Emergency peripartum hysterectomy: a 5 year retrospective analysis in a peripheral medical college in Eastern India.
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 .
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Debjani Deb , Utpal Ghosh , Anirban Dasgupta , Sumanta Kumar Mondal , Subhendu Dasgupta , Anindya Kumar Das 
[1.] Debjani Deb
[2.] Utpal Ghosh
[3.] Anirban Dasgupta
[4.] Sumanta Kumar Mondal
[5.] Subhendu Dasgupta
[6.] Anindya Kumar Das
PARTICULARS OF CONTRIBUTORS:
. Assistant Professor, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College, West-Bengal, India.
. Post Graduate Trainee, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College, West-Bengal, India.
. Senior Resident, Department of Obstetrics and Gynecology, JIPMER.
. RMO Cum Clinical Tutor, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College, West-Bengal, India.
. Professor and HOD, Department of Obstetrics and Gynecology, Bankura Sammilani Medical College, West-Bengal, India.
. 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.
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
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|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|
|Date:||Sep 16, 2013|
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