Emergency peripartum hysterectomy: single center ten-year experience

Incidence, Indications, Risk Factors, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis

OBJECTIVE

To describe the incidence, indications, risk factors, outcomes, and management of emergency peripartum hysterectomy globally and to compare outcomes among different income settings.

DATA SOURCES

PubMed, MEDLINE, EMBASE, ClinicalTrials.gov, Cochrane Library, Web of Science, and Emcare databases up to December 10, 2021.

METHODS OF STUDY SELECTION

Update of a systematic review and meta-analysis (2016). Studies were eligible if they reported the incidence of emergency peripartum hysterectomy, defined as surgical removal of the uterus for severe obstetric complications up to 6 weeks postpartum. Title and abstract screening and full-text review were performed using Endnote data-management software. Of 8,775 articles screened, 26 were included that were published after 2015, making the total number of included studies 154. A subanalysis was performed for the outcomes of interest per income setting.

TABULATION, INTEGRATION, AND RESULTS

The meta-analysis included 154 studies: 14,409 emergency peripartum hysterectomies were performed in 17,127,499 births in 42 countries. Overall pooled incidence of hysterectomy was 1.1 per 1,000 births (95% CI 1.0-1.3). The highest incidence was observed in lower middle-income settings (3/1,000 births, 95% CI 2.5-3.5), and the lowest incidence was observed in high-income settings (0.7/1,000 births, 95% CI 0.5-0.8). The most common indications were placental pathology (38.0%, 95% CI 33.9-42.4), uterine atony (27.0%, 95% CI 24.6-29.5), and uterine rupture (21.2%, 95% CI 17.8-25.0). In lower middle-income countries, uterine rupture (44.5%, 95% CI 36.6-52.7) was the most common indication; placental pathology (48.4%, 95% CI 43.5-53.4) was most frequent in high-income settings. To prevent hysterectomy, uterotonic medication was used in 2,706 women (17%): 53.2% received oxytocin, 44.6% prostaglandins, and 17.3% ergometrine. Surgical measures to prevent hysterectomy were taken in 80.5% of women, the most common being compressive techniques performed in 62.6% (95% CI 38.3-81.9). The most common complications were febrile (29.7%, 95% CI 25.4-34.3) and hematologic (27.5%, 95% CI 20.4-35.9). The overall maternal case fatality rate was 3.2 per 100 emergency peripartum hysterectomies (95% CI 2.5-4.2) and was higher in lower middle-income settings (11.2/100 emergency peripartum hysterectomies 95% CI 8.9-14.1) and lower in high-income settings (1.0/100 emergency peripartum hysterectomies 95% CI 0.6-1.6).

CONCLUSION

Substantial differences across income settings exist in the incidence of emergency peripartum hysterectomy. Women in lower-income settings have a higher risk of undergoing emergency peripartum hysterectomy and suffer more procedure-related morbidity and mortality. The frequency of emergency peripartum hysterectomy is likely to increase in light of increasing cesarean delivery rates.

Uterine Factor Infertility, a Systematic Review

Uterine factor infertility (UFI) is defined as a condition resulting from either a complete lack of a uterus or a non-functioning uterus due to many causes. The exact prevalence of UFI is currently unknown, while treatments to achieve pregnancy are very limited. To evaluate the prevalence of this condition within its different causes, we carried out a worldwide systematic review on UFI. We performed research on the prevalence of UFI and its various causes throughout the world, according to the PRISMA criteria. A total of 188 studies were included in qualitative synthesis. UFI accounted for 2.1 to 16.7% of the causes of female infertility. We tried to evaluate the proportion of the different causes of UFI: uterine agenesia, hysterectomies, uterine malformations, uterine irradiation, adenomyosis, synechiae and Asherman syndrome, uterine myomas and uterine polyps. However, the data available in countries and studies were highly heterogenous. This present systematic review underlines the lack of a consensual definition of UFI. A national register of patients with UFI based on a consensual definition of Absolute Uterine Factor Infertility and Non-Absolute Uterine Factor Infertility would be helpful for women, whose desire for pregnancy has reached a dead end.

The effect of surgical procedure on surgical outcomes in patients undergoing emergency peripartum hysterectomy: a retrospective multicenter study

OBJECTIVE

To investigate the effect of surgical procedure on the operation's results in patients undergoing emergency peripartum hysterectomy (EPH).

METHODS

The records of patients who underwent EPH due to postpartum hemorrhage between 2010 and 2020 in two tertiary centers with a high crude delivery rate were retrospectively analyzed. Surgical data were compared according to the EPH type.

RESULTS

During the study period, 115,709 births occurred in these two centers. EPH was administered for 181 (1.6%) of these patients. Sixty-seven (37%) of the EPH cases involved subtotal EPH (SEPH), and 114 (63%) were total EPH (TEPH). Surgical time (107.3 ± 17.6 vs. 134.2 ± 32.3 min, p < 0.001), erythrocyte transfusion count (2.6 ± 1.3 vs. 4.3 ± 6.2, p < 0.001), ureter injury (0.0 vs. 7.9%), bladder injury (1.5 vs. 28.1%), disseminated intravascular coagulation (1.5 vs. 9.6%), need for relaparotomy (4.5 vs. 14%), and intensive care unit admission (19.4 vs. 52.6%) were found to be higher in the TEPH group compared to the SEPH group (p < 0.05). In addition, the total length of hospitalization was longer in the TEPH group (4.5 ± 2.3 vs. 6.1 ± 4.6 day, p = 0.011).

CONCLUSION

According to the results, if the bleeding in peripartum hemorrhage requiring EPH can be controlled with SEPH, attempting to remove the cervix completely may be associated with increased surgical time, blood transfusion need, and surgical complications.