Novel use of the Bakri® postpartum balloon in gestational trophoblasticneoplasia with bleeding vaginal metastatic lesions refractory to conventionaltreatment modalities

Abstract

Introduction: Although gestational trophoblastic neoplasia (GTN) tumours are exquisitely chemosensitive with survival rates from 90% to 100%, bleeding vaginal metastatic lesions pose a clinical conundrum. Whilst these patients should be treated in specialised centres, they may present to non-specialised centres requiring emergency lifesaving treatment. We review the current management of haemorrhage from vaginal metastatic lesions and describe a novel, lifesaving technique that is readily available and easy to use in emergencies in most settings.

Methods: We discuss a 21-year-old patient referred with GTN stage III and score 14 with extensive vaginal metastasis. Sequentially she received antibiotics and tranexamic acid, percutaneous embolisation of the anterior branches of the internal iliac arteries and feeder vessels, and required haemostatic radiotherapy. Two attempts at removing her vaginal pack resulted in catastrophic bleeds and haemodynamic instability.

Results: On the third attempt, we inserted a Bakri® postpartum balloon into the vaginal canal, inflated it with 230 ml of sterile water, and strapped the balloon’s catheter tubing to the patient’s thigh to secure the balloon. Over the next 24 hours, after draining 150 ml, the haemorrhage seized. The controlled and slow reduction of the balloon in theatre resulted in the atraumatic removal of the balloon and no further significant haemorrhage. We suggest that using the Bakri® balloon as described is an effective and easy measure to tamponade vaginal GTN lesions. We propose that the manner in which the balloon applies the tamponade effect, by pressing against the tissue and not integrating with the tissue as a porous gauze would, ensures less tissue trauma upon removal. In addition to allowing accurate monitoring of any continuous haemorrhage, the balloon can be deflated incrementally and reinflated quickly should a haemorrhage ensue, whereas a gauze pack is removed in its entirety and replaced if bleeding is noted.

Conclusion: The use of the Bakri® postpartum balloon in bleeding vaginal GTN lesions should be considered as an emergency tamponade method in both specialised and non-specialised centres as a primary tamponading method.