Annals of Reproductive Medicine and Treatment

Post Partum Hemorrhage: A Case Report of Successful Management via Conservative Surgery

Short Communication | Open Access

  • 1. Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Italy
+ Show More - Show Less
Corresponding Authors
Michela Torricelli, Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Via Aldo Moro 2, 53100 Siena

Postpartum hemorrhage is an obstetric emergency. Conservative management of hemorrhage is gaining popularity. Initial management consists of uterotonic administration but in cases of failure of response to medication, uterine cavity tamponade can be effective. The balloon is an alternative method to the surgery approach. The authors describe a case which a uterine tamponade with Bakri balloon successfully used to control postpartum hemorrhage after a cesarean delivery, in a 41 years old woman, in her third pregnancy. A Bakri balloon was placed transvaginally and inflated with 400 ml of saline. Atony and post partum hemorrhage were resolved.


Post partum hemorrhage, Uterotonic drugs, Bakri balloon, Uterine tamponade


Starace AC, Torricelli M, Cannoni A, Luisi S, Severi FM (2017) Post Partum Hemorrhage: A Case Report of Successful Management via Conservative Surgery. Ann Reprod Med Treat 2(3): 1017


PPH: Post partum hemorrhage


Post partum hemorrhage (PPH) is commonly defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 ml following cesarean delivery, and it occurs with a frequency of around 5% [1]. PPH is a major cause of pregnancy related death in both developed and non developed countries and, in addition, is the highest cause of obstetric disease specific morbidity [2-4]. Several risk factors for PPH are known such as multiple pregnancy, operative delivery and chorioamnionitis [1], however PPH may occur among patient with no known risk factors. Our ability to reduce the risk of PPH depends on ongoing investigations of previously unaccounted for causes and risk factors.

The leading cause is uterine atony, up of 80% of the causes result from suboptimal contraction of the myometrium following placental separation, but the incidence of atony has been reduced by intrapartum care by active management with oxytocin [5- 7]. Retained placental tissue, genital tract trauma (vaginal and cervical laceration), uterine rupture or maternal coagulation disorders also results in PPH. The recommendation is a stepwise approach to management of PPH from less invasive therapy like uterine massage and uterotonic drugs to more invasive one like uterine arteries embolization, uterine compression sutures, uterine artery ligation and hysterectomy in case of failure of conservative management, which may be associated with further blood loss and additional morbidity [8-9]. Recently intrauterine balloon tamponade is an effective intermediate, fertility sparing therapy option that can be used in any situation which hemorrhage should be conservatively managed. Multiple type of balloon are available but Bakri balloon is specifically designed for postpartum intrauterine tamponade and is the only device approved by US Food and Drugs Administration for this application [10]. The Bakri balloon has become an integral part of the “HEMOSTASIS” management algorithm advocated in the UK [8,11].


We report a case of a 41 years old woman. It was her third pregnancy: in the 2013 an urgent cesarean section, at 32 weeks, for preeclampsia and uterine artery’s flow alteration, the placenta had posterior localization; the baby was female, with birth weight of 1300 gr. In the 2015 the woman had an abortion. On her medical history she had a controlled hypertension during all the pregnancy.

The patient was admitted for the first time to the present department due to an increased blood pressure, at 28+6 weeks’ gestation, treated with drugs. The ultrasound examinations of the three trimester were normal and the thickness of the lower uterine segment was of 2.5 mm (cut-off 2.0-3.5mm) and the myometrium was of 1.6 mm (cut-off 1.4-2.0) [12].

At 36+4 weeks she referred to our obstetric department with irregular uterine contractions and a cervix dilation of 1 cm. She had a blood pressure of 130/80 mmHg and a pulse rate of 78/ min. Placenta was anterior and with normal insertion, no vasa previa. CTG was normal. After 30 minutes an emergency cesarean was performed because of initial labor in fetus in breech position, in woman with hypertension. Blood was taken for hemoglobin and grouping and cross matching.

Entering in abdominal cavity the authors noted a dehiscence at previous cesarean section. A male baby was delivered and he weighed 2600 gram and had 5 and 10 minute Apgar score of 10. After fetal extraction, the placenta was removed difficulty because of a lateral left part of the placenta was tenaciously adherent to uterine wall. At macroscopic examination appear to be accreta; histological examination was done and the result was of 5 % of placental infarction..

Following repair of lower segment, an uterine bleeding occurred while oxytocin (the prophylactic dose: 10 UI of Syntocinon intravenous in 250 cc of physiological solution and the therapeutic dose: 20 UI intravenous in 250 cc of physiological solution) and carbetocin (1 ml of Duratocin that contains 100 microgram of carbetocin) were administered. It was reached a first hemostasis’ control. Uterus appeared contract and the vaginal loss stopped with an amount of 1100 cc. Soon after the open wound was closed, uterus appeared flabby and 5 misoprostol’s tablets intrarectal (Cytotec 200 mg) and 1 gram in 100 cc of physiological solution intravenous of tranexamic acid were administrated. The intra-procedure control of hemoglobin showed a value of 7.9 g/dl. Hemorrhage continued so for its management Bakry balloon was placed through vaginal way, filled with 400 cc of saline, under sonographic guide and a vaginal swab was placed. The bleeding stopped briefly. Total amount of lost was 2300 cc.

The patient received 5 pached cells, 1 pool of platelets and 2 units of fresh frozen plasma. When transfusion started, the hemoglobin level reached the lowest value (6.3 g/dl). The patient remained circulatory stable but she was transferred to the intensive care unit for close monitoring of her hemodynamic status and replacement of fluid and other blood components.

During our observation post operative hemoglobin level was 8.3 g/dl. The tamponade was emptied and removed after 36 hours and no substantial bleeding occurred. The woman was covered with broad spectrum of antibodies. The transvaginal sonographic examination revealed an echoic mass, with a poor vascularization, measuring 38 mm in its maximum diameter, compatible with retained placental fragment. The woman remains in stable conditions and she was discharged home well on post delivery day 6 with hemoglobin of 9,3 g/dl. She was given oral haematinics, antihypertensive therapy, postnatal prophylactic LMWH and antibiotics.

Two days later the patient was returned at our attention for a transvaginal ultrasound control, in which the echoic mass appeared not more vascularized and its maximum diameter was 30 mm. Hemoglobin was of 9.6 g/dl. We programmed a new access to our department, 6 days later, to monitoring the mass and the uterine cavity appeared to be empty, the bHCG value was negative and uterus was contract. In the follow up she hasn’t got complications.


This case report demonstrates that the uterine tamponade with Bakri balloon was an useful intervention for the management of post partum hemorrhage [13]. The mechanism of action in stopping the bleeding is by creating an intrauterine pressure which exerts hydrostatic pressure on the capillaries and veins in the uterus [8,14]. In the literature the successful utilization of tamponade techniques has been well described in case of hemorrhage due to uterus’ atony or placenta previa [15]. Failure may be due to damage or displacement of the balloon or others causes not well defined. There are some review in which are described cases of PPH non responsive to tamponade and that needed additional procedure or hysterectomy. Some authors remarked that diagnostic “tamponade test” rapidly identified patients with PPH that might otherwise warrant a laparotomy [13,16].

Management of PPH is a life sparing intervention. Using uterotonic agents is the preferred primary medical treatment. In case of failure, surgery can be the second option. Intrauterine balloon application should be considered as an alternative method when that has several advantage include being promptly implantable, cost effective and capable of eliminating major surgeries and their complications in cases with successful outcomes [17].

Bakri balloon device doesn’t contains latex and once inflated it conforms very closely to the shape of the entire uterine cavity, unlike the Foley; this last one, such as condom, doesn’t allow for drainage of the uterine cavity and it’s possible for blood to accumulate [18]. It cannot be applied in case of organ failure associated with sepsis or disseminated intravascular section.

In our case we performed Bakri Balloon procedure according to the algorithm for the management of PPH, in a woman that had in her medical history some risk factors that we analyzed retrospectively: history of hypertension, a previous urgent cesarean section complicated by preeclampsia and retained placenta.

We remember that despite the identification of risk factors, primary PPH occurs unpredictably in women without any risk factor and in absence of effective medical intervention, patients with PPH on the average die within 2 hours. It is necessary to highlight the importance to shared hemorrhage protocols to improve outcomes related to postpartum hemorrhage. In this way the multidisciplinary approach, a team work communication and practice skills play a key role to improve systems processes in the health care setting.


1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for ObstetricianGynecologists. Postpartum hemorrhage. Obstet Gynecol. 2006; 108: 1039-1047.

2. World Health Organization (WHO). World Health Report 2005: make every mother and child count. WHO. 2005.

3. Ghana Statistical Service, (GSS), Ghana Health Service (GHS), and Macro International 2009. Ghana Maternal Health Survey 2007. 37.

4. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006; 367: 1066-1074. 

5. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg. 2010; 110: 1368-1373.

6. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev. 2000.

7. Loic Sentilhes, Benjamin Merlot, Hugo Madar, Francois Sztark, Stephanie Brun, Tharaux CD. Postpartum haemorrhage: prevention and treatment. Expert Review of Hematology 2016; 9: 1043-1061

8. Knight M. UKOSS. Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage. BJOG. 2007; 114: 1380- 1387.

9. Chandraharan E, Arulkumaran S. Surgical aspects of postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2008; 22: 1089- 1102.

10. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG. 2009; 116: 748-757.

11. Varatharajan L, Chandraharan E, Sutton J, Lowe V, Arulkumaran S. Outcome of the management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS”. Int J Gynaecol Obstet. 2011; 113: 152-154.

12. Jastrow N, Chaillet N, Roberge S, Morency AM, Lacasse Y, Bujold E. Sonographic lower uterine segment thickness and risk of uterine scar defect: a systematic review. J Obstet Gynaecol Can. 2010; 32: 321-327.

13. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv. 2007; 62: 540-547.

14. Sinha SM. The “tamponade test” in the management of massive postpartum hemorrhage. Obstet Gynecol. 2003; 102: 641-642.

15. Lo A, St Marie P, Yadav P, Belisle E, Markenson G. The impact of Bakri balloon tamponade on the rate of postpartum hysterectomy for uterine atony. The Journal of Maternal-Fetal & Neonatal Medicine. 2017; 30: 1163-1166.

16. Kong MC, To WW. Balloon tamponade for postpartum haemorrhage: case series and literature review. Hong Kong Med J. 2013; 19: 484- 490.

17. Bakri YN, Amri A, Jabbar FA. Tamponade-balloon for obstetrical bleeding. Int J Gynaecol Obstet. 2001; 74: 139-142.

18. Cengiz H, Dagdeviren H, Kaya C, Yildiz S, Ekin M. Successful management of a second-trimester post-abortion hemorrhage with the Bakri balloon tamponade. Clin Exp Obstet Gynecol. 2015; 42: 246- 247

Received : 12 Jun 2017
Accepted : 23 Aug 2017
Published : 28 Aug 2017
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
TEST Journal of Dentistry
ISSN : 1234-5678
Launched : 2014
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X