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• W2000670574 abstract "We appreciate the fact that intrauterine balloon use has become a topic of further discussion, and we thank Makino and his colleagues for their comments 1. Makino et al. 1 raised two questions regarding the woman that we described 2: (a) changes of her vital signs, and (b) intraperitoneal blood accumulation through the Fallopian tube. We understand their viewpoint: if (a) and (b) could have been detected earlier, bleeding also may have been detected much earlier, avoiding hysterectomy. Actually, we stated, “frequent ultrasound and vital sign check-ups may be mandatory after Bakri balloon placement” 2, which fully agrees with their view 1. In this woman, as is typical, we monitored vital signs continuously and performed ultrasound check-ups for both intrauterine and extrauterine blood accumulation approximately every 1–2 h. Vital signs were stable just before the bleeding manifestation, and ultrasound 1 h before revealed no blood accumulation in either the intrauterine or the extrauterine space. Hence, we believe that bleeding occurred acutely in this patient. We have never been “absent-minded” about possible after-bleeding. We wish to briefly describe some specific features of this patient. She was 45 years old and had a twin pregnancy. Partial placenta accreta was present in the uterine body. Although this was not described, histological examination revealed placenta accreta occupying approximately one-half of the placental attachment, meaning shallow, but wide, abnormally invasive placentation. Hence, we believe that bleeding had stopped once after the cesarean section, but uterine contractions weakened and then bleeding occurred acutely from the placenta accreta area, i.e. cephalad of the Bakri balloon. Greater age 3 and twin pregnancy are high-risk factors for postpartum hemorrhage, so these may have also been associated with this event. Even so, our belief that “no drainage does not indicate no bleeding” is still valid. It is our experience that the Bakri drainage portion (uterine side) is frequently blocked by clots, and so we cannot rely too much on the Bakri drainage function. In retrospect, we should have performed a “uterine sandwich” in this patient. As described, we introduced a new concept of “role sharing” 4. Uterine compression suture (Matsubara–Yano) should be inserted to stop bleeding from the uterine body (cephalad), and the Bakri balloon should be placed to stop bleeding from the lower segment (caudal): Matsubara–Yano for cephalad and Bakri for caudal, hence “role sharing.” However, in this patient, intraperitoneal adhesions, especially adhesions between the posterior uterine surface and rectum, were noted, and we “skipped” the uterine compression suture. We should have separated the adhesions and performed uterine compression suture, which might have improved the outcome. Lastly, please allow us to add one thing: the same caution is necessary on “holding the cervix” (Matsubara) – a novel hemostatic technique for postpartum hemorrhage 5. Both the anterior and posterior cervical lips should be grasped by ring forceps, thereby closing the cervical ostium. This may “prevent the Bakri balloon from slipping out of the uterus (concomitant use with Bakri)” and “tamponade the uterus by intrauterine blood accumulation, thus stopping bleeding (single use)” 5. Caution should also be exercised to detect bleeding concealed both within and outside the uterus. “No vaginal (drainage) bleeding does not indicate no bleeding” holds true not only for Bakri balloon use but also for holding the cervix." @default.
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• W2000670574 date "2015-03-19" @default.
• W2000670574 modified "2023-10-17" @default.
• W2000670574 title "Authors' reply: No vaginal bleeding does not indicate no bleeding: still valid for Bakri balloon and also for “holding the cervix”" @default.
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• W2000670574 doi "https://doi.org/10.1111/aogs.12617" @default.
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