We found the success rate of BBT as 86% in the management of postpartum uterine atony in fertility preserving management option. This ratio is compatible with the 70-100% rates reported in the literature
6,10,11,19,20. Since it is a retrospective case series and the absence of a control group are the limitations of our study.
Recently, intrauterine balloon insertion was suggested to be included in the treatment protocol for PPH 13-15. In Hong Kong, intrauterine balloon tamponade for the management of massive postpartum hemorrhage is in use as part of obstetric training 16. Various balloons such as condom, Sengstaken-Blakemore tube, Foley, Rusch or Bakri catheter are in use for uterine tamponade 17. Bakri balloon is specially designed to be inserted into the uterine cavity which is infused with liquid up to 500 ml and effective in controlling acute PPH refractory to medical treatment. The lumen at the center of the catheter provides the drainage of blood which enables the detection of ongoing bleeding 10. The mechanism of action of BBT is still not well understood. It has been speculated that the balloon acts by raising the intrauterine pressure to a greater pressure than the systemic arterial pressure 18.
In the literature, case series were reported describing the effectiveness of uterine balloon tamponade with various balloon types in acute postpartum hemorrhage unresponsive to medical treatment 16. Success rates in preventing hysterectomy were between 70-100 %. In some reports analysing only uterine atony cases, 100 % success rate was presented 19. Similarly, 80-100 % success rates were reported in case series which combined the uterine compression sutures with Bakri balloon tamponade for the treatment of uterine atony 6,7,1011,20. UBT might be combined with other conservative techniques like external uterine compression sutures or endouterine square hemostatic sutures. Bakri balloon is probably the least invasive conservative management modality for acute postpartum hemorrhage and convenient for both transvaginal and trans-abdominal insertion, immediately reduces bleeding and decreases the need for more aggressive procedures such as hysterectomy 21. Therefore, uterine balloon tamponade is recommended as the first step in the management of postpartum hemorrhage 22-24. We performed BBT as the first step in 22 cases of 30 cases of uterine atony who did not respond to medical treatment in our clinic. Two of these cases required emergency hysterectomy. Sandwich method was applied to 8 cases. In two of these cases there was a failure and hysterectomy was required.
Uterine compression sutures and intrauterine balloon tamponade are defined as fertility preserving management options in PPH and both of those techniques were suggested to be combined in order to apply pressure on the surface of myometrium both internally (Bakri balloon) and externally (B-Lynch suture) 8,9,11,25-27. Yoong et al. 20 similarly suggested that sandwich technique is a simple and quick surgical technique that can be used especially for the treatment of atonic post-partum hemorrhage in infiltrating placenta praevia. Vitthala et al. 6 reported the success rate of sandwich method as 100 % in vaginal delivery and 57 % in cesarean section birth. This method fails mostly in abnormal placentation cases such as placenta previa and placenta accrete, In our series, we used Bakri balloon together with B-Lynch compression suture in eight cases. In 2 of these cases this method failed and hysterectomy was required. In 1 case Asherman’s syndrome developed which resulted in amenorrhea and infertility. In this case the balloon inflation volume was 350 ml. When B-Lynch sutures and BBT applied together, that inflated volume may cause more ischemia in endometrium and myometrium which leads to Asherman’s syndrome. The other balloon inflation volumes that we applied during sandwich method were 200 ml or less.
There wasn’t any gynecological and obstetric problems in these cases. Nelson et al. 11 reported that when the sandwich method was applied in cases where the B-Lynch procedure was inadequate, infusion of 100 ml of Bakri balloon was effective in stopping the bleeding in all cases. Diemert et al. 28 reported a success rate of 85 % in 7 cases of Sandwich method. Our success rate in the sandwich method was 75 %.
The effects of B-Lynch sutures on fertility are controversial. Some studies didn’t report any adverse effects whereas others reported adverse effects on fertility like intrauterine adhesion, abdominal adhesion, deformation of uterine fundus, endometriosis, placenta previa and preterm birth 29-35. We did not find any complaints about menstrual irregularity, endometriosis or preterm labor in which we performed the Sandwich method successfully too. We did not encounter any complications in 25 cases of uterine preservation such as pyometra or uterine necrosis in our cases, which we followed up in 1-4 years. Asherman’s syndrome developed in only one case.
In conclusion, Bakri balloon tamponade alone or in combination with B-Lynch compression suture is an effective method to control bleeding in the management of acute postpartum uterine atony refractory to medical treatment. This technique is also invaluable in providing time to prepare for further surgical interventions or transportation to another clinic in critical cases. Nevertheless, in such life-threatening situations, various treatment modalities should be used in a stepwise approach but depending on the different stages of emergency.