Bakri Balloon

27 yo female with postpartum hemorrhage. Diagnosis? • Xray of the Week

Figure 1. Sagittal ultrasound image of the uterus showing placement of Bakri balloon in the mid-uterine position.

Figure 2. Diagram of Bakri balloon. A. 3D image showing correct placement of the Bakri balloon in the uterine cavity. B. Correct and incorrect placement of the Bakri balloon in the uterine cavity. The balloon should not traverse the cervix. C. Silicone catheter inflated to 500 ml. Note the distal drainage port. - Cook Medical.

Figure 3. Video of placement of Bakri Postpartum Balloon - Cook Medical.

Discussion:

Postpartum hemorrhage is the leading cause of maternal mortality in developing countries (1). The Bakri balloon is an FDA-approved “minimally invasive intrauterine tamponade device” used to control and reduce postpartum hemorrhage when conservative management is required (1-4). It consists of a 24-French, 54-cm long silicone catheter that can be inflated to 500 mL (1) (Figs. 2,3).

Contraction of the myometrium constricts the placental blood vessels and causes hemostasis (2). In postpartum hemorrhage, this vessel constriction does not occur. The Bakri balloon applies pressure directly on the myometrium and placental bed when the uterus contracts on the balloon, which causes hemostasis through a similar mechanism (2). When positioned correctly, the Bakri balloon can reduce the need for hysterectomy, uterine artery ligation, embolization, and other more invasive interventions (1).

On imaging, the balloon appears as a round anechoic structure in the center of the uterus with a hyperechoic rim (1) (Fig. 1). Ultrasonography is the preferred imaging modality compared to CT and MRI due to cost, portability, and time efficiency (1,2). US guidance can also be used to determine the uterine volume, confirm that there are no retained products of conception, and ensure proper placement of the balloon past the cervical canal and internal ostium in the transvaginal approach (2-4). A transabdominal approach can also be used to position the balloon in cases of Cesarean section. US examination is used to determine the uterine volume, and the Cesarean incision is used to pass the inflation port through the uterus and cervix (2,3). This ensures that the balloon is in the uterus and limits the spread of vaginal flora into the peritoneal cavity (3). The balloon is then inflated with sterile liquid.

The Bakri balloon is associated with serious complications due to migration of the balloon or uterine rupture via over-inflation of the balloon (1,3). It is contraindicated in cases of balloon material allergy, uterine rupture, uterine anomalies, cervical cancer, disseminated intravascular coagulation, or retained products of conception (1,3). Continuous patient monitoring is necessary as persistent bleeding may require more aggressive treatment.

References:

1. Katsinis BR. Bakri balloon displacement in the uterus: sonographic demonstration. Journal of Diagnostic Medical Sonography. 2015;31(6):386-389. doi:10.1177/8756479315611658

2. Cho Y, Rizvi C, Uppal T, Condous G. Ultrasonographic visualization of balloon placement for uterine tamponade in massive primary postpartum hemorrhage. Ultrasound Obstet Gynecol. 2008 Oct;32(5):711-3. doi:10.1002/uog.5408.

3. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J Gynaecol Obstet. 2001 Aug;74(2):139-42. doi:10.1016/s0020-7292(01)00395-2.

4. Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis. Am J Obstet Gynecol 2020;222:293.e1-52. doi:10.1016/j.ajog.2019.11.1287

Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends.

Follow Amara Ahmed on Twitter @Amara_S98

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Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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