Original Investigation
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Changing trends in emergency peripartum hysterectomy in a tertiary obstetric center in Turkey during 2000–2013 Osman Temizkan1, Doğukan Angın2, Resul Karakuş2, İlhan Şanverdi2, Mesut Polat2, Ateş Karateke2 1 Department of Obstetrics and Gynecology, Şişli Etfal Training and Research Hospital, İstanbul, Turkey 2 Department of Obstetrics and Gynecology, Zeynep Kamil Women and Children’s Training and Research Hospital, İstanbul, Turkey
Abstract Objective: To evaluate emergency peripartum hysterectomy (EPH) cases over a 14-year period in a tertiary center in İstanbul, Turkey. Material and Methods: In this retrospective descriptive study, the records of all cases of EPH performed at the Zeynep Kamil Women and Children’s Training and Research Hospital between January 2000 and January 2014 were analyzed. Results for 2000–2006 and 2007–2013 were compared to identify changing trends. Demographic and clinical factors associated with EPH were assessed. Results: During the 14-year study period, a total of 161,836 births occurred, out of which 104,783 (64.8%) were vaginal deliveries and 57,053 (35.2%) were cesarean section (CS). EPH was performed in 81 patients with an overall incidence of 0.5 in 1000 deliveries. The EPH rate in 2007–2013 (0.07%) was significantly higher than in 2000–2006 (0.03%). The major difference in the EPH populations between the two periods was the higher number of previous CS in 2007–2013 compared with 2000–2006 (p=0.01). Indications for EPH did not differ between the two periods. There were 7 (8.6%) maternal deaths in 2000–2013, with significantly fewer maternal deaths in 2007–2013 than in 2000–2006 (19.2% vs. 3.6%). Conclusion: Rate of EPH increased considerably from 2000 to 2013. This increase was mostly related to the increasing rate of CS. Indications for EPH did not change over the study period, and the number of maternal deaths markedly decreased. (J Turk Ger Gynecol Assoc 2016; 17: 26-34) Keywords: Postpartum hemorrhage, placenta accreta, emergency peripartum hysterectomy, trend
Received: 26 November, 2015
Accepted: 18 January, 2016
Introduction Emergency peripartum hysterectomy (EPH) is performed as a life-saving procedure in cases of intractable obstetric hemorrhage secondary to uterine atony, uterine rupture, placental disorders, fibroids, and lacerations during cesarean section (CS) or vaginal parturition (1). Postpartum hemorrhage is a leading cause of maternal morbidity and mortality (2-4). The incidence of EPH varies from 0.2–1.6 per 1000 deliveries per year in developed countries, with a higher incidence in developing countries (5-7). Indications for peripartum hysterectomy have changed throughout the years. In developing countries, uterine atony and uterine rupture are the most common indications for EPH, but in developed countries, abnormal placental invasion is the most common indication (1, 7). In particular, the increasing rate of cesarean delivery worldwide has been associated with an increasing rate of placenta previa and accreta (8). The incidence of EPH reported in previous studies from
Turkey varies between 0.25 and 5.3 per 1000 deliveries (9-12). This wide variation is probably a result of differences in population characteristics and the availability of health services among regions in Turkey. During the past decade, the practice of obstetrics has changed and the rate of cesarean delivery has increased nationwide. The aim of the present study was to review EPHs performed over a 14-year period at a tertiary care center and to determine trends in EPH by comparing two different time periods.
Material and Methods In this retrospective descriptive study, the records of all cases of EPH performed at Zeynep Kamil Women and Children’s Training and Research Hospital, between January 2000 and January 2014, were analyzed. The study was approved by the Institutional Ethics Committee. All participants’ rights were protected, and informed consents were obtained according to the Helsinki Declaration.
Address for Correspondence: Osman Temizkan e.mail:
[email protected] ©Copyright 2016 by the Turkish-German Gynecological Education and Research Foundation - Available online at www.jtgga.org DOI: 10.5152/jtgga.2015.16239
Temizkan et al. Trends in emergency peripartum hysterectomy
J Turk Ger Gynecol Assoc 2016; 17: 26-34
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Table 1. Maternal and delivery characteristics of cases of emergency peripartum hysterectomy during 2000–2006 and 2007–2013 Characteristics Age (years)
2000–2006 (n=26)
2007–2013 (n=55)
p
32.8±5.1
33.4±5.6
0.55
18–25
2 (7.7%)
4 (7.3%)
26–35
17 (65.4%)
35 (63.6%)
36–40≥
7 (26.9%)
16 (29.1%)
Gravidity 3≥ Parity
3.4±1.8
3.5±1.3
0.65
19 (73.1%)
46 (83.6%)
0.26 0.65
1.9±0.9
2.0±1.1
2 (7.7%)
3 (5.5%)
1
7 (26.9%)
14 (25.5%)
2≥
17 (65.4%)
38 (69.1%)
0
0.74
Prior dilatation and curettage
4 (15.4%)
7 (12.7%)
0.35
Prior abortion
4 (15.4%)
12 (21.8%)
0.29
0.9±0.8
1.5±0.9
0.01
1
8 (30.8%)
16 (29.1%)
2
8 (30.8%)
23 (41.8%)
Previous CS in EPH population
3≥
0
7 (8.6%)
33.9±4.7
35.3±4.3
24–32
9 (34.6%)
13 (23.6%)
33–37
10 (38.5%)
25 (45.5%)
38–42
7 (26.9%)
17 (30.9%)
Gestational age (weeks)
Birthweight (g)
2571±937
2616±957
11 (42.3%)
20 (36.4%)
2500–3999
13 (50%)
34 (61.8%)
4000≥
2 (7.7%)
1 (1.8%)
Vertex
20 (76.9%)
44 (80%)
Breech
3 (11.5%)
9 (16.4%)
Transverse
3 (11.5%)
2 (3.6%)
3 (11.6 %)
6 (10.9%)
0
1 (1.8%)
