Bakri Balloon Placement - Indications, Contraindications, Procedure, and Complications

What Is a Bakri Balloon?

Bakri balloon is an intrauterine device intended to temporarily lessen or manage postpartum hemorrhage (PPH) when conservative treatment is warranted. It seems to be a good alternative for treating acute postpartum hemorrhage when medical treatment is ineffective and using it only requires a little expertise. The system comprises a catheter made of silicone that is attached to a silicone balloon. When the collapsed balloon is inflated with liquid and placed within the uterine cavity, it assumes the shape of the uterine cavity and stops the bleeding. Blood loss can be measured once the blood has been allowed to drain through the core lumen of the catheter.

What Is Postpartum Hemorrhage?

Postpartum hemorrhage (PPH) is a delivery complication that poses a life-threatening risk. It is a significant cause of maternal morbidity and mortality and can happen following vaginal or cesarean delivery. Postpartum hemorrhage is defined by the American College of Obstetricians and Gynecologists (ACOG) as a cumulative blood loss of more than 1000 mL or blood loss linked to hypovolemia within 24 hours following childbirth.

Causes of Postpartum Hemorrhage:

• Uterine atony (reduced uterine tone and myometrial contraction cause less constriction of the blood arteries supplying the placental bed, increasing postpartum blood loss).

• Retained placenta.

• Trauma to the genital tract.

• Uterine rupture.

• Uterine inversion.

• Coagulopathy (defect in blood clotting mechanism).

Complications of Postpartum Hemorrhage:

• Hypovolemic shock.

• Hemorrhagic shock.

• Tissue hypoxia.

• Dilutional coagulopathy.

• Acidosis.

• Damage to the kidneys, pituitary gland, and lungs due to increased perfusion pressure. It may lead to severe sequelae like Sheehan syndrome (postpartum hypopituitarism), renal failure, or acute respiratory distress syndrome.

Management of Postpartum Hemorrhage:

It can be divided into two categories as,

• Operative Interventions- Surgical therapies may be used in cases of acute postpartum hemorrhage that are resistant to medical treatment and other conservative measures. These include arterial embolization, uterine compression sutures, uterine artery ligation, and hysterectomy. These procedures are very intrusive, need a lot of resources and expertise, and are linked to severe morbidities.

• Non-operative Interventions- Intrauterine balloon tamponade is an effective, simple, minimally invasive therapy to control uterine bleeding while preserving the mother's capability to bear additional children. Several balloons are available, like the Sengstaken-Blakemore tube, the Bakri balloon, the BT-cath balloon tamponade catheter, Foley catheters, Rusch balloons, and condom catheters.

How Does a Bakri Balloon Work?

The intrauterine balloon is intended to function by applying pressure from the inside to the outside of the uterine wall, which reduces recurrent capillary and venous bleeding from the endometrium and the myometrium.

What Are the Indications of Bakri Balloon Placement?

• A Bakri balloon is used to temporarily stop or reduce postpartum hemorrhage when conservative therapy of uterine bleeding is warranted. It is done after bleeding due to genital tract injuries, and retained fetus has been ruled out.

• As a short-term fix to stop bleeding while waiting and getting ready for other definitive treatments, like,

  • Open abdominal surgery like- uterine artery ligation, uterine compression suture, or hysterectomy.

  • Uterine artery embolization.

  • It can be placed while the patient is transported to another medical unit with more expertise and resources.

• Bleeding after delivered pregnancies with invasive or adherent placentas, placenta previa, low-lying placentas, or as a supplement to cervical ectopic pregnancy treatment.

• Secondary postpartum hemorrhage (24 hours to 12 weeks after delivery).

What Are the Contraindications of Bakri Balloon Placement?

The following conditions are contraindicated for the placement of the Bakri balloon,

• Pregnancy.

• Cervical cancer.

• Severe arterial bleeding (that requires surgical exploration or angiographic embolization).

• Congenital uterine anomaly.

• Suspected uterine rupture.

• Uterine distorting pathology (leiomyoma).

• Allergy to silicone (balloon material).

• Infection (purulent) of the vagina, cervix, or uterus.

• Disseminated intravascular coagulation (DIC).

What Are the Advantages of Bakri Balloon Placement?

The Bakri balloon is an effective technique for controlling postpartum hemorrhages. The Bakri balloon provides many distinct advantages compared to other intrauterine tamponade devices.

These benefits include the following,

• Patients with latex allergies benefit from the silicone construction of the Bakri balloon catheter.

• Less chance of uterine perforation.

• Compared to other catheters, the shape fits the uterine cavity more naturally.

• It is pre-sterilized and ready to use.

• Currently, there is no proof that using a Bakri balloon or another intrauterine tamponade device can harm the ability of the woman to conceive in the future or make subsequent pregnancies more likely to end in miscarriage.

What Is the Procedure for Bakri Balloon Placement?

Before Procedure:

• A bedside ultrasound of the uterine cavity is performed before the procedure to rule out retained fetal tissue and to determine the angulation and shape of the uterine cavity, which will be used to direct the placement of the balloon catheter.

• Anesthesia is administered before the procedure for adequate pain-relieving during the procedure.

Bakri Balloon Placement Procedure:

After Vaginal Delivery:

The following actions should be taken into consideration for transvaginal placement following vaginal delivery,

• A Foley catheter is placed to ensure the bladder is empty before inserting the balloon.

• With the help of an antiseptic solution, such as Povidone-iodine, the cervix and vagina are cleaned.

• Under ultrasound guidance, the balloon is inserted into the uterine cavity, making sure that the entire balloon passes through the cervical canal.

• Once the placement is certain, the balloon is filled with sterile saline using the enclosed syringe. 500 mL is the maximum recommended capacity of the Bakri balloon.

• Light traction is applied to the balloon's shaft to increase the impact of the tamponade. This can be done and managed by fastening the balloon shaft to the patient's leg or fastening it to weight (not more than 500 grams).

• The drainage port is attached to a fluid collection bag to track hemostasis.

• The patient is monitored for uterine cramps and signs of increased bleeding.

After Cesarean Section Delivery:

• The catheter tip is introduced into the vagina after passing through the open uterine incision and cervix.

• The uterine incision is closed with extreme caution so that the suture needle does not puncture the balloon.

• The balloon is filled from the top while looking directly at it.

Combination With Other Techniques:

• Uterine Sandwich or External Compression Plus Internal Tamponade - With various surgical procedures, intrauterine balloon catheters can be used to increase effectiveness potentially.

• Uterine Vessel Ligation Plus Internal Tamponade - Along with inserting an intrauterine Bakri balloon, other procedures, including hypogastric artery ligation, O'Leary uterine artery ligation, or bilateral looping uterine vessel sutures (B-LUVS), are also alternatives.

What Is the Tamponade Test?

The "tamponade test" can be used to evaluate the efficacy of the intrauterine balloon catheter. The test is deemed successful when control is attained after the balloon has inflated. Depending on personnel and resources, patients with a negative test (persistent bleeding despite the balloon placement) should move on to more invasive therapeutic techniques such as laparotomy or embolization.

What Are the Complications of Bakri Balloon Placement?

Complications of Bakri balloon placement are as follows,

• Uterine rupture.

• Balloon prolapse.

• Endometritis (placed for more than 24 hours).

• Air embolism (when the balloon is inflated using air or carbon dioxide instead of saline).

Conclusion:

Postpartum hemorrhage is an obstetric emergency that causes 25 % of maternal mortality globally. The primary form of treatment is uterotonic administration, but uterine cavity tamponade may be beneficial if the drug fails to work. The Bakri balloon catheter is the first-ever uterine tamponade balloon system used to treat PPH resistant to first-line uterotonic medicines. The device is only meant to be used once. It works by exerting inward-to-outward hydrostatic pressure against the uterine wall, which causes the blood vessels there to constrict, reducing blood flow and promoting clotting. Bakri balloon tamponade can save lives and delay the need for a hysterectomy in many women.