Comparison between two management protocols for postpartum hemorrhage during cesarean section in placenta previa: Balloon protocol versus non-balloon protocol

Assessment of Uterine Contraction and Atonic Bleeding during the Third Stage of Labor Using Shear Wave Elastography

OBJECTIVE

This study aimed to clarify the relationship between fluctuations in uterine stiffness during the third stage of labor and blood loss upon placenta delivery using shear wave elastography.

METHODS

This prospective cohort study enrolled consecutive singleton pregnant women above 37 weeks of gestation who delivered infants transvaginally at a single perinatal center. Shear wave velocities (SWV) were continuously measured during the third stage of transvaginal labor using transabdominal ultrasound and these values were compared between groups with large (≥500 g) and small amounts of bleeding during this stage.

RESULTS

In total, 8 cases of large bleeding and 47 cases of small bleeding were compared. The large amount of bleeding group had a significantly lower median of minimum SWV values (0.97 [0.52-1.01] m/s than the small amount of bleeding group (1.25 [1.04-1.48] m/s p = 0.02). However, no significant differences were observed between the two groups in terms of median, mean, and maximum SWV values. The time from delivery of the infant to placental delivery was significantly longer in the large amount of bleeding group (median time: 370.5 s vs. 274 s, p < 0.05).

CONCLUSION

Ultrasound quantification of uterine stiffness using shear wave elastography demonstrated that uterine contractions may influence the biological hemostasis of the uterus during the third stage of labor. Baseline uterine stiffness was weak and a longer duration of placental separation might be associated with cases of large amounts of bleeding during this stage.

Risk factors for Bakri balloon tamponade failure in the management of postpartum hemorrhage

OBJECTIVE

To predict risk factors for Bakri balloon tamponade (BBT) failure in the management of postpartum hemorrhage (PPH).

METHODS

The data of 599 patients who underwent BBT were retrospectively analyzed from January 1, 2017 to December 31, 2021 in a tertiary hospital in Shanghai, East China. The patients were divided into the failure group and the success group. Failure was defined as the inability to control bleeding, which required surgical interventions. Maternal characteristics, PPH characteristics, PPH management approaches, and maternal complications were compared between the groups. The independent predictors of BBT failure were analyzed by logistic regression analysis.

RESULTS

The overall success rate of BBT was 83.0% (497/599). The blood loss before and after balloon insertion in the failure group was significantly greater than that in the success group. Of the 102 failures, B-Lynch suture was performed in one patient, uterine artery embolization was performed in 99 patients (with one failure), and total hysterectomy was performed in three patients. Some risk factors, including twin gestation (odds ratio [OR] 9.68), placenta accreta spectrum with/without placenta previa (OR 4.45), estimated blood loss at least 1135 ml at balloon insertion (OR 3.35), multiparous (OR 2.72), and in vitro fertilization-embryo transfer (OR 2.00) were strongly associated with BBT failure.

CONCLUSION

BBT seemed to be a less effective tool in the management of PPH due to placenta accreta spectrum with/without placenta previa and twin gestation.

Risk Factors for Intrauterine Tamponade Failure in Postpartum Hemorrhage

OBJECTIVE

To identify factors associated with intrauterine tamponade failure after vaginal or cesarean delivery.

METHODS

This was a nationwide population-based cohort study that used data from the French Programme de Médicalisation des Systèmes d'Information. This study compared the failure and effectiveness of intrauterine tamponade among all women who received the procedure in France from January 1, 2019, to December 31, 2019. Failure was defined as the use of a second-line method (uterine artery embolization, conservative or radical surgery, or death) within 7 days of intrauterine tamponade. Factors associated with intrauterine tamponade failure were identified by univariate analyses and tested using multivariate generalized logistic regression models (with a random intercept on institution) to obtain adjusted odds ratio (aOR) and 95% CI statistics.

RESULTS

A total of 39,193 patients presented with postpartum hemorrhage in 474 French maternity wards. Of these patients, 1,761 (4.5%) received intrauterine tamponade for persistent bleeding. The effectiveness rate of intrauterine tamponade was 88.9%. For 195 women (11.1%), a second-line method was indicated. Patients for whom intrauterine tamponade failed had a higher maternal age, a lower mean gestational age, and more frequent instances of placental abnormalities, preeclampsia, cesarean birth, and uterine rupture. The multivariate analysis revealed that cesarean birth (aOR 4.2; 95% CI 2.9-6.0), preeclampsia (aOR 2.3; 95% CI 1.3-4.0), and uterine rupture (aOR 14.1; 95% CI 2.4-83.0) were independently associated with intrauterine tamponade failure.

CONCLUSION

Cesarean delivery, preeclampsia, and uterine rupture are associated with intrauterine tamponade failure in the management of postpartum hemorrhage.

Differential Effects of Intrauterine Balloon Tamponade Indications on Postpartum Hemorrhage Outcomes

Objective

To determine whether the indication of intrauterine balloon tamponade (IUBT) was associated with postpartum hemorrhage (PPH) outcomes.

Methods

Patients with PPH who underwent IUBT between January 2013 and November 2021 were included in a cohort study. PPH outcomes in patients who had IUBT for indications of uterine atony were compared to those who had IUBT for indications of placental site bleeding. PPH outcomes included uterine artery embolization (UAE) or hysterectomy after IUBT, estimated blood loss (EBL) after balloon placement, and blood transfusion. Statistical analysis was performed using multivariate logistic regression.

Results

IUBT was performed on 603 cases, with 121 (20.1%) undergoing it for placental site bleeding and 482 (79.9%) for uterine atony. In general, IUBT was a reliable treatment for PPH, but the specific efficacy varied depending on the indication for placement. After controlling for confounding variables, compared to the indication of uterine atony, the indication of placental site bleeding increased the risk of transfusion of ≥4 units of PRBCs (aOR 2.47, 95%CI 1.32–3.98), EBL ≥ 300 ml after IUBT (aOR 3.78, 95%CI 2.22–5.33), and UAE or hysterectomy (aOR 2.52, 95%CI 1.20–6.01), respectively. Other factors associated with adverse PPH outcomes were lower antenatal hemoglobin, higher IUBT volume, longer duration of IUBT and larger shock index values.

Conclusions

IUBT was less effective in treating PPH patients with indications of placental site bleeding than with indications of uterine atony. Follow-up monitoring of PPH patients with placental site bleeding should be intensified.

Predictors of Failed Intrauterine Balloon Tamponade in the Management of Severe Postpartum Hemorrhage

To identify the factors predicting intrauterine balloon tamponade (IUBT) failure for severe postpartum hemorrhage (PPH) after delivery, we conducted a retrospective cohort study of women who underwent IUBT for severe PPH after delivery from October 1, 2016 until September 30, 2017. The failure of IUBT was defined as the need of additional surgical procedures or uterine embolization. A total of 99,650 deliveries occurred during the study period. Among the patients, 106 cases of severe PPH were managed with IUBT, and the global success rate was 70.8% (75/106). Least absolute shrinkage and selection operator (LASSO) regression was performed to select the potential risk factors predicting IUBT failure. The associated risk factors-obesity, multiple gestation, cesarean delivery, estimated blood loss (EBL), and placenta accreta spectrum (PAS)-were included in multivariate logistic models. Ultimately, these models identified multiple gestation, EBL, and PAS as independent risk factors for IUBT failure. In conclusion, IUBT is an effective method for severe PPH. The presence of factors affecting IUBT failure should be recognized early, and other modalities of management should be anticipated.

Factors Associated with Failure of Bakri Balloon Tamponade for the Management of Postpartum Haemorrhage. Case Series Study and Systematic Review

Background: Postpartum haemorrhage (PPH) is an unpredictable obstetric emergency that requires a multidisciplinary approach. Bakri balloon tamponade (BBT) is recommended when PPH does not respond to medical treatment. Nowadays few published studies have performed a multivariate analysis to determine the variables independently associated with BBT failure. Methods: Our study purpose was to determine the variables independently associated with BBT failure: first, in a large single-centre cohort study between 2010 and 2020, and second, in a systematic literature review using Medline and the Cochrane Library. Maternal and perinatal variables, PPH characteristics, technique-related variables and complications were recorded in the case series study, comparing between successful and failed BBT patients. Study characteristic and variables significantly associated with BBT failure were recorded in the systematic review. All studies used a logistic regression test. Results: The case series included 123 patients. The profile of these patients were primiparous, with vaginal delivery and a full-term new-born. BBT was successful in 81.3% of cases. Five studies were included in the systematic review, providing data from 551 patients. BBT was successful in 79.5% of cases. Conclusions: Maternal age, caesarean delivery, ≥7 red blood cells units (RBCU) transfused and curettage before BBT insertion, history of caesarean section, pre-pregnancy obesity, anteriorly placed placenta, placenta accreta, caesarean delivery, estimated blood loss before insertion of BBT, long operation duration, and coagulopathy were independent factors for BBT failure.

The routine use of prophylactic Bakri balloon tamponade contributes to blood loss control in major placenta previa

OBJECTIVE

To verify the blood loss control effect of routine prophylactic Bakri balloon tamponade on major and minor placenta previa (PP).

METHODS

We conducted a retrospective cohort study of all singleton pregnancies that involved cesarean section (CS) for PP at our hospital. All participants were divided into Bakri balloon (underwent routine prophylactic use just after placenta removal) and non-balloon groups, and into major and minor PP groups. Clinical outcomes in major and minor PP were compared between balloon and non-balloon groups.

RESULTS

The balloon and non-balloon groups contained 74 and 89 patients, respectively. There were 41 and 33 (balloon group) and 48 and 41 (non-balloon group) major and minor PP cases, respectively. Intraoperative and perioperative blood losses of major PP were significantly lower in the balloon group than the non-balloon group (1045 ml versus 1553 ml, P = 0.016; and 1189 ml versus 1810 ml, P = 0.006, respectively). The frequency of massive postpartum hemorrhage (>500 ml) with major PP was lower in the balloon group than in the non-balloon group (2.4% versus 16.7%, P = 0.027), but with no significant difference with minor PP.

CONCLUSION

Routine prophylactic use of Bakri balloon tamponade during and after CS is effective in controlling blood loss in major PP.

Efficacy of Intra-Uterine Tamponade Balloon in Post-Partum Hemorrhage after Cesarean Delivery: An Impact Study

Invasive therapies (surgery or radiological embolization) are used to control severe post-partum hemorrhage. The intra-uterine tamponade balloon is a potential alternative, well documented after vaginal delivery. However, available data on its use after cesarean delivery remain scarce. This study assessed the efficacy of the intra-uterine tamponade balloon during post-partum hemorrhage in a cesarean delivery setting. Using a retrospective impact design, post-partum hemorrhage-related outcomes before (“pre-balloon” period) versus after implementation of intra-uterine tamponade balloon (“post-balloon” period) were compared. All women with post-partum hemorrhage requiring potent uterotonic treatment with prostaglandins after cesarean delivery over a 9-year period were eligible. The primary outcome was the rate of invasive procedure (conservative surgery, radiological embolization and/or hysterectomy). p < 0.05 was considered statistically significant. A total of 279 patients were included (140 vs. 139). Most baseline characteristics were comparable between the two studied periods. The success rate of the intra-uterine tamponade balloon was 82%, and no related complications occurred. Rates of invasive procedures and transfusion were significantly reduced (28.6% vs. 11.5%, p < 0.001 and 44.3% vs. 28.1%, p = 0.006 respectively) during the “post-balloon” period, and length of hospital stay was shorter (p < 0.001). Implementation of intra-uterine tamponade balloon during post-partum hemorrhage after cesarean delivery appears to be safe and effective, with a decrease in both invasive procedures and transfusion rates.

Obstetric outcomes in major vs minor placenta praevia: A retrospective cohort study

BACKGROUND

Placenta praevia (PP) is a rare obstetric condition associated with significant maternal and perinatal morbidity. Traditionally, the degree of PP has been classified into minor and major; however, there are very few robust studies that compare the maternal outcomes of these types of PP.

AIMS

To identify any significant differences in obstetric outcomes between major and minor PP, including antepartum, intraoperative and postpartum complications.

MATERIALS AND METHODS

A retrospective cohort study was conducted at the Royal Brisbane & Women's Hospital between 2009 and 2018; all women were diagnosed with PP.

RESULTS

Of the total of 368 women recruited, over half of the participants were diagnosed with major PP (57%), while the remaining had minor PP. Women with major PP, compared to women with minor PP, had an increased risk of antepartum haemorrhage (odds ratio (OR) 2.77, P < 0.001), delivery at an earlier gestational age (36.1 vs 37.4 weeks), general anaesthesia (OR 3.25, P < 0.001), greater proportion of emergency lower segment (51% vs 40%) and classical caesarean (7.7% vs 3.8%), increased number of uterotonics (incidence rate ratio (IRR) 1.17, P < 0.031), greater blood loss (IRR 1.32, P < 0.001) and higher frequency of blood transfusion (IRR 2.00, P < 0.027), and longer postpartum hospital stay (IRR 1.26, P < 0.001). Hysterectomy was performed for three women with major PP, compared to one with minor PP.

CONCLUSIONS

The degree of PP significantly impacts obstetric outcomes, with major PP associated with worse maternal morbidity antenatally, intraoperatively and postpartum. Therefore, to optimise patient care, this study emphasises the importance of identifying and distinguishing between different types of PP.

Local uterine resection with Bakri balloon placement in placenta accreta spectrum disorders

OBJECTIVE

Placenta accreta spectrum (PAS) is a potentially life-threatening condition characterized by the abnormal adherence of the placenta to the implantation site. We sought to evaluate the efficacy, surgical feasibility, risks, and advantages of local uterine resection in cases complicated with PAS.

MATERIALS AND METHODS

This study included 97 patients with PAS, which was confirmed during surgery and by histopathological examination between January 2013 and December 2019. The patients were divided into two groups based on operative approach. The study population (local resection group) consisted of 30 cases in whom total resection of adherent placenta and myometrium was performed, whereas the control group (hysterectomy group) of 67 cesarean hysterectomy cases.

RESULTS

Patients who underwent hysterectomy had significantly more bleeding than the local resection group (1180±160 mL vs 877±484 mL; p=0.002). The mean number of transfused packed red blood cells (pRBCs) was greater in the hysterectomy group (4.5±2.3) than in the local resection group (2.6±3.1; p=0.001). Transfusion rate of four and/or more pRBCs was 67.2% in the hysterectomy group and 33.3% in the local resection group, which indicated a statistically significant difference (p=0.002). Of patients, 29.6% required intensive care unit in the hysterectomy group and 6.7% in the local resection group (p=0.023).

CONCLUSION

Local resection can be performed safely in selected PAS cases. In these cases, using a standardized protocol in terms of patient selection and surgical procedure will reduce morbidity and mortality.

Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis

OBJECTIVE

To assess the efficacy, effectiveness, and safety of uterine balloon tamponade for treating postpartum hemorrhage.

STUDY DESIGN

We searched electronic databases (from their inception to August 2019) and bibliographies. We included randomized controlled trials, nonrandomized studies, and case series that reported on the efficacy, effectiveness, and/or safety of uterine balloon tamponade in women with postpartum hemorrhage. The primary outcome was the success rate of uterine balloon tamponade for treating postpartum hemorrhage (number of uterine balloon tamponade success cases/total number of women treated with uterine balloon tamponade). For meta-analyses, we calculated pooled success rate for all studies, and relative risk with 95% confidence intervals for studies that included a comparative arm.

RESULTS

Ninety-one studies, including 4729 women, met inclusion criteria (6 randomized trials, 1 cluster randomized trial, 15 nonrandomized studies, and 69 case series). The overall pooled uterine balloon tamponade success rate was 85.9% (95% confidence interval, 83.9-87.9%). The highest success rates corresponded to uterine atony (87.1%) and placenta previa (86.8%), and the lowest to placenta accreta spectrum (66.7%) and retained products of conception (76.8%). The uterine balloon tamponade success rate was lower in cesarean deliveries (81.7%) than in vaginal deliveries (87.0%). A meta-analysis of 2 randomized trials that compared uterine balloon tamponade vs no uterine balloon tamponade in postpartum hemorrhage due to uterine atony after vaginal delivery showed no significant differences between the study groups in the risk of surgical interventions or maternal death (relative risk, 0.59; 95% confidence interval, 0.02-16.69). A meta-analysis of 2 nonrandomized before-and-after studies showed that introduction of uterine balloon tamponade in protocols for managing severe postpartum hemorrhage significantly decreased the use of arterial embolization (relative risk, 0.29; 95% confidence interval, 0.14-0.63). A nonrandomized cluster study reported that use of invasive procedures was significantly lower in the perinatal network that routinely used uterine balloon tamponade than that which did not use uterine balloon tamponade (3.0/1000 vs 5.1/1000; P < .01). A cluster randomized trial reported that the frequency of postpartum hemorrhage-related invasive procedures and/or maternal death was significantly higher after uterine balloon tamponade introduction than before uterine balloon tamponade introduction (11.6/10,000 vs 6.7/10,000; P = .04). Overall, the frequency of complications attributed to uterine balloon tamponade use was low (≤6.5%).

CONCLUSION

Uterine balloon tamponade has a high success rate for treating severe postpartum hemorrhage and appears to be safe. The evidence on uterine balloon tamponade efficacy and effectiveness from randomized and nonrandomized studies is conflicting, with experimental studies suggesting no beneficial effect, in contrast with observational studies. Further research is needed to determine the most effective programmatic and healthcare delivery strategies on uterine balloon tamponade introduction and use.

Prophylactic application of Bakri balloon tamponade versus uterine gauze packing during cesarean section in patients with placenta previa

Objective

This study was performed to compare the effectiveness of routine Bakri balloon tamponade (BBT) and uterine gauze packing (UGP) during cesarean section in patients with placenta previa.

Methods

This study involved women with placenta previa who underwent cesarean section with either prophylactic BBT (n = 98) or UGP (n = 64) from January 2016 to December 2018. The clinical variables and pregnancy outcomes were compared between the two groups.

Results

The estimated intraoperative blood loss was significantly lower in the BBT than UGP group (667 ± 358 vs. 791 ± 360 ml, respectively). Additionally, the proportion of patients who required transfusion was significantly lower in the BBT than UGP group (9/98 vs. 17/64, respectively). The operative duration (97.8 ± 17.7 vs. 108.2 ± 16.9 minutes) and the length of stay (3.79 ± 0.89 vs. 4.12 ± 0.85 days) were significantly shorter in the BBT than UGP group.

Conclusions

In patients with placenta previa who undergo cesarean section, preventive application of BBT is superior to UGP for decreasing the intraoperative blood loss and transfusion rate. BBT is a more reliable technique to prevent and control postpartum hemorrhage.

Patient blood management in obstetrics - Review

Patient blood management (PBM) aims to reduce red blood cell transfusion, minimize preoperative anemia, reduce intraoperative blood loss as well as optimize hemostasis, and individually manage postoperative anemia. Benefits include improved clinical outcome with a reduction in patient morbidity and mortality, but also lower hospital costs and shorter hospital length of stay. To date, it has been successfully implemented in several medical specialties, such as cardiac, trauma and orthopedic surgery. In obstetrics, postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality. PBM has the potential to improve outcome of mother and child. However, pregnancy and childbirth pose a special challenge to PBM, and several adaptations compared to PBM in elective surgery are necessary. To date, awareness of the clinical advantages of PBM among obstetricians and midwifes regarding PBM and its concept in PPH is limited. In the following review, we therefore aim to present the current status quo in PBM in obstetrics and its challenges in the clinical routine.

Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta

The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.

Feasibility of using a handheld tissue hardness meter to quantify uterine contractions and its clinical application for obstetric bleeding management

Postpartum haemorrhage (PPH) is a potentially life-threatening condition. Women undergoing caesarean section (CS) are at particular risk, and improvements in the management of PPH during CS are required. We investigated the use of a tissue hardness metre to quantify uterine contractions during CS with a view to its application for obstetric bleeding management. Fifty pregnant women at term who underwent elective CS were recruited. Using a tissue hardness metre, we measured uterine hardness twice during CS: after placental removal and before peritoneum closure. Each measurement was conducted at two standardised points: fundus and corpus uteri. Concurrently, obstetricians subjectively graded uterine contractions as weak, medium, or strong. The hardness metre accurately quantified the degree of uterine contraction assessed by the obstetricians, and could be an effective clinical tool for early recognition of intra-operative massive bleeding. IMPACT STATEMENT What is already known on this subject? Maintaining adequate uterine contraction leads to prevention of excessive blood loss, which decreases the incidence and severity of PPH. However, the assessment of uterine contraction is currently judged by obstetricians, who manually and subjectively evaluate uterine contraction according to uterine hardness. Therefore, uterine atony remains a clinical diagnosis without a universal definition. What do the results of this study add? The present study investigated the use of a tissue hardness metre to quantify uterine contractions during CS with a view to its application for obstetric bleeding management. The hardness metre was able to quantify the degree of uterine contraction perceived by obstetricians. Quantifying uterine hardness during CS correlates with the amount of intra-operative bleeding and is useful for early recognition of massive haemorrhage. What are the implications of these findings for clinical practice and/or further research? To improve the management of atonic PPH and avoid serious complications, the tissue hardness metre should be considered as a potential clinical tool during CS.

Prognostic factors for the use of intrauterine balloon tamponade in the management of severe postpartum hemorrhage

OBJECTIVE

To identify prognostic factors associated with successful management of severe postpartum hemorrhage (PPH) using intrauterine balloon tamponade (IUBT).

METHODS

Retrospective review of all cases of severe PPH with blood loss greater than 1 L in a tertiary unit in Hong Kong from July 1, 2012, to June 30, 2017. Records of patients who had undergone IUBT insertion were reviewed. Univariate analysis and logistic regression models were used to identify prognostic factors for successful management with IUBT.

RESULTS

Of 22 860 deliveries during the study period, severe PPH occurred in 1.4% (n=311), and IUBT was attempted in 26.0% (n=81) of these patients. IUBT alone was successful in arresting hemorrhage in 72.8% (n=59), and the overall rate for avoiding hysterectomy was 86.4% (n=70). Presence of coagulopathy (P=0.048) and placenta accreta (P=0.048) were the adverse prognostic factors associated with higher failure rates. Less blood loss (≤1400 mL) at the time of insertion of IUBT and a positive tamponade test (≤50 mL of blood drained from the uterus within the first 30 minutes after insertion of IUBT) were good predictors for success of IUBT.

CONCLUSION

The presence of adverse prognostic factors should prompt early resort to other treatment modalities or hysterectomy as a salvage procedure.

Intrauterine Inflated Foley's Catheter Balloon in the Management of Abnormally Invasive Placenta Previa: A Case-Control Study

Objective

To describe the use of intrauterine inflated Foley's catheter balloon for control of postpartum hemorrhage (PPH) during cesarean section (CS) in cases of abnormally invasive placenta previa aiming to preserve the uterus.

Methods

Retrospective case-control study of the data of women who underwent elective CS on abnormally adherent placenta previa was carried out. Women in whom inflated Foley's catheter balloon was used for control of PPH during CS (n = 40) were compared with a control group of women who underwent elective CS by the same technique but without use of intrauterine catheter balloon (n = 38).

Results

Use of intrauterine inflated Foley's catheter balloon significantly reduced the estimated amount of blood loss (P = 0.008), amounts of crystalloids, colloids and packed red blood cells transfusion (P = 0.025, 0.017 and 0.022, respectively), and the need for bilateral internal iliac artery (IIA) ligation (P = 0.016). No significant difference was observed between both groups regarding the use of massive transfusion protocol, performing cesarean hysterectomy, relaparotomy, and admission to the intensive care unit.

Conclusion

Application of an intrauterine inflated Foley's catheter balloon during CS in cases of morbidly adherent placenta previa helps to control PPH with preservation of the uterus and decreases the need for the invasive IIA ligation.

Bakri balloon placement in the successful management of postpartum hemorrhage in a bicornuate uterus: A case report

•

This is the first reported case of successful use of Bakri balloon placement in the presence of postpartum hemorrhage in a bicornuate uterus.

•

Physicians should be aware that uterine malformation is not a contraindication to Bakri balloon placement.

•

When performing Bakri balloon placement in the presence of uterine malformation, efforts be made to precisely locate the site of bleeding.

Introduction

Postpartum hemorrhage is an obstetric emergency that accounts for 25% of maternal deaths worldwide. Initial management consists of uterotonic administration but in cases in which there is a failure of response to medication, uterine cavity tamponade can be effective. This is the first reported case of successful Bakri balloon placement in the management of postpartum hemorrhage at the time of cesarean delivery in a patient with a bicornuate uterus.

Presentation of case

The patient was a primigravid female who presented at 40 weeks and 1 day gestation with known bicornuate uterus and findings suggestive of placental abruption. Labor was subsequently induced and magnesium was administered after a diagnosis of preeclampsia with severe features was made. Cesarean delivery was then performed for category II fetal heart rate tracing remote from delivery. Intraoperative course was significant for uterine atony unresponsive to oxytocin, carboprost, methylergonovine and misoprostol administration. The right uterine horn was noted to be markedly atonic compared to the left. A Bakri balloon was then placed transvaginally and inflated with 600 mL of saline in this location. Atony then resolved.

Discussion

Although uterine malformation is not a documented contraindication to Bakri balloon placement, there is no literature on its efficacy in the treatment of hemorrhage in the presence of this anomaly.

Conclusion

In the management of postpartum hemorrhage, Bakri balloon placement is associated with success in the presence of a bicornuate uterus. Care should be taken to direct insertion of the balloon in the appropriate location.