Maternal Morbidity - OB Hysterectomy Resources

OBJECTIVE: This investigation aimed to identify pregnancy complications and risk factors for women who experienced severe maternal morbidity during the delivery hospitalization and to estimate severe maternal morbidity rates. STUDY DESIGN: We used the National Hospital Discharge Survey for 1991-2003 to identify delivery hospitalizations with maternal diagnoses and procedures that indicated a potentially life-threatening diagnosis or life-saving procedure. RESULTS: For 1991-2003, the severe maternal morbidity rate in the United States was 5.1 per 1000 deliveries. Most women who were classified as having severe morbidity had an ICD-9-CM code for transfusion, hysterectomy, or eclampsia. Severe morbidity was more common at the extremes of reproductive age and for black women, compared with white women. CONCLUSION: Severe maternal morbidity is 50 times more common than maternal death. Understanding these experiences of these women potentially could modify the delivery of care in healthcare institutions and influence maternal health policy at the state and national level.

BACKGROUND: All cases of obstetric hysterectomies that were performed in our hospital during a seven-year study period were reviewed in order to evaluate the incidence, indications, risk factors, and complications associated with emergency obstetric hysterectomy.
METHODS: Medical records of 45 patients who had undergone emergency hysterectomy were scrutinized and evaluated retrospectively. Maternal age, parity, gestational age, indication for hysterectomy, the type of operation performed, estimated blood loss, amount of blood transfused, complications, and hospitalization period were noted and evaluated. The main outcome measures were the factors associated with obstetric hysterectomy as well as the indications for the procedure.
RESULTS: During the study period there were 32,338 deliveries and 9,601 of them (29.7%) were by cesarean section. In this period, 45 emergency hysterectomies were performed, with an incidence of 1 in 2,526 vaginal deliveries and 1 in 267 cesarean sections. All of them were due to massive postpartum hemorrhage. The most common underlying pathologies was placenta accreta (51.1%) and placenta previa (26.7%). There was no maternal mortality.
CONCLUSIONS: Obstetric hysterectomy is a necessary life-saving procedure. Abnormal placentation is the leading cause of emergency hysterectomy when obstetric practice is characterized by a high cesarean section rate. Therefore, every attempt should be made to reduce the cesarean section rate by performing this procedure only for valid clinical indications

OBJECTIVES: The purpose of this study was to evaluate the incidence, risk factors, indications, outcomes, and complications of emergency hysterectomy performed after cesarean deliveries (cesarean hysterectomy) and vaginal deliveries (postpartum hysterectomy).
STUDY DESIGN: We conducted a retrospective cohort study from 1990 to 2002 of patients who had peripartum hysterectomies at a single tertiary hospital. Comparisons were made between cesarean and postpartum hysterectomies.
RESULTS: There were 55 cases of emergency peripartum hysterectomy (38 cesarean hysterectomies, and 17 postpartum hysterectomies), for a rate of 0.8 per 1000 deliveries. Overall, the most common indication for hysterectomy was uterine atony (56.4%), followed by placenta accreta (20.0%). Average estimated blood loss was 3325.6+/-1839.2 mL, average operating time was 157.1+/-75.4 minutes, average time from delivery to completing the hysterectomy was 333.8+/-275.7 minutes, and the average length of hospitalization was 11.0+/-7.9 days. The cesarean delivery rate at Grady Memorial Hospital during the study period was 14.2%. There were no statistically significant differences between variables examined when comparisons were made by cesarean vs postpartum hysterectomy.
CONCLUSION: Uterine atony is the leading indication for emergency hysterectomy performed following cesarean and vaginal deliveries.

OBJECTIVE: To estimate the rate of peripartum hysterectomy over the last 8 years in Calgary, the primary indication for peripartum hysterectomy (defined as any hysterectomy performed within 24 hours of a delivery), and whether there was an increase in the rate of peripartum hysterectomy during that time.
METHOD: Detailed chart review of all cases of peripartum hysterectomy, 1999-2006, including previous obstetric history, details of the index pregnancy, indications for peripartum hysterectomy, outcome of the hysterectomy, and infant morbidity.
RESULTS: The overall rate of peripartum hysterectomy was 87 of 108,154 or 0.8 per 1,000 deliveries. The primary indications for hysterectomy were uterine atony (32 of 87, 37%) and suspected placenta accreta (29 of 87, 33%). After hysterectomy, 46 (53%) women were admitted to the intensive care unit. Women were discharged home after a mean 6-day length of stay. The rate of peripartum hysterectomy did not appear to increase over time.
CONCLUSION: Our population-based study found that abnormal placentation is the main indication for peripartum hysterectomy. The most important step in prevention of major postpartum hemorrhage is recognizing and assessing women's risk, although even perfect management of hemorrhage cannot always prevent surgery.
LEVEL OF EVIDENCE: III.

Objectives: To identify women undergoing peripartum hysterectomy in the UK and to describe the causes, management and outcome of the associated haemorrhage. Design: A population-based descriptive study using the UK Obstetric Surveillance System (UKOSS). Setting: All 229 hospitals with consultant-led maternity units in the UK. Population: All women in the UK delivering between February 2005 and February 2006. Methods: Prospective case identification through the UKOSS monthly mailing. Main outcome measures: Rates with 95% CIs. Odds ratio estimates. Results: Three hundred and eighteen women underwent peripartum hysterectomy. The most commonly reported causes of haemorrhage were uterine atony (53%) and morbidly adherent placenta (39%). Women were not universally managed with uterotonic therapies. Fifty women were unsuccessfully managed with B-Lynch or other brace suture prior to hysterectomy, 28 with activated factor VII and 9 with arterial embolisation. Twenty-one percent of women suffered damage to other structures, 20% required a further operation and 19% were reported to have additional severe morbidity. Bladder damage was more likely in women with placenta accreta (OR 3.41, 95% CI 1.55–7.48) than in women with uterine atony. There were no significant differences in outcomes between women undergoing total or subtotal hysterectomy. Two women died; case fatality 0.6% (95% CI 0–1.5%). Conclusions: For each woman who dies in the UK following peripartum hysterectomy, more than 150 survive. The associated haemorrhage is managed in a variety of ways and not universally according to existing guidelines. Further investigation of the outcomes following some of the more innovative therapies for control of haemorrhage is needed.

OBJECTIVE: The objective was to investigate the incidence, indications, and risk factors of peripartum emergent hysterectomy.
METHOD: Fifty-nine cases of emergent peripartum hysterectomy performed at Zeynep Kamil Women and Children's Education and Research Hospital during a 13-year period between January 1990 and January 2003 were evaluated retrospectively. Emergent peripartum hysterectomy was defined as that performed for haemorrhage unresponsive to other therapeutic interventions within the first 24 h of delivery.
RESULT: Emergent peripartum hysterectomy was performed in 59 cases of 234,958 women (25.1/100,000). Total and subtotal hysterectomy was performed in 25 and 34 cases respectively. The rates of emergent peripartum hysterectomy after vaginal and caesarean deliveries were 8.7/100,000 and 104.5/100,000 respectively. Uterine atony was the most frequent indication (62.7%). The rates of emergent peripartum hysterectomy due to uterine atony in primiparous and multiparous women were 61.1 and 65.2% respectively. The rate of maternal mortality was 8% (5 cases).
CONCLUSION: Uterine atony was the most common indication for emergent peripartum hysterectomy.

Over the past 25 years, 43 peripartum hysterectomies were performed at the authors' institution, an incidence of 0.64/1,000 deliveries; 31 procedures followed caesarean section and 12 were performed for haemorrhage following vaginal delivery. The common indications for hysterectomy were abnormal placentation (39.5%), uterine atony (23.3%), uterine rupture (23.3%), and haemorrhage during caesarean section (11.6%). The risk factors for hysterectomy included advancing maternal age and parity, previous caesarean section scars and abnormal placentation. Subtotal hysterectomy was performed in 72.1% cases which appeared a quicker and safer procedure than total hysterectomy in desperately ill patients. Five (11.6%) maternal deaths occurred in the series. Mortality was associated with massive haemorrhage. With rising caesarean section rates worldwide, MRI and colour Doppler sonography is useful to diagnose antepartum placenta accreta/bladder involvement in order to plan elective surgery that is associated with reduced maternal morbidity and mortality. Early decision to perform an emergency hysterectomy is essential before the patient's condition deteriorates, besides availability of an experienced obstetrician to undertake a technically demanding operation.

A retrospective case-review of 52 mothers who had a peripartum hysterectomy over the past 27 years was conducted at the Rotunda hospital, Dublin, Ireland. The chief indications were uncontrollable haemorrhage due to rupture of the uterus, placenta praevia and uterine atony. Obstetric hysterectomy is a formidable operation, usually performed as a life-saving measure and requires expert surgical dexterity in order to minimise the significant morbidity. The benefits of the subtotal operation appear to be superior to those of total hysterectomy. Counselling patients having a caesarean section regarding the possibility of hysterectomy is advisable in those who have had previous uterine surgery, multiple caesarean sections or placenta praevia.

OBJECTIVE: Most studies of peripartum hysterectomy are conducted in single institutions, limiting the ability to provide national incidence estimates and examine risk factors. The objective of this study was to provide a national estimate of the incidence of peripartum hysterectomy and to examine factors associated with the procedure.
METHODS: We used data for 1998-2003 from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, an annual nationally representative survey of inpatient hospitalizations. Peripartum hysterectomy was defined as a hysterectomy and delivery occurring during the same hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for maternal and hospital characteristics using logistic regression.
RESULTS: During 1998-2003, an estimated 18,339 peripartum hysterectomies occurred in the United States (0.77 per 1,000 deliveries). Compared with vaginal delivery without a previous cesarean delivery, the ORs of peripartum hysterectomy for other delivery types were as follows: repeat cesarean, 8.90 (95% CI 8.09-9.79); primary cesarean, 6.54 (95% CI 5.95-7.18); and vaginal birth after cesarean, 2.70 (95% CI 2.23-3.26). Multiple births were associated with an increased risk compared with singleton births (OR 1.41, 95% CI 1.16-1.71).
CONCLUSION: Our results suggest that vaginal birth after cesarean, primary and repeat cesarean deliveries, and multiple births are independently associated with an increased risk for peripartum hysterectomy. These findings may be of concern, given the increasing rate of both cesarean deliveries and multiple births in the United States.
LEVEL OF EVIDENCE: III.

OBJECTIVE: To determine the incidence, indications, risk factors, and complications of emergency peripartum hysterectomy.
STUDY DESIGN: A retrospective study of the patients requiring an emergency peripartum hysterectomy of a 9-year period was conducted. Emergency peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment less than 24 h after delivery. Demographic and clinical variables were obtained from the maternal records.
RESULTS: There were 34 emergency peripartum hysterectomies out of 117,095 deliveries for a rate of 0.29 per 1,000. Of the 16 cases that were delivered by cesarean section, seven had a previous cesarean section and 18 cases were delivered vaginally, including two using vacuum extraction. Total hysterectomy was performed in 24 patients, and subtotal hysterectomy in ten patients. The indications for hysterectomy were uterine rupture (n=12), placenta accreta (n=10), uterine atony (n=7), and hemorrhage (n=5). There were two maternal deaths, six stillbirths, and two early neonatal deaths.
CONCLUSION: This study identified surgical deliveries, uterine rupture, placenta accreta, and uterine atony as risk factors for emergency peripartum hysterectomy. The most common reason for abnormal placental adherence was a previous cesarean section. Multiparity and oxytocin use for uterine stimulation were among the risk factors for uterine atony that necessitated emergency peripartum hysterectomy.

My focus is on post partum hemorrhage (PPH) and emergency hysterectomy (this is commonly called “the ordeal” by the women who have experienced it) is driven by a desire to understand several interwoven questions, 1) what takes place during the ordeal and how embodied knowledge is disjointed and ruptured, 2) how women recreate embodied wholeness through narrative and defining the ordeal, and 3) how women create healing and resiliency through collective empathy and a redefine family through various means. PPH often results in death or near death experiences as a result of various complications brought on from hemorrhaging.