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■■ JOGC ■■ 2017 • 1
UROGYNAECOLOGY
that has been commonly used clinically. In this study, we Figure. Protocol for uterine and vaginal tamponade.
combined those two methods to evaluate the success rate Postpartum hemorrhage during CS
of Bakri balloon tamponade in treating PPH.
We reviewed 78 708 deliveries, among which 35 120 were Active uterine bleeding still persisted or
if the amount of bleeding approached 500 mL
CS procedures, from January 1, 2010 to December 31, 2015
in the International Peace Maternal and Child Health Hos-
pital (IPMCH), Shanghai, China. The Ethics Committee of Bakri balloon tamponade inserted Bakri balloon tamponade inserted
the IPMCH approved this study. A single use of an intra- within the uterine cavity within the uterine cavity together
with vaginal gauze
uterine Bakri balloon was applied in some cases, and
additional vaginal tamponade combined with abdominal com-
pression was applied in other cases. We compared the there was still active bleeding, then this raised the possibil-
outcomes of these two methods in the management of PPH. ity of failure of the balloon, and the other methods (e.g.,
uterine artery embolization or hysterectomy) were imple-
Diagnosis of Postpartum Hemorrhage and mented. If the bleeding was controlled, then the Bakri
Postoperative Morbidity: the Procedure before Use balloon was left in the uterine cavity for 24 hours before it
of Tamponade was taken out. In the study group, we used the method of
The Bakri uterine balloon (also called SOS Bakri) was pur- “double compression”: the Bakri balloon was filled in the
chased from Cook Medical (Bloomington, IN). The criterion uterine cavity, with vaginal gauze packing. The balloon and
for use of uterine tamponade was, during CS and after vaginal tampons were removed within 24 hours. The pro-
massage and use of a uterotonic (e.g., oxytocin and tocol used is summarized diagrammatically in the Figure.
tromethamine), the presence of persistent active uterine
bleeding or an amount of bleeding that reached a volume The dimensions of the vaginal tampon used were about
of 500 mL. PPH after CS is defined as an amount of bleed- 200 × 40 mm. The tampon was placed in the vagina for 24
ing during CS in excess of 1000 mL. Treatment of PPH hours together with the balloon. Intravenous antibiotics (e.g.,
includes intraoperative uterine massage and use of cephalosporins or clindamycin) were routinely used to prevent
uterotonics, including oxytocin and carboprost tromethamine, infection during all these procedures.
which are the two most commonly used medications in our
hospital. If balloon tamponade fails to control the bleed- Statistical Analysis
ing, a uterine artery embolization or hysterectomy is normally All statistical analyses were performed with SPSS V.20.0 for
performed. Windows (IBM, Armonk, NY). A value of P < 0.05 was con-
sidered statistically significant.
After the first 24 hours of the operation, the patient’s tem-
perature was measured every 4 hours and four times daily
for up to 3 days. Postoperative fever is diagnosed when the RESULTS
patient’s temperature reaches 38°C on two occasions on the
The amount of blood loss in the control group was
same day.
805.63 ± 459.52 mL, and it was 863.21 ± 467.15 mL in the
double compression group (Table 1). In the double com-
Protocol for Uterine and Vaginal Tamponade pression group, 96.3% cases of PPH were successfully
Patients were randomly divided into two groups on the basis treated, a higher number than in the control group (87.3%;
of individual doctors’ experience and practices. The control P < 0.05). There were no differences in patients’ ages, GAs,
group was treated with Bakri balloon tamponade within the or the rates of CS between the two groups (Table 1). There
uterine cavity. If PPH was in progress during CS and the was no difference in the percentage of patients with uterine
bleeding could not be controlled by uterine massage or atony with or without placenta previa or placenta accreta,
uterotonics, a Bakri balloon was placed in the bottom of the nor was there any difference in the incidence of postop-
uterus, distally through the cervix and indwelling in the erative fever in either of the two groups.
vagina. Then the balloon was filled with 250 to 350 mL of
saline. A catheter in the Bakri balloon allows the blood in There was no difference in the success rate of controlling
the uterus to be released. Therefore, the amount of vaginal uterine atony caused by PPH in both groups (Table 2). In
bleeding after placement of the balloon could be noted. If PPH caused by placental effects and uterine atony, double
2 • ■■ JOGC ■■ 2017
Managing Postpartum Hemorrhage
compression (100%) was more effective than use of the Bakri the others underwent uterine arterial embolization. In no
balloon alone (57.14%). patient was a hysterectomy performed.
Furthermore, the amount of blood loss in the double com-
pression group (1040 ± 508.90 mL) was greater than in the
control group (776.43 ± 306.99 mL), but this was not sig- DISCUSSION
nificantly different. Six cases in the double compression The Bakri balloon is normally used when uterotonics or pros-
group with blood loss of 900–2525 mL underwent uterine taglandins fail to control PPH.10 One study showed that the
arterial embolization, whereas five subjects in the control rate of maternal mortality increased if patients were not
group with blood loss of 700 to 1200 mL had uterine and stable in the first hour after operation.11 In 2009, a report
vaginal tampons. by the Royal College of Obstetricians and Gynaecologists
In the treatment of PPH caused by placental effects, the recommended using the Bakri balloon in PPH caused by
blood loss in the double compression group was less than uterine atony.12 This device was further recommended for
in the control group. The cure rate of the control group use in PPH for other reasons in 2011 because complica-
in management of placental effects in addition to uterine tions arising from its use are extremely rare.13
atony as the causes of PPH is only 57.1% (4 of 7) (Table 3).
A study published in 2009 showed that the efficacy of the
In the control group, eight patients had further invasive man- Bakri balloon was 80% in 18 cases of PPH.5 In other studies,
agement after use of the Bakri balloon; three of these the efficacy was 87% and 75% in 16 and 23 cases of PPH,
patients had uterine atony with placenta previa or placenta respectively.10,14 In our study, the efficacy of the Bakri balloon
accreta, and the other patient had uterine atony. Among all was 93.26%, a rate similar to that reported in the study by
the patients who required further management, one patient Gao et al.15 (93%). Use of an intrauterine Bakri balloon in
in the control group had uterine and vaginal tampons, and addition to vaginal tamponade combined with abdominal
Table 2. The success rate of bleeding control in different clinical circumstances of the two groups of patientsa
Double compression (n = 163) Control (n = 142)
Uterine atony, n (%) 74/80 (92.5) 57/62 (91.94)
Placenta previa and placenta accreta, n (%) 40/40 (100) 58/58 (100)
Uterine atony and placenta previa and/or placenta accreta, n (%) 43/43 (100)b 16/31 (51.61)
Total, n (%) 157 (96.32) 131 (92.25)
a
In cases of uterine atony and placenta previa and/or placenta accreta, double compression is more efficient than the single use of a Bakri balloon. The chi-square
test was used to compare the data, and n refers to the number of patients in each group.
b
A significant difference of P < .001.
■■ JOGC ■■ 2017 • 3
UROGYNAECOLOGY
compression is more effective in PPH than using the Bakri that included 51 cases of placenta previa, the Bakri balloon was
balloon alone (96.5% vs. 87.5%). Some clinicians sug- placed in every patient in the study group as a preventive
gested that vaginal tampons should be used only in patients measure. The results showed that this technique did not help
with a dilated cervix. Their opinion was that an increase in to reduce the use of other uterotonics.19 In our study, among
the pressure within the uterus would lead to an increased 21 patients with a single risk of placenta previa, the Bakri balloon
risk of uterine rupture.16 There was no side effect such as was used in 16, and although bleeding was active, the amount
infection noted in our study. Uterine arterial embolization of blood loss did not reach over 1000 mL. The efficacy was
was performed in two cases in which double compression 100% in both the double compression (n = 12) and control
failed to control PPH. groups (n = 4). The efficacy of Bakri balloon use in the other
28 cases with placental factors and PPH was 100% (double com-
Placental implantation increases the risk of PPH such that pression; 18 of 18) and 81.25% (control group, 13 of 16). In
a hysterectomy would be recommended to patients who do conclusion, in cases of PPH caused by placenta previa, the use
not wish to maintain their fertility. Uterine arterial embo- of double compression is more effective than use of the Bakri
lization before hysterectomy would decrease the amount of balloon alone.
bleeding and obviate the need for a blood transfusion.17 We
successfully used double compression to treat PPH in pla- In recent years, researchers have gradually combined applica-
cental implantation, except for one patient, who had both tion of the Bakri balloon with other compression methods, such
uterine atony and placental implantation; this situation re- as the B-lynch procedure. The “sandwich” technique is to apply
sulted in uterine arterial embolization, and hence a the balloon within the uterus, by using the B-lynch procedure
hysterectomy was prevented. with external pressure applied, to restrict the movement of the
fundus, thereby enhancing the effect of packing.9 A study that
Placenta previa is a single risk factor for PPH.9 Kumru et al.18 included 20 patients showed that the efficacy of Bakri balloon
found that the rate of PPH related to use of the Bakri balloon use, with or without the B-lynch procedure, to reduce severe
in placenta previa was 88% (22 of 25). These investigators re- PPH was 90%.20 Canonico et al.21 suggested that the Bakri
ported that only two patients required further uterine arterial balloon, in addition to the B-lynch procedure, was effective in
embolization or the B-Lynch procedure. Hysterectomy was per- reducing PPH caused by placenta previa. However, this ap-
formed in one of these patients. Side effects of the use of the proach may cause some side effects, such as endometritis, uterine
Bakri balloon were very rare. In a randomized controlled study rupture, and necrosis.22
4 • ■■ JOGC ■■ 2017
Managing Postpartum Hemorrhage
Uterine atony in addition to a placental abnormality generally 7. Yoong W, Ridout A, Memtsa M, et al. Application of uterine compres-
sion suture in association with intrauterine balloon tamponade (“uterine
causes a large amount of blood loss and therefore requires blood sandwich”) for postpartum hemorrhage. Acta Obstet Gynecol Scand
transfusion.23 Our study also found that double compression 2012;91:147–51.
was more effective than method used in the control group, es- 8. Kaya B, Tuten A, Daglar K, et al. Balloon tamponade for the manage-
pecially in PPH that resulted from placental factors and uterine ment of postpartum uterine hemorrhage. J Perinat Med 2014;42:745–53.
atony. Three patients in the control group required further
9. Nelson WL, O’Brien JM. The uterine sandwich for persistent uterine
uterine arterial embolization. The possible reason could be that atony: combining the B-Lynch compression suture and an intrauterine
patients with uterine atony had active bleeding at the placen- Bakri balloon. Am J Obstet Gynecol 2007;196:e9–10.
tal detachment surface, the Bakri balloon alone failed to stop 10. Condous GS, Arulkumaran S, Symonds I, et al. The “tamponade test” in
the bleeding, and double compression could help to improve the management of massive postpartum hemorrhage. Obstet Gynecol
the situation. In our study, abdominal compression bandag- 2003;101:767–72.
ing can limit movement of the fundus of uterus and the vaginal 11. Lewis G. Saving Mothers’ Lives: the continuing benefits for maternal
tampons and thus prevent the downward movement of the health from the United Kingdom (UK) Confidential Enquires into Ma-
ternal Deaths. Semin Perinatol 2012;36:19–26.
balloon and compression of the lower uterine segment. This
approach produced a double pressure on the uterus. This double 12. Royal College of Obstetricians and Gynaecologists. Prevention and man-
compression did not result in uterine rupture, uterine necro- agement of postpartum haemorrhage. Green-top guidelines 52. BJOG
2017;124:e106–49. London: Royal College of Obstetricians and
sis, or other complications, nor did it increase postoperative Gynaecologists.
morbidity. This finding suggests that the increased vaginal gauze
13. Johnston TA, Paterson-Brown S, Guidelines Committee of the Royal
did not increase the chances of infection. Therefore, the method College of Obstetricians and Gynaecologists. Placenta praevia, placenta
appears to be clinically safe to use. In addition, abdominal com- praevia accreta and vasa praevia: diagnosis and management. Green-top
pression bandaging and vaginal tampons are economical and guidelines 27. London: Royal College of Obstetricians and
Gynaecologists; 2011.
practical.
14. Dabelea V, Schultze PM, McDuffie RS Jr. Intrauterine balloon tampon-
ade in the management of postpartum hemorrhage. Am J Perinatol
CONCLUSION 2007;24:359–64.
Our study suggests that in patients with uterine atony and 15. Gao Y, Wang Z, Zhang J, et al. [Efficacy and safety of intrauterine Bakri
balloon tamponade in the treatment of postpartum hemorrhage: a multi-
placental factors, the double pressure option for the treat- center analysis of 109 cases]. Zhonghua Fu Chan Ke Za Zhi
ment of PPH should be recommended. 2014;49:670–5 [in Chinese].
18. Kumru P, Demirci O, Erdogdu E, et al. The Bakri balloon for the man-
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