The Bakri balloon implementation during cesarean section without switching to the lithotomy position

Introduction

Bakri balloon implementations for the conservative management of postpartum hemorrhage (PPH) have become more popular in recent years. The procedure may be regarded as simple, however, it becomes challenging when there is excessive bleeding and it becomes a race against time. Here we would like to present a woman with uterine atony and fundal placenta accreta bleeding, managed initially with the Bakri balloon without switching to the lithotomy position for the first time in the literature.

Case presentation

A 34-year-old, gravida 4, para 3, woman with three previous cesarean sections (CS) was admitted to our clinic at the 38^th gestational week (GW) for elective CS. Her pregnancy follow-up was uneventful. Following administration of 1 g 1^st generation cephalosporin before Pfannenstiel skin incision, a 3150 g healthy baby was delivered via a lower uterine segment incision. During the CS, after delivery of the baby, the uterus was exteriorized along with the placenta and the placenta was manually removed from the fundus with moderate resistance. Following complete removal of the placenta, a profuse hemorrhage began, which did not respond to 40 Units of oxytocin infusion and 0.2 mg methylergonovine intramuscular (IM) injection (We do not have carboprost or misoprostol in our institution.) We initially decided to apply a Bakri balloon. The Bakri balloon was placed to the fundus through the uterine incision and its catheter was pushed through the cervix into the vagina. The uterine incision was sutured with 1/0 Vicryl^® and the uterus was replaced into the abdomen. The patient’s position could not be switched to the lithotomy position as usual because the leg holders of the operation table were at that moment in use in the urology and general surgery operating theaters. Therefore we decided to open the drapes and take out the distal portion of the Bakri balloon from the vagina (Figure 1). Then we passed the distal part of the shaft of the balloon under the right gluteal fold (Figure 2A and B). The patient was re-draped with new sterile surgical drapes. At first, the Bakri balloon was inflated by a nurse up to 500 mL under the right hip of the woman (Figure 3A) however, the hemorrhage could not be controlled. We assessed the ongoing bleeding using the catheter under the level of the operation table. We checked the uterus inside the abdomen and felt that the Bakri balloon was inflated at mid-level instead of at the fundus of the uterus. As we re-exteriorized the uterus including the Bakri balloon, we realized that the Bakri balloon did not reach the fundus at all. We pushed the Bakri balloon upwards by external maneuvers to the uterus and placed it to the fundus. The Bakri balloon was inflated to the maximum capacity of the uterus by 800 mL (Figure 3B) however, the bleeding still continued. The addition of the bilateral uterine artery ligation at the time was very time consuming and not even adequate to stop the profuse bleeding, which led to serious hypotension (56/30 mm Hg), We therefore performed an emergency subtotal hysterectomy. Noradrenalin and crystalloid solution infusions were administered in order to elevate the blood pressure. The estimated blood loss was 3000 mL and the four units of packed red blood cells (pRBCs) and two units of fresh frozen plasma (FFP) were transfused during the operation. The patient was followed up for 2 days in the intensive care unit. A total of six units of PRBC and four units of FFP were given. Broad-spectrum antibiotic therapy was given during the hospital stay. She was discharged on the 7^th postoperative day without any complications. The diagnosis of fundal placenta accreta was confirmed by the pathologic examination of the uterus.

Figure 1:

The surgical drapes are uncovered and the distal portion of the Bakri balloon catheter is taken out through the vagina.

Figure 2:

(A, B) The distal part of the shaft of the Bakri balloon is placed under the right gluteal fold and inflated by the nurse.

Figure 3:

(A) Inflation of the Bakri balloon with sterile saline up to 500 mL, the pincette shows displaced Bakri balloon inside the uterus, (B) Inflation of the Bakri balloon to the full capacity of the uterus with 800 mL sterile saline.

Discussion

After its first introduction in 2001 [1] the Bakri balloon was readily embraced by the obstetricians worldwide and became even more popular following approval of the Food and Drug Administration (FDA) and being mentioned in the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on the conservative management of PPH in 2006 [2]. The procedure during CS and after vaginal delivery is well defined by Bakri et al. [1] in their first report in 2001 and there has been no major change ever since. However, with the increasing number of studies on Bakri balloon implementation [3], [4], [5], some modifications have been suggested. Matsubara et al. [6] described a simple technique to achieve passage through the narrow cervix in placenta previa cases by removing the stopcock, tying the double ends of the balloon together and connecting it to a Nelaton catheter by a thread.

Yoong et al. [7] described an interesting transabdominal drainage method of the Bakri balloon in a placenta accreta case, where the balloon could not be passed through the cervix. Yoong et al. [7] placed the Bakri balloon’s distal portion on a debated place – the patient’s abdominal wall.

Classically, the Bakri balloon application steps include positioning the patient in the lithotomy position, if not already in the lithotomy position, inflating the balloon with sterile saline up to adequate volume and evaluating the ongoing hemorrhage using the distal drainage part of the balloon. It is important to keep the distal end of the catheter under the body level so that the blood flows downwards with gravity. We previously published a case about non-invasive management of recurrent puerperal uterine inversion with the Bakri balloon [8] and a case-series of the Bakri balloon [5]. In our clinic, we do not use the lithotomy position routinely in CS except in placenta previa cases, which is why we always spent a long time and had difficulties in switching the patient’s position to the lithotomy position to apply the Bakri balloon tamponade. Switching to the lithotomy position in an actively bleeding patient may be time consuming and increase the risk of contamination of the surgical site.

In our method, by passing the distal part of the shaft of the balloon under the right (surgeon’s side) gluteal fold; we easily and quickly assessed the ongoing bleeding which led to hysterectomy.

One of the weaknesses of this method is that the catheter length may not be adequate in obese women; however, this problem may be overcome by production of the balloons with longer catheters.

In our case, we preferred uterine artery ligation while the balloon was in place; nevertheless we spent a great deal of time and effort to avoid puncturing the balloon when it was inflated at the maximum capacity of the uterus. Although there is not enough data existing about the combination of vessel ligation with balloon tamponade. To date the latest issue recommends to combine the Bakri balloon method with uterine artery ligation before the balloon insertion [9]. We previously performed internal iliac artery (IIA) ligation in six patients when the Bakri balloons failed to achieve hemostasis and we saved the uterus in 50% of patients [5]. Bakri et al. added IIA ligation to Bakri balloons in two cases of placenta previa in their first report and achieved hemostasis [1]. As mentioned before, according to our experiences, addition of uterine artery ligation after inflation of the Bakri baloon may be technically difficult and time-consuming because of the efforts involved in avoidance of puncturing the balloon. Therefore; in our opinion, considering the order of priorities, we do not recommend preforming uterine artery ligation first, if the balloon has already been inflated. However, if the surgeon is experienced enough, the internal iliac artery (IIA) ligation may be more suitable as the risk of damaging or puncturing the balloon is almost none.

Conclusion

In conclusion, we suggest a new and simple method of the Bakri balloon implementation without switching the patient to the lithotomy position, by passing the distal portion of the balloon under the right gluteal fold and then the balloon could be inflated by a nurse under the supervision of both surgeons. The bleeding would be easily assessed as the catheter is under the body level.

Switching the supine position to the lithotomy position is the best way to inflate the balloon and assess the bleeding; nonetheless our method is faster and may be used in the lack of required equipment or staff in the operating theater.

The addition of uterine artery ligation to the Bakri balloon may be time consuming and challenging in an already inflated balloon inside the uterus. We therefore may recommend IIA ligation rather than uterine artery ligation after balloon implementation if the surgeon is experienced enough.