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• W1991397370 abstract "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. 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.1Bakri Y.N. Uterine tamponade-drain for hemorrhage secondary to placenta previa-accreta.Int J Gynaecol Obstet. 1992; 37: 302-303Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 2Bakri Y.N. Amri A. Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding.Int J Gynecol Obstet. 2001; 74: 139-142Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar 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 ReportA 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.Figure 2Laparotomy view 2: inflated Bakri balloon located in left broad ligamentShow full captionThe arrow indicates the Bakri balloon. LO, left ovary; LT, left fallopian tube; U, uterus. Leparco. Migration of Bakri balloon to broad ligament. Am J Obstet Gynecol 2013.View Large Image Figure ViewerDownload Hi-res image Download (PPT)CommentThe insertion technique of the Bakri tamponade balloon catheter is simple. However, the current case shows that the insertion of such a tamponade balloon may be associated with severe complication, even if the procedure is guided by manual and ultrasonographic guidance. There was no indication during the placement or inflation (still done under ultrasound guidance) that the balloon was in the wrong place (ie, not in midline or moved to the side). Obstetricians should be aware of this potential complication because the inflation of the balloon may increase the size of the preexisting uterine perforation.The real cause of uterine rupture will remain unknown. The delivery occurred 18 days before the severe hemorrhage; however, the patient also displayed a postpartum hemorrhage just after delivery. The most probable cause was perforation during dilation. We do not think that the uterine perforation had been performed by the insertion of the tamponade balloon because the placement was easy and performed under ultrasound guidance. Another hypothesis is that the inflated balloon provoked the uterine rupture during the inflation (overdistension). The amount of saline fluid that was instilled to inflate the balloon in the present case was 500 mL (manufacturer recommended volume).Finally, several studies have reported a successful procedure in the use of the balloons, but few difficulties or failures have been reported.2Bakri Y.N. Amri A. Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding.Int J Gynecol Obstet. 2001; 74: 139-142Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar, 3Georgiou G. Balloon tamponade in the management of postpartum haemorrhage: a review.BJOG. 2009; 116: 748-757Crossref PubMed Scopus (189) Google Scholar, 4Vitthala S. Tsoumpou I. Anjum Z.K. Aziz N.A. Use of Bakri balloon in post-partum haemorrhage: a series of 15 cases.Aust N Z J Obstet Gynaecol. 2009; 49: 191-194Crossref PubMed Scopus (64) Google Scholar, 5Aibar L. Aguilar M.T. Puertas A. Valverde M. Bakri balloon for the management of postpartum hemorrhage.Acta Obstet Gynecol Scand. 2013; 92: 465-467Crossref PubMed Scopus (33) Google Scholar However, a number of potential, but as yet unreported complications, may occur that include ulceration/necrosis from the pressure effect of the balloon with prolonged use, uterine rupture from uterine overdistension, and uterine perforation during insertion. The current reported case of balloon complication highlights the need for further evaluation of intrauterine tamponade balloons. Uterine tamponade with an intrauterine balloon seems to be an effective procedure.1Bakri Y.N. Uterine tamponade-drain for hemorrhage secondary to placenta previa-accreta.Int J Gynaecol Obstet. 1992; 37: 302-303Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 2Bakri Y.N. Amri A. Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding.Int J Gynecol Obstet. 2001; 74: 139-142Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar 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 ReportA 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. 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. CommentThe insertion technique of the Bakri tamponade balloon catheter is simple. However, the current case shows that the insertion of such a tamponade balloon may be associated with severe complication, even if the procedure is guided by manual and ultrasonographic guidance. There was no indication during the placement or inflation (still done under ultrasound guidance) that the balloon was in the wrong place (ie, not in midline or moved to the side). Obstetricians should be aware of this potential complication because the inflation of the balloon may increase the size of the preexisting uterine perforation.The real cause of uterine rupture will remain unknown. The delivery occurred 18 days before the severe hemorrhage; however, the patient also displayed a postpartum hemorrhage just after delivery. The most probable cause was perforation during dilation. We do not think that the uterine perforation had been performed by the insertion of the tamponade balloon because the placement was easy and performed under ultrasound guidance. Another hypothesis is that the inflated balloon provoked the uterine rupture during the inflation (overdistension). The amount of saline fluid that was instilled to inflate the balloon in the present case was 500 mL (manufacturer recommended volume).Finally, several studies have reported a successful procedure in the use of the balloons, but few difficulties or failures have been reported.2Bakri Y.N. Amri A. Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding.Int J Gynecol Obstet. 2001; 74: 139-142Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar, 3Georgiou G. Balloon tamponade in the management of postpartum haemorrhage: a review.BJOG. 2009; 116: 748-757Crossref PubMed Scopus (189) Google Scholar, 4Vitthala S. Tsoumpou I. Anjum Z.K. Aziz N.A. Use of Bakri balloon in post-partum haemorrhage: a series of 15 cases.Aust N Z J Obstet Gynaecol. 2009; 49: 191-194Crossref PubMed Scopus (64) Google Scholar, 5Aibar L. Aguilar M.T. Puertas A. Valverde M. Bakri balloon for the management of postpartum hemorrhage.Acta Obstet Gynecol Scand. 2013; 92: 465-467Crossref PubMed Scopus (33) Google Scholar However, a number of potential, but as yet unreported complications, may occur that include ulceration/necrosis from the pressure effect of the balloon with prolonged use, uterine rupture from uterine overdistension, and uterine perforation during insertion. The current reported case of balloon complication highlights the need for further evaluation of intrauterine tamponade balloons. The insertion technique of the Bakri tamponade balloon catheter is simple. However, the current case shows that the insertion of such a tamponade balloon may be associated with severe complication, even if the procedure is guided by manual and ultrasonographic guidance. There was no indication during the placement or inflation (still done under ultrasound guidance) that the balloon was in the wrong place (ie, not in midline or moved to the side). Obstetricians should be aware of this potential complication because the inflation of the balloon may increase the size of the preexisting uterine perforation. The real cause of uterine rupture will remain unknown. The delivery occurred 18 days before the severe hemorrhage; however, the patient also displayed a postpartum hemorrhage just after delivery. The most probable cause was perforation during dilation. We do not think that the uterine perforation had been performed by the insertion of the tamponade balloon because the placement was easy and performed under ultrasound guidance. Another hypothesis is that the inflated balloon provoked the uterine rupture during the inflation (overdistension). The amount of saline fluid that was instilled to inflate the balloon in the present case was 500 mL (manufacturer recommended volume). Finally, several studies have reported a successful procedure in the use of the balloons, but few difficulties or failures have been reported.2Bakri Y.N. Amri A. Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding.Int J Gynecol Obstet. 2001; 74: 139-142Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar, 3Georgiou G. Balloon tamponade in the management of postpartum haemorrhage: a review.BJOG. 2009; 116: 748-757Crossref PubMed Scopus (189) Google Scholar, 4Vitthala S. Tsoumpou I. Anjum Z.K. Aziz N.A. Use of Bakri balloon in post-partum haemorrhage: a series of 15 cases.Aust N Z J Obstet Gynaecol. 2009; 49: 191-194Crossref PubMed Scopus (64) Google Scholar, 5Aibar L. Aguilar M.T. Puertas A. Valverde M. Bakri balloon for the management of postpartum hemorrhage.Acta Obstet Gynecol Scand. 2013; 92: 465-467Crossref PubMed Scopus (33) Google Scholar However, a number of potential, but as yet unreported complications, may occur that include ulceration/necrosis from the pressure effect of the balloon with prolonged use, uterine rupture from uterine overdistension, and uterine perforation during insertion. The current reported case of balloon complication highlights the need for further evaluation of intrauterine tamponade balloons." @default.
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• W1991397370 title "Migration of Bakri balloon through an unsuspected uterine perforation during the treatment of secondary postpartum hemorrhage" @default.
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