Journal of Obstetrics and Gynaecology, January 2015; 35: 19–21 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.935712
OBSTETRICS
Emergency peripartum hysterectomy: Experience of a major referral hospital in Ankara, Turkey N. Danisman, E. Baser, C. Togrul, O. Kaymak, M. Tandogan & T. Gungor
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Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Health Training and Research Hospital, Ankara, Turkey
The objective of this study was to report and discuss the incidence, clinical characteristics and outcomes of emergency peripartum hysterectomies (EPH) performed at a tertiary referral hospital in Ankara, Turkey. The labour and delivery unit database was retrospectively analysed for emergency peripartum hysterectomies (EPH) performed between January 2008 and January 2013, at the Zekai Tahir Burak Women’s Health Training and Research Hospital. A total of 92,887 deliveries were accomplished within the study period. EPH was performed in 48 cases, and the incidence was 0.51 in 1,000. Abnormal placentation was the most common indication for EPH. Most common complications were blood product transfusion and postoperative fever. None of the cases resulted in maternal mortality. Serious maternal complication rates were relatively low in our study. In cases that are unresponsive to initial conservative measures, EPH should be performed without delay and a multidisciplinary team approach should be conducted whenever possible. Keywords: Emergency peripartum hysterectomy, placenta accreta, placenta praevia, postpartum bleeding, uterine atony
Introduction Emergency peripartum hysterectomy (EPH) is a life-saving procedure that is performed in about 0.1% of all deliveries (Bateman et al. 2012). Various frequencies were reported for this procedure among different populations and institutions (Glaze et al. 2008; Al-Sibai et al. 1987; Lau et al. 1997; Sakse et al. 2007; Jou et al. 2008; Karayalcin et al. 2011). Uterine atony, uterine rupture, abnormal placentation and bleeding due to coagulopathy are the most frequent clinical situations that may necessitate EPH (Gungor et al. 2009). In patients with severe postpartum uterine bleeding, conservative interventions, such as uterine massage, administering uterotonics (oxytocin, ergotamine), uterine and hypogastric vessel ligation/embolisation and haemostatic uterine suturing are generally performed as the initial approach. When these measures fail, a timely decision to proceed to hysterectomy is of utmost importance to decrease the risk of subsequent serious maternal morbidity and mortality. In this study, we aimed to investigate and report the incidence, risk factors, outcomes and complications of EPH procedures that were performed within a 5-year period at a major referral hospital in the capital city of Turkey.
Materials and methods Following approval from the institutional review board, we searched our labour and delivery unit database for emergency peripartum hysterectomies (EPH) performed between January 2008 and January 2013 at the Zekai Tahir Burak Women’s Health Training and Research Hospital in Ankara, Turkey. Data, including: patient age; body mass index (BMI); reproductive history (gravidity, parity, abortion, prior caesarean section); gestational age (GA) at delivery; mode of delivery; caesarean section indications for the current delivery; status of fetal membranes; labour induction; additional procedures for haemostasis; indication and type of EPH; time from delivery to completion of hysterectomy; perioperative complications; estimated blood loss (EBL) during surgery; blood product transfusions; hospitalisation length and fetal outcome parameters (birth weight, APGAR scores and intensive care unit (NICU) admission) were retrieved from patient charts and the hospital computer database. Study parameters were analysed using the SPSS 20.0 statistical program. Continuous variables were expressed as mean ⫾ standard deviation (SD), and categorical variables were expressed as number (percentage). Descriptive analyses of study parameters were performed. When comparing means of continuous variables, Student’s t-test, Mann–Whitney U and one-way ANOVA tests were used, where appropriate. A p value of ⬍ 0.05 was considered statistically significant.
Results A total of 92,887 deliveries were performed at our institution within the study period. EPH was performed in 48 cases, and the incidence was 0.51/1,000. Total abdominal hysterectomy was performed in 38 (79.2%), while subtotal hysterectomy was performed in 10 (20.8%) cases. Mean maternal age was 30.7 ⫾ 5.9 (range, 18–42), and was similar between groups of total vs subtotal hysterectomy (30.5 ⫾ 6.21 vs 31.4 ⫾ 4.6, p ⬎ 0.05). Mean BMI was 26.4 ⫾ 3.0 (range, 21.5–35.6). None of the women had a gynaecological or medical comorbidity that could lead to abnormal bleeding. Also, none of them had prior abdominal surgery except caesarean section. Median gravidity, parity and abortion frequencies were 3, 2 and 1, respectively. Six women (12.5%) were primigravidas and 42 (87.5%) were multigravidas. A total of 12 cases (25%) had at least one prior caesarean section. In total, 41 (85.4%) women had regular prenatal follow-up visits and seven women (14.6%) had not attended any prenatal visits prior to delivery.
Correspondence: E. Baser, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Health Training and Research Hospital, Ankara, Turkey. E-mail: [email protected]
20
N. Danisman et al. Table III. Emergency peripartum hysterectomy indications.
Table I. Caesarean section indications for the current deliveries. Indication
n
(%)
Previous C/S Previous C/S ⫹ placenta praevia Arrested labour Abnormal presentation Fetal distress Cephalopelvic disproportion Placenta praevia Twin pregnancy Uterine rupture Total
9 3 7 5 5 4 4 2 1 40
22.5 7.5 17.5 12.5 12.5 10 10 5 2.5 100
Indication
n
(%)
Uterine atony Placenta praevia ⫹ placenta accreta Uterine atony ⫹ placenta praevia Placenta praevia Uterine atony ⫹ infection Placenta increta Placenta percreta Uterine atony ⫹ placenta accreta Uterine atony ⫹ uterine rupture Total
16 12 8 4 4 1 1 1 1 48
33.3 25 16.6 8.3 8.3 2.1 2.1 2.1 2.1 100
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C/S, caesarean section.
Two women (4.1%) had twins and the remaining 46 (95.9%) had a singleton pregnancy, resulting in a total of 50 delivered fetuses. The mean GA at delivery was 35.9 ⫾ 4.1 (range, 25– 40.6). Of the women, 25 (52.1%) had a preterm delivery; eight (16.7%) had a vaginal delivery and 40 (83.4%) patients had a caesarean delivery. Of the caesarean sections, 17 (42.5%) were emergency and 23 (57.5%) were planned procedures. Caesarean section indications for the current deliveries are presented in Table I. Six (12.5%) patients had premature rupture of membranes (PROM) upon admission, and three (50%) of these were preterm (PPROM). Two of the cases had prolonged PROM (⬎ 12 h). Four of the cases had clinical chorioamnionitis at the time of hysterectomy. Nine (18.8%) women underwent induction of labour. All of these patients received intravaginal PGE2 (Propess®). In 15 (31.2 %) women, there were no definable risk factors for severe uterine bleeding prior to delivery. Significant risk factors for postpartum bleeding in the remainder of the study patients are presented in Table II. In cases with uterine atony in our study, initial conservative measures, such as fundal massage and administering uterotonic drugs (oxytocin, methylergonovine and misoprostol) were taken first. When these measures failed to control bleeding, we proceeded with other methods. Bakri balloon tamponade was performed in 21 cases (43.7%). B-Lynch suture and vertical–horizontal compression sutures were performed in 13 (27.1%) and nine (18.7%) cases, respectively. Bilateral uterine artery and utero-ovarian artery ligations were performed in 44 (91.6%) cases. Hypogastric artery ligation was performed in 29 cases (60.4%). Haemostatic suturing of the placental bed was performed in 23 cases (47.9%). Indications for EPH are presented in Table III. The mean time from delivery to completion of hysterectomy was 204.5 ⫾ 84.9 min and did not differ significantly according to delivery type (p ⫽ 0.05). The mean EBL during surgery was 2,890 ⫾ 300.8 ml. The mean EBL during surgery in cases that had vaginal, planned caesarean and emergency caesarean deliveries was 2,886.2 ⫾ 164.4, 2,846.6 ⫾ 320.6 and 2,985.4 ⫾ 319.1 ml, respectively. There were no significant differences in terms of EBL during surgery among groups according to delivery
type (p ⫽ 0.63). Blood products were transfused in all of the study cases. Mean transfused units of red blood cell (RBC) concentrate, whole blood, fresh frozen plasma and thrombocyte suspension were 7.4 ⫾ 3.8 (range, 2–24 units), 2.3 ⫾ 3.1 (range, 0–16 units), 5.06 ⫾ 3.8 (range, 0–17) units and 1.4 ⫾ 2.9 (range, 0–13 units), respectively. Fibrinogen was transfused in 24 (50%) patients. None of the cases resulted in maternal mortality. Perioperative complications are presented in Table IV. Median hospitalisation length was 8 days (range, 4–29). Mean fetal birth weight was 2,794 ⫾ 960 g (range, 520–4,270). Median (range) 1 and 5 min APGAR scores were 7 (0–7) and 9 (0–9), respectively. A total of 13 (27.1%) infants needed NICU admission. There were five (10.4%) neonatal deaths.
Discussion Emergency peripartum hysterectomy is generally performed for treating intractable uterine bleeding that cannot be controlled by other measures. Despite considerable medical and surgical developments in recent decades, maternal morbidity or mortality due to postpartum haemorrhage is still an important issue worldwide. In low-resource settings throughout the world, the risk of fatality is highest due to inaccessibility to timely surgical intervention and blood products (Omole-Ohonsi and Olayinka 2012; Kausar et al. 2012). Severe postpartum bleeding may be anticipated, especially in women with significant risk factors such as placenta praevia, chorioamnionitis, coagulopathies, precipitous or prolonged labour, fetal macrosomia and previous primary postpartum haemorrhage (Karayalcin et al. 2011). However, a specific risk factor may not be identified in certain patients (Glaze et al. 2008). In our study, the most frequent risk factor was placenta praevia, which was present in more than half of the women with a definable risk factor. Other risk factors, such as multiple pregnancy, chorioamnionitis and prolonged labour were much less common. Whenever possible, obstetricians should identify these risk factors, and take precautions, including detailed antepartum counselling of the patient and her family Table IV. Perioperative complications.
Table II. Risk factors for postpartum haemorrhage. Risk factor
n
(%)
Placenta praevia Chorioamnionitis Twin pregnancy Placenta praevia ⫹ pre-eclampsia Fetal macrosomia (⬎ 4,500 g) Prolonged second stage of labour Total
22 4 2 2 2 1 33
66.6 12.1 6.1 6.1 6.1 3 100
Complication
n
(%)
Blood product transfusion Postoperative fever Bladder injury Reoperation Disseminated intravascular coagulation (DIC) Surgical wound infection Pulmonary embolus Postoperative ileus Bowel injury
48 30 13 13 11 8 4 3 1
100 62.5 27.1 27.1 22.9 16.6 8.3 6.2 2.1
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Emergency peripartum hysterectomy 21 about the risk of hysterectomy. Pre-delivery preparation of blood products and medical team organisation is also crucial in cases carrying high risk for postpartum haemorrhage. The incidence of EPH was 0.5 per 1,000 deliveries in our study. In previous reports, the incidence ranged between as low as 0.25 per 1,000, and as high as five per 1,000 deliveries (Karayalcin et al. 2011; Sakse et al. 2007; Zorlu et al. 1998). In large-scale institutions such as ours, increased rates of high-risk pregnancy referrals are generally present, and this further adds to the risk of EPH. Tertiary institutions must be fully equipped with adequate medical resources for appropriate treatment of these high-risk patients. Abnormal placentation was the most common indication for EPH in our study, followed by uterine atony. Compared with previous studies that reported uterine atony as the most common indication, recent papers suggest that this is being replaced by abnormal placentation (placenta praevia, placenta accreta, increta or percreta) (Daskalakis et al. 2007; Baskett 2003; Stanco et al. 1993; Kastner et al. 2002; Rossi et al. 2010). This is most probably attributable to increased caesarean section rates. Women with prior caesarean section should be carefully evaluated for preoperative detection of a placental abnormality. Placenta praevia in a patient with a prior caesarean section should raise concern on a co-existing placental adhesion anomaly (Oyelese and Smulian 2006). Every effort should be made to prevent unnecessary caesarean section procedures in order to decrease the risk of EPH. Uterine atony is generally unpredictable. Obstetricians must be prepared for such an occurrence in all cases, and must be able to take the necessary steps in a timely fashion. Patients with prolonged labour, multiple pregnancy, macrosomic fetus or chorioamnionitis, the risk of uterine atony is significantly increased. In nine cases (18.7%) in our study, patients had at least one of these risk factors. Perioperative complications are reported to be common in EPH cases (Briery et al. 2007; Wright et al. 2010b; Wright et al. 2010a; Shellhaas et al. 2009). In our study, the most common complication was blood product transfusion, and the second most common was postoperative fever. Bladder injury and reexploration was also common. Bladder injuries were mostly due to dense adhesions of bladder to the uterus as a consequence of previous caesarean sections, and the emergency nature of the hysterectomy procedure. Re-explorations were performed in 10 cases of postoperative bleeding and in three cases of previously undiscovered bladder injuries. These underline the necessity of a multidisciplinary team approach to these patients, in which specialists of various disciplines, such as infectious diseases, urology, general surgery and internal medicine should take place. Infectious diseases specialists especially take a role in the management of cases with serious uterine infections leading to postpartum haemorrhage and subsequent hysterectomy. It is very important to manage these cases with a proper antibiotic regimen to prevent and treat possible life-threatening complications, such as septicaemia. EPH may occasionally have to be performed in areas that are remote to multidisciplinary referral centres. Patients should be transferred only after initial surgical and medical stabilisation, as failure to do so may result in lifethreatening complications during patient transfer. NICU admissions were common, and neonatal complications were mostly due to prematurity in our study population. To prevent lethal complications, EPH should be performed in a timely manner in cases that are unresponsive to initial conservative treatments. As the duration of time until hysterectomy
increases, the likelihood of development of coagulopathy, hypovolaemia, tissue hypoxia, hypothermia and acidosis also increase. Prenatal identification of women that carry increased risk for EPH, and taking necessary precautions for the worst case scenario is crucial to obtain an optimal outcome. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Al-Sibai MH, Rahman J, Rahman MS, Butalack F. 1987. Emergency hysterectomy in obstetrics – a review of 117 cases. Australian and New Zealand Journal of Obstetrics and Gynaecology 27:180–184. Baskett TF. 2003. Emergency obstetric hysterectomy. Journal of Obstetrics and Gynaecology 23:353–355. Bateman BT, Mhyre JM, Callaghan WM, Kuklina EV. 2012. Peripartum hysterectomy in the United States: nationwide 14 year experience. American Journal of Obstetrics and Gynecology 206:63e1–e8. Briery CM, Rose CH, Hudson WT, Lutgendorf MA, Magann EF, Chauhan SP et al. 2007. Planned vs emergent cesarean hysterectomy. American Journal of Obstetrics and Gynecology 197:154e1–e5. Daskalakis G, Anastasakis E, Papantoniou N, Mesogitis S, Theodora M, Antsaklis A. 2007. Emergency obstetric hysterectomy. Acta Obstetricia et Gynecologica Scandinavica 86:223–227. Glaze S, Ekwalanga P, Roberts G, Lange I, Birch C, Rosengarten A et al. 2008. Peripartum hysterectomy: 1999 to 2006. Obstetrics and Gynecology 111:732–738. Gungor T, Simsek A, Ozdemir AO, Pektas M, Danisman N, Mollamahmutoglu L. 2009. Surgical treatment of intractable postpartum hemorrhage and changing trends in modern obstetric perspective. Archives of Gynecology and Obstetrics 280:351–355. Jou HJ, Hung HW, Ling PY, Chen SM, Wu, S. C. 2008. Peripartum hysterectomy in Taiwan. International Journal of Gynaecology and Obstetrics 101:269–272. Karayalcin R, Ozcan S, Ozyer S, Mollamahmutoglu L, Danisman N. 2011. Emergency peripartum hysterectomy. Archives of Gynecology and Obstetrics 283:723–727. Kastner ES, Figueroa R, Garry D, Maulik D. 2002. Emergency peripartum hysterectomy: experience at a community teaching hospital. Obstetrics and Gynecology 99:971–975. Kausar F, Morris JL, Fathalla M, Ojengbede O, Fabamwo A, Mourad-Youssif M et al. 2012. Nurses in low resource settings save mothers’ lives with non-pneumatic anti-shock garment. American Journal of Maternal Child Nursing 37:308–316. Lau WC, Fung HY, Rogers MS. 1997. Ten years experience of caesarean and postpartum hysterectomy in a teaching hospital in Hong Kong. European Journal of Obstetrics, Gynecology, and Reproductive Biology 74:133–137. Omole-Ohonsi A, Olayinka HT. 2012. Emergency peripartum hysterectomy in a developing country. Journal of Obstetrics and Gynaecology Canada 34:954–960. Oyelese Y, Smulian JC. 2006. Placenta previa, placenta accreta, and vasa previa. Obstetrics and Gynecology 107:927–941. Rossi AC, Lee RH, Chmait RH. 2010. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstetrics and Gynecology 115:637–644. Sakse A, Weber T, Nickelsen C, Secher NJ. 2007. Peripartum hysterectomy in Denmark 1995–2004. Acta Obstetricia et Gynecologica Scandinavica 86:1472–1475. Shellhaas CS, Gilbert S, Landon MB, Varner MW, Leveno KJ, Hauth JC et al. 2009. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstetrics and Gynecology 114:224–229. Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr. 1993. Emergency peripartum hysterectomy and associated risk factors. American Journal of Obstetrics and Gynecology 168:879–883. Wright JD, Bonanno C, Shah M, Gaddipati S, Devine P. 2010a. Peripartum hysterectomy. Obstetrics and Gynecology 116:429–434. Wright JD, Devine P, Shah M, Gaddipati S, Lewin SN, Simpson LL et al. 2010b. Morbidity and mortality of peripartum hysterectomy. Obstetrics and Gynecology 115:1187–1193. Zorlu CG, Turan C, Isik AZ, Danisman N, Mungan T, Gokmen O. 1998. Emergency hysterectomy in modern obstetric practice. Changing clinical perspective in time. Acta Obstetricia et Gynecologica Scandinavica 77:186–190.
OBSTETRICS
Emergency peripartum hysterectomy: Experience of a major referral hospital in Ankara, Turkey N. Danisman, E. Baser, C. Togrul, O. Kaymak, M. Tandogan & T. Gungor
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Health Training and Research Hospital, Ankara, Turkey
The objective of this study was to report and discuss the incidence, clinical characteristics and outcomes of emergency peripartum hysterectomies (EPH) performed at a tertiary referral hospital in Ankara, Turkey. The labour and delivery unit database was retrospectively analysed for emergency peripartum hysterectomies (EPH) performed between January 2008 and January 2013, at the Zekai Tahir Burak Women’s Health Training and Research Hospital. A total of 92,887 deliveries were accomplished within the study period. EPH was performed in 48 cases, and the incidence was 0.51 in 1,000. Abnormal placentation was the most common indication for EPH. Most common complications were blood product transfusion and postoperative fever. None of the cases resulted in maternal mortality. Serious maternal complication rates were relatively low in our study. In cases that are unresponsive to initial conservative measures, EPH should be performed without delay and a multidisciplinary team approach should be conducted whenever possible. Keywords: Emergency peripartum hysterectomy, placenta accreta, placenta praevia, postpartum bleeding, uterine atony
Introduction Emergency peripartum hysterectomy (EPH) is a life-saving procedure that is performed in about 0.1% of all deliveries (Bateman et al. 2012). Various frequencies were reported for this procedure among different populations and institutions (Glaze et al. 2008; Al-Sibai et al. 1987; Lau et al. 1997; Sakse et al. 2007; Jou et al. 2008; Karayalcin et al. 2011). Uterine atony, uterine rupture, abnormal placentation and bleeding due to coagulopathy are the most frequent clinical situations that may necessitate EPH (Gungor et al. 2009). In patients with severe postpartum uterine bleeding, conservative interventions, such as uterine massage, administering uterotonics (oxytocin, ergotamine), uterine and hypogastric vessel ligation/embolisation and haemostatic uterine suturing are generally performed as the initial approach. When these measures fail, a timely decision to proceed to hysterectomy is of utmost importance to decrease the risk of subsequent serious maternal morbidity and mortality. In this study, we aimed to investigate and report the incidence, risk factors, outcomes and complications of EPH procedures that were performed within a 5-year period at a major referral hospital in the capital city of Turkey.
Materials and methods Following approval from the institutional review board, we searched our labour and delivery unit database for emergency peripartum hysterectomies (EPH) performed between January 2008 and January 2013 at the Zekai Tahir Burak Women’s Health Training and Research Hospital in Ankara, Turkey. Data, including: patient age; body mass index (BMI); reproductive history (gravidity, parity, abortion, prior caesarean section); gestational age (GA) at delivery; mode of delivery; caesarean section indications for the current delivery; status of fetal membranes; labour induction; additional procedures for haemostasis; indication and type of EPH; time from delivery to completion of hysterectomy; perioperative complications; estimated blood loss (EBL) during surgery; blood product transfusions; hospitalisation length and fetal outcome parameters (birth weight, APGAR scores and intensive care unit (NICU) admission) were retrieved from patient charts and the hospital computer database. Study parameters were analysed using the SPSS 20.0 statistical program. Continuous variables were expressed as mean ⫾ standard deviation (SD), and categorical variables were expressed as number (percentage). Descriptive analyses of study parameters were performed. When comparing means of continuous variables, Student’s t-test, Mann–Whitney U and one-way ANOVA tests were used, where appropriate. A p value of ⬍ 0.05 was considered statistically significant.
Results A total of 92,887 deliveries were performed at our institution within the study period. EPH was performed in 48 cases, and the incidence was 0.51/1,000. Total abdominal hysterectomy was performed in 38 (79.2%), while subtotal hysterectomy was performed in 10 (20.8%) cases. Mean maternal age was 30.7 ⫾ 5.9 (range, 18–42), and was similar between groups of total vs subtotal hysterectomy (30.5 ⫾ 6.21 vs 31.4 ⫾ 4.6, p ⬎ 0.05). Mean BMI was 26.4 ⫾ 3.0 (range, 21.5–35.6). None of the women had a gynaecological or medical comorbidity that could lead to abnormal bleeding. Also, none of them had prior abdominal surgery except caesarean section. Median gravidity, parity and abortion frequencies were 3, 2 and 1, respectively. Six women (12.5%) were primigravidas and 42 (87.5%) were multigravidas. A total of 12 cases (25%) had at least one prior caesarean section. In total, 41 (85.4%) women had regular prenatal follow-up visits and seven women (14.6%) had not attended any prenatal visits prior to delivery.
Correspondence: E. Baser, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Health Training and Research Hospital, Ankara, Turkey. E-mail: [email protected]
20
N. Danisman et al. Table III. Emergency peripartum hysterectomy indications.
Table I. Caesarean section indications for the current deliveries. Indication
n
(%)
Previous C/S Previous C/S ⫹ placenta praevia Arrested labour Abnormal presentation Fetal distress Cephalopelvic disproportion Placenta praevia Twin pregnancy Uterine rupture Total
9 3 7 5 5 4 4 2 1 40
22.5 7.5 17.5 12.5 12.5 10 10 5 2.5 100
Indication
n
(%)
Uterine atony Placenta praevia ⫹ placenta accreta Uterine atony ⫹ placenta praevia Placenta praevia Uterine atony ⫹ infection Placenta increta Placenta percreta Uterine atony ⫹ placenta accreta Uterine atony ⫹ uterine rupture Total
16 12 8 4 4 1 1 1 1 48
33.3 25 16.6 8.3 8.3 2.1 2.1 2.1 2.1 100
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C/S, caesarean section.
Two women (4.1%) had twins and the remaining 46 (95.9%) had a singleton pregnancy, resulting in a total of 50 delivered fetuses. The mean GA at delivery was 35.9 ⫾ 4.1 (range, 25– 40.6). Of the women, 25 (52.1%) had a preterm delivery; eight (16.7%) had a vaginal delivery and 40 (83.4%) patients had a caesarean delivery. Of the caesarean sections, 17 (42.5%) were emergency and 23 (57.5%) were planned procedures. Caesarean section indications for the current deliveries are presented in Table I. Six (12.5%) patients had premature rupture of membranes (PROM) upon admission, and three (50%) of these were preterm (PPROM). Two of the cases had prolonged PROM (⬎ 12 h). Four of the cases had clinical chorioamnionitis at the time of hysterectomy. Nine (18.8%) women underwent induction of labour. All of these patients received intravaginal PGE2 (Propess®). In 15 (31.2 %) women, there were no definable risk factors for severe uterine bleeding prior to delivery. Significant risk factors for postpartum bleeding in the remainder of the study patients are presented in Table II. In cases with uterine atony in our study, initial conservative measures, such as fundal massage and administering uterotonic drugs (oxytocin, methylergonovine and misoprostol) were taken first. When these measures failed to control bleeding, we proceeded with other methods. Bakri balloon tamponade was performed in 21 cases (43.7%). B-Lynch suture and vertical–horizontal compression sutures were performed in 13 (27.1%) and nine (18.7%) cases, respectively. Bilateral uterine artery and utero-ovarian artery ligations were performed in 44 (91.6%) cases. Hypogastric artery ligation was performed in 29 cases (60.4%). Haemostatic suturing of the placental bed was performed in 23 cases (47.9%). Indications for EPH are presented in Table III. The mean time from delivery to completion of hysterectomy was 204.5 ⫾ 84.9 min and did not differ significantly according to delivery type (p ⫽ 0.05). The mean EBL during surgery was 2,890 ⫾ 300.8 ml. The mean EBL during surgery in cases that had vaginal, planned caesarean and emergency caesarean deliveries was 2,886.2 ⫾ 164.4, 2,846.6 ⫾ 320.6 and 2,985.4 ⫾ 319.1 ml, respectively. There were no significant differences in terms of EBL during surgery among groups according to delivery
type (p ⫽ 0.63). Blood products were transfused in all of the study cases. Mean transfused units of red blood cell (RBC) concentrate, whole blood, fresh frozen plasma and thrombocyte suspension were 7.4 ⫾ 3.8 (range, 2–24 units), 2.3 ⫾ 3.1 (range, 0–16 units), 5.06 ⫾ 3.8 (range, 0–17) units and 1.4 ⫾ 2.9 (range, 0–13 units), respectively. Fibrinogen was transfused in 24 (50%) patients. None of the cases resulted in maternal mortality. Perioperative complications are presented in Table IV. Median hospitalisation length was 8 days (range, 4–29). Mean fetal birth weight was 2,794 ⫾ 960 g (range, 520–4,270). Median (range) 1 and 5 min APGAR scores were 7 (0–7) and 9 (0–9), respectively. A total of 13 (27.1%) infants needed NICU admission. There were five (10.4%) neonatal deaths.
Discussion Emergency peripartum hysterectomy is generally performed for treating intractable uterine bleeding that cannot be controlled by other measures. Despite considerable medical and surgical developments in recent decades, maternal morbidity or mortality due to postpartum haemorrhage is still an important issue worldwide. In low-resource settings throughout the world, the risk of fatality is highest due to inaccessibility to timely surgical intervention and blood products (Omole-Ohonsi and Olayinka 2012; Kausar et al. 2012). Severe postpartum bleeding may be anticipated, especially in women with significant risk factors such as placenta praevia, chorioamnionitis, coagulopathies, precipitous or prolonged labour, fetal macrosomia and previous primary postpartum haemorrhage (Karayalcin et al. 2011). However, a specific risk factor may not be identified in certain patients (Glaze et al. 2008). In our study, the most frequent risk factor was placenta praevia, which was present in more than half of the women with a definable risk factor. Other risk factors, such as multiple pregnancy, chorioamnionitis and prolonged labour were much less common. Whenever possible, obstetricians should identify these risk factors, and take precautions, including detailed antepartum counselling of the patient and her family Table IV. Perioperative complications.
Table II. Risk factors for postpartum haemorrhage. Risk factor
n
(%)
Placenta praevia Chorioamnionitis Twin pregnancy Placenta praevia ⫹ pre-eclampsia Fetal macrosomia (⬎ 4,500 g) Prolonged second stage of labour Total
22 4 2 2 2 1 33
66.6 12.1 6.1 6.1 6.1 3 100
Complication
n
(%)
Blood product transfusion Postoperative fever Bladder injury Reoperation Disseminated intravascular coagulation (DIC) Surgical wound infection Pulmonary embolus Postoperative ileus Bowel injury
48 30 13 13 11 8 4 3 1
100 62.5 27.1 27.1 22.9 16.6 8.3 6.2 2.1
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Emergency peripartum hysterectomy 21 about the risk of hysterectomy. Pre-delivery preparation of blood products and medical team organisation is also crucial in cases carrying high risk for postpartum haemorrhage. The incidence of EPH was 0.5 per 1,000 deliveries in our study. In previous reports, the incidence ranged between as low as 0.25 per 1,000, and as high as five per 1,000 deliveries (Karayalcin et al. 2011; Sakse et al. 2007; Zorlu et al. 1998). In large-scale institutions such as ours, increased rates of high-risk pregnancy referrals are generally present, and this further adds to the risk of EPH. Tertiary institutions must be fully equipped with adequate medical resources for appropriate treatment of these high-risk patients. Abnormal placentation was the most common indication for EPH in our study, followed by uterine atony. Compared with previous studies that reported uterine atony as the most common indication, recent papers suggest that this is being replaced by abnormal placentation (placenta praevia, placenta accreta, increta or percreta) (Daskalakis et al. 2007; Baskett 2003; Stanco et al. 1993; Kastner et al. 2002; Rossi et al. 2010). This is most probably attributable to increased caesarean section rates. Women with prior caesarean section should be carefully evaluated for preoperative detection of a placental abnormality. Placenta praevia in a patient with a prior caesarean section should raise concern on a co-existing placental adhesion anomaly (Oyelese and Smulian 2006). Every effort should be made to prevent unnecessary caesarean section procedures in order to decrease the risk of EPH. Uterine atony is generally unpredictable. Obstetricians must be prepared for such an occurrence in all cases, and must be able to take the necessary steps in a timely fashion. Patients with prolonged labour, multiple pregnancy, macrosomic fetus or chorioamnionitis, the risk of uterine atony is significantly increased. In nine cases (18.7%) in our study, patients had at least one of these risk factors. Perioperative complications are reported to be common in EPH cases (Briery et al. 2007; Wright et al. 2010b; Wright et al. 2010a; Shellhaas et al. 2009). In our study, the most common complication was blood product transfusion, and the second most common was postoperative fever. Bladder injury and reexploration was also common. Bladder injuries were mostly due to dense adhesions of bladder to the uterus as a consequence of previous caesarean sections, and the emergency nature of the hysterectomy procedure. Re-explorations were performed in 10 cases of postoperative bleeding and in three cases of previously undiscovered bladder injuries. These underline the necessity of a multidisciplinary team approach to these patients, in which specialists of various disciplines, such as infectious diseases, urology, general surgery and internal medicine should take place. Infectious diseases specialists especially take a role in the management of cases with serious uterine infections leading to postpartum haemorrhage and subsequent hysterectomy. It is very important to manage these cases with a proper antibiotic regimen to prevent and treat possible life-threatening complications, such as septicaemia. EPH may occasionally have to be performed in areas that are remote to multidisciplinary referral centres. Patients should be transferred only after initial surgical and medical stabilisation, as failure to do so may result in lifethreatening complications during patient transfer. NICU admissions were common, and neonatal complications were mostly due to prematurity in our study population. To prevent lethal complications, EPH should be performed in a timely manner in cases that are unresponsive to initial conservative treatments. As the duration of time until hysterectomy
increases, the likelihood of development of coagulopathy, hypovolaemia, tissue hypoxia, hypothermia and acidosis also increase. Prenatal identification of women that carry increased risk for EPH, and taking necessary precautions for the worst case scenario is crucial to obtain an optimal outcome. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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