Emergency peripartum hysterectomy: A prospective study in The Netherlands

Changing trends in emergency peripartum hysterectomy in a tertiary obstetric center in Turkey during 2000-2013

OBJECTIVE

To evaluate emergency peripartum hysterectomy (EPH) cases over a 14-year period in a tertiary center in İstanbul, Turkey.

MATERIAL AND METHODS

In this retrospective descriptive study, the records of all cases of EPH performed at the Zeynep Kamil Women and Children's Training and Research Hospital between January 2000 and January 2014 were analyzed. Results for 2000-2006 and 2007-2013 were compared to identify changing trends. Demographic and clinical factors associated with EPH were assessed.

RESULTS

During the 14-year study period, a total of 161,836 births occurred, out of which 104,783 (64.8%) were vaginal deliveries and 57,053 (35.2%) were cesarean section (CS). EPH was performed in 81 patients with an overall incidence of 0.5 in 1000 deliveries. The EPH rate in 2007-2013 (0.07%) was significantly higher than in 2000-2006 (0.03%). The major difference in the EPH populations between the two periods was the higher number of previous CS in 2007-2013 compared with 2000-2006 (p=0.01). Indications for EPH did not differ between the two periods. There were 7 (8.6%) maternal deaths in 2000-2013, with significantly fewer maternal deaths in 2007-2013 than in 2000-2006 (19.2% vs. 3.6%).

CONCLUSION

Rate of EPH increased considerably from 2000 to 2013. This increase was mostly related to the increasing rate of CS. Indications for EPH did not change over the study period, and the number of maternal deaths markedly decreased.

Emergency hysterectomy for life-threatening postpartum haemorrhage: Risk factors and psychological impact

BACKGROUND

Emergency postpartum hysterectomy (EPH) is usually considered the final resort for the management of postpartum hemorrhage (PPH). The aim of this observational study was to identify the risk factors for EPH, to evaluate the ability of EPH to stop bleeding and, finally, to estimate its psychological impact.

METHODS

This was a retrospective analysis of postpartum hysterectomy in all patients with PPH admitted between 2004 and 2011 to Lariboisière Hospital. We compared women for whom EPH was successful and those who required an advanced interventional procedure (AIP) to stop the bleeding despite hysterectomy. We also evaluated the severe PPH (SPPH) score in this particular setting. The psychological impact of emergency hysterectomy was also assessed.

RESULTS

A total of 44 hysterectomies were performed among 869 cases of PPH. Twenty were successful, while an additional AIP was required in 22 others (50%). Prothrombin time<50% and a shorter interval between the onset of PPH and hysterectomy were independently associated with the need for an additional AIP. The area under the ROC curve of the SPPH score to predict the need for another AIP was 0.738 (95% confidence interval 0.548-0.748). Furthermore, 64% of the hysterectomized patients suffered from post-traumatic stress disorder.

CONCLUSION

Failure of postpartum hysterectomy to control bleeding was frequent, and it was associated with persistence of coagulopathy. Hysterectomy in this context had important psychological impacts.

Emergency peripartum hysterectomy: our experience

PURPOSE

To investigate the incidence of and reasons for emergency peripartum hysterectomy (EPH) between 2009 and 2013 in our hospital, one of the three hospitals with the highest rates of delivery in Turkey.

METHODS

A retrospective study. Seventy-six peripartum hysterectomies were evaluated. We compared the modes of delivery and examined whether bilateral internal iliac artery ligation was performed.

RESULTS

The incidence of EPH was 0.77 in 1000. The majority of cases involved multiparity, uterine rupture, placenta praevia, or placental invasion abnormalities. The most frequent reason for EPH was uterine atony (64.5 %). There was no statistically significant relationship with mode of delivery; however, the complication rate and requirement for fresh frozen plasma were significantly (p < 0.01) related to whether bilateral internal iliac artery ligation was performed.

CONCLUSION

Uterine atony was the most common indication for EPH. The most important step to avoid performing EPH is to calculate patients' risks for postpartum bleeding. Postpartum haemorrhage may not be preventable, but when it happens, obstetricians must be prepared to perform EPH, and in high-risk patients, to perform internal iliac artery ligation.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Comparison of blood transfusion and surgical complications in peripartum hysterectomy when anticipated and unanticipated

The aim of the study was to determine the incidence and aetiology of peripartum hysterectomy (PH) for major obstetric haemorrhage (MOH) in our population and to compare estimated blood loss (EBL), blood transfusion, surgical complications and duration of hospital stay in PH that was anticipated and PH that was unanticipated. 26 cases of MOH requiring PH were identified from 50,548 women who delivered between 1 January 2006 and 31 December 2011 (0.5/1000). PH was anticipated in 17 and unanticipated in 9 cases. When compared, the anticipated group was more likely to have placenta accreta 15/17 (88%) vs 4/9 (44%): p = 0.03 and a gynaecological oncologist as the principal operator 15/17 (88%) vs 3/9 (33%): p = 0.007. The EBL 5.5 ± 3.7 SD vs 6.6 ± 3.9 SD l; p = 0.5, units of red cell concentrate or RCC transfused 7 ± 5 SD vs 9 ± 5 SD: p = 0.3, and mean operating time 134 ± 60 SD vs 190 ± 96 SD min: p = 0.07 were less in the anticipated than the unanticipated group, but not significantly so. The intraoperative complication rate 7/17 (41%) vs 3/9 (33%): p = 1.0 and the mean duration of hospital stay 7 ± 1 SD vs 8 ± 3 SD days: p = 0.27 were similar in both groups. PH is associated with a large volume of blood loss and significant surgical complications regardless of whether the procedure is anticipated or not.

The future of human uterus transplantation

The only untreatable subgroup of female infertility is absolute uterine factor infertility (AUFI), which is due to congenital or surgical absence of a uterus or presence of a nonfunctional uterus. The solitary option for a woman with AUFI to become a biological mother today is through a gestational surrogate mother, a procedure that is prohibited in Sweden and large parts of the world. Uterus transplantation (UTx) is a potential future treatment of AUFI. After extensive animal research, also involving non-human primates, a small number of human UTx cases have recently been performed. Here, we summarize the primate UTx experiments that have paved the way for the human UTx cases, which are described and analyzed in more detail. We also estimate how many women of fertile age are affected by AUFI and describe the causes. The ethics around UTx is complex and is also addressed.

Cesarean section and the risk of emergency peripartum hysterectomy in high-income countries: a systematic review

INTRODUCTION

Our objective was to determine the incidence and mortality rates associated with emergency peripartum hysterectomy, factors that lead to uncontrolled hemorrhage and emergency peripartum hysterectomy, and to determine the relationship between cesarean section and risk of emergency peripartum hysterectomy.

MATERIALS AND METHODS

Studies published between January 1, 2000 and December 31, 2012 were identified using PubMed, OVID and Web of Science databases. Studies were included if they reported incidence rates for emergency peripartum hysterectomy, factors that lead to hemorrhage and emergency peripartum hysterectomy, or the association of emergency peripartum hysterectomy with cesarean section in high-income countries.

RESULTS

Four hundred and fifty-one studies were identified, and 52 were included. The incidence of emergency peripartum hysterectomy ranged from 0.20 to 5.09 per 1000 deliveries with a median incidence rate of 0.61 per 1000 deliveries. These rates have increased over time. Rates varied by region/country, specifically with the United States reporting higher rates than North American, Asian, Oceania, and European countries. The most common factor leading to emergency peripartum hysterectomy was placental abnormalities. Both cesarean section and prior cesarean section were strong risk factors for emergency peripartum hysterectomy with higher risks conferred for each additional cesarean section. The mean percentage of maternal deaths for EPH survivors was 3.0 %.

CONCLUSION

Given the association of cesarean section with emergency peripartum hysterectomy, the increased risk of emergency peripartum hysterectomy should be factored into the decision of whether to proceed with cesarean delivery, particularly for women who desire more children.

Cesarean scar pregnancies: experience of 60 cases

OBJECTIVES

To evaluate the management, clinical courses, and outcomes of cesarean scar pregnancies diagnosed in the first trimester.

METHODS

We identified 60 cases of cesarean scar pregnancies diagnosed between 5 and 14 weeks. Group A contained 48 patients with fetal/embryonic cardiac activity; group B comprised 12 patients without cardiac activity; and group C included 11 patients with cardiac activity who chose expectant management.

RESULTS

Five of the 48 patients (10.4%) in group A were successfully treated for vaginal bleeding. Thirty-three (68.7%) received methotrexate injections, and all had full resolution. Three (6.3%) required uterine artery embolization for late-developing arteriovenous malformations. Ten of the 12 patients (83.3%) in group B were managed expectantly and had full recovery. Two of the 10 (20.0%) had arteriovenous malformations; 1 had unsuccessful uterine artery embolization followed by a hysterectomy, and the second requested a hysterectomy. Ten of the 11 patients (90.9%) in group C continued the pregnancies. One declined local injection. Four of the 10 (40.0%) delivered live offspring by successive elective cesarean deliveries. Three (30.0%) had hysterectomies for placenta percreta, and 1 did not have a hysterectomy after delivery. Five (50%) had second-trimester complications, all leading to hysterectomies. Of the 60 patients, 20 (33.3%) had serious complications: 5 had arteriovenous malformations; 4 had uterine artery embolization; and 11 had hysterectomies.

CONCLUSIONS

A cesarean scar pregnancy is a serious complication for patients who have had cesarean deliveries. Counseling, treatment, and follow-up are challenging for patients and caregivers. However, emerging data from different management approaches confirm that a cesarean scar pregnancy may progress and result in a live neonate at the expense of further fertility. This study confirmed that expectant management of a cesarean scar pregnancy is associated with a high risk of hysterectomy due to morbidly adherent placenta.

Might uterus transplantation be an option for uterine factor infertility?

Current data on uterus allotransplantation research has been reviewed and summarized. Over the past 15 years, progress in uterus transplantation research has increased dramatically. As a consequence, the first pregnancy and delivery following uterus allotransplantation in rats have been reported. The technique has been better defined. Although clinical pregnancy and delivery following uterus allotransplantation has been reported in humans, there are still many questions to be answered before clinical application. Gestational surrogacy still remains an important option for being a genetic parent in selected cases with uterine factor infertility.

Women are designed to deliver vaginally and not by cesarean section: an obstetrician's view

Worldwide, there is a rapid increase in deliveries by cesarean section. The large differences among countries, from about 16% to more than 60%, suggest that the cesarean delivery (CD) rate has little to do with evidence-based medicine. In this review, the background for the increasing CD rate is discussed as well as the limited positive effects on neonatal outcome in both term and preterm neonates. Negative effects of CD, including direct maternal morbidity, complications of subsequent pregnancies and iatrogenic early delivery resulting in increased neonatal morbidity, are discussed in addition to long-term implications for the offspring involving altered development of the immune system. The 'battle' to lower the CD rate will be difficult, but we should not forget that women are designed to deliver vaginally and not by cesarean section.

Peripartum hysterectomy in a tertiary hospital in Western Sydney

The aim of this study was to review the incidence, indication, management and complications of peripartum hysterectomy (PH) in a tertiary level hospital over a decade. A retrospective review of all cases of PH performed at Westmead Hospital, Western Sydney, 2003-2012, was undertaken. PH was defined as hysterectomy performed after 20 weeks' gestation or any time after delivery but within 6 weeks' postpartum ( Awan et al. 2011 ). There were 56 cases of peripartum hysterectomy of 46,177 births, a rate of 1.22 per 1,000 births. The most common indication for PH was morbid adherence of the placenta (58.2%) followed by uterine atony. Having a history of both caesarean section and placenta praevia is highly associated with a morbidly adherent placenta in the index pregnancy (p = 0.002). The most common complication was coagulopathy followed by febrile illness and urinary tract injury. Our data showed previous caesarean section and placenta praevia to be associated with abnormal placentation, the leading indication for PH. Since there is an association between a planned caesarean hysterectomy and reduced amount of estimated blood loss and blood transfused, the knowledge of placentation and adequate preoperative planning and consideration for elective hysterectomy could be beneficial. The morbidity associated with PH is considerable.

Emergency peripartum hysterectomy: a 13-year review at a tertiary center in kuwait

OBJECTIVE

To determine the incidence, indications, risk factors, and complications of emergency peripartum hysterectomy (EPH) and to evaluate total versus subtotal hysterectomy for EPH.

MATERIALS AND METHODS

This is a retrospective case series involving thorough examination of the files of all women who had EPH between January 2000 and December 2012 in the department of Obstetrics and Gynecology, Al-Jahra hospital, Kuwait after taking approval from the ethics committee. Incidence, indications, risk factors, type of hysterectomy, and complications of EPH were obtained from patient files.

RESULTS

There were 63,337 deliveries of which 70.3 % were vaginal deliveries, and 29.6 % were by cesarean section (CS). Sixty-eight women underwent EPH representing an overall incidence of 1 case per 1,000 deliveries. The indications for EPH included abnormal placentation (77.4 %), uterine atony (14.5 %), and uterine rupture (8.1 %). There was one maternal death. Maternal morbidity occurred in 25 (40.3 %) women. The most common complications were mild to severe coagulopathy (19.35 %) and injury to the urinary tract (17.74 %). Injury to the ureter was avoided by placing ureteric stents preoperatively. Our population was significant in having higher rate of CS deliveries (91.9 %), women with prior CS (83.87 %), and high parity (mean 5.8).

CONCLUSION

Abnormal placentation was the most common indication to perform EPH. The relative risk of EPH was 27 for CS deliveries as compared to vaginal deliveries. There was no significant difference between subtotal versus total hysterectomy with respect to age, parity, previous CS, operative time, blood transfusion, and intra and post operative complications.

Women's experiences, emotional responses, and perceptions of care after emergency peripartum hysterectomy: a qualitative survey of women from 6 months to 3 years postpartum

BACKGROUND

Little is known of the experience and perceptions of care for survivors of emergency peripartum hysterectomy (EPH), an obstetric event that is increasing in incidence. We sought to explore women's experiences of EPH to make recommendations for care.

METHODS

This qualitative study utilized purposive sampling through an online support group of women who experienced EPH. Eligible participants were at least 18 years old, had their hysterectomy at least 6 months but no more than 3 years before the interview, had a surviving infant associated with the delivery, and did not report suicidal ideation. In-depth, semi-structured telephone interviews were conducted and analyzed using Constant Comparative Analysis. Kappa statistics assessed interrater reliability for two independent coders.

RESULTS

Fifteen women participated with a mean age of 32.5 years. Most had a cesarean section, with uterine atony as the most common indication for EPH. Kappa statistics indicated near-perfect interrater agreement between two coders, ranging from .82 to .89. Seven major themes were identified: fear; pain; death and dying; numbness or delay in emotional reaction; bonding with baby; communication; and the need for information. Psychological upset occurred postpartum and was often delayed. A major finding is the need for additional follow-up visits to address the emotional after-effects and to fill in gaps in women's understanding and memory of what had occurred.

CONCLUSION

Understanding women's experiences with EPH can help practitioners address not only women's initial complications but provide needed long-term support.

Emergency peripartum hysterectomy: our 12-year experience

OBJECTIVE

The aim of this study was to determine the incidence, indications and the risk factors and complications of emergency peripartum hysterectomy (EPH).

METHODS

We analyzed retrospectively 44 cases of EPH performed at tertiary obstetric center between January 2001 and April 2013. Data related to demographics, reproductive histories, indications for EPH, and postoperative follow-up were obtained by analyses of hospital records.

RESULTS

The overall incidence of EPH was 0.48 per 1,000 deliveries during the study period. The most common indications of EPH were abnormal placentation (50 %), uterine atony (36 %) and uterine rupture (9 %). All patients who underwent EPH with abnormal placentation had one or more previous cesarean sections (CS) except one. In our series, 24 cases (54 %) underwent total hysterectomy, most of which had the diagnosis of abnormal placentation (75 %), whereas subtotal hysterectomy was the choice of management of bleeding in cases with uterine atony (60 %). Maternal mortality was seen in 2 patients (4.5 %). The causes were disseminated intravascular coagulation in one and adult respiratory distress syndrome in the other patient. Perinatal mortality was observed in 7 patients (16 %). The causes for perinatal mortality were placental abruption in 4 and prematurity in 3 patients.

CONCLUSIONS

In our series, abnormal placentation was the most common indication for EPH. The risk factors for EPH were previous CS for abnormal placentation and placental abruption for uterine atony and peripartum hemorrhage. Limiting the number of CS deliveries would bring a significant impact on decreasing the risk of EPH.

Postpartum hemorrhage: the role of the Maternal-Fetal Medicine specialist in enhancing quality and patient safety

Postpartum hemorrhage in excess of 1000 mL affects 2.9-4.3% of deliveries in North America and the prevalence is increasing (Calvert et al., 2012(1); Callaghan et al., 2010(2)). Given the unpredictable nature of most postpartum hemorrhages, all obstetric providers must understand the initial steps in the assessment and management of this emergency. In this monograph we will review the potential role of the Maternal-Fetal Medicine (MFM) specialist in managing this acute obstetric emergency. MFMs are uniquely positioned to develop hospital protocols, advocate for investment in resources to optimize outcomes, and utilize novel educational models, such as simulation, to educate other providers on the recognition and management of this condition. MFMs can also aid in the antepartum diagnosis of abnormal placentation, which is an increasingly common risk factor for severe hemorrhage.

Clinical pregnancy after uterus transplantation

OBJECTIVE

To present the first clinical pregnancy after uterus transplantation.

DESIGN

Case study.

SETTING

Tertiary center.

PATIENT(S)

A 23-year-old Mayer-Rokitansky-Kuster-Hauser syndrome patient with previous vaginal reconstruction and uterus transplantation.

INTERVENTION(S)

Eighteen months after the transplant, the endometrium was prepared for transfer of the thawed embryos.

MAIN OUTCOME MEASURE(S)

Implantation of embryo in an allografted human uterus.

RESULT(S)

The first ET cycle with one day 3 thawed embryo resulted in a biochemical pregnancy. The second ET cycle resulted in a clinical pregnancy confirmed with transvaginal ultrasound visualization of an intrauterine gestational sac with decidualization.

CONCLUSION(S)

We have presented the first clinical pregnancy in a patient with absolute uterine infertility after uterus allotransplantation. Although the real success is the delivery of a healthy near-term baby, this clinical pregnancy is a great step forward and a proof of concept that the implantation phase works.

The influence of pregnancy termination on the outcome of subsequent pregnancies: a retrospective cohort study

OBJECTIVE

To compare the incidences of preterm delivery, cervical incompetence treated by cerclage, placental implantation or retention problems (ie, placenta praevia, placental abruption and retained placenta) and postpartum haemorrhage between women with and without a history of pregnancy termination.

DESIGN

 A retrospective cohort study using aggregated data from a national perinatal registry.

SETTING

All midwifery practices and hospitals in the Netherlands.

PARTICIPANTS

All pregnant women with a singleton pregnancy without congenital malformations and a gestational age of ≥20 weeks who delivered between January 2000 and December 2007.

MAIN OUTCOME MEASURES

Preterm delivery, cervical incompetence treated by cerclage, placenta praevia, placental abruption, retained placenta and postpartum haemorrhage.

RESULTS

A previous pregnancy termination was reported in 16 000 (1.2%) deliveries. The vast majority of these (90-95%) were performed by surgical methods. The incidence of all outcome measures was significantly higher in women with a history of pregnancy termination. Adjusted ORs (95% CI) for cervical incompetence treated by cerclage, preterm delivery, placental implantation or retention problems and postpartum haemorrhage were 4.6 (2.9 to 7.2), 1.11 (1.02 to 1.20), 1.42 (1.29 to 1.55) and 1.16 (1.08 to 1.25), respectively. Associated numbers needed to harm were 1000, 167, 111 and 111, respectively. For any listed adverse outcome, the number needed to harm was 63.

CONCLUSIONS

In this large nationwide cohort study, we found a positive association between surgical termination of pregnancy and subsequent preterm delivery, cervical incompetence treated by cerclage, placental implantation or retention problems and postpartum haemorrhage in a subsequent pregnancy. Absolute risks for these outcomes, however, remain small. Medicinal termination might be considered first whenever there is a choice between both methods.

Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accreta

OBJECTIVE

We surveyed obstetricians to determine their knowledge, patterns of care and treatment preferences for women with placenta accreta.

METHODS

A 27-item survey was mailed to fellows of the American College of Obstetricians and Gynecologists. The survey included demographics, questions regarding knowledge and items to examine practice patterns.

RESULTS

Among 994 surveyed practitioners 508 responded including 338 who practiced obstetrics. Among generalists, 23.8% of respondents referred patients with placenta accreta to a sub-specialist. Overall, 20.4% referred women to the nearest tertiary center, and 7.1% referred to a regional center. Delivery was recommended at 34-36 weeks by 41.2%. Adjuvant interventions including ureteral stents (26.3%), iliac artery embolization catheters (28.1%), and balloon occlusion catheters (20.1%) were used infrequently. Six or more units of blood were crossed for delivery by only 29.0% of practitioners.

CONCLUSION

There is widespread variation in the care of women with or at risk for placenta accreta.

Emergency peripartum hysterectomy in Isfahan; maternal mortality and morbidity rates among the women who underwent peripartum hysterectomy

Background:

Peripartum hysterectomy is associated with significant morbidity and mortality. We determined the factors leading to and maternal mortality and morbidity rates among the women whose underwent peripartum hysterectomy in Iran.

Materials and Methods:

This case-series study was conducted from March 2004 to March 2009 in the Department of Gynecology and Obstetrics at two central university hospitals (Azahra hospital and Shahid Beheshti Hospital) in Isfahan. Forty one women among 29,444 deliveries underwent peripartum hysterectomy. Women who had delivery before 24 weeks and a hysterectomy for other reasons like sterilizations were excluded. Incidence, indications and maternal complications including maternal death and urological, infectious and wound complications were evaluated after operation.

Results:

During the study period, the incidence of peripartum hysterectomy estimated about 1.39 per 1,000 deliveries. The maternal mortality rate was 17.07%. There was no statistical difference in mortality rates between referrals and non-referrals women (P = 0.6). Post-operative complications included infection (22%), bladder injuries (7.3%), urine retention (4.8%) and wound dehiscence (4.87%). The main indication was placenta accreta 28 (68.3%).

Conclusion:

This study indicated the high rate of mortality among patients underwent peripartum hysterectomy. Evaluation of management during referring the patients and designing more studies to evaluate the mortality and morbidities are warranted.

Emergency peripartum hysterectomy: Incidence, indications, risk factors and outcome

Background:

Peripartum hysterectomy is a major operation and is invariably performed in the presence of life threatening hemorrhage during or immediately after abdominal or vaginal deliveries.

Material and Methods:

A Medline search was conducted to review the recent relevant articles in English literature on emergency peripartum hysterectomy. The incidence, indications, risk factors and outcome of emergency peripartum hysterectomy were reviewed.

Results:

The incidence of emergency peripartum hysterectomy ranged from 0.24 to 8.7 per 1000 deliveries. Emergency peripartum hysterectomy was found to be more common following cesarean section than vaginal deliveries. The predominant indication for emergency peripartum hysterectomy was abnormal placentation (placenta previa/accreta) which was noted in 45 to 73.3%, uterine atony in 20.6 to 43% and uterine rupture in 11.4 to 45.5 %. The risk factors included previous cesarean section, scarred uterus, multiparity, older age group. The maternal morbidity ranged from 26.5 to 31.5% and the mortality from 0 to 12.5% with a mean of 4.8%. The decision of performing total or subtotal hysterectomy was influenced by the patient's condition.

Conclusion:

Emergency 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. Antenatal anticipation of the risk factors, involvement of an experienced obstetrician at an early stage of management and a prompt hysterectomy after adequate resuscitation would go a long way in reducing morbidity and mortality.

Temporal trends and determinants of peripartum hysterectomy in Lombardy, Northern Italy, 1996-2010

PURPOSE

To analyze the temporal trends of peripartum hysterectomy (PH) in the period 1996-2010 in Lombardy, Italy.

METHODS

Using data from the Regional Database, PH ratios/1,000 deliveries were calculated from 1996 to 2010, in strata of age and mode of delivery among women resident in Lombardy, Italy. PH cases were identified searching the database for the ICD-9 and ICD-10 codes for subtotal and total hysterectomy. PH ratios/1,000 deliveries in strata of age, mode of delivery and calendar year were computed. Poisson's regression analysis was used to test trend over time.

RESULTS

A total of 905 PH and 1,289,163 deliveries were recorded between 1996 and 2010. The overall PH ratio was 0.70/1,000 deliveries. The PH ratio/1,000 deliveries increased over time, being 0.57 in 1996 and 0.88/1,000 deliveries in 2010 (P < 0.0001). After including calendar year, mode of delivery and maternal age in the Poisson's regression equation, no significant linear trend emerged in the PH ratio over time (P = 0.28). Women who underwent cesarean section (CS) (CS vs. vaginal delivery: OR 5.66, 95 % CI 4.91-6.54) and older women were at increased risk of PH (maternal age ≥40 vs. <30 years: OR 5.66, 95 % CI 4.48-7.15). The frequency of intractable peripartum hemorrhage and placenta praevia/accreta, the main indications for PH, significantly increased over the study period.

CONCLUSIONS

In Lombardy, the PH ratio increased between 1996 and 2010. In our population, rising frequency of CS and older maternal age may explain this trend.

Breastfeeding following emergency peripartum hysterectomy

Emergency peripartum hysterectomy (EPH) is usually performed in cases of intractable obstetric hemorrhage unresponsive to conservative treatment. EPH is associated with a high incidence of maternal morbidity and mortality. Most of these women do not have the opportunity to even start breastfeeding. We report a case where breastfeeding was attempted after EPH. The mother spent 6 days in the intensive care unit and suffered several medical and surgical complications. On day 7 she was reunited with her baby. One month later, a diagnosis of post-traumatic stress disorder was made. Breastfeeding became very important, with the patient frequently expressing that this was the most healing aspect in her recovery from the traumatic EPH. At 3 months, five daily feeds were supplemented with formula. Breastfeeding, principally nocturnal, continued 6 months after childbirth, with the baby being weaned at 7 months. Women who undergo EPH need psychological support. The option of breastfeeding should be considered even days or weeks after the surgical intervention as it can be a healing experience for some women who are grieving the loss of their fertility. Professional specialized breastfeeding support should be offered in these cases, and the possibility of reuniting mother and infant even when the mother is in the intensive care unit should be considered.

Uterus transplantation: animal research and human possibilities

Uterus transplantation research has been conducted toward its introduction in the human as a treatment of absolute uterine-factor infertility, which is considered to be the last frontier to conquer for infertility research. In this review we describe the patient populations that may benefit from uterus transplantation. The animal research on uterus transplantation conducted during the past two decades is summarized, and we describe our views regarding a future research-based human attempt.

Planned caesarean hysterectomy versus "conserving" caesarean section in patients with placenta accreta

OBJECTIVES

Invasive placentation (placenta accreta, increta, or percreta) presents significant challenges at Caesarean section. Caesarean hysterectomy in such circumstances may result in massive blood loss despite surgical expertise. We reviewed two divergent surgical approaches: planned Caesarean hysterectomy versus a "conserving surgery" in which the placenta is left in situ after Caesarean section.

METHODS

We conducted a single-centre retrospective review of all patients who delivered with invasive placentation between 2000 and 2009. We included only patients with antenatally diagnosed invasive placentation and planned mode of delivery.

RESULTS

Twenty-six patients met the inclusion criteria. Caesarean hysterectomy was planned in 16 patients and conserving surgery in 10. Intraoperative and postoperative complications were comparable in the two groups. Four of 10 patients initially treated by conservative surgery required a subsequent hysterectomy for severe vaginal bleeding, coagulopathy, or sepsis. No pregnancies were subsequently reported in the conserving surgery group.

CONCLUSION

An initial conserving surgical procedure is an option in patients with extensive invasive placentation, but it requires further monitoring for potential complications and carries a high subsequent hysterectomy rate.

Cutting-edge advances in the medical management of obstetrical hemorrhage

Hemorrhagic shock is the most common form of shock encountered in obstetric practice. Interventions that may limit transfusion requirements include normovolemic hemodilution, use of recombinant activated factor VII, selective embolization of pelvic vessels by interventional radiology, and the use of the cell saver intraoperatively. Current understanding of the mechanisms of acute coagulopathy calls into question the current transfusion guidelines, leading to a tendency to apply massive transfusion protocols based on hemostatic resuscitation despite lack of prospective data.

Screening for placenta accreta at 11-14 weeks of gestation

OBJECTIVE

We sought to describe the potential value of 11-14 weeks' screening for placenta accreta (PA).

STUDY DESIGN

Patients with a history of lower segment cesarean section were prospectively included between 11-13+6 weeks over a 1.5-year period. The first 258 were offered standard screening whereas the following 105 underwent screening for PA. Women were considered high-risk when the trophoblast overlapped the scar visualized by transvaginal ultrasound and low-risk otherwise.

RESULTS

The group screened for PA did not differ from the nonscreened group for demographic characteristics. In all, 6 of 105 (5.8%) women were considered high-risk. In the nonscreened group, 1 case of PA was discovered during an elective repeat cesarean. In the screened population, 1 case of PA occurred in a high-risk patient allowing a conservative planned management at 35 weeks.

CONCLUSION

At 11-14 weeks, ultrasound may help risk stratification for PA with a specific follow-up. Early recognition of patients at risk might improve the perinatal outcome of PA.

Experience of emergency peripartum hysterectomies at a tertiary care hospital in quetta, pakistan

Emergency peripartum hysterectomy (EPH) is associated with significant morbidity and mortality worldwide. The purpose of our paper was to determine the incidence, morbidity, and mortality of EPH done at our institution; the largest tertiary care government hospital in the city of Quetta, Pakistan. During the study period there were 12,642 deliveries, out of which 46 women had undergone an EPH, translating into an incidence of ∼4 per 1,000 births. Disturbingly, 82.6% of these patients had received no antenatal care prior to their presentation. There were 4 (8.7%) maternal deaths and 31 (67.4%) perinatal deaths. The commonest indication noted was uterine rupture in 21 (45.7%) cases. Lack of antenatal care is indeed a modifiable factor that needs to be addressed to help reduce maternal and fetal morbidity/mortality not only from emergency hysterectomies but also from all other preventable causes.