Dr. Ahmed M. Abbas
CONTROVERSIES IN REPRODUCTIVE MEDICINE
The 9th Annual Conference of Ob. & Gyn. Department Faculty of Medicine Assiut University Maritim Jolie Ville Luxor 1st – 4th of March 2016 Dr. Ahmed M. Abbas
Dr. Ahmed M. Abbas Women Health Hospital Faculty of medicine - Assiut E-mail :
[email protected]
Dr. Ahmed M. Abbas
1876 The first Elective Peripartum Hysterectomy
Senator Eduardo Porro (1842–1902), Italy
Dr. Ahmed M. Abbas
1876 Julia Cavillini
Julia Cavillini, Italy
Dr. Ahmed M. Abbas
1901
Cesarean operation by excision of the uterus and adnexae Della amputazione utero-ovarica come complemento di taglio cesareo (1876)
Dr. Ahmed M. Abbas
1868
The first Emergency Peripartum Hysterectomy
Horatio Robinson Storer (1830–1922), USA
Dr. Ahmed M. Abbas
Joseph Cavallini, Italy in 1763, who experimented with hysterectomy in animal and successfully excised the pregnant uteri in dogs and sheep
Postpartum Hemorrhage (PPH) PPH is the leading cause of maternal mortality and morbidity in developing countries contributing to 25% of direct maternal deaths. Conservative treatment of PPH includes uterine massage, uterotonics, uterine packing, uterine artery embolization, pelvic
vessel ligation, B-Lynch suture and recombinant activated f. VII Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Emergency peripartum hysterectomy (EPH) EPH is performed for life-threatening obstetric conditions
especially when conservative treatment approach fails to stop PPH.
The surgery itself can be associated with severe hemorrhage,
risk
of
blood
transfusion,
intraoperative
complications and a high maternal mortality and morbidity risk. Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Emergency peripartum hysterectomy (EPH) Previous studies have reported the incidence of EPH varies from 0.29 to 5.09 per 1000 deliveries. Indications of EPH have changed throughout the years. In the past, the major indications were uterine rupture and atony. But,
now abnormal placentation (placenta previa and placenta accreta) is the leading cause of EPH. Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
WHAT about Upper Egypt?
Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
WHAT about Women Health Hospital?
Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
RETROSPECTIVE ANALYSIS • 5 years from 2010 till 2014. • Information obtained from the medical records. •EPH is defined as a hysterectomy performed for hemorrhage unresponsive to other treatment within 24 hours of delivery.
Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
94196
123 Dr. Ahmed M. Abbas
1.3 / 1000 3/5/2016 6:39 PM
Characteristics Age (years) Age groups < 20 20-29 30-39 ≥ 40 Gravidity Primipara P 1-4 ≥P5 Previous cesarean delivery Mode of delivery Vaginal Cesarean Dr. Ahmed M. Abbas Gestational age at delivery (weeks)
Mean ± SD (range), n (%) 30.12 ± 6.04 (18-44) 7 (5.69%) 49 (39.84%) 52 (42.28%) 15 (12.19%) 5.23 ± 2.72 (0-10) 4 (3.25%) 54 (43.90%) 65 (52.85%) 68 (55.28%) 51 (41.46%) 72 (58.54%) 3/5/2016 6:39 PM 36.5 ± 2.3 (24- 41)
Characteristics Indications of hysterectomy Uterine atony Abnormal Placentation Rupture uterus Placental abruption Others Type of hysterectomy Supracervical Total Duration of hysterectomy (minutes)
Mean ± SD (range), n (%)
Duration of hospital stay (days) Dr. Ahmed M. Abbas
60 (48.78%) 27 (21.95%) 25 (20.32%) 2 (1.63) 9 (7.32) 71 (57.72%) 52 (42.28%) 139.22 ± 75.3 8.8 ± 5.7 3/5/2016 6:39 PM
Characteristics Bladder injury Ureteric ligation Re-exploration DIC Pulmonary embolism ARDS Acute Renal Failure Multi-organ failure Dehiscence and wound infection Maternal mortality
(n=123) 26 (21.13) 2 (1.63) 11 (8.94) 11 (8.94) 5 (4.07) 4 (3.25) 3 (2.44) 3 (2.44) 3 (2.44) 48 (39.02)
Perinatal mortality ICU admission
25 (20.32) 74 (60.16) Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Variables Age ≥ 40 years Gravidity Parity ≥ 5 Gestational age at delivery Mode of delivery Type of hysterectomy Uterine atony Rupture uterus Hb level before surgery Blood transfusion
p-value 0.000 0.10 0.009 0.60 0.38 0.61 0.90 0.38 0.13 0.13
Dr. Ahmed M. Abbas
Odds ratio 5.49 1.13 0.34 1.03 0.73 0.83 0.90 2.25 1.51 1.10
95 % CI 2.16 – 13.96 0.98 – 1.30 0.15 – 0.77 0.92 – 1.16 0.35 – 1.51 0.39 – 1.73 0.17 – 4.85 0.37 – 13.67 0.88 – 2.58 0.97 – 1.25
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Emergency peripartum hysterectomy (EPH) The incidence of EPH is 1.3 /1000 deliveries Uterine atony was the main indication of EPH in our institution in Upper Egypt. The parity-related increase is explained by its association with placenta previa, high liability of rupture uterus during delivery and higher incidence of uterine atony after delivery Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Emergency peripartum hysterectomy (EPH) CS also is a well-known risk factor for EPH. In our study, 58.54% of EPH cases were carried out in women who delivered by CS. EPH is associated with extensive blood loss which necessitates
a higher number of blood transfusions; an average of 10.4±6.9 units of blood products was transfused for our cases. Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Emergency peripartum hysterectomy (EPH) A planned rather than an EPH in women at high risk may be associated with lower morbidity rates. Supracervical hysterectomy was the commonly performed procedure in our study (71/123). It is relatively easier and takes
less time to control the hemorrhage in hemodynamically unstable patients. Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Emergency peripartum hysterectomy (EPH) EPH in the current study was associated with high
maternal morbidity. The most experienced obstetrician should carry out this procedure.
Timing of EPH is critical to achieve an optimal outcome and decrease maternal deaths as it should not carried out too
early or too late. Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Emergency peripartum hysterectomy (EPH) There were 48 cases (39.02%) of maternal mortality in our
study. This may be attributed to the delay in arrival of most of patients
to our hospital from discrete and rural areas. Also, the delay in taking decision of EPH in near-miss cases until failure of all conservative trials to stop bleeding was a major contributor in this high rate. Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Emergency peripartum hysterectomy (EPH) In the current study, age ≥ 40 years and parity ≥ 5 were the most significant variables associated with maternal mortality in cases of EPH:
The false sense of security in labor due to previous experience of repeated deliveries The substandard nutrition in our community. Our policy in management; increasing the community awareness about the family planning services, providing regular antenatal care with correction of
anemia before delivery and delivery should be in health facilities with good resources to prevent PPH.
Dr. Ahmed M. Abbas
3/5/2016 6:39 PM
Women have made sacrifices and endured risks to bring the gift of life to our world.
Despite knowing how to save women’s lives, we still leave women to die. Why? “Because societies have yet to make the decision that their lives are worth saving.”
We will eradicate preventable maternal mortality
