doi:10.1111/jog.13596 J. Obstet. Gynaecol. Res.

2018

Intraluminal pressure of uterine balloon tamponade in

the management of severe post-partum hemorrhage

Choi Wah Kong and William W. K. To

Department of Obstetrics and Gynaecology, United Christian Hospital, Hong Kong

Abstract
Aim: Intrauterine balloon tamponade has been increasingly used for the management of post-partum hem-
orrhage (PPH) in recent years. However, data on the precise mechanisms and pressure required for the bal-
loon tamponade are scanty in the literature. This study aims to review the intraluminal pressure (ILP)
generated by the Bakri intrauterine balloon that is necessary to produce a ‘positive tamponade test’ during
severe PPH.
Methods: This was a prospective cohort study. The ILP of the Bakri balloon was measured using a manome-
ter after a positive tamponade test was clinically achieved during severe PPH (blood loss >1 L). The patient’s
blood pressure was recorded, and ultrasound scan was performed to verify the position of the balloon and
the presence of forward flow in the uterine arteries. The main outcome measure is the ILP of the Bakri bal-
loon required to achieve a positive tamponade test.
Results: Twenty patients were included for final analysis. The net ILP measured ranged from 67 to
92 mmHg, and this pressure was lower than the concurrent systolic pressure in all cases. Color Doppler con-
firmed positive forward flow in the uterine vessels in all cases. There were no differences in the pressure
measured with the balloon position, and there was no relationship between the volumes of saline infused
and the net pressure.
Conclusion: A positive tamponade test in an intrauterine balloon is probably achieved by local compression
pressure exerted on the vasculature of the placental bed rather than by generating an ILP exceeding systemic
blood pressure or by occlusion of flow to the uterine arteries.
Key words: balloon tamponade, post-partum hemorrhage, uterine/cervical physiology.

Introduction hysterectomy, including external compression sutures,

Post-partum hemorrhage (PPH) continues to be one
of the leading causes of maternal mortality.1 Severe
PPH has been variously defined as blood loss
between 1000 and 2000 mL or above.2 A peripartum
hysterectomy should be performed in patients with
severe PPH as a life-saving rescue procedure in those
who failed to respond to uterotonics. However, due
to the high morbidity associated with peripartum hys-
terectomies, various conservative surgical procedures
have been developed to reduce the need for a
selective devascularization by surgical ligation or
radiological embolization of the uterine and pelvic
arteries.3 Traditionally, uterine packing has been
employed as a method to control PPH by direct pres-
sure effects.4 The use of the uterine-specific Bakri
intrauterine balloon tamponade (IUBT) for the treat-
ment of obstetric hemorrhage with low-lying placen-
tae during cesarean delivery was first published in
1992.5 Other non-uterine-specific balloons, such as the
Sengstaken–Blakemore tube, Foley or Rusch catheters,
have also been commonly used for the management

Received: October 7 2017.

Accepted: December 31 2017.
Correspondence: Dr Choi Wah Kong, Department of Obstetrics and Gynaecology, United Christian Hospital, 130 Hip Wo Street,
Kwun Tong, Hong Kong. Email: melizakong@gmail.com

© 2018 Japan Society of Obstetrics and Gynecology 1

C. W. Kong and W. W. K. To
of PPH,6 and in general, a success rate of over 80%
has been reported.7 Due to its simplicity and rela-
tively noninvasive nature, IUBT has been incorpo-
rated into standard protocols for the management of
severe PPH as a second-line conservative surgical pro-
cedure.3,8 Recent data have shown that the increasing
use of a balloon tamponade was associated with a
reduction in the need for more invasive procedures,
such as radiological uterine artery embolization or
compression sutures,9,10 as well as the incidence of
peripartum hysterectomy.11,12
Despite the increasing utilization of IUBT, protocols
for the appropriate use of intrauterine balloon devices
remain empirical,13 and data on the precise mecha-
nisms and pressure required were scanty in the litera-
ture. The present study aimed to review the
intraluminal pressure (ILP) generated by the Bakri
intrauterine balloon that is necessary to produce a
‘positive tamponade test’14 during the management of
severe PPH. We believe that such data should facili-
tate our understanding of the mechanisms of action
of IUBT.
Methods
All cases of PPH would be managed according to a
standard protocol in our Department. When first-line
medical management using uterotonic agents, includ-
ing syntocinon, Synometrine and Carboprost, failed
to control bleeding, second-line surgical procedures
such as IUBT, compression sutures or uterine artery
embolization would be applied according to the pref-
erence of the obstetrician in charge. The Bakri intra-
uterine balloon catheter (Cook Medical, Bloomington
[IN], US) was the only available balloon tamponade
device for this purpose in our department. We have
established a protocol for using this intrauterine bal-
loon device for the management of severe PPH in the
Department since 2011. Severe PPH was defined as
an estimated blood loss exceeding 1000 mL. The pro-
cedure for the application of the Bakri balloon was in
accordance with that generally described in the
literature.4–6 The Bakri balloon can be placed trans-
vaginally through the cervix or transabdominally
through the caesarean uterine wound. When the bal-
loon was placed through the uterine wound, it would
be half inflated after placement and then further
inflated after closure of the uterine wound so that
inadvertent puncturing of the balloon during suturing
of the wound would be promptly noted. Vaginal
2 © 2018 Japan Society of Obstetrics and Gynecology
packing was not routinely performed unless there
was evidence of slippage or prolapse of the balloon
through the cervix. If bleeding was arrested after bal-
loon inflation, the balloon tamponade was continued
for around 24 h, after which the deflation was per-
formed in a single stage before removal.7
With increasing utilization of this device in the
department, a protocol for measuring ILP after the
achievement of a positive tamponade test was also
instituted since 2015. The purpose of this protocol
was to ensure that the ILP would not grossly exceed
the systemic blood pressure of the patient as there
were concerns in the literature that excessive pressure
generated by the balloon could lead to complications
such as subsequent uterine rupture15,16 or ischemic
necrosis, particularly when IUBT was coupled with
the concurrent application of compression sutures.17
In addition, we believe that the collection of such
data would be useful to evaluate any correlation
between the infusion volumes used and the actual
ILPs generated. After a positive tamponade test was
clinically achieved, pressure readings were made in
each case using a Benetech pressure manometer
GM520 (Shenzhen Jumaoyan Science and Technology
Co Ltd., China). The ILP was measured by compar-
ing the difference in pressures between the total bal-
loon pressure (as measured via a three-way tap
connection to the infusion port of the Bakri catheter)
and the baseline intrauterine pressure (as measured
via the outflow port of the Bakri catheter). Three
readings were made sequentially to ensure consistent
readings (Fig. 1). The patient’s blood pressure and
Figure 1 The photo showing how the pressure manom-
eter is connected to the Bakri balloon.

other vital parameters were also recorded simulta-
neously. Ultrasound scan was also performed to ver-
ify the position of the balloon and the presence of
forward flow in the uterine arteries using color
Doppler (Fig. 2). Patients who had additional com-
pression sutures or had uterine artery embolization
after the Bakri balloon tamponade were excluded as
compression sutures or uterine artery embolization
could affect the ILP of the Bakri balloon. Verbal con-
sent was obtained for all conscious patients when
performing the measurements.
The study was conducted over a period of
24 months, from October 2015 to September 2017. All
the patients with an IUBT inserted and who had a
positive tamponade test without the need of other
second-line procedures, such as compression sutures
or uterine artery embolization, were recruited. The
details of each patient were recorded, including the
mode of delivery, etiology of the PPH, intrapartum
Figure 2 Ultrasound pictures showing positive flow in
the uterine artery (a) with the Bakri balloon in situ
(b, c).
© 2018 Japan Society of Obstetrics and Gynecology
Intraluminal pressure of uterine balloon
complications, estimated total blood loss, route of
placement of the balloon, amount of saline infused
and the presence of clinical shock or coagulopathy.
The study was approved by the Research Ethics Com-
mittee of the Kowloon Central/Kowloon East Cluster
of the Hospital Authority, Hong Kong.
Results
There were a total of 8362 deliveries during the 24-
month study period. The frequency of primary PPH
with an estimated blood loss equal to or exceeding
500 mL was 8.12% (n = 679). The frequency of severe
PPH with an estimated blood loss exceeding 1000 mL
was 1.15% (n = 96). Among these patients, medical
treatment was successful in 62, while direct hysterec-
tomy was performed in 4 for placenta accreta. Com-
pression sutures were performed in four patients after
failed medical treatment, and IUBT was attempted as a
primary procedure in 26 (27.1%) of them. In addition,
among the 26 patients with IUBT, 1 patient required
additional compression sutures, and 2 patients required
uterine artery embolization after Bakri balloon inser-
tion. Three patients did not have ILP measurements as
a positive tamponade test was not achieved, and they
were hemodynamically unstable after Bakri balloon
insertion, so a hysterectomy was immediately per-
formed. Therefore, 20 patients were included for final
analysis. The success rate of the IUBT as the first
second-line procedure to control severe PPH and to
avoid peripartum hysterectomy was 20/26 (76.9%).
Of the 20 cases analyzed, 9 had spontaneous vagi-
nal deliveries, and 11 had caesarean sections. Uterine
atony occurred in 13 cases, while bleeding from the
placenta site occurred in the rest. The total blood loss
ranged from 1000 to 2900 mL. The Bakri balloon was
inserted vaginally in all patients with vaginal deliver-
ies and in six who had caesarean sections when exces-
sive bleeding occurred after closure of the uterine and
abdominal wound. Transabdominal placement was
performed in the other five cases that delivered by
caesarean section, with the balloon inserted before
closure of the uterine wound. Peripartum hysterec-
tomy was required in one patient (case 11, Table 1) in
whom caesarean section was performed for placenta
praevia Type III at 37 weeks. Brisk bleeding from the
placental bed of around 1.2 L was encountered at
removal of the placenta. A Bakri balloon was inserted
via the uterine wound, and a positive tamponade test
was achieved with infusion of 350 mL saline after
3
4
Table 1 The clinical details of the 20 patients included for final analysis
C. W. Kong and W. W. K. To

Case Etiology Mode of delivery/ Total blood Presence Presence of Amount of Mean pressure Concurrent Uterine blood Position
number route of balloon loss (mL) of shock coagulopathy saline infused at positive systemic blood flow on color of balloon in
insertion in balloon tamponade pressure Doppler cavity
(mL) test (mmHg) (mmHg)
1 Uterine atony NSD; vaginal 1200 No No 400 69 106/57 Positive Fundal
2 Placenta praevia CS; Abdominal 1100 No No 300 73 89/52 Positive Lower
3 Uterine atony NSD; Vaginal 2050 Yes No 300 90 95/60 Positive Fundal
4 Uterine atony NSD; Vaginal 1560 Yes No 200 73 103/69 Positive Lower
5 Uterine atony NSD; Vaginal 1450 No No 300 89 101/70 Positive Fundal
6 Placenta praevia CS; Abdominal 1000 No No 400 82 113/65 Positive Fundal
7 Uterine atony CS; Vaginal 1200 No No 300 78 124/73 Positive Lower
8 Placenta praevia CS; Abdominal 2100 No No 400 81 92/55 Positive Fundal
9 Placenta praevia NSD; Vaginal 1050 No No 300 77 131/68 Positive Lower
10 Uterine atony CS; Vaginal 1000 No No 250 85 100/67 Positive Fundal
11 Placenta praevia CS; Abdominal 2400 Yes Yes 400 92 110/72 Positive Fundal
12 Uterine atony NSD; Vaginal 1200 No No 380 85 97/69 Positive Fundal
13 Uterine atony NSD; Vaginal 2000 Yes No 200 83 115/71 Positive Fundal
14 Uterine atony NSD; Vaginal 1500 Yes No 300 87 143/79 Positive Lower
15 Placenta praevia CS; Vaginal 1500 No No 450 86 120/61 Positive Fundal
16 Uterine atony CS; Vaginal 1700 No No 300 82 128/75 Positive Fundal
17 Uterine atony CS; Abdominal 2900 Yes Yes 300 81 104/58 Positive Fundal
18 Uterine atony CS; Vaginal 1500 No No 400 88 108/61 Positive Lower
19 Placenta praevia NSD; Vaginal 1400 Yes Yes 180 67 120/65 Positive Lower
20 Uterine atony CS; Vaginal 1000 No No 240 85 117/55 Positive Lower
Shock is defined as systolic blood pressure < 70 and pulse rate ≥ 120. Coagulopathy is defined as either activated partial thromboplastin time ≥ 40 s or fibrinogen level < 2.0 g/L. CS,
caesarean section; NSD, normal vaginal delivery.

© 2018 Japan Society of Obstetrics and Gynecology


closure of the wound. There was minimal drainage
from the Bakri balloon, and the patient remained
hemodynamically stable. Recurrence of PPH with
brisk bleeding of around 1 L was encountered when
the balloon was deflated and withdrawn in one step
24 h later. Relaparotomy and peripartum total hyster-
ectomy was performed. The final histopathological
report of the uterus confirmed placenta accreta.
The net ILP measured in this series of patients ran-
ged from 67 to 92 mmHg, and this pressure was
lower than the concurrent systolic pressure in all
cases. Color Doppler confirmed positive forward flow
in the uterine vessels in all cases (Fig. 2). There were
no significant differences in the pressures measured
irrespective of whether the balloon was considered to
be in the fundal region or in the lower segment of the
uterine cavity, nor was there a direct relationship
between the volume of saline infused and the net
pressure (Fig. 3).
Discussion
Our case series showed that the ILP generated by
the Bakri balloon to establish a positive tamponade
Figure 3 Scatter plot of the volume of saline infused into the Bakri balloon versus the intraluminal pressure generated.
© 2018 Japan Society of Obstetrics and Gynecology
Intraluminal pressure of uterine balloon
test during the management of severe PPH varied
within a narrow range of around 60–90 mmHg and
had no direct relationship to the mode of delivery,
the volume of saline infused into the balloon and the
position of the balloon in the uterine cavity and
probably has no direct impact on the clinical
success rate.
Application of intrauterine pressure to produce an
internal compression effect to control PPH has proba-
bly evolved from uterine packing. While the earliest
reports of uterine packing could be dated back to the
19th century,18 recent studies comparing uterine pack-
ing techniques with IUBT have found that they were
equally effective without any increase in infective
morbidity.19,20 In practice, effective uterine packing
required appropriate training, and the packing proce-
dure would likely take longer than the inflation of an
IUBT. While the Bakri catheter was initially designed
to be used for low-lying placenta,4 it has been widely
used for PPH arising from uterine atony as well. 21,22
Despite arguments against the ‘paradoxical’ use of
IUBT in uterine atony to expand rather than contract
the uterus, recent studies have found that the method
was equally effective for managing PPH from uterine
atony or placental site bleeding.23
5
C. W. Kong and W. W. K. To
In vitro studies have shown that, in the absence of
any external restrictions, the ILP of the Bakri balloon
would reach a peak of 60–80 mmHg at 50 mL insuf-
flation, and the pressure does not vary by more than
10–25 mmHg despite the balloon being incrementally
filled to the maximal volume of 500 mL.14,18 Our
in vivo pressure readings were in line with these find-
ings. The net ILPs that we have measured were pre-
cisely within this range, and the amount of saline
infused did not appear to be correlated to the final
pressure. While it was reported that the relationship
between the ILP and the volume of infusion was
curvilinear,18 such a curve probably existed only for
the initial 50–100 mL of infusion, after which the gen-
erated pressure would plateau off as long as there
was residual contractility within the uterus to coun-
teract the increase in cavity volume. In our experi-
ence, the final infusion volume appeared to be related
more to the contractility and capacity of the uterus.
However, using the Glenveigh OTS-Ebb tamponade
system in normal post-partum patients without PPH
has been found that an exponential curvilinear rela-
tionship between ILP and infusion volume existed,
greater than 1000 mL.24 The difference in the design
and the materials of the balloon catheters prevented
the direct comparison of these findings.
Proposed mechanisms by which the intrauterine
balloon can generate its tamponade effect include cre-
ating an intrauterine pressure that exceeded the sys-
temic arterial pressure25 or by direct occlusion of the
uterine arteries to arrest bleeding.26 With the Glen-
veigh OTS-Ebb system, it had been shown that there
was progressive increase in the systolic/diastolic
velocity ratio on ultrasound Doppler, and when infu-
sion volume reached 1000 mL or more (beyond the
recommended maximal inflation volume of 500 mL),
reversal of diastolic flow would be seen.23 Our find-
ings were in contrast to these as the net ILP obtained
never exceeded the concurrent systolic blood pres-
sure, and color Doppler had consistently demon-
strated continuous forward flow in the uterine
arteries. A more compatible hypothesis could be that,
by filling up the uterine cavity, the balloon tampo-
nade controls bleeding with direct pressure over the
sinuses of the uterus.27,28 Thus, as long as the pressure
generated is greater than the pressure within the
bleeding vessels, further hemorrhage would cease,
and if the pressure is applied for long enough, the sta-
sis should allow clot formation, and the involved ves-
sels should constrict and close down.18 Such
mechanisms were probably similar to the use of a
6 © 2018 Japan Society of Obstetrics and Gynecology
vacuum-induced uterine tamponade to control PPH.29
Apparently, the range of ILPs of 60–90 mmHg that
we recorded was already sufficient to exert such a
pressure effect on the sinuses of the placental bed to
achieve hemostasis.
The manufacturer of the Bakri balloon has included
disseminated intravascular coagulopathy as one of the
contraindications for Bakri balloon management. Coa-
gulopathy would often begin as massive bleeding
occurred and could be regarded as an inevitable sequel
of uncontrolled PPH. In this study, 3 of 20 patients
successfully managed by IUBT had coagulopathy.
While it would be difficult to distinguish whether coa-
gulopathy was the cause or the result of the uncon-
trolled PPH, once such a vicious cycle effects has
begun, the attending obstetrician should be alerted to
the high chance of failed management with IUBT.
The value of this study is that we specifically pro-
spectively measured ILP in patients with severe PPH
in whom a positive balloon tamponade was
achieved. Very scanty data of ILP measurements
were available in the literature, and the only pro-
spective case series on the Bakri balloon reported
only two cases18 that was subsequently expanded to
seven cases in a book chapter by the same author.13
Another study described ILP studies in eight women
using the OT-ebb balloon in normal post-partum
women without PPH.24 We believe that the data
from our current series would be most valuable in
documenting intrauterine balloon pressure relation-
ships in women with severe PPH. The major limita-
tion of this study is the small number of cases
analyzed. As our cohort included patients with PPH
due to uterine atony as well as placental site bleed-
ing, as well as both vaginal and caesarean delivery,
we believe the pressure measurements in these cases
should be typical and generalizable. However, we
were unable to measure pressure in any patient in
whom a positive tamponade test could not be suc-
cessfully achieved as these situations were dire emer-
gencies in which other modalities of management
were immediately indicated. While there were pre-
liminary data attempting to quantity uterine stiffness
using acoustic radiation force impulse elastography
as a surrogate measurement of the contractions of
the uterus before and after IUBT,30 in practice, there
is as yet no simple direct method to gauge the com-
pliance and contractility of the uterine wall in
response to expansion of the cavity by the balloon.
We agree that the uterus should not be regarded as
passively atonic,13 and the contractility of the uterus

and its response to stretching should probably be
the key physiological factor that determines whether
the PPH could be controlled by IUBT.
Our findings suggested that a positive tamponade
test is probably achieved by local compression pres-
sure exerted on the vasculature of placental bed rather
than by generating an ILP exceeding systemic blood
pressure or by occlusion of flow to the uterine arteries.
We believe that the achievement of a positive tampo-
nade test would require a certain degree of contractil-
ity of the uterine myometrium to maintain the
pressure required for hemostasis. The ILP generated
by the Bakri balloon fell within a specific range and
probably reflected the inherit design of the balloon.
Disclosure
None declared.
References
1. World Health Organization. WHO Recommendations for the
Prevention and Treatment of Postpartum Haemorrhage. Geneva,
Switzerland: World Health Organization, 2012.
2. Mavrides E, Allard S, Chandraharan E et al. Prevention and
management of postpartum haemorrhage. BJOG 2016; 124:
e106–e149.
3. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Sys-
tematic review of conservative management of postpartum
hemorrhage: What to do when medical treatment fails.
Obstet Gynecol Surv 2007; 62: 540–547.
4. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for
obstetrical bleeding. Int J Gynecol Obstet 2001; 74: 139–142.
5. Rezk M, Saleh S, Shaheen A, Fakhry T. Uterine packing ver-
sus Foley’s catheter for the treatment of postpartum hemor-
rhage secondary to bleeding tendency in low-resource
setting: A four-year observational study. J Matern Fetal Neo-
natal Med 2017; 30: 2747–2751.
6. Georgiou C. Balloon tamponade in the management of post-
partum haemorrhage: A review. BJOG 2009; 116: 748–757.
7. Kong MCW, To WWK. Balloon tamponade for postpartum
haemorrhage: case series and literature review. Hong Kong
Med J 2013; 19: 484–490.
8. Varatharajan L, Chandraharan E, Sutton J, Lowe V,
Arulkumaran S. Outcome of the management of severe post-
partum haemorrhage using the algorithm ‘HEMOSTASIS’.
Int J Obstet Gynecol 2011; 113: 152–154.
9. Gauchotte E, Torre M, Perdriolle-Galet E, Lamy C,
Gauchotte G, Morel O. Impact of uterine balloon tamponade
on the use of invasive procedures in severe postpartum
hemorrhage. Acta Obstet Gynecol Scand 2017; 96: 877–882.
10. Laas E, Bui C, Popowski T, Mbaku OM, Rozenberg P.
Trends in the rate of invasive procedures after the addition
of the intrauterine tamponade test to a protocol for manage-
ment of severe postpartum haemorrhage. Am J Obstet Gyne-
col 2012; 207: 281.e1–281.e7.
© 2018 Japan Society of Obstetrics and Gynecology
Intraluminal pressure of uterine balloon
11. Chan LL, Lo TK, Lau WL et al. Use of second line therapies
for management of severe primary postpartum haemor-
rhage. Int J Obstet Gynecol 2013; 122: 238–243.
12. Kong CW, To WWK. Trends in conservative procedures and
peripartum hysterectomy rates in severe postpartum hae-
morrhage. J Matern Fetal Neonatal Med 2017; 27: 1–7. https://
doi.org/10.1080/14767058.2017.1357169.
13. Einerson BD, Son M, Schneider P, Fields I, Miller ES. The
association between intrauterine balloon tamponade dura-
tion and postpartum hemorrhage outcomes. Am J Obstet
Gynecol 2017; 216: 300.e1–300.e5.
14. Georgiou C. Intraluminal pressure readings whilst achieving
a positive ‘tamponade test’ in the management of postpartum
hemorrhage. In: Arulkumaran S, Karoshi M, Keith LG,
Lalonde AB, B-Lynch C (eds). A Comprehensive Textbook of
Postpartum Haemorrhage, 2nd edn. London: The Global Library
of Women’s Medicine. Spaiens Publishing, 2012; 369–376.
15. Leparco S, Viot A, Benachi A, Deffieux X. Migration of Bakri
balloon through an unsuspected uterine perforation during
the treatment of secondary postpartum hemorrhage.
Am J Obstet Gynecol 2013; 208: e6–e7.
16. Soon R, Aeby T, Kaneshiro B. Cesarean scar dehiscence asso-
ciated with intrauterine balloon tamponade placement after
a second trimester dilation and evacuation. Hawaii Med J
2011; 70: 137–138.
17. Lodhi W, Golra M, Karangaokar V, Yoong W. Uterine
necrosis following application of combined uterine compres-
sion suture with intrauterine balloon tamponade. J Obstet
Gynaecol 2012; 32: 30–31.
18. Georgiou C. Intraluminal pressure readings during the
establishment of a positive ‘tamponade test’ in the manage-
ment of postpartum haemorrhage. BJOG 2010; 117: 295–303.
19. Rezk M, Saleh S, Shaheen A. Fakhry. Uterine packing versus
Foley catheter for the treatment of postpartum hemorrhage
secondary to bleeding tendency in low resource setting: A
four year observational study. J Matern Fetal Neonatal Med
2016; 14: 1–5.
20. Guo YN, Ma J, Wang XJ, Wang BS. Does uterine gauze
packing increase the risk of puerperal morbidity in the man-
agement of postpartum haemorrhage during caesarean sec-
tion: A retrospective cohort study. Int J Clin Exp Med 2015;
15: 13740–13747.
21. Lo A, St marie P, Yadav P, Belisle E, Markenson G. The
impact of Bakri balloon tamponade on the rate of postpar-
tum hysterectomy for uterine atony. J Matern Fetal Neonatal
Med 2016; 29: 1–4.
22. Vintejoux E, Ulrich D, Mousty E et al. Success factors for
Bakri balloon usage secondary to uterine atony: A retrospec-
tive multicentre study. Aust NZ J Obstet Gynaecol 2015; 55:
572–577.
23. Son M, Einerson B, Schneider P, Fields IC, Grobman WA,
Miller EI. There an association between indication for intra-
uterine balloon tamponade and balloon failure?
Am J Perinatol 2017; 34: 164–168.
24. Belfort MA, Dildy GA, Garrido J, White GL. Intraluminal
pressure in a uterine tamponade balloon is curvilinearly
related to the volume of fluid infused. Am J Perinatal 2011;
28: 659–666.
25. Arulkumarah S, Condus G. The tamponade test in the man-
agement of severe postpartum haemorrhage. Obstet Gynecol
2003; 102: 641–642.
7
C. W. Kong and W. W. K. To
26. Cho Y, Rizvi C, Uppal T, Condous G. Ultrasonographic
visualization of balloon placement for uterine tamponade in
severe primary postpartum haemorrhage. Ultrasound Obstet
Gynecol 2008; 32: 711–713.
27. Dabelea V, Schultze PM, McDuffie RS Jr. Intrauterine bal-
loon tamponade in the management of postpartum haemor-
rhage. Am J Perinatol 2007; 24: 359–364.
28. Akhter S, Begum MR, Kabir I. Condom hydrostatic tampo-
nade for severe postpartum haemorrhage. Int J Gynecol
Obstet 2005; 90: 134–135.
8 © 2018 Japan Society of Obstetrics and Gynecology
29. Purwosunu Y, Sarkoen W, Arulkumaran S, Segnitz J.
Control of postpartum hemorrhage using vacuum-
induced uterine tamponade. Obstet Gynecol 2016; 128:
33–36.
30. Yurifuji T, Tanaka T, Makino S, Sugimur M, Takeda S.
Balloon tamponade in atonic bleeding induces uterine
contraction: Attempt to quantify uterine stiffness using
acustic radiation forece impulse elastography before and
after balloon tamponade. Acta Obstet Gynecol 2011; 90:
1171–1172.