Bakri Associated Uterine Rupture - When Treatment Becomes the Disease
Abstract Number: S2C-2
Abstract Type: Case Report/Case Series
Introduction: Uterine balloon tamponade (UBT) is increasingly used to treat refractory postpartum hemorrhage. Studies have shown benefit from UBT, but few have assessed complications. We describe a case of uterine rupture associated with Bakri balloon placement in a patient with a prior hysterotomy and pre-operative concern for abnormal placentation.
Case: A 39-year-old woman, gravida 4 para 1, with one previous cesarean delivery (CD) for macrosomia, presented for scheduled CD of singleton intrauterine pregnancy at 34 5/7 weeks for complete placenta previa and concern for placenta accreta. A combined spinal epidural technique resulted in unintentional dural puncture. The spinal dose was given and catheter placed in the intrathecal space. During CD, the placenta was delivered with obstetricians reporting it was not pathologically adherent. Intraoperative uterine atony was treated and resolved with Oxytocin 36 units/hour IV and Methylergonovine 200mcg IM. Hemostasis was achieved and the hysterotomy closed without complication.
Immediately postoperative, increasing blood loss required aggressive resuscitation. A Bakri balloon was placed under ultrasound guidance to manage uterine atony. Vital signs remained stable; however, the patient complained of severe pain during fundal examination requiring multiple local anesthetic redoses through her intrathecal catheter. Two hours later, the Bakri spontaneously delivered through the cervix. A fundal exam expressed 1500 mL of clot and bright red blood. The patient returned emergently to the operating room for exploratory laparotomy under general anesthesia. A uterine rupture was found distal and lateral to the hysterotomy site where suture line was intact (Image). Hysterectomy was performed.
Discussion: Bakri balloon placement can cause iatrogenic uterine rupture in a patient with prior hysterotomy. Interestingly, the rupture site was distinct from the hysterotomy site in this patient. This rare complication should be considered in a patient who complains of severe pain despite analgesia, has refractory hemorrhage, or who shows signs of intravascular depletion or hemodynamic instability following Bakri balloon placement.
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