Postpartum Hemorrhage Management with Bakri Balloon: Investigating Retained Placenta Risk

Introduction

Retained products of conception (RPOC) is a rare complication that occurs after second-trimester delivery or pregnancy termination and often causes massive hemorrhage [1]. RPOC is diagnosed by ultrasonography or computed tomography (CT), and the presence of chorionic villi is confirmed by histological examination [2]. Symptoms in most women include genital bleeding, and the need for surgical intervention is determined by the thickness of the endometrium on ultrasound [3]. Abortion in the second trimester of pregnancy and use of placental forceps during delivery are risk factors for RPOC [4]. The Bakri balloon is used for treating postpartum atonic hemorrhage that does not respond to drugs [5]. Here, we report a case in which RPOC was diagnosed at the 1-month postpartum ultrasound examination after the use of a Bakri balloon owing to flaccid hemorrhage during full-term delivery.

Case Report

The patient was a 32-year-old woman with no relevant medical history. Her pregnancy history included 4 pregnancies and 3 births. Pregnancy was established by frozen embryo transfer. This was the first treatment for infertility in our patient. Thereafter, the pregnancy was managed at our hospital. Blood tests performed at 36 weeks of gestation revealed a hemoglobin level of 10.4 g/dl. Labor began at 38 weeks 2 days of gestation, and the baby was delivered vaginally on the same day. The placenta was delivered smoothly. After delivery of the placenta, uterine contractions were poor and bleeding persisted. Continuous administration of oxytocin and uterine massage did not improve uterine contractions. Ultrasonography confirmed the absence of placental remnants in the uterus, and a Bakri balloon was inserted into the uterus to stop the bleeding. Ultrasonography revealed that the Bakri balloon was retained in the uterus. Thereafter, the bleeding stopped. No anesthesia was administered during the procedure. The total bleeding volume was 2263 cc. Blood tests revealed a decreased Hb level of 5.3 g/dl, and 6 units of RBC were transfused. The next morning, the Bakri balloon was removed, and hemostasis was confirmed. Blood tests showed improvement to Hb 9.2 g/dl. Transvaginal ultrasonography performed on the fourth postpartum day revealed no specific complications (Figure 1), and the patient was discharged on postpartum day 5. At the 1-month postpartum checkup, 33 days after delivery, the patient had a small amount of genital bleeding. Transvaginal ultrasonography revealed multiple pulsatile vascular shadows in the uterus (Figure 2). Contrast-enhanced CT revealed mass staining of the uterine body from the arterial phase to the equilibrium phase, and a residual placenta was suspected (Figure 3). The following day, the patient was referred to a high-level facility capable of providing endovascular treatment. During a gynecological examination at the higher-level institution, the placenta was almost completely ejected from the uterus; therefore, it was removed vaginally. Heavy bleeding occurred, and a balloon catheter (not a Bakri balloon) was inserted into the uterus to stop the bleeding. The balloon catheter was removed after several minutes, hemostasis was confirmed, and the procedure was completed. The patient was scheduled for follow-up at an outpatient clinic but refused; therefore, the visit was canceled.

Discussion

In the present case, a Bakri balloon was used for postpartum hemorrhage due to contraction failure during full-term delivery, and RPOC was diagnosed 1 month later.

Uterine balloon tamponade devices are commonly used to manage postpartum flaccid hemorrhage, and the Bakri balloon is usually a safe, simple, and effective method for treating excessive postpartum bleeding [6]; however, risks such as infection have also been reported [7]. Placental adhesions are a factor in Bakri balloon failure [8]. However, the risk of RPOC due to Bakri balloon use has not been reported.

RPOC often develops after abortion, and risk factors in patients who have undergone manual vacuum aspiration have been discussed [9]. Placental forceps have also been reported as a risk factor for RPOC [4]. Bakri balloon use may also be associated with RPOC.

However, excessive postpartum hemorrhage is a risk factor for RPOC [10]; therefore, it remains unclear whether the Bakri balloon definitively can cause RPOC. Further studies with larger sample sizes are warranted to determine the general safety of the Bakri balloon for postpartum hemorrhage.

Conclusions

We encountered a case of RPOC 1 month after using a Bakri balloon. Although the relationship between the 2 remains unclear, it may be preferable to avoid such cases in the future.