We thank Hequet et al for their comments regarding our recent article.

We are happy to clarify that our cohort study included only inpatients specifically to avoid a recruitment bias (ie, we did not include patients with severe postpartum hemorrhage who had been referred for embolization from other hospitals in our network). Furthermore, during the first (preballoon) period, we performed embolization only in cases of severe postpartum hemorrhage after vaginal delivery, as indicated in Figure 1 of our article. Severe postpartum hemorrhage during or after cesarean delivery was always treated by conservative surgical procedures or hysterectomy. These important differences explain the reason that our embolization rate was so much lower than that in the French embolization register, as reported by Bartoli et al. We would like to highlight that a major recruitment bias is inherent in this register, which records embolization activity only from referral centers. For example, as Dr Hequet indicates, 80% of the patients treated for postpartum hemorrhage in her referral center come from other hospitals.

Second, we agree that uterine rupture from over distention is a potential risk when the balloon tamponade test is performed after cesarean delivery. Nonetheless, the review by Georgiou that includes 8 publications about the use of intrauterine balloon tamponade during or after cesarean deliveries reports no cases of uterine rupture; thus, it is consistent with our experience. Furthermore, the recent article by Diemert et al describes the use of the intrauterine balloon tamponade in 16 patients during cesarean deliveries, with no complications directly related to the Bakri balloon. For more security, we suggest that the balloon should be inflated progressively: a first plateau should occur at 250 cc, which is often sufficient to stop the bleeding. We would point out that the “Instructions for Use” of the 2 devices that are designed specifically to manage postpartum uterine bleeding (the Bakri balloon and the Belfort-Dildy Obstetric Tamponade System) indicate that the balloons may be used in cases of both vaginal and cesarean deliveries.

Finally, we fully agree with Hequet et al that intrauterine balloon tamponade should be recommended to increase the safety of transfers of women with severe postpartum hemorrhage to referral centers with embolization units. We made and implemented this recommendation in our network 3 years ago.