Objective
To evaluate intrauterine balloon tamponade with or without B-Lynch sutures in avoiding postpartum hysterectomy in cases with severe postpartum hemorrhage.
Study Design
Retrospective analysis using all women delivering between January 2005 and July 2010 in our center. Prevention of hysterectomy was the main outcome studied.
Results
Twenty-four cases of severe postpartum hemorrhage occurred in which medical treatment alone failed. In 20 cases, the Bakri balloon was the first choice to stop hemorrhage. Sixty percent (n = 12) of these were successfully treated with the balloon alone, 30% (n = 6) with the balloon and the B-Lynch suture. Therefore, 90% (n = 18) were successfully treated with the balloon as part of the treatment. The balloon tamponade was not successful in 2 cases. Four cases were treated with emergency hysterectomy a priori.
Conclusion
The Bakri balloon with or without B-Lynch sutures in a stepwise approach is an effective option for the treatment of severe PPH.
Postpartum hemorrhage (PPH) accounts for a quarter of maternal deaths worldwide and is the major cause of maternal deaths in industrialized countries with a trend to increase in frequency. Established risk factors for PPH include preeclampsia, prolonged or augmented or rapid labor, an overdistended uterus, and chorioamnioitis. Today, hysterectomy is the most common procedure to achieve arrest of severe PPH.
Postpartum hysterectomy is associated with short- and long-term complications such as blood loss, injury of other organs, impaired wound healing, infection, and loss of fertility. Taking into account the serious complications related to hysterectomy after PPH alternative procedures, such as uterine compression sutures or intrauterine balloon tamponade have gained popularity.
The Bakri balloon is a fluid-filled tamponade balloon that is inserted into the uterine cavity to achieve temporary control or reduction of PPH. B-Lynch sutures are brace sutures used to mechanically compress an atonic uterus in the face of severe PPH. Occasionally, the B-Lynch surgical procedure has been combined with the Bakri balloon to achieve successful hemostasis, but the experience with this combined approach is limited to 5 cases. The purpose of this report is to describe the success rate of the Bakri balloon as a first line of therapy to prevent postpartum hysterectomy after failure of uterotonic agents. Prevention of hysterectomy was the main outcome studied.
Methods
This is a retrospective study of consecutive patients diagnosed to have a severe PPH and unsuccessful medical treatment with uterotonic agents who were subsequently treated with the Bakri balloon in our unit between January 2005 and July 2010. The cases were identified by review of medical records. This case series includes all cases of PPH managed with the uterine balloon tamponade (Bakri SOS balloon; Cook Woman’s Health, Spencer, IN) after its introduction in our department in 2005. After identification of cases in the delivery registry, clinical records were reviewed to gather data on risk factors for PPH, estimated blood loss, need for transfusion, or intensive care treatment.
We defined severe PPH as >500 mL estimated blood loss after vaginal delivery or >1000 mL after cesarean section. Standard management for PPH included uterine massage, bimanual compression, and medication with oxytocin or analogues of prostaglandins E1 or E2 in selected cases. Surgical treatment included placement of the Bakri balloon tamponade alone or in combination with compression sutures and hysterectomy, if the tamponade failed to stop PPH.
The insertion of the balloon was either done transvaginally as originally described or, if introduced during a cesarean section, the distal end of the balloon shaft was passed through the cervical opening with an assistant pulling vaginally. It was then partially filled to keep it in place and correct positioning was checked and adjusted through the uterine incision, which was closed before filling the balloon completely. The amount of saline used to inflate it ranged from 250–500 mL depending on the size and capacity of the uterus as well as cervical dilatation and in cases with cervical dilatation additional vaginal tamponade using gauze strips was applied. We considered the procedure successful, if the bleeding stopped after the balloon was inflated. If the bleeding did not cease within 15 minutes, we performed additional uterine compression sutures as described by B-Lynch. If the uterine compression sutures were needed in a case of PPH after vaginal delivery and balloon placement, we performed a laparotomy to place the uterine sutures.
The balloon remained in place for a maximum of 24 hours. All patients had a Foley catheter in place and were treated with a broad-spectrum antibiotic. They were kept under constant surveillance and a decision for intensive care treatment was made according to the cardiovascular and respiratory status of the patient. After 12 hours, the balloon was deflated by removing 50% of the fluid, and if there was no bleeding, the balloon was removed 12 hours later. This preserved the option of refilling the balloon if bleeding recurred.
Patients admitted to our unit provide written consent to use their clinical data for research purposes, provided that anonymity is maintained. The policy of our institution is that retrospective review of medical records to which patients have consented does not require review and approval by the ethics committee.
Results
During the study period, there were 9838 deliveries and the incidence of severe PPH unresponsive to standard medical treatment was 0.24% (n = 24/9838). The Bakri balloon tamponade was used in 20 cases (0.2% of all deliveries). The Table summarizes the clinical characteristics of the patients included in this report.
| Case no. | Delivery mode | Age | Parity | Gestational age, wks | Adjunctive treatment | Transfusion, units | ICU | Risk factors for PPH | Hb, g/dL | ||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Bakri | B-Lynch | Other | |||||||||
| 1 | Vaginal | 38 | 2 | 42 | + | + | 9PBCs, 8FFPs | + | 7.1 | ||
| 2 | Cesarean | 42 | 1 | 42 | + | + | 14PBCs, 8FFPS | + | 4.1 | ||
| 3 | Cesarean | 29 | 1 | 38 | + | + | 6PBCs, 2FFPs | − | Placenta previa | 7.0 | |
| 4 | Cesarean | 27 | 2 | 42 | + | + | 2PBCs | − | Placenta previa | 8.1 | |
| 5 | Cesarean | 30 | 1 | 41 | + | + | − | − | 9.2 | ||
| 6 | Miscarriage | 21 | 1 | 23 | + | + | H | 26PBCs, 16FFPs | + | Placenta increta | 4.0 |
| 7 | Cesarean | 29 | 1 | 41 | + | + | 24PBCs, 11FFPs | + | 5.6 | ||
| 8 | Cesarean | 33 | 2 | 39 | + | − | 4PBCs, 3FFPs | − | Placenta previa | 7.1 | |
| 9 | TOP | 35 | 3 | 18 | + | − | 3PBCs, 4FFPs | + | 7.2 | ||
| 10 | Cesarean | 32 | 1 | 36 | + | − | − | − | Low lying placenta, twin gestation | 7.4 | |
| 11 | Cesarean | 39 | 2 | 41 | + | − | 4PBCs, 3FFPs | − | 4.3 | ||
| 12 | Cesarean | 42 | 3 | 36 | + | − | − | − | Placenta previa | 7.8 | |
| 13 | Cesarean | 30 | 1 | 41 | + | − | UA ligation | 13PBCs, 4FFPs | + | 7.0 | |
| 14 | Cesarean | 34 | 1 | 41 | + | − | 2PBCs | − | 8.6 | ||
| 15 | Cesarean | 34 | 3 | 37 | + | − | − | − | Placenta previa | 7.8 | |
| 16 | Cesarean | 32 | 2 | 36 | + | − | − | − | Placenta bipartita | 8.7 | |
| 17 | Cesarean | 31 | 1 | 38 | + | − | 2PBCs | − | Twin gestation | 7.1 | |
| 18 | Cesarean | 28 | 4 | 36 | + | − | 2PBCs | − | Placenta previa | 7.0 | |
| 19 | Vaginal | 38 | 1 | 36 | + | − | 2PBCs | − | 5.1 | ||
| 20 | Cesarean | 37 | 1 | 36 | + | − | 4PBCs, 4FFPS | − | Twin gestation | 6.4 | |
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