Indication For Emergency Peripartum Hysterectomy Research Articles

Peripartum Hysterectomy among Patients Admitted to the Department of Obstetrics and Gynaecology in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Emergency peripartum hysterectomy is a life-saving procedure performed as an emergency procedure to control torrential bleeding and it is associated with significant maternal morbidity and mortality. There are only a few studies regarding this topic so this study guides us to monitor the trend and start appropriate policies to reduce unnecessary caesarean deliveries. The aim of this study was to find out the prevalence of peripartum hysterectomy among patients admitted to the Department of Obstetrics and Gynaecology in a tertiary care centre. A descriptive cross-sectional study was conducted in the Department of Obstetrics and Gynaecology of the tertiary care centre. Data from 1 January 2015 to 31 December 2022 were collected between 25 January 2023 and 28 February 2023 from the hospital records. Ethical approval was obtained from the Institutional Review Committee of the same institute (Reference number: 2301241700). Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Among 54,045 deliveries, peripartum hysterectomy was seen in 40 (0.074%) (0.05-0.10, 95% Confidence Interval). The major indication of emergency peripartum hysterectomy was abnormal placentation (placenta accreta spectrum) which was 25 (62.50%) followed by uterine atony in 13 (32.50%) of patients and uterine rupture in 2 (5%). The prevalence of peripartum hysterectomy was lower than in other studies done in similar settings. The indication for Emergency peripartum hysterectomy has changed in recent years from uterine atonicity to the morbidly adherent placenta which is due to a rise in the caesarean section rate. caesarean section; hysterectomy; placenta accreta.

To Determine The Risk Factors and Indications of Emergency Peripartum Hysterectomy

Objective: To determine the frequency of factors leading to emergency peripartum hysterectomy Introduction: The emergency peripartum hysterectomy (EPH) is a dreadful complication and to determine its risk factors is very important to early and prompt management. Objective: My objective is to determine the frequency of factors leading to emergency peripartum hysterectomy. Main outcome: EPH is the main outcome which is surgical removal of uterus due to severe postpartum hemorrhage Study design: Descriptive case series Setting: Obstetrics and Gynaecology Department, District Headquarter Hospital, Gujranwala Duration of study: 1 July 2019 to 31 December 2019 Material and methods: Seventy patients undergoing emergency peripartum hysterectomy were selected from the Obstetrics and Gynecology emergency department of District Headquarter Hospital, Gujranwala. Hospital registration numbers was noted and for all enrolled women. The major risk factors like uterine atony, uterine rupture and abnormal placentation was noted down from detailed history and clinical and ultrasound examinations and surgeon notes was collected. All patients will be efficiently managed throughout a per standard guidelines. Data was analyzed using SPSS version 20. The quantitative variables were age, gestational age and BMI. Mean and standard deviation was calculated for quantitative data. Frequency and percentages were calculated for qualitative data like parity and risk factors. Effect modifiers like age, parity and BMI was controlled by stratification. Post stratification Chi square test was applied. P value ≤ 0.05 was considered as statistically significant. Results: The mean age was 28.64 ± 6.836 years. The mean gestational age and BMI were 31.61 ± 3.576 weeks and 23.66 ± 2.904 kg/m2 respectively. The frequency of parity groups was as follows; for parity 1, 2, 3, 4 and ≥5 was 13 (18.6%), 10 (14.3%), 11 (15.7%), 25 (35.7%) and 11 (15.7%) respectively. The main causes of EPH were uterine rupture, abnormal placentation and uterine atony with proportions of 30%, 44.3% and 12.9% respectively. The data was stratified according to age, gestational age, parity and BMI. The results showed that there was no significant impact of age, gestational age, parity and BMI as all p values were >0.05 Conclusion: The emergency peripartum hysterectomy has various causative factors and uterine rupture, abnormal placentation and uterine atony are the most significant factors which can be minimized to reduce its incidence. Keywords: Emergency Hysterectomy Obstetric Outcome Postoperative Complications Postpartum Hemorrhage/epidemiology/surgery Pregnancy

PERIPARTUM HYSTERECTOMY AND ITS RISK FACTORS

Background: Emergency Peripartum Hysterectomy (EPH) is an important lifesaving surgical procedure considered in cases of severe hemorrhage unresponsive to medical and conservative management. The objective is to review incidence, identification, intervention and impact of emergency peripartum hysterectomy.
 Methods: The retrospective, cross-sectional study designed was to used. EPH data were collected from January 2014 to December 2018.Descriptive statistics was used to analyzed data and presented in tables and charts.
 Results: Incidence of Emergency Peripartum Hysterectomies was 2.3% out of 252(2.6%) cases of obstetrical emergencies and 0.06% that is 1 in 1600 deliveries. Most common indications for EPH were uterine rupture (33.3%); placenta accreta (33.3%) followed by retained placenta (16.6%) and endometritis with pyometritis (16.6%). Estimated blood loss 1916 ml., timeliness from delivery to hysterectomy was 140 minutes; most common post-operative complication was surgical site infection (33.3%) and length of hospital stay 11.7 days. Maternal morbidity rate was 33.3%. There was no maternal mortality recorded.
 Conclusions: The timely intervention improves the outcome in Peripar­tum Hysterectomy, which is frequently associated with abnormal placen­tation as a consequence of increasing caesarean deliveries rate.

Emergency peripartum hysterectomy in a tertiary teaching hospital in Northern Jordan: a 15-year review

Emergency peripartum hysterectomy is a major operation performed when conservative measures fail to stop life-threatening postpartum hemorrhage. It is associated with a high rate of maternal morbidity among survivors. This work aims to evaluate the incidence, indication, and complications of peripartum hysterectomy at King Abdulla University Hospital over 15 years. A retrospective cohort study of emergency peripartum hysterectomy. The incidence was calculated. Risk factors for abnormally adherent placenta were explored. A comparison between total and subtotal hysterectomy in terms of morbidity outcomes was conducted. The chi-square test, Fisher’s exact, and independent sample T test were used for analysis. Statistical significance was declared at α < 0.05. The incidence of peripartum hysterectomy was 1.38 per 1000 births. Fifty-nine were performed after cesarean section and three were performed after vaginal delivery (P<0.001). Abnormally adherent placenta (accreta, increta, and percreta) was the main indication (44.06%). The strongest risk factor for abnormally adherent placenta was placenta previa with previous cesarean section (P=0.001, OR 16.25, 95% CI 1.95-135.01). One maternal and three neonatal deaths were recorded. Urinary bladder injury was the most frequent complication (27.11%). No difference in morbidity was noted between total and subtotal hysterectomy. The incidence of emergency peripartum hysterectomy is increasing steadily over the last two decades in the north of Jordan. Abnormally adherent placenta is the most common indication for emergency peripartum hysterectomy. There is no significant difference between total and subtotal hysterectomy in terms of complications’ development, admission to the intensive care unit, and estimated blood loss. The morbidity associated with emergency peripartum hysterectomy is significant.

Clinical Audit of Obstetrical Hysterectomies for a Period of One Year in A Tertiary Care Hospital

Objectives: To audit the obstetric hysterectomies in a tertiary care hospital during one year. Methods: It was an observational retrospective study design, where all the pregnant women were assessed for fetomaternal outcomes, indications and complications for peripartum hysterectomy. The records were retrieved from Jan 2015 to Dec 2015 by using hospital record system. The study duration was of one year. The venue of the study was Lahore General hospital, Lahore. The exclusion criteria included all unmarried women, women with chronic kidney disease or renal failure, past surgical history of heart disease, whereas all the women who delivered in hospital, private clinic or at home after atleast 28 weeks of gestational age and experience hysterectomy at the time of delivery or after delivery in the puerperium, were included in the study. Results: The data over 32 women were retrieved from the hospital record system. The mean age of the women was 30.34+2.23 with range 26-34. The average number of parity was 3 of all females. The range of parity was 2 to 7. The average gestational age was 36.18 weeks. All the deliveries were done by cesarean section whereas 4 (12.5%) were elective and 28 (87.5%) were with emergency indications. 13 (40.6%) of the deliveries were in private clinic, 9 (28.1%) were done by LHV/ mid wife, 5(15.6%) were in private hospitals, 4(12.5%) were in LGH and only 1(3.1%) was at home. 18(56.3%) of the women were having at least one abortion in previous history. Conclusion: We concluded that emergency peripartum hysterectomy is very vital procedure that saves lives and manage life threatening obstetrical hemorrhage when other methods failed to control it.The major indications for emergency peripartum hysterectomy were placental abruption, placenta praevia/accrete, uterine atony and ruptured uterus. Key Words: Uterine artery embolization, Emergency peripartum hysterectomy, maternal morbidity and mortality, healthcare providers How to Cite: Latif F, Ilyas S, Mehmood S. Arif H. Khawaja P. Nuzhat. Jawad Z. J Clinical audit of obstetrical hysterectomies for a period of one year in a tertiary care hospital. Esculapio.2020;16(04):50-53.

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

IntroductionEmergency peripartum hysterectomy (EPH) is a foremost operation and is perpetually implemented in the presence of life intimidating hemorrhage during or immediately after abdominal or vaginal deliveries. The aim of this study was to review cases managed at the Department of Gynecology and Obstetrics at Jordan University Hospital (JUH).Material and methodsAll women who underwent EPH due to any cause in the period from January 2010, to December 2017 were included in the study. Data were collected retrospectively using the patients’ files namelessly. Main measures: age, gravidity, parity, number of previous cesarean sections, previous uterine surgeries, indication for hysterectomy, complications, antepartum bleeding and the need for blood transfusion.ResultsIn total, 74 cases of EPH were managed during the study period. The incidence of EPH ranged from 0.24 to 8.7 per 1000 deliveries. EPH was found to be more common following cesarean sections than vaginal deliveries. The prime indication was abnormal placentation, uterine atony, and uterine rupture. The risk factors included previous cesarean sections, scarred uteruses, multiparity, older age group. Maternal morbidity ranged from 26.5 to 31.5% and mortality from 0 to 12.5% with a mean of 4.8%.ConclusionsEPH is the most demanding obstetric surgery performed in very tiresome circumstances of life threatening hemorrhage. The indication for EPH in recent years has changed from outdated uterine atony to abnormal placentation. Antenatal eagerness of the risk factors, engrossment of proficient obstetricians at an early stage of management and a prompt hysterectomy after adequate resuscitation would go a long way in tumbling morbidity and mortality.

Peripartum hysterectomy and its risk factors

Background: Emergency Peripartum Hysterectomy (EPH) is an important lifesaving surgical procedure considered in cases of severe hemorrhage unresponsive to medical and conservative management. The objective is to review incidence, identification, intervention and impact of emergency peripartum hysterectomy. &#x0D; Methods: The retrospective, cross-sectional study designed was to used. EPH data were collected from January 2014 to December 2018.Descriptive statistics was used to analyzed data and presented in tables and charts. &#x0D; Results: Incidence of Emergency Peripartum Hysterectomies was 2.3% out of 252(2.6%) cases of obstetrical emergencies and 0.06% that is 1 in 1600 deliveries. Most common indications for EPH were uterine rupture (33.3%); placenta accreta (33.3%) followed by retained placenta (16.6%) and endometritis with pyometritis (16.6%). Estimated blood loss 1916 ml., timeliness from delivery to hysterectomy was 140 minutes; most common post-operative complication was surgical site infection (33.3%) and length of hospital stay 11.7 days. Maternal morbidity rate was 33.3%. There was no maternal mortality recorded. &#x0D; Conclusions: The timely intervention improves the outcome in Peripar­tum Hysterectomy, which is frequently associated with abnormal placen­tation as a consequence of increasing caesarean deliveries rate.

Incidence and Complications of Emergency Peripartum Hysterectomy: A Retrospective Study at Maternal and Child Health Training Institute, Dhaka

Introduction: Emergency peripartum hysterectomy (EPH) is a major surgical venture performed in the setting of life threatening hemorrhage during or immediately after abdominal and vaginal deliveries. In developing countries, 8-10% of maternal mortality directly occurs due to massive obstetrical hemorrhage. Most common indication for emergency peripartum hysterectomy has been uterine atony and uterine rupture. The decision to perform an emergency hysterectomy on a young woman especially one with low parity poses a dilemma for the obstetrician particularly in our society.&#x0D; Objective: To estimate incidence, indications and postoperative complications associated with emergency hysterectomy at Maternal and Child Health Training Institute (MCHTI), Azimpur, Dhaka.&#x0D; Materials and Methods: This is a retrospective study and registration numbers of all women who underwent emergency peripartum hysterectomy were indentified. With the numbers, the case notes were retrieved from the medical records department for in-depth study. Information abstracted included the socio-demographic characteristics of the patients, indications for the hysterectomy, type of hysterectomy performed, booking status of patients, mode of delivery, gestational age at delivery and maternal outcome were recorded in a pre-designed data form. The data were analyzed using simple proportion, rates and tables.&#x0D; Results: There were 18 cases of emergency peripartum hysterectomies performed during the study period of January 2011 to December 2013 (incidence 1.26/1000 deliveries). Commonest age of the middle group was 29-34 years. Ruptured uterus was the commonest indication (9 cases, 50%) and other indications were uterine atony/ PPH (8 cases, 44.44%), placenta praevia (1 case, 5.56%). Subtotal abdominal hysterectomy was done in 17(94.44%) cases whereas total abdominal hysterectomy in 01(5.56%) cases. This emergency procedure was associated with significant number of intraoperative and postoperative complications, However maternal and perinatal outcome was satisfactory.&#x0D; Conclusion: EPH remains an essential life saving procedure and its incidence continues to remain high in our community when compared with developed countries. Effective antenatal care, identification of patients at risk, enhancement of blood transfusion facilities together with improvement of surgical skills are important to reduce the incidence of peripartum hysterectomy as well as morbidity and mortality.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.13(1) 2017: 106-110

English

OBJECTIVE: To determine the incidence, indications, maternal and perinatal outcome of emergency peripartum hysterectomy. METHOD: A prospective observational study of all patients who underwent peripartum hysterectomy was conducted from June 2011 to November 2012 in the Department of Obstetrics and Gynecology, Lalla Ded Hospital, an associated hospital of Government Medical College, Srinagar, Kashmir. Data, specifically on the incidence of emergency peripartum hysterectomy, the total number of deliveries, the maternal parameters, the indications of peripartum hysterectomy and associated maternal morbidity and mortality were recorded on a proforma. RESULTS: There were 87 cases of peripartum hysterectomy (75 caesarean hysterectomies, 86.2% and 12 postpartum hysterectomies, 13.8%), making an incidence of 2.56/1000 deliveries. Most of the patients were para 3, 32 (36.8%), were mostly in age group of 35-39 years 38 (43.7%) and belonged to rural areas. Overall, the most common indication for emergency peripartum hysterectomy was morbidly adherent placenta with placenta previa 39(44.8%) followed by uterine rupture 24 (27.6%), uterine atony 13 (14.9%) and accidental haemorrhage 6 (6.9%). In 38 (43.7%) patients total abdominal hysterectomy was performed while 49 (56.3%) patients required subtotal hysterectomy. There were 9 (10.3%) maternal and 40 (46%) perinatal deaths; all were due to severity of conditions necessitating hysterectomy. CONCLUSION: Emergency peripartum hysterectomy is potentially a lifesaving procedure associated with significant maternal morbidity and mortality. Morbidly adherent placenta with placenta previa was the commonest indication for emergency peripartum hysterectomy. Previous scar, multiparity and abnormal placentation were the significant risk factors.

Exaggerated placental site/placental site trophoblastic tumor: an underestimated risk factor for emergency peripartum hysterectomy

Objective: To assess the indications and possible underlying causes of emergency peripartum hysterectomy (EPH) at the present hospital during the 2001-2011 period. Materials and Methods: A revision of the charts and pathology reports corresponding to 42,728 parturients. Results: During the study period, 25 peripartum hysterectomies were performed (0.61/1.000), of which 23 were EPHs (0.54/1.000) and two were planned cesarean hysterectomies. The indication for EPH was acute postpartum hemorrhage in 22 of 23 instances (95.7%). Roughly two-thirds of the operated uteri (16/25, 64%) showed placental site anomalies, half corresponding to different degrees of placental accretism and half to anomalies derived from the implantation site intermediate trophoblast. In five cases (31%), the anomaly was an exaggerated placental site and three cases corresponded to placental site trophoblastic tumors. Of the 16 cases showing placental site anomalies, ten (62.5%) were associated with one or more previous cesarean sections. Conclusions: Roughly one-third of EPHs performed at the present center during the last ten years were associated with placental site anomalies originating in the implantation site intermediate trophoblast (exaggerated placental site and placental site trophoblastic tumor). This association has not been described before, and should be taken into consideration when facing acute peripartum hemorrhage predisposing to EPH.

Incidence of emergency peripartum hysterectomy in Ain-shams University Maternity Hospital, Egypt: a retrospective study.

To estimate the incidence of emergency peripartum hysterectomy over 6 years in Ain-shams University Maternity Hospital. Detailed chart review of all cases of emergency peripartum hysterectomy, 2003-2008, including previous obstetric history, details of the index pregnancy, indications for emergency peripartum hysterectomy, outcome of the hysterectomy and infant morbidity. The overall rate of emergency peripartum hysterectomy was 149 of 66,306 or 2.24 per 1,000 deliveries. The primary indications for hysterectomies were placenta accreta/increta 59 (39.6 %), uterine atony 37 (24.8 %), uterine rupture 35 (23.5 %) and placenta previa without accreta 18 (12.1 %). After hysterectomy, 115 (77 %) women were admitted to the intensive care unit. Women were discharged home after a mean 11.2 day length of stay. Using multifactorial logistic regression analysis, we found that woman's age, atonic uterus, placenta accreta/increta, previous cesarian section and ruptured uterus were independent predictors for peripartum hysterectomy Abnormal placentation was the main indication for peripartum hysterectomy. The risk factors for peripartum hysterectomy were morbid adherence of placentae in scared uteri, uterine atony and uterine rupture. The most important step in prevention of major postpartum hemorrhage is recognizing and assessing women's risk. The risk of peripartum hysterectomy seems to be significantly decreased by limiting the number of cesarean section deliveries, thus reducing the occurrence of abnormal placentation in the form of placenta accreta, increta or percreta.

Risk factors associated with emergency peripartum hysterectomy

Background Use of an emergency peripartum hysterectomy (EPH) as a lifesaving measure to manage intractable postpartum hemorrhage (PPH) appears to be increasing recently around the world, and the indications for EPH have changed. The object of this study is to identify risk factors associated with EPH. Methods We conducted a case-control study of 21 patients who underwent EPH because of intractable PPH between January 1, 2005 and June 30, 2013, at the International Peace Maternity and Child Health Hospital Shanghai Jiao Tong University, School of Medicine (IPMCH). The parametric t-test, chi-square tests and Logistic regression models were used for analysis to identify the risk factors. The results were considered statistically significant when P&lt;0.05. Results There were 89 178 deliveries during the study period. Twenty-one women had an EPH, with an incidence of 24 per 100 000 deliveries. The loss of blood during postpartum hemorrhage of the EPH group was (5 060.7±3 032.6) ml, and that of the control group was (2 040.8±723.5) ml. There was a significant difference of PHH between the EHP group and the control group (P=0.001). Independent risk factors for EPH from a logistic regression model were: disseminated intravascular coagulation (DIC) (OR: 9.9, 95% CI 2.8-34, P=0.003), previous cesarean section (OR: 5.27; 95% CI: 1.48-17.9, P=0.009), placenta previa (OR: 6.9; 95% CI 1.6-2.9, P=0.008), the loss of PPH (OR: 1.001; 95% CI 1.001-1.002, P=0.002), placenta accreta (OR: 68; 95% CI 10-456, P=0.004), the use of tocolytic agents prenatally (OR: 6.55, 95% CI 1.34-32.1, P=0.049), and fetal macrosomia (OR: 6.9, 95% CI 1.25-38, P=0.049). Conclusion Significant risk factors of EPH are DIC, placenta previa, PPH, previous cesarean delivery, and placenta accrete, the use of tocolytic agents prenatally, and fetal macrosomia.

English

OBJECTIVES: To determine the incidence, risk factors, outcome, complications and the changing trends of indications for Emergency Peripartum Hysterectomy (E.P.H.), and compare the results with other reports in the literature. METHODS: A population based 5 year retrospective study of 72 cases of emergency peripartum hysterectomy was carried out using hospital database from January 2008 to December 2012 in a peripheral medical college of Eastern India. RESULTS: A total of 72 EPH were performed among 94276 deliveries with an incidence of 0.76/1000 deliveries. The incidence was more among multiparous women (69%) and highest in the age group of 20 to 29 years (77.7%). Ruptured uterus was most common indication for Emergency Peripartum Hysterectomy (52.7%).Maternal mortality was 11.11% following peripartum hysterectomy. Our study in eastern India shows a statistically significant lower incidence of peripartum hysterectomy compared to that in other parts of India (0.076% versus 0.35% deliveries; P value <0.0101). CONCLUSION: Emergency Peripartum Hysterectomy is a life saving procedure and often puts the obstetrician in a dilemma for decision making. In this rural and backward area of Eastern India, primary and post CS deliveries are associated with an increased risk of Emergency Peripartum Hysterectomy. These results are of particular concern considering the steady rise in post CS pregnancy particularly in this backward region of our country.

Maternal Near Miss Review: A Way Forward

Maternal Near Miss Review: A Way Forward

Emergency Peripartum Hysterectomy: A one year review at a tertiary care hospital

Background: Emergency Peripartum Hysterectomy (EPH) is a lifesaving surgical procedure. The higher incidence of EPH in developing countries is because of the higher prevalence of risk factors of primary postpartum haemorrhage like, multiple pregnancy, grandmultiparity, cephalo-pelvic disproportion and prolonged obstructed labor/uterine rupture, previous caesarean section. The increasing incidence of the procedure in developed countries has been attributed to the increasing caesarean section rate which predisposes to placenta previa. Aims & Objective: To estimate the incidence, indications and complications associated with peripartum hysterectomy performed at a tertiary care hospital. Material and Methods: The retrospective observational analytical study was conducted at the Department of Obstetrics and Gynecology, Lady Goshen hospital, Mangalore from January 2012 to December 2012. Records of all patients who had undergone peripartum hysterectomy during the study period were explored for age, parity, booking status, indication and the type of operation performed. Maternal morbidity and mortality were also recorded. Results: During the study period there were 5497 deliveries, out of which 6 women had undergone an EPH. The incidence was 1.2/1000 deliveries. The main indication was uterine atony 4 (66.7%), followed by rupture uterus 1 (16.7%) and placenta previa with placenta accreta 1 (16.7%). Maternal complications included febrile illness (50%) and anaemia (33.3%). All women, 6 (100%) required blood transfusions, 2(33.3%) cases transferred to ICU. No maternal deaths occurred. Conclusion: The leading indications for emergency peripartum hysterectomy in our study are uterine atony, placenta previa with placenta accreta and uterine rupture. The higher incidence of emergency peripartum hysterectomy is because of the higher prevalence of risk factors like multiparity, previous caesarean section and cesarean section in the index pregnancy. Proper antenatal care, early identification of risk factors and timely intervention by an obstetrician are necessary in preventing this disastrous event.

Emergency peripartum hysterectomy in a tertiary hospital in Ankara, Turkey: a 5-year review

To determine the incidence, indications and the risk factors of emergency peripartum hysterectomy (EPH). We analyzed retrospectively 30 cases of emergency peripartum hysterectomy performed at the Obstetrics Department of a tertiary, research and education hospital between the years of 2006 and 2010. Demographic, medical and clinical data of the patients were recorded. Data stored were expressed as mean ± standard deviation. There were 30 cases of EPH among 82,363 deliveries. The overall incidence of EPH was 0.364 per 1,000 deliveries from 2006 to 2010. Nine hysterectomies were performed after vaginal delivery (0.16/1,000 vaginal deliveries) and the remaining 21 hysterectomies were performed after cesarean section (0.78/1,000 cesarean sections). Two cases (6.7 %) were performed as subtotal and remaining 28 cases (93.3 %) were performed as total hysterectomy. Indications of EPH were uterine atony (43.3 %, 13/30), placenta accreta (40.0 %, 12/30) and uterine rupture (16.7 %, 5/30). All patients [7/7 (100 %)] with placenta previa and 11 of 12 patients (91.7 %) with placenta accreta had previously cesarean sections. There were two maternal deaths due to coagulopathy and pulmonary embolism. Two stillbirths (6.6 %) and 2 early neonatal deaths (6.6 %) were recorded. It should be kept in mind that cases of placenta previa and/or placenta accreta with previous cesarean sections have a very high probability of EPH. The delivery should be performed in suitable clinical settings with experienced surgeons when the risk factors like placenta previa and/or placenta accreta are determined so as to achieve optimal outcome.

Emergency Peripartum Hysterectomy

Background: There appears to be a rise in the rate of emergency peripartum hysterectomy (EPH) in the developed world. Aims: To determine the incidence, indications, risk factors, complications and management of EPH in our tertiary level teaching hospital, the Royal Hospital for Women (RHW) in Sydney, over the last decade. Methods: A retrospective analysis was conducted of all cases of EPH performed at the RHW between the years 1999–2008 inclusive. EPH was defined as one performed after 20 weeks gestation for uncontrollable uterine bleeding not responsive to conservative measures occurring at any time after delivery but within the first 6 weeks post-partum. Cases were ascertained via our hospital obstetric database. Results: There were 33 EPH among 38 998 births, a rate of 0.85 per 1000 births. Indications for EPH were morbid adherence of the placenta (54.8%), placenta praevia (19.4%), uterine atony (12.9%) and uterine rupture or cervical laceration (9.7%). A significant association between previous caesarean section (CS) and abnormal placentation was confirmed (P = 0.011), especially for morbid adherence of the placenta (P = 0.004). There was one maternal death. Maternal morbidity was significant, with disseminated intravascular coagulation and urinary tract injury among the most common complications. All women required blood transfusions, and over a quarter were admitted to the intensive care unit. Conclusions: In our series, abnormal placentation causing severe haemorrhage was the commonest indication for EPH. Previous CS is a risk factor for abnormal placentation and particularly for morbid adherence of the placenta. The morbidity associated with EPH is considerable.

Emergency peripartum hysterectomy: Incidence, indications, risk factors and outcome

Background:Peripartum hysterectomy is a major operation and is invariably performed in the presence of life threatening hemorrhage during or immediately after abdominal or vaginal deliveries.Material and Methods:A Medline search was conducted to review the recent relevant articles in English literature on emergency peripartum hysterectomy. The incidence, indications, risk factors and outcome of emergency peripartum hysterectomy were reviewed.Results:The incidence of emergency peripartum hysterectomy ranged from 0.24 to 8.7 per 1000 deliveries. Emergency peripartum hysterectomy was found to be more common following cesarean section than vaginal deliveries. The predominant indication for emergency peripartum hysterectomy was abnormal placentation (placenta previa/accreta) which was noted in 45 to 73.3%, uterine atony in 20.6 to 43% and uterine rupture in 11.4 to 45.5 %. The risk factors included previous cesarean section, scarred uterus, multiparity, older age group. The maternal morbidity ranged from 26.5 to 31.5% and the mortality from 0 to 12.5% with a mean of 4.8%. The decision of performing total or subtotal hysterectomy was influenced by the patient's condition.Conclusion:Emergency peripartum hysterectomy is a most demanding obstetric surgery performed in very trying circumstances of life threatening hemorrhage. The indication for emergency peripartum hysterectomy in recent years has changed from traditional uterine atony to abnormal placentation. Antenatal anticipation of the risk factors, involvement of an experienced obstetrician at an early stage of management and a prompt hysterectomy after adequate resuscitation would go a long way in reducing morbidity and mortality.

Emergency Peripartum Hysterectomy: 16-year Experience of a Medical Hospital

We conducted this retrospective study to evaluate the outcomes and indications of emergency peripartum hysterectomy (EPH) as a life-saving procedure. We analyzed a series of 140 cases of EPH, between January 1993 and December 2008 in our clinic, retrospectively. The data were collected from the patients' files. The incidence, demographic characteristics, risk factors, indications and outcomes of hysterectomy, peripartum complications, the operation types, maternal morbidity and mortality and fetal mortality were evaluated. A total of 26,015 of women were delivered. The incidence of EPH was 5.38 per 1,000 deliveries. The mean age was 34.19 +/- 6.04 years (range, 21-49 years), gravidity was 6.84 +/- 3.38 (1-17) and parity was 5.58 +/- 3.04 (0-15). Of the 140 cases, 90 were delivered by cesarean section [29 (20.71%) of these had had a previous cesarean section] and 50 were vaginally delivered. One hundred and five cases had subtotal hysterectomy and 35 had total abdominal hysterectomy. The most common indications for EPH were uterine atony followed by uterine rupture and abnormal placentation. Mean operation time was 142.23 +/- 43.70 minutes. The average blood transfusion was 4.79 +/- 3.36 (1-14) units. Relaparotomy was performed in 23 cases. Maternal mortality was seen in 13 cases. Seventy-nine of the cases delivered at an outside center and were referred to our clinic for the intensive care unit. Sixty-one of the cases delivered at our clinic and 31 had stillbirths. This study suggests that the most common indications for EPH are uterine atony, uterine rupture and abnormal placentation. This is probably due to the advanced age of pregnancies and multiparity in our region. Therefore, we believe that the risk of EPH may be decreased with appropriate and closer prenatal care as well as education of the pregnant women.

Emergency peripartum hysterectomy in a tertiary hospital in Lagos, Nigeria: a five-year review

This was a retrospective descriptive study of all the patients who underwent emergency peripartum hysterectomy from January 1st 2003 to December 31st 2007 at the Lagos State University Teaching Hospital. Of the 15,067 deliveries during the study period, 57 patients had emergency peripartum hysterectomy (3.78/1000 deliveries). 19.3% of these patients were booked for antenatal care in the hospital, while 80.7% were unbooked. The mean age of patients was 32.7 years (SD = 5.5) and the mean parity was 3.08 (SD = 1.9). The major indications for emergency peripartum hysterectomy were ruptured uterus (77.2%), uterine atony (10.5%), abruptio placentae (3.5%) and sepsis (3.5%). Subtotal hysterectomy was performed in 96.5% of the cases. The maternal mortality was 19.3% and the perinatal mortality was 75.4%. The incidence of emergency peripartum hysterectomy in this study is high and the major indication is ruptured uterus. It is associated with high maternal and perinatal morbidity and mortality.