Printer Friendly

Emergency peripartum hysterectomy: a 5 year retrospective analysis in a peripheral medical college in Eastern India.

INTRODUCTION: Emergency peripartum hysterectomy is an uncommon obstetrics procedure, usually performed as a lifesaving measure in cases of intractable obstetric haemorrhage. (1-3) It was first proposed in 1869(4) by Horatio Storer to reduce maternal mortality.

Emergency Peripartum hysterectomy (EPH) was defined as an emergency lifesaving procedure, where hysterectomy was performed at or after delivery (5) during the same hospitalization.

Although the exact incidence of EPH is not known, several authors have reported widely varying rates of 0.004 to 1.5 per 1000 deliveries (6) depending on the facilities available at the peripheral medical centres. Severe PPH was reported to occur in 6.7 per 1000 deliveries worldwide. Rochat and colleagues reported an incidence of 11 % of maternal deaths resulting from Haemorrhage (7) and it is one of the leading causes of maternal mortality and morbidity representing the most challenging complication that an obstetrician will face. (8)

The present study was undertaken to evaluate the incidence, indications, risk factors, outcome and complications of peripartum hysterectomy done to reduce maternal mortality. MATERIALS AND METHODS: This was a case series study. Medical records of the patients who had undergone EPH following vaginal delivery and caesarean section in between Jan 2008 to Dec 2012 in this medical college were reviewed retrospectively. Cases were ascertained via a review of hospital obstetrics database by checking the obstetric admission register, OT records, case records and mortality register. All deliveries were performed after 28 wk of gestation. Both medical and surgical measures were used for conservative management. The study was approved by the Institutional Ethical Committee.

Information obtained from the medical records include demographic details, risk factors, previous obstetrics history, current pregnancy and delivery detail, indication for EPH, outcome of hysterectomy and operative and postoperative complications, maternal morbidity and mortality. The data was analyzed using Graph, Microsoft Excel, 2007. The comparison was done by Medical software. P value < 0.05 is statistically significant.

RESULTS: During the 5 year study period following information were gathered.

Table 1 and Fig 1 show that there were 94276 deliveries over a 5 year period and 72 peripartum hysterectomies with an incidence of 0.76/1000 deliveries. Majority were multiparous and within the age group of 20-29 years.

Fig 3 and Fig 4 shows the maximum no of deliveries at 38 wks of gestation and maximum number of patients who underwent peripartum hysterectomy was post CS cases.

Table 2 shows uterine rupture as the most frequent indication of EPH followed by atonic uterus, abnormal placentation, and uterine inversion.

Table 3 and Fig 6 shows the incidence ranging from 0.8/1000 to 1.00/1000 over a 5 year period. Table 4 summarizes the maternal morbidity, mortality and the post operative complications following peripartum hysterectomy.

DISCUSSION: Despite advances in the medical and surgical technique, PPH remains one of the leading causes of maternal mortality and morbidity. PEH is performed in life threatening obstetrical haemorrhage, that could not be controlled by conventional methods. Obstetric hysterectomy often puts the surgeon in a dilemma as the maternal reproductive capability is sacrificed to save the mother's life.

Although the exact incidence of EPH is not known, several authors have reported widely varying rate of 0.004 to 1.5 thousand deliveries (6) Praneshwari Devi (9) reported an incidence of (0.7/1000) deliveries which is consistent with our study (0.76)/1000 deliveries. Marwaha et al (10), Sahasrabojane et al (11), Kumari et al (12), Zeteroglu et al (13), reported an incidence of 3.1/1000, 3.5/1000, 7. 3/1000 and 5/1000 deliveries respectively, which is higher than our study. In our series majority of patients who have undergone EPH were in the group of [greater than or not equal to] 25 yrs and were multipara. Similar trend was observed by Amad and Mir (5 and Barcley et al (6)

In our study most of the patients upon whom EPH was performed were post CS pregnancy with the most frequent indication of EPH in the present study being uterine rupture (52.7%), followed by atonic uterus (27.7%), abnormal placentation, uterine inversion and others.

Other risk factors for EPH were increased age, multiparty, uterine atony, abnormal placentation, obstructed labour, current caesarean delivery and were similar to the literature (2,14,15-,16,17,-18,19). Abnormal placentation is higher in post CS pregnancy compare to normal pregnancy. A single CS increase the risk of placenta pra.evia by 0.65%, two CS increase the risk by 1.5% (9) There has been a significant change in indication of EPH over time and from one region to other region. But the recent studies in the the US(20) show abnormal placentation is the most common cause of EPH.

But in our institution, ruptured uterus is still the most common cause of EPH and most of the rupture occurred in post CS pregnancy. As the number of post CS pregnancy is gradually rising, the complication and incidence of EPH is also on the rise. The most severe complication of haemorrhage in pregnancy is maternal death. In developing country the risk is as high as 1 in 1000 deliveries. Other complications includes shock, DIC, renal failure, ARDS, infection, transfusion related complications. (19,21) In this study the maternal mortality was 11.11%. Marwaha reported a mortaljty of 12.2% whereas P. Devi et al reported no mortality at all. The critical condition of the mother is responsible for the mortality and morbidity.

Our study in eastern India shows a statistically significant lower incidence of peripartum hysterectomy compared to other parts of India (0.076% versus 0.35% deliveries; P value <0.0101)

This institute serves a very large rural and backward geographical area in Eastern India with poor communication. Due to inadequate health facilities, poor referral systems and inadequate knowledge about the high risk pregnancy we receive these cases in very grave condition. Transport facilities are inadequate as well .

CONCLUSION: In developing countries, the obstetrician will continue to encounter this unfortunate event of EPH in their day to day life but the incidence can definitely be decreased by upgrading the infrastructure, regular antenatal check up, timely referral of high risk cases, continuous upgradation of knowledge and skills, and managing these cases through various programmes such as EMOC, upgrading socioeconomic status and health education .

REFERENCES:

(1.) Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstetrics and Gynecology 2010; vol. 115, no. 3: pg. 637-644.

(2.) Kwee A, Bots ML, Visser GHA, Bruinse HW. Emergency peripartum hysterectomy: a prospective study in the Netherlands. European Journal of Obstetrics Gynecology and Reproductive Biology 2006; vol. 124, no. 2: pg. 187-192.

(3.) Akar ME, Yilmaz E S, Yuksel B, Yilmaz Z. Peripartum hysterectomy. European Journal of Obstetrics, Gynecology and Reproductive Biology 2004; vol. 113, no. 2: pg. 178-181.

(4.) Daskalakis G, Anastasakis E, Papantoniou N, Mesogitis S, Theodora M, Antsaklis A. Emergency obstetric hysterectomy. Acta Obstetriciaet Gynecologica Scandinavica 2007; vol.86, no. 2: pg. 223-227.

(5.) Amad SN and Mir IH. Emergency peripartum hysterectomy: experience at Apex Hospital of Kashmir Valley. Internet Journal of Gynecology& Obstetric 2007; vol. 8, no. 2: http:www.ispub.com/journal/the internet journal of gynecology and obstetrics/volume 8 number 2/article/emergency peripartum hysterectomy experience at apex hospital of Kashmir valley.html.

(6.) Graves CR. Obstetric Problems. In: Rock JA, Jones III HW, editors, Telinde's Operative Gynaecology, 10th edition, chapter 35A. Philadelphia (PA): Lippincott-Williams & Wilkins; 2003; Pg 831.

(7.) GraveS CR. Obstetric Problems. In: Rock JA, Jones III HW, editors, Telinde's Operative Gynaecology, 10th edition, chapter 35A. Philadelphia (PA): Lippincott-Williams & Wilkins; 2003, pg 826.

(8.) Sakse A, Weber T, Nickelsen C, Secher NJ. Peripartum hysterectomy in Denmark 1995-2004. Acta Obstetricia et Gynecologica Scandinavica 2007; vol. 86, no. 12, pg. 1472-1475.

(9.) Praneshwari Devi RK, Singh NN, Singh TD. Emergency Obstetric hysterectomy. J obstet Gynaecol India 2004; 54:127-9.

(10.) Marwaha P, Kaur M, Gupta A. Peripartum Hysterectomy: A 5 Year Study. J Obstet Gynaecol India 2008; 58: 504-6.

(11.) Sahasrabojanee M, Jindal M, Kamat A. Obstetric Hysterectomy: a life saving procedure. J Obstet Gynaecol India 2008; 58:138-141.

(12.) Kumari A, Sahay PB. A Clinical Review of emergency obstetric hysterectomy. J obstet Gynaecol India 2009; 59:427-1.

(13.) Zeteroglu S, Ustun Y, Engin-Ustun Y, Sahin G, Kamaci M, Peripartum hysterectomy in a teaching hospital in the eastern region of Turkey. European Journal of Obstetrics Gynecology and Reproductive Biology 2005; vol. 120, no. 1, pp. 57-62.

(14.) Bakshi S. Meyer BA. Indications for and outcomes of emergency peripartum hysterectomy: a five-year review. Journal of Reproductive Medicine for the Obstetrician and Gynecologist 2000; vol. 45, no. 9, pp. 733-737.

(15.) Baskett TF, Emergency obstetric hysterectomy. Journal of Obstetrics and Gynaecology 2003; vol. 23, no. 4: pp. 353-355.

(16.) Selo-Ojeme DO, Bhattacharjee P, Izuwa-Njoku NF, Kadir RA. Emergency peripartum hysterectomy in a tertiary London hospital. Archives of Gynecology and Obstetrics 2005 vol.271, no. 2: pp. 154-159.

(17.) Kayabasoglu F, Guzin K, Aydogdu S, Sezginsoy S, Turkgeldi L, Gunduz G. Emergency peripartum hysterectomy in a tertiary Istanbul hospital. Archives of Gynecology and Obstetrics 2008; vol. 278, no. 3: pp. 251-256.

(18.) Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. American Journal of Obstetrics and Gynecology 2005; vol. 192, no. 5, pp. 1458-1461.

(19.) Graves CR., Obstetric Problems. In: Rock JA, Jones III HW, editors, Telinde's Operative Gynaecology, 10th edition, chapter 35A, Philadelphia (PA): Lippincott-Williams & Wilkins; 2003; Pg 831. Telinde's operative gynaecology. 10th edition. Chapter 35A. page 832.

(20.) Zelop CM, Harlow BL, Frigoletto FD, et al. Emergency peripartum hysterectomy. Am J Obstet Gynecol 1993; 168:1443.

(21.) Mousa HA, Walkinshaw S, Major postpartum haemorrhage. Current Opinion in Obstetrics and Gynecology 2001; vol. 13, no. 6: pp. 595-603.

Debjani Deb [1], Utpal Ghosh [2], Anirban Dasgupta [3], Sumanta Kumar Mondal [4], Subhendu Dasgupta [5], Anindya Kumar Das [6]

AUTHORS:

[1.] Debjani Deb

[2.] Utpal Ghosh

[3.] Anirban Dasgupta

[4.] Sumanta Kumar Mondal

[5.] Subhendu Dasgupta

[6.] Anindya Kumar Das

PARTICULARS OF CONTRIBUTORS:

[1]. Assistant Professor, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College, West-Bengal, India.

[2]. Post Graduate Trainee, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College, West-Bengal, India.

[3]. Senior Resident, Department of Obstetrics and Gynecology, JIPMER.

[4]. RMO Cum Clinical Tutor, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College, West-Bengal, India.

[5]. Professor and HOD, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College, West-Bengal, India.

[6]. Professor, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College West-Bengal, India.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Debjani Deb, Nirmaldanga, Bankura, PIN--722101, W.B.

Email- debjani163@gmail.com

Date of Submission: 29/08/2013.

Date of Peer Review: 30/08/2013.

Date of Acceptance: 04/09/2013.

Date of Publishing: 10/09/2013

Table 1: Showing the incidence of Peripartum
Hysterectomy (5 year)

Total no. deliveries   94276
Total NVD              62536
Total CS               20239
Others                 9597
Total EPH              72
Incidence (BSMCH)      0.76/1000 deliveries

Table 2 Indications for EPH

Ruptured   Uterine   Abnormal       Others-Ut
uterus     atony     placentation   Inversion

38/72      20/72     11/72          03/72

Table 3: Year wise distribution of number of cases and incidence
of EPH

Year        No of     No of            Incidence of EPH
            cases   deliveries

2008         14       16695      0.8/1000 deliveries (0.08%)
2009         11       18431      0.59/1000 deliveries (0.059%)
2010         11       18799      0.58/1000 deliveries (0.058%)
2011         20       19941      1.00/1000 deliveries (0.100%)
2012         16       20410      0.78/1000 deliveries (0.07%)
2008-2012    72       94276      0.76/1000 deliveries (0.076%)

Table 4: Maternal morbidity, postoperative
complications and maternal mortality.

Re-laparotomy for hemoperitoneum   5
DIC                                6
Acute renal failure                4
Infection                          5
ITU admission                      20
Maternal death                     8

Table 5: Comparative study of peripartum hysterectomy
at BSMCH (5 year study)

Authors                   Praneshwari      Marwaha
                        Devi et al 2004   et al 2008
                             2004

Incidence                    0.07%          0.31%
Rupture uterus                23%            60%
Atonic placenta PPH         19.20%           10%
Abnormal placentation        26.9%           20%

Authors                 Sahasrabojanee      Kumari     Present study
                          et al 2008      et al 2009     2008-2012

Incidence                    0.35%          0.73%         0.076%
Rupture uterus               26.6%           75%           52.7%
Atonic placenta PPH          33.3%          8.03%          27.7%
Abnormal placentation         10%           8.03%          15.2%

Fig. 3: Mean gestational age at delivery

37wks   10

38wks   36

39wks   20

40wks    4

41wks    2

Fig 4: Mode of delivery: For cases who underwent Peripartum
Hysterectomy

Caesarean section   Normal delivery   Operative vaginal delivery

53                  17                2

Fig 5: Mode of Delivery cases who underwent EPS

Rupture   Uterine   Abnormal       Others-Ut
Uterus    atony     placentation   Inversion

38        20        11             3

Fig 7: Causes of ruptured uterus

Post cs ruptured uterus      22
Rupture due to other cause   16
COPYRIGHT 2013 Akshantala Enterprises Private Limited
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2013 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:ORIGINAL ARTICLE
Author:Deb, Debjani; Ghosh, Utpal; Dasgupta, Anirban; Mondal, Sumanta Kumar; Dasgupta, Subhendu; Das, Anind
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Sep 16, 2013
Words:2109
Previous Article:Incidence of urogenital infections in preterm labour and premature rupture of membranes.
Next Article:Naturopathy system--a complimentary and alternative aid in dentistry--a review.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters