ACTA Obstetricia et

ynec
G ologica

AOGS SHORT RESEARCH REPORT

Bakri balloon for the management of postpartum

hemorrhage
LAURA AIBAR1, MARIA TERESA AGUILAR1, ALBERTO PUERTAS1 & MERCEDES VALVERDE2
Obstetrics and Gynecology Department, Virgen de las Nieves University Hospital, Granada, and
Obstetrics and Gynecology Department, Santa Ana Hospital, Motril, Spain

1
2

Key words
Intrauterine balloon tamponade, Bakri
balloon, postpartum hemorrhage,
pregnancy complications
Correspondence Alberto
Puertas, Avenida de las Fuerzas
Armadas 2, 18014 Granada,
Spain. E-mail:
apuertas51@hotmail.com

Conflict of interest The authors

have stated explicitly that there are
no conflicts of interest in connection
with this article.

Abstract

Theaimofthisstudywastoev
aluatetheeffectivenessofth

eBakriballoonintreating postpartum hemorrhage

refractory to medical treatment. This retrospective
study included 24 women with postpartum hemorrhage
treated with a Bakri balloon as a conservative
therapeutic option. The Bakri balloon was successful in
controlling hemorrhage in 87.5% of the women. It was
effective in all women with vaginal delivery (five of five)
and in all women with uterine atony who did not
respond to medical uterotonic treatment (eight of
eight). Its ease of use and high effectiveness make the
Bakri balloon a useful approach for the conservative
management of acute postpartum hemorrhage. This
device reduces bleeding, shortens the hospital stay and
avoids the need for more aggressive procedures.
Abbreviation:

PPH, postpartum hemorrhage.

Please cite this article as: Aibar L,

Aguilar MT, Puertas A, Valverde M.
Bakri balloon for the management of
postpartum hemorrhage. Acta Obstet
Gynecol Scand 2013; 92:46 46 .. 5 7

Received: 4 October 2011

Accepted: 12 June 2012
DOI: 10.1111/j.1600-0412.2012.01497.x

Introduction
Postpartum hemorrhage (PPH), an
obstetric emergency that can complicate
vaginal or cesarean deliveries, accounts
for 25% of all maternal deaths worldwide
(1). In women who do not respond to
uterotonic medical treatment, a variety
of procedures, such as arterial

embolization, surgical ligation of the

uterine arteries or obstetric
hysterectomy, may be used.
The Bakri balloon is an intrauterine
device indicated to reduce or control
PPH temporarily when conservative
treatment is warranted. It appears to be
an effective alternative for the
management of acute PPH refractory to
medical treatment, and requires minimal
training to use. The device consists of a
silicone balloon connected to a catheter
of the same material. The collapsed
balloon is inserted into the uterine
cavity, and when it is inflated with liquid
it conforms to the

 2012 The Authors

shape of the cavity and stops the

bleeding. The blood drains through the
central lumen of the catheter, and
blood loss can then be evaluated (2).
The main advantages described for the
Bakri balloon are its easy transvaginal
or transabdominal insertion, which can
bring about rapid tamponade of the
uterine cavity, simplify control of the
bleeding and avoid the need for other
more invasive procedures, such as
hysterectomy.
The aim of this study was to evaluate
the effectiveness of the Bakri balloon for
the treatment of PPH.

Material and methods

This retrospective study investigated
the effectiveness of the Bakri balloon

standard management consisting of

uterine massage, volume replacement
and uterotonic medical treatment. The
protocol we followed called for
uterotonic treatment initially, i.e.
intravenous oxytocin or carbetocin,
followed by intramuscular
methylergometrine if the bleeding was
not controlled. If bleeding persisted,
intramyometrial prostaglandins
(carbopost) were used, and if this did
not control the bleeding, misoprostol
was given rectally.

Results
A total of 24 cases were identified in
which a Bakri balloon was used. Mean
maternal age was 36.5 6 years
(range 2448 years). Of the women for
whom the balloon was used, 14
(58.3%) were nullipara. Mean

Acta Obstetricia et Gynecologica Scandinavica 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 46546 7

as a conservative treatment option for

PPH in women seen at Virgen de las
Nieves University Hospital
Bakri balloon for postpartum hemorrhage

(Granada, Spain) from January 2010 to

April 2011. The hospital is a tertiary
facility that serves as a reference
center for obstetric pathologies. Our
study was approved by the centers
ethics committee.

465

gestational age at the time of delivery

was 38 weeks (range 3441 weeks).
The main risk factors associated with
PPH (3) were cesarean delivery
(79.1%), induced labor (29.2%),
previous cesarean delivery (29.2%),
multiple gestation (29.2%), use of
assisted reproduction techniques
(25%) and hypertension (20.8%).

Demographic and epidemiological data

were recorded, as were factors
associated with PPH and variables
related to the appropriate use of the
Bakri balloon. The study group
includedwomenforwhomtheballoonwasi
nsertedvaginally and after cesarean
delivery.

Onsetoflaborwasspontaneousinonewo
manandinduced in seven (with
oxytocin in all cases), and elective
cesarean delivery was used for 16
women. The motive for inducing labor
was premature rupture of the
membranes in five women, meconiumstained amniotic fluid in one and preeclampsia in one. Mean duration of
induction before the second stage
began was 9 5 h (range 315 h).

Women were considered candidates for

treatment with a Bakri balloon if they
had PPH that did not respond to

Of the 24 deliveries, five were vaginal.

One was spontaneous and the
remaining four required vacuum

extraction. In the other 19 women,

labor ended in cesarean delivery. The
main indications for ending labor with
cesarean delivery were
contraindication for vaginal delivery
(57.9%), maternal pathology (21%),
breech presentation (15.8%) and
failure of induction (15.8%). Delivery of
the placenta was spontaneous
inonecase,manualineightandrequiredth
eCredemaneuver in 15 cases.
The most frequent indication for using
the Bakri balloon was bleeding at the
placental implantation site, followed by
bleeding from the lower uterine
segment (Table 1). The mean volume
of saline solution used to fill the
balloon initially was
25752mL(range150
300mL),andthetimeduringwhich the
balloon remained inflated was 21 14
h (range 10 min
L. Aibar et al.

Table 1. Indications for using the Bakri balloon.

Indication

Bleeding from the placental implantation

site
Bleeding from the lower uterine segment
Uterine atony
Placenta accreta
Total

Percenta
ge
29.2

7
8
2
24

29.2
33.3
8.3
100

to 48 h). A mean volume of 182 144

mL blood (range 30575 mL) was
drained while the balloon and catheter
were in place. While the balloon was in
place, uterotonic treatment with
oxytocin was given by continuous
perfusion.
According to our definition of
effectiveness as control of PPH not
requiring any further nonpharmacological intervention, the Bakri
balloon was effective in 87.5% of the
cases (21 of 24 women). Of the three
women for whom the balloon failed to

control PPH, one was treated with

surgical ligation of the uterine arteries
and two required peripartum
hysterectomy.
Therewerenocomplicationsrelatedwithus
eoftheballoon except for pain in one
woman, which was treated with an
intravenous analgesic. Mean hemoglobin
concentration for the whole group after
delivery was 8.1 1 g/dL, and 10
women required blood transfusion. Mean
length of hospital stay for the whole
group was 6 3 days (range 317 days).

Discussion
To our knowledge, no randomized
studies have appeared on the use of
intrauterine balloons; the data available
to date are from case series. The
importance of the present report lies in
the number of women included in our
analysis (n= 24) and in the fact that all
women in this series were treated with
the same device, i.e. an intrauterine
Bakri balloon. Other series involving
larger numbers of women included cases
that were treated with different types of
devices.
A study by Vitthala and colleagues (4)
included 15 women, and the Bakri
balloon was effective in 80% of the
cases. For vaginal deliveries, the success
rate was 100%, whereas for labors that
ended with cesarean delivery, the
success rate was only 57%. Georgiou
studied 106 cases of PPH (5) that were
treated with different types of
intrauterine balloons, with an overall
success rate of 91.5%.
The design of the balloon is an important
consideration. The Bakri balloon is
preferable to the Rusch balloon, because
blood loss via the drainage catheter can
be quantified with the former design.

The Bakri device is also preferable to the

Foley catheter, because the balloon is
more effective in providing intrauterine
tamponade. Earlier reports found the
SengstakenBlakemore balloon to be
similar to the Bakri balloon in effectively
controlling PPH; success rates with the
former device were 81% according to
Doumouchtsis and
466

The results of the present study are

similar to those published for earlier
series of women (46). Posptartum
hemorrhage was controlled in all five
women who delivered vaginally and in
all eight with uterine atony who did not
respond to medical uterotonic treatment.
The effectiveness of the Bakri balloon
was not compromised by the presence in
some patients of risk factors for PPH, a

Acta Obstetricia et Gynecologica Scandinavica 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 46 465
7
2012 The Authors

L. Aibar et al.

colleagues (6) and 71% according to

Seror and colleagues (7). However, the
main advantages in comparison to the
SengstakenBlakemore balloon are that
the Bakri device contains no latex, and
once inflated, it conforms closely to the
interior of the uterine cavity. In one of
the largest series involving 23 women
(8), the balloon was effective in 90% of
the cases. For hemorrhage resulting
from uterine atony, the success rate was
100%. This finding is consistent with the
results of the present study, in which the
balloon controlled PPH in all eight
women for whom it was used because of
uterine atony.
The effectiveness of intrauterine balloon
tamponade is similar to that of other
methods used for the conservative
management of PPH (9), such as arterial
embolization, surgical ligation of the
uterine arteries or uterine compression
suture. Balloon tamponade can also be
used together with thesocalledsandwichtechnique(10).However,in
trauterine balloon tamponade is less
invasive, faster, and more
straightforward to perform; all of these
features make this method a useful
option as a first step in the conservative
management of PPH.

result that supports the use of this

treatment in this type of patient.

The straightforward technique for

inserting the Bakri balloon and
monitoring blood loss, along with its high
effectiveness, make this a useful device
for the conservative management of
acute PPH that avoids the need for
hysterectomy. As a result, the womans
fertility is conserved, blood loss is
reduced,andthehospitalstayisshortened.
Nevertheless,randomized trials are
needed to compare the effectiveness of
balloontamponadewithotherconservative
modesoftreatment, such as arterial
embolization, surgical ligation of the
uterine arteries or uterine compression
suture. However, prospective
randomized studies will be challenging
to design and carry out because of the
urgent or emergency nature of the
context in which treatment decisions
need to be made, and the lack of
appropriate resources at many centers.

2012 The Authors

Bakri balloon for postpartum hemorrhage

Funding
No specific funding.
References
1.

2.

3.

4.

5.

World Health Organization (WHO). Attending to

136 million births, every year. Chapter 4. In:
Make Every Mother and Child Count: The World
Report 2005, Geneva, Switzerland: WHO, 2005;
623.
Bakri YN, Amri A, Abdul Jabbar F. Tamponadeballoon forobstetrical bleeding. Int J Gynaecol
Obstet. 2001;74: 13942.
Rossen J, Okland I, Nilsen OB, Eggeb TM. Is
there anincrease of postpartum hemorrhage,
and is severe hemorrhage associated with
more frequent use of obstetric interventions?
Acta Obstet Gynecol Scand. 2010;89: 124855.
Vitthala S, Tsoumpou I, Anjum ZK, Aziz NA. Use
of Bakriballoon in post-partum haemorrhage: a
series of 15 cases. Aust N Z J Obstet Gynaecol.
2009;49:1914.
Georgiou C. Balloon tamponade in the
management ofpostpartum haemorrhage: a

review. BJOG. 2009;116:74857. 6.

Doumouchtsis SK, Papageorghiou AT, Vernier C,
Arulkumaran S. Management of postpartum
hemorrhage by uterine balloon tamponade:
prospective evaluation of effectiveness. Acta
Obstet Gynecol Scand. 2008;87: 84955.
7. Seror J, Allouche C, Elhaik S. Use of
SengstakenBlakemoretube in massive
postpartum hemorrhage: a series of 17 cases.
Acta Obstet Gynecol Scand. 2005;84:6604.
8. Dabelea V, Schultze PM, McDuffie RS.
Intrauterine balloontamponade in the
management of postpartum hemorrhage. Am J
Perinatol. 2007;24:35964.
9. Doumouchtsis SK, Papageorghiou AT,
Arulkumaran S.Systematic review of
conservative management of postpartum
hemorrhage: what to do when medical
treatment fails. Obstet Gynecol Surv.
2007;62:5407.
10. Yoong W, Ridout A, Memtsa M, Stavroulis A,
Aref-Adib M,Ramsay-Marcelle Z, et al.
Application of uterine compression suture in
association with intrauterine balloon
tamponade (uterine sandwich) for
postpartum hemorrhage. Acta Obstet Gynecol
Scand. 2012; 91:14751.

Acta Obstetricia et Gynecologica Scandinavica 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 465467

467