Australian and New Zealand Journal of Obstetrics and Gynaecology 2011; 51: 377–380 DOI: 10.1111/j.1479-828X.2011.01309.x

Short Communication

Post-partum haemorrhage from the lower uterine segment secondary toplacenta praevia ⁄accreta: Successful conservative management withFoley balloon tamponade

Mustafa ALBAYRAK,1 Ismail OZDEMIR,1 Onder KOC2 and Yavuz DEMIRARAN3

Departments of 1Obstetrics and Gynecology, Duzce University School of Medicine, Duzce, 2Obstetrics and Gynecology, Abant IzzetBaysal University School of Medicine, Bolu, and 3Anesthesiology and Reanimation, Duzce University School of Medicine, Duzce,Turkey

Profuse bleeding from the lower uterine segment secondary to placenta praevia ⁄ accreta during caesarean delivery is achallenging problem in obstetrics. We present our experiences using intrauterine Foley balloon tamponade for theconservative management of post-partum haemorrhage from the lower uterine segment. Intraoperative haemostasis wasachieved in all women who were unresponsive to other conservative methods. Foley balloon tamponade may beconsidered in the management of lower uterine segment bleeding at caesarean delivery.

Key words: balloon tamponade, placenta accreta, placenta praevia, post-partum haemorrhage.

Introduction

Severe post-partum haemorrhage (PPH) is the leading causeof maternal mortality worldwide. Post-partum haemorrhageassociated with an estimated mortality rate of 140 000deaths ⁄ year, or one maternal death every 4 minutes.1 Therate of abnormal placentation has increased in conjunctionwith caesarean deliveries and is a significant contributor tosevere PPH; it is now the most common indication forcaesarean hysterectomy.1–3

Profuse bleeding from the lower uterine segment due toplacenta praevia ⁄ accreta, immediately upon removal of theplacenta during caesarean delivery, is a challenging problemin modern obstetrics. Emergency peripartum hysterectomy isgenerally performed when the haemorrhage is lifethreatening and all conservative measures have failed toachieve haemostasis. However, before hysterectomy astepwise conservative approach should be attempted.Uterotonics, uterine packing and oversewing are the usualconservative measures used to control heavy bleeding fromthe lower uterine segment during caesarean delivery. Whenthese measures fail, invasive interventions, such as theligation of uterine and hypogastric arteries, may be

Correspondence: Dr Mustafa Albayrak, Department ofObstetrics and Gynecology, Duzce University School ofMedicine, 81620, Konuralp, Duzce, Turkey.Email: drmustalbayrak@yahoo.com

Conflicts of interest: none.

Received 18 November 2010; accepted 27 February 2011.

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Th e Australian and New Zealand Journal of Obstetrics and Gynaecology

attempted, but these are technically challenging and requireexperience and surgical skill.

The use of intrauterine balloon tamponade, beforeproceeding with invasive interventions, has recently becomean effective management option for PPH.4,5 However,reports describing the use of balloon tamponade specificallyfor the management of bleeding from the lower uterinesegment because of placenta praevia ⁄ accreta are limited.6–8

We describe the use of Foley balloon tamponade for theconservative management of PPH secondary to placentapraevia with or without placenta accreta at caesareandelivery.

Methods

We reviewed the records of all pregnant women, betweenApril 2005 and October 2010, who were managed withintrauterine balloon tamponade using a Foley catheter whenthe standard conservative measures failed to control PPHfrom the lower uterine segment secondary to placentapraevia ⁄ accreta at caesarean delivery. Women whoresponded to conservative methods and those ones withPPH from other causes such as uterine atony and genitallaceration were excluded.

The study was approved by the Ethics committee of ourhospital. Women were consulted preoperatively about thepossibility of heavy bleeding, transfusions and hysterectomy.Written informed consent was obtained from all women.

Patient age, parity, placentation type and location,intraoperative blood loss, amount and type of transfusion,additional interventions and postoperative outcome werenoted.

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The diagnosis of placenta praevia ⁄ accreta was based ontransvaginal sonography and ⁄ or intraoperative bleeding upona difficult and fragmented placental removal. All women hadan intraoperative evaluation of the lower segment andbladder to exclude the possibility of higher degrees ofinvasion.

Following delivery of the fetus, the placenta was extirpatedin fragments after failed spontaneous extraction. Oxytocin(40 IU in 500 mL saline at a rate of 100 mL ⁄ h IV infusion)and 0.2 mg ergometrine (IM injection, a few times, at least20 min apart if no hypertension was identified) wereadministered following the onset of heavy bleeding from thelower uterine segment. Simultaneously, the uterus wasexteriorised and stretched cranially. The lower uterinesegment was compressed with roller gauze packs totemporarily control the heavy bleeding. Heavily bleedingpoints, visible at the placental bed, were over sewn in afigure-of-eight fashion.

If these standard conservative measures failed, a single24 F Foley catheter was inserted through a hysterotomyincision and the distal end was passed through the cervixand carefully pulled from the vagina by an assistant. Theballoon was infused with 60–100 mL saline, and moderatetraction applied. If haemostasis was achieved, thehysterotomy incision was closed, taking care not to rupturethe balloon with the needle. A plastic glove was tied at thedistal end of the catheter to drain the uterine cavity andmonitor the bleeding. Vaginal packing was used if the cervixwas dilated to prevent slippage of the balloon into thevagina. A plastic bag filled with 500 mL saline was tied tothe distal end of the catheter and hung over the patient’s bedfor traction.

Postoperatively, the oxytocin infusion was continued for12 h, and 800 mcg mg misoprostol was given rectally. Three

Table 1 Clinical data and variables pertaining to intrauterine balloondelivery

Age,Parity

Gestation(week)

Placentalpathology

1 27, G3 P2 36 w + 0 d Total PP + Accreta2 27, G2 P1 38 w + 2 d Total PP + Accreta3 25, G5 P3 36 w + 2 d Total PP + Accreta4 35, G4 P3 31 w + 0 d Total PP + Accreta5 24, G2 P1 28 w + 0 d Total PP6 32, G3 P1 36 w + 5 d Total PP7 25, G3 P2 35 w + 5 d Total PP + Accreta8 39, G3 P2 34 w + 4 d Partial PP9 33, G6 P2 38 w + 1 d Partial PP

10 21, G2 P1 36 w + 2 d Low-lying11 27, G4 P3 38 w + 1 d Total PP + Accreta12 28, G1 P0 38 w + 6 d Total PP13 35, G3 P1 38 w + 2 d Partial PP14 34, G1 P0 37 w + 0 d Partial PP15 23, G2 P1 32 w + 4 d Total PP + Accreta

PP, placenta praevia (Total PP: the internal cervical os is completely covby the placenta); Preop, preoperative; Postop, postoperative; PRBC, pac

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doses of cefazolin was administered. The balloon was left insitu, usually for 18–24 h, and withdrawn gradually thereafterby aspiration of 20 mL saline at 2 h intervals if haemostasiswas achieved.

Results

We reviewed the medical records of 15 women during thestudy period. The clinical characteristics and parametersrelated to the haemorrhage are summarised in Table 1. Themean gestational age was 35.1 weeks, and the meanoperation time was 61 min. Six women were emergentlytreated for bleeding, and nine were operated on electively.Blood loss ranged from 900 to 2400 mL (mean 1510 mL).In total, 29 units of blood and 13 units of fresh frozenplasma were transfused.

Haemostasis was achieved successfully in all women.However, bleeding recurred in one woman followingslippage of the balloon in the early postoperative period(2nd h). It was controlled with reinsertion and infusion ofthe catheter balloon with 120 mL saline and vaginalpacking (case 9). Rupture of the balloon with a sutureneedle was encountered during closure of the hysterotomyincision in another, and the procedure was repeated(case 10). Both women did well after reinsertion of theballoon. There was no case of endometritis, difficultyduring withdrawal of the balloon or tissue trauma causedfrom the balloon.

Discussion

The lower uterine segment does not usually respond touterine massage or uterotonics, because of its poorcontractile nature. Oversewing the fragile placental bed slows

tamponade for bleeding from lower uterine segment at caesarean

Operationtime (min)

Estimatedintraoperative bleeding

(mL)Total

transfusion

95 2200 3 PRBC, 2 FFP80 2400 4 PRBC, 2 FFP70 1800 4 PRBC, 2 FFP45 1700 3 PRBC, 1 FFP40 1400 2 PRBC, 1 FFP55 1200 2 PRBC, 1 FFP70 1200 2 PRBC, 1 FFP40 1300 2 PRBC, 1 FFP40 1600 –55 1600 2 PRBC, 1 FFP60 1100 2 PRBC65 900 –50 1200 –75 1600 2 PRBC60 1300 1 PRBC, 1 FFP

ered by the placenta, partial PP: the internal os is partially coveredked red blood cells; FFP, fresh frozen plasma; w, weeks; d, days.

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Foley balloon tamponade in placenta praevia ⁄ accreta

bleeding, but may not control it completely. Special cervico-isthmic sutures, such as parallel vertical and transverseannular compression sutures, may be used to controlbleeding, but clinical experience with these techniques islimited.9,10 Additionally, sutures in the lower uterine segmentduring severe haemorrhage have some potential risks, suchas injury to the ureter, bladder and vascular structures, andmay narrow or obstruct the cervical channel, resulting inhaematometra and pyometra.11 Compression suturetechniques, such as the B-Lynch, may also assist, but theseare more useful for uterine atony, and the suture sequencemay be difficult to remember in an emergency.9 Anotheroption is to tamponade the lower uterine segment either withuterine packs or with intrauterine balloons. Intrauterinepacking has been widely used in the past but abandoned dueto the risk of concealed haemorrhage, infection and trauma.In a previous study from our institution from 1995 to 2003,10 of 34 emergency peripartum hysterectomies wereperformed for placentation abnormalities.12 However, in thepast 5 years, we have primarily been using the balloontamponade in women with bleeding from the lower uterinesegment because of placenta praevia ⁄ accreta unresponsive toconservative methods.

A recent review has described balloon tamponade whencompared to other conservative approaches as the leastinvasive, most rapid and effective therapy for use as a firstline therapy in the management of severe PPH followingfailed medical treatment.11 In some small case studies,Sangstaken-Blakemore, Bakri and Rusch balloon catheterswere used successfully, but these involved heterogeneouscauses of PPH, mostly atony, and not specifically placentapraevia and ⁄ or accreta.13–15

The Foley balloon is underused for PPH today because ofconcerns that such a small balloon (30 mL) cannottamponade the capacious post-partum uterine cavity,compared with other high-capacity balloon catheters.1,7,13,16

This may be true for atony bleeding where global uterinetamponade is needed, but it can conform and tamponadethe lower uterine segment efficiently, particularly atsupraphysiological volumes. A volume of 100 mL or lessstopped bleeding in the majority of our patients, althoughthe balloon can hold up to 150 mL fluid without rupture.

Only a few case reports describe the use of a single Foleycatheter in placenta praevia or accreta.7,8 Bakri17 reportedhaemostasis using five to ten Foley balloons each filled with35–75 cm3 saline, but this was cumbersome. We believeproceeding with a single Foley balloon tamponade as soonas possible may be efficacious, instead of losing time givingoverdoses of uterotonics, over sewing the placental bed, orusing compression sutures; the timely control of bleeding isof the utmost importance.

Foley balloon tamponade is easy to perform, effective,cheap and widely available; junior obstetricians can performit readily. It has a drainage tip that allows bleeding to bemonitored. It produces rapid results, and even if it fails, itmay slow and temporise bleeding until a definitive procedureis attempted such as transfer to an interventional radiologycatheter laboratory for embolisation. Disadvantages include

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slippage through a dilated cervix and rupture of the balloon.However, slippage is unlikely in placenta praevia as cervicaldilatation is usually minimal, and if it occurs, it can beprevented by vaginal packing.

In conclusion, our experience indicates that the Foleyballoon tamponade may be considered as an option in themanagement of PPH from the lower uterine segment atcaesarean delivery. Although we appreciate the effectivenessof other high-capacity balloons, we emphasise that theefficacy of Foley balloon tamponade should not beunderestimated. Obstetricians should keep the Foley catheterin mind, particularly where other balloons are notimmediately available.

References

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2 Zaki ZM, Bahar AM, Ali ME et al. Risk factors and morbidityin patients with placenta previa accreta compared to placentaprevia non-accreta. Acta Obstet Gynecol Scand 1998; 77: 391–394.

3 Kwee A, Bots ML, Visser GH et al. Emergency peripartumhysterectomy: a prospective study in the Netherlands. Eur JObstet Gynecol Reprod Biol 2006; 124: 187–192.

4 Georgiou C. Balloon tamponade in the management ofpostpartum haemorrhage: a review. BJOG 2009; 116: 748–757.

5 Royal Collage of Obstetricians and Gynaecologists. RCOGDraft Guideline. Prevention and Management of PostpartumHaemorrhage. 2008.

6 Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloonfor obstetrical bleeding. Int J Gynaecol Obstet 2001; 74: 139–142.

7 Bowen LW, Beeson JH. Use of a large Foley catheter balloonto control postpartum hemorrhage resulting from a lowplacental implantation. A report of two cases. J Reprod Med1985; 30: 623–625.

8 Marcovici I, Scoccia B. Postpartum hemorrhage andintrauterine balloon tamponade. A report of three cases.J Reprod Med 1999; 44: 122–126.

9 Hwu YM, Chen CP, Chen HS et al. Parallel verticalcompression sutures: a technique to control bleeding fromplacenta praevia or accreta during caesarean section. BJOG2005; 112: 1420–1423.

10 Ying H, Duan T, Bao YR et al. Transverse annularcompression sutures in the lower uterine segment to controlpostpartum hemorrhage at cesarean delivery for completeplacenta previa. Int J Gynaecol Obstet 2010; 108: 247–248.

11 Doumouchtsis SK, Papageorghiou AT, Arulkumaran S.Systematic review of conservative management of postpartumhemorrhage: what to do when medical treatment fails. ObstetGynecol Surv 2007; 62: 540–547.

12 Yucel O, Ozdemir I, Yucel N et al. Emergency peripartumhysterectomy: a 9-year review. Arch Gynecol Obstet 2006; 274:84–87.

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13 Seror J, Allouche C, Elhaik S. Use of Sengstaken-Blakemoretube in massive postpartum hemorrhage: a series of 17 cases.Acta Obstet Gynecol Scand 2005; 84: 660–664.

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15 Vitthala S, Tsoumpou I, Anjum ZK et al. Use of Bakriballoon in post-partum haemorrhage: a series of 15 cases.Aust N Z J Obstet Gynaecol 2009; 49: 191–194.

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16 Goldrath MH. Uterine tamponade for the control ofacute uterine bleeding. Am J Obstet Gynecol 1983; 147: 869–872.

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