Elective versus emergency cesarean hysterectomy cases in a residency program setting: a review of 129 cases from 1984 to 1988

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.

The frequency and complication rates of hysterectomy accompanying cesarean delivery

OBJECTIVE

To estimate the frequency, indications, and complications of cesarean hysterectomy.

METHODS

This was a prospective, 2-year observational study at 13 academic medical centers conducted between January 1, 1999, and December 31, 2000, on all women who underwent a hysterectomy at the time of cesarean delivery. Data were abstracted from the medical record by study nurses. The outcomes included procedure frequency, indications, and complications.

RESULTS

A total of 186 cesarean hysterectomies (0.5%) were performed from a cohort of 39,244 women who underwent cesarean delivery. The leading indications for hysterectomy were placenta accreta (38%) and uterine atony (34%). Of the hysterectomy cases with a diagnosis recorded as accreta, 18% accompanied a primary cesarean delivery, and 82% had a prior procedure (P<.001). Of the hysterectomy cases with atony recorded as a diagnosis, 59% complicated primary cesarean delivery, whereas 41% had a prior cesarean (P<.001). Major maternal complications of cesarean hysterectomy included transfusion of red blood cells (84%) and other blood products (34%), fever (11%), subsequent laparotomy (4%), ureteral injury (3%), and death (1.6%). Accreta hysterectomy cases were more likely than atony hysterectomy cases to require ureteral stents (14% compared with 3%, P=.03) and to instill sterile milk into the bladder (23% compared with 8%, P=.02).

CONCLUSION

The rate of cesarean hysterectomy has declined modestly in the past decade. Despite the use of effective therapies and procedures to control hemorrhage at cesarean delivery, a small proportion of women continue to require hysterectomy to control hemorrhage from both uterine atony and placenta accreta.

LEVEL OF EVIDENCE

II.

Peripartum hysterectomies at the korle-bu teaching hospital: a review of 182 consecutive cases

SUMMARY OBJECTIVES

The main objectives of this study were to determine the incidence, maternal characteristics, indications, the maternal and perinatal outcomes and the complications of emergency peripartum hysterectomies done at the Korle-Bu Teaching Hospital.

STUDY DESIGN

This is a retrospective descriptive study covering the period January 1, 2000 to June 30, 2003.

SETTING

Maternity Unit of the Korle-Bu Teaching Hospital

RESULTS

The incidence of peripartum hysterectomy during the study period was 4.34/1000 deliveries. The main indication was severe uterine bleeding from uterine rupture 89 (48.9%), uterine atony 60 (33%), placenta accreta 20 (11%) and post caesarean uterine wound sepsis and necrosis 11 (6%). The average blood loss was 2.02 (SD 0.86) L and all patients received blood transfusion. The mean age of the patients was 31.6 (SD 5.3) years and the mean parity was 2.7 (SD 1.7). Complications occurred in 28 (19.8%) patients. The stillbirth rate was 483.5/1000 deliveries and the maternal mortality was 12.9%. The average duration of hospital stay was 11 (SD 8) days.

CONCLUSIONS

The incidence of emergency peripartum hysterectomy is high. It is performed for young nulliparous women through to elderly grand-multiparous women. The surgery is associated with significant maternal and perinatal morbidity and mortality. Timely expert management in a well resourced centre is advocated.

Peripartum hysterectomy

OBJECTIVES

To review the cases receiving peripartum hysterectomies treated in this hospital during the period 1967-1995. Clinical characteristics, indications, and results were more closely analyzed.

STUDY DESIGN

A chart review of all cases operated since January 1967 to December 1995 was done. Demographic and clinical data were extracted, coded, and entered into a computer file for analysis. Indications, type of operation, pre-op planning or emergency decision, blood loss, transfusion, complications, were compared and cross-tabulated. Statistical analysis included: chi-square and Fisher exact tests, where appropriate, and two-sample t test.

RESULTS

In 58% of 217 cases the operation was planned, and total hysterectomy was done in 94%. Indications changed through the years, from predominantly elective to almost exclusively emergencies. These were mostly bleeding complications, in particular placenta previa and/or accreta. The presence of a uterine scar or submucous fibroid was associated with 79% (26/33) of accretas, and 51% (19/37) of previas. Among the 126 planned, 57% did not receive a transfusion and 84% of 91 emergencies did have one. The average amount of blood received by the latter was 3009 ml compared to 1262 ml for the former (p < 0.0001). There was a direct relationship between amount of blood loss and volume transfused. There were 26% intraoperatory bleeding complications and 5% urinary tract injuries. Postoperatory morbidity such as bleeding, infections, wound dehiscence, and others was observed in 17% of planned, and 23% of emergencies. Twelve patients needed another operation to treat some of these complications. There were no deaths recorded.

CONCLUSIONS

Peripartum hysterectomy is a major operation, and in current times almost always an emergency with high risk for significant blood loss. The obstetrician should be ready to do it, and an early decision should save blood and prevent complications. Postoperative complications, mostly bleeding and infections may be severe. Early intervention and proper technique facilitate good outcomes.

Emergency postpartum hysterectomy in obstetric practice

OBJECTIVES

To review cases of emergency postpartum hysterectomies performed in the setting of life-threatening hemorrhaging.

METHODS

A retrospective study of 17 patients who underwent postpartum hysterectomies during January 1, 1985-December 31, 1998 was undertaken. Maternal characteristics, method of delivery, antenatal complications for hysterectomy, obstetric history, placental location, blood loss before hysterectomy and during operation, intraoperative and postoperative complications, and operative procedures were investigated, as was whether prostaglandin F2alpha and/or oxytocin were administrated during labor. The operative procedures also were examined.

RESULTS

The incidence was 1 in 6,978 deliveries (0.014%). All patients were transported from affiliated clinics. The leading cause for a hysterectomy was uterine rupture (35.3%), followed by disseminated intravascular coagulation (DIC) due to placental abruption (29.4%), and uterine atony (23.5%). Failure of internal iliac-artery ligation occurred in 7 patients.

CONCLUSIONS

Internal iliac-artery ligation is not effective for patients with massive blood loss. In such cases, it is desirable for the private physician to make an early decision for maternal transport.

Emergency obstetric hysterectomies for postpartum haemorrhage

OBJECTIVE

To review emergency obstetric hysterectomy in our unit, including the indications for and morbidity associated with the procedure.

DESIGN

A retrospective cases analysis.

SUBJECTS AND METHODS

Records of obstetric patients who had undergone emergency hysterectomies in between 15 October 1993 and 31 December 1997 were reviewed retrospectively.

RESULTS

There were 15,474 deliveries and 7 emergency obstetric hysterectomies. All cases had total abdominal hysterectomy. The indications for hysterectomy were uterine atony and placental disorders. There were one case of urinary bladder injury and 2 cases of disseminated intravascular coagulopathy. There was no maternal mortality.

CONCLUSION

Emergency obstetric hysterectomy remains a potentially life-saving procedure in unavoidable catastrophe. The 7 patients with life threatening postpartum haemorrhage underwent hysterectomy after failure of conservative measures. The morbidity is low and there was no mortality in this series.

Planned cesarean hysterectomy: A preferred alternative to separate operations

OBJECTIVE

The aim of this study was to evaluate our institutional experience with planned cesarean hysterectomy.

STUDY DESIGN

In this retrospective case-control investigation of a 16-year experience, 100 pregnant women who underwent planned cesarean hysterectomy were compared with 37 patients who underwent cesarean delivery followed by a hysterectomy performed within 6 months.

RESULTS

Women undergoing planned cesarean hysterectomy did not have any demonstrable increase in intraoperative or postoperative complications when compared with the cesarean delivery plus later hysterectomy group. Primarily as a result of significantly reduced hospital stay and shorter total operative time, there was a significant financial advantage associated with a single planned cesarean hysterectomy with respect to separate operations.

CONCLUSIONS

A policy to undertake planned cesarean hysterectomy for carefully selected patients appeared to produce advantages without increasing risks for these patients. Secondarily, it provided resident physicians the opportunity to learn the operation with supervision and under controlled circumstances.