Trends in the rates of peripartum hysterectomy and uterine artery embolization

Long-Term Effect on Ovarian Function After Uterine Artery Embolization During the Postpartum Period: A Nationwide Population-Based Study

Uterine artery embolization(UAE) is widely used in obstetrical indications, including postpartum bleeding and placental implantation abnormality, to manage many conditions to conserve the uterus. However, physicians are concerned about future fertility or ovarian function due to the occlusion of major pelvic vessels in the uterine artery embolization. However, there are limited data related to UAE usage during the postpartum period. This study was to evaluate the impact of UAE during the postpartum period on primary ovarian failure(POF), menstrual disorders, and infertility in women. Using the Korea National Health Insurance claims database, all pregnant women who delivered between January 2007 and December 2015 and underwent UAE during the postpartum period were identified. The occurrence of POF, female infertility, and menstrual disorders after delivery was evaluated. Using Cox proportional hazards models, the adjusted hazard ratios and 95% confidence intervals were estimated. 779,612 cases were analyzed in the study with 947 women in the UAE group. After delivery, the incidence of POF (0.84% vs.0.27%, P<.0001) and female infertility (10.24% vs. 6.89%, P<.0001) were higher in UAE group than in the control group. After adjusting for covariates, the POF risk was significantly higher in UAE group than in the control group (HR 2.37, 95% CI 1.16-4.82). The risk for the disorder of menstrual frequency (HR 1.28, 95% CI 1.10-1.50) and female infertility (HR 1.37, 95% CI 1.10-1.71) was significantly higher in UAE group than in the control group. This study confirmed UAE during the postpartum period is a risk factor for POF after delivery.

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.

The association between race/ethnicity and peripartum hysterectomy and the risk of perioperative complications

OBJECTIVE

To compare perioperative outcomes by patient race/ethnicity.

METHODS

A retrospective cohort study identified 7 331 638 childbirth hospitalizations for women aged 12-55 years in the USA between 2004-2014. Peripartum hysterectomy, in-hospital mortality, perioperative complications, length of stay, and cost of hysterectomy data were analyzed using SAS.

RESULTS

Among childbirth hospitalizations (52.9% white, 13.5% black, 23.0% Hispanic, 5.2% Asian, and 5.4% other), peripartum hysterectomy occurred in 6619. The incidence of peripartum hysterectomy was 90.3 (95% confidence interval [CI] 87.7-93.0) per 100 000 hospitalizations, and higher for black (111.0, 95% CI 104.5-117.4), Hispanic (104.9, 95% CI 99.1-110.8), and Asian women (119.6, 95% CI 109.1-130.2) compared to whites (75.7, 95% CI 72.8-78.5). After adjustment, Hispanic women had an 18% higher odds of undergoing peripartum hysterectomy (odds ratio [OR] 1.18, 95% CI 1.08-1.29; P=0.004) than white women. Non-white women had a 2-3-fold higher odds of in-hospital mortality (OR_black 2.76, 95% CI 1.44-5.30; OR_Hispanic 1.99, 95% CI 1.04-3.82; OR_Asian+other 2.44, 95% CI 1.11-5.40. Black and Asian/other women were more likely to undergo blood transfusions.

CONCLUSION

Women of color have higher rates of peripartum hysterectomy and experience higher rates of poor perioperative outcomes and mortality.

Uterine artery embolization versus hysterectomy in the treatment of refractory postpartum hemorrhage: a systematic review and meta-analysis

Introduction: We carried out a systematic review and meta-analysis to assess the safety and effectiveness of uterine artery embolization (UAE) compared with conventional hysterectomy on refractory postpartum hemorrhage (PPH).Methods: We searched PubMed, Embase, Chinese National Knowledge Infrastructure database (CNKI), Cochrane Library, and Wanfang database through October 2017 for randomized controlled trials (RCTs) and observational studies assessing the safety and effectiveness of UAE compared with hysterectomy on refractory PPH. The main outcome measures included the blood loss, operating time, hemostatic effective rate, and length of stay.Results: Six RCTs and nine observational studies were included in the meta-analysis, which involved 1142 women with refractory PPH. The results demonstrated that UAE was more beneficial on refractory PPH compared with hysterectomy using four scales: blood loss (WMD 893.39 mL; 95% CI: -1205.65, -581.13; p < .001); operating time (WMD -37.19 minutes; 95% CI: -44.42, -29.96; p < .001); length of stay (WMD -5.36 days; 95% CI: -5.76, -4.97; p < .001), hemostatic effective rate (OR 1.58, 95% CI: 0.80, 3.12, p = .184) .Conclusions: In the present meta-analysis, the positive findings suggest UAE has beneficial effects on refractory PPH. UAE significantly reduced blood loss, shortened the operating time, and length of stay compared with hysterectomy. And there is no difference between the UAE group and hysterectomy group in hemostatic effective rate. However, those findings should be treated with caution because of heterogeneity and potential biases.

Emergency Peripartum Hysterectomy: A 14-Year Experience at a Tertiary Care Centre in India

Introduction

Emergency Peripartum Hysterectomy (EPH), although relatively infrequent in present day obstetrics, is a life-saving procedure in the event of a massive postpartum haemorrhage.

Aim

To assess incidence, risk factors, indications and complications of peripartum hysterectomies at a tertiary care teaching hospital in India.

Materials and Methods

A retrospective study was conducted at 650-bedded tertiary care medical teaching hospital in Southern India. All emergency peripartum hysterectomies performed between February 2002 and December 2015 at a tertiary care teaching hospital, were included in the study. Demographic characteristics, risk factors, antepartum, intrapartum and post-partum events, need for blood transfusion, length of stay in intensive care unit and postoperative complications were noted. Data was entered in Microsoft Excel spreadsheet and analysed using SPSS software version 22.0. For categorical variables, data was compiled as frequency and percent. For continuous variables, data was calculated as mean±SD.

Results

Among 16,473 deliveries in the study period, 12 emergency peripartum hysterectomies were undertaken, the incidence being 0.073%. Women were aged 20 to 40 years (mean 30.25 years). Majority (83%) were multiparous women. Atonic postpartum haemorrhage was the most common (58%) indication for hysterectomy. About 67% of hysterectomies performed were subtotal hysterectomies. One half of them had a previous caesarean section. Two patients had bilateral internal iliac artery embolization for ongoing haemorrhage. All patients required intensive care and blood transfusion. Two patients did not survive even after hysterectomy.

Conclusion

Atonic postpartum haemorrhage was the most common reason for performing an emergency peripartum hysterectomy. Women with previous caesarean section are at increased risk, both due to atonic and traumatic postpartum haemorrhage. Regular departmental audits are needed to formulate appropriate protocols to decrease mortality and near-miss events like EPH. Stringent protocols should be instituted for managing obstetric haemorrhage. Although EPH is life-saving, early intervention by a senior obstetrician well versed with conservative procedures may avoid morbidity associated with EPH.

Previous uterine artery embolization increases the rate of repeat embolization in a subsequent pregnancy

This study aimed to determine the rate of repeat uterine artery embolization (UAE) in women with a previous UAE. Study data were collected from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service for 2009–2013. We enrolled women who had a first delivery in 2009 and a second delivery between 2010 and 2013. Among 226,408 women who had a first delivery in 2009, 296 underwent UAE. A total of 127,506 women had a second delivery between 2010 and 2013. Of 296 women who underwent UAE after the first delivery, 94 had a second delivery between 2010 and 2013. Women with a previous UAE had a higher rate of UAE at the second delivery than women without a previous UAE. Multivariate adjusted analysis showed that a UAE at the first delivery increased the rate of UAE at the second delivery (odds ratio 25.56, 95% confidence interval 9.86–66.23). Women with a previous UAE should be appropriately counseled and monitored for the need for a repeat UAE.

Trends in conservative procedures and peripartum hysterectomy rates in severe postpartum haemorrhage

OBJECTIVE

The objective of this study is to explore whether increase in use of second-line conservative surgical procedures will alter the rate of peripartum hysterectomies in management of severe postpartum haemorrhage (PPH).

METHODS

This is a retrospective cohort. All pregnant patients with gestation > = 28 weeks with severe PPH (> = 1.5 L) within 72 h of delivery from year 2000 to 2015 (16-year period) in an obstetric training unit was recruited. Basic patient anthropometric characteristics and the main causes for PPH were calculated. The incidence of any second-line conservative surgical procedures and peripartum hysterectomies were evaluated. The total number of patients in each category was then stratified into four 4 years-intervals (4 quadrennium) to compare trends.

RESULTS

The incidence of severe PPH gradually increased over the study period (lowest 0.21% in 2002 to 0.76% in 2015) (p < .001). There is an obvious increasing trend in the overall use of second-line surgical procedures from nil to 82% (p < .001), with balloon tamponade constituting up to 48%. The incidence of successful second-line procedures increased gradually from 72.2% in the second quadrennium to 89% in the fourth quadrennium. The total peripartum hysterectomy rate among cases of severe PPH could be seen to drop from 40.2% in the first to 10.9% in the fourth quadrennium (p = .04).

CONCLUSIONS

Despite the increasing trends in PPH, the increasing utilisation of second-line conservative surgical procedures in severe PPH should be able to reduce the need for peripartum hysterectomy.

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

OBJECTIVE

To compare prevalence, indications, risk indicators, and outcomes of emergency peripartum hysterectomy across income settings.

DATA SOURCES

PubMed, MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases up to March 30, 2015.

METHODS OF STUDY SELECTION

Studies including emergency peripartum hysterectomies performed within 6 weeks postpartum. Not eligible were comments, case reports, elective hysterectomies for associated gynecologic conditions, studies with fewer than 10 inclusions, and those reporting only percentages published in languages other than English or before 1980. Interstudy heterogeneity was assessed by χ test for heterogeneity; a random-effects model was applied whenever I exceeded 25%.

TABULATION, INTEGRATION, AND RESULTS

One hundred twenty-eight studies were selected, including 7,858 women who underwent emergency peripartum hysterectomy, of whom 87% were multiparous. Hysterectomy complicated almost 1 per 1,000 deliveries (range 0.2-10.1). Prevalence differed between poorer (low and lower middle income) and richer (upper middle and high income) settings: 2.8 compared with 0.7 per 1,000 deliveries, respectively (relative risk 4.2, 95% confidence interval [CI] 4.0-4.5). Most common indications were placental pathology (38%), uterine atony (27%), and uterine rupture (26%). Risk indicators included cesarean delivery in the current pregnancy (odds ratio [OR] 11.38, 95% CI 9.28-13.97), previous cesarean delivery (OR 7.5, 95% CI 5.1-11.0), older age (mean difference 6.6 years between women in the case group and those in the control group, 95% CI 4.4-8.9), and higher parity (mean difference 1.4, 95% CI 0.7-2.2). Having attended antenatal care was protective (OR 0.12, 95% CI 0.06-0.25). Only 3% had accessed arterial embolization to prevent hysterectomy. Average blood loss was 3.7 L. Mortality was 5.2 per 100 hysterectomies (reported range 0-59.1) and higher in poorer settings: 11.9 compared with 2.5 per 100 hysterectomies (relative risk 4.8, 95% CI 3.9-5.9).

CONCLUSION

Emergency peripartum hysterectomy is associated with considerable morbidity and mortality and is more frequent in lower-income countries, where it contains a higher risk of mortality. A (previous) cesarean delivery is associated with a higher risk of emergency peripartum hysterectomy.

Towards Actualizing the Value Potential of Korea Health Insurance Review and Assessment (HIRA) Data as a Resource for Health Research: Strengths, Limitations, Applications, and Strategies for Optimal Use of HIRA Data

Health Insurance and Review Assessment (HIRA) in South Korea, also called National Health Insurance (NHI) data, is a repository of claims data collected in the process of reimbursing healthcare providers. Under the universal coverage system, having fee-for-services covering all citizens in South Korea, HIRA contains comprehensive and rich information pertaining to healthcare services such as treatments, pharmaceuticals, procedures, and diagnoses for almost 50 million beneficiaries. This corpus of HIRA data, which constitutes a large repository of data in the healthcare sector, has enormous potential to create value in several ways: enhancing the efficiency of the healthcare delivery system without compromising quality of care; adding supporting evidence for a given intervention; and providing the information needed to prevent (or monitor) adverse events. In order to actualize this potential, HIRA data need to actively be utilized for research. Thus understanding this data would greatly enhance this potential. We introduce HIRA data as an important source for health research and provide guidelines for researchers who are currently utilizing HIRA, or interested in doing so, to answer their research questions. We present the characteristics and structure of HIRA data. We discuss strengths and limitations that should be considered in conducting research with HIRA data and suggest strategies for optimal utilization of HIRA data by reviewing published research using HIRA data.

The income-based disparities in preeclampsia and postpartum hemorrhage: a study of the Korean National Health Insurance cohort data from 2002 to 2013

There is limited evidence on the effects of relatively low socioeconomic status on maternal health. Additionally, the global economic recession that began in 2008 could have worsened disparities in maternal complications. To explore disparities in maternal health, we analyzed the occurrence of preeclampsia and postpartum hemorrhage according to level of household income. A population-based cohort data set from the Korean National Health Insurance was used to calculate the age-adjusted incidence, slope index of inequality, and Kunst and Mackenbach relative index of inequality (RII_KM) for preeclampsia and postpartum hemorrhage from 2002 to 2013. In the aggregated data of 65,479 live births, women with lower household income showed a higher risk of developing preeclampsia and postpartum hemorrhage than those with higherhigher incomes after adjusting for conventional risk factors. The absolute and relative inequalities for both complications showed no significant change over the period from 2002 to 2013. Considering the difference in the trends and risks of major obstetric complications according to level of household income, policies to monitor and reduce disparities in maternal health across different economic levels need to be implemented.

Emergency peripartum hysterectomy: 2-year experiences in non-tertiary center

PURPOSE

The aim of this study was to evaluate risk factors, indications and materno-fetal outcomes for emergency peripartum hysterectomy.

METHODS

Retrospective evaluation was made of 23 cases. Maternal and neonatal outcomes, need for referral to the tertiary center and related complications were compared to those at the initial diagnosis for surgery, location of delivery, type of surgery and the admission diagnosis. The risk factors associated with emergency peripartum hysterectomy were also investigated. Significance was evaluated at p values of <0.01 and <0.05.

RESULTS

There was a correlation between peripartum hysterectomy and uterine atony or uterine rupture (p < 0.01). The referral rates of patients with home delivery were significantly higher than those of patients who delivered in hospital (p = 0.02) but no significant difference was observed in the neonatal outcomes (p = 0.38). There was no significant difference in the rates of maternal complications between home and hospital delivery (p = 0.068). According to the indication for surgery, no significant difference was observed between the rates of referral to the tertiary center, maternal outcomes, complications, or need for maternal intensive care (p > 0.05). However, a highly significant difference was observed between the neonatal outcomes (p = 0.001).

CONCLUSION

The results of this study showed the most important risk factors associated with peripartum hysterectomy to be uterine atony, grand multiparity, and uterine rupture. Maternal intensive care, maternal death, neonatal death, or neonatal intensive care were associated with home delivery or delayed presentation at hospital.

Comparison of maternal morbidity and medical costs during pregnancy and delivery between patients with gestational diabetes and patients with pre-existing diabetes

AIMS

To evaluate the effects of gestational diabetes and pre-existing diabetes on maternal morbidity and medical costs, using data from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service.

METHODS

Delivery cases in 2010, 2011 and 2012 (459 842, 442 225 and 380 431 deliveries) were extracted from the Health Insurance Review and Assessment Service database. The complications and medical costs were compared among the following three pregnancy groups: normal, gestational diabetes and pre-existing diabetes.

RESULTS

Although, the rates of pre-existing diabetes did not fluctuate (2.5, 2.4 and 2.7%) throughout the study, the rate of gestational diabetes steadily increased (4.6, 6.2 and 8.0%). Furthermore, the rates of pre-existing diabetes and gestational diabetes increased in conjunction with maternal age, pre-existing hypertension and cases of multiple pregnancy. The risk of pregnancy-induced hypertension, urinary tract infections, premature delivery, liver disease and chronic renal disease were greater in the gestational diabetes and pre-existing diabetes groups than in the normal group. The risk of venous thromboembolism, antepartum haemorrhage, shoulder dystocia and placenta disorder were greater in the pre-existing diabetes group, but not the gestational diabetes group, compared with the normal group. The medical costs associated with delivery, the costs during pregnancy and the number of in-hospital days for the subjects in the pre-existing diabetes group were the highest among the three groups.

CONCLUSIONS

The study showed that the rates of pre-existing diabetes and gestational diabetes increased with maternal age at pregnancy and were associated with increases in medical costs and pregnancy-related complications.