Non-invasive management of acute recurrent puerperal uterine inversion with Bakri postpartum balloon

Abstract

Uterine inversion is a rare and alarming obstetric emergency, the accurate management of which is very challenging to inexperienced obstetricians. Recurrence of uterine inversion is not only even more challenging, but also quite rare [1]. A 22-year-old G1 Turkish woman experienced a second-degree uterine inversion (the uterine fundus was protruding through the cervical ostium) with excessive bleeding and shock. This occurred following the spontaneous vaginal delivery of the baby and removal of the placenta by umbilical cord traction. Vaginal manual reduction of the inverted uterus was unsuccessful both in the delivery room and under general anesthesia in the operating theater. No tocolytic agent was used due to the hemodynamic instability of the patient. A laparotomy ensued and the uterus was successfully reduced as described by Huntington [2]. However despite the infusion of uterotonics, the fundal portion of the uterus softened and a dimple appeared which expanded and deepened. This resulted in a tendency of the uterus to re-invert. Accordingly, an SOS Bakri tamponade balloon catheter (Cook Medical Incorporated, Bloomington, IN, USA) was transvaginally inserted into the uterus and inflated until the dimple in the flaccid uterus disappeared. Six hundred milliliters was required to achieve this and resulted in a significant decrease in uterine bleeding with no recurrence of uterine inversion. Estimated total blood loss was 2,500 ml and four units of packed red blood cells were administered. There are few reports within the literature of uterine inversion recurrence following repositioning. The earliest report described re-inversion occurring on three occasions following manual repositioning. In that case, the uterus remained flaccid and inversion recurred every time manual compression was ceased [3]. Consequently, gauze packing of the uterus was performed and removed 28 h later without any complication. Similarly, other methods such as modified uterine compression sutures have been described to prevent recurrence of uterine inversion [1, 4]. However, in one such case, involving Cho compression sutures, a hysterectomy was required due to uterine necrosis and purulent peritonitis 11 days following the procedure [5]. The Bakri postpartum balloon has been increasingly used worldwide in the conservative management of postpartum uterine bleeding since Food and Drug Administration certification in 2006. Soleymani Majd et al. [6] first described the use of the Bakri balloon in preventing uterine re-inversion in a patient who was discovered to have uterine re-inversion 2 h after the initial replacement. In the present case, we applied a Bakri balloon during the original laparotomy to correct the inverted uterus. This was done as soon as a fundal dimple was observed, which signified the tendency of the uterus to re-invert (Fig. 1). Therefore, although uterine compression sutures may be successful in the management of recurrence of uterine B. Kaya (&) Department of Obstetrics and Gynecology, Faculty of Medicine, Near East University Medical School, Nicosia-TRNC, Mersin 10, Turkey e-mail: drbariskayaizmir@gmail.com