Evidence-based data depicts that various pharmacological agents should be used as a first line approach in the management of PPH after rubbing up the uterus. If these first line uterotonics (FLU) are unsuccessful, various second-line approaches (SLA) have been advocated including balloon tamponade technology.1
Although many factors are considered when deciding which SLA is/are to be used, the parity of the mother and her potential future fertility is an important consideration. Consequently, hysterectomy is not always the first choice in women of low parity. The belief is that by sparing the uterus, a patient’s future fertility is preserved (Table 1).2
Despite the increasing number of publications demonstrating an effective use of the uterine-specific Bakri balloon (Cook Medical, Bloomington, USA), few publications have commented on subsequent pregnancies in such cases (Fig. 1).
Four cases are described in which a subsequent pregnancy occurred following the use of a Bakri balloon that was solely used as a SLA in the management of PPH when FLU failed. These examples were identified from a personal case series of over 30 cases in which a Bakri balloon was used.3
A 26 yr old Jehovah’s Witness, with an uncomplicated first pregnancy, presented in established labour at 39 weeks gestation. Following the vaginal birth of her baby and placenta, profuse PPH occurred. Despite the use of 10iu im oxytocin, 250ug ergometriene and 40iu oxytocin infusion, bleeding persisted. A combination of an atonic uterus, cervical/vaginal trauma was identified in the operating theatre. A Bakri balloon was insufflated with 450mls N-Saline (in order to achieve a positive tamponade test), together with the appropriate repair of the genital tract trauma. Estimated blood loss (EBL) was 2.5l. The balloon eas removed within 24hrs with continual oxytocin infusion.The patient was discharged on day 4 and was seen at 6 weeks with an ultrasound scan (USS) that was reported as “normal”. In addition, normal menses returned following cessation of breast feeding.
Eighteen months later, this woman presented at 6 weeks gestation. At 39+1 weeks gestation, she had a social induction of labour using ARM, due to living at a distant location with respect to the main hospital. Four hours later, she birthed her baby with a first degree perineal tear that eventually was sutured. Active management of the third stage together with a 40 IU syntocinon infusion was commenced as previously planned throughout her pregnancy.
Despite this, a subsequent trickle of blood ensued that was managed with PR misoprostol (800mcg) and IM (250mcg) ergometriene. A total estimated blood loss of 1000mls was recorded. The patient was discharged on the second day following delivery, after breast-feeding was established.
(More cases in poster)