treatment of hemorrhage during or after cesarean section for placenta previa. The Bakri balloon successfully controlled bleeding in 22 of the 25 cases (88%). In the 3 failed cases, additional procedures like artery ligation or hysterectomy were required. The Bakri balloon is a minimally invasive method that was generally effective in managing hemorrhage from placenta previa with few complications.
This document summarizes a study evaluating the effectiveness of the Bakri balloon in managing postpartum hemorrhage due to placenta previa. The study reviewed 25 cases where the Bakri balloon was used after failed medical treatment of hemorrhage during or after cesarean section for placenta previa. The Bakri balloon successfully controlled bleeding in 22 of the 25 cases (88%). In the 3 failed cases, additional procedures like artery ligation or hysterectomy were required. The Bakri balloon is a minimally invasive method that was generally effective in managing hemorrhage from placenta previa with few complications.
This document summarizes a study evaluating the effectiveness of the Bakri balloon in managing postpartum hemorrhage due to placenta previa. The study reviewed 25 cases where the Bakri balloon was used after failed medical treatment of hemorrhage during or after cesarean section for placenta previa. The Bakri balloon successfully controlled bleeding in 22 of the 25 cases (88%). In the 3 failed cases, additional procedures like artery ligation or hysterectomy were required. The Bakri balloon is a minimally invasive method that was generally effective in managing hemorrhage from placenta previa with few complications.
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. References [1] World Health Organization (WHO). Attending to 136 million births, every year: make every mother and child count. Risking death to give life. The World Health Report 2005. Geneva: WHO; 2005 [chapter 4]. [2] Yucel O, Ozdemir I, Yucel N. Emergency peripartum hysterectomy: a 9-year review. Archives of Gynecology and Obstetrics 2006;274:847. 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