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doi:10.1111/j.1447-0756.2011.01625.

J. Obstet. Gynaecol. Res. Vol. 38, No. 1: 102107, January 2012

Balloon tamponade during cesarean section is useful for


severe post-partum hemorrhage due to placenta previa
jog_1625

102..107

Takako Ishii1, Kenjiro Sawada1, Shunsuke Koyama1, Aki Isobe1, Atsuko Wakabayashi1,
Tsuyoshi Takiuchi1, Takeshi Kanagawa1, Takuji Tomimatsu1, Kazuhide Ogita2 and
Tadashi Kimura1
1

Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, and 2Department of
Obstetrics and Gynecology, Rinku General Medical Center, Izuminsano, Osaka, Japan

Abstract
Aim: Severe post-partum hemorrhage during cesarean section due to placenta previa is still one of the leading
causes of maternal mortality. The aim of this study was to evaluate the efficiency of intrauterine tamponade
with a Sengstaken-Blakemore tube (SB-tube) for the treatment of severe post-partum hemorrhage in cases of
placenta previa.
Material and Methods: Data were collected from our departmental clinical records on all patients who
underwent caesarian section due to placenta previa between 2007 and 2009.
Results: During the period analyzed, 37 patients underwent caesarian section due to placenta previa/lowlying placenta. Four (11%) underwent hysterectomy due to placenta accreta and 33 (89%) were treated
conservatively. Of the 33 patients with conserved uterus, 10 (28%) patients required a SB-tube during the
cesarean section because of continuous post-partum hemorrhage despite appropriate medical treatment. The
median bleeding during the operation was 2030 860 mL in the patients who used SB-tube. None of them
presented severe complications related to these procedures or required any further invasive surgery.
Conclusion: Intrauterine balloon-tamponade could successfully control severe hemorrhage from a lower
uterine segment of a patient with placenta previa. This technique is simple to use, scarcely invasive, and
available at a low cost to all maternity wards, and should be considered as one of the first management options
to reduce the risk of undesirable hysterectomy.
Key words: balloon-tamponade, cesarean section, placenta previa, post-partum hemorrhage, SengstakenBlakemore tube.

Introduction
The incidence of placenta previa at the time of birth
varies widely in published series, but on average it
occurs once in every 150250 live births. Obstetrical
bleeding (intrapartum/post-partum) secondary to placenta previa with variable degrees of accretion is not
uncommon. Post-partum bleeding is usually from the
placental bed at the lower uterine segment and occurs
immediately after the placenta is delivered. Although

recent developments in transvaginal ultrasonography


allow clinicians to diagnose prenatally, it is still one of
the leading causes of maternal mortality.1
Hysterectomy can be an undesirable action to take,
especially in the case of a low parity patient. Usually,
this step is taken when other traditional measures to
stop hemorrhage fail.2 Various management options
are utilized for control of bleeding caused by this clinical abnormality and conservative approaches are
becoming increasingly used instead of hysterectomy.

Received: July 15 2010.


Accepted: March 3 2011.
Reprint request to: Dr Kenjiro Sawada, Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2
Yamadaoka, Suita, Osaka, Japan. Email: daasawada@gyne.med.osaka-u.ac.jp

102

2011 The Authors


Journal of Obstetrics and Gynaecology Research 2011 Japan Society of Obstetrics and Gynecology

Balloon tamponade for placenta previa

Arterial embolization under fluoroscopic guidance


requires expertise in interventional radiology and specialized equipment, although the success rate is high
and the procedure has the potential to preserve fertility. This procedure is limited to centers with a high
degree of expertise.3
Nowadays, the use of intrauterine balloons has been
well described in the literature for the control of
massive post-partum hemorrhage (PPH) due to atonic
uterus not responding to oxytocics such as prostaglandins.4 Placement of a uterine balloon tamponade Foley,5
Bakri balloon,6 or Sengstaken-Blakemore tube (SBtube),7 which may be inserted either after cesarean
section or vaginal delivery, is an option with interesting
advantages, and is thus often preferred to gauze
packing. Placement of a uterine balloon can act as a
diagnostic test to screen those women who need hysterectomy. In addition, it minimizes the risk of occult
bleeding and removal of the balloon is not a painful
procedure. However, the efficacy of the use of intrauterine balloon in PPH after cesarean section complicated by placenta previa remains unclear because only
a small series of a few cases have been reported.8,9
With these points in mind, we analyzed the clinical
outcomes of uterine tamponade with SB-tube for the
treatment of severe PPH due to placenta previa in a
larger series. In all 10 cases analyzed, hemostasis was
adequately achieved after the insertion of the tube and
no patient required any further invasive surgical procedures. Uterine balloon-tamponade was highly effective in controlling PPH originating from the placental
site and should be considered as the first step in order
to reduce undesirable hysterectomy.

centa edge to the internal os was less than 2 cm. Of 37


patients, four patients (11%) required hysterectomy
because the placenta did not separate from the uterus
due to placenta accretion. Six patients (16%) had no
major troubles because the placenta separated
promptly and bleeding was controlled easily. In the
remaining 27 cases, after delivery of the placenta, PPH
originating from the placental site continued to be
resistant to medical therapies, which included intravenous infusions of oxytocin (1020 U), intravenous ergometrine (0.5 mg), intra muscular prostaglandin F2a or
rectal insertion of misoprostol (400 mg). In 10 of those
with no response to these medical treatments, the
SB-tube was inserted into the uterine cavity during the
operation. The insertion of the tube was performed by
a single qualified operator (K. S.). In the remaining 17
cases, rolled gauze was used to control severe PPH.
The insertion of SB-tube was based on the method
reported by Condous et al.10 Briefly, after cutting the
distal end of the tube beyond the balloon, the insertion
was facilitated by grasping the anterior and lateral
margins of the cervix with sponge forceps and placing
the esophageal or stomach balloon into the uterine
cavity via the cervix. The balloon was positioned to fit
the cervix of the uterus and inflated with 200300 mL
of saline as appropriate for the uterine size. Applying
gentle traction confirmed that the SB-tube was firmly
fixed in situ in the uterine cavity and good control of
the hemorrhage was provided. A representative picture
of the procedure is shown in Figure 1. The hysterotomy
incision was carefully sutured with VicrylR 10 without
entrapping the balloon. Broad-spectrum antibiotic

Methods
Between January 2007 and December 2009, there were
1731 deliveries in the Perinatal Medical Center of
Osaka University Hospital (Osaka, Japan). Of these, 37
(2.1%) underwent caesarian section due to placenta
previa/low-lying placenta. All were Asian, aged
2741 years and from a middle-class community in
Osaka or Hyogo prefecture in Japan. Since our unit
accepts high-risk pregnant women who can not be
treated in usual neighborhood hospitals, the percentage of placenta previa/low-lying placenta was relatively high. Placenta previa was diagnosed by
transvaginal ultrasonography in late pregnancy and it
was confirmed that the placental edge overlapped the
internal cervical os just before the operation. Low-lying
placenta was diagnosed when the distance of the pla-

Figure 1 A representative picture of SengstakenBlakemore tube inserted from hysterotomy incision.

2011 The Authors


Journal of Obstetrics and Gynaecology Research 2011 Japan Society of Obstetrics and Gynecology

103

104

No
No
No
No
Yes
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
No
Yes
Yes
RCC 8U
None
RCC 6U
None
None
None
None
None
None
None
120
56
121
40
170
40
320
140
125
125
3160
1000
3220
1300
1500
1700
1360
1450
2830
2780
5 min
1 min
2 min
4 min
4 min
8 min
5 min
4 min
6 min
2 min
Previa totalis
Previa totalis
Previa totalis
Previa totalis
Previa totalis
Low lying placenta
Previa totalis
Previa totalis
Low lying placenta
Previa totalis
RCC, red cell concentrate.

G4P0
G2P1
G5P4
G2P0
G2P0
G1P0
G2P0
G2P1
G1P0
G2P1
37
30
34
34
35
29
37
37
36
34
1
2
3
4
5
6
7
8
9
10

37w0d
36w1d
36w3d
34w6d
36w3d
37w3d
36w5d
36w6d
37w0d
36w0d

Antibiotics
after operation
Transfusion
Drainage
blood
loss (mL)
Estimated
blood
loss (mL)
Duration between
baby delivery and
placenta delivery
Position of
placenta
Gestation
Gravidity
and parity
Age
(y)

Balloon tamponade with SB-tube was used in a total of


10 patients during cesarean section due to uterine hemorrhage resistant to medical therapy. The clinical outcomes of those 10 patients are summarized in Table 1.
Complete hemostasis was achieved in all cases. The
drainage blood was continuously monitored until the
next morning after the operation. The median drainage
blood until the next morning was 125.7 81.3 (40320)
mL. The median age of the women was 34.3 2.8 years.
The median gestational age was 36.5 weeks of gestation.
Six women (60%) were nulliparas and three were para 1.
The median birth weight was 2.74 0.21 kg and none of
the neonates had apparent congenital abnormalities.
The median bleeding during the operation was
2030 860 mL. Two cases (cases 1 and 3) required
transfusion due to massive bleeding during the operations. One (case 5) experienced postoperative fever.
There were no severe adverse events in any cases and
no further invasive surgical procedures were required.
Next, we compared clinical outcomes among the
treatment options employed in Table 2. The median
blood loss of six patients who required no further treatments was 935 271 mL and significantly lesser than
that of rolled gauze (P = 0.043). The median bleeding
during the operation was 2030 860 mL in the patients
who used SB-tube and 2241 1378 mL in those that
used the gauze. No significant differences were noted

Case
No.

Result

Table 1 Summary of clinical outcomes of the patients who used Sengstaken-Blakemore tube

therapy was systematically used just before the


operation in all cases. In several cases, prophylactic
antibiotics were used after the procedure based on the
operators decision. The blood drainage was collected
through the distal end of the shaft by attaching a collection bag, and closely observed. SB-tube was
removed 24 h after the operation and complete hemostasis was confirmed.
Clinical data were collected from medical records.
The clinical, biochemical and hematological data were
recovered together with data on age, number of pregnancies, parity, gestational age, duration of time
between delivery of baby and placenta, estimated
blood loss and volume of blood transfused. Postoperative fever was defined as a temperature rise above 38C
maintained over 24 h or recurring during the period
from the 1st to the 10th day after childbirth.
Statistical analysis was performed with Stat View
(Abacus Conceptus Inc, Berkeley, CA, USA). Statistical
differences between groups were analyzed by KruskalWallis test along with post hoc test (Scheffes test).

Postoperative
fever

T. Ishii et al.

2011 The Authors


Journal of Obstetrics and Gynaecology Research 2011 Japan Society of Obstetrics and Gynecology

Balloon tamponade for placenta previa

Table 2 The summary of clinical outcomes of the cases of cesarean section due to placenta previa

Number
Age (y)
Previous cesarean section
Previous myomectomy
Estimated blood loss (mL)
Uterine artery embolization required
Transfusion
Postoperative fever

SengstakenBlakemore tube

Rolled
gauze

No
treatment

Hysterectomy
required

10
34.3 2.8
0/10
1/10
2030 860
0/10
2/10
2/10

17
33.7 5.2
2/17
1/17
2241 1378
1/17
3/17
8/17

6
35.0 2.4
1/6
0/6
935 271
0/6
0/6
1/6

4
35.3 4.0
4/4
0/4
3300 1764
N.A.
3/4
2/4

N.A., not applicable.

Table 3 Summary of clinical outcomes of the patients who required hysterectomy


Case

Age
(y)

Gravity and
parity

Previous
CS

Gestation

Prenatal
diagnosis

Estimated
blood loss (mL)

Transfusion
required

Pathological
diagnosis

1
2
3
4

31
37
40
33

G2P1
G4P3
G4P2
G3P1

1
2
2
1

35w2d
35w4d
36w0d
35w3d

Yes
No
Yes
Yes

2900
5000
4300
1000

RCC 4U
RCC 8U FFP 8U
RCC 8U
None

Placenta percreta
Placenta accreta
Placenta accreta
Placenta increta

Estimated blood loss during the initial cesarean section. CS, cesarean section; FFP, fresh frozen plasma; RCC, red cell concentrate.

between these two groups. One case of gauze packing


group required uterine artery embolization due to continuous bleeding after the procedure. In the remaining
26 cases in which SB-tube or rolled gauze was used,
adequate hemostasis (less than 100 mL/2 h) was
achieved soon after the insertion and no further treatments were required. Two cases (20%) of SB-tube
group and three cases (18%) of gauze packing required
transfusion due to massive bleeding during the operations. Two (20%) of the SB-tube group and eight (47%)
of gauze group experienced postoperative fever. Both
uterine gauze packing and balloon-tamponade were
similarly effective in controlling PPH, and there were
no severe adverse events (i.e. severe infectious symptoms) in any cases.
In Table 3, the clinical outcomes of the cases required
hysterectomy are summarized. In case 1, 3 and 4, placenta accrete was strongly suspected prenatally by MRI
and Doppler ultrasonography. Since a 25% to 50% incidence of placenta accreta in patients with placenta
previa with prior cesarean delivery has been well
recognized, the patient and her family agreed with hysterectomy when placenta was not separated spontaneously. In case 4, to avoid the risk of hemorrhage, we
scheduled and performed stepwise treatment suggested by Sumigama et al. in Nagoya University.11 The
brief procedure was as follows: a cesarean section was
performed without separation of the placenta; on the

operation day, transcatheter angiographic uterine arterial embolization was conducted with gelatin sponge
particles and platinum coils; one week later, total hysterectomy was carried out. In Table 3, the blood loss
during the initial cesarean section was shown. In case 2,
although the placenta was partially separated spontaneously, the other part of placenta was tightly attached to
the uterine wall and massive bleeding occurred. Since
the operator considered it was not possible to control
bleeding, the hysterectomy was emergently performed.

Discussion
Post-partum hemorrhage in cases of placenta previa
remains a serious obstetric complication. Successful
control of bleeding can often be achieved medically
using uterotonics including oxytocin, ergometrine,
15-methyl prostaglandin F2a and misoprostol.9
However, once these medical treatments fail, it is often
necessary to intervene surgically with uterine or internal iliac ligation, uterine compression sutures or hysterectomy. When dealing with young women who may
wish to have more children, the cesarean-hysterectomy
without delay, resulting in devastating emotional
and/or cultural consequences, should be avoided
wherever possible.12 Actually, in our reports, six
women were nulliparas and all 10 cases who used
SB-tube strongly wished to preserve fertility.

2011 The Authors


Journal of Obstetrics and Gynaecology Research 2011 Japan Society of Obstetrics and Gynecology

105

T. Ishii et al.

While a variety of surgical techniques have been proposed to avoid hysterectomy, a suitable conservative
technique is still lacking in the literature and all the
advantages shown by the proposed options are counterbalanced by some risks.2 Herein, we described that
not only uterine gauze packing but uterine balloon
tamponade with a SB-tube showed similarly high efficacy in controlling PPH originating from the placental
site of the lower uterine segment during caesarian sections. Historically, the use of uterine gauze packing in
the management of PPH fell into disfavor after the
1960s, following concerns of concealing ongoing hemorrhage, development of infection and its nonphysiological approach.13 Condous et al. commented,
based on their experiences, that uterine packing with
gauze packs is outdated and should only be reserved in
cases when a balloon catheter is unavailable.10 Control
of PPH by uterine balloon packing itself is not a new
idea. Although some of the balloons, such as the Rusch
balloon and the condom catheter, are reported to be
effective,14 they do not allow blood drainage from the
uterine cavity. On the contrary, in SB-tube system, the
blood drainage is collected through the distal end of
the shaft by attaching a collection bag. This drainage
system helps prevent blood collection inside the
uterine cavity and provide an accurate estimation of
bleeding. Besides, if the procedure fails to stop the
bleeding, the failure is immediately visible, as opposed
to the use of the conventional balloons as tamponade.
With these reasons, we consider SB-tube system to be
superior to the other treatment options such as rolled
gauze or the conventional balloon.
Reports are accumulating suggesting that methods
of uterine tamponade are effective to avoid hysterectomy in frequently unstable patients and can preserve
fertility, especially in the case of severe PPH secondary
to uterine atony.15 A recent American College of Obstetricians and Gynecologists practice bulletin suggests
that tamponade of the uterus can be an effective way to
decrease hemorrhage secondary to uterine atony, and
procedures such as uterine artery ligation or B-Lynch
suture may be used to obviate the need for hysterectomy. Furthermore, it is suggested that if hysterectomy
is performed for uterine atony, there should be documentation of these therapies attempts.16 On the other
hand, the use of a balloon tamponade in severe PPH
due to placenta previa has been reported only in a
small series of a few cases. Bowen et al. reported the
first attempt to archive hemostasis in case of PPH complicated by placenta previa by compression using a
Foley catheter.17 Bakri et al. used a self-made original

106

tamponade balloon in two cases of placenta previa


together with additional surgical procedures such as
bilateral hypogastric ligation.6 Recently, Condous et al.
reported the use of SB-tube in the management of
PPH.10 In this series of 17 cases, two patients experienced severe PPH complicated by placenta previa but
were successfully treated without any further invasive
procedures. Those reports offer evidence that further
clinical attention should be given to this procedure,
and herein we reported a larger series of 10 cases and
demonstrated that intrauterine balloon tamponade
should be considered as a management option before
performing surgical procedures in PPH resulting from
placental site bleeding.
In this report, uterine tamponade with SB-tube controlled PPH during cesarean section for placenta previa
in all 10 patients, although the success rate of uterine
balloon tamponade as a single measure for the management of major PPH has been reported as 77.588.8%
in a recent systematic review.13 One possible reason for
this discrepancy is that the use of a balloon tamponade
has been reported in the management of severe PPH
mainly resulting from uterine atony. In our experience,
a balloon tamponade is more effective in cases of
placenta previa than those of uterine atony. The intrauterine balloon is considered to act by exerting in
inward-to-outward pressure that is greater than the
systemic arterial pressure to prevent continual bleeding.18 Since the uterine cavity itself is well contracted in
cases of placenta previa, adequate inward-to-outward
pressure produced by the tube is likely to be achieved
easily. In addition, by halting ongoing hemorrhage
from the placental bed promptly during the operation,
consumptive coagulopathy can be reversed in most
cases. Further data from a larger prospective study are
needed to verify our hypothesis.
One possible problem with using the SB-tube for
placenta previa is that it takes some time to insert the
SB-tube because it must be inserted into the uterine
cavity transvaginally during the operation. The
SB-tube has two separated drainage catheters with
attached parts, which might cause further tearing of
the lower uterine segment if inserted through the hysterotomy incision because the uterine cervical canal of
the patients is usually almost closed in cases of placenta previa. Since PPH occurs immediately after the
placenta is delivered, even a few minutes of lost time
might cause additional bleeding. In that sense, the
more simple and flexible tamponade balloon, which is
specially designed for a uterus and can be inserted
through the hysterotomy incision, might decrease

2011 The Authors


Journal of Obstetrics and Gynaecology Research 2011 Japan Society of Obstetrics and Gynecology

Balloon tamponade for placenta previa

PPH during the operation. Indeed, the SOS Bakri


Tamponade Balloon Catheter is designed just for
the uterus and is reported easily administered,
although this type of catheter is not commercially
available in Japan. Such an improved device should
be examined to achieve better outcomes in cases of
severe PPH.
In conclusion, the uterine balloon-tamponade was
effective in controlling PPH originating from the placental site, although our results are from a retrospective study of a small series. This method is very
effective, simple to use, scarcely invasive, and available
at a low cost for all maternity wards. It should be considered as the first step in order to reduce undesirable
hysterectomy.

Acknowledgments
This work was supported in part by a Grant-in-Aid for
scientific research from the Ministry of Education,
Science, Sports and Culture of Japan. The authors are
grateful to Remina Emoto and Ayako Okamura for
their secretarial assistance.

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Journal of Obstetrics and Gynaecology Research 2011 Japan Society of Obstetrics and Gynecology

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