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Chapter 3
Introduction
Emergency Obstetric Hysterectomy: A Necessary Tool for the Obstetrician Anjali Gupta
Emergency Obstetric hysterectomy (EOH) is defined as removal of the uterus at the time of cesarean section, or following vaginal delivery, or within the puerperium period, or for complications following pregnancy termination such as perforation and sepsis.
Corresponding Author: Anjali Gupta, Department of Obstetrics & Gynecology, Pt. B.D.Sharma, PGIMS, Rohtak, Haryana 124001, India, Email: ajiii2003@yahoo. co.in
Storer performed the first cesarean hysterectomy in the United States in 1869. Soon thereafter, Porro of Milan described the first cesarean hysterectomy in which the infant and mother survived. As a mark of honor, the procedure is frequently referred to as the Porro operation [1]. It is a vital procedure to save life of a mother although it is opted as a desperate attempt when all other measures fail to control catastrophic hemorrhage.
First Published November 29, 2016
It is important to study such events since they provide an insight into the standard of care provided and help to reduce maternal and perinatal morbidity and mortality.
Department of Obstetrics & Gynecology, Pt. B.D.Sharma, PGIMS *
Incidence
Copyright: © 2016 Anjali Gupta. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source.
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In modern obstetrics, the overall incidence of Emergency hysterectomy is 0.05%, but there are considerable differences in incidence in different parts of the world, depending on modern obstetric services, standards and awareness of antenatal care and the effectiveness of family planning activities of a given community [2]. In recent times ,the incidence of obstetric hysterectomy is rising worldwide mostly due to rising cesarean section rate [3]. In developed countries, the reported inwww.avidscience.com
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cidence of emergency hysterectomy is below 0.1% of total deliveries performed while in developing countries, the incidence rates are as high as 1-5/1000 of all deliveries performed [4].
Risk Factors The risk factors identified for EOH are age group ≥ 35 years, high parity, previous cesarean birth and current cesarean delivery. In a study by Mathe JK, the mean age and parity of the women who underwent obstetric hysterectomy was 35.8 and 7 respectively [5]. Carvalho reported majority of patients (7/13) of EOH in the age group ≥ 35 years and were multiparous (9/13) [2]. Cesarean section does not only increase the occurrence of scar rupture but also placenta praevia and placenta accreta. The incidence of previous cesarean section ranges between 59.8% in patients with adherent placenta and 75% in patients with placenta previa [6]. A difference in the incidence of emergency peripartum hysterectomy is noted following vaginal delivery and cesarean section. While the incidence of EOH after vaginal delivery varies from 0.1 to 0.3/1000 deliveries and the incidence of EOH following cesarean section varies widely between 0.17 and 8.7/1000 deliveries [7]. All these risk factors put the patient at increased risk of obstetric complications, which can lead to hysterectomy.
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Indications First EOH was performed in the 19th century for grave sepsis and hemorrhage. Subsequently common indications for EOH were uterine rupture and uterine atony. Over the past 2-3 decades abnormal placentation is replacing uterine atony as the most common indication [8]. But still there is considerable variability in the indication of EOH worldwide and it varies with obstetric practice in each center. Uterine atony is an indication for EOH in 12.9% to 41.2%% of the cases [9-12]. Its incidence has been reduced due to the use of newly developed pharmacologic treatment strategies including prostaglandins and other conservative measures. Driessen et al in their study reported primiparity, previous PPH, previous cesarean delivery, cervical ripening, prolonged labor, delay in intial care for PPH as independent risk factors for uterine atony [13]. Uterine rupture as an indication for EOH ranged from 9% to 45.7% [10,14-16]. In a study by Gupta et al the risk factors identified were mainly obstructed labor (52.63%) due to cephalopelvic disproportion, malpresentation and contracted pelvis; and traumatic (8.77%) in unscarred uterus. The scar rupture was reported in 35.08% cases [17]. I have come across a case of scar rutpure in first trimester of pregnancy due to scar pregnancy and a case of placenta percreta causing uterine fundal rupture at term gestation.
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The hysterectomy is done in cases in which repair of uterus is not possible; rupture in the lateral uterine wall or it is involving cervix or vagina or colporrhexis. In recent years, abnormal placentation has become a more common indication in developed countries as well as in some centers in developing countries also due to the greater number of pregnant women with previous cesarean section deliveries. Its incidence varies from 21% to 73.3% [11,14,15,18]. As reported by Clarke et al, the incidence of placenta previa increases from 0.5% in general population to 3.9% after one cesarean section and upto 10% after four cesarean sections. The incidence of placenta accreta is 5% in patients with placenta previa and one cesarean scar, while moribund placental adherence increases to 67% with previous four cesarean sections [19]. The incidence of EOH was higher in patients with placenta previa and accreta than in patients with placenta previa alone. The factors such as high parity, number of previous cesarean sections, abortion, previous curettage, strongly increases risk of abnormal adherent placenta [6]. Interstitial ectopic pregnancy and cervical pregnancy Rarely in women with an interstitial ectopic pregnancy and cervical pregnancy, hysterectomy becomes necessary to stop life threatening hemorrhage. Infected uterus Sometimes, in illegal or septic abortion, the uterus is badly injured or gangrenous, that hysterectomy becomes essential. 6
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Intractable secondary PPH may also require hysterectomy. Concealed accidental hemorrhage Uncontrolled bleeding due to uterine inertia may require hysterectomy. In Hydatidiform mole Invasive mole causing uterine perforation and rarely excessive hemorrhage during evacuation may demand hysterectomy. Uterine fibroids Cesarean section followed by hysterectomy is to be done if there are multiple intramural fibroids preventing uterine contraction and hemostasis.
Alternatives to Hysterectomy Hysterectomy renders loss of woman’s reproductive capability. In emergency situation, sequence of conservative measures should be attempted in quick succession before resorting to hysterectomy in order to avoid the morbidity and sterilization that comes with hysterectomy. The measures such as bimanual uterine massage, uterotonic drugs like oxytocin, PGE1, 15- methyl PGF2α, uterine tamponade by uterine packing or condom Foley catheter, hemostatic sutures like B-Lynch suture, uterine or internal iliac artery ligation have been advocated to effectively manage obstetric hemorrhage. Internal iliac artery ligation requires skill and may not be effective due to presence of collateral circulation. One should weigh the gains of the procedure against the exwww.avidscience.com
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pense of the definitive hysterectomy. Following ligation of internal iliac artery, there is a reduction of 85% in pulse pressure and 48% in the blood flow in the arteries distal to the ligation. Thereby the arterial pressure approaches the venous pressure and is rendered more amenable to hemostasis by a simple clot formation [20]. Uterine or hypogastric artery embolisation (UAE) has been advocated but this is feasible in specialized centers where interventional radiologist is available. Embolization under angiographic guidance has the potential to arrest severe pelvic hemorrhage without removing the uterus and without hazarding general anesthesia in a hemodynamically unstable patient. Successful pregnancies after angiographic embolization have been reported by many studies. In a study by Juneja SK et al UAE was done in 53 patients and 11 patients were able to have subsequent successful pregnancies with a favorable outcome [21]. Conservative management is of particular importance in patients who are young, have low parity and who are haemodynamically stable. The success rate of 96% has been reported following uterine artery ligation, others have achieved success in only 39.4% of cases [6]. The choice between conservative management and EOH should be individualized. In situations where conservative treatment is not able to control bleeding, there should be no further delay in performing EOH as delay leads to increase in blood loss, transfusion requirement, operative time, DIC, and increased possibility of admission to ICU. 8
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Type of Surgery Obstetric hysterectomy can be total or subtotal. Total hysterectomy is the recommended surgical method of EOH due to the potential risk of malignancy developing in the cervical stump and the need for regular cytology and other associated problems such as bleeding or discharge associated with the residual cervical stump. The subtotal hysterectomy is desirable in situations where patient‘s condition is unstable or the procedure is unusually difficult. When patient is in moribund condition and/or having disseminated intravascular coagulopathy (DIC), the subtotal hysterectomy is preferred as it is simple, faster, associated with lesser blood loss, reduced bladder and ureteric injuries and should be done when pathology is confined to the upper uterine segment. It may not be effective in management of placenta previa and accreta. Total hysterectomy should however be considered when active bleeding occurs from lower uterine segment as the cervical branch of uterine artery may remain intact as in cases of placenta previa, placenta accreta, tears extending to the lower uterine segment, and colporrehexis. So, the decision to perform subtotal or total hysterectomy will depend on the patient’s condition and surgeon’s judgement.
Maternal and Perinatal Mortality The maternal mortality ranged from 4.5 to 17.7%. The causes of maternal death were mainly DIC, hemorrhagic shock, sepsis and adult respiratory distress syndrome (ARDS) [12,14,15,18]. The high mortality in developing www.avidscience.com
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countries may be due to delay in arrival to hospital and till they reach the higher center, their condition is already unstable. No maternal death due to peripartum hysterectomy was reported in developed countries. This is because of the fact that in those countries women were in good health prior to pregnancy, good antenatal care further improves that condition and quick and proper intervention was carried out before their condition deteriorated [22]. The perinatal mortality varied from 3.9 to 67.4% and were mainly due to uterine rupture, abruption placentae and prematurity [10,12,15].
Practical Points in Technique The physiological changes of pregnancy accounts for difficulty in performing obstetric hysterectomy as compared to non-pregnant uterus. It is important to ligate the stumps doubly and carefully, as tissues are more vascular and edematous. The vessels that supply the uterus, ovaries, and bladder are remarkably larger and more tortuous in pregnancy. Exteriorize the uterus first. Clamp the round ligament with straight Kocher’s clamp, then cut and ligate. Clamp the tubo-ovarian ligament, cut and ligate by transfixing with Vicryl no 1 or chromic catgut no 1. Repeat the same procedure on the other side. Dissect the uterovesical pouch and reflect the bladder downwards by sharp and blunt dissection. Skeletonise the uterine vessels, doubly clamp, cut and ligate bilaterally. The clamp is to be placed 10
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perpendicular to the uterine vessels. The clamps are then placed sequentially lower down medial to the uterine vessel clamp and hugging the cervix so as to avoid the ureter. At the level of external os, identify the cervix from vagina and cut at this level. Before this, secure both vaginal cuff angles by sutures. Vaginal cuff is then closed by figure of eight sutures. In subtotal hysterectomy, the uterus is amputated at the level of isthmus above the uterine arteries ligature. If patient is in DIC, there is generalized oozing present from all the pedicles and vaginal cuff, apply the pelvic pressure with packs tied together. The tail of the pack can be brought out through the abdominal incision and can be removed after 24 hours. In the mean time, improve the coagulation profile by transfusing fresh frozen plasma, platelet rich plasma and cryoprecipitate. Careless manipulation of clamps, cutting of pedicles, or placement of sutures may precipitate severe bleeding. Edema of the structures surrounding the uterus allows easy dissection of surgical planes but produces large pedicles from which blood vessels may escape. Special attention must be given to the proper size of pedicles and careful hemostatic suturing techniques.
Complications Intra and post-operative complications were mainly continuation of sequel of poor preoperative status rather than due to operative intervention. Obstetric hysterectomy is associated with extensive blood loss and need for www.avidscience.com
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higher number of transfusions. In many studies, all the patients who underwent EOH required blood / blood products transfusions. It is associated with coagulopathy, injury to the urinary tract, need for reexploration because of persistent bleeding, fever, wound infection, paralytic ileus, sepsis, ARDS and ICU admission. Urological injuries may be related to scarring and adhesion of the vesicouterine space following previous cesarean section and may be due to the distortion of the lower uterine segment and pelvic anatomy caused by the morbidly adherent placenta and praevia. These injuries may also be due to the conditions leading on to hysterectomy such as rupture uterus causing bladder rupture/injury. The maternal morbidity ranged from 26.5% to 31.5% as reported in a metaanalysis. The complications included blood transfusion (88%), febrile episodes (26.5%), perinatal death (22.8%), bladder injuries (8.8%), wound infection, DIC, ileus, vaginal cuff bleeding and adnexectomy [6].
Prevention EOH can be prevented by preventing obstetric complications by providing good antenatal care, identification of high risk cases, timely referral, and easy availability of transport, blood and blood component facilities. The predisposing risk factors for placenta accrete like previous curettage, previous cesarean section and placenta previa can be identified and placenta accreta can be determined to a certain extent by performing antenatal ultrasound with color Doppler and magnetic resonance imaging 12
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(MRI). These cases should be referred timely to higher center where these can be dealt by a team of senior obstetricians, anaesthetists. Placental mapping of placenta by ultrasound can be done preoperatively to reduce the maternal morbidity and mortality.
Recommendations Every obstetrician should be trained in early diagnosis, treating and performing conservative procedures as uterine or ovarian artery ligation, B-Lynch sutures, internal iliac artery ligation and hysterectomy. Effective antenatal care, enhancement of blood transfusion facilities, improvement of surgical skills, timely decision, referral and surgery by experienced surgeon at early stage should be done to reduce the incidence of obstetric hysterectomy and morbidity associated with this procedure. Primary cesarean section should be performed when exclusively necessary. It will prevent the cases of placenta accrete.
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