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ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 3  |  Page : 324-328

Peripartum hysterectomy in a tertiary care hospital: Epidemiology and outcomesImproving outcomes for peripartum hysterectomy: Still a long way to go!


1 Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication11-Sep-2017

Correspondence Address:
Pooja Sikka
Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_380_16

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  Abstract 

Background and Aims: Peripartum hysterectomy is associated with significant maternal morbidity and mortality. We reviewed all peripartum hysterectomies at our institute over a 1-year period. The aim of this study was to determine the incidence, surgery and anesthesia-related issues of peripartum hysterectomies and to compare outcomes of emergency and electively planned peripartum hysterectomies.
Material and Methods: This was a retrospective analysis of records of women who underwent emergency or elective peripartum hysterectomy in a tertiary care hospital. The study included all women who underwent peripartum hysterectomy in a teaching hospital and referral institute in North India over a span of 1 year (April 1, 2014, to March 31, 2015). Association of variables was based on Chi-square test, Fisher's exact test, and comparison on “t” statistics (normal distribution) and Mann–Whitney (nonnormal distribution).
Results: Forty women underwent peripartum hysterectomy during the study period. The incidence was 6.9/1000 deliveries. In 16 (40%) cases, peripartum hysterectomy was planned electively while emergency hysterectomy was done in 24 (60%) cases. Main indications of peripartum hysterectomies were placenta accreta (60%), atonic postpartum hemorrhage (PPH) (27.5%), and uterine rupture (7.5%). Intensive care management was required in 35% women postoperatively. The common maternal complications were febrile morbidity, bladder injury, disseminated intravascular coagulation, and wound infection. There were 4 maternal deaths following emergency peripartum hysterectomy done for atonic PPH whereas no mortality occurred in elective hysterectomy group.
Conclusions: The most common indication for peripartum hysterectomy was placenta accrete. Electively planned peripartum hysterectomies with a multidisciplinary team approach had better outcomes and no mortality as compared to emergency peripartum hysterectomies.

Keywords: Near miss event, peripartum hysterectomy, placenta accrete, postpartum hemorrhage


How to cite this article:
Sharma B, Sikka P, Jain V, Jain K, Bagga R, Suri V. Peripartum hysterectomy in a tertiary care hospital: Epidemiology and outcomesImproving outcomes for peripartum hysterectomy: Still a long way to go!. J Anaesthesiol Clin Pharmacol 2017;33:324-8

How to cite this URL:
Sharma B, Sikka P, Jain V, Jain K, Bagga R, Suri V. Peripartum hysterectomy in a tertiary care hospital: Epidemiology and outcomesImproving outcomes for peripartum hysterectomy: Still a long way to go!. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2017 Sep 22];33:324-8. Available from: http://www.joacp.org/text.asp?2017/33/3/324/214317




  Introduction Top


Postpartum hemorrhage (PPH) is a life-threatening condition. Various drugs and surgical techniques have been developed over time, especially to preserve the uterus. However, in some circumstances, an emergency peripartum hysterectomy has to be performed often as the last resort in saving a woman's life. It is thus an unequivocal marker of severe maternal morbidity and mortality.[1],[2] We have reviewed all peripartum hysterectomies done at our institute over a period of 1 year with the aim of determining the incidence, surgery, and anesthesia-related management issues and also to compare emergency and electively planned peripartum hysterectomies for perioperative and postoperative complications.


  Material and Methods Top


The present study included all women who underwent peripartum hysterectomy in the Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, a teaching hospital and referral institute in North India over a span of 1 year (April 1, 2014 to March 31, 2015). Records of all women who underwent peripartum hysterectomy were collected from medical record department. Each case file was studied in detail for demographic profile, clinical characteristics, operative notes for indications, intraoperative findings, duration of surgery and blood loss, anesthesia records, and postoperative events. Ethical approval for the study was obtained from the institute ethics committee.

The data was presented as frequency or mean ± standard deviation. Data from emergency group and elective group were compared using Chi-square test or Fisher's exact test. P value <0.05 was considered as statistically significant.


  Results Top


A total of 40 women underwent peripartum hysterectomy during this period. The total numbers of deliveries were 5824. Thus, the incidence of peripartum hysterectomies was 6.9/1000 deliveries. The mean age of women was 28.4 ± 3.8 years. Of these 40 women, 2 (5%) were primigravida, 7 (17.5%) were second gravida, and the remaining 31 (77.5%) were multigravida. Only 2 women were booked in our institute and the other 38 (95%) were referrals. Among booked patients, one had peripartum hysterectomy for atonic PPH following a twin pregnancy and the other was a case of placenta accreta with previous three cesareans.

Thirty (75%) patients had more than 34 weeks of gestation at the time of surgery, 7 (17.5%) had between 28 and 34 weeks, and 3 (7.5%) had <28 weeks. Out of these three patients, one had hysterectomy for cervical pregnancy, one for arteriovenous malformation (postabortal), and one had morbidly adherent placenta at 20 weeks.

Only 6 (15%) women had an unscarred uterus. Thirty-four (85%) women had previous cesarean section/s, of which 10 (29.4%) had previous one cesrean and 24 (70.6%) had undergone 2 or more previous cesareans. The main indications for peripartum hysterectomy in this study were placenta accrete (60%), atonic PPH (27.5%), and rupture uterus (7.5%) [Table 1]. All women who had uterine rupture were referrals from other institutes. Two-thirds of women with uterine rupture were hemodynamically unstable at the time of admission. Clinical characteristics of all women are shown in [Table 2].
Table 1: Indications of peripartum hysterectomy

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Table 2: Clinical characteristics of cases

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In 16 (40%) cases, peripartum hysterectomy was planned electively while emergency hysterectomy was done in 24 (60%) cases. All electively planned hysterectomies were diagnosed as placenta accreta either on magnetic resonance imaging or on Doppler sonography. A classical cesarean was done before proceeding to hysterectomy in these cases.

The maternal characteristics were compared in the two groups (elective/emergency peripartum hysterectomy). Both groups were similar in age and parity [Table 3]. Among all women who underwent electively planned peripartum hysterectomy, 93.7% cases were after 34 weeks of gestation, whereas in emergency group, only 29% were done after 34 weeks of gestation (P < 0.001). A good fetal outcome was seen in electively planned group. Women in emergency group had a low preoperative hemoglobin as compared to electively planned group (P = 0.01).
Table 3: Maternal characteristics of elective versus emergency surgery

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Preoperatively, 11 (27.5%) patients were hemodynamically unstable and required resuscitation. Nine (81.1%) patients had atonic PPH and only 2 had bleeding due to placenta accreta. All cases were done under general anesthesia. Five (12.5%) patients were initially taken up in spinal anesthesia, but later converted to general anesthesia. Twenty-two (55%) women required more than 5 units of blood transfusion and maximum amount transfused was 12 units in one patient. Mean duration of surgery was 2.8 ± 1 h. Twenty-three (57.5%) patients were extubated on operation theater table after surgery while 17 (42.5%) had delayed extubation. Among them, 14 (82.3%) patients were shifted to the Intensive Care Unit (ICU). In ICU, the maximum duration of stay was 5 days and minimum was 1 day. Three (21%) out of 14 women who were shifted to ICU died.

[Table 4] includes anesthetic and perioperative management of both groups (emergency/electively planned peripartum hysterectomy). Estimated blood loss, intraoperative blood replacement, intraoperative hypotension, and administration of inotropes were similar in the two groups. Fifty percent of all women who had emergency peripartum hysterectomy required ICU care compared to 12.5% in electively planned group (P = 0.02).
Table 4: Anesthetic and perioperative management of elective versus emergency surgery

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Most common maternal complication [Table 5] was febrile morbidity (27.5%). Bladder injury occurred in 20%, disseminated intravascular coagulation in 12.5%, and wound infection in 5% of the women. There were 4 (10%) maternal deaths, all of whom were referrals from outside. Cause of maternal death in all was atonic PPH. There was no mortality in electively planned cases as compared to emergency group (P = 0.036).
Table 5: Postoperative complications

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  Discussion Top


PPH along with sepsis and hypertensive disorders of pregnancy is a major cause of maternal mortality in India. Peripartum hysterectomy is a lifesaving surgery performed on a mother with intractable obstetric hemorrhage. In active management of third stage of labor, drugs such as misoprostol and uterine artery embolization among other measures have markedly reduced maternal deaths from PPH. However, describing a reduction in maternal mortality rate is just describing the tip of an iceberg. The WHO has thus emphasized on the concept of maternal near miss.[3] Any pregnant woman who undergoes peripartum hysterectomy thus could have potentially died without timely and proper management.

The incidence of peripartum hysterectomy is increasing in this era not because of improperly managed third stage of labor or obstructed labor but most likely because of increasing incidence of cesarean sections. Chances of repeat cesarean sections thus increase. This ultimately increases the incidence of placenta previa and accreta.

In our analysis, the incidence of peripartum hysterectomy is 6.9/1000 deliveries, which is much higher than reported incidence of 0.2 and 5.4 in 1000 deliveries.[4],[5] Over the years, the incidence of peripartum hysterectomy has drastically increased from 0.2% to 0.7% in our institute although the indications have changed. This may be explained by our institute being a referral center and women are referred either after a complication or electively for surgery after diagnosing accreta in the antenatal period.

In our study, 85% of women had a history of previous cesarean section, and out of these, 75% had ≥2 cesareans. In recent studies, the incidence of peripartum hysterectomy was higher in women who had a history of either one or two previous cesarean sections.[6],[7],[8],[9] Placenta accreta has been the primary indication in these women and accounts for 38%–50% of all peripartum hysterectomies.[9],[10],[11],[12],[13]

In our study, the most common indications of peripartum hysterectomy were placenta accrete (60%), atonic PPH (27.6%), and rupture uterus (7.5%). In a similar study from our institute two decades back, the main indications were uterine rupture (62%) followed by atony (18%) and adherent placenta (18%).[14]

The incidence of uterine rupture as an indication for peripartum hysterectomy has significantly reduced from 62% to 7.5% in our institute.[14] This may be attributed to decreased referrals of women with obstructed labor. In our study, there were 4 maternal deaths (10%). All of these women were referred from outside, and the cause of death was atonic PPH. In previous studies, also, the maternal mortality ranges from 1.2% to 19.4%.[5],[15] Although the incidence of atonic PPH as an indication of peripartum hysterectomy has reduced, it is still important and was the only cause of maternal deaths in our study.

In our study, 40% peripartum hysterectomies were electively planned and rest were done in emergency. All electively planned hysterectomies were done for placenta accrete. To prevent hemorrhage, classical cesarean was immediately followed by peripartum hysterectomy. Both groups required large number of perioperative blood transfusions. The perioperative morbidity and postoperative complications were significantly less in electively planned group. Only 12.5% of electively planned group required ICU care, whereas in emergency group, 50% were shifted to ICU (P = 0.02). There was no mortality in electively planned cases (P = 0.036). A study by Chestnut et al. had reported that there was significantly more hemorrhage with emergency hysterectomy as compared to an electively planned procedure.[16]


  Conclusion Top


We conclude that the incidence of peripartum hysterectomy in our institute has increased from 2/1000 to 6.9/1000 deliveries. There is also a change in the indications of peripartum hysterectomy in the past two decades with placenta accrete being the commonest in our study. This is because of rising number of cesareans and early diagnosis by imaging. Patients who underwent emergency peripartum hysterectomy due to atonic PPH had a higher mortality. Elective peripartum hysterectomies with multidisciplinary approach and ICU backup for diagnosed cases of placenta accrete had better outcomes with less morbidity.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Baskett TF, Sternadel J. Maternal intensive care and near-miss mortality in obstetrics. Br J Obstet Gynaecol 1998;105:981-4.  Back to cited text no. 1
    
2.
Baskett TF, O'Connell CM. Severe obstetric maternal morbidity: A 15-year population-based study. J Obstet Gynaecol 2005;25:7-9.  Back to cited text no. 2
    
3.
World Health Organization. Evaluating the Quality of Care for Severe Pregnancy Complications, the WHO Near-Miss Approach for Maternal Health. World Health Organization; 2011.  Back to cited text no. 3
    
4.
Umezurike CC, Feyi-Waboso PA, Adisa CA. Peripartum hysterectomy in Aba Southeastern Nigeria. Aust N Z J Obstet Gynaecol 2008;48:580-2.  Back to cited text no. 4
    
5.
Zeteroglu S, Ustun Y, Engin-Ustun Y, Sahin G, Kamaci M. Peripartum hysterectomy in a teaching hospital in the Eastern region of Turkey. Eur J Obstet Gynecol Reprod Biol 2005;120:57-62.  Back to cited text no. 5
    
6.
Jou HJ, Hung HW, Ling PY, Chen SM, Wu SC. Peripartum hysterectomy in Taiwan. Int J Gynaecol Obstet 2008;101:269-72.  Back to cited text no. 6
    
7.
Knight M, Kurinczuk JJ, Spark P, Brocklehurst P; United Kingdom Obstetric Surveillance System Steering Committee. Cesarean delivery and peripartum hysterectomy. Obstet Gynecol 2008;111:97-105.  Back to cited text no. 7
    
8.
Rahman J, Al-Ali M, Qutub HO, Al-Suleiman SS, Al-Jama FE, Rahman MS. Emergency obstetric hysterectomy in a university hospital: A 25-year review. J Obstet Gynaecol 2008;28:69-72.  Back to cited text no. 8
    
9.
Agrawal S, Yadav R, Raghunandan C, Dhingra S, Kaur H. Peripartum hysterectomy in a teaching hospital in India. Asian J Med Sci 2013;4:5-9.  Back to cited text no. 9
    
10.
Korejo R, Nasir A, Yasmin H, Bhutta S. Emergency obstetric hysterectomy. J Pak Med Assoc 2012;62:1322-5.  Back to cited text no. 10
    
11.
Kastner ES, Figueroa R, Garry D, Maulik D. Emergency peripartum hysterectomy: Experience at a community teaching hospital. Obstet Gynecol 2002;99:971-5.  Back to cited text no. 11
    
12.
Kwee A, Bots ML, Visser GH, Bruinse HW. Emergency peripartum hysterectomy: A prospective study in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2006;124:187-92.  Back to cited text no. 12
    
13.
Sakse A, Weber T, Nickelsen C, Secher NJ. Peripartum hysterectomy in Denmark 1995-2004. Acta Obstet Gynecol Scand 2007;86:1472-5.  Back to cited text no. 13
    
14.
Saxena SV, Bagga R, Jain V, Gopalan S. Emergency peripartum hysterectomy. Int J Gynaecol Obstet 2004;85:172-3.  Back to cited text no. 14
    
15.
Flood KM, Said S, Geary M, Robson M, Fitzpatrick C, Malone FD. Changing trends in peripartum hysterectomy over the last 4 decades. Am J Obstet Gynecol 2009;200:632.e1-6.  Back to cited text no. 15
    
16.
Chestnut DH, Dewan DM, Redick LF, Caton D, Spielman FJ. Anesthetic management for obstetric hysterectomy: A multi-institutional study. Anesthesiology 1989;70:607-10.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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