Peripartum hysterectomy audit at Port Shepstone Regional Hospital, South Africa : a five year review.

Master of Medical Science in Obstetrics and Gynaecology. University of KwaZulu-Natal. Durban, 2017.Background Over the years the peripartum hysterectomy has become a life-saving procedure in cases of intractable postpartum haemorrhage or when medical and/or surgical conservative interventions have failed and in severe puerperal sepsis. Aim To audit the clinical management preceding peripartum hysterectomy and evaluate maternal and neonatal outcomes in patients who were done peripartum hysterectomy. Material and Methods The researcher developed a structured audit form based on specific types of pregnancy and delivery complications leading to peripartum hysterectomy. The medical records of 126 patients who had postpartum hemorrhage and 83 patients who had undergone peripartum hysterectomy from 1st January, 2010 to 31st December, 2014 (5 years), at Port Shepstone Hospital in Kwa-Zulu Natal were reviewed retrospectively. Maternal characteristics and details of the present pregnancy and delivery, hysterectomy indications, complications, postoperative complications, and maternal and neonatal outcomes were evaluated. A statistical package (SPSS version 24.0) was used to analyze the data. Results During the 5-year study period, a total of 17657 births occurred. There were 83 peripartum hysterectomy cases and 126 postpartum hemorrhage cases. The incidence for peripartum hysterectomy was 0.47% (4.7/1000 deliveries) and incidence for postpartum hemorrhage was 0.71% (7.1/1000 deliveries). In patients with PPH, post C/S peripartum hysterectomy incidence was 7.2/1000 C/S deliveries and post vaginal peripartum hysterectomy incidence was 0.65/1000 normal vaginal deliveries. There was a statistical significant relationship between peripartum hysterectomy and cesarean section delivery in the current pregnancy and previous cesarean delivery (p=0.0001 and p=0.01 respectively). Sixty two (49.2%) of 126 postpartum hemorrhage cases were unresponsive to conservative medical and surgical measures and required peripartum hysterectomy. Five patients with uterine rupture did not have any conservative management and proceeded to peripartum hysterectomy. Sixteen (19.3%) patients with sepsis were sent directly for peripartum hysterectomy

Emergency peripartum hysterectomy, physical and mental consequences: a 6-year study

Emergency peripartum hysterectomy (EPH) is performed for massive postpartum hemorrhage following a cesarean delivery or vaginal delivery, in order to save the patient’s life. The current study was performed on a sample of 13.162 patients, which underwent cesarean or vaginal delivery during a period of 6 years, from 2010 to 2015, in Bucur Maternity Hospital. There were two subsequential groups consisting in: 6593 patients with cesarean operations and 6569 patients with vaginal delivery. In 12 cases occurred one or more of the risk factors that lead to EPH, divided equally across the two groups above. The main two types of surgery are a more frequent subtotal hysterectomy, which is the preferred type of EPH as it takes less time and is associated with fewer complications, and a total hysterectomy. The majority of procedures were performed at patients over 35 years old (9 of 12), with a median age of 31,16 (ranging from 21 to 44 years old). The most important risk factor present across the lot was multiparity (11 from 12), with cicatricial uterus being the second one (4 of 12). ICU median time was 4,5 days (ranging from 3 to 15 days), with a median blood transfusion necessity of around 2,4 I.U per patient. There were no mother or newborn reported deaths, neither PTSD following EPH.EPH is a procedure performed as last-resort, life-saving surgery, leaving no time for mental preparation of the patients. This may predispose to negative psychological outcomes, especially because they are not part of decision-making process due to the emergency character of hysterectomy

Peripartum hysterectomy: a five year review at a tertiary care centre

Background: Peripartum hysterectomy is a life-saving procedure resorted to when conservative measures fail to control obstetric haemorrhage. Several predisposing factors, suboptimal care and lack of infrastructure may lead to this emergency procedure. We wanted to find out factors associated with peripartum hysterectomy and the adverse maternal outcomes at our centre.Methods: A retrospective case series analysis of 40 cases of peripartum hysterectomy performed over a period of 5 years from January 2010 to December 2014 at Government Medical College Hospital, Thrissur, Kerala was done.Results: The incidence of peripartum hysterectomy was 0.29%. The most common indication for peripartum hysterectomy was hysterectomy was uterine atony (50%). Thirty-five women (88%) were between 20 and 35 years. Most of the subjects were unbooked. There were two maternal deaths (case fatality rate of 5%) following peripartum hysterectomy during this period. All the subjects required blood transfusion.Conclusions: Prompt performance hysterectomy before the patient’s clinical condition deteriorates is the key to success. The incidence of adherent placenta is increasing, so every effort should be taken to reduce the caesarean section rates globally.

Epidemiological analysis of peripartum hysterectomy across nine European countries

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. Material and methods We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (rho = 0.67, P < .05). Conclusions Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy

A study on peripartum hysterectomy in a tertiary referral government hospital

Background: Emergency peripartum hysterectomy (EPH) is a major surgical venture invariably performed in the setting of life-threatening haemorrhage during or immediately after abdominal and vaginal deliveries. Aim of the study was to study the frequency and indications for peripartum hysterectomy and to assess the maternal outcome of peripartum hysterectomy.Methods: Cross sectional study was done in the department of obstetrics and gynaecology, Vanivilas hospital, Bangalore from September 2018 to august 2019. This study consists of 24 cases of emergency peripartum hysterectomy within 24 hours of delivery, operated at Vanivilas hospital.Results: The frequency of peripartum hysterectomy was 1.102/1000 deliveries and following caesarean section and vaginal deliveries are 3.544/1000 deliveries and 0.248/1000 deliveries respectively. Among 24 cases who had peripartum hysterectomy, 16 cases were delivered by caesarean section and 4 cases delivered by vaginal route while another 4 cases delivered by laparotomy for rupture uterus. 22 cases (91.67%) survived with major number of cases having morbidities and there were 2 (8.33%) maternal death.Conclusions: The most common mode of delivery before peripartum hysterectomy was Caesarean section. The most common indication was atonic postpartum haemorrhage. Better protocols for induction and augmentation of labour will decrease the necessity of peripartum hysterectomies

A retrospective study on epidemiology and outcomes of peripartum hysterectomy

Background: Peripartum hysterectomy is a rare condition which is associated with maternal morbidity and mortality, and the last resort to control hemorrhage when all the other methods fail. The main aim of this study was to evaluate the indications, incidence and complications, maternal and perinatal outcome and compare the risk of peripartum hysterectomy in women who underwent LSCS previously with the women who did not have previous LSCS. Methods: A retrospective study was done over one year at a tertiary care teaching hospital in southern Rajasthan. All the women who underwent peripartum hysterectomy were included. Patients were divided into two groups, one who did not have any previous lower segment caesarean section (LSCS) and other who had history of previous LSCS, and their data was compared. The, results were calculated and represented as mean, frequency or median as appropriate. Results: 34 women underwent peripartum hysterectomy yielding the incidence of 2.21/ 1000 deliveries. The main indication of peripartum hysterectomy was abnormally adherent placenta followed by rupture uterus. 73% cases of peripartum hysterectomy were associated was the history of LSCS. Conclusions: The indication of peripartum hysterectomy has changed from atonic PPH to placenta spectrum syndrome. A major change can be brought about by the reduction of index cases of LSCS which has been on the rise in the recent years. Strict protocols should be made. Early transportation facility and institutional deliveries should be promoted to prevent the emergency peripartum hysterectomy

Changing trends in incidence, type, indication and maternal outcome of peripartum hysterectomy over 10 years at a tertiary care centre

Background: Peripartum hysterectomy is the most dramatic operation in modern obstetrics and is generally performed when all conservative measures fail to achieve haemostasis in the setting of life threatening haemorrhage. The objective was to review all peripartum hysterectomies performed at a tertiary care centre over a ten-year period from 2007 to 2016 to determine the incidence, types, indications and maternal outcome and also to study the changing trendsMethods: This was a retrospective, observational, analytical study of parturient women requiring peripartum hysterectomy (PH). We looked at data over a ten-year period, from January 2007 to December 2016. Case records were reviewed for socio-demographic characteristics of the patients, type and indications for the hysterectomy performed, booking status of patients, mode of delivery, gestational age at delivery and maternal outcome. Change in trends of the rate and indications of peripartum hysterectomy at the centre was also reviewed.Results: The overall rate of peripartum hysterectomy was 1/876 deliveries. The rate of peripartum hysterectomy had a 4-fold rise from 2007 to 2016.The primary indication was abnormal placentation which included morbidly adherent placentation 22/59 (37.2%) and placentapraevia 5/59 (8.4%), followed by intractable atonic haemorrhage in 35.6% of cases. Abnormal placentation as an indication for PH increased significantly form 34.6% (2007-2011) to 54.54% (2012-2016). After hysterectomy, 56% cases were admitted to ICU. All patients needed blood transfusion. Maternal mortality was 10.1%.Conclusions: Peripartum hysterectomy is a most demanding obstetric surgery performed in very trying circumstances of life threatening hemorrhage. The indication for emergency peripartum hysterectomy in recent years has changed from traditional uterine atony to abnormal placentation.

Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial.

BACKGROUND: Peripartum hysterectomy can cause significant morbidity and mortality. Most studies of peripartum hysterectomy are from high income countries. This cohort study examined risk factors for peripartum hysterectomy using data from Africa, Asia, Europe and the Americas. METHODS: We used data from the World Maternal Antifibrinolytic (WOMAN) trial carried out in 193 hospitals in 21 countries. Peripartum hysterectomy was defined as hysterectomy within 6 weeks of delivery as a complication of postpartum haemorrhage. Univariable and multivariable random effects logistic regression models were used to analyse risk factors. A hierarchical conceptual framework guided our multivariable analysis. RESULTS: Five percent of women had a hysterectomy (1020/20,017). Haemorrhage from placenta praevia/accreta carried a higher risk of hysterectomy (17%) than surgical trauma/tears (5%) and uterine atony (3%). The adjusted odds ratio (AOR) for hysterectomy in women with placenta praevia/accreta was 3.2 (95% CI: 2.7-3.8), compared to uterine atony. The risk of hysterectomy increased with maternal age. Caesarean section was associated with fourfold higher odds of hysterectomy than vaginal delivery (AOR 4.3, 95% CI: 3.6-5.0). Mothers in Asia had a higher hysterectomy incidence (7%) than mothers in Africa (5%) (AOR: 1.2, 95% CI: 0.9-1.7). CONCLUSIONS: Placenta praevia/accreta is associated with a higher risk of peripartum hysterectomy. Other risk factors for hysterectomy are advanced maternal age, caesarean section and giving birth in Asia

The changing scenario of pattern of peripartum hysterectomy: prevention and preparedness matters

Background: Peripartum hysterectomy is a life-saving procedure, often associated with significant morbidity. The indication for peripartum hysterectomy has been shifted from PPH and rupture uterus to placental abnormalities and haemorrhage. Reducing the number of caesarean sections is the major step towards minimizing the chance of undergoing peripartum hysterectomy in subsequent pregnancy at the same time the morbidity is more if the peripartum hysterectomy is a on table decision.Methods: This was a descriptive study from a tertiary care centre, South India and all the case records of women who underwent peripartum hysterectomy were reviewed from 2012 to 2017. All the details including demographic details, clinical characteristics, indications and clinical outcome of those women were recorded. The data was analyzed using SPSS version 20.Results: The incidence of peripartum hysterectomy was 0.7/1000 deliveries and it was 0.24% and 0.03% after caesarean section and vaginal deliveries respectively. The placental abnormalities (46.2%) were the commonest cause followed by uterine atony (28.8%) and rupture uterus (21.2%). It was total hysterectomy in all of them except 2 women who underwent subtotal hysterectomy (3.8%) and the commonest visceral injury was bladder (15.4%). The maternal mortality rate was 9.8% and 61.5% (n=32) received massive blood transfusions.Conclusions: Even though a life-saving procedure, the timing and the preoperative hemodynamic status of the women were the major determinants of adverse outcome associated with peripartum hysterectomy. Preoperative planning and risk stratification models are essential to minimize the risk of undergoing hysterectomy and to reduce the morbidity associated with the procedure.

Nine years review of emergency peripartum hysterectomy at tertiary care university teaching hospital

Introductions: This study documented the frequency, indications, and outcome of emergency obstetric hysterectomies in a tertiary care hospital in Nepal. Methods: This was a nine years retrospective study of peripartum hysterectomy at Patan Hospital, Patan Academy of Health Sciences, Nepal, during 2006 to 2014. Patients’ charts were retrieved from the medical record section for review. Study variables included previous obstetric history, details of the index pregnancy, indications for peripartum hysterectomy, outcome of the hysterectomy and infant morbidity. Results: There was total of 73,130 deliveries. Emergency peripartum hysterectomies was performed in 28 (0.04%),of which 23 (82%) after cesarean and 5 (18%) after vaginal delivery. The primary indication for hysterectomy was uterine atony with postpartum hemorrhage, and placental causes with PPH and uterine rupture. Twelve (43%) patients had postoperative complications. There was one maternal and two neonatal mortalities, and one stillbirth. Conclusion: The rate of emergency peripartum hysterectomy in our institute is low at 0.04%, primarily due to uterine atony with postpartum hemorrhage. Keywords: maternal morbidity mortality, peripartum hysterectomy, postpartumhemorrhage, uterineatonyÂ