Emergency Postpartum Hysterectomy Research Articles

Emergency postpartum hysterectomy as a consequence of cervical varix during pregnancy; a case report and literature review

Vaginal bleeding might accrue during pregnancy and it has different causes due to the pregnancy trimester and the diagnosis and management would be crucial to prevent maternal-fetal life-threatening situations. In uncommon cases, varicose veins can emerge in the neck of the uterus, leading to a severe maternal hemorrhage. We presented a pregnant woman with vaginal bleeding and spotting during pregnancy with the diagnosis of cervical varix at 22 weeks of gestation. Close monitoring and proper patient education led to a term delivery at 37 weeks of gestation. Otherwise, an emergency postpartum hysterectomy after a cesarean section was performed due to uncontrolled bleeding from cervical varix. Although rare, cervical varix should be included in the differential diagnosis in a pregnant patient who appears with extensive vaginal bleeding to reduce maternal and/or neonatal morbidity or fatality. The approved diagnosis for that is not clear. This case report showed that Doppler and transvaginal sonography could be suitable diagnostic tools. The best management for cervical varix needs further research.

Pelvic packing in the treatment of severe postpartum posthysterectomiam hemorrhage.

Pelvic packing (PP) as a simple method of ”damage control surgery” in severe abdominopelvic hemorrhage in gynecological and obstetric surgery after emergency obstetrics or gynecological hysterectomy. To present the case of successful PP as a simple and effective method in refractory pelvic bleeding after emergent peripartum hysterectomy and severe obstetric shock with consumptive coagulopathy. Acording to laboratory findings and clinical condition in a 30-year-old (G2 P2) parturient, it was most likely an obstetric embolism with uterine rupture as the cause of severe postparum hemorrhage with disseminated intravascular coagulopathy and obstetrics hemorrhagic shock development in the described case. Pelvic packing after postpartum hysterectomy was the definitive minimally invasive and simple hemostatic procedure. The use of pelvic packing and obstetrics skills should be included in the protocol as a necessary, life-saving, and uncomplicated vital indication procedure.

Dads in Distress: symptoms of depression and traumatic stress in fathers following poor fetal, neonatal, and maternal outcomes

BackgroundThis study aims to explore the prevalence of symptoms of depression and traumatic stress in fathers in the setting of poor fetal, neonatal, and maternal outcomes.MethodsA prospective mixed-methods study was conducted at an outer metropolitan public teaching hospital in Brisbane, Australia, with quantitative results presented here. Subjects included 28 fathers whose partners had experienced pregnancy or childbirth complicated by a significant congenital abnormality or aneuploidy, termination of pregnancy, fetal death in-utero, stillbirth, admission to the neonatal intensive care unit or special care nursery or significant maternal morbidity, such as a postpartum haemorrhage or an emergency postpartum hysterectomy. These experiences were classified into two groups: anticipatory (time to prepare) and sudden (no warning). The fathers were screened using the Edinburgh Postnatal Depression Scale (EPDS) and the Impact of Events Scale-Revised (IES-R) to assess subjective distress at 2-3 weeks (timepoint 1) and 3-4 months (timepoint 2) after the event.ResultsData for both the EPDS and IES-R scales was available for 26 fathers (92.9%) at timepoint 1 and for 15 fathers (53.6%) at timepoint 2. High overall EPDS scores (≥10) were noted in 16/27 (59.3%) fathers at timepoint 1 and 6/15 fathers (40.0%) at timepoint 2. High overall IES-R scores ≥33 were noted in 12/26 (46.2%) fathers at timepoint 1 and 4/15 fathers (26.7%) at timepoint 2. A higher percentage of fathers who experienced anticipatory events had EPDS and IES-R score above these cut-offs at timepoint 1 (8/13 or 61.5%) compared to those experiencing sudden events (8/14 or 57.1%), however, percentages were similar between groups at time point 2 (2/7 or 28.6%% and 4/8 or 50.0%, respectively). More fathers who experienced anticipatory events had IES-R scores ≥33 at timepoint 1 (7/13 or 53.8%) compared to those experiencing sudden events (5/14 or 38.0%).ConclusionOur study indicates high rates of distress in fathers exposed to poor fetal, neonatal, and maternal outcomes, which can persist for months after the event. Increased support for fathers in this setting may be required to prevent poor mental health. Further research on the long-term effects of these adverse events is warranted.

Placental complications among Iraqi Pregnant Women with Placenta Accreta

Background: Placenta accreta is an abnormal attachment of the placenta to the myometrium. It is the most common reason for an emergency postpartum hysterectomy, which is a major cause of maternal morbidity and mortality. If placenta accreta has been detected or suspected prior to birth, the best time to deliver is about (34-35) weeks, with a multidisciplinary team strategy to prevent complications during birth such as uterine infection, massive vaginal bleeding, uterine wall rupture, and uterine inversion secondary due to tried manual placenta removal.Aims of the study: To assess placenta complications for pregnant women with placenta accreta and to assess the obstetrical history of pregnant women with placenta accreta.Methodology: This study was conducted at Maternity wards in Baghdad City's. The study sample consists of (410) pregnant women diagnosed with placenta accreta out of 58,600 cesarean sections. Retrospective study for last three years ago, of January /2018 to December/ 2020, The data collected of patient records in the Statistical Department of the hospitals.Results: The results of the study showed that all women suffer of the adherence of the placenta to the uterine wall at a rate of (100%). The study found (45.6%) of women needing from 4 to 5 pints of blood, the amount of blood transferred to the mother after childbirth. Also, about (52.7%) was noticed to be a critical cesarean delivery requires a multidisciplinary surgeon.Conclusion: women diagnosed with placenta accreta suffer of adhesion placenta to the uterine wall and need a blood transfusion during the delivery process, as well as the need to provide a multidisciplinary surgeon because some women have the adhesion extended to the organs adjacent to the uterus.Recommendations: Increase awareness of women regarding the complications of placenta accreta, Encourage women to commit to prenatal visits and early diagnosis is important to minimize complications.

Effectiveness of Intrauterine Bakri Balloon® Tamponade for Placenta Previa and Placenta Accreta Spectrum.

To investigate the effectiveness and success rate of Bakri balloon tamponade (BBT) for postpartum haemorrhage (PPH) in patients with placenta previa and placenta accreta spectrum (PAS). Descriptive study. Department of Obstetrics and Gynaecology, Bursa Yüksek Ihtisas Education and Research Hospital, Bursa, Turkey, from June 2016 to June 2019. Patients treated with BBT for severe PPH and uncontrollable bleeding due to treatment failure with uterotonic agents were retrospectively analysed. Exclusion criteria were age <18 years and >46 years, having multiple pregnancies, less amount of bleeding than indicated in the definition of PPH and requiring no BBT and those with hemodynamic instability before BBT requiring emergency postpartum hysterectomy, and having missing obstetric and laboratory data. The main outcome was the rate of surgical exploration and peripartum hysterectomy following the use of BBT as an adjunct treatment for refractory PPH. Secondary outcome was the need for blood transfusion. The BBT was considered to fail, if the bleeding from drainage catheter was continued and more than 100 mL during failure was 10 minutes. In case of BBT failure, C-section hysterectomy was performed. Of the 128 patients, 14 (10.9%) had vaginal birth and 109 (85.2%) had Cesarean section delivery. Of patients with cesarean section delivery, 84 (65.6%) had multiple repeat cesarean deliveries and 22 (17.2%) were previous cesarean cases. Ninety-one patients (71.1%) had placental site abnormality. Twenty patients (15.6%) underwent hypogastric and uterine artery ligation. Eleven patients (8.7%) with persistent uterine bleeding and hemodynamic instability underwent hysterectomy. Success rate of BBT was found to be 91.3% in PPH. No mortality was observed. BBT is an effective tool for management of postpartum uterine atony and prevention of persistent PPH in patients with placenta previa and placenta accreta spectrum due to increased cesarean section and uterine surgeries in recent years. Key Words: Placenta previa, Placenta accreta spectrum, Postpartum haemorrhage, Balloon tamponade, Bakri balloon.

Shock parameters and shock index during severe post-partum haemorrhage and implications for management: a clinical study

The aim of this study was to report the association between shock severity, laboratory parameters and treatment in patients with severe post-partum haemorrhage (PPH) requiring the transfusion of ≥4 blood unit. Patients were divided into two groups: (1) conservative therapy and (2) emergency post-partum hysterectomy. The aggressive decision was always shared by two consultants. Out of 26,094 deliveries, severe PPH occurred in 34 (0.13%) women, emergency post-partum hysterectomy was required in 13 (0.05%), while 21 (0.08%) were treated conservatively. Grade of shock, shock index (SI) and the number of blood units transfused were significantly higher in the hysterectomy group. No statistically significant difference among the two groups was observed for haemoglobin and coagulation results. The severity of shock was associated with the therapeutic choice in the treatment of severe PPH. Therefore, grade of shock and SI should be taken into consideration by the leading obstetrician in the decision making process toward the emergency hysterectomy.Impact StatementWhat is already known on this subject? Primary post-partum haemorrhage (PPH) is the leading cause of maternal death in developing and industrialised countries. Emergency post-partum hysterectomy is considered a life-saving procedure performed when the women is experiencing a life-threatening haemorrhage.What the results of this study add? Therapeutic dichotomy between conservative and aggressive approach in severe PPH has not been defined, in particular emergency post-partum hysterectomy timing. Shock index (SI) has been proposed as an indicator of adverse maternal outcome. However, the association between shock parameters and advanced treatment modalities has not yet been reported. In our study, grade of shock, SI and the number of blood units transfused were significantly higher in the patients which needed hysterectomy suggesting that it may have a role in the decision making among conservative and aggressive treatment. No statistically significant difference was observed for haemoglobin and coagulation results.What the implications are of these findings for clinical practice and/or further research? Grade of shock and SI should be taken into consideration in the decision making process toward the emergency hysterectomy in severe PPH. The choice between conservative and aggressive treatment should be based on hemodynamic parameters that may represent, in more accurate way, the severity of blood loss. Nevertheless, these data need further confirmation in a larger study.

Use of a gelatin-thrombin hemostatic matrix in obstetrics and gynecological surgery

Gelatin-thrombin matrix (GTM) is a hemostatic sealant consisting of bovine-derived gelatin matrix and human-derived thrombin, combining both mechanical and active mechanisms to achieve hemostasis. It was approved by the Food and Drug Administration in 1999. GTM has been used by several surgical specialties; however, it is a possibly an under-used tool in obstetrics and gynecology. A limited number of studies have been performed on its use during laparoscopic endometrioma excision and myomectomy. It may prove useful in endometrioma excision in reproductive aged women because it is likely to harm ovarian reserve less than electrocautery; however, this conclusion needs to be validated. The only study on GTM use in myomectomy included 50 women randomized into GTM and control groups, and showed decreased blood loss and shorter hospital stays in the GTM group. In gynecologic oncology, it was successfully used to reduce lymphocele cases in a cohort study. GTM has been used successfully in obstetrics in a handful of cases of uncontrolled bleeding from caesarean scar, placental site, ectopic pregnancy, rectovaginal hematoma, and venous plexus over the vaginal vault after emergency postpartum hysterectomy. Risk of viral transmission is a major concern about GTM, yet there are no reports on disease transmission with GTM use to date. Rare but serious adverse effects and complications have been reported such as fatal or near-fatal thromboembolism and small bowel obstruction. Although GTM is mostly a safe product, it is still not free of complications and risks. In conclusion, although routine use of GTM cannot be recommended due to concerns about its safety, cost, and availability, it may prove useful when conventional hemostatic methods such as suturing and electrocauterization fail or are not appropriate.

Emergency obstetric hysterectomy for life-threatening postpartum hemorrhage: A 12-year review.

The aim of the study was to review the operative experiences of emergency hysterectomy for life-threatening postpartum hemorrhage (PPH) performed over a 12-year period at Fujian Provincial Maternity and Children's Hospital; to examine the incidence and risk factors for emergency obstetric hysterectomy; and to evaluate the curative effectiveness and safety of subtotal hysterectomy for life-threatening PPH.The records of all cases of emergency obstetric hysterectomy performed at Fujian Maternity and Children Health Hospital between January 2004 and June 2016 were analyzed. The incidence, risk factors, and outcomes of hysterectomy, the peripartum complications, and the coagulation function indices were evaluated.A total of 152,023 of women were delivered. The incidence of emergency postpartum hysterectomy was 0.63 per 1000 deliveries: 96 patients underwent hysterectomy for uncontrolled PPH, 19 (0.207‰) underwent hysterectomy following vaginal delivery, and 77 (1.28‰) underwent the procedure following cesarean delivery (P < .001). Common risk factors included postpartum prothrombin activity ≤ 50% (61.5%), placenta accreta (43.76%), uterine atony (37.5%), uterine rupture (17.5%), and grand multiparity > 6 (32.3%). Forty-one patients underwent subtotal abdominal hysterectomy (STH) and 55 patients underwent total abdominal hysterectomy (TH). The mean operation time was significantly shorter for TH (193.59 ± 83.41 minutes) than for STH (142.86 ± 78.32 minutes; P = .002). The mean blood loss was significantly greater for TH (6832 ± 787 mL) than for STH (6329 ± 893 mL; P = .003). The mean number of red cell units transfusion was higher during TH (16.24 ± 9.48 units vs 12.43 ± 7.2, respectively; P = .047). Postoperative prothrombin activity was significantly higher than preoperative levels (56.84 ± 14.74 vs 44.39 ± 15.69, respectively; P < .001) in women who underwent TH and in those who underwent STH (57.63 ± 15.68 vs 47.87 ± 12.86, respectively; P < .001). There was no significant difference in the maternal complications after TH or STH for PPH.Cesarean deliveries were associated with an increased risk of emergency hysterectomy, and postpartum prothrombin activity < 50% was the greatest risk factor for hysterectomy in most women who underwent hysterectomy. STH was the preferred procedure for emergency obstetric hysterectomy.

A new facilitating technique for postpartum hysterectomy at full dilatation: Cervical clamp

BackgroundPostpartum hysterectomy is a life saving emergency procedure in the management of uncontrollable severe maternal hemorrhage that every obstetrician should be closely acquainted with despite developments in medical and non-surgical interventions for obstetric hemorrhage. It can be difficult to detect the real boundaries of the cervix at full effacement and dilatation in patients who undergo emergency hysterectomy after vaginal delivery. MethodsHereby we propose a simple and effective method to ease the operation by placing two atraumatic ring forceps to the anterior and posterior sides of the cervix during the preoperative vaginal examination and leave the two ring forceps while taking the patient into surgery. The boundary of the vagina and cervix will be determined with the help of the ring forceps intraoperatively, which are already placed before the operation. ResultsCervical clamp technique was successfully performed in four cases underwent to emergency postpartum hysterectomy due to uncontrollable postpartum atony. There were no postoperative complication and re-exploration for the persistent hemorrhage. Postoperative FSFI scores of the cases were 26.7, 27.4, 30.3 and 30.7. ConclusionTaking extra vaginal tissue from the lower level of the cervix may be avoided and the last stage of the total hysterectomy may be facilitated by this simple technique with ensuring of bleeding management.

Increased rates of cesarean sections and large families: a potentially dangerous combination.

Rates of cesarean sections have been on the rise over the past three decades all over the world, despite the ideal rate of 10-15% that had been set by the World Health Organization (WHO) in 1985, in Fortaleza, Brazil. This epidemic increase in the rate of cesarean delivery is due to many factors which include, cesarean delivery on request, advanced maternal age at first pregnancy, decrease in number of patients who are willing to try vaginal birth after cesarean delivery, virtual disappearance of vaginal breech delivery, perceived increase in the weight of the fetus and increase in the number of women with chronic medical conditions such as Diabetes Mellitus and congenital heart disease in the reproductive age. There is no doubt that cesarean delivery is a safe procedure and it is getting safer and safer for many reasons. However, like all other surgical procedures it is not without risks both to the mother and the new born. There is a substantial increase in the incidence of morbidly adherent placenta and the risk of scar pregnancy. In the Middle East and many African and Asian countries women tend to have large families. The number of previous cesarean section deliveries is directly proportional to the risk of developing morbidly adherent placenta. Morbidly adherent placenta is the most common cause of emergency postpartum hysterectomy, which is often associated with multiple surgical complications, severe maternal morbidity and mortality. The increased rates of cesarean sections lead to increased rates of scar pregnancies, which can have lethal consequences. Cesarean delivery has a negative impact on the infant immune system. This effect on the infant led to the introduction of a new concept called "Vaginal seeding". This refers to the practice of transferring some maternal vaginal fluid to the infant born via cesarean section in an effort to enhance its immune system.

Emergency postpartum hysterectomy in Sisaket Hospital: clinical characteristic and risk factors

Background: Postpartum hemorrhage remains a leading cause of maternal death. Although there had been the improvement of various treatments, such as prostaglandin and s-Lynch suture, some women did not respond to these treatments and needed Emergency peripartum hysterectomy (EPH) to control intractable bleeding. The aim of this study was to determine clinical characteristics associated with EPH in Sisaket Hospital. Objective: To determine the incidence, indications, clinical characteristics and risk factors influencing EPH. Design: A retrospective hospital-based descriptive and case control study. Setting: Department of Obstetrics and Gynecology, Sisaket Hospital. Methods and Materials: Women who was pregnant 28 weeks gestational age or more and carried out EPH within 24 hours after delivery at Sisaket Hospital from January 2012 to June 2015 (total 26 cases) were identified from labor registration records. Their medical records were reviewed to assess the following outcomes (1) incidence of EPH (2) indications for EPH (3) clinical characteristics and risk factors associated with EPH (4) complications after EPH. Women who gave birth before (2 cases) and after (2 cases) the cases of EPH (total 104 cases ) were the control used to assess the risk factors associated with EPH. Result: During the study period, there were 17,566 deliveries at 28 weeks gestational age or more. Among them, there were 26 cases undergoing EPH. The incidence was 1.48 per 1,000 deliveries. Medical records showed that placenta adherent (65.38%) was the most common indication of EPH followed by uterine atony (26.92%) and uterine rupture (7.69%). The significant risk factors affecting EPH by multivariate logistic regression analysis were maternal age ≥ 35 years, cesarean delivery and delivery at 28-36 weeks gestational age. There were two maternal deaths after EPH. Conclusions: Clinical characteristics and risk factors associated with EPH were age ≥ 35 years, cesarean delivery and delivery at GA28-36weeks.

Human uterus transplantation with live births; Outcome of the first clinical trials

The last frontier to conquer in female infertility is absolute uterine factor infertility (AUFI), affecting 1:500 women. This would correspond to around 160,000 AUFI women between 20 and 40 years of age in Europe. The cause of AUFI may be uterine aplasia, hysterectomy at young age (cervical/uterine malignancy, emergency postpartum hysterectomy), Asherman's syndrome or uterine malformation. Uterine transplantation (UTx) is now the first available treatment for this large group of women. Today, more than 20,000 children have been born from women with organ transplants and under immunosuppression (IS). Although these pregnancies usually can be managed with a positive outcome there are indications that the rates of obstetric complications (preeclampsia, preterm delivery, and growth restriction) are increased. However, this may well be due to the underlying disease (majority renal disease) and that the largest subpopulation of this group only have single kidneys. UTx was developed by us towards human application, by performing animal research for more than 15 years. It is imperative that a complicated surgical procedure such as UTx, with implications also in the fields of ART and fetal-maternal medicine, is prepared meticulously by research and training in animals to be safe at the time of clinical introduction.

Management of Intrauterine Arteriovenous Malformation (AVM) in 14 Patients by Sonographically Guided Tisseel Application.

AVMs are rare tumorous vascular lesions derived from placental tissue that may present with massive post-partum hemorrhage (PPH) causing potentially life-threatening anemic shock. Current treatment options include the embolization of uterine arteries and emergency postpartum hysterectomy. We present a new form of minimally invasive, highly specific sonographically guided treatment in the form of the application of a human fibrin sealant leading to the instant cease of blood loss. A management protocol was established and a case series of 14 patients is presented. Diagnosis by endovaginal color Doppler sonography is followed by the sonographically guided application of biological glue (TISSEEL®), thus allowing for super-selective occlusion of the feeding vessels. The procedure was technically successful in all 14 patients, 3 of whom (21 %) had a repeated procedure after 4 - 7 days. The mean age (yrs.) of the patients was 31 (25 - 40), thegravity was median 2 (1 - 5) and the parity was median 1 (0 - 4), the lowest Hb value was on average 9.35 ± 2.25 (5.2 - 14.2) g/dl, the lowest Ht was on average 30.82 ± 6.02 (18 - 41 %). Spectral Doppler analysis revealed an average of 80.71 ± 11.2 (66 - 115) cm/sec for the maximal detectable PSV. In the period of 4 - 55 months after treatment, 7 patients (50 %) had 8 successful pregnancies and 2 miscarriages. In PPH there is vital interest in timely diagnosis of the underlying cause, thus allowing fertility-sparing, minimally invasive and super-selective emergency treatment. In AVMs causing PPH, a positive impact on perinatal morbidity and mortality may be achieved by sonographically guided application of this biological glue.

Utility of ultrasound and magnetic resonance imaging in prenatal diagnosis of placenta accreta: A prospective study.

Context:Placenta accreta is the abnormal adherence of the placenta to the uterine wall and the most common cause for emergency postpartum hysterectomy. Accurate prenatal diagnosis of affected pregnancies allows optimal obstetric management.Aims:To summarize our experience in the antenatal diagnosis of placenta accreta on imaging in a tertiary care setup. To compare the accuracy of ultrasound (USG) with color Doppler (CDUS) and magnetic resonance imaging (MRI) in prenatal diagnosis of placenta accreta.Settings and Design:Prospective study in a tertiary care setup.Materials and Methods:A prospective study was conducted on pregnant females with high clinical risk of placenta accreta. Antenatal diagnosis was established based on CDUS and MRI. The imaging findings were compared with final diagnosis at the time of delivery and/or pathologic examination.Statistical Analysis Used:The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for both CDUS and MRI. The sensitivity and specificity values of USG and MRI were compared by the McNemar test.Results:Thirty patients at risk of placenta accreta underwent both CDUS and MRI. Eight cases of placenta accreta were identified (3 vera, 4 increta, and 1 percreta). All patients had history of previous cesarean section. Placenta previa was present in seven out of eight patients. USG correctly identified the presence of placenta accreta in seven out of eight patients (87.5% sensitivity) and the absence of placenta accreta in 19 out of 22 patients (86.4% specificity). MRI correctly identified the presence of placenta accreta in 6 out of 8 patients (75.0% sensitivity) and absence of placenta accreta in 17 out of 22 patients (77.3% specificity). There were no statistical differences in sensitivity (P = 1.00) and specificity (P = 0.687) between USG and MRI.Conclusions:Both USG and MRI have fairly good sensitivity for prenatal diagnosis of placenta accreta; however, specificity does not appear to be as good as reported in other studies. Both modalities have complimentary role and in cases of inconclusive findings with one imaging modality, the other modality may be useful for obtaining the diagnosis. CDUS remains the first primary modality for antenatal diagnosis of placenta accreta, with MRI reserved for cases where USG is inconclusive.

Finding Meaning in Life Following Emergency Postpartum Hysterectomy: What Doesn't Kill Us Makes Us Stronger.

Childbirth is generally perceived to be a triumphant and joyous moment in a woman's life. However, current research indicates that it can also be a time of fear, dread, and apprehension, particularly when the birth experience is traumatic. Some women attempt to seek the positives of their traumatic or unexpected childbirth experience to be able to cope with their experience. However, little attention is directed toward how women rebuild their lives and grow following traumatic birth experiences such as severe postpartum hemorrhage and emergency hysterectomy. Twenty-one Australian women, aged 24 to 57 years, who had experienced severe postpartum hemorrhage and emergency hysterectomy were interviewed in an in-depth qualitative study about their experiences. Thematic analysis revealed the major theme of moving forward and 4 subthemes: appreciating life and what you have; what really counts: learning and growing; accepting it: it's just the way it is; and reframing the experience: seeking the positives All of the women found meaning following their hysterectomy, which produced a positive perspective on their lives. The way that women find meaning and cope with the trauma of having a severe postpartum hemorrhage and emergency hysterectomy is significant to their ability to move forward and live life to the fullest. Midwives and other health care providers may be in a position to provide support for women in the aftermath of severe postpartum hemorrhage and emergency hysterectomy.

Uterus preservation as an alternative to an emergency hysterectomy for postpartum hemorrhage

4. For obstetricians who perform cesarean sections who can easily perform selective ligation of the uterine and hypogastric arteries, we recommend performing selec-tive ligation.5. For obstetricians who cannot perform selective ligation easily, we recommend uterine compression sutures for obstetricians who can do so easily.6. If obstetricians cannot insert compression sutures, but UAe is available, then UAe should be considered.7. Finally, if the patient has unstable vital signs and dis-seminated intravascular coagulation (DIC), or UAe is not available, emergency postpartum hysterectomy should be considered.Based on our clinical data and experience, stable vital signs without DIC are key points to consider when decid-ing to perform UAe [5]. We found a significant difference in the outcome of UAe for Ph in referred patients. Dur-ing transfer, the patients are bleeding massively and often cannot endure UAe. the health care systems in other coun-tries might not be the same as the Korean system, but in countries with similar systems, it is helpful for evaluating patients transferred with Ph.Postpartum hemorrhage is an emergency and the stand-ard management is emergency postpartum hysterectomy. Nevertheless, uterine preservation is important when pos-sible. If a hospital is not equipped to perform UAe or if the obstetricians lack skill at performing uterine preservation procedures, such as ligation of the uterine artery or uterine compression sutures, then an emergency postpartum hys-terectomy should be performed immediately.We recommend following our algorithm for preserving the uterus and reducing the morbidity associated with Ph based on our clinical experience and the article by Sadik et al. Deliveries with Ph are very dynamic, stressful, Sir,We are responding to the article by Sadik et-al. and Furkan et al. on emergency postpartum hysterectomy, which is a very important obstetrics procedure [2]. We have 1, some comments regarding the control of postpartum hem-orrhage (Ph). Sadik etal. reported the incidence, risk fac -tors, indications, outcomes, and complications of emer-gency postpartum hysterectomy. the current management of Ph focuses on preserving the uterus, using uterine artery embolization (UAe), compression suture methods, and ligation of the hypogastric or uterine artery. We have reported methods such as a modified uterine compression suture for placenta previa; i.e., the hYUNhO method, and uterine compression sutures with intrauterine balloon tam-ponade, which is helpful for preserving the uterus [3, 4].Based on Sadik et al. and our articles, we take the fol-lowing steps in the management of Ph.1. Before a delivery or cesarean section, we check for placental abnormalities using ultrasonography and a history of risk factors.2. If we are suspicious after delivery or cesarean sec-tion, we immediately start conventional management, including fundal massage and the administration of oxytocin and prostaglandins.3. We monitor the vital signs closely, obtain a complete blood count and differential, and consider the use of blood products.

Emergency postpartum hysterectomy: incidence, trends, indications, and complications

Emergency postpartum hysterectomy: incidence, trends, indications, and complications

Incidence, Indications, and Predictors of Adverse Outcomes of Postpartum Hysterectomies: 20-Year Experience in a Tertiary Care Centre

ObjectivePostpartum hysterectomy is an uncommon yet serious obstetric procedure associated with maternal morbidity and mortality. The objectives of our study were to assess the incidence of and indications for PH and to identify predictors of massive hemorrhage and coagulopathy. MethodsWe conducted a retrospective cohort study on all cases of PH performed at the Jewish General Hospital, McGill University, between 1992 and 2011. Data were collected from individual patient charts and logistics regression models were used to evaluate predictors of adverse events. ResultsOver a 20-year study period, there were 76 938 live births and 67 postpartum hysterectomies for an overall incidence of 0.87/1000. Although overall PH rates increased over time predominantly because of increasing rates of planned PH for placental abnormalities, there was a decrease in unplanned emergency postpartum hysterectomies. The main indications for PH were abnormal placentation (64.2%) and postpartum hemorrhage (26.9%). In adjusted analysis, the risk of requiring massive blood transfusion was increased when PH was performed after vaginal delivery or Caesarean section (OR 102.1; 95% CI 4.22 to 2468) and in association with postpartum hemorrhage (OR 9.1; 95% CI 1.3 to 64.3). The risk of massive hemorrhage was lower if occlusive balloons were placed antenatally in the uterine arteries (OR 0.13; 95% CI 0.03 to 0.68) and if PH was performed by a dedicated experienced surgeon (OR 0.23; 95% CI 0.06 to 0.86). ConclusionAlthough overall rates of PH are increasing, antenatal recognition of placental pathologies have resulted in fewer postpartum hysterectomies being done as emergencies. The use of occlusive balloons in the uterine arteries and having the procedure performed by a dedicated surgeon skilled in performing postpartum hysterectomy can reduce overall serious morbidity.

Risk Factors for Emergency Postpartum Hysterectomy

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Risk Factors for Emergency Postpartum Hysterectomy

The objective of this retrospective case-control study was to identify clinical factors associated with emergency peripartum hysterectomy. Deliveries from January 2003 through October 2009 in this tertiary care obstetrics hospital were reviewed. Cases were women who underwent emergency peripartum hysterectomy. Controls were those who delivered immediately after the cases but in whom hysterectomy was not needed. They were matched to cases in a 5:1 ratio. Thirty-eight cases and 190 controls were selected. Variables found to be significantly associated with emergency postpartum hysterectomy were a stage III-IV placenta previa (p<0.001), previous surgical abortions (p=0.001) and number of fetuses (p=0.039). The corresponding adjusted odds ratios were 40.2 (95% confidence interval 5.6-287.0), 6.0 (95% confidence interval 2.1-17.2) and 7.8 (95% confidence interval 1.1-55.0), respectively. The study confirms the detrimental role of major placenta previa in influencing the risk of postpartum hysterectomy, but also suggests multiple pregnancy and surgical abortion as potential additional risk factors.