Department of Obstetrics and Gynaecology, Armed Forces Hospital, Riyadh, Kingdom of ... remove causing bleeding and necessitating hysterectomy.
Journal of Obstetrics and Gynaecology
(1998 ) Vol. 18, No. 6, 533± 537
OBSTETRICS
Emergency peripartum hysterectomy R. M ESLEH, H. AYOUB, A. ALGW ISER and A. KURDI Department of Obstetrics and Gynaecology, Saudi Arabia
Summary A total of 54 166 mothers delivered at the Riyadh Armed Forces Hospital between 1990 and 1997, including 6119 (11´3%) caesarean sections. Emergency peripartum hysterectomy for obstetric haemorrhage was carried out in 16 cases (0´3/1000 deliveries). The operation followed major degrees of placenta praevia in 12 (75%) cases and atonic postpartum haemorrhage in four (25% ). All patients required blood transfusion. There was one neonatal death and no maternal deaths. Although the operation was straightforward, bladder injury occurred in ® ve (31%) cases which was repaired with no residual damage. Placenta accreta was con® rmed histologically in 12 (75%) patients. In conclusion, all obstetricians should be aware of the strong association between a scarred uterus, placenta praevia and placenta accreta which can be very adherent and dif® cult to remove causing bleeding and necessitating hysterectomy. The operation should be performed by an experienced obstetrician before the patient’ s condition is extreme.
Introduction
The ® rst documented hysterectomy on a live patient at the time of delivery was performed in the United States by Horatio Storer in 1866 (Plauche, 1988, Eltabbakh and Watson, 1995) and reported in 1869 (Park and Duff, 1980). Although the uterus was removed successfully, the patient died on the third day after surgery (Park and Duff, 1980). Seven years later Eduardo Porro of Milan described the ® rst caesarean hysterectomy in which both infant and mother survived (Park and Duff, 1980). The operation was performed in July 1871 (Plauche, 1988), and details were published in 1876 (Park and Duff, 1980). Within several months of Porro’ s report more and more cases were reported with modi® cations of Porro’ s technique. The operation was originally devised as a surgical attempt to manage life-threatening obstetric haemorrhage and uterine sepsis (amnionitis) after prolonged labour (Haynes and Martin, 1979; Plauche, 1986; Thonet, 1986). By the 1950s it was being undertaken as an elective procedure for minor indications such as sterilisation (Thonet, 1986), then fell into disrepute due to the association of this procedure with excessive blood loss and the risk of urological injury. Advances in blood transfusion and the use of blood products to correct coagulopathy as well as advances in the conservative treatment of uterine atony (e.g. prostaglandins) have greatly reduced the need for hysterectomy in cases of uterine atony and severe placental abruption. Abnormal placental adherence
Armed Forces Hospital, Riyadh, Kingdom of
(placenta accreta, per-creta or increta) is emerging as a major indication for postpartum hysterectomy. The aim of this retrospective case record analysis was to record our experience with emergency peripartum hysterectomy at the Riyadh Armed Forces Hospital (RAFH), Riyadh, over the past 8 years and discuss its place in modern obstetric practice. Subjects and methods
We analysed retrospectively the hospital records of 16 women who underwent peripartum hysterectomy at the Riyadh Armed Forces Hospital, Riyadh between January 1990 and December 1997 inclusive. Labour and delivery records were collected manually from each patient’ s chart. The cases were examined and analysed regarding maternal parameters including age, parity, previous caesarean section, estimated blood loss, blood transfusion, the indications for and complications of peripartum hysterectomy and maternal morbidity and mortality. All operations were carried out by or under direct supervision of senior members of staff, after being seen and assessed by the consultants who will only decide whether to proceed to hysterectomy when conservative measures in the form of curetting and suturing of placental bed, the use of intravenous oxytocics and intramural prostaglandins and applying a uterine pack, have failed. All cases were performed as an emergency for life-threatening bleeding at the time of caesarean section or in the immediate postpartum period. All caesarean sections and hysterectomies described were performed after 24 weeks’ gestation. Histological reports were obtained and documented evidence of placenta accreta was recorded. Evidence of intra-operative complications and the occurrence of surgical mishaps were obtained from the operative record. Intra-operative and postoperative blood loss and blood transfusions were also recorded. Maternal outcome was evaluated by the length of hospital stay and postoperative morbidity as identi® ed by the treating physician. Prophylactic antibiotics were administered in all cases and continued at the discretion of the treating physician. Results
During the 8-year study period, there were 54 166 mothers delivered of infants weighing 500 grams or over at the RAFH, Riyadh, including 6119 caesarean sections (11´3% caesarean section rate). There were
Correspondence to: Dr. R. Mesleh, C125 Armed Forces Hospital, P.O. Box 7897, Riyadh 11159, Kingdom of Saudi Arabia. 0144-3615/98/060533-05 $9.50 ã
Institut e of Obstetrics and Gynaecology Trust, 1998
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R. Mesleh et al.
Table I. Details of peripartal hysterectomy, patients and outcome Placenta previa (grade)
Blood loss (ml)
Transfusion (units )
2
IV
7000
13
Gestation (weeks)/ birth weigh (g)/ outcome
Histology
Maternal morbidity
Hospital stay (days)
37 3010 alive
accreta
reopened
13
No.
Age
1
43
11 1
2
35
31
2
3
IV
3000
3
38 1 3300 alive
accreta
3
32
41
4
3
IV
3000
7
35 1950 alive
normal placental bed
4
34
51
1
5
IV
5000
14
36 2570 alive
remnants of placenta
5
25
11
0
1
IV
6000
10
24 700 NND
accreta
bladder injury low grade pyrexia
15
6
26
51
0
2
IV
2000
6
37 2500 alive
accreta
reopened
6
7
34
61
0
2
anterior placenta
1500
6
30 1340 alive
accreta
bladder injury (pyrexia) haematoma
16
8
36
51
1
2
IV
3000
7
35 2780 alive
accreta
9
35
41
2
3
IV
2000
6
33 2150 alive
placenta accreta increta
10
36
31
1
3
IV
3000
6
35 1 2150 alive
accreta
11
50
15 1
±
anterior placenta
3000
5
39 3150 alive
normal
12
12
21
21
1
±
anterior placenta
5000
12
41 3581 alive
normal
7
13
40
61
3
2
II
9000
13
38 3030 alive
accreta
reopened
8
14
30
61
3
2
III
4000
14
38 2360 alive
accreta
bladder injury
22
15
28
31
2
2
anterior placenta
1000
2
38 3600 alive
normal
reopened
6
16
31
31
2
2
IV
2000
4
37 3030 alive
accreta
CS 5
Parity
Previous CS
0
2
caesarean section; NND 5
6 reopened wound haematoma
15
9
Bladder injury
16
burst abdomen resutured
21
bladder injury Haematoma Pyrexia
16
7
neonatal death.
16 cases of peripartum hysterectomy (Table I), giving a prevalence for obstetric hysterectomy of 1 in 3385 deliveries (0´3/1000 deliveries) or 2´3/1000 abdominal deliveries. There were no maternal deaths related to the procedure. All infants except one survived. The neonatal death weighed 700 grams at 24 weeks of pregnancy. The mother had low lying placenta completely covering the internal os. The antepartum bleeding was so heavy that it warranted emergency laparotomy. The placenta was very adherent, removed in pieces, bleeding was heavy and failed to respond to conservative measures and total hysterectomy was completed. The patient received 10 units of blood, 14 units of fresh frozen plasma and 6 units
of platelets. The bladder was accidentally opened and repaired. She stayed in hospital for 15 days. Fifteen cases received more than 2 units of blood. None of the cases was performed as an elective peripartum hysterectomy for gynaecological indications. One patient had one, eight patients had two, four had three and one had ® ve previous caesarean sections (14/16 had a previous abdominal delivery). The uterus was unscarred in only two cases. One woman was 24 weeks pregnant, and 13 were over 35 weeks’ gestation. The indications were adherent placenta praevia in 12 and atonic postpartum haemorrhage not responding to the conventional methods of conservative treatment in four cases. Histological evi-
Emergency peripartum hysterectomy
535
Table II. Peripartum characteristics of all cases of peripartal hysterectomy Hysterectomy indications Abnormal placenta
All subjects Blood loss , 3000 ml . 3000 ml Type of hysterectomy Total Subtotal General anaesthesia Mode of delivery Normal Caesarean
%
n
%
n
%
12
100
4
100
16
100
3 9
25 75
2 2
50 50
5 11
31 69
6 6 12
50 50 100
1 3 4
25 75 100
7 9 16
44 56 100
0 12
0 87
2 2
50 50
2 14
13 87
Table III. Complications associated with emergency peripartal hysterectomy
Febrile morbidity Re-exploration due to haemorrhage W ound infection/dehiscence Hospital stay over 7 days Blood transfusion over 2 units Bladder injury
All subjects
n
dence of placenta praevia accreta was evident in 11 cases, increta in one and normal placental bed in another four cases. During the study period there were 24 cases of uterine rupture which was treated by repair and none required hysterectomy. The highest incidence was in patients aged 40 years or over and grande multiparous women (para 10 and over). As parity goes up, so does age. Table II shows the characteristics of the 16 cases of peripartum hysterectomy. Eleven patients had a blood loss over 3000 ml. Nine had sub-total hysterectomy and in seven cases total hysterectomy was performed. General anaesthesia was given in all cases. Table III shows the complications associated with the 16 cases of emergency peripartum hysterectomy. Eleven patients stayed in hospital over 7 days and seven stayed more than 15 days. Operative complications were urinary tract injuries in ® ve cases, bleeding from an ovarian pedicle or vaginal vault in ® ve others. All accidental bladder lacerations that were recognised and repaired healed uneventfully after 10 days of catheter drainage. Five patients had to be re-explored due to clinical evidence of internal bleeding, four cases whilst in recovery and one 12 hours later. One patient had wound dehiscence and had to be re-sutured, another three had wound haematomas which responded to conservative measures. There were 12 patients with evidence of coagulopathy with clinical bleeding or abnormal clotting pro® le. This was corrected by fresh frozen plasma, and platelet concentrate.
Maternal complication
Uterine atony
n
%
3 5
18´7 31´2
4 11 15 5
25´0 68´7 93´7 31´2
Discussion
While hypertensive disorders are the leading cause of maternal deaths in the UK (Con® dential Enquiries, 1996), haemorrhage is the leading cause of death in the Kingdom of Saudi Arabia (Al Meshari et al., 1996). Obstetric hysterectomy is an obstetric emergency which is performed as a life-saving procedure for life-threatening haemorrhage which cannot be controlled by the conventional methods. The rate of caesarean hysterectomy varied between 0´35% and 18´5% of abdominal deliveries (Barclay et al., 1976; Haynes and Martin, 1979; Stanco et al., 1993; Zelop et al., 1993; Boriboonhirunsarn et al., 1996). Emergency postpartum hysterectomy is associated with signi® cant blood loss, need for transfusion. Postoperative complications are common and longer hospitalisation inevitable. The decision should be taken by an experienced obstetrician. Except in desperate circumstances, total hysterectomy is preferred thus avoiding late sequelae involving the cervical stump (Thonet, 1986). Gonsoulin et al. (1991) found that the incidence of transfusion was 68% in emergency cases and 14´6% in the elective ones. The transfusion rate was 100% for emergency caesarean hysterectomy for bleeding placenta praevia or atony (Sherman et al., 1993). All of our patients received blood transfusion with its potential risk of hepatitis and possible human immunode® ciency virus infection despite full screening. Urological injuries are usually related to scarring from previous caesarean deliveries encountered when dissecting the bladder from the lower uterine segment (Zelop et al., 1993). In our study, ® ve cases sustained bladder injury with no ureteric injury. Placenta accreta occurs in about 1 in 10 000 pregnancies (Gibb et al., 1994), where there is an abnormal adherence either in whole or in part to the underlying uterine wall. The incidence of placenta accreta in cases of placenta praevia has risen from 2:1000 in 1952 to 101:1000 in 1985 (Craigo, 1997). The marked rise in caesarean section rate in the past decade may be a contributing factor to the apparent steady rise in the incidence of placenta accreta. In the presence of placenta praevia, the risk of placenta accreta is directly related to the number of prior scars: no previous scar 5%, one previous scar 20%, two
536
R. Mesleh et al.
previous scars 38±49%, three previous scars 67% (Clark et al., 1985a; Chattopadhyay et al., 1993; Craigo, 1997). All obstetricians should be aware of the strong association between placenta praevia in a scarred uterus and placenta accreta (Clark et al., 1985a). In cases of placenta membranacea and accreta, the placenta can be very adherent and dif® cult to remove causing profuse bleeding necessitating hysterectomy (Dinh et al., 1992). It should be suspected in cases of painless ® rst and second trimester bleeding (Sherman et al., 1993). The diagnosis of placenta accreta may be suspected on ultrasound by the presence of a placenta in the area of a previous uterine incision (Baker and D’ alton, 1994). However, high false negative rates have been reported (Greenberg et al., 1991). A signi® cant association exists between placenta accreta/ percreta/increta and elevated maternal serum alphafeto protein (Kupferminc et al., 1993). Clark et al. (1984) in a study of 70 cases of caesarean hysterectomy found that 53% of all patients presenting at term with both a placenta praevia and one or more previous caesarean sections subsequently underwent hysterectomy for placenta accreta. Stanco et al. (1993) found that caesarean delivery, prior caesarean section, placenta praevia, placenta accreta and uterine atony were identi® ed risk factors for emergency peripartum hysterectomy. For clinicians faced with a placenta that cannot be separated from the uterus, the possibility of conservative management with meticulous observation should be considered especially in women who are opposed to hysterectomy. Conservative measures to control obstetric haemorrhage remain the mainstay of therapy. Several methods are usually adopted to stop bleeding with varying degrees of success. The use of intravenous or intra-mural prostaglandins (Sulprostone, Schering AG, Germany) and oxytocics (Syntocinon, Sandoz) have been used. Synthetic vasopressive (Pitressin, Parke-Davis) injected subendometrially at the site of the bleeding decreased the blood loss within 90 seconds (Zaki and Bahar, 1997). Ligation of internal iliac arteries may be considered in patients of low parity (Clark et al., 1985b). The B-Lynch brace suturing had proved invaluable in the control of massive postpartum haemorrhage as an alternative to hysterectomy (B-Lynch et al., 1997) but is not always successful. In cases of placenta praevia or increta multidisciplinary approaches for preoperative, intra-operative and postoperative management optimises maternal outcome (Leaphart et al., 1997). The advent of modern blood banking, antibiotics, safe anaesthesia and advances surgical technique was a major contributing factor in improving the outcome, and reducing maternal and fetal morbidity and mortality to a minimum. In conclusion, obstetric haemorrhage is a lifethreatening condition leading to maternal death if not treated promptly by an experienced obstetrician. Every effort should be made to perform caesarean sections in cases of placenta praevia and previous caesarean section as an elective procedure by an experienced surgeon and not to be left to our on call junior doctor.
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