Elective cesarean hysterectomy: a 5 year comparison with cesarean section

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.

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.

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

A retrospective study was performed to compare elective versus emergency cesarean hysterectomy in a residency program. We noted the following statistically significant differences between emergency and elective cases: (1) Estimated blood loss (mean +/- SD) for emergency and elective cases was significantly different at 1495 +/- 772 and 875 +/- 396 ml (p = 0.001). (2) Operative time in emergency cases was significantly longer than in elective cases (105 +/- 38 vs 83 +/- 27 minutes, p = 0.003). (3) The incidence of transfusion was 68% in our emergency cases and 14.6% in the elective series (p less than 0.05). (4) Febrile morbidity in our series was 40% in emergency cases and 18.3% in elective cases (p less than 0.05). Our series was comparable to previous series reported. Our experience suggests that cesarean hysterectomy can be performed safely in a residency training program when done as an elective procedure in the well-prepared patient.

Elective caesarean hysterectomy. Indications and outcome: a 17-year experience of 140 cases

In an earlier report of 86 elective Caesarean hysterectomies (1970-1979) we showed that the operation was associated with few complications but a high blood transfusion rate. In this paper we report an extended series comprised of 140 cases (1970-1986), and compare results of the 1970's series with that of the 1980's. The operative and postoperative complications were minimal during the entire period. The blood transfusion rate which was 64% in 86 cases of the 1970-1979 period decreased to 17% in 54 cases of the 1980-1986. Our results show that Caesarean hysterectomy is a safe procedure with some long-term advantages; therefore this option should be discussed with women who ask for tubal sterilization at the time of Caesarean section.

Sterilization at the time of cesarean section: tubal ligation or hysterectomy?

The operative, postoperative and subsequent course of 86 patients who underwent cesarean hysterectomy (C.H.) during the years 1970-1979 are compared to an equal number of cesarean sections with tubal ligation (C.S.L.). Both groups are similar regarding age, gravidity, parity, number of living children and indications for abdominal delivery. Operative and postpartum complications of both groups were all minor, although significantly (p less than 0.05) more frequent in the C.S.L. group. More patients of the C.H. group required blood transfusions than the C.S.L. group (p less than 0.01). The mean period of hospitalization was similar in both groups. Two pregnancies occurred after tubal sterilization, a failure rate of 1:43. During the follow-up period, 49 surgical gynecological procedures were performed in the C.S.L. group compared to 1 in the C.H. group. Ten patients of the C.S.L. group subsequently underwent abdominal hysterectomy. Hysterectomy is the procedure of choice for permanent sterilization and prevention of many subsequent gynecological problems. Consideration must be given to coexisting gynecological conditions while considering sterilization at elective C.S. and C.H. should be offered to those patients.

Cervical intra-epithelial neoplasia in pregnancy

A retrospective analysis of 110 cases of suspected cervical intra-epithelial neoplasia (CIN) associated with pregnancy seen at the State University of New York at Buffalo (SUNYAB) affiliated hospitals is the subject of this report. One hundred anf five patients had abnormal cytology and five had negative pap smears. The majority of patients (60%) were in their twenties, and 24% were primigravidas. Colposcopic examination with or without directed biopsy eliminated the need for conization in 104 of 107 patients. Only two patients had to have cone biopsy and one had a modified conization after colposcopically directed biopsies. Varying degrees of cervical intra-epithelial neoplasia (Grades I-III) were diagnosed in 55 cases. One patient had therapeutic conization and two with a poor follow-up history had cesarean section hysterectomies. Post pregnancy regression of CIN was documented in 20 cases and persistence in 19 cases. The literature is surveyed and the management of CIN in pregnancy is discussed.

Sterilization: a comparative review

Publications relating to surgical procedures for sterilization have been reviewed, and the incidences of complications and subsequent pregnancies compared. Laparoscopic sterilization has the lowest incidence of complication, the morbidity rate being lower than that of laparotomy sterilization or hysterectomy, and the mortality rate lower than that of a single pregnancy or taking oral contraceptives for 1 year.