Bakri balloon effectiveness for postpartum hemorrhage: a "real world experience".

INTRODUCTION: The Bakri balloon has been advocated for management of obstetric hemorrhage, based on several small studies (2-16 patients) where it was over 90% effective. OBJECTIVE: To estimate the effectiveness of the Bakri balloon for treating postpartum hemorrhage (PPH) in clinical practice at academic institutions. METHODS: This is a retrospective cohort study evaluating efficacy of Bakri balloon use in 35 women with PPH, performed as a chart review. Charts were reviewed to determine if balloon placement was deemed a "success" or "failure", as well as to abstract relevant demographic and clinical factors. Failure was defined as need for another form of hemorrhage control. RESULTS: Success rate was 67.57%. Bakri failure was associated with Cesarean section (67% versus 16%, p = 0.031) and predelivery Pitocin (67% versus 28%, p = 0.003) and had more ICU admissions (58% versus 4%, p = 0.0003), transfusions (5.4 red blood cell units versus 1.6, p = 0.007) and hospital days (5.65 versus 3.75, p = 0.011). Reasons for failure were continued bleeding or balloon extrusion. CONCLUSION: Our results suggest that the Bakri balloon is useful for treating PPH but not as effective as previously published. When balloon use is effective, however, the maternal morbidity is significantly decreased.

Pelvic exenteration in the age of modern chemoradiation.

BACKGROUND: To examine outcomes after pelvic exenteration in women treated with modern chemoradiation and surgical techniques. METHODS: All patients at our institution with a diagnosis of gynecologic malignancy who underwent pelvic exenteration after treatment with chemoradiation between 1/90 and 6/08 were evaluated with a retrospective chart review. RESULTS: 44 women were identified, of whom 29 (66%) had cervical, 6 (14%) had uterine, 5 (11%) had vaginal, and 4 (9%) had vulvar cancer. The majority of patients (82%) were initially treated with external beam whole-pelvic radiation with concurrent cisplatin. 38 patients (86%) underwent exenteration for a central pelvic recurrence, and the remaining 6 patients (14%) for radiation necrosis. The most common surgical complication was transfusion requirement in 36 patients (82%), followed by wound infection in 15 (34%), small bowel obstruction in 8 (18%), and sepsis in 6 (14%). The median time spent in the ICU post-operatively was 2 days. One patient (2%) died during her post-operative hospital stay. The mean EBL overall was 2497 cc and the mean operative time was 544 min. Use of electrothermal bipolar coagulation, which was used in 64% of the exenterations, significantly reduced blood loss (3679 cc vs. 1836 cc, p=0.014). After exenteration, 21 patients (48%) were diagnosed with a recurrence of cancer, and the mean progression free survival was 31 months. Patients who received exenteration less than 2 years after their initial chemoradiation had a significantly shorter overall survival time (8 months vs. 33 months, p=0.016). CONCLUSIONS: Approximately 50% of women develop recurrence following exenterations done after chemoradiation. Survival is significantly longer in patients who necessitate exenteration greater than 2 years out from initial treatment. Electrothermal bipolar coagulation appears to significantly reduce blood loss during these surgeries.