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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 4  |  Page : 483-489

Retrospective evaluation of peripartum hysterectomy patients: 8 years' experience of tertiary health care


Department of Obstetrics and Gynecology, Gaziosmanpasa University, Tokat, Turkey

Date of Submission04-Aug-2021
Date of Acceptance07-Jan-2022
Date of Web Publication19-Apr-2022

Correspondence Address:
Dr. S Gulucu
Department of Obstetrics and Gynecology, Gaziosmanpasa University, Merkez, Tokat - 60100
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1722_21

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   Abstract 


Background: Peripartum hysterectomy (PPH), which means surgical removal of the uterus during pregnancy or postpartum period, is a life-saving procedure performed as a last resort to stop obstetric serious bleeding. Aim: Evaluation of the prevalence, risk factors, indications, associated complications, and neonatal outcomes of PPH performed in our clinic. Patients and Methods: A total of 35 patients who underwent PPH in our clinic between 2013 and 2020 were analyzed retrospectively. Clinical and demographic characteristics of patients, age, gestational week, delivery type, type of hysterectomy performed, length of hospital stay, PPH indications, additional procedures and complications during PPH, maternal and fetal mortality, neonatal characteristics, intensive care unit (ICU) need after PPH, and blood transfusion amount and time were recorded. Patients with PPH were subdivided and studied in subgroups: Emergency - elective surgery, total - subtotal hysterectomy. Results: PPH was performed in 35 (3.2/1000) patients who gave birth during the study period. The most common indication for hysterectomy was placental invasion anomaly (57.1%, n = 20), and the most performed operation was total hysterectomy (68.6%, n = 24). Bilateral hypogastric artery ligation (14.3%, n = 5) was the most common alternative procedure performed before hysterectomy, and the most common complication was bladder injury (22.9%, n = 8). Blood transfusion was performed in 94.3% (n = 33) of the patients due to acute blood loss. The mean newborn weight was 2788.79 ± 913.37 g, and the 1st and 5th-minute APGAR scores were 6.71 ± 2.25 and 7.56 ± 2.35, respectively. Conclusion: Before PPH, uterine integrity should be preserved using medical and surgical methods, but if success is not achieved, hysterectomy is the last life-saving step. It should be kept in mind that in patients with anemia and increased gravidity, the risk of bleeding may be high in the first 24 h after birth and therefore PPH may be required. It would be more appropriate for patients with placentation anomalies to be operated in experienced centers due to possible complications, increased blood transfusion, and intensive care requirement.

Keywords: Abnormal placentation, hysterectomy, peripartum, postpartum hemorrhage


How to cite this article:
Gulucu S, Uzun K E, Ozsoy A Z, Delibasi I B. Retrospective evaluation of peripartum hysterectomy patients: 8 years' experience of tertiary health care. Niger J Clin Pract 2022;25:483-9

How to cite this URL:
Gulucu S, Uzun K E, Ozsoy A Z, Delibasi I B. Retrospective evaluation of peripartum hysterectomy patients: 8 years' experience of tertiary health care. Niger J Clin Pract [serial online] 2022 [cited 2022 May 18];25:483-9. Available from: https://www.njcponline.com/text.asp?2022/25/4/483/343455




   Introduction Top


Peripartum hysterectomy (PPH), which means surgical removal of the uterus during pregnancy or postpartum, is a life-saving procedure performed as a last resort to stop obstetric serious bleeding.[1],[2] This procedure may be required during or after cesarean section and vaginal delivery and may cause complications such as increased blood transfusion need, bladder or ureter injuries, infection, fever, and permanent infertility.[3] Known risk factors for PPH are high parity, abnormal placentation, history of cesarean section, and advanced maternal age.[4] Although the risk of PPH in women who give birth by cesarean section varies between 8.5 and 18.3, this result varies from country to country and even from clinic to clinic.[5] In most patients, PPH is performed in an emergency setting with severe obstetric bleeding.[5] In addition, planned cesarean hysterectomy may be performed in patients with suspected prenatal placenta accreta spectrum in which villous tissue adheres to or invades the uterine wall.[5] Placenta accreta spectrum (PAS) includes placenta accreta, increta, and percreta.

The optimal timing of PPH during bleeding is unclear and remains controversial. Studies demonstrating the most successful strategies regarding potentially preventable PPH are scarce. Along with the stress experienced during the operation, surgeons hesitate between conservative and aggressive treatment and have some concerns by considering medico-legal problems.

The aim of the present study is to evaluate the prevalence, risk factors, indications, associated complications, and neonatal outcomes of peripartum hysterectomies performed in our clinic to investigate alternative methods and blood transfusion periods before PPH in these patients.


   Material and Method Top


Patients

Patients who had peripartum hysterectomy at Medical Faculty Hospital, Gynecology and Obstetrics Clinic between January 2013 and December 2020 were included in the study. The study was designed retrospectively. By scanning the patient files from the hospital registry system, patients' age, gravidity, parity, gestational week, delivery type, hysterectomy application time, type of hysterectomy performed, length of hospital stay, PPH indications, additional surgeries and complications during PPH, maternal and fetal mortality, pre-op hemogram values, post-op hemogram values, blood transfusion amount and time, blood products used in transfusion, previous cesarean and curettage histories, PPH count by years, PPH prevalence, post-PPH intensive care unit (ICU) need, pathology results, anesthesia types applied, and neonatal 1 APGAR scores and neonatal birth weight at the 1st and 5th minute were recorded. The incidence of PPH was presented as the number of hysterectomies per 1000 births.[6] Patients with PPH were divided into subgroups and evaluated in detail. These subgroups were total/subtotal hysterectomy depending on the type of surgery, emergency or elective surgery status depending on the time of delivery, and type of skin incision.

Inclusion criteria for the study: Patients in the peripartum period who underwent PPH after vaginal or cesarean delivery were accepted. Exclusion criterion for the study: Patients who were referred to our clinic for follow-up with PPH in another center were excluded from the study.

The gestational week was determined by taking into account the first day of the last menstrual period (LMP) or first-trimester ultrasonography measurements in patients whose LMP was unknown. Length of hospital stay was defined as the time between the day of birth and the day of discharge.

Ethical statement

Ethical approval was obtained from the Ethical Committee of Gaziosmanpasa University Hospital before the study [Project No.: 21-KAEK-051].

Statistical analyses

Study data were evaluated using the Statistical Package for Social Sciences (SPSS, Inc., Chicago, USA) 22 software for statistical analysis. Data evaluation of the study was performed using descriptive statistical methods (standard deviation, mean, maximum-minimum, median, ratio, and frequency). The conformity of the quantitative data to the normal distribution was tested using the Kolmogorov–Smirnov test. Chi-square test or Fisher's exact test was used as appropriate to test the relationship between categorical factors. The odds ratio (OR) was also reported. Independent sample t test was used for parametric continuous factors. Statistical significance was accepted as P < 0.05.


   Results Top


A total of 10,796 deliveries took place in our clinic between 2013 and 2020. Cesarean sections constituted 72% (n = 7773) of these deliveries and vaginal deliveries were 38% (n = 3023). PPH was applied to 35 (3.2/1000) patients who gave birth. PPH was not performed on any patient after vaginal delivery. Medical procedures (fundal massage, oxytocin, and ergometrine) were applied to all patients before PPH. The mean age of the patients was 33.03 ± 4.6 years. Demographic characteristics of the patients are shown in [Table 1]. The clinical features of the patients were evaluated, and the number of previous cesarean sections was between 1 and 5. Two patients had PAS despite the first cesarean section. One of these patients had curettage and multiparity risk factors in their obstetric history, while the other had only multiparity. The mean hospital stay was 5.57 ± 3.76 days. The mean hemoglobin before and after the operation was 10.06 ± 2.09 9.01 ± 1.56 g/dL, respectively. The clinical characteristics of the patients are shown in [Table 1]. Maternal mortality was not observed in patients who underwent PPH. When the newborns of the patients were evaluated, the mean newborn weight was 2788.79 ± 913.37 g, and the mean APGAR scores at the 1st and 5th minutes were 6.71 ± 2.25 and 7.56 ± 2.35, respectively. While calculating the newborn weight and APGAR score averages, a patient with multiple pregnancy was not included in the calculation. Stillbirth was detected in two of the patients. Perinatal mortality rate was 5.88% in patients who underwent PPH. Newborn characteristics are shown in [Table 1]. General anesthesia was applied to 94.2% (n = 33) of the patients, and spinal anesthesia was applied to one patient (3.1%). Only one patient was administered general anesthesia after spinal anesthesia (3.1%).
Table 1: Demographic and clinical characteristics of the patients who underwent peripartum hysterectomy

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While 22 patients (62.9%) did not have a history of abortion, seven patients (20%) had a history of abortion once, four patients (11.4%) had a history of abortion twice, and two patients (5.7%) had a history of abortion four times. Blood transfusion was performed in 94.3% (n = 33) of the patients due to acute blood loss. While 77.1% (n = 27) of the preoperative and intraoperative patients received erythrocyte suspension (mean: 2.31 ± 1.90), 60% (n = 21) of them were given fresh frozen plasma (FFP) (mean: 1.49 ± 1.99), one (2.9%) patient was given apheresis, and two (5.7%) patients were given whole blood. After the operation, 65.7% (n = 23) of the patients had ES (mean: 1.29 ± 1.10), 28.6% (n = 10) had FFP (mean: 0.51 ± 0.91), 5.7% (n = 2) had apheresis, and 11% (n = 4) had whole blood transfusion.

All PPHs were applied after cesarean delivery. The most common indication was PAS (57.1%, n = 20). When the pathology reports of the hysterectomy material of the patients were evaluated, it was found that PAS was 65.7% (n = 23), and the most frequently observed ones were placenta accreta (25.7%, n = 6) and placenta percreta (25.7%, n = 6). Placenta previa was found to be 11.4% (n = 4).

Total hysterectomy was performed in 68.6% (n = 24) of the patients, and subtotal hysterectomy was performed in 31.4% (n = 11). Patients who were taken to cesarean section under emergency conditions constituted 57.1% (n = 20) of the cases. The Pfannenstiel incision was usually made as a skin incision during the PPH operation (71.4%, n = 25). When PPH application time was evaluated, it was detected that PPH was performed in 32 patients (91.4%) during the operation, and in three patients (8.6%), it was performed by re-laparotomy within the first 24 h after the operation. Bilateral hypogastric artery ligation (BHAL) (14.3%, n = 5) was the most common alternative procedure performed before hysterectomy. The most common complication in the perioperative period was bladder injury (22.9%, n = 8). Ureteral injury was not observed in any patient. It was observed that blood transfusion was applied more frequently to the patients in the intraoperative and postoperative periods (48.6%, n = 17). The characteristics of the patients regarding the operation are in [Table 2] and [Table 3]. Eighteen patients (51.4%) were followed up in the intensive care unit (ICU) in the postoperative period, and no maternal mortality was observed.
Table 2: Clinical features of the patients

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Table 3: Clinical features of the patients

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When patients who underwent total and subtotal hysterectomy were evaluated, no statistically significant difference was detected between groups in terms of age, gravidity, parity, gestational week, length of hospital stay, number of cesarean sections, 1st and 5th-minute Apgar scores, and pre- and postoperative hemoglobin levels. In addition, no significant relationship was found between the operation type and indication, intensive care admission, skin incision, TAH time, and complications. Because the operation times could not be evaluated clearly, a comparison between the groups could not be made.

Emergency and elective operations were evaluated by dividing them into two groups. A significant difference was found between the two groups in terms of gestational week, preoperative hemoglobin, total ES, and FFP (P < 0.001, P = 0.014, P = 0.011, and P = 0.044, respectively).

When the differences between the groups were evaluated, a smaller gestational week (33.20 ± 3.27 vs. 37.07 ± 1.03) and lower preoperative hemoglobin level (9.29 ± 2.25 vs. 11.09 ± 1.31 g/dL) was noted, and it was determined that more ES (4.35 ± 2.05 vs. 2.60 ± 1.68) and FFP (2.70 ± 2.61 vs. 1.07 ± 1.22) transfusions were performed. While 33.3% of the elective planned group needed ICU care, 65% of the emergency group were followed up in the ICU.

Patients who were planned for elective hysterectomy due to placental anomaly were evaluated by ultrasonography, and it was observed that additional imaging such as MRI was not performed.

When comparing the mean APGAR scores of the newborns at the 1st and 5th minutes between those who underwent emergency and elective surgery, both the 1st and 5th minute APGAR scores were higher than those of the newborns who underwent elective surgery. APGAR scores of neonates from patients who underwent emergency surgery were statistically lower (APGAR 1 min: 5.90 ± 2.59 vs. 7.73 ± 0.88; P = 0.007) and (APGAR 5 min: 6.65 ± 2.66 vs. 8.73 ± 0.88; P = 0.001). Two patients were identified whose in utero ex fetus was retrieved under emergency conditions, and no in utero ex fetus was observed in elective patients.

The changes in the number of PPH operations performed in our clinic over the years are presented in [Graph 1].




   Discussion Top


PPH is a technique used as a last resort in obstetric hemorrhage to reduce maternal morbidity and mortality. Different results were found in different centers regarding the incidence of PPH. While the incidence of PPH is <1/1000 births in developed countries, it has increased rates of up to 11 per 1000 births in developing countries.[7] In a meta-analysis evaluating a total of 128 studies, the incidence of PPH in low-income countries was stated as 2.8/1000.[4] The incidence of PPH in our clinic was found to be 3.2/1000. The reason for the high incidence of PPH in our clinic compared to the rates of developed countries was attributed to the low number of vaginal deliveries, the high rates of risky cesarean section, and our hospital being the referral center of the region. Despite the increase in the number of patients at risk for PPH, increasing experience has reduced the rate of PPH in recent years, which explains the differences in numbers between years.

Risk factors for PPH have been reported as advanced maternal age, abnormal placentation, high parity, and cesarean delivery in a previous or current pregnancy.[4] In previous studies, it was shown that the frequency of PPH increased in women who gave birth by cesarean section or had a previous cesarean section.[8],[9],[10] In our study, we observed that the risk of PPH was associated with increasing age, parity number, and cesarean section number. All of the PPHs in our study were after cesarean section, and it was found that hysterectomy was never performed after vaginal delivery. This was attributed to the fact that patients with suspected abnormal placentation were delivered by cesarean section, and the absence of complications, such as uterine rupture during vaginal delivery, and the effect of pharmacological and surgical methods used in cases such as uterine atony.

PAS is defined as the abnormal invasion of the placental tissue into the myometrium and it remains firmly adhered to the uterine wall after delivery, causing severe blood loss. In these cases, if conservative treatment is not successful, hysterectomy can be performed. The incidence of PAS is increasing along with cesarean section in recent years.[11],[12],[13] In our study, PAS was found to be the most common factor (in 57.1% of patients) causing PPH. In our study, it was determined that uterine atony was the third most common cause of PPH after PAS and placenta previa, with a rate of 11.4%. In a previous review, the most common cause of PPH was reported as uterine atony.[14] In a recent review, it was found that the most common indication for PPH is abnormal placentation, replacing uterine atony. This has been attributed to the effective use of pharmacological agents to prevent uterine atony and increased cesarean section rates leading to placentation disorder.[15] The causes and frequencies of PPH in our study were found to be compatible with the literature.

During the second and third trimester examination, abnormal placentation can be identified by both ultrasonography and magnetic resonance imaging, and risky patients can be detected.[15],[16] This allows risky patients to be referred to appropriate centers. All of the electively operated patients in the present study were diagnosed by ultrasonography. It has not been clearly evaluated how many of the patients who underwent emergency surgery were diagnosed preoperatively. It should be kept in mind that this situation may vary depending on the short preoperative evaluation period of the patient to be operated, the number of patients without follow-up, and the experience of the evaluating physician. In a meta-analysis study, it was reported that only 56.4% of posterior PAS cases were detected prenatally and 73.5% of posterior PAS was detected in prenatal magnetic resonance imaging (MRI). It should be noted that PAS can be encountered during the operation if only ultrasonography is used in prenatal diagnosis.[17]

Increased morbidity and mortality rates are observed in women who have had PPH. The most serious complications were reported as blood loss, disseminated intravascular coagulation (DIC), and genitourinary system injury.[18] In previous studies, the maternal mortality rate was reported between 1.2% and 19.4%.[6],[10],[12] Maternal mortality was not observed in our study. This was attributed to the fact that our hospital is a tertiary level hospital, the rapid delivery of referrals to our hospital, proper intervention to the patients as early as possible, and the high capacity of the blood bank. In our study, blood transfusion was performed in 94.3% (n = 33) of the patients due to acute blood loss. Further, 51.4% (n = 18) of the patients with PPH were followed up in the ICU. Systematic studies stated that many patients with PPH required blood transfusion and ICU follow-up.[1],[8] In a study that evaluated a total of 67,572 deliveries between 2006 and 2014, it was reported that an average of 4–6 units of ES are transfused to patients who underwent PPH.[19] In our study, blood products were transfused at similar rates. As there may be excessive blood loss due to obstetric hemorrhage in patients undergoing PPH, it was stated that it would be appropriate to prepare adequate blood products, especially in patients with PAS or placental previa.[20] The rate of bladder injury during PPH varies between 9% and 15%.[6],[21] In our study, bladder injury (22.9%) was the most common complication after blood transfusion in the intraoperative period. In another study, the rate of urological damage was found to be 22.6% in patients who underwent PPH.[22] The reason for our high rate of bladder injury was attributed to the matter that the patients had a history of previous cesarean section, bladder invasion due to PAS, the adhesion of the bladder to the uterus, and the narrow operation field due to the more frequent Pfannenstiel skin incision. In one of our patients, unilateral salpingo-oophorectomy secondary to intra-abdominal adhesions was performed. Acute renal failure was observed in one patient in the postoperative period. After the necessary follow-up, the patient was discharged with recovery.

An alternative surgical procedure was performed in 28.5% of the patients before PPH. The most frequently performed alternative procedure was BHAL, and PAS was detected in all patients who underwent BHAL. Conservative methods can be used to protect the uterus as quickly as possible when patients are hemodynamically stable, but it should be kept in mind that these methods require more experience. When the hysterectomy application periods were examined, 91.4% (n = 32) of the patients underwent PPH during the operation and 8.6% (n = 3) within the first 24 h after the operation with re-laparotomy. The need for re-laparotomy for bleeding in patients undergoing PPH has been reported between 1.3% and 17.5% in the literature.[10],[23]

When the histopathology reports of the patients were evaluated, it was found that the rate of PAS was 65.7%, and when the histopathological incidences of PAS were evaluated, the most common ones were found to be placenta accreta (25.7%) and placenta percreta (25.7%).[24] In a study, the histopathological incidence rates of PAS were found to be 55.5% placenta accreta, 38.8% placenta increta, and 5.5% placenta percreta.[25]

In our clinic, total hysterectomy was performed in 68.6% of the patients and subtotal hysterectomy was performed in the remainder. Two systematic studies reported the rates of total hysterectomies as 51.1%[4] and 52.2%,[26] respectively. There was no significant difference between the types of hysterectomy for the results analyzed in our study. As the operation times could not be evaluated clearly, a comparison could not be made. There was no finding showing the superiority of total hysterectomy over subtotal hysterectomy. Previous studies have reported that there is no difference in terms of total or subtotal PPH.[27],[28],[29] In a study, it was reported that patients with emergency PPH had significantly more bleeding than those who were planned elective.[30] In our study, 57.1% of the patients were operated under emergency conditions, and it was found that these patients received more ES and FFP transfusions than the patients who were operated in the elective period. While 33.3% of the electively operated patients needed ICU care, 65% of the patients operated under emergency conditions were followed up in the ICU. It was detected that the gestational weeks and newborns of the patients who were operated under emergency conditions had lower APGAR scores at both the 1st and 5th minutes.

Two patients were found to have an ex-fetus in utero, and these patients were delivered by cesarean section under emergency conditions. In the present study, the maternal preoperative hemogram value of the ex-fetuses was very low (3.8 g/dL and 5.5 g/dL, respectively). Fetal mortality was attributed to severe anemia from active bleeding and fetal hypoxia from anemia. One study compared the 1st and 5th minute APGAR scores of patients with PPH after cesarean section and neonates with PPH after vaginal delivery, and found that patients with PPH after cesarean section had lower APGAR and fetal mortality.[20]

It is believed that the rate of peripartum hysterectomy in our hospital has changed over the years with the number of patient admissions, blood bank reserves, ICU admission conditions in our hospital, and increasing surgical experience.

Limitations of our study were the high number of pregnant women at risk, the retrospective nature of the study, the relatively low number of patients, data from a single institution, and our hospital being a referral center. Among the strengths of the study are that the study period covers an 8-year period and that a certain number of surgeons have done all the cases.


   Conclusion Top


It should be kept in mind that PPH is a last-step surgical procedure in obstetric hemorrhages, but it should be applied as a life-saving procedure when necessary. The decision to perform PPH depends on the skills and experience of the surgeon; however, increasing cesarean section rates also increase the probability of PAS and thus the risk of PPH. It should be kept in mind that in patients with anemia and increased gravidity, the risk of bleeding may be high in the first 24 h after birth and therefore PPH may be required. To reduce the prevalence of PPH, it is necessary to reduce the cesarean section rates first and standardize the practices to be performed when PAS is encountered. Considering the risk factors for PPH, it is important to refer the patients to a tertiary hospital, prepare the necessary blood products, and be managed by experienced surgeons. Further prospective studies with a large number of cases are required to better understand the factors that influence PPH.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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  In this article
    Abstract
   Introduction
   Material and Method
   Results
   Discussion
   Conclusion
    References
    Article Tables

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