The current case describes an unreported complication of Bakri balloon placement: the migration of the Bakri balloon to the broad ligament through an unsuspected uterine rupture. Finally, a hysterectomy had been required. The Bakri balloon may be involuntary introduced in an unexpected uterine rupture, even if the balloon is placed with ultrasound guidance.
Uterine tamponade with an intrauterine balloon seems to be an effective procedure. Few studies have reported difficulties, failures, and side-effects in the use of intrauterine tamponade balloons. The current case describes an unreported complication of Bakri balloon (Cook Medical Inc, Bloomington, IN) placement.
Case Report
A 29-year-old woman (neither previous cesarean delivery nor uterine surgery), para 2, gave birth to a 3690-g boy without an episiotomy or the need for instrumental assistance. Postpartum hemorrhage was diagnosed 10 minutes after delivery (spontaneous delivery of the placenta). The uterine and vaginal inspections revealed no vaginal/cervical laceration. The infusion of oxytocin was stopped and replaced by sulprostone. Consequently, the primary postpartum hemorrhage resolved.
Eighteen days after delivery, the patient came back to the emergency room because of a recurrence of minor vaginal bleeding. Ultrasonography revealed intrauterine retention of placental tissue. Dilation was performed with the evacuation of blood and placental retention. After dilation with a bore plastic cannula (but without ultrasound guidance), a massive hemorrhage occurred. Despite the use of uterotonic agents, uterine bleeding remained poorly controlled. The patient was then transferred to our hospital. At arrival, her hemoglobin level was 03.8 g/dL, and massive vaginal bleeding was observed. No sign of endometritis was noted. Subinvolution and uterine atony were also noted. Because of patient hemodynamic instability, uterine artery embolization was not an option.
Ultrasonography revealed persistence of retained placental tissue; ultrasound-guided intrauterine aspiration with a suction catheter was performed concomitantly to resuscitation. Retained placental tissue was totally removed. Despite this, massive hemorrhage and uterine atony (subinvolution) continued. An intrauterine tamponade Bakri balloon was inserted and inflated (up to 500 mL) under manual and ultrasonographic guidance; however, the massive bleeding did not stop.
Laparotomy was then performed. Intraperitoneal examination revealed that the inflated Bakri balloon was located in the left broad ligament ( Figures 1 and 2 ). The peritoneum had disrupted spontaneously on the left broad ligament, and persistent intraperitoneal and vaginal bleeding was noted (drainage channel of the Bakri balloon catheter). After deflation of the balloon, the surgical examination revealed an extensive laceration of the left broad ligament and active bleeding from the uterine vessels that was associated with a uterine rupture (left side of uterine wall, in the broad ligament). After left ureteral dissection and internal iliac artery ligation, the hemorrhage was controlled with hysterectomy and multiple ligations of arterial and venous vessels in the left broad ligament. After the total hysterectomy, hemostasis in the broad ligament, and vaginal suturing, hemorrhage rapidly resolved. In total, 18 units of packed red cells, 16 units of fresh frozen plasma, 1 platelet unit, 3 g of tranexamic acid, and 3 g of fibrinogen were administered. Pathologic testing revealed no placenta accreta.
