Postpartum Hysterectomy Research Articles

Intra-operative uterine artery embolization with caesarean delivery in an adjoining operating theatre and catheter lab (OT/CL) complex vs. conventional management in patients with abnormally invasive placenta: a retrospective case control study

Patients of abnormally invasive placenta (AIP) undergoing caesarean delivery are at increased risk of haemorrhage. Conventional management includes piecemeal removal of placenta or placenta left in situ. However, they often require hysterectomy after delivery. Post-delivery prophylactic uterine artery embolisation (UAE) can help reduce morbidity and preserve fertility. We created an adjoining operating theatre and catheter lab (OT/CL complex). This is a retrospective case control study in which 37 patients of AIP were evaluated. Sixteen subjects (cases) had UAE immediately after caesarean delivery, and 21 subjects (controls) had usual care with traditional methods of controlling postpartum haemorrhage and hysterectomy where required. The hysterectomy rate (18.7% vs. 85.7%), mean duration of hospital stay (6.8 ± 2.6 vs. 13.9 ± 8.1) and number of units of blood transfusion required were significantly less in the case group as compared with controls. UAE is an effective conservative treatment along with caesarean delivery in patients with AIP.Impact statementWhat is already known? AIP is associated with high rates of PPH, maternal morbidity and mortality and need for hysterectomy after delivery. UAE has been advocated to preserve fertility and reduce PPH in these patients along with caesarean delivery.What does the study add? We created an adjoining operating theatre and catheter lab (OT/CL complex) in a tertiary care centre and managed these patients with prompt UAE after caesarean delivery with team approach. We have shown significant reduction in morbidity and hospital stay with this coordinated management.What are the implications for clinical practice and/or further research? UAE with caesarean delivery is a preferred mode of delivery for patients of AIP. These patients should be diagnosed and referred to tertiary care centres with such facilities electively so as to provide optimal care to these patients. Cooperation between interventionist and obstetrician and adjoining availability of OT and catheter lab can further help in reducing the time to embolisation after delivery. A hybrid operating theatre with digital subtraction angiography (DSA) facilities would be ideal for the management of such patients.

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.

The Usefulness of Zhukovsky Double Balloon in Obstetric Hemorrhage

Abstract Objective: To evaluate the effectiveness of the use of a modified Zhukovsky double (vaginal and uterine) balloon to improve the results of treatment in women with obstetric hemorrhage. Methods: We conducted an observational controlled study including 701 puerperas, which were divided into two groups: The main group consisted of 508 women, who underwent a combined management, that is, traditional (transfusion of fresh frozen plasma, erythrocyte mass, uterotonics, hemostatic agents), surgical hemostasis in cases of caesarean section, and insertion of a double Zhukovsky balloon; while the comparison group included 193 patients, who were managed traditionally. The main group and the comparison group were divided into subgroups according to the main etiology of obstetric hemorrhage: IA and IB—postpartum; IIA and IIB—placenta accreta; IIIA and IIIB—postpartum hysterectomy. Results: The most frequent causes of massive obstetric hemorrhage were atony of the uterus (39.2%), placenta previa (29.1%), and placental abruption (11.5%). Of the 508 balloon insertions, 345 (70.7%) were inserted for hemorrhage during cesarean section and 148 (29.3%) for obstetric hemorrhage after spontaneous delivery. Among the obstetric hemorrhage at caesarean section, lower segment bleeding prevailed (78.1%), caused mainly by placenta previa, placenta accreta, placental abruption, polyhydramnios, and uterine scar defects. Combined management, including surgical hemostasis and insertion of vaginal and uterine balloon of Zhukovsky, reduced blood loss by 1.5 times and the number of hysterectomies by 6.72 times compared to controls. Conclusion: The use of a modified Zhukovsky double balloon in the management of obstetric hemorrhage may reduce the number of hysterectomies and the amount of blood loss.

Risk factors of obstetric admissions to the intensive care unit: An 8-year retrospective study.

The aim of this study was to identify risk factors among obstetric patients admitted to the intensive care unit (ICU).The study was conducted in Third Affiliated Hospital of Guangzhou Medical University during January 1, 2009 and December 31, 2016. A total of 44,817 pregnant women ≥20 weeks of gestational age were scanned. Demographic characteristics, perinatal outcomes, and risk factors among participants were analyzed.A number of factors (21) were more prevalent in the ICU admission group. The greatest for admission to the ICU occurred with amniotic fluid embolism, heart disease, acute fatty liver, and referral for care. The incidence of postpartum hemorrhage, hysterectomy, organ failure, and method of delivery differed significantly between groups (P < .05). Adverse neonatal outcome differed significantly between groups (P < .05).Complications of pregnancy are risk factors for referral to the ICU and may increase risk for unexpected outcomes among mothers and neonates.

Inhaled nitric oxide might be a\xa0contributing tool for successful resuscitation\xa0of cardiac arrest\xa0related to pulmonary hypertension

We describe a case where inhaled nitric oxide (iNO) was successfully initiated during cardiopulmonary resuscitation (CPR) in a younger patient with cardiac arrest related to pulmonary hypertension after disseminated intravascular coagulation (DIC) postpartum bleeding and hysterectomy. This case illustrates that iNO might be a potential lifesaving tool for resuscitation of patients with cardiac arrest related to pulmonary hypertension, for whom most other resuscitation strategies often are futile.

The use of Zhukovsky vaginal and intrauterine balloons to improve the outcome of postpartum hysterectomies in patients with severe bleeding

Aim: To assess the efficacy of a Zhukovsky obstetric double balloon for improving outcomes in women undergoing hysterectomy for postpartum hemorrhage.Materials and methods: This was a randomized controlled study. Participants were divided into two groups to undergo insertion of a Zhukovsky obstetric double balloon prior to hysterectomy (n = 16) or conventional hysterectomy (n = 25).Results: The main reasons for major obstetric hemorrhage were placenta accreta (53.6%), uterine atony (26.8%), uteroplacental apoplexy (14.6%), and amniotic fluid embolism (4.8%). The use of a Zhukovsky obstetric double balloon during postpartum hysterectomy was associated with a 1.7-fold reduction in blood loss and a 2.3-fold reduction in blood loss > 2000 ml compared with conventional hysterectomy.Conclusion: The use of a Zhukovsky obstetric double balloon represents a potent tool for improvement of immediate outcomes of hysterectomy in women with severe postpartum bleeding.

A Different Method in the Treatment of Placenta Previa: A Comparison of Lower Uterine Segment Transverse Suture Technique and Bakri Balloon Application

Objective: The incidence of placenta previa (PP) has been increasing due to the rise in cesarean rates. The aim of this study is to determine the success of lower uterine segment compression suture and bakri balloon applications in patients diagnosed with placenta previa. Materials and Methods: 257 patients who underwent cesarean section due to placenta previa totalis (PPT) between the years of 2010-2018 in Ondokuz Mayis University were screened retrospectively. The patients were evaluated in four groups according to their treatment method: medical treatment, bakri balloon application, compression suture and hysterectomy. Results: In the study, between the years 2010-2015, postpartum hysterectomy was performed in the cases of adherent placenta previa, and hysterectomy was performed in 33 patients. Between the years of 2015-2018, first, bakri balloon or compression suture was applied; and if bleeding control was not achieved despite these, then, hysterectomy was performed. Between 2015 and 2018, a total of 27 patients underwent compression suture and 1 patient had a hysterectomy after all. The success rate was 96.3% with compression suture and 91.7% for bakri balloon application. Totally, 24 patients were treated with bakri balloon and yet, two patients underwent hysterectomy. When all the cases were examined, complications caused by urinary bladder and ureteral injury were seen in 5.6% of patients, and all of these complications were also seen in hysterectomy patients. Conclusion: Lower uterine segment transverse suture technique and bakri balloon application should be considered as a good alternative to prevent hysterectomy in patients with placenta previa totalis. In addition, they are effective treatment methods that can be used without increasing maternal morbidity.

Tersiyer Bir Referans Hastanesinin Postpartum Histerektomi Endikasyonları

Tersiyer Bir Referans Hastanesinin Postpartum Histerektomi Endikasyonları

Non-Vitamin K oral anticoagulant treatment – behind the mask there is a story

Pelvic radiation disease is a term related to complications developed after radiotherapy used for pelvic cancers. Symptomatology can be overt, dull or even absent depending on variable factors. We present the case of a 78-year-old female patient with a declared post-partum hysterectomy, known cardiovascular disease, and fatigue and dizziness as main symptoms. She was diagnosed with pelvic radiation disease only after the symptoms were triggered by a non-vitamin K anticoagulant treatment and carefully reassessed anamnesis. Despite it being a predictable condition in patients receiving pelvic radiation, the disease is underdiagnosed, clinicians often overlooking the scale of the problem by treating the symptoms or by focusing on a small fraction of the disease within their medical branch. The case presented displays the value of shifted focus from survivorship to life quality and the importance of patient-tailored management. Sometimes, complementary therapy uncovers a masked illness which can initially be a real challenge but early diagnosis can lead to a satisfactory medical outcome.

Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome.

What are the live birth rate and risks of obstetric complications following the surgical management of intrauterine adhesions (IUA) such as Asherman syndrome (AS)? The live birth rate is 63.7%, and obstetric complications including placentation issues, prematurity and postpartum hysterectomy require that pregnancies in women after treatment for IUA should be considered moderate to high risk. Studies reviewing short-term surgical, menstrual and fertility outcomes following hysteroscopic management are reassuring, with success correlated to the severity of IUA. There are limited data reporting live birth, neonatal and maternal complications. This retrospective study included all women treated for IUA by hysteroscopic synechiolysis under fluoroscopic guidance in two tertiary University-affiliated hospitals. All women reported at least one pre-treatment symptom including menstrual dysfunction, subfertility or pelvic pain and intended to become pregnant post-treatment. Survival curve analysis was performed for time to pregnancy, and obstetric data were collated from a National Obstetric Database for delivery and neonatal outcomes. A total of 154 women were included in the study. Surgical intervention involved hysteroscopic synechiolysis under fluoroscopic guidance until cavity restoration was confirmed. Questionnaires regarding fertility and its outcomes were sent to all women undergoing surgery, with analysis of menstrual, fertility rates and outcomes of those pregnancies including risks and complications to the woman and the offspring. Women were followed up for a minimum of 1 year (range: 1-14 years) from index surgery. The chance of pregnancy was 98/124 (79.0% CI: 63.6, 83.1%) in women wishing to conceive and the chance of a live birth was 79/124 (63.7% CI: 51.3, 70.7%). The chance of a miscarriage was 29/124 (23.4% CI: 18.8, 37.1%). There were 93 live births in 79 women following surgery, with detailed obstetric data available for 85 of these births. They were complicated by abnormal placentation in 15/85 (17.6% CI: 13.0, 30.2%), postpartum hysterectomy in 4/85 (4.7% CI: -0.4, 7.0%), and prematurity in 25/85 (29.4% CI: 17.0, 35.3%) women. The retrospective nature of the study and extended follow-up time may cause selection and recall bias, however, pregnancy and its outcomes-particularly in women with problems of subfertility-are frequently key milestones, with birthdates readily recalled. Menstrual outcomes are more likely to be subject to recall bias. Our surgical data are similar to the published literature with reassuring short-term outcomes for menstruation and cavity reconstruction following surgery for IUA. Long-term outcomes including pregnancy rates were higher than published data, however, the obstetric and neonatal complication rates were increased, indicating a continuation of risk beyond infertility and into pregnancy. An altered biochemical or vascular environment is a possible explanation for impaired implantation resulting in poorer reproductive obstetric and neonatal outcomes. The relative rarity of IUA-particularly severe disease-makes prospective data collection difficult. Our data suggest that women with IUA should be treated as moderate-high risk obstetric patients in subsequent pregnancy and counselled appropriately. No funding and no competing interests.

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.

Role of ultrasound, Doppler, and MRI in the diagnosis of placenta accreta

Objectives The objectives of this study were to compare the accuracy of ultrasonography and MRI for prenatal diagnosis of placenta accreta (PA) and to compare the sensitivity and specificity of individual ultrasonographic and MRI markers in predicting placental invasion in cases of PA. Background PA is a significant cause of maternal morbidity and mortality, and at present it is the most common reason for emergent postpartum hysterectomy. Placenta previa and previous cesarean section are the two most important known risk factors for PA. Accurate prenatal identification of affected pregnancies allows optimal obstetric management. Ultrasonography still remains the diagnostic standard. However, in recent years, there has been increased interest in MRI in evaluating PA. Patients and methods A combined prospective and retrospective study was carried out on 20 pregnant women with persistent placenta previa (after 28 weeks gestation). All patients were subjected to history taking, complete medical examination, and ultrasound, Doppler, and MRI. Results The sensitivity and specificity of ultrasonography were 63.6 and 91.6%, whereas the sensitivity and specificity of MRI were 72.70 and 100%, respectively, in their ability to diagnose PA. Conclusion MRI hand-in-hand with ultrasound is important for the accurate diagnosis of placenta previa and the serious coexisting PA. Use of both modalities may provide more diagnostic information.

Pre-cesarean prophylactic balloon placement in the internal iliac artery to prevent postpartum hemorrhage among women with pernicious placenta previa.

To evaluate pre-cesarean prophylactic balloon placement (PBP) in the internal iliac artery among women with pernicious placenta previa. The present retrospective study included women with pernicious placenta previa who underwent cesarean delivery at Shanghai Renji Hospital, Shanghai, China, between March 1, 2011, and June 30, 2017. Data were compared between patients who did and did not undergo PBP. Among 42 patients included, 20 underwent PBP and 22 did not. Mean±SD estimated blood loss was 2900.00±2352.21mL in the PBP group, and 4549.77±2366.67mL in the non-PBP group (P=0.025). The amount of transfused red blood cells was 8.40±7.14U and 13.00±7.93U (P=0.018), respectively. No patients in the PBP group developed postoperative disseminated intravascular coagulopathy, compared with 3 (14%) in the non-PBP group (P=0.087). In the PBP and non-PBP groups, the hospital stay duration was 7.40±3.07 and 8.68±2.58days (P=0.029), and there were 1 and 7 patients who had obstetric hysterectomies (P=0.027), respectively. Two patients experienced PBP-related adverse events, including thrombosis and re-bleeding. There were no deaths. Pre-cesarean PBP in the internal iliac artery was a safe and effective treatment that could reduce the incidence of both postpartum hemorrhage and hysterectomy among women with pernicious placenta previa.

Management of caesarean section postpartum hemorrhage

Introduction . Postpartum haemorrhage is an important cause of maternal mortality and morbidity. The most common causes are: uterine atonia, lacerations, abnormal placental adhesions and coagulopathy. Materials and method. We have reviewed international medical databases with randomized studies, meta-analyzes of current trends in postpartum hysterectomy and alternative techniques in postpartum hemorrhage. Results. The incidence of postpartum hemorrhage is 1% under a rapid therapeutic attitude. The treatment is directed to the cause. Thus, for initial uterine atony, pharmacological means and subsequent surgical gestures such as ligature of the uterine artery - O’Leary or ligature of the hypogastric artery are initiated. Sutura B-Lynch and its variants are designed to perform the compression of the uterus by mechanical force. Uterine balloons are designed to perform placental bleeding areas buffering. This is the most effective method because the catheter applies direct blood pressure to the bleeding site. Uterine bladder devices specifically designed for uterine tamponade after vaginal or caesarean birth include: Foley catheter, Bakri baloon, B-T Cath device and double-bladder device Ebb, which is also designed for cervical haemostasis. Interventional radiology requires advanced, minimally invasive management of postpartum hemorrhage. Conclusions . The use of uterotonics, pelvic vascular ligatures and balloon buffers are the first steps in the therapeutic approach to postpartum hemorrhage. Appropriate conduct consists of a pro-active attitude, often with a multidisciplinary team.

Application of uterine lower part breakwater-like suture operation in placenta previa

Objective: To explore the efficacy and safety of uterine lower posterior wall breakwater-like suture technique in controlling the intraoperative bleeding of placenta previa. Methods: From June 2016 to June 2017, 47 patients were diagnosed placenta previa in Union Hospital, Tongji Medical College of Huazhong University of Science and Technology. Posterior wall breakwater-like suture technique was used preferentially, as for cases with poor myometrium layer, lower anterior wall stitch suture was used at the same time. Bilateral descending branches of uterine artery ligation and Cook balloon compression of uterine lower segment was conducted when necessary. The clinic data of the 47 cases were analyzed. Results: Thirty cases (63.8, 30/47) were diagnosed placenta inccreta or percreta by ultrasound or MRI preoperatively. Senventeen cases were diagnosed as placenta accreta (36.2%, 17/47) . Thirty-four cases had the previous history of cesarean section. The average cervical canal length of 47 patients was (2.8±0.9) cm. There were 19 cases (40.4%,19/47) with 1 time posterior wall breakwater-like sutured and 16 cases (34.0%,16/47) with 2 or 3 times posterior wall breakwater-like sutured; 12 cases (25.5%,12/47) were treated with anterior wall stitch suture simultaneously.Ten cases (21.3%, 10/47) underwent uterine artery ligation, 17 cases (36.2%, 17/47) underwent COOK balloon compression on the staxis surface of lower segment. None of them had postpartum hemorrhage or performed internal iliac artery embolization. The median blood loss in the operation was 700 ml, the percentiles 25 was 500 ml, and the percentiles 75 was 1 200 ml. The blood loss ≥1 000 ml in 18 (38.3%, 18/47) patients,and the most serious one was 2 500 ml. The median blood transfusion volume (including allogenetic transfusion and autotransfusion) was 450 ml, the percentiles 25 was 228 ml, and the percentiles 75 was 675 ml. The average vaginal bleeding volume was (150±63) ml first day after operation. The mean hospitalization time was (4.7±1.0) days. The mean gestational weeks of pregnancy termination was (36.1±1.5) weeks, and the mean birth weight of newborns was (2 817±492) g. Apgar score:1-minute 7.8±1.1, 5-minute 8.9±0.8. No neonatal death, 16 cases were transferred to neonatal ICU (34.0%, 16/47) mainly for premature delivery and low birth weight. No complication was found in 6 months post-operation. Conclusions: Uterine posterior wall breakwater-like suture technique is a simple, safe and effective way in controlling intraoperative bleeding of placental previa.Lower anterior wall stitch suture could effectively stop bleeding and restore the normal uterine shape. Combined application of various methods could significantly reduce the incidence of postpartum hemorrhage and hysterectomy, and improve maternal and fetal prognosis.

Maternal morbidity after implementation of a postpartum hemorrhage protocol including use of misoprostol.

To compare maternal morbidity before and after implementation of a postpartum hemorrhage (PPH) protocol that included misoprostol. A retrospective analysis was performed using data from 34631 deliveries recorded at a Spanish hospital between January 1, 2007, and December 31, 2014. The PPH protocol was implemented in 2009 and included use of misoprostol and the Bakri balloon. The pre-implementation and post-implementation groups comprised 9394 and 25237 women, respectively. Women in the pre-implementation group tended to have lower hemoglobin levels than did those in the post-implementation group: 811 (8.6%) versus 1349 (5.3%) for levels less than 90g/L, and 272 (2.9%) versus 497 (2.0%) for levels less than 80g/L (both P<0.001). Implementation of the PPH protocol was also associated with a decrease in the frequency of postpartum hysterectomies owing to uterine atony (0.11 cases per 1000 deliveries vs 0.53 cases per 1000 deliveries for the pre-implementation group; P=0.063). Pregnancy length, maternal age, neonatal weight at delivery, multiple pregnancy, previous cesarean delivery, parity, operative vaginal delivery, induced labor, cesarean delivery, and not using the PPH protocol were found to predict postpartum anemia in the multivariate analysis (all P<0.001). Implementation of the PPH protocol decreased rates of postpartum anemia and postpartum hysterectomy owing to uterine atony.

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.

Comparison of results of Bakri balloon tamponade and caesarean hysterectomy in management of placenta accreta and increta: a retrospective study

The aim of this study was to compare the postoperative results of the patients who were treated with Bakri balloon tamponade or hysterectomy for placenta accreta and increta. Patients who were diagnosed with placenta accreta or increta preoperatively and intraoperatively and treated with Bakri balloon tamponade (Group 1) or caesarean hysterectomy (Group 2) were compared in regards to the postoperative results. Among the 36 patients diagnosed with placenta accreta or increta, 19 patients were treated with Bakri balloon tamponade while 17 cases were treated with hysterectomy. Intraoperative blood loss amount was 1794 ± 725 ml in G1, which was lower than that in G2 (2694 ± 893 ml). Blood transfusion amount was 2.7 ± 2.6 units in G1, lower than that in G2 (5.7 ± 2.4 units), too. Operation time was 64.5 ± 29 min and 140 ± 51 min in G1 and G2, respectively, showing significant differences between two groups. The success rate of Bakri balloon was determined as 84.21%. In conclusion, cases with placenta accreta/increta, with predicted placental detachment who are willing to preserve fertility, application of uterine balloon tamponade devices before the hysterectomy is encouraging with its advantages compared with the hysterectomy. Impact statement What is already known on this subject: Invasive placental anomalies are the most common indication of postpartum hysterectomy. Recently, uterine balloon tamponade was also included in the treatment modalities of postpartum haemorrhage.This study aimed to compare the postoperative results of UBT or hysterectomy for patients with placenta accreta and increta. What the results of this study add: In this study, the total amount of blood loss was higher in the caesarean hysterectomy group when compared with the Bakri balloon tamponade group. The mean transfusion requirement, mean operation time and hospitalisation period was significantly longer in the caesarean hysterectomy group. The success rate of the Bakri balloon was determined as 84.21%. Two patients who were treated with balloon application had a successful pregnancy and delivery later. Maternal mortality was reported in neither balloon nor hysterectomy groups. What the implications are of these findings for clinical practice and/or further research: In conclusion, patients diagnosed with placenta accreta/increta with ultrasound should be taken into the operation in elective conditions, if possible, on lithotomy position. In cases with predicted placental detachment that are willing to preserve fertility, application of uterine balloon tamponade devices before the hysterectomy has advantages compared with the hysterectomy.

Study of risk factors of abruption placenta in Al.wahda teaching hospital, Aden

The aim of this study is to determine the prevalence and associated risk factors of abruption placenta in Al-Wahda Teaching Hospital in Aden Governorate, from 1st of November 2011to 30th of November 2012. A case control study was performed for 33 of abruption placenta cases with 165 control cases, conducted at the Department of Obstetrics and Gynecology, Al-Wahda Teaching Hospital. Out of 6765 deliveries included in the study period, 33 (4.88%) were complicated by placental abruption. Most complications occurred were urgent and in need of massive blood transfusion. The most frequent complication were Postpartum hemorrhage (51.52%), cesarean section (42.43%), hemorrhagic shock (18.18%), hysterectomy (12.12%), renal failure (6.06%), pulmonary embolism (3.03%), and congestive cardiac failure (3.03%). There was one maternal mortality case in the period of study from abruption placenta. Women aged more than 35 were more likely for experiencing abruption placenta, while grand multipara ( &gt; 5 children) were at higher risk for abruption placenta. Gestational age &lt; 37 weeks increased the risk by eight folds. The risk of abruption placenta increased by six folds in hypertensive patients, as well as those with previous history of abruption and previous abortion. Poly hydramnios and abdominal trauma increased the risk of abruption placenta by two folds. he fetal outcomewas characterized by low body weight &lt;2500 gram seen in 20 cases (60.6%), low APGAR score at 5th min&lt;7 was seen in 4 cases (21.05%), and stillbirth rate in 14 cases (42.42%).