Before placing the balloon, one to four toothless oval forceps were usually used to clamp the upper and lower lips of the cervix at three o’clock and nine o’clock ( deep to both sides of the fornix) according to the cervical condition, leaving the gap being just equivalent to the width of the balloon catheter (it is worth noting that such procedure should not be applied for those with tight and tough cervix). This approach can prevent balloon from slipping in an effective way. Furthermore, The application of oval forceps to cervix can not merely block part of the blood vessels distributed in uterus for supply, but also facilitate uterine contraction through reflective stimulation so as to reduce colporrhagia.
Of all 169 cases of Bakri balloon hemostasis, 148 cases were successful, with a success rate of 87.6% (148/169). Separately, the success rate of balloon hemostasis presented 87.1% (121/139) in 139 vaginal delivery cases including 11 abortion cases on malformation and 6 cases of forceps delivery. The success rate presented 90.0% (27/30) in 30 massive postpartum hemorrhage cases (three failures out of 22 cases of transvaginal balloon placement after cesarean section and eight success cases of balloon placement through surgical incision during cesarean section. There was no correlation between the Bakri balloon infused volume and the hemostatic effect. The balloon infused volume is generally determined based on the cause of bleeding, the use (or not use) of uterine binding suture, and the results of balloon tamponade test[5] .Bakri balloons have been widely recommended for the treatment of postpartum hemorrhage. Most studies consider its effectiveness to be more than 90%, but some scholars believe that the effectiveness of Bakri balloons for treating PPH is questioned. A retrospective study by Olsen Richelle et al[6]. found that the success rate of Bakri balloon hemostasis was around 67.57%, which was not so effective as previously announced. However, the success rate of Bakri balloon hemostasis in this study was close to 90%, which basically supports the previous reports of most domestic and foreign scholars[7–9].
Many domestic and foreign studies have suggested that once PPH is diagnosed, Bakri balloon hemostasis should be used in a timely manner when first-line hemostatic drugs and methods cannot effectively control bleeding[10]. This study found that the hemostasis effect of Bakri balloons was remarkable when the postpartum bleeding volume was less than 1500 ml, but the failure rate would increase significantly when the bleeding volume reached 1500 ml. Therefore, once the bleeding exceeds 1500 ml, other hemostatic methods shall be considered.
In this research, Bakri balloons were successfully placed through surgical incision in 8 patients who had undergone cesarean section. Bakri balloons are mainly used for those with poor uterine contraction, those with diffuse bleeding in the uterine cavity, and those who had low compliance with suture. With the improvement of surgical suture skills, hemostasis can be achieved in most cases during cesarean section by means of first-line hemostatic drugs and various suture techniques. In the case of heavy intraoperative bleeding and difficulty in suture, the adoption of balloons can play a role in temporarily pressing hemostasis and reducing the amount of bleeding, so as to win time for the further hemostatic measures such as uterine/internal iliac artery interventional embolization therapy, thus effectively reducing the rate of uterine resection. Relevant studies from home and abroad have indicated that prophylactic adoption of Bakri balloons can greatly reduce postpartum blood loss and hysterectomy rate[11–12]. Some scholars have advocated the prophylactic application of Bakri balloons in cesarean section of placenta previa[13]. Rapid diagnosis or prognosis of postpartum hemorrhage combined with early use of Bakri balloon is more effective in controlling postpartum hemorrhage[14]. As the least invasive and fastest approach, Balloon tamponade is considered as the first attempt of conservative surgical method for PPH.
In this study, it was found that postpartum hemorrhage was mainly related to uterine contraction weakness, and placental factors accounted for 58.6% (99/169), including placenta previa, placental abruption, placental adhesion and placental implantation. Of the 21 cases of failed balloon hemostasis, 15 cases were related to placental factors, including 11 cases of placental adhesion with implantation, accounting for 52.4% (11/21), suggesting that placental implantation was an important factor leading to Bakri balloon hemostasis failure. This is probably due to that retained placenta leads to uneven inner wall of uterine cavity and irregular shape, which is against the effective fitting of balloon and uterine cavity, thus imposing a negative influence on the hemostatic effect of balloon compression. Furthermore, the residual placenta continued to bleed, resulting in balloon hemostasis failure. Therefore, Bakri balloons may not be the optimal treatment for hemostasis in case of placental implantation, especially in large areas, or even placental penetration. Soyama H[15] pointed out that invasive treatment is an unavoidable method for patients with placental retention to stop bleeding. If continuous bleeding in the intrauterine drainage tube is caused by placenta retention, further hemostasis should be performed immediately[11]. After a series of basic treatments such as removal of placenta tissue and suture of bleeding site, if the balloon is placed to stop bleeding, the bleeding situation in the catheter should be closely observed, and the interventional embolization or hysterectomy should be prepared at any time. Bakri balloons have insignificant effect on the patients with placental penetration. However, prior to more invasive procedures, pre-positioned Bakri balloons may be a good choice for placental implantation / penetration[16]. The Bakri balloon can play a temporary role in compressing hemostasis, and can effectively control the rapidly opened blood sinus. Although it may fail as a treatment, it can slow bleeding and win time for further invasive procedure such as uterine/internal iliac artery embolization or hysterectomy and for safely transferring the patient to a superior medical treatment center[11].