Research www. AJOG.

org

OBSTETRICS
The combination of intrauterine balloon tamponade
and the B-Lynch procedure for the treatment
of severe postpartum hemorrhage
Anke Diemert, MD; Gerhard Ortmeyer, MD; Bettina Hollwitz, MD; Manuela Lotz, MD;
Thierry Somville, MD; Peter Glosemeyer, MD; Werner Diehl, MD; Kurt Hecher, MD

OBJECTIVE: To evaluate intrauterine balloon tamponade with or with-
out B-Lynch sutures in avoiding postpartum hysterectomy in cases with
severe postpartum hemorrhage.
STUDY DESIGN: Retrospective analysis using all women delivering be-
tween January 2005 and July 2010 in our center. Prevention of hyster-
ectomy was the main outcome studied.
RESULTS: Twenty-four cases of severe postpartum hemorrhage oc-
curred in which medical treatment alone failed. In 20 cases, the Bakri
balloon was the first choice to stop hemorrhage. Sixty percent (n ⫽ 12)
of these were successfully treated with the balloon alone, 30% (n ⫽ 6)
with the balloon and the B-Lynch suture. Therefore, 90% (n ⫽ 18) were
successfully treated with the balloon as part of the treatment. The bal-
loon tamponade was not successful in 2 cases. Four cases were treated
with emergency hysterectomy a priori.
CONCLUSION: The Bakri balloon with or without B-Lynch sutures in a
stepwise approach is an effective option for the treatment of severe
PPH.
Key words: Bakri balloon, B-Lynch, postpartum hemorrhage

Cite this article as: Diemert A, Ortmeyer G, Hollwitz B, et al. The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of
severe postpartum hemorrhage. Am J Obstet Gynecol 2012;206:65.e1-4.

P ostpartum hemorrhage (PPH) ac-

counts for a quarter of maternal
deaths worldwide1 and is the major cause
of maternal deaths in industrialized
countries2 with a trend to increase in fre-
quency.3,4 Established risk factors for
PPH include preeclampsia, prolonged or
augmented or rapid labor, an overdis-
tended uterus, and chorioamnioitis.5
Today, hysterectomy is the most com-
mon procedure to achieve arrest of se-
vere PPH.6,7
Postpartum hysterectomy is associ-
ated with short- and long-term compli-
cations such as blood loss, injury of other
organs, impaired wound healing, infec-
tion, and loss of fertility. Taking into ac-
count the serious complications related
to hysterectomy after PPH alternative
From the Department of Obstetrics and
Fetal Medicine, University Medical Center
Hamburg-Eppendorf, Hamburg, Germany.
Received Mar. 30, 2011; revised May 23,
2011; accepted July 25, 2011.
The authors report no conflict of interest.
Reprints not available from the authors.
0002-9378/$36.00
© 2012 Published by Mosby, Inc.
doi: 10.1016/j.ajog.2011.07.041
procedures, such as uterine compression
sutures8,9 or intrauterine balloon tam-
ponade10-15 have gained popularity.
The Bakri balloon is a fluid-filled tam-
ponade balloon that is inserted into the
uterine cavity to achieve temporary con-
trol or reduction of PPH.16 B-Lynch su-
tures are brace sutures used to mechani-
cally compress an atonic uterus in the
face of severe PPH.17 Occasionally, the
B-Lynch surgical procedure has been
combined with the Bakri balloon to
achieve successful hemostasis, but the
experience with this combined approach
is limited to 5 cases.12 The purpose of this
report is to describe the success rate of
the Bakri balloon as a first line of therapy
to prevent postpartum hysterectomy
after failure of uterotonic agents. Pre-
vention of hysterectomy was the main
outcome studied.
M ETHODS
This is a retrospective study of consecu-
tive patients diagnosed to have a severe
PPH and unsuccessful medical treat-
ment with uterotonic agents who were
subsequently treated with the Bakri bal-
loon in our unit between January 2005
and July 2010. The cases were identified
by review of medical records. This case
series includes all cases of PPH managed
with the uterine balloon tamponade
(Bakri SOS balloon; Cook Woman’s
Health, Spencer, IN) after its introduc-
tion in our department in 2005. After
identification of cases in the delivery reg-
istry, clinical records were reviewed to
gather data on risk factors for PPH, esti-
mated blood loss, need for transfusion,
or intensive care treatment.
We defined severe PPH as ⬎500 mL
estimated blood loss after vaginal deliv-
ery or ⬎1000 mL after cesarean section.5
Standard management for PPH included
uterine massage, bimanual compression,
and medication with oxytocin or ana-
logues of prostaglandins E1 or E2 in se-
lected cases. Surgical treatment included
placement of the Bakri balloon tampon-
ade alone or in combination with com-
pression sutures and hysterectomy, if the
tamponade failed to stop PPH.
The insertion of the balloon was either
done transvaginally as originally described16
or, if introduced during a cesarean section,
the distal end of the balloon shaft was
passed through the cervical opening with
an assistant pulling vaginally. It was then
partially filled to keep it in place and cor-

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Research Obstetrics www.AJOG.org

TABLE
Patient characteristics
Adjunctive treatment
Delivery Gestational Transfusion, Risk factors Hb,
Case no. mode Age Parity age, wks Bakri B-Lynch Other units ICU for PPH g/dL
1 Vaginal 38 2 42 ⫹ ⫹ 9PBCs, 8FFPs ⫹ 7.1
................................................................................................................................................................................................................................................................................................................................................................................
2 Cesarean 42 1 42 ⫹ ⫹ 14PBCs, 8FFPS ⫹ 4.1
................................................................................................................................................................................................................................................................................................................................................................................
3 Cesarean 29 1 38 ⫹ ⫹ 6PBCs, 2FFPs ⫺ Placenta previa 7.0
................................................................................................................................................................................................................................................................................................................................................................................
4 Cesarean 27 2 42 ⫹ ⫹ 2PBCs ⫺ Placenta previa 8.1
................................................................................................................................................................................................................................................................................................................................................................................
5 Cesarean 30 1 41 ⫹ ⫹ ⫺ ⫺ 9.2
................................................................................................................................................................................................................................................................................................................................................................................
6 Miscarriage 21 1 23 ⫹ ⫹ H 26PBCs, 16FFPs ⫹ Placenta increta 4.0
................................................................................................................................................................................................................................................................................................................................................................................
7 Cesarean 29 1 41 ⫹ ⫹ 24PBCs, 11FFPs ⫹ 5.6
................................................................................................................................................................................................................................................................................................................................................................................
8 Cesarean 33 2 39 ⫹ ⫺ 4PBCs, 3FFPs ⫺ Placenta previa 7.1
................................................................................................................................................................................................................................................................................................................................................................................
9 TOP 35 3 18 ⫹ ⫺ 3PBCs, 4FFPs ⫹ 7.2
................................................................................................................................................................................................................................................................................................................................................................................
10 Cesarean 32 1 36 ⫹ ⫺ ⫺ ⫺ Low lying placenta, 7.4
twin gestation
................................................................................................................................................................................................................................................................................................................................................................................
11 Cesarean 39 2 41 ⫹ ⫺ 4PBCs, 3FFPs ⫺ 4.3
................................................................................................................................................................................................................................................................................................................................................................................
12 Cesarean 42 3 36 ⫹ ⫺ ⫺ ⫺ Placenta previa 7.8
................................................................................................................................................................................................................................................................................................................................................................................
13 Cesarean 30 1 41 ⫹ ⫺ UA ligation 13PBCs, 4FFPs ⫹ 7.0
................................................................................................................................................................................................................................................................................................................................................................................
14 Cesarean 34 1 41 ⫹ ⫺ 2PBCs ⫺ 8.6
................................................................................................................................................................................................................................................................................................................................................................................
15 Cesarean 34 3 37 ⫹ ⫺ ⫺ ⫺ Placenta previa 7.8
................................................................................................................................................................................................................................................................................................................................................................................
16 Cesarean 32 2 36 ⫹ ⫺ ⫺ ⫺ Placenta bipartita 8.7
................................................................................................................................................................................................................................................................................................................................................................................
17 Cesarean 31 1 38 ⫹ ⫺ 2PBCs ⫺ Twin gestation 7.1
................................................................................................................................................................................................................................................................................................................................................................................
18 Cesarean 28 4 36 ⫹ ⫺ 2PBCs ⫺ Placenta previa 7.0
................................................................................................................................................................................................................................................................................................................................................................................
19 Vaginal 38 1 36 ⫹ ⫺ 2PBCs ⫺ 5.1
................................................................................................................................................................................................................................................................................................................................................................................
20 Cesarean 37 1 36 ⫹ ⫺ 4PBCs, 4FFPS ⫺ Twin gestation 6.4
................................................................................................................................................................................................................................................................................................................................................................................
FFP, fresh frozen plasma; H, hysterectomy; Hb, hemoglobin (lowest concentration recorded before transfusion); ICU, intensive care unit; PBC, packed blood cells; PPH, postpartum hemorrhage; TOP,
termination of pregnancy; UA, uterine artery; wks, weeks.
Diemert. Balloon tamponade for PPH. Am J Obstet Gynecol 2012.

rect positioning was checked and adjusted Foley catheter in place and were treated R ESULTS
through the uterine incision, which was with a broad-spectrum antibiotic. They During the study period, there were 9838
closed before filling the balloon com- were kept under constant surveillance deliveries and the incidence of severe
pletely. The amount of saline used to in- and a decision for intensive care treat- PPH unresponsive to standard medical
flate it ranged from 250 –500 mL depend- ment was made according to the cardio- treatment was 0.24% (n ⫽ 24/9838). The
ing on the size and capacity of the uterus as vascular and respiratory status of the pa- Bakri balloon tamponade was used in 20
well as cervical dilatation and in cases with tient. After 12 hours, the balloon was cases (0.2% of all deliveries). The Table
cervical dilatation additional vaginal tam- deflated by removing 50% of the fluid, summarizes the clinical characteristics of
ponade using gauze strips was applied. We and if there was no bleeding, the balloon the patients included in this report.
considered the procedure successful, if the was removed 12 hours later. This pre- Estimated blood loss ranged from 800-
bleeding stopped after the balloon was in-
served the option of refilling the balloon 8000 mL (median 2000) and patients re-
flated. If the bleeding did not cease within
if bleeding recurred. ceived a median of 2.5 units of packed
15 minutes, we performed additional uter-
Patients admitted to our unit provide red blood cells (range, 0 –26) and a me-
ine compression sutures as described by
written consent to use their clinical data dian of 1 unit of fresh frozen plasma
B-Lynch.17 If the uterine compression su-
for research purposes, provided that an- (range, 0 – 8). The median hemoglobin
tures were needed in a case of PPH after
vaginal delivery and balloon placement, we onymity is maintained. The policy of our level before transfusion was 7.1 mg/dL
performed a laparotomy to place the uter- institution is that retrospective review of (range, 4.0 –9.2). The median age of the
ine sutures. medical records to which patients have study population was 33.5 years (range,
The balloon remained in place for a consented does not require review and 21– 42). The median birthweight of the
maximum of 24 hours. All patients had a approval by the ethics committee. overall study population (excluding

65.e2 American Journal of Obstetrics & Gynecology JANUARY 2012

www.AJOG.org
cases 6 and 9) was 3035 g (range, 1990 –
4370). Five of the patients had a repeat
cesarean delivery, 3 of them after a trial
of labor. No medical complications oc-
curred in the study group. Six patients
were admitted to the intensive care unit
for postoperative surveillance.
In 9 cases, there was bleeding from
what was described as the previous pla-
cental site (6 cases with placenta previa, 1
with placenta increta, 1 with a low lying
placenta, and 1 with placenta bipartita).
In 11 cases, PPH was due to uterine at-
ony, which was unresponsive to oxytocin
(20-40 units in 1 L normal saline or lac-
tated Ringer’s solution intravenously),
or analogs of prostaglandin E1 (800-
1.000 mcg rectally or 200 mcg orally plus
400 mcg sublingually) or E2 (500 mcg in
1 L lactated Ringer’s solution intrave-
nously). PPH occurred in the majority of
cases after cesarean section (n ⫽ 16), in 2
cases after a vaginal delivery, in 1 case after
a second-trimester termination of preg-
nancy because of trisomy 21 and in 1 case
after a second-trimester miscarriage.
The Bakri balloon was successfully in-
serted in all cases, in 8 patients transvagi-
nally, and in 12 through the hysterotomy
incision. Balloon tamponade alone was
effective in 12 cases (2 after vaginal deliv-
ery, and 10 after cesarean delivery). Fur-
thermore, it was successful after a com-
bination with B-Lynch sutures in 6 cases
(5 after cesarean section and 1 after vag-
inal delivery). In the overall group, we
did not observe surgical complications
directly related to the Bakri balloon or
B-Lynch suture such as endomyometri-
tis, wound infection, or fever. Two cases
required a second exploratory laparot-
omy because of hemorrhage from a lac-
eration of an uterine artery branch (case
13, Table), and 1 case for the placement
of additional compression sutures. One
patient had an emergency hysterectomy
because of placenta increta (case 6,
Table).
Thus, in 20 cases of severe PPH, 60%
(n ⫽ 12) were successfully treated with
the balloon alone, and 30% (n ⫽ 6) with
the balloon and the B-Lynch suture.
Therefore, a total of 18 cases (90%) were
successfully treated with the balloon as
part of the treatment.
During the study period, we performed
5 hysterectomies. One case was a treatment
failure of the balloon, as described previ-
ously, and in 4 patients with completed
family planning the attending obstetrician
opted for emergency hysterectomy in the
first place because of placenta increta, mas-
sive uterine fibroids, or placenta praevia.
C OMMENT
This study shows, that the Bakri balloon
alone or in combination with B-Lynch
sutures was effective in avoiding hyster-
ectomy in 90% of cases with severe PPH,
after cesarean section as well as after vag-
inal delivery.
Balloon tamponade may avoid the ne-
cessity for laparotomy after vaginal de-
livery as previously described.10 Even in
those cases in which treatment with the
Bakri balloon was unsuccessful, it did
not result in a significant delay to the op-
erating room and allowed enough time
to stabilize the patient and obtain cross-
matched blood. Timing of postpartum
emergency hysterectomies is pivotal as
the probability of survival decreases
sharply after the first hour, if the bleed-
ing persists and the patient’s vital signs
remain unstable.18
It is noteworthy that only 1 patient
with a balloon needed a hysterectomy
and 2 needed a second exploratory lapa-
rotomy, 1 for a ligation owing to bleed-
ing from a branch of the uterine artery,
which was an intraoperative diagnosis,
and another 1 for an additional uterine
compression suture. We classified the
case with the uterine artery suture as a
treatment failure of the balloon tampon-
ade, in which additional compression
sutures of the uterus would not have
helped. We suggest that, if hysterectomy
is performed for uterine atony, there
should be documentation of other ther-
apeutic attempts as set forth by the
American College of Obstetrics and Gy-
necology.5,18 However, known cases of
placenta increta may benefit from a
prompt postpartum hysterectomy, if
they no longer desire children. Uterine
and placental embolization before hys-
terectomy in placenta accreta has been
shown to decrease maternal morbidity,19
whereas the prophylactic placement of
JANUARY 2012 American Journal of Obstetrics & Gynecology
Obstetrics Research
an intravascular balloon catheter has not
decreased morbidity.20
The combination of the intrauterine
balloon with uterine compression sutures
applies forces to the myometrium from in-
side and from outside. One may speculate
that the B-Lynch sutures enhance tampon-
ade by limiting the upward migration of
the fundus from the outward pressure of
the intrauterine balloon.13 The potential
complications of this combined method
include endomyometritis, uterine lacera-
tions, and uterine necrosis resulting from
poor perfusion as described by Kumara et
al.21 To minimize this risk of uterine in-
jury, we inflated the balloon completely
only after placement of the sutures while
visualizing the myometrial response. We
also attempted to minimize duration of the
maximum balloon pressure by deflating it
by 50% after 12 hours, to avoid these po-
tential complications.
We acknowledge the weakness of our
study that it does not allow any conclu-
sion regarding the total blood loss of the
patients. It is well established that visual
estimation of blood loss is not reliable22
and there can be doubt about the accu-
racy. Another weakness of our study is its
retrospective nature. However, with the
severity of this emergency condition a
prospective randomized control trial
would not be possible.19
The strength of our study is that it is
the largest series reporting on the treat-
ment of PPH with the Bakri balloon in
combination with or without B-Lynch
sutures in a stepwise approach. To our
knowledge, there are 4 case series and 1
review reporting on the application of
the balloon tamponade.10-14 The first
case series reported on 16 consecutive
cases in which the tamponade test with a
Senkstaken-Blakmore balloon was used
as a last step before embarking on a lap-
arotomy.10 The bleeding stopped imme-
diately in 14 patients and in the 2 re-
maining cases, it at least reduced the
hemorrhage and allowed time to stabi-
lize the patient before surgery. The sec-
ond study with 23 cases reported on a
successful balloon placement (Seng-
staken and Bakri balloon) in 20 of 23 pa-
tients and an overall success rate of 78%
(18/23).11 Vitthala and colleagues14 re-
ported 15 PPH cases treated with the
65.e3
Research Obstetrics
Bakri balloon with an overall effective-
ness of 80%. However, in none of these
series was the Bakri balloon combined
with B-Lynch sutures as a second step.
This technique has previously been de-
scribed to be effective only in a small series
of 5 cases by Nelson and O’Brien.13 Our
results with a stepwise approach confirm
their good experience. Using a combina-
tion of the Bakri balloon and B-Lynch su-
tures as a second step in 7 of 20 cases (35%)
we observed an overall procedural success
rate of 90%.
The higher success rate observed in
our case series compared with previous
reports using balloon tamponade alone
suggests that the combination of balloon
tamponade with B-Lynch sutures might
be a superior approach in comparison to
each method used on its own. f Chapman R, Sinha A, Razvi K. The tamponade
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