Introduction

Emergency obstetric hysterectomy is the surgical extraction of the uterus either at the time of cesarean section or following vaginal delivery, or within 42 days of delivery. It is usually performed at the setting of a life-threatening obstetric hemorrhage that is uncontrolled even after adopting the most suitable medical and surgical methods. Cesarean hysterectomy can be classified as elective for the management of incidental diseases like cervical intraepithelial neoplasia (CIN), or for the purpose of sterilization,1 but in most cases is performed on an unplanned, emergency basis and proves to be life-saving in most of such cases.

Uterine atony and uterine rupture were formerly regarded as the commonest indications necessitating emergency hysterectomy. However, more recent reports have mentioned placenta accreta as the most common indication, which is attributed to the increasing number of Caesarean deliveries all over the world.

Objective

To evaluate frequency, indications, demographic characters and the fetomaternal outcomes of emergency obstetric hysterectomy in a tertiary care teaching hospital in Eastern India.

Materials and Methods

Results and Analysis

The total number of deliveries during the study period was 34,567 of which 11,678 were vaginal and 22,889 were by caesarean section. A total of 22 obstetric hysterectomies were carried out during the study period. The incidence of obstertric hysterectomy in the institute was 0.63 per 1000 deliveries.

The mean age of the subjects was 26.81 ± 1.11 years. Majority of the subjects were multigravida and in the age group 21-30 years.

Placenta accreta spectrum was the most frequent indication for obstetric hysterectomy (36.36%), followed by atonic post partum hemorrhage (31.81%), abruption placentae (13.63%), uterine rupture (9.09%) and broad ligament hematoma (4.54%).

In each case, several measures were undertaken before actually proceeding for hysterectomy and more than one method was used in most of the cases.

All the subjects needed blood products either intra-operatively or in the post operative period or both. Each subject received more than one type of blood product.

Hypotension requiring the use of vasopressors (77.27%) was the commonest complication faced by the subjects, followed by fever (59.09%). The mortality rate among the subjects following obstetric hysterectomy was 9.09%.

Fetal outcomes of the cases who underwent obstetric hysterectomy were varied. 68.18% of the newborns were healthy. The mortality rate among the newborns was 9.09%.

Discussion

Storer performed the first cesarean hysterectomy in the United States in 1869.2 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.2

An observational, prospective study was carried out in the department of obstetrics and gynecology of R.G Kar Medical College, Kolkata for a period of 20 months.

A total 22 obstetric hysterectomies were carried out during the study period, 7 (31.81%) cases following vaginal delivery and 15 (68.18%) cases during or following Caesaren section. The incidence of Obstetric Hysterectomy was 0.63 per thousand deliveries. The mean age of the subjects was 26.81 ± 1.11years. Majority of the subjects (18 out of 22) were multigravida. Placenta accrete spectrum was the most frequent indication for obstetric hysterectomy (36.36%), followed by atonic post partum hemorrhage (31.81%), abruption placentae (13.63%), uterine rupture (9.09%) and broad ligament hematoma (4.54%). In each case, several measures were undertaken to control hemorrhage before actually proceeding for hysterectomy, like Foley’s catheter tamponade, bilateral uterine artey ligation, B-Lynch suture, modified B-Lynch suture, bilateral internal iliac artery ligation.

Fetal outcomes of the cases who underwent obstetric hysterectomy were varied. 68.18% of the newborns were healthy. The mortality rate among the newborns was 9.09%. Several studies on emergency obstetric hysterectomies have been carried out in India and abroad.

In a study conducted in China for a period of 12 years, the incidence of obstetric hysterectomy was 0.63 per 1000 deliveries. The commonest causes were post partum prothrombin activity <50% (61.5%) and placenta accreta (43.76%).3 In another study conducted in the US, the incidence of obstetric hysterectomy was 0.06%4 and the commonest cause was placenta accreta (63.7%).

Uterine artery embolization has recently emerged as a safe and effective nonsurgical technique for controlling acute and chronic genital bleeding in a variety of obstetric and gynecological conditions.5 Angiographic selective arterial embolization has been found to be a safe and effective method of controlling severe PPH in 90% to 95% of cases irrespective of the cause of PPH6, 7 and can reduce the incidence of obstetric hysterectomies in near future. However this newer modality requires radiological expertise.

Conclusion

Emergency obstetric hysterectomy can be considered a necessary evil in the field of obstetrics.8 Although it restricts the future child bearing capacity of the woman, in many cases it saves the life of the mother. Most of its morbidity is attributed to its indications and underlying disorders rather than to the procedure itself. Training junior residents and senior residents in this rare skill can prove lifesaving in situations where expertise or facilities for newer modalities of management, such as uterine artery embolization, do not exist, or fail. Rising rates of cesarean section and multiple pregnancies are bound to increase the incidence of obstetric hysterectomy in the future.

Source of Funding

None.

Conflict of Interest

None.