Planned cesarean hysterectomy: A preferred alternative to separate operations

Emergent versus planned delivery in patients with placenta accreta spectrum disorders: A retrospective study

ABSTRACT

The aim of this study is to compare the clinical outcomes and to identify risk factors for emergent cesarean delivery and planned cesarean delivery in patients with placenta accreta spectrum (PAS) disorders in Vietnam.The medical records of patients admitted to our hospital with a diagnosis of PAS disorders >5 years were retrospectively reviewed.A total of 255 patients with PAS disorders were identified, including 95 cases in the emergent delivery group and 160 cases in the planned delivery group. The percentage of complete/partial placenta previa in the planned delivery group was significantly higher than that in the emergent delivery group (59.22% vs 32.16%, P = .027). Fewer patients in the planned group had vaginal bleeding compared with those in the emergent group (29 vs 36 cases, P < .001). The percentage of blood transfusion was similar between the 2 groups; however, the transfused units of pack red blood cells were greater in the emergent delivery group (5.3 ± 0.33 vs 4.5 ± 0.25 U, P = .036). When considering the neonatal outcomes, the data demonstrated that the planned delivery group had a significantly higher birth weight and a lower rate of preterm delivery than the emergent group (P < .001). The mean gestational age at delivery for the emergent group was 35.1 ± 0.27 weeks compared with 38.0 ± 0.10 weeks for the planned group (P < .001). The increased risk factors for emergent delivery were vaginal bleeding (odds ratio 2.86, 95% confidence interval 1.59-5.26) and preterm delivery (odds ratio 5.26, 95% confidence interval 2.13-14.29).Planned delivery is strongly associated with a lower need for blood transfusion and better neonatal outcomes compared with emergent delivery. Antenatal vaginal bleeding and preterm labor are risk factors for emergent delivery among patients with PAS disorders. Based on the results of this study, we recommend that the management strategies for patients with PAS disorders should be individualized to determine the optimal timing of delivery and to decrease the rate of emergent cesarean delivery.

Obstetric management for stillbirth complicated by a prior cesarean delivery: a cost-effectiveness analysis

BACKGROUND

The primary concern for a trial of labor after cesarean (TOLAC) is a uterine rupture leading to neonatal injury or mortality and maternal mortality. In individuals who have a term stillbirth, the neonatal concern is absent, yet repeat cesarean delivery remains common in this setting. Given the increased maternal risks from cesarean, it is important to evaluate obstetric management options in the population of women who have a term stillbirth and prior cesarean delivery (CD).

OBJECTIVES

To examine the outcomes and costs of a TOLAC via induction of labor verses a repeat CD for cases of stillbirth occurring near term.

STUDY DESIGN

A decision-analytic model incorporating the current and a subsequent delivery using TreeAge software was designed to compare outcomes in women induced for a TOLAC to those undergoing repeat CD in the setting of stillbirth at 34-41 weeks' gestation. We used a theoretical cohort of 6000 women, the estimated annual number of women a prior cesarean who experience a stillbirth in the United States. Outcomes included quality-adjusted life years (QALY) for both modes of delivery with consideration of future pregnancy risks. Future pregnancy risks included uterine rupture, hysterectomy, placenta accreta, maternal death, neonatal death, and neonatal neurological deficits. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY.

RESULTS

In our theoretical cohort of 6000 women with a prior CD and current stillbirth, induction of labor resulted in 4836 fewer cesarean deliveries during stillbirth management, 1040 fewer cesarean deliveries in the subsequent pregnancy, and 14 fewer cases of placenta accreta in the subsequent pregnancy, despite 29 additional uterine ruptures across both pregnancies. Induction of labor was found to be the dominant strategy, resulting in decreased costs and increased QALYs. Univariate sensitivity analyses demonstrated that induction of labor was cost effective until the risk of uterine rupture in the first delivery exceeded 0.83% (baseline estimate: 0.38%). Additional univariate sensitivity analyses found that induction of labor was cost effective until the risk of IOL failure in the first delivery exceeded 64% (baseline estimate: 19%).

CONCLUSION

In our theoretical cohort, induction of labor for TOLAC in the setting of a stillbirth with a history of prior CD is cost effective compared to a repeat CD. The results of this analysis demonstrate the benefit of induction of labor among women in this scenario who desire a future pregnancy.

Anesthesia for Cesarean Section in Parturients with Abnormal Placentation: A Retrospective Study

Introduction Placental invasion anomalies are associated with high mortality and may require hysterectomy due to the high risk of massive hemorrhage. The aim of this retrospective study was to evaluate intraoperative anesthetic management, postoperative follow-up, clinical features, and fetal wellbeing in patients undergoing cesarean section due to placental invasion anomalies in a tertiary health center. Methods The retrospective study included patients that underwent cesarean section due to placental invasion anomalies at a tertiary health center over the period between 2013 and 2018. Intraoperative anesthetic management, blood and blood products transfusion, and total volume of blood loss, as well as neonatal Apgar score and postoperative intensive care unit (ICU) follow-up, were reviewed for each patient. Results The study evaluated a total of 92 patients that underwent cesarean section due to placental invasion anomalies, including 49 patients with placenta previa, 42 patients with placenta percreta, and one patient with placenta accreta. Of the 92 patients, 59 (64.1%) patients underwent general anesthesia, 31 (33.7%) underwent spinal anesthesia, and two (2.2%) underwent spinal anesthesia followed by general anesthesia. Hysterectomy was performed in four patients, including three patients who underwent general anesthesia and one patient who started with spinal anesthesia and subsequently switched to general anesthesia prior to a hysterectomy. The Apgar scores at min 1 and min 5 after the induction of anesthesia were significantly lower in patients who underwent general anesthesia as compared to those who underwent spinal anesthesia (p=0.002 and p=0.007, respectively). The duration of surgery and intraoperative blood loss were significantly higher in patients with placenta percreta as compared to other patients (p<0.001 for both). Conclusion In surgical planning for the patients with placental invasion anomalies, care should be taken by anesthesiologists to select the most ideal anesthetic technique, by taking into account the type of anomaly, probable volume of blood loss, and surgical complications, to ensure both maternal and fetal wellbeing. Moreover, the coordination of a team of well-educated and experienced staff is essential.

Emergency peripartum hysterectomy: a 10-year review at the Royal Hospital for Women, Sydney

BACKGROUND

There appears to be a rise in the rate of emergency peripartum hysterectomy (EPH) in the developed world.

AIMS

  To determine the incidence, indications, risk factors, complications and management of EPH in our tertiary level teaching hospital, the Royal Hospital for Women (RHW) in Sydney, over the last decade.

METHODS

A retrospective analysis was conducted of all cases of EPH performed at the RHW between the years 1999-2008 inclusive. EPH was defined as one performed after 20 weeks gestation for uncontrollable uterine bleeding not responsive to conservative measures occurring at any time after delivery but within the first 6 weeks post-partum. Cases were ascertained via our hospital obstetric database.

RESULTS

There were 33 EPH among 38,998 births, a rate of 0.85 per 1000 births. Indications for EPH were morbid adherence of the placenta (54.8%), placenta praevia (19.4%), uterine atony (12.9%) and uterine rupture or cervical laceration (9.7%). A significant association between previous caesarean section (CS) and abnormal placentation was confirmed (P=0.011), especially for morbid adherence of the placenta (P=0.004). There was one maternal death. Maternal morbidity was significant, with disseminated intravascular coagulation and urinary tract injury among the most common complications. All women required blood transfusions, and over a quarter were admitted to the intensive care unit.

CONCLUSIONS

In our series, abnormal placentation causing severe haemorrhage was the commonest indication for EPH. Previous CS is a risk factor for abnormal placentation and particularly for morbid adherence of the placenta. The morbidity associated with EPH is considerable.

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.

Changing trends in peripartum hysterectomy over the last 4 decades

OBJECTIVE

The purpose of this study was to identify changing trends in peripartum hysterectomy (PH) in a single large obstetric population over the last 40 years.

STUDY DESIGN

A retrospective cohort study was performed from 1966-2005 of patients who had PH in any of the 3 Dublin obstetric hospitals. Cases were identified, and details were obtained from the combined patient databases of each hospital.

RESULTS

There were 872,379 deliveries during the study period, among which 358 women underwent PH (0.4/1000 deliveries). In a comparison of the study decades 1966-1975 with 1996-2005, PH decreased from 0.9 per 1000 deliveries to 0.2 of 1000 deliveries. Although the overall cesarean delivery rate has increased from 6-19% during these 2 decades, the percentage of PH that occurs in the setting of a previous cesarean delivery has increased from 27-57% (P < .00001). Indications for PH have changed significantly in this time period, with "uterine rupture" as the indication for PH decreasing from 40.5-9.3% (P < .0001) and placenta accreta as the indication increasing significantly from 5.4-46.5% (P < .00001).

CONCLUSION

PH has decreased over the last 4 decades. However, alongside the rising cesarean delivery rate, there has been a marked increase in the incidence of placenta accreta.

Planned vs emergent cesarean hysterectomy

OBJECTIVE

The aim of this study was to compare operative and postpartum outcomes between planned and emergent cesarean hysterectomy.

STUDY DESIGN

In this multicenter retrospective review over a 5-year period, 65 cases of cesarean hysterectomy (30 planned vs 35 emergent) were identified. Demographic, operative, and postoperative data were extracted and stratified by group (planned vs emergent).

RESULTS

Patients who underwent an emergent cesarean hysterectomy were more likely to have higher estimated blood loss (2597.1 +/- 1369.4 mL vs 1963.3 +/- 1180.2 mL; P = .05), have transfusion (66% vs 33%; P = .02), and require greater quantities of packed red blood cells (4.49 +/- 4.7 x10(12)/L vs 1.6 +/- 3.1 x10(12)/L; P = .006) compared with the planned cesarean hysterectomy group. Patients who underwent emergent cesarean hysterectomy had higher overall complication rates (37% vs 66%; P = .03) and more intensive care unit admissions (7% vs 29%; P = .03).

CONCLUSION

After planned cesarean hysterectomy, patients had a significantly lower rate of blood loss, less need for blood transfusions, and fewer complications compared with patients who underwent an emergent cesarean hysterectomy.

Tourniquet technique prevents profuse blood loss in placenta accreta cesarean section

AIM

Profuse bleeding in placenta accreta is life-threatening even under well-prepared cesarean sections.

METHODS

We used a tourniquet technique to temporally shut off blood flow through the uterine and ovarian vessels at the level of the uterine cervix. The tourniquet consisted of manual compression followed by a rubber tube.

RESULTS

Total blood loss in cesarean section and hysterectomy in the two cases in which we applied this technique was significantly reduced compared with that in the two cases without it.

CONCLUSION

This technique not only prevented massive bleeding from the accreted placentation, but also allowed physicians time to consider the necessity of subsequent hysterectomy.

Emergency peripartum hysterectomy in Northern Jordan: indications and obstetric outcome (an 8-year review)

OBJECTIVE

To review cases of emergency peripartum hysterectomy regarding their incidence, risk factors, indications and complications and their results were carefully analysed.

MATERIALS AND METHODS

A retrospective study of cases of emergency peripartum hysterectomy which were performed in the period between February 1994 and February 2002 at the Princess Badeea Teaching Hospital in Northern Jordan. Demographic and clinical data were extracted and closely interpreted

RESULTS

In the study period there were a 70,252 deliveries and 61 cases of emergency peripartum hysterectomies. The overall incidence was 0.87 peripartum hysterectomies per 1,000 deliveries. There were 50 cases (82%) delivered by caesarean section and 11 cases (18%) were delivered vaginally. Caesarean hysterectomy was performed in 50 cases and postpartum hysterectomy was performed in 11 cases. Total hysterectomy was performed in 39 cases (64%) and subtotal hysterectomy was performed in 22 cases (36%). The main indications for hysterectomy were morbidly adherent placenta (47.5%), ruptured uterus (27.9%) and uncontrollable haemorrhage from uterine atony (21.3%). There were two maternal deaths and 7 cases of stillbirths and 4 cases of early neonatal deaths.

CONCLUSION

Peripartum hysterectomy is a dramatic with high risk but a life saving operation. It is usually associated with significant maternal and fetal morbidity and mortality. Obstetricians should identify patients at risk and anticipate the procedure and complications, as early intervention and proper management facilitate optimal outcome.

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.