Arch Gynecol Obstet DOI 10.1007/s00404-014-3306-5
Maternal-Fetal Medicine
Incidence of emergency peripartum hysterectomy in Ain-shams University Maternity Hospital, Egypt: a retrospective study Ihab Serag Allam · Ihab Adel Gomaa · Hisham Mohamed Fathi · Ghada Fathi Mahmoud Sukkar
Received: 10 December 2013 / Accepted: 28 May 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To estimate the incidence of emergency peripartum hysterectomy over 6 years in Ain-shams University Maternity Hospital. Methods 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. Results 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
I. S. Allam · I. A. Gomaa · H. M. Fathi · G. F. M. Sukkar Obstetrics and Gynaecology Department, Ain‑shams Faculty of Medicine, Ain Shams University Maternity Hospital, Abbasiya square, Cairo, Egypt e-mail: [email protected] H. M. Fathi e-mail: [email protected] G. F. M. Sukkar e-mail: [email protected] Present Address: I. S. Allam (*) Block 2, Piece 29; Zahrat Almadina, Alnozha Algadida, Cairo 11769, Egypt e-mail: [email protected]
cesarian section and ruptured uterus were independent predictors for peripartum hysterectomy Conclusion 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. Keywords Abnormal placentation · Maternal morbidity and mortality · Peripartum hysterectomy · Placenta accreta · Placenta previa · Uterine atony · Cesarean hysterectomy Abbreviations ANOVA Analysis of variance CI Confidence interval DIC Disseminated intravascular coagulopathy ICU Intensive care unit OR Odds ratio RR Relative risk
Introduction Peripartum hysterectomy is a procedure performed at the time of delivery or in the immediate postpartum period (within 24 h). It is one of the most severe complications in obstetrics and it is related to significant maternal mortality and morbidity. This procedure is typically reserved
13
for situations in which severe obstetric hemorrhage fails to respond to conservative treatment. Peripartum hysterectomy is associated with severe blood loss with risk of transfusion, intraoperative complications, and significant postoperative morbidity. Emergency peripartum hysterectomy is mostly performed as life-saving procedure in case of intractable obstetric hemorrhage [1]. It is important to estimate national incidence rates and trends for peripartum hysterectomy to inform obstetrics practitioners and to assess risks and complications of pregnancy. Early studies on peripartum hysterectomy included hysterectomies done for non-emergency conditions. Between 1950 and the late 1970s, cesarean hysterectomy was most commonly used for sterilization, defective uterine scar, myomas, and other gynecologic disorders [2]. Zelop et al [3]. found that placenta accreta and uterine atony were the most common reasons for emergency peripartum hysterectomy. Placenta accreta has become the most common cause for an emergency peripartum hysterectomy. It may be attributed to the increase in cesarean births and uterine curettages over the past two decades. Placenta accreta is strongly associated with placenta previa in scared uterus, mainly due to a previous cesarean section, and increasing maternal age, both being independent risk factors [4]. The incidence of uterine rupture has not increased in terms of percentage but increased in absolute numbers due to the increased cesarean section rate. In addition to the associations between a previous cesarean section with placenta accreta and uterine rupture, cesarean section itself increases the risk of emergency peripartum hysterectomy [5]. Many studies describe high complication rates of emergency peripartum hysterectomy mainly due to the need of massive blood transfusions, coagulopathy, injury of the urinary tract, need for re-exploration because of persistent bleeding and febrile morbidity. Maternal death is reported occasionally [6] . The aim of the current study was to estimate the incidence of emergency peripartum hysterectomy over 6 years in Ain-shams University Maternity Hospital.
Patients and methods This study conducted a retrospective analysis of all cases of emergency peripartum hysterectomy performed at Ain Shams University Maternity Hospital between 2003 and 2008 after the approval of the research ethics committee. Emergency peripartum hysterectomy was defined as a hysterectomy performed at the time of delivery or in the immediate postpartum period (within 24 h). Hundred and fortynine hysterectomies were performed and records were available for analysis.
13
Arch Gynecol Obstet
Data collected to determine • Maternal characteristics: age, parity, gestational age, previous cesarean delivery, previous uterine curettage, history of antepartum hemorrhage, history of previous postpartum hemorrhage and mode of delivery. • Neonatal outcome. • Surgical details: indication of hysterectomy, type of hysterectomy, additional procedures, need for blood transfusion, postoperative complications, postoperative hospital stay and intensive care unit (ICU) admission rate. Statistical analysis It was performed using Microsoft® Excel® version 2010 and Statistical Package for Social Sciences (SPSS®) for Windows® version 15.0. Measured variables were expressed in descriptive statistics in terms of mean and standard deviation (for parametric variables), range, median and interquartile range (for non-parametric variables), number and percentage (for categorical variables). Difference between two independent groups was estimated using continuity-corrected Chi-squared test. Association between two dichotomous variables was estimated using binary logistic regression analysis; the outcome was in terms of relative risk (RR), odds ratio (OR) and its 95 % confidence interval (95 % CI). Multifactorial logistic regression analysis was used to identify independent risk factors for peripartum hysterectomy. One way analysis of variance (ANOVA) was used to analyze the differences between group means (age, parity, previous cesarean section, number of previous curettage, gestational age) and their associated variant (such as atonic uterus placenta accreta, etc.) using F value. Significance level was set at 0.05.
Results Total deliveries performed in Ain-shams University Maternity Hospital between years 2003 and 2008 were 66,306. 149 deliveries were followed by emergency peripartum hysterectomy, the mean maternal age was 31.58 + 5.4 year and the mean parity was 2.77 + 1.5. Concerning parity, all primigravidas who underwent peripartum hysterectomies were due to uterine atony (100 %). On the other hand, cases of emergency peripartum hysterectomy due to either uterine rupture or placenta previa with or without accreta were exclusively multipara [p
Maternal-Fetal Medicine
Incidence of emergency peripartum hysterectomy in Ain-shams University Maternity Hospital, Egypt: a retrospective study Ihab Serag Allam · Ihab Adel Gomaa · Hisham Mohamed Fathi · Ghada Fathi Mahmoud Sukkar
Received: 10 December 2013 / Accepted: 28 May 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To estimate the incidence of emergency peripartum hysterectomy over 6 years in Ain-shams University Maternity Hospital. Methods 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. Results 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
I. S. Allam · I. A. Gomaa · H. M. Fathi · G. F. M. Sukkar Obstetrics and Gynaecology Department, Ain‑shams Faculty of Medicine, Ain Shams University Maternity Hospital, Abbasiya square, Cairo, Egypt e-mail: [email protected] H. M. Fathi e-mail: [email protected] G. F. M. Sukkar e-mail: [email protected] Present Address: I. S. Allam (*) Block 2, Piece 29; Zahrat Almadina, Alnozha Algadida, Cairo 11769, Egypt e-mail: [email protected]
cesarian section and ruptured uterus were independent predictors for peripartum hysterectomy Conclusion 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. Keywords Abnormal placentation · Maternal morbidity and mortality · Peripartum hysterectomy · Placenta accreta · Placenta previa · Uterine atony · Cesarean hysterectomy Abbreviations ANOVA Analysis of variance CI Confidence interval DIC Disseminated intravascular coagulopathy ICU Intensive care unit OR Odds ratio RR Relative risk
Introduction Peripartum hysterectomy is a procedure performed at the time of delivery or in the immediate postpartum period (within 24 h). It is one of the most severe complications in obstetrics and it is related to significant maternal mortality and morbidity. This procedure is typically reserved
13
for situations in which severe obstetric hemorrhage fails to respond to conservative treatment. Peripartum hysterectomy is associated with severe blood loss with risk of transfusion, intraoperative complications, and significant postoperative morbidity. Emergency peripartum hysterectomy is mostly performed as life-saving procedure in case of intractable obstetric hemorrhage [1]. It is important to estimate national incidence rates and trends for peripartum hysterectomy to inform obstetrics practitioners and to assess risks and complications of pregnancy. Early studies on peripartum hysterectomy included hysterectomies done for non-emergency conditions. Between 1950 and the late 1970s, cesarean hysterectomy was most commonly used for sterilization, defective uterine scar, myomas, and other gynecologic disorders [2]. Zelop et al [3]. found that placenta accreta and uterine atony were the most common reasons for emergency peripartum hysterectomy. Placenta accreta has become the most common cause for an emergency peripartum hysterectomy. It may be attributed to the increase in cesarean births and uterine curettages over the past two decades. Placenta accreta is strongly associated with placenta previa in scared uterus, mainly due to a previous cesarean section, and increasing maternal age, both being independent risk factors [4]. The incidence of uterine rupture has not increased in terms of percentage but increased in absolute numbers due to the increased cesarean section rate. In addition to the associations between a previous cesarean section with placenta accreta and uterine rupture, cesarean section itself increases the risk of emergency peripartum hysterectomy [5]. Many studies describe high complication rates of emergency peripartum hysterectomy mainly due to the need of massive blood transfusions, coagulopathy, injury of the urinary tract, need for re-exploration because of persistent bleeding and febrile morbidity. Maternal death is reported occasionally [6] . The aim of the current study was to estimate the incidence of emergency peripartum hysterectomy over 6 years in Ain-shams University Maternity Hospital.
Patients and methods This study conducted a retrospective analysis of all cases of emergency peripartum hysterectomy performed at Ain Shams University Maternity Hospital between 2003 and 2008 after the approval of the research ethics committee. Emergency peripartum hysterectomy was defined as a hysterectomy performed at the time of delivery or in the immediate postpartum period (within 24 h). Hundred and fortynine hysterectomies were performed and records were available for analysis.
13
Arch Gynecol Obstet
Data collected to determine • Maternal characteristics: age, parity, gestational age, previous cesarean delivery, previous uterine curettage, history of antepartum hemorrhage, history of previous postpartum hemorrhage and mode of delivery. • Neonatal outcome. • Surgical details: indication of hysterectomy, type of hysterectomy, additional procedures, need for blood transfusion, postoperative complications, postoperative hospital stay and intensive care unit (ICU) admission rate. Statistical analysis It was performed using Microsoft® Excel® version 2010 and Statistical Package for Social Sciences (SPSS®) for Windows® version 15.0. Measured variables were expressed in descriptive statistics in terms of mean and standard deviation (for parametric variables), range, median and interquartile range (for non-parametric variables), number and percentage (for categorical variables). Difference between two independent groups was estimated using continuity-corrected Chi-squared test. Association between two dichotomous variables was estimated using binary logistic regression analysis; the outcome was in terms of relative risk (RR), odds ratio (OR) and its 95 % confidence interval (95 % CI). Multifactorial logistic regression analysis was used to identify independent risk factors for peripartum hysterectomy. One way analysis of variance (ANOVA) was used to analyze the differences between group means (age, parity, previous cesarean section, number of previous curettage, gestational age) and their associated variant (such as atonic uterus placenta accreta, etc.) using F value. Significance level was set at 0.05.
Results Total deliveries performed in Ain-shams University Maternity Hospital between years 2003 and 2008 were 66,306. 149 deliveries were followed by emergency peripartum hysterectomy, the mean maternal age was 31.58 + 5.4 year and the mean parity was 2.77 + 1.5. Concerning parity, all primigravidas who underwent peripartum hysterectomies were due to uterine atony (100 %). On the other hand, cases of emergency peripartum hysterectomy due to either uterine rupture or placenta previa with or without accreta were exclusively multipara [p
