198 BRIEF COMMUNICATIONS
[2] Selcuk NY, Tonbul HZ, San A, Odabas AR. Changes in frequency and etiology of
acute renal failure in pregnancy (1980–1997). Ren Fail 1998;20(3):513–7.
[3] Kellum JA, Bellomo R, Ronco C. Classification of acute kidney injury using RIFLE:
What's the purpose? Crit Care Med 2007;35(8):1983–4.
[4] Pertuiset N, Grünfeld JP. Acute renal failure in pregnancy. Baillieres Clin Obstet
Gynaecol 1994;8(2):333–51.
[5] Arora N, Mahajan K, Jana N, Taraphder A. Pregnancy-related acute renal failure in
eastern India. Int J Gynecol Obstet 2010;111(3):213–6.
[6] Ansari MR, Laghari MS, Solangi KB. Acute renal failure in pregnancy: one year
observational study at Liaquat University Hospital, Hyderabad. J Pak Med Assoc
2008;58(2):61–4.
[7] Prakash J, Niwas SS, Parekh A, Pandey LK, Sharatchandra L, Arora P, et al. Acute
kidney injury in late pregnancy in developing countries. Ren Fail 2010;32(3):
309–13.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2011.05.029
A method to improve the effectiveness of the Bakri balloon for management of
postpartum hemorrhage at cesarean
Mohamed I. Khalil a,⁎, Hessa Al-Dohami b, Mohamed M. Aldahish c
a
Department of Obstetrics and Gynecology, Security Forces Hospital, Riyadh, Saudi Arabia
b
Faculty of Medicine, Menoufiya University, Shebin El-Kom, Egypt
c
Department of Anesthesiology, Security Forces Hospital, Riyadh, Saudi Arabia
a r t i c l e i n f o
Article history:
Received 30 October 2010
Received in revised form 13 April 2011
Accepted 1 August 2011
Keywords:
Bakri balloon with traction stitch
Postpartum hemorrhage
Uterine tamponade
The Bakri balloon, which is used as a uterine tamponade, is the
only balloon product specifically designed for the control of atonic
postpartum hemorrhage (PPH); however, it may lose its effect if
displaced into the vagina [1–4]. The aim of the present study was to
evaluate the effectiveness of a new technique for keeping the balloon
inside the uterine cavity.
Between April 1, 2004, and April 30, 2009, a study was conducted
among women with severe atonic PPH during emergency cesarean,
following failed attempts at medical treatment, at the Security Forces
Hospital, Riyadh, Saudi Arabia. The hospital Ethics Committee
approved the study, and informed consent was obtained from all
participants.
Women who were less than 28 weeks pregnant, and those with
traumatic bleeding or placenta previa were excluded. All participants
had undergone cesarean for different indications at 6 cm to full
dilation of the cervix, and in all cases coagulopathy had been excluded
as the cause of or a catalyst for hemorrhage. Following failed attempts
at medical treatment for PPH, a Bakri balloon (Cook, Bloomington, IN,
USA) was placed inside the uterine cavity during cesarean. Women
who required the balloon tamponade were randomized (via computer-
based random assignment) into 2 groups: the traction stitch group
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Security
Forces Hospital, PO Box 3643, Riyadh 11481, Saudi Arabia. Tel.: +966 509551209;
fax: +966 1 4764757.
E-mail address: khalil1464@hotmail.com (M.I. Khalil).
[8] Vladutiu DS, Spanu C, Patiu IM, Neamtu C, Gherman M, Manasia M. Abortion
prohibition and acute renal failure: the tragic Romanian experience. Ren Fail
1995;17(5):605–9.
[9] Sawhney H, Aggarwal N, Biswas R, Vasishta K, Gopalan S. Maternal mortality
associated with eclampsia and severe preeclampsia of pregnancy. J Obstet
Gynaecol Res 2000;26(5):351–6.
[10] Stratta P, Canavese C, Dogliani M, Todros T, Gagliardi L, Vercellone A. Pregnancy-
related acute renal failure. Clin Nephrol 1989;32(1):14–20.
[11] Khalil MA, Azhar A, Anwar N, Aminullah, Najm-ud-Din, Wali R. Aetiology,
maternal and foetal outcome in 60 cases of obstetrical acute renal failure. J Ayub
Med Coll Abbottabad 2009;21(4):46–9.
(n= 25; study group); and the non-traction stitch group (n= 25;
control group). In the study group, the Bakri balloon was fixed with
nylon loop stitching through the hole of its proximal shaft, and the
needle was then passed through the uterine cavity and the anterior
abdominal wall (Fig. 1). The thread was fixed to the skin to keep the
balloon within the uterine cavity without any additional packing or the
insertion of a balloon vaginally (Fig. 1). This is a new technique perfected
by the authors, and no reports have described it previously. In the
control group, the balloon was left inside the uterine cavity without any
traction stitching, additional packing, or the insertion of a balloon
vaginally. In both groups, the distal end of the balloon was passed
through the cervical opening, with an assistant pulling that end
vaginally.
The uterine incision was sutured before refilling the balloon with
saline solution. The balloon was inflated until it conformed to the
contour of the uterus in order to provide a symmetric tamponade
effect. All patients were administered intravenous broad-spectrum
antibiotics for the first 48 hours and underwent oxytocin infusion for
8 hours. The balloon was removed after 24 hours in the presence of a
consultant to determine whether bleeding had stopped. The proce-
dure was considered successful if the bleeding was minimized, or
unsuccessful if another surgical procedure (e.g. uterine or internal
iliac artery ligation, uterine artery embolization, and/or hysterectomy)
was needed to stop the bleeding.
Only a small number of patients consented to involvement in the
study and, because there was a high rate of balloon displacement in
the control group, the comparison was stopped after 50 cases.
Statistical analyses were performed using the Mann–Whitney test.
P b 0.05 was considered to be statistically significant.
In the study group, the balloon remained in situ without
migration to the vagina in all cases, via the effect of the traction
stitching. Removal of Bakri balloon plus traction stitching is easy,
painless, and unlikely to cause trauma or complication; the balloon is
deflated and, if no bleeding occurs, the traction stitch can be cut and
the balloon withdrawn vaginally. After Bakri balloon deflation in the
present study, only 1 (4.0%) woman in the study group experienced
bleeding and, because the balloon was still in situ owing to the
stitching, reinflation was carried out, after which the patient
underwent bilateral uterine artery embolization. The balloon was
 BRIEF COMMUNICATIONS 199

Fig. 1. Bakri balloon fixed with a stitch to the skin of the anterior abdominal wall. The Bakri balloon can be fixed with nylon loop stitching through the hole of its proximal
shaft (A). The needle is then passed through the uterine cavity (B) and the anterior abdominal wall (C). The thread is fixed to the skin (D) to keep the balloon within the
uterine cavity.

deflated again 4 hours after embolization, at which time the bleeding balloon was removed 24 hours after insertion. The optimal timing
had been controlled. interval for the tamponade to remain in situ needs to be assessed in
In 10 (40%) women in the control group, the balloon migrated to future studies.
the vagina, with continuation of bleeding in 8 of these 10 cases. Displacement of the Bakri balloon, through a dilated cervix, from
Replacement of the balloon controlled the bleeding for 3 women, the uterine cavity to the vagina can decrease its effect in controlling
whereas 3 required uterine artery and internal iliac artery ligation, atonic PPH. To improve the effectiveness of the procedure, the use
and 2 required hysterectomy to control the bleeding. Thus, the of a vaginal pack in the form of ribbon gauze plus a Sengstaken–
success rate was 96% in the study group, compared with 80% in the Blakemore tube or, alternatively, an inflated condom in the vagina
control group, and 88% overall (Table 1). This compares favorably to a to hold the balloon in the uterine cavity has been recommended
success rate of 80% reported for Bakri balloon insertion without [1,2]. Over-inflating the balloon while it is in the uterus is also an
traction stitching [2–4]. No bleeding or other complications were option to prevent migration of the balloon into the vagina, but
present at the site of traction stitching. In all cases in both groups, the over-inflation may cause other problems [1,2]. Therefore, one
should aim for the minimal amount of uterine distention to
accomplish homeostasis. The amount of saline fluid instilled to
inflate the balloon in the present study ranged from 300 to 500 mL,
Table 1
General characteristics of participants (n = 50).a depending on the size and capacity of the uterus. Others have
reported the use of intrauterine balloons without vaginal packing or
Characteristic Study group Control group P value
vaginal balloon [1–3]. There is often a risk of displacement, even if
(n = 25) (n = 25)
the above-mentioned methods are used.
Age, y 32 (46–20) 31 (46–20) 0.09 We recommend the use of a traction stitch to keep the Bakri
Parity-[primiparous] 5 (12–0)-[6] 5 (12–0)-[6] 0.10
balloon within the uterus. This increases the success rate of the
Gestational age at delivery, wk 38 ± 3 38 ± 3 0.10
Displacement of the balloon 0 (0.0) 10 (40.0) b0.01 balloon in controlling atonic PPH compared with its use without a
Bleeding after displacement 0 (0.0) 8 (32.0) b0.01 stitch. When reinflation of the balloon is necessary in cases of bleeding
of the balloon after deflation, the traction stitch may prevent the balloon from being
Estimated blood loss, L 1.7 (1.5–3.1) 2.1 (1.6–4.9) b0.05
displaced completely into the vagina and may assist in further
Hysterectomy required 0 (0.0) 2 (8.0) b0.05
Other surgeries required b 1 (4.0) 3 (12.0) 0.09 management of intractable PPH.
Bleeding after deflation of balloon 1 (4.0) 0 (0.0) 0.09
a
Values are given as median (range), mean ± SD, or number (percentage) unless
Conflict of interest
otherwise indicated.
b
Uterine artery and internal iliac artery ligation or embolization. The authors have no conflicts of interest.
200 BRIEF COMMUNICATIONS
References
[1] Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a
review. BJOG 2009;116(6):748–57.
[2] Royal College of Obstetricians and Gynaecologists. Postpartum Haemorrhage,
Prevention and Management (Green-top 52). www.rcog.org.ukhttp://www.rcog.
org.uk/womens-health/clinical-guidance/prevention-and-management-
postpartum-haemorrhage-green-top-52 Published 2009.
0020-7292/$ – see front matter. Crown Copyright © 2011 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. All rights reserved.
doi:10.1016/j.ijgo.2011.04.018
D-dimer testing versus multislice computed tomography in the diagnosis of
postpartum pulmonary embolism in symptomatic high-risk women
Ibrahim M.A. Hassanin a, Ahmed Y. Shahin b,⁎, Mohamed S. Badawy c, Khalid Karam d
a
Department of Obstetrics and Gynecology, Faculty of Medicine, Sohag University, Sohag, Egypt
b
Women's Health Centre, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
c
Chest Department, Faculty of Medicine, Sohag University, Sohag, Egypt
d
Radiology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
a r t i c l e i n f o
Article history:
Received 26 December 2010
Received in revised form 8 May 2011
Accepted 27 July 2011
Keywords:
High risk
Postpartum
Pulmonary embolism
Spiral multislice computed tomography
Postpartum pulmonary embolism (PE) is a challenging diagnosis
because physiologic changes during pregnancy can yield benign
symptoms that mimic or mask the condition. All PE tests have
limitations, and diagnosis is confirmed only in approximately one-
third of high-risk symptomatic women [1].
Because it yields nonspecific results—which can be related to
pregnancy events, cancer, and infections [1]—D-dimer testing has not
significantly impacted the diagnosis of PE and is used only as an
exclusion tool. In high-risk patients, imaging should be performed
instead of D-dimer testing [2]. Multislice computed tomography
(MSCT) creates thinner sections and involves shorter scanning times
and clearer visualization of segmental and subsegmental vessels than
other types of computed tomography (CT). In cases of suspected PE
that have been shown to be negative, MSCT use has prevented
unnecessary treatment [3]. The aim of the present study was to
compare D-dimer testing with spiral MSCT plus contrast agent in the
diagnosis of postpartum PE in symptomatic women.
The present study took place at Sohag University Hospital, Sohag,
Egypt. In total, 2359 women experiencing different postpartum (i.e.
within 42 days after delivery or abortion) symptoms and signs of PE
were evaluated. The study was approved by the institutional Ethics
Committee and informed consent was obtained from all participants.
Histories included age, presenting symptoms, and signs of PE
such as shortness of breath, chest pain, hemoptysis, wheezy chest,
palpitations, and cyanosis. The women were given follow-up cards
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Assiut
University, 71116 Assiut, Egypt. Tel.: +20 100024322; fax: +49 1212532706248.
E-mail address: ahmed.shahin@web.de (A.Y. Shahin).
[3] Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J
Gynecol Obstet 2001;74(2):139–42.
[4] Vitthala S, Tsoumpou I, Anjum ZK, Aziz NA. Use of Bakri balloon in post-partum
haemorrhage: a series of 15 cases. Aust N Z J Obstet Gynaecol 2009;49(2):191–4.
and encouraged to report any symptoms to the emergency unit or to
phone the study investigators to be booked for follow-up. Risk factors
for thromboembolism included age over 35 years; parity of 3 or more;
body mass index (BMI, calculated as weight in kilograms divided by
the square of height in meters) of 30 or more; past or family history
of deep vein thrombosis and/or PE; past history of contraceptive pill
use; and recent history of trauma, surgery, bed rest, malignancy, and/
or autoimmune disorders. A positive Homans’ sign was noted if
discomfort was elicited in the upper calf during forced dorsiflexion of
the ankle joint. Leg swelling was considered to be significant if there
was a 2-cm difference in calf and ankle measurements (at the widest
point of each) between legs.
Vital signs were reported and general, chest, and heart examina-
tions were undertaken. Imaging included plain chest X-ray in the
posterior–anterior view, electrocardiography, echocardiography, and
MSCT scan (Multidetector 6 Philips; Koninklijke Philips Electronics,
Amsterdam, Netherlands) plus contrast agent. Normal renal function
was confirmed before contrast injection. Laboratory tests included D-
dimer testing via enzyme-linked immunosorbent assay using an
immunochemical automated analyzer (Abbott AxSYM; Abbott Labo-
ratories, Chicago, IL, USA). In the present study, 500 IU/mL or less of
fibrinogen was considered negative for PE and 1500 IU/mL or more
was considered to be highly suggestive of PE.
Caudocranial thoracic images were acquired via MSCT scan
(Brilliance 6 CT Scanner; Koninklijke Philips Electronics, Amsterdam,
Netherlands). To gain an intravenous view, an 18–20-gauge catheter
with a 100–125-mL injection (adjusted for weight) of iodinated
contrast agent (350 mg I/mL) was introduced at 4 mL/second into an
antecubital vein. Images were obtained via a standard algorithm and
viewed using imaging software (IMPAX 4.1; AGFA, Teterboro, NJ,
USA). They were displayed with 3 different grayscales, enabling lung
window-specific (window width/level, 1500/600 HU), mediastinal
window-specific (400/40 HU), and PE-specific (700/100 HU) settings.
Reformatted images enabled differentiation between true PE and a
variety of patient-related, technical, anatomic, and/or pathologic
factors that can mimic PE. Contrast material-enhanced spiral CT of the
veins of the lower extremities was performed with the same contrast
material bolus used for chest CT. Images of the iliac, femoral, and
popliteal veins were obtained 4 minutes after the onset of enhance-
ment from the initial contrast material injection. Women diagnosed
with PE via spiral CT were treated immediately according to
department protocol; treatment lasted for 6 months in total.