Journal of Obstetrics and Gynaecology (June 2004) Vol. 24, No. 4, 372–373
OBSTETRICS
Emergency peripartum hysterectomy in a Nigerian hospital: a 20-year review O. C. EZECHI, B. K. E. KALU, F. O. NJOKANMA, C. A. NWOKORO and G. C. E. OKEKE
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Havana Specialist Hospital, Surulere, Lagos, Nigeria
Summary Postpartum haemorrhage is a major cause of maternal morbidity and mortality and occasionally severe enough to warrant hysterectomy to prevent maternal death. Hysterectomy often is fraught with danger and regular audit is necessary to assist in the reduction of these dangers. A 20-year audit of all emergency peripartum hysterectomies, performed at Havana Specialist hospital Lagos, Nigeria, is reported. Of the 6599 deliveries and peripartum referrals seen during the period, 22 had an emergency hysterectomy as a result of severe postpartum haemorrhage (0.33%). The aetiological factors associated with the postpartum haemorrhage included uterine atony (45.5%), placenta praevia (27.3%), pathologically adherent placenta (18.2%) and ruptured uterus (9.1%). The majority of the procedures were subtotal hysterectomy (81.8%) and the mean operative time was significantly shorter than for total hysterectomy (P 5 0.05). The postoperative complications included postoperative anaemia (28.6%), febrile morbidity (36.9%), wound infection (19.0%) and urinary tract infection (9.5%), together with three maternal deaths. In conclusion, emergency peripartum hysterectomy, although life-saving, is associated with severe morbidity and mortality and subtotal hysterectomy is usually the operation of choice.
Methods This was a retrospective review of all cases of emergency obstetric hyststerectomy performed at Havana Specialist Hospital over a 20-year period (January 1983 to January 2003). Havana Specialist Hospital Lagos (HSH) is a multidisciplinary proprietary hospital situated in the cosmopolitan city of Lagos, Nigeria. Most of the patients are drawn from the upper socio-economic stratum, but patients from low economic groups are not discriminated against specifically; rather, the relatively high hospital charges reduces their patronage. Patients who had an emergency peripartum hysterectomy were identified from the theatre operation notes and their records retrieved from the medical records library. The case files were reviewed carefully and information on age, parity, gestational age at delivery, indication and type of hysterectomy, intra-operative and postoperative complication was extracted. The collected data were fed into an IBM-compatible PC using SPSS version 10.0 for Windows for analysis.
Introduction Emergency peripartum hysterectomy for obstetric haemorrhage is usually the last resort to save the life of a woman (Ogunniyi and Essen, 1990; Ozumba and Mbagwu, 1991; Sinha and De, 1993; Chew and Biswas, 1997; Kore et al., 2001). In no other obstetric surgery is the surgeon in such a dilemma as when deciding to resort to hysterectomy especially in women of low parity (Kore et al., 2001). There is usually a conflict between the removal of the uterus to save the woman’s life and preservation of her future fertility. Many of the operations are performed when the condition of the patient has deteriorated and has become too critical to withstand anaesthesia and the trauma of surgery (Ogunniyi and Essen, 1990; Chew and Biswas, 1997; Kore et al., 2001). Thus maternal outcome depends greatly on a timely decision to perform this procedure (Ogunniyi and Essen, 1990; Sinha and De, 1993; Kore et al., 2001). The purpose of this report is to review all peripartum hysterectomies performed at Havana Specialist Hospital between 1983 and 2002, looking specifically at the morbidity and mortality associated with the surgery, and to suggest how to reduce them in future.
Results During the 20 years of study there were 6599 deliveries and 22 emergency obstetric hysterectomies. The incidence of emergency obstetric hysterectomy was 0.33%. Sixteen were for booked patients (72.7%) and only six were for unbooked patients (27.3%). All the hysterectomies were undertaken for uncontrollable postpartum haemorrhage: 14 (63.6%) followed caesarean section, six (27.3%) and two (9.1%) were following vaginal delivery and ruptured uterus, respectively. The mean maternal age of these patients was 32.6 + 5.3 (range 22 – 40 years). There were four primigravidae (18.2%), while 81.8% were parous. The modal parity was 3 (range 1 – 6). The mean gestational age at delivery among these patients was 38.1 + 1.7 (range 34 – 41weeks). The indication for caesarean section in the 14 patients who delivered by caesarean section included placenta praevia in five (35.7%), failed induction of labour in one (7.1%), previous caesarean section in five (35.7%), prolonged labour in two (14.3%) and malpresentation in one (7.1%). The aetiological factors associated with
Correspondence to: Dr Oliver C. Ezechi, Department of Obstetrics and Gynaecology, Havana Specialist hospital, 115 Akerele Extension, PO Box 488, Surulere, Lagos, Nigeria. E-mail:
[email protected] ISSN 0144-3615 print/ISSN 1364-6893 online/04/040372-02 # Taylor & Francis Limited, 2004 DOI: 10.1080/01443610410001685466
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Emergency peripartum hysterectomy postpartum haemorrhage in these patients included uterine atony (68.2%), pathologically adherent placenta (22.7%) and ruptured uterus (9.1%). Subtotal hysterectomy was performed in 18 (77.3%) cases and total hysterectomy in four (22.7%). The mean operation time was 141.8 + 39.8 (range 86 – 202 minutes). The mean operation time for subtotal hysterectomy (101.8 + 24.5 minutes) was significantly less than 187.0 + 42.6 minutes for total hysterectomy (P = 0.042). The mean blood loss for total hysterectomy, 5985.0 + 2094.2 ml was significantly higher than the blood loss during subtotal hysterectomy, 2010.0 + 1000.9 ml (P = 0.0042). Ancillary procedures performed to control haemorrhage before hysterectomy included manual compression in all the patients, uterine packing in nine (40.9%), intramyometrial oxytocic in seven (31.8%) and ligation of the uterine artery in four (18.2) patients. The complications among these patients included postoperative anaemia (31.8%), disseminated intravascular coagulopathy (13.6%), wound infection (18.2%), febrile morbidity (36.4%) and urinary tract infection (13.6%). All the patients required blood transfusion. The mean volume of blood transfused was 4865.0 + 2095.87 (range 2700.0 – 9450.0). Three maternal deaths occurred, giving a case fatality rate of 13.6%. The causes of maternal deaths were irreversible hypovolaemic shock with disseminated intravascular coagulopathy in all three cases. The three deaths occurred within 12 hours of hysterectomy. The deaths were in patients with ruptured uterus, placenta accreta and prolonged uterine atony. The mean total hospital stay for the 19 surviving cases were 9.9 + 2.7 days (range 7 – 17days).
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postpartum haemorrhage due to uterine atony, placenta praevia, placenta accreta were the most common indications for emergency hysterectomy, but in contrast to reports from our environment where ruptured uterus was the leading cause (Ogunniyi and Essen, 1990; Ozumba and Mbagwu, 1991). Our institution is a private specialist hospital and tends to see patients of high socio-economic status and thus has very few ruptured uteri. Ruptured uterus has been described as a disease of the poor. The estimated blood loss associated with emergency hysterectomy varies in different reports. In our series the mean operative blood loss was 4865 ml. This is more than the 3575 ml reported by Clark et al. (1984). The difference might be due to observer error because both volumes were by visual estimation. Kore and colleagues (Kore et al., 2001), in their series, report a subtotal : total hysterectomy ratio of 6.2 : 3.8. In our study it was 8.2 : 1.8. Unlike in Clark’s (1984) report, there was a statistically significant difference between subtotal and total hysterectomy in terms of estimated blood loss and operation time. Chew’s report (Chew and Biswas, 1997) was in agreement with our report of shorter duration of surgery but not in blood loss. Although this procedure is life-saving, the complication associated with it should not be underestimated. The case fatality rate of 13.6% in our report is testimony to this. Other complications reported in our study are similar to others (Clark et al., 1984; Ogunniyi and Essen, 1990; Ozumba and Mbagwu, 1991). In conclusion, although emergency peripartum hysterectomy is associated with severe morbidity and mortality, it remains a potential life-saving procedure such that any doctor performing caesarean section must be familiar with it.
Discussion The incidence of emergency peripartum hysterectomy of 0.32% in our series is comparable to the report by Chew and colleague in Singapore (Chew and Biswas, 1997), but much higher than previous reports by Ogunniyi et al. (1990) and Ozumba et al. (1991) from Ife and Enugu, Nigeria. The difference may be due to fewer deliveries taking place in our hospital compared with the two Nigerian centers, or possibly many of the women that may have benefited from hysterectomy may have died before surgery. It has already been shown that phase three delay is a major cause of morbidity and mortality in patients with a ruptured uterus (Orji et al., 2002). The age of women requiring peripartum hysterectomy varies in different reports (Ogunniyi and Essen, 1990; Ozumba and Mbagwu, 1991; Sinha and De, 1993; Chew and Biswas, 1997). While Gupta and Ganesh (1994) reported an average below 30 years and Clark et al. (1984) an average age of 30 years, in our series 68.2% were aged over 30 years with a mean of 32.6 years. This probably reflects the difference in the mean age of obstetric population at the different centres. In our series, although the majority (81.8%) of our patients were parous women, three patients (18.2%) were primigravida. This finding is similar to that of Clark et al. (1984), but in contrast to Gupta’s report where only three grandimultiparous patients who presented with ruptured uterus were reported (Gupta and Ganesh, 1994). Our report is in agreement with previous studies by Clark et al. (1984) and Chew and Biswas (1997), where
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