Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial

Intramyometrial and intravenous oxytocin compared to intravenous carbetocin for prevention of postpartum hemorrhage in elective cesarean section-A quasi-randomized controlled phase IV non-inferiority interventional trial

INTRODUCTION

Our objective was to assess non-inferiority of the unique approach used in our institution of combined 10 IU IM (intramyometrial) and 10 IU IV (intravenous) oxytocin to carbetocin IV in preventing severe postpartum blood loss in elective cesarean sections. The design was a prospective controlled phase IV non-inferiority interventional trial. The setting was a tertiary center at University Hospital, Zurich, Switzerland.

MATERIAL AND METHODS

The population consisted of 550 women undergoing elective cesarean section after 36 completed weeks of gestation at low risk for postpartum hemorrhage (PPH). Subjects were assigned to either combined oxytocin regimen (10 IU IM and 10 IU IV) or carbetocin (100 μg IV). Non-inferiority for oxytocin for severe PPH was assessed with a 0.05 margin using the Newcombe-Wilson score method. The main outcome measures were severe postpartum blood loss defined as delta hemoglobin (∆Hb, Hb prepartum-Hb postpartum) ≥30 g/L.

RESULTS

Non-inferiority of combined oxytocin (IM/IV) in preventing severe postpartum blood loss was not shown (17 women in the oxytocin group vs. 7 in the carbetocin group). The number needed to treat when using carbetocin was 28. The risk difference for ∆Hb ≥30 g/L was 0.04 (oxytocin 0.06 vs. 0.03), 95% confidence interval (CI) (0.00-0.08). No significant difference was observed for ∆Hb (median 12 [IQR 7.0-19.0] vs. 11 [5.0-17.0], p = 0.07), estimated blood loss (median 500 [IQR 400-600] vs. 500 [400-575], p = 0.38), or the PPH rate defined as estimated blood loss ≥1000 mL (12[4.5] vs. 5 [2.0], risk difference 0.03, 95% CI (-0.01 to 0.06), p = 0.16). More additional uterotonics were administered in the oxytocin group compared to the carbetocin group (15.2% vs. 5.9%, p = 0.001). Total case costs were non-significantly different in the oxytocin group (US $ 10 146 vs. 9621, mean difference 471.4, CI (-476.5 to 1419.3), p = 0.33).

CONCLUSIONS

Combined (IM/IV) oxytocin is not non-inferior to carbetocin regarding severe postpartum blood loss defined as postpartum Hb decrease ≥30 g/L in elective cesarean sections. We recommend carbetocin for use in clinical practice for elective cesarean sections.

Pregnancy with endometriosis: Assessment of national-level trends, characteristics, and maternal morbidity at delivery

OBJECTIVE

To examine pregnancy characteristics and maternal morbidity at delivery among pregnant patients with a diagnosis of endometriosis.

STUDY DESIGN

This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 17,796,365 hospital deliveries from 2016 to 2020, excluded adenomyosis and uterine myoma. The exposure was endometriosis diagnosis. Main outcome measures were clinical and pregnancy characteristics and severe maternal morbidity at delivery related to endometriosis, assessed with multivariable regression model.

RESULTS

Endometriosis was diagnosed in 17,590 patients. The prevalence of endometriosis increased by 24 % from one in 1,191 patients in 2016 to one in 853 patients in 2020 (adjusted-odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.19-1.30). Clinical and pregnancy characteristics that had greater than two-fold association to endometriosis included polycystic ovary syndrome, placenta previa, cesarean delivery, maternal age of ≥30 years, prior pregnancy loss, and anxiety disorder. Pregnant patients with endometriosis were more likely to have the diagnosis of measured severe maternal morbidity during the index hospitalization for delivery (47.8 vs 17.3 per 1,000 deliveries, aOR 1.91, 95%CI 1.78-2.06); these associations were more prominent following vaginal (aOR 2.82, 95%CI 2.41-3.30) compared to cesarean (aOR 1.85, 95%CI 1.71-2.00) deliveries. Among the individual morbidity indicators, endometriosis was most strongly associated with thromboembolism (aOR 5.05, 95%CI 3.70-6.91), followed by sepsis (aOR 2.39, 95%CI 1.85-3.09) and hysterectomy (aOR 2.18, 95%CI 1.85-2.56). When stratified for endometriosis anatomical site, odds of thromboembolism was increased in endometriosis at distant site (aOR 9.10, 95%CI 3.76-22.02) and adnexa (aOR 7.37, 95%CI 4.43-12.28); odds of sepsis was most increased in endometriosis at multi-classifier locations (aOR 7.33, 95%CI 2.93-18.31) followed by pelvic peritoneum (aOR 5.54, 95%CI 2.95-10.40); and odds of hysterectomy exceeded three-fold in endometriosis at adnexa (aOR 3.00, 95%CI 2.30-3.90), distant site (aOR 5.36, 95%CI 3.48-8.24), and multi-classifier location (aOR 4.46, 95%CI 2.11-9.41).

CONCLUSION

The results of this nationwide analysis suggest that pregnancy with endometriosis is uncommon but gradually increasing over time in the United States. The data also suggest that endometriosis during pregnancy is associated with increased risk of severe maternal morbidity at delivery, especially for thromboembolism, sepsis, and hysterectomy. These morbidity risks differed by the anatomical location of endometriosis.

Timely use of Bakri intrauterine balloon tamponade contributes to the effectiveness in controlling severe postpartum hemorrhage

The aim of the present study was to explore the effectiveness of Bakri intrauterine balloon tamponade (IUBT) in treating severe postpartum hemorrhage (SPPH). A cohort of 198 women with SPPH using IUBT were retrospectively selected. The baseline and maternal outcome characteristics were examined. The results demonstrated that women with SPPH had a high proportion of placenta accrete (53.0%). Bakri IUBT demonstrated a global effectiveness of 84.5% in SPPH treatment, accounting for 82.9% in women with placenta accrete. Compared with women with Bakri failure, women who experienced Bakri success had reduced rates of less use of pre-/post-IUBT intervention, blood transfusion, lower genital tract trauma, estimated blood loss (EBL), and a longer indwelling duration (P<0.05). Logistic regression revealed that the pre-IUBT intervention (OR=3.910; 95% CI: 1.684-9.079; P=0.002) was positively associated with hemostasis success, while lower genital tract trauma was negatively associated with Bakri success (OR=0.091; 95% CI: 0.009-0.894; P=0.040). Moreover, women diagnosed with placenta accrete underwent a greater number of transabdominal placed Bakri IUBT and pre-IUBT interventions than those without placenta accrete (P<0.05). No significant differences were observed in Bakri success, total EBL, pre-/post-IUBT EBL, infused volume of IUBT, IUBT indwelling duration, even the rate of hemostasis, lower genital tract trauma, blood transfusion, post-IUBT intervention, and puerperal fever between women with and without placenta accrete (P>0.05). In conclusion, placenta accrete may be the leading cause of SPPH. Bakri IUBT is an effective and safe measure for SPPH. Pre-IUBT intervention may be predictive of Bakri's success. The timely use of IUBT during labor may mitigate the impact of risk factors identified on PPH.

Efficacy and safety of prophylactic balloon occlusion in the management of placenta accreta spectrum disorder: a retrospective cohort study

OBJECTIVE

Placenta accreta spectrum disorder (PAS) is a serious obstetric complication associated with significant maternal morbidity and mortality. Prophylactic balloon occlusion (PBO), as an intravascular interventional therapies, has emerged as a potential management strategy for controlling massive hemorrhage in patients with PAS. However, current evidence about the clinical application of PBO in PAS patients are still controversial. This study aimed to evaluate the effectiveness and safety of PBO in the management of PAS.

METHODS

A retrospective cohort study including PAS patients underwent cesarean delivery was conducted in a tertiary hospital from January 2015 to March 2022. Included PAS patients were further divided into balloon and control groups by whether PBO was performed. Groups were compared for demographic characteristics, intraoperative and postoperative parameters, maternal and neonatal outcomes, PBO-related complication and follow up outcomes. Additionally, multivariate-logistic regression analysis was performed to determine the definitive associations between PBO and risk of massive hemorrhage and hysterectomy.

RESULTS

A total of 285 PAS patients met the inclusion criteria were included, of which 57 PAS patients underwent PBO (PBO group) and 228 women performed cesarean section (CS) without PBO (control group). Irrespective of the differences of baseline characteristics between the two groups, PBO intervention did not reduce the blood loss, hysterectomy rate and postoperative hospital stay, but it prolonged the operation time and increased the cost of hospitalization (All P < 0.05) Additionally, there were no significant differences in postoperative complications, neonatal outcomes, and follow-up outcomes(All P > 0.05). In particular, patients undergoing PBO were more likely to develop the venous thrombosis postoperatively (P = 0.001). However, multivariate logistic regression analysis showed that PBO significantly decreased the risk of massive hemorrhage (OR 0.289, 95%CI:0.109-0.766, P = 0.013). The grade of PAS and MRI with S2 invasion were the significant risk factors affecting massive hemorrhage(OR:6.232 and OR:5.380, P<0.001).

CONCLUSION

PBO has the potential to reduce massive hemorrhage in PAS patients undergoing CS. Obstetricians should, however, be aware of potential complications arising from the PBO. Additionally, MRI with S2 invasion and PAS grade will be useful to identify PAS patients who at high risk and may benefit from PBO. In brief, PBO seem to be a promising alternative for management of PAS, yet well-designed randomized controlled trials are needed to convincingly demonstrate its benefits and triage the necessity of PBO.

Efficacy of Bakri Intrauterine Balloon in Managing Postpartum Hemorrhage: A Comparative Analysis of Vaginal and Cesarean Deliveries with Placenta Accreta Spectrum Disorders

BACKGROUND The incidence of placenta accreta spectrum disorder (PAS) has been increasing in past decades, and women with PAS are a high-risk maternal population. This study aimed to explore the performance of Bakri intrauterine balloon tamponade (IUBT) in the treatment of postpartum hemorrhage (PPH), among those with and without PAS. MATERIAL AND METHODS The outcomes of 198 women who underwent treatment for PPH using IUBT were retrospectively analyzed. The demographics and maternal outcomes were analyzed for vaginal and cesarean births, with PAS and without PAS. RESULTS Compared to women with vaginal births (n=130), women who underwent cesarean births (n=68) showed a higher proportion of age ≥35 years (χ²=6.85, P=0.013), multiple births (χ²=13.60, P<0.001), preeclampsia (χ²=9.81, P=0.002), use of transabdominal IUBT (χ²=84.12, P<0.001) and pre-IUBT interventions (χ²=41.61, P<0.001), but had less infused volume of physiological saline (t=6.41, P<0.001). Women with PAS (n=105) showed a higher rate of pre-IUBT intervention (χ²=4.96, P=0.029) and transabdominal IUBT placement (χ²=9.37, P=0.002) than non-PAS women (n=93). The 36 women with PAS (n=36) showed a higher rate of preeclampsia (χ²=4.80, P=0.029), pre-IUBT intervention (χ²=5.90, P=0.015), and transabdominal IUBT placement (χ²=14.94, P<0.001) and a shorter duration from delivery to Bakri insertion (χ²=3.31, P=0.002), than non-PAS women (n=32). CONCLUSIONS PAS was a major cause of PPH at 198 vaginal and cesarean births. An accurate and timely pre-IUBT intervention and Bakri IUBT placement was critical for controlling PPH in cesarean births, especially in women with PAS.

Peripartum hysterectomy: A 9-year population-based study in Slovakia

OBJECTIVE

To assess the incidence of peripartum hysterectomy (PH) in Slovakia. Additionally, we wanted to describe reasons for the procedure, associated clinical circumstances, and complications.

METHODS

This was a descriptive, population-based study among women who underwent PH in Slovakia between January 2012 and December 2020. Peripartum hysterectomy was defined as surgical removal of the uterus from the peripartum period up to 42 days postpartum. Data were obtained retrospectively from the standardized questionnaires that are completed in Slovakia for any case of PH. The background population consisted of all other women who delivered during the study period.

RESULTS

Of the 436 136 births, there were 397 cases of PH, giving an incidence of 0.91 per 1000 births. It was higher with advanced maternal age, multiparity, multiple pregnancies, and cesarean deliveries. The main reasons for the procedure were placental pathologies and uterine atony in 52.9% and 33.0%, respectively. A total of 150 (37.8%) women required admission to an intensive care unit. The mortality rate was 1.5%.

CONCLUSION

The incidence of PH is relatively high in Slovakia when compared with other European countries, highlighting the need to improve prenatal diagnosis of morbidly adherent placenta and the management of peripartum hemorrhage.

Prevalence and determinants of hysterectomy in India

Increase in the prevalence of hysterectomy among low-and middle-income countries (LMICs) such as India has become a significant concern. Reports based on either a particular group or region show an increasing trend in hysterectomy, but there is a dearth of national-level data in this domain. Hence, there seems to be an urgent need to garner evidence on the prevalence and determinants of hysterectomy, which could pave the way for future programs and policies. We aimed to estimate the prevalence of hysterectomy and assess its determinants using a nationally representative sample. An observational analysis was conducted using data from Longitudinal Aging Study in India (LASI), 2017-2018. 38,154 women aged > 18 years were included. A multivariable logistic regression, presented as an adjusted odds ratio (AOR) with a 95% confidence interval (CI), was used to predict the association between various socio-demographic characteristics and hysterectomy. A separate multivariable logistic regression model was executed to determine the association between selected non-communicable diseases (NCDs) and hysterectomy. Survey weights compensated the complex study design. The overall prevalence of hysterectomy was around 11.35%. Excessive menstrual bleeding followed by fibroids emerged as the leading causes of hysterectomy. The various determinants of hysterectomy were urban residents [AOR: 1.54 (1.21-1.96)], other backward class [AOR: 2.19 (1.72-2.78], working women [AOR: 1.19(1-1.42)] and the most affluent (rich) group [AOR: 2.06 (1.62-2.63)]. Hysterectomy was associated with cancer [AOR: 4.83 (2.51-9.29)], diabetes [AOR: 1.79 (1.25-2.57)], hypertension [AOR: 1.48 (1.27-1.71)] and joint diseases [AOR: 1.43 (1.09-1.88)]. Hysterectomy is considerably prevalent in India, which cannot be overlooked. Health promotion regarding hysterectomy and its implications is needed especially among urban residents, affluent groups and those with a higher body mass index. Health programmes aimed at women should follow a life course approach by prioritizing health and overall well-being even after reproductive years.

Incidence, indications, and maternal outcomes of emergency peripartum hysterectomy at a tertiary hospital in Ethiopia: A retrospective review

OBJECTIVE

To determine the incidence, indications, and maternal outcomes of emergency peripartum hysterectomy (EPH) at a tertiary setting in Ethiopia.

MATERIALS AND METHODS

A 4-year retrospective review of EPH cases was conducted at St. Paul's Hospital Millennium Medical College (Ethiopia) from January 2016 to December 2019. Data were collected by reviewing maternal charts of EPH cases using a structured data extraction format. Stata Statistical Software, release 14, was used for data analysis. Frequency and percentages are used to present the significance of results.

RESULTS

Among 39 629 deliveries during the study period, there were 105 EPH, making the incidence rate 2.6 per 1000 deliveries. The common indications for EPH were uterine rupture (63/105; 60%), intractable uterine atony (23/105; 21.9%), and placenta accreta spectrum (14/105; 14.7%). The most common complications were anemia (85/105; 80.9%), puerperal fever (13/105; 12.4%), acute kidney injury (10/105; 9.5%), and relaparotomy (7/105; 6.7%).

CONCLUSION

The incidence of EPH observed in our institution is high. Appropriate patient selection for vaginal delivery and strict labor follow up with early intervention for labor abnormalities should be the guiding principles of optimal obstetrical care to alleviate the burden of uterine rupture.

Bakri Balloon for Treatment of Postpartum Hemorrhage: A Real-World 2016-2020 Study in 279 Women from a Single Center

BACKGROUND Postpartum hemorrhage (PPH) may be primary or secondary and is defined as the loss of 500 ml or more of blood within the first 24 h after birth. The Bakri balloon tamponade (BBT) is an intrauterine device used as an adjunctive treatment for refractory PPH. The aim of this study was to present the real-world experience from a single center on the effectiveness of the BBT for the treatment of PPH. MATERIAL AND METHODS This cohort study of 279 women was conducted in a real-world setting. Patients' characteristics and clinical outcomes between the BBT Success group and BBT Failure group were analyzed by t test or chi-square test. The primary outcome was the success rate of BBT. The secondary outcomes were the perinatal outcomes. RESULTS The success rate of BBT was 88.89% (248/279). A blood transfusion rate of 65.95% (184/279) was observed. After using the BBT, significant differences were observed in intervention (P<0.001), blood loss (P<0.001), indwelling time of BBT (P<0.001), and blood transfusion (P<0.001) between the Success group and Failure group. The Success group showed greater range of descent in blood loss (991.56.15±13.65 mL in Success group vs 816.23±7.57 mL in Failure group). Of the 31 women with BBT failure, 87.10% (27/31) received uterine artery embolization (UAE), 96.77% (30/31) received blood transfusion, and none required a hysterectomy. CONCLUSIONS The findings from this study from a single center in China supported those from previous studies showing that the BBT was an effective treatment to control PPH.

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.

Prevalence, socio-demographic determinants, and self-reported reasons for hysterectomy and choice of hospitalization in India

BACKGROUND

There is limited evidence of hysterectomy in India because of a lack of data in large-scale, nationally representative health surveys. In 2015-16, the fourth National Family Health Survey (NFHS-4)-a cross-sectional survey-collected for the first-time direct information on hysterectomy and self-reported reasons for undergoing the procedure among women in the reproductive age group. The current study evaluates the prevalence, determinants, and choice of hospitalization (Public vs. Private) for conducting hysterectomy in India among women aged 15-49 years in 29 states and seven union territories (UTs) based on the new large-scale population-based nationally representative dataset (NFHS 5).

METHODS

Cross-tabulations and percentage distributions were utilized to analyse the prevalence of hysterectomy and the choice of hospitalization (public vs. private) across different socioeconomic backgrounds and reasons for undergoing hysterectomy. A multivariate binary logistic regression model was also used to find statistically significant determinants of hysterectomy.

RESULTS

In India as a whole, 3.3% of women aged 15-49 years had undergone a hysterectomy. The percentage of women who had undergone the procedure was found to vary considerably across the states and the UTs. The southern region stands out for the considerably higher prevalence of hysterectomy; particularly in the states of Andhra Pradesh (8.7%) and Telangana (8.2%), the prevalence was very high followed by Bihar (6%) and Gujrat (4%). On the other hand, the North-eastern region had the lowest prevalence of hysterectomy (1.2%). A noticeable fact that emerged was that the majority of the hysterectomies were performed in the private sector (69.6%) in India. But the scenario was quite different in north-eastern region as in this region more hysterectomies were performed in public health facilities (73%) rather than private health facilities (26.7%). Age, place of residence, religion, caste, level of education, geographic region, wealth quintiles, parity, age at first cohabitation of women were found to be the socio-demographic determinants statistically associated with hysterectomy in India. The likelihood of hysterectomy was higher among women living in rural areas (AOR: 1.3, CI: 1.23-1.35), in the richest wealth quintile (AOR 2.6; CI 2.37-2.76) and in the southern region (AOR 1.6; CI 1.47-1.66). The reasons frequently reported for hysterectomy were excessive menstrual bleeding/pain, followed by fibroids/cysts.

CONCLUSION

This study has attempted to analyse hysterectomy prevalence and its socio-economic determinants using the latest fifth round of NFHS data of all the states and covering 21 states and union territories of India, which gives wider coverage of hysterectomy and more recent with accurate data. More research is needed therefore to unravel the complex dynamics of hysterectomy in India (and elsewhere) which could be used to help women make more informed choices and in turn advance their reproductive health and rights.

Peripartum hysterectomy due to severe postpartum hemorrhage: A hospital-based study

INTRODUCTION

A peripartum hysterectomy is typically performed as a lifesaving procedure in obstetrics to manage severe postpartum hemorrhage. Severe hemorrhages that lead to peripartum hysterectomies are mainly caused by uterine atony and placenta accreta spectrum disorders. In this study, we aimed to estimate the incidence, risk factors, causes and management of severe postpartum hemorrhage resulting in peripartum hysterectomies, and to describe the complications of the hysterectomies.

MATERIAL AND METHODS

Eligible women had given birth at gestational week 23+0 or later and had a postpartum hemorrhage ≥1500 mL or a blood transfusion, due to postpartum hemorrhage, at Oslo University Hospital, Norway, between 2008 and 2017. Among the eligible women, this study included those who underwent a hysterectomy within the first 42 days after delivery. The Norwegian Medical Birth Registry provided the reference group. We used Poisson regression to estimate adjusted incidence rate ratios with 95% confidence intervals to identify clinical factors associated with peripartum hysterectomy.

RESULTS

The incidence of hysterectomies with severe postpartum hemorrhage was 0.44/1000 deliveries (42/96313). Among the women with severe postpartum hemorrhage, 1.6% ended up with a hysterectomy (42/2621). Maternal age ≥40, previous cesarean section, multiple pregnancy and placenta previa were associated with a significantly higher risk of hysterectomy. Placenta accreta spectrum disorders were the most frequent cause of hemorrhage that resulted in a hysterectomy (52%, 22/42) and contributed to most of the complications following the hysterectomy (11/15 women with complications).

CONCLUSIONS

The rate of peripartum hysterectomies at Oslo University Hospital was low, but was higher than previously reported from Norway. Risk factors included high maternal age, previous cesarean section, multiple pregnancy and placenta previa, well known risk factors for placenta accreta spectrum disorders and severe postpartum hemorrhage. Placenta accreta spectrum disorders were the largest contributor to hysterectomies and complications.

Peripartum Ηysterectomy: A Four-Year Obstetric and Anesthetic Experience in a Tertiary Referral Hospital in Greece

Background

Although peripartum hysterectomy (PH) is a life-saving procedure in cases of abnormal placentation and postpartum hemorrhage, it can be associated with major obstetric and anesthetic complications. This retrospective study aimed to evaluate the incidence, etiology, perioperative anesthetic and obstetric management, complications, and fetal outcomes in women undergoing PH in a single tertiary referral hospital in Greece.

Methodology

This was a retrospective analysis of medical records of women who underwent emergency or elective PH in our hospital between January 2015 and December 2018.

Results

During the study period, 69 women who underwent a PH were identified. The incidence rate of elective and emergency PH was 4 and 1.2 per 1,000 deliveries, respectively. The main indication for PH was abnormal placentation (81.2%), followed by uterine atony (13%). Conversion to general anesthesia (GA) was performed in 21 (30.4%) cases.

Conclusions

This study showed a high prevalence of PH in our hospital compared to high-income countries. A neuraxial-only technique may be a safe alternative in individual cases of abnormal placentation. Conversion to GA can be reserved for complex surgical cases when massive hemorrhage is anticipated and, if possible, after the neonate has been delivered.

Prevalence and Factors Associated with Peripartum Hysterectomy among Iranian Pregnant Women: A Retrospective Study

BACKGROUND

Peripartum hysterectomy (PPH) is one of the effective treatment modalities which is increasingly performed to save the life of pregnant women with uncontrollable severe postpartum hemorrhage. The aim of this study was to assess the prevalence and factors associated with PPH among Iranian pregnant women.

METHODS

In a retrospective study, 33 pregnant women with PPH referred to Imam Khomeini Hospital in Sari, Mazandaran province, northern Iran were enrolled. Data were collected using census sampling from March 2017 to 2020. Patients' sociodemographic and clinical characteristics were collected. Fisher's exact test, Kruskal-Wallis, and Mann-Whitney tests were used to evaluate the study variables.

RESULTS

The prevalence of PPH among Iranian pregnant women was 2.81 per 1000 deliveries. The mean length of stay in the hospital and intensive care unit (ICU) was 6.15 (SD=2.91) and 3.17 (SD=1.50) days, respectively. Of the participants, 90.9% had a cesarean section, 51.6% had emergency PPH, 88.2% had emergency PPH in 24 hours after delivery, 9.1% had an induction, and 60.6% had PPH due to placental abnormalities. The mean duration of PPH procedure was 2.51 (SD=1.14) hours. The most common post-operative complication in participants was fever. Participants with older gestational age had more elective PPH (P=0.029). The length of ICU stay was more in patients with total PPH procedure compared to the supracervical (P<0.017). The induction rate was higher in emergency PPH after vaginal delivery compared to cesarean section (P=0.005).

CONCLUSION

This study showed a high prevalence of PPH among pregnant women. Also, there was a significant relationship between the PPH and length of ICU stay, especially after supracervical hysterectomy. The results of this study can help obstetrician-gynecologist to provide a better intervention for managing patients with postpartum hemorrhage requiring PPH.

Peripartum Hysterectomy: Is There Any Difference Between Emergency and Planned Surgeries?

OBJECTIVE

 To compare the outcomes of emergency and planned peripartum hysterectomies.

METHODS

 The present retrospective cross-sectional study was conducted in two hospitals. Maternal and neonatal outcomes were compared according to emergency and planned peripartum hysterectomies.

RESULTS

 A total of 34,020 deliveries were evaluated retrospectively, and 66 cases of peripartum hysterectomy were analyzed. Of these, 31 were cases of planned surgery, and 35 were cases of emergency surgery. The patients who underwent planned peripartum hysterectomy had a lower rate of blood transfusion (83.9% versus 100%; p = 0.014), and higher postoperative hemoglobin levels (9.9 ± 1.3 versus 8.3 ± 1.3; p < 0.001) compared with the emergency hysterectomy group. The birth weight was lower, although the appearance, pulse, grimace, activity, and respiration (Apgar) scores were higher in the planned surgery group compared with the emergency cases.

CONCLUSION

 Planned peripartum hysterectomy with an experienced team results in less need for transfusion and improved neonatal outcomes compared with emergency peripartum hysterectomy.

Incidence of Emergency Peripartum Hysterectomy in a Tertiary Obstetrics Unit in Romania

Background and Objectives: Emergency peripartum hysterectomy (EPH) is a life-saving surgical procedure performed when medical and surgical conservative measures fail to control postpartum hemorrhage. The objective of this study was to estimate the incidence of EPH and to determine the factors leading to this procedure and the maternal outcomes. Materials and Methods: A retrospective cohort study with all cases of EPH performed at Filantropia Clinical Hospital in Bucharest between January 2012 and May 2021. Results: There were 36 EPH, from a total of 36,099 births recorded. The overall incidence of EPH was 0.99 per 1000 deliveries, most cases being related to placenta accreta spectrum disorder and uterine atony. Conclusions: Peripartum hysterectomy is associated with an important maternal morbidity rate and severe complications. Efforts should be made to reduce the number of unnecessary cesarean deliveries.

Utilization and Comparative Effectiveness of Uterine Artery Embolization vs. Hysterectomy for Severe Postpartum Hemorrhage: A National Inpatient Sample Study

PURPOSE

To assess if uterine artery embolization conferred a lower risk of mortality or prolonged hospital stay compared to hysterectomy in severe post-partum hemorrhage (PPH) and to analyze if geographical or clinical determinants affected which therapy was received.

MATERIALS AND METHODS

This National Inpatient Sample study from 2005-2017 included all patients with live-birth deliveries. Severe PPH was defined as those requiring transfusion, hysterectomy, or uterine artery embolization (UAE). Propensity score weighting adjusted demographic, maternal, and delivery risk factors were used to assess mortality and prolonged hospital stay.

RESULTS

Of 9.8 million identified live births, PPH occurred in 31.0 per 1,000. The most common intervention for PPH was transfusion (116.4 per 1,000 cases of PPH). Hysterectomy was used more frequently than UAE (20.4 vs 12.9 per 1,000). The following factors predicted hysterectomy would be used more commonly than UAE: previous cesarean delivery, breech fetal position, placenta previa, transient hypertension of pregnancy without pre-eclampsia, pre-existing hypertension without pre-eclampsia, pre-existing hypertension with pre-eclampsia, unspecified maternal hypertension, and gestational diabetes (all p<0.001). Delivery risk factors associated with greater utilization of hysterectomy over UAE included post-dates pregnancy, premature rupture of membranes, cervical laceration, forceps vaginal delivery, and shock (all p<0.001). There was no difference in mortality between hysterectomy and UAE. After balancing demographic, maternal, and delivery risk factors, the odds of prolonged hospital stay were 0.38 times lower with UAE than hysterectomy (p<0.001).

CONCLUSION

Despite similar mortality and shorter hospital stays, UAE is used far less than hysterectomy in the management of severe PPH.

Obstetrical Hemorrhage

Obstetric hemorrhage is a leading cause of morbidity and mortality. Prevention includes identifying patients with risk factors and actively managing the third stage of labor. The anesthesiologist should be ready to manage hemorrhage with general strategies as well as strategies tailored to the specific cause of hemorrhage. Both neuraxial anesthesia and general anesthesia are appropriate in different situations. Treatments proven to be effective include increasing the oxytocin infusion, administering tranexamic acid early, guiding transfusion with point-of-care tests, and using cell salvage. Utilization of protocols and checklists within systems that encourage effective communication between teams should be implemented.

What is new in peripartum hysterectomy? A seventeen year experience in a tertiary hospital

OBJECTIVE

To identify changing trends in peripartum hysterectomy (PH), both elective. cesarean hysterectomy and emergency cesarean hysterectomy, at a single training and research hospital over the last 17 years in Istanbul, Turkey.

MATERIALS AND METHODS

A retrospective cohort study was performed between January 2001 and September 2017. The records of all patients who had PH at Kanuni Sultan Süleyman Training and Research Hospital were analyzed.

RESULTS

There were 243 cases of PH during the study period. A total of 266,386 births occurred, of which 60.1% were vaginal deliveries and 39.8% were cesarean sections. The incidence of PH increased from 0.67 per 1000 deliveries to 1.14 per 1000 deliveries during 2001-2008 and 2009-2017, respectively, with an overall incidence of 0.91 per 1000 deliveries during the 17 years. The main indication for PH changed significantly during this time from uterine atony (57.1%) to placenta accreta spectrum (85%). About 37% of women who underwent PH had at least one previous cesarean delivery during 2001-2008, whereas that percentage increased to 95.4% during 2009-2017.

CONCLUSION

Placenta accreta spectrum was the leading cause of PH and was associated with significant maternal morbidity and mortality.

Refractory uterine atony: still a problem after all these years

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine atony include induced or augmented labor, preeclampsia, chorio-amnionitis, obesity, multiple gestation, polyhydramnios, and prolonged second stage of labor. Although a risk assessment is recommended for all parturients, many women with uterine atony do not have risk factors, making uterine atony difficult to predict. Oxytocin is the first-line drug for prevention and treatment of uterine atony. It is a routine component of the active management of the third stage of labor. An oxytocin bolus dose as low as 1 IU is sufficient to produce satisfactory uterine tone in almost all women undergoing elective cesarean delivery. However, a higher bolus dose (3 IU) or infusion rate is recommended for women undergoing intrapartum cesarean delivery. Carbetocin, available in many countries, is a synthetic oxytocin analog with a longer duration than oxytocin that allows bolus administration without an infusion. Second line uterotonic agents include ergot alkaloids (ergometrine and methylergonovine) and the prostaglandins, carboprost and misoprostol. These drugs work by a different mechanism to oxytocin and should be administered early for uterine atony refractory to oxytocin. Rigorous studies are lacking, but methylergonovine and carboprost are likely superior to misoprostol. Currently, the choice of second-line agent should be based on their adverse effect profile and patient comorbidities. Surgical and radiologic management of uterine atony includes uterine tamponade using balloon catheters and compression sutures, and percutaneous transcatheter arterial embolization.

Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the effectiveness and safety of prophylactic intraoperative uterine artery embolization (UAE) performed immediately after fetal delivery during planned cesarean section or cesarean hysterectomy in patients with placenta accreta spectrum disorder or placenta previa.

METHODS

A systematic search was conducted on Ovid MEDLINE and Embase, PubMed, Web of Science, and Cochrane databases. Studies were selected using the Population/Intervention/Comparison/Outcomes (PICO) strategy. The intraoperative blood loss and the rate of emergent peripartum hysterectomy (EPH) were the primary outcomes, whereas the length of hospital stay and volume of blood transfused were the secondary outcomes. A random-effects model was employed to pool each effect size. The cumulative values of the primary outcomes were calculated using the generic inverse variance method.

RESULTS

Eleven retrospective cohort studies and five case series were included, recruiting 421 women who underwent prophylactic intraoperative UAE (UAE group) and 374 women who did not (control group). Compared with the control group, the UAE group had significantly reduced intraoperative blood loss (p = 0.020) during cesarean section or cesarean hysterectomy. Furthermore, the EPH rate was also significantly decreased (p = 0.020; cumulative rate: 19.65%), but not the length of hospital stay (p = 0.850) and volume of pRBC transfused (p = 0.140), after cesarean section in the UAE group. The incidence of major complications was low (3.33%), despite two patients with uterine necrosis.

CONCLUSION

The currently available data provides encouraging evidence that prophylactic intraoperative UAE may contribute to hemorrhage control and fertility preservation in women with abnormal placentation.

REGISTRATION

PROSPERO registration code: CRD42021230581. https://clinicaltrials.gov/ct2/show/CRD42021230581 LEVEL OF EVIDENCE: Level 2a, systematic review of retrospective cohort studies.

Pregnancy-Related Hysterectomy for Peripartum Hemorrhage: A Literature Narrative Review of the Diagnosis, Management, and Techniques

Postpartum hemorrhage is a life-threatening situation, in which hysterectomy can be performed to prevent maternal death. However, it is associated with high rates of maternal morbidity and mortality and permanent infertility. The incidence of pregnancy-related hysterectomy varies across countries, but its main indications are the following: uterine atony and placenta spectrum (PAS) disorders. PAS disorder prevalence is rising during the last years, mainly due to the increased number of cesarean sections. As a result, obstetricians should be aware of the difficulties of this emergent condition and improve its accurate antenatal diagnosis rates, as well as its modern management strategies. Of course, special skills are required during a pregnancy-related hysterectomy, so these patients should be referred to centers of excellence in antenatal care, where a multidisciplinary team approach is followed. This study is a narrative review of the literature of the last 5 years (PubMed, Cochrane) regarding postpartum hemorrhage to offer obstetricians up-to-date knowledge on this pregnancy-related life-threatening issue. However, there is a lack of available high-quality data, because most published papers are retrospective case series or observational cohorts.

Efficacy and safety of prophylactic abdominal aortic balloon occlusion versus internal iliac arterial balloon occlusion for placenta accreta spectrum disorder: A systematic review and meta-analysis

PURPOSE

To assess the efficacy and safety of abdominal aortic (AA) balloon occlusion versus internal iliac arteries (IIA) balloon occlusion in patients with placenta accreta spectrum (PAS) disorders.

METHODS

Databases of Embase, PubMed, Web of Science and Cochrane Library were systematically searched from inception to May 2020. The relevant literature was screened and the quality was assessed. RevMan software 5.3 was used to analyze the data.

RESULTS

Six studies involving 239 patients in AA occlusion and 281 patients in IIA occlusion were included. The results demonstrated that the intraoperative hemorrhage volume (MD - 410.61 ml, 95% CI -779.74 to -41.47 ml, p < 0.001), balloon dilatation duration (MD -5.34 min, 95% CI -9.91 to -0.77 min, p = 0.02) and fetus radiation dose (MD-20.81 mGy, 95% CI -31.84 to -9.78 mGy, p < 0.001) were significantly less in AA occlusion compared to IIA occlusion. There was no significant difference in the rate of lower extremity thrombosis between AA occlusion and IIA occlusion (OR 0.21, 95% CI 0.02 to 2.21, p = 0.19); similarly, no significant differences were found in blood transfusion volume (MD -344.50 ml, 95% CI -735.74 to 46.74 ml, p = 0.08), the rate of hysterectomy (OR 0.99, 95% CI 0.22 to 4.44, p = 0.99) and other outcome variables.

CONCLUSION

The available data demonstrated AA occlusion was more effective in reducing intraoperative hemorrhage volume and fetus radiation dose compared with IIA occlusion in patients with PAS disorders. Larger studies or randomized controlled trials are needed to further assert this evidence.

Incidence, Management and Outcomes in Women Undergoing Peripartum Hysterectomy in a Tertiary Care Centre in India

Background Peripartum hysterectomy (PRH) is the surgical removal of the uterus performed in obstetrical complications such as uncontrolled postpartum haemorrhage (PPH), unrepairable uterine rupture, and sepsis. Its incidence has increased in recent years. The objective of this study was to review all the cases of PRH in a tertiary care teaching hospital over three years (January 2017-December 2019) to determine its incidence and analyse clinico-demographic characteristics in these women. Method All women undergoing PRH from January 2017 to December 2019 were included in the study. Data were collected retrospectively from medical records, of patients who underwent a PRH at the time of delivery, or within 24 hours, or performed any time before discharge from the same hospitalization and obstetric event. The total number of deliveries including caesarean and vaginal deliveries were recorded. Main outcome measures were the incidence of PRH, indication for hysterectomy, management option used, maternal outcomes (PPH, bladder injury and maternal death) and fetal outcomes (stillbirth). Results There were a total of 3904,4 deliveries; 27,337 vaginal and 11,697 caesarean sections in three years. A total of 50 patients underwent a PRH. The incidence of PRH in our study was 1.3 per 1,000 deliveries and 3.5/1,000 caesareans, respectively. PRH was found to be more common following cesarean sections than vaginal deliveries (odds ratio 22.86 [95% CI: 8.16 to 63.98]). Morbid adherent placenta (MAP) (n=30, 62%) was the most common indications of PRH. Seven (15%) women had PRH due to uterine rupture. Twenty-seven women of the 30 women (90%) with the MAP had a previous caesarean delivery. The case fatality rate per hysterectomy was 4%. Stillbirth rate (SBR: n=8,16%) among women having PRH was seven-fold higher than overall SBR in our country. Conclusion There has been a rise in MAP as an indication of PRH in our study for a decade in comparison to uterine atony. Caesarean delivery is a significant risk factor for PRH. Previous caesarean section and major placenta previa were common occurring obstetric risk factors present in the MAP in our cohort. Our maternal mortality in PRH was low and the stillbirth rate was high when compared with national data.

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.

Adverse obstetric outcomes in two Brazilian maternity hospitals

PURPOSE

Obstetric adverse outcomes (AOs) are an important topic and the use of composite measures may favor the understanding of their impact on patient safety. The aim of the present study was to estimate AO frequency and obstetric care quality in low and high-risk maternity hospitals.

DESIGN/METHODOLOGY/APPROACH

A one-year longitudinal follow-up study in two public Brazilian maternity hospitals. The frequency of AOs was measured in 2,880 randomly selected subjects, 1,440 in each institution, consisting of women and their newborn babies. The frequency of 14 AOs was estimated every two weeks for one year, as well as three obstetric care quality indices based on their frequency and severity as follows: the Adverse Outcome Index (AOI), the Weighted Adverse Outcome Score and the Severity Index.

FINDINGS

A significant number of mothers and newborns exhibited AOs. The most prevalent maternal AOs were admission to the ICU and postpartum hysterectomy. Regarding newborns, hospitalization for > seven days and neonatal infection were the most common complications. Adverse outcomes were more frequent at the high-risk maternity, however, they were more severe at the low-risk facility. The AOI was stable at the high-risk center but declined after interventions during the follow-up year.

ORIGINALITY/VALUE

High AO frequency was identified in both mothers and newborns. The results demonstrate the need for public patient safety policies for low-risk maternity hospitals, where AOs were less frequent but more severe.

Women's experiences following emergency Peripartum hysterectomy at St. Francis hospital Nsambya. A qualitative study

Background

Emergency peripartum hysterectomy (EPH) is a known remedy for saving women’s lives when faced with the challenging situation of severe post partum hemorrhage not responsive to conservative management. However, EPH by its nature is also a traumatic birth event that causes serious physical, emotional and psychological harm. Unfortunately at St. Francis Hospital Nsambya nothing much is known about these experiences since no study has been undertaken and these women are not routinely followed up. The purpose of this study was to explore these emotional experiences.

Methods

This was a qualitative phenomenological study carried out between August and December 2018. All those women who had undergone EPH between January 2015 and August 2018 were eligible to participate in the study. Purposive sampling was used. 18 women were interviewed before saturation was reached. All interviews were audio-recorded and then transcribed verbatim. Thematic analysis was used to analyze the data.

Results

Three major themes were identified as the main experiences of these women in this study and they were; Loss of Womanhood, Joy for being alive and Loss of marital safety.

Conclusion

Women experience serious emotional consequences following EPH. We recommend routine follow-up to help appreciate these experiences and advise them on appropriate mitigating measures.

Inner myometrial laceration: Case report and literature review

Inner myometrial laceration is a rarely encountered intrapartum uterine trauma, which usually present as post-partum hemorrhage (PPH). The diagnosis can only be confirmed by direct examination of the uterine cavity but it should be suspected in PPH with good uterine contraction. Discussed here are the characteristics and management of the reported cases including two women managed at our center.

Emergency peripartum hysterectomy at Jordan University hospital - a teaching hospital experience

Introduction

Emergency peripartum hysterectomy (EPH) is a foremost operation and is perpetually implemented in the presence of life intimidating hemorrhage during or immediately after abdominal or vaginal deliveries. The aim of this study was to review cases managed at the Department of Gynecology and Obstetrics at Jordan University Hospital (JUH).

Material and methods

All women who underwent EPH due to any cause in the period from January 2010, to December 2017 were included in the study. Data were collected retrospectively using the patients’ files namelessly. Main measures: age, gravidity, parity, number of previous cesarean sections, previous uterine surgeries, indication for hysterectomy, complications, antepartum bleeding and the need for blood transfusion.

Results

In total, 74 cases of EPH were managed during the study period. The incidence of EPH ranged from 0.24 to 8.7 per 1000 deliveries. EPH was found to be more common following cesarean sections than vaginal deliveries. The prime indication was abnormal placentation, uterine atony, and uterine rupture. The risk factors included previous cesarean sections, scarred uteruses, multiparity, older age group. Maternal morbidity ranged from 26.5 to 31.5% and mortality from 0 to 12.5% with a mean of 4.8%.

Conclusions

EPH is the most demanding obstetric surgery performed in very tiresome circumstances of life threatening hemorrhage. The indication for EPH in recent years has changed from outdated uterine atony to abnormal placentation. Antenatal eagerness of the risk factors, engrossment of proficient obstetricians at an early stage of management and a prompt hysterectomy after adequate resuscitation would go a long way in tumbling morbidity and mortality.

Epidemiological analysis of peripartum hysterectomy across nine European countries

INTRODUCTION

Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries.

MATERIAL AND METHODS

We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section.

RESULTS

A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (ρ = 0.67, P < .05).

CONCLUSIONS

Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy.

FREQUENCY, DISTRIBUTION BY PLACE OF DELIVERY AND PARITY, CAUSES, MANAGEMENT OPTIONS AND OUTCOME OF PRIMARY POSTPARTUM HAEMORRHAGE IN POSTPARTUM WOMEN OF DISTRICT PESHAWAR, PAKISTAN

Background: Primary postpartum haemorrhage (PPPH) is the leading cause of maternal morbidity and mortality in low resource countries like Pakistan. The objectives of this study were to determine the frequency, distribution by place of delivery and parity, causes, management options and outcome of PPPH in postpartum women of District Peshawar, Pakistan. Materials & Methods: This cross-sectional study was conducted in Department of Gynaecology & Obstetrics, Lady Reading Hospital, Peshawar, Pakistan from 1st January 2019 to 30th June 2019. Sample size of 4,034 was with 0.39342 % margin of error, 95% confidence level, prevalence of PPPH 2% and a population of 23,607 postpartum women. All postpartum women were eligible. Those with secondary PPH, surgical management for PPPH done at some other hospital, with known bleeding disorders and on anticoagulants were excluded. All these patients were managed according to standard protocols. Data was collected for following variables; presence of PPPH (yes/ no), place of delivery (in-hospital deliveries/ referred cases), parity (primipara/multipara/grandmultipara), causes of PPPH (uterus atony/retained placenta-RPOC/ruptured uterus/genital tract tears), management options of PPPH (conservative management/laparotomy with repair of ruptured uterus/laparotomy with uterine artery ligation and B-Lynch/repair of genital tract tears other than ruptured uterus/removal of retained placenta & RPOC/hysterectomy) and outcome of PPPH (uneventful recovery/maternal near miss/maternal mortality). Frequencies and percentages with confidence intervals were calculated for these variables. Results: Out of 4034 postpartum women, frequency of PPPH was 400 (9.92%). Out of 4034 women, distribution of 400 cases of PPPH by place of delivery was 222 (5.50%) in-hospital deliveries and 178 (4.42%) referred cases and by parity it was primipara 79 (1.96%), multipara 243 (6.03%) and grandmultipara 78 (1.93%) cases. Out of 400 cases of PPPH, frequency of uterine atony was 254 (63.50%) and conservative management 245 (61.25%). Out of 400 cases, frequency of uneventful recovery was 352 (88%), maternal near miss 40 (10%) and maternal mortality eight (2%) cases. Conclusion: Primary postpartum haemorrhage (PPPH) continues to be a common and serious complication of delivery with uterine atony being its most predominant cause.

Old and novel insights into emergency peripartum hysterectomy: a time-trend analysis

PURPOSE

To assess changing trends, role of the triad patient-pregnancy-health professionals and health care cost in emergency peripartum hysterectomy (EPH).

METHODS

Demographics, indications, perinatal outcomes, perioperative complications in EPH cases performed in a 10-year period were extracted from the local birth registry. Experience of health professionals in the management of the post-partum haemorrhage was valued. Two subgroups (Period I, 2009-2013 vs. Period II, 2014-2018) were recognized. Overall and detailed EPH ratios/1000 deliveries were calculated. Cost analysis was achieved in agreement with the diagnosis-related group (DGR) system.

RESULTS

A total of 39 EPH were performed among 36,053 deliveries. EPH incidence increased from 0.8 to 1.32‰ across study periods (p < 0.001). The mean maternal age (36.9 ± 4.7 vs. 38.9 ± 5.9 years, p = 0.035) and the high socio-economic status (0 vs. 19.2%, p = 0.027) were statistically different. Multiparity (84.6 vs. 96.2%, p = 0.005), previous caesarean section (CS) (0.9 ± 0.9 vs. 1.2 ± 1.6, p = 0.049), and emergent CS (7.7 vs. 19.2%, p = 0.048) were found statistically different. In Period II, increased attempts in conservative approaches (7.7 vs. 36.8%, p = 0.007), reduction in blood loss (3184 ± 1753 vs. 2511 ± 1252 mL, p = 0.045), advanced age of gynecologists performing EPH (54.5 ± 9.2 vs. 60.3 ± 6.4 years, p = 0.024), and augmented health care costs (mean DRG of € 2.782 vs. 3.371,95, p < 0.001) were observed.

CONCLUSIONS

As a "near-miss" event, advances on identification of EPH factors are mandatory. Time-trend analyses might add information and address novel strategies.

Clinical outcomes of prophylactic compression sutures for treatment of uterine atony during the cesarean delivery of twins

BACKGROUND

Twin pregnancy has a high risk for developing uterine atony (UA). This study aimed to evaluate efficacy and clinical outcomes of prophylactic compression sutures to treat UA during twin cesarean section (CS).

METHODS

All patient records of twin deliveries by CS after gestational age of 24 weeks in a large maternity hospital in South Korea between January 2013 and June 2018 were reviewed. Patients with monochorionic monoamniotic twins were excluded from data analysis. In total, 953 women were eligible for data analysis.

RESULTS

Of the 953 patients, compression sutures were applied to 147 cases with postpartum bleeding that were refractory to uterine massage and uterotonics. Out of the 147, two patients (1.4%) proceeded to additional uterine artery ligation to achieve hemostasis, yielding a success rate of 98.6%. The rate of transfusion after the first 24 h of delivery in the suture group was not significantly different from that in the non-suture group, suggesting that both groups achieved hemostasis at an equal rate after the first 24 h of delivery. The difference in the operation time between the two groups was only 8.5 min. The rate of subsequent pregnancy among the patients who received compression sutures was 44.4%.

CONCLUSIONS

Overall, our findings suggest that with early and fast implementation of compression sutures, UA can be treated in the setting of twin cesarean delivery without significantly increasing maternal morbidity.

Symptoms of Discomfort and Problems Associated with Mode of Delivery During the Puerperium: An Observational Study

Despite abundant literature on antenatal and delivery care received by pregnant women, there is a wide knowledge gap on the prevalence of symptoms of discomfort or problems during the postpartum period and their relationship with the mode of delivery. This cross-sectional study, carried out with 3324 participants in Spain in 2017, aimed to investigate the association between the mode of delivery and self-reported postpartum symptoms of discomfort and maternal problems during the puerperium. An ad hoc online questionnaire was used to collect data on socio-demographic and obstetric variables, symptoms of discomfort, and maternal problems during the puerperium. The crude odds ratios (OR) and adjusted OR (aOR) and their 95% confidence intervals (95%CI) were calculated using binary logistic regression. In total, 3324 women participated. Compared to a normal vaginal delivery, having a cesarean section was associated with increased odds of an infected surgical wound (aOR: 11.62, 95%CI: 6.77–19.95), feeling sad (aOR: 1.31, 23 95%CI: 1.03–1.68), and symptoms of post-traumatic stress (aOR: 4.64, 95%CI: 2.94–7.32). Instrumental delivery vs. normal vaginal delivery was a risk factor for constipation (aOR: 1.35 95%CI: 25 1.10–1.66), hemorrhoids (aOR: 1.28, 95%CI: 1.04–1.57), urinary incontinence (aOR: 1.30, 95%CI: 26 1.05–1.61), and fecal incontinence (aOR: 1.94, 95%CI: 1.29–2.92) during the puerperium. Women who gave delivery via cesarean section or instrumental delivery had higher incidences of infection and psychological alterations than those who had a normal vaginal delivery. Identifying women at risk of giving birth by cesarean section and informing them about subsequent symptoms of discomfort and maternal problems during the puerperium must be included in pregnancy health program policies and protocols to allow women to make informed decisions regarding their birthing plan.

Prevalence, sociodemographic determinants and self-reported reasons for hysterectomy in India

Background

Evidence of hysterectomy in India is limited mainly due to lack of information in large-scale nationally representative health surveys. In 2015–16, the fourth National Family Health Survey (NFHS-4) – a cross-sectional survey – collected for the first time direct information on hysterectomy and self-reported reasons for undergoing the procedure among women in the reproductive age group. This paper examines the prevalence and determinants of hysterectomy in India among women aged 30–49 years in 29 states and seven union territories (UTs) of India using the NFHS-4 dataset.

Methods

Percentage weighted by sampling weights was used for estimating the prevalence of hysterectomy. The paper used crosstabulations and percentage distributions to estimate the prevalence of hysterectomy across different socioeconomic backgrounds and reasons for undergoing hysterectomy respectively. A multivariate binary logistic regression model was also used to find statistically significant determinants of hysterectomy.

Results

In India as a whole, 6 % of women aged 30–49 years had undergone a hysterectomy. The percentage of women who had undergone the procedure was found to vary considerably across the states and the UTs (from a minimum of 2% in Lakshadweep to a maximum of 16% in Andhra Pradesh). A noticeable fact that emerged was that the majority of the hysterectomies were performed in the private sector except in the northeast region. Years of schooling, caste, religion, geographic region, place of residence, wealth quintiles, age, parity, age at first cohabitation, marital status, and body mass index of women were found to be the sociodemographic determinants statistically associated with hysterectomy in India. The reasons reported frequently for hysterectomy were excessive menstrual bleeding/pain (56%), followed by fibroids/cysts (20%).

Conclusion

The percentage and likelihood of undergoing hysterectomy are relatively high among women from older age groups (45–49), those who reside in rural areas, those without schooling, those who are obese, those having high parity, those with a low age at first marriage, and those who reside in the eastern and southern parts of India. The policy implication of these findings is that the reproductive health program managers should ensure regular screening and timely treatment of the problems resulting in hysterectomy.

Comparison of outcome between intrauterine balloon tamponade and uterine artery embolization in the management of persistent postpartum hemorrhage: A propensity score-matched cohort study

INTRODUCTION

The aim of this study was to compare the outcomes of women who were initially managed by intrauterine balloon tamponade or uterine artery embolization because of persistent postpartum hemorrhage demanding an immediate intervention to control bleeding.

MATERIAL AND METHODS

Propensity score-matched cohort study including women who had intrauterine balloon tamponade or uterine artery embolization as initial management strategy to control persistent postpartum hemorrhage, that is, refractory to first-line therapy combined with at least one uterotonic agent. The primary outcome measure was a composite of peripartum hysterectomy and/or maternal mortality. Secondary outcomes measures were total volume of blood loss and total number of packed red blood cells transfused.

RESULTS

Our 1:1 propensity score-matched cohort comprised of 50 women who had intrauterine balloon tamponade and 50 women who underwent uterine artery embolization at a blood loss between 1000 and 7000 mL. There was no statistically significant difference in the hysterectomy risk between the two groups (n = 6 in each group, odds ratio [OR] 1.00, 95% confidence interval [CI] .30-3.34), in total volume of blood loss (median 4500 mL, interquartile range [IQR] 3600-5400) for balloon vs 4000 mL (IQR 3250-5000) for embolization, P = 0.382) or in total units of packed red blood cells transfused (median 7 (IQR 5-10) for balloon vs 6 [IQR 4-9] for embolization, P = 0.319). Fifteen women (30%) who were initially managed by an intrauterine balloon still underwent uterine artery embolization, of whom one had an embolization-related thrombo-embolic event. Maternal mortality occurred in neither of the intervention groups.

CONCLUSIONS

No difference in the risk of peripartum hysterectomy and/or maternal death was observed between women who had intrauterine balloon tamponade and women who underwent uterine artery embolization as an initial management for persistent postpartum hemorrhage. Although this study was underpowered to demonstrate equivalence, our study design provides a framework for future research in which intrauterine balloon tamponade may prove to be a suitable intervention of first choice in the management of persistent postpartum hemorrhage.

No longer rare diseases and obstetric anesthesia

PURPOSE OF REVIEW

With new medical technologies and changing life styles, maternal demographics has changes and consequently older and sicker women are becoming pregnant.In this review, we present these different high-risk parturient populations, which were once considered rare for the practicing obstetric anesthesiologist.

RECENT FINDINGS

With lifestyle and medical advances, older and sicker women are getting pregnant. Older women are more prone to pregnancy complications. Cancer survivors are becoming pregnant and more pregnant women are being diagnosed with cancer. Previous neurological and cardiac conditions considered not compatible with pregnancy are now seen more frequently. As the rate of obesity increases so does the rate of obstructive sleep apnea, which is known to be associated with many adverse maternal and neonatal sequalae. Finally, increased use of both opioids and marijuana has led to increased number of pregnant women using these illicit substances.

SUMMARY

Future research and implementation of international guidelines for management of these high-risk parturient population is necessary in order to reduce maternal and neonatal morbidity.

Clinical analysis of uterine artery embolization combined with double balloon catheter plus curettage for patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester: Three case reports

RATIONALE

It is very difficult to treat patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester.

PATIENT CONCERNS

In this study, case 1 was with fetal malformation of 18-trisomy syndrome at gestation of 19 weeks + 2 days, case 2 was with fetal malformation of 18-trisomy syndrome at gestation of 22 weeks + 1 day, and case 3 was for intrauterine fetal death at gestation of 27 weeks. All the 3 cases were completely placenta previa.

DIAGNOSES

For the 3 patients, completely placenta previa was confirmed by ultrasound examination after hospitalization and underwent pregnancy termination for fetal death or fetal malformation in the 2nd trimester.

INTERVENTIONS

The 3 patients with placenta previa underwent pregnancy termination by mifepristone combined with ethacridine lactate in the 2nd trimester for intrauterine fetal death or fetal malformation from June 2017 to May 2018, and suffered antenatal massive hemorrhage during termination. Uterine artery embolization (UAE) was immediately performed to achieve hemostasis, then double balloon catheter (DBC) was carried out to promote cervical ripen, at last curettage was implemented with the help of ultrasound. After all these procedures, the clinical outcomes were observed.

OUTCOMES

The antenatal bleeding volume of these 3 patients were about 500, 600, and 550 mL. After implementing the combined treatment, all patients completed the abortion. The UAE-DBC time interval and DBC-curettage time interval were 58.4 and 6.0 hours, respectively, for case 1, whereas almost 0 (i.e., immediately) for cases 2 and 3. Case 1 had a fever lasting for 3 days, and the maximum body temperature was up to 39°C after UAE. Moreover, the blood culture was positive for Escherichia coli after curettage in case 1, whereas it was negative in the other 2 cases.

LESSONS

The UAE-DBC-curettage combined treatment is safe and effective for patients with placenta previa who undergo pregnancy termination and suffered massive antenatal hemorrhage in the 2nd trimester. Future studies are needed to advance our observation.

The Relevance of the Second Cesarean Delivery in the Reduction of Institutional Cesarean Delivery Rates

OBJECTIVE

The cesarean delivery rate has increased worldwide. The aim of our study was to assess the events associated with the second cesarean deliveries in our institution.

SUBJECTS AND METHODS

All cesarean deliveries at the Maternity Hospital, Kuwait, from January 1 to December 31, 2013, were identified. A comparative study was undertaken on patients having their first and second cesarean deliveries. The social and clinical characteristics of these patients were extracted from our records and the antenatal, intrapartum, and postpartum course of the pregnancies and their outcomes documented.

RESULTS

During the study period, 10,586 deliveries were recorded, including 3,676 cesarean deliveries, i.e., a cesarean delivery rate of 34.7%. 840 of these patients were undergoing their first cesarean delivery (group A) and 607 patients were undergoing their second (group B); 484 patients from group A and 341 patients from group B with complete records were analyzed. Mean age (30.89 ± 4.93 vs. 29.94 ± 5.56 years, p = 0.008), parity (1.49 ± 1.22 vs. 0.98 ± 1.60, p < 0.0001), gestational age at delivery (38.12 ± 2.61 vs. 37.66 ± 3.11 weeks, p = 0.02), and fetal birth weight (3,211.60 ± 691.51 vs. 2,829.73 ± 863.26 g, p < 0.001) were significantly higher in group B than in group A. 53.2% of the patients in group B requested repeat cesarean delivery, their second cesarean. The rate of maternal morbidity was low.

CONCLUSIONS

The incidence of repeat cesarean delivery in group B is high, and its reduction should contribute to a lowering of the overall cesarean delivery rate.