Peripartum hysterectomy in a tertiary care hospital: Epidemiology and outcomes

Women's Experiences Following Peripartum Hysterectomy: A Qualitative Study

Objective

Peripartum hysterectomy is a major operation and is inevitably performed where certain indications require removal of the uterus at the time of delivery or in the immediate postpartum period. It is a traumatic birth event that affects women's physical, physiological, psychological, social, and sexual health. This study aimed to explore the lived experiences of women undergone peripartum hysterectomy.

Materials and methods

Qualitative phenomenological design was adopted to explore the lived experiences of women undergone peripartum hysterectomy. Purposive sampling technique was adopted to enroll the participants and 19 women were interviewed before saturation of responses was reached. All interviews were audio recorded and then transcribed into verbatims. Colaizzi's thematic analysis method was used to analyze the data.

Results

Based on participants' verbatims eight major themes emerged: Awareness status regarding peripartum hysterectomy; Body's response to peripartum hysterectomy; Perceived need of support; Facilitators in overcoming post-hysterectomy challenges; Relational turbulence; financial burden; Perceived psychological adaptation; Disturbed body image and low self-esteem.

Conclusion

Derived themes in the present study highlighted the multidimensional effects of peripartum hysterectomy. Peripartum hysterectomy affected physical, psychological, sexual and financial health of the women. Increased dependence and changes in the self concept are the other problems faced by peripartum hysterectomy women. Need based individualized psychological therapeutic interventions will facilitate the successful adaptation to the traumatic situation by the reinforcement of positive coping mechanisms.

Peripartum Hysterectomy Outcomes: Our Eleven-Year Experience at a Tertiary Care Hospital

Aim

To investigate the outcomes of peripartum hysterectomies (PHs) conducted to prevent maternal morbidity and mortality at a tertiary care hospital with 15,000 deliveries per year.

Method

Patients who underwent PHs during delivery and/or within 24 h of delivery between the years 2011-2022 were retrospectively evaluated. Hysterectomies not performed in the peripartum period, cases that were managed by methods such as balloon tamponade, compression suture, or arterial ligation rather than hysterectomy, and hysterectomies performed before 20 weeks were excluded. Obstetric and demographic characteristics of the cases, as well as indications and outcomes of PH, were investigated.

Results

Among the 130 patients who underwent PH, 4 (3.04%) patients delivered vaginally, 1 (0.7%) patient delivered vaginally after cesarean section, 12 (9.2%) patients delivered by primary cesarean section, and 113 (86.9%) patients delivered by secondary cesarean section. Placenta accreta spectrum disorder was the reason for PH in 54.6% (n = 71) of the cases while 16.1% (n = 21) underwent PH due to uterine atony. The PH rate was 0.75 per 1000 births, and the maternal mortality rate was 7.6 per 1000 hysterectomies in this study.

Conclusion

Obstetricians in developed/ing countries support the active management of the third stage of labor mainly to mitigate the preventable risk factors of post-/peri-partum hemorrhage. The current study suggests that obstetricians need to focus on the placenta in order to reduce PH.

Prophylaxis Effect of Metronidazole Vaginal Gel in Decreasing the Risk of Surgical Site Infections after Elective Hysterectomy

Objective

Infections are an important cause of morbidity and mortality after hysterectomy. Here, we aimed to investigate and evaluate the beneficial effects of metronidazole vaginal gel on the rate of surgical site infections in women undergoing elective abdominal hysterectomy.

Methods

This is a randomized prospective, double-blind controlled clinical trial performed in 2020 in Isfahan on 108 candidates for elective hysterectomy. At the beginning of the study, we completed a checklist of the patient's characteristics (patient age, body mass index [BMI], and history of medical conditions such as diabetes, hypertension, anemia, and immune deficiency) and the cause of hysterectomy. All patients were randomized into two groups. The first group received a lubricant vaginal gel single dosage, and the second group received a 0.75% metronidazole vaginal gel single dosage the night before surgery. Patients were visited up to 6 weeks after surgery, and the frequency of infection at the surgical site was determined.

Findings

The rates of infection were lower in patients who received metronidazole vaginal gel (5.8%) compared to the control group (11.6%) (P = 0.03). Patients with an estimated blood loss volume of more than 500 mL had higher rates of infection (13.46%) compared to patients with a bleeding volume of fewer than 500 mL (1.9%) (P = 0.001). We also found that patients with diabetes (13.5%) and patients with BMI more than 30 kg/m2(13.5%) had higher rates of infection compared to patients without diabetes (5.8%) and patients with BMI <30 kg/m2 (11.5%) (P = 0.001 for both). Patients with higher hospitalization duration had higher infection rates (P = 0.009).

Conclusion

Administration of a single dosage of metronidazole vaginal gel before abdominal hysterectomy may reduce surgical site infection and have clinical values.

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

OBJECTIVE

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

DATA SOURCES

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

METHODS OF STUDY SELECTION

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

TABULATION, INTEGRATION, AND RESULTS

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

CONCLUSION

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

Uterine Factor Infertility, a Systematic Review

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

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, 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.

Bladder filling before accreta surgery is a very effective method for preventing bladder injury: a retrospective cohort study

OBJECTIVES

The aim of this study is to show whether bladder filling with saline before percreta surgery diminish the rate of bladder injuries or not. A secondary aim was to check the operative and postoperative outcomes between the cases of filled and unfilled bladder in placenta accreta surgery.

METHODS

This retrospective multicentric cohort study involved 88 patients who were diagnosed with placenta accreta and underwent cesarean hysterectomy between 1 January 2009 and 1 January 2019. Women who had cesarean hysterectomies due to the indication of placenta accreta and did not have bladder filling were used as the control group.

RESULTS

Eighty-eight women met the inclusion criteria. Forty-nine of the cases, the bladder was filled with saline solution before the operation, whereas in 39 the bladder was not filled. Intraoperative bladder injury occurred less in patients with preoperative filled bladders than in patients with unfilled bladders (p = .015; p < .05). There was a statistically significant difference between the duration of surgery according to bladder inflation (p = .001; p < .01); in the filled bladder group, the operation time was shorter than in the unfilled group.

CONCLUSIONS

Filling the bladder with 200 ml saline solution before starting a cesarean section is an easy and useful technique that can reduce the possibility of bladder injury in placenta accreta surgery.