A C TA Obstetricia et Gynecologica

AOGS SHORT R E S E A R C H R E P O R T

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 2 Obstetrics and Gynecology
Department, Santa Ana Hospital, Motril, Spain

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
The aim of this study was to evaluate the effectiveness of the Bakri balloon in treating
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
. 5467.

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

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 as a conservative treatment option for PPH
in women seen at Virgen de las Nieves University Hospital

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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.
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
included women for whom the balloon was inserted vaginally
and after cesarean delivery.
Women were considered candidates for treatment with
a Bakri balloon if they had PPH that did not respond to
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 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%).
Onset of labor was spontaneous in one woman and induced
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,
meconium-stained amniotic fluid in one and pre-eclampsia
in one. Mean duration of induction before the second stage
began was 9 5 h (range 315 h).
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
in one case, manual in eight and required the Crede maneuver
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
257 52 mL (range 150300 mL), and the time during which
the balloon remained inflated was 21 14 h (range 10 min

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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

Percentage

7
7
8
2
24

29.2
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 non-pharmacological 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.
There were no complications related with use of the balloon
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

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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
the so-called sandwich technique (10). However, intrauterine
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.
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 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, and the hospital stay is shortened. Nevertheless, randomized trials are needed to compare the effectiveness of balloon tamponade with other conservative modes of treatment,
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.

Funding
No specific funding.
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