ABSTRACT

CORRESPONDING AUTHOR:
Dr. Debjani Deb,
Nirmaldanga,
Bankura, PIN – 722101, W.B.
Email- debjani163@gmail.com

ABSTRACT: OBJECTIVES: To determine the incidence, risk factors, outcome, complications and the changing trends of indications for Emergency Peripartum Hysterectomy (E.P.H.), and compare the results with other reports in the literature. METHODS: A population based 5 year retrospective study of 72 cases of emergency peripartum hysterectomy was carried out using hospital database from January 2008 to December 2012 in a peripheral medical college of Eastern India. RESULTS: A total of 72 EPH were performed among 94276 deliveries with an incidence of 0.76/1000 deliveries. The incidence was more among multiparous women (69%) and highest in the age group of 20 to 29 years (77.7%). Ruptured uterus was most common indication for Emergency Peripartum Hysterectomy (52.7%).Maternal mortality was 11.11% following peripartum hysterectomy. Our study in eastern India shows a statistically significant lower incidence of peripartum hysterectomy compared to that in other parts of India (0.076% versus 0.35% deliveries; P value <0.0101). CONCLUSION: Emergency Peripartum Hysterectomy is a life saving procedure and often puts the obstetrician in a dilemma for decision making. In this rural and backward area of Eastern India, primary and post CS deliveries are associated with an increased risk of Emergency Peripartum Hysterectomy. These results are of particular concern considering the steady rise in post CS pregnancy particularly in this backward region of our country.

KEYWORDS: Emergency peripartum hysterectomy, uterine rupture, post partum haemorrhage. EmOC

INTRODUCTION: Emergency peripartum hysterectomy is an uncommon obstetrics procedure, usually performed as a lifesaving measure in cases of intractable obstetric haemorrhage.^(1-3) It was first proposed in 1869⁽⁴⁾  by Horatio Storer to reduce maternal mortality.

Emergency Peripartum hysterectomy (EPH) was defined as an emergency lifesaving procedure, where hysterectomy was performed at or after delivery⁽⁵⁾ during the same hospitalization.

Although the exact incidence of EPH is not known, several authors have reported widely varying rates of 0.004 to 1.5 per 1000 deliveries ^{(6 )}  depending on the facilities available at the peripheral medical centres. Severe PPH was reported to occur in 6.7 per 1000 deliveries worldwide. Rochat and colleagues reported an incidence of 11 % of maternal deaths resulting from haemorrhage⁽⁷⁾and  it is one of the leading causes of maternal mortality and morbidity representing the most challenging complication that an obstetrician will face.⁽⁸⁾

The present study was undertaken to evaluate the incidence, indications, risk factors, outcome and complications of peripartum hysterectomy done to reduce maternal mortality.

MATERIALS AND METHODS: This was a case series study. Medical records of the patients who had undergone EPH following vaginal delivery and caesarean section in between Jan 2008 to Dec 2012 in this medical college were reviewed retrospectively. Cases were ascertained via a review of hospital obstetrics database by checking the obstetric admission register, OT records, case records and mortality register.  All deliveries were performed after 28 wk of gestation. Both medical and surgical measures were used for conservative management. The study was approved by the Institutional Ethical Committee.

Information obtained from the medical records include demographic details, risk factors, previous  obstetrics history , current pregnancy  and delivery detail, indication for EPH ,outcome of hysterectomy and operative and postoperative complications, maternal morbidity and mortality. The data was analysed using Graph, Microsoft Excel, 2007. The comparison was done by Medcal software. P value < 0.05 is statistically significant.

RESULTS:  During the 5 year study period following information were gathered.

Fig 1: Age group of patients undergoing peripartum hysterectomy

Table  1 and Fig 1 show that there were 94276 deliveries over a 5 year period and 72 peripartum hysterectomies with an incidence of 0.76/1000deliveries.Majority were multiparous and within the age group of 20-29 years.

Fig. 2: Incidence among multiparous and primiparous

Fig. 3: Mean gestational age at delivery

Fig 4 : Mode of delivery:For cases who underwent  Peripartum

Fig 3 and Fig 4 shows the maximum no of deliveries at 38 wks of gestation and maximum number of patients who underwent peripartum hysterectomy was post CS cases.

Table 2 shows uterine rupture as the most frequent indication of EPH followed by atonic uterus, abnormal placentation, and uterine inversion.

Fig 5: Mode of Delivery of cases who underwent EPS

Fig 6: Incidence of EPH, year wise distribution

Table 3 and Fig 6 shows the incidence ranging from 0.8/1000 to 1.00/1000over a 5 year period. Table 4 summarizes the maternal morbidity, mortality and the post operative complications following peripartum hysterectomy.

Fig 7: Causes of ruptured uterus

DISCUSSION:  Despite advances in the medical and surgical technique, PPH remains one of the leading causes of maternal mortality and morbidity. PEH is performed  in  life threatening obstetrical haemorrhage, that could not be controlled by conventional methods. Obstetric hysterectomy often puts the surgeon in a dilemna as the maternal reproductive capability is sacrificed to save the mother’s life.

                Although the exact incidence of EPH is not known, several authors have reported widely varying rate of 0.004 to 1.5 thousand deliveries(6.) Praneshwari Devi9  reported an incidence of (0.7/1000) deliveries  which is consistent with our study (0.76) /1000 deliveries. Marwaha et al10, Sahasrabojane et al11, Kumari et al 12,  Zeteroglu et al(13), reported an incidence of 3.1/1000, 3.5/1000, 7. 3/1000  and  5/1000 deliveries respectively, which is higher than  our study. In our series majority of patients who have undergone EPH were in the group of ≥25 yrs and were multipara. Similar trend was observed by Amad and Mir(5 and Barcley et al(6)

In our study most of the patients upon whom EPH was performed were post CS pregnancy with the most frequent indication of EPH in the present study being uterine rupture(52.7%), followed by atonic uterus(27.7%), abnormal placentation, uterine inversion and others.

                Other risk factors for EPH were increased age, multiparty, uterine atony, abnormal placentation, obstructed labour, current caesarean delivery and  were similar to the literature(2,14,15-,16,17,-18,19) .Abnormal placentation is higher in post CS pregnancy compare to normal pregnancy. A single CS increase the risk of placenta pra.evia by 0.65%, two CS increase the risk by 1.5%(9)There has been a significant change  in indication of EPH over time and from one region to other region. But the recent studies in the the US(20)  show abnormal placentation is the most common cause of EPH.

But in our institution, ruptured uterus is still the most common cause of EPH and most of the rupture occurred in post CS pregnancy. As the number of post CS pregnancy is gradually rising, the complication and incidence of EPH is also on the rise. The most severe complication of haemorrhage in pregnancy is maternal death .In developing country the risk is as high as 1 in 1000 deliveries. Other complications includes shock, DIC, renal failure, ARDS, infection,  transfusion related complications.(19,21) In this study the maternal mortality was 11.11%. Marwaha reported a mortaljty  of 12.2% whereas P. Devi et al reported no mortality at all. The critical condition of the mother is responsible for the mortality and morbidity.

Our study in eastern India shows a statistically significant lower incidence of peripartum hysterectomy compared to other parts of India (0.076% versus 0.35% deliveries; P value <0.0101)

This institute serves a very large rural and backward geographical area in Eastern India with poor communication. Due to inadequate health facilities, poor referral systems and inadequate knowledge about the high risk pregnancy we receive these cases in very grave condition. Transport facilities are inadequate as well .

CONCLUSION:  In developing countries, the obstetrician will continue to encounter this unfortunate event of EPH in their day to day life but the incidence  can definitely be decreased by upgrading the infrastructure, regular antenatal check up ,timely referral of high risk cases, continuous upgradation of knowledge and skills,  and managing these cases  through various programmes such as EMOC, upgrading socioeconomic status and health education .

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