We read with interest the recent article from Laas et al. This was a really interesting study concerning a new treatment of a main cause of maternal death.

We want to congratulate the authors for evaluating the efficiency of the intrauterine tamponade test by Bakri balloon in severe postpartum hemorrhage. Literature about Bakri balloon tamponade is limited to case reports or a few retrospective series. Moreover, the efficiency of Bakri balloon tamponade alone was not demonstrated clearly in the literature. In most studies, this procedure has been associated with invasive surgery (surgical artery ligation or compressive uterine sutures).

We have 2 major concerns with the current study: First, we were surprised by the low rate of embolization in this study. Indeed, during the control period, only 16 patients of 820 who experienced postpartum hemorrhage required embolization. This represents an embolization rate of <2%, which is not in accordance with the French register of embolization published by Bartoli et al (5.1% in the same French area). Our Department is also a French reference center in the same area, and 80% of the patients who are treated for postpartum hemorrhage come from other hospitals because of persistent bleeding after the administration of sulprostone. The embolization rate for severe postpartum hemorrhage that is unresponsive to sulprostone in our institution decreased from 33-22% between 2005 and 2010.

Second, we would like to highlight the potential danger of inflating a Bakri balloon after cesarean delivery. When hemorrhage occurs after cesarean delivery, insertion of the Bakri balloon by the authors was transvaginal. Indeed, even with abdominal ultrasound scanning, we cannot have a safety control on uterine scarring.

Finally, we thank the authors who demonstrated that tamponade by Bakri balloon is effective and can reduce the embolization rate. Bakri balloon tamponade could also be an effective tool that will allow a safer transfer for patients in referral centers with an embolization unit.