Incidence, Causes, Complications, and Trends Associated with Peripartum Hysterectomy and Interventional Management for Postpartum Haemorrhage: a 14-Year Study

Abstract

Objectives: To identify possible causes for peripartum hysterectomy (PH), how the mode of delivery impacts on having the procedure, and whether other interventional management reduces the likelihood of resorting to this intervention.
Methods: This was a study of patients encountered over the period 1998 to August 2012. The records of all patients who underwent a PH and those who had other non-hysterectomy interventional management (uterine and/or iliac artery embolisation, uterine and/or iliac artery ligation, uterine compression sutures, and balloon tamponade) for postpartum haemorrhage were retrospectively reviewed. Those managed by medical management alone were excluded. Causes and complications associated with a PH were identified and trends over the 14-year study period were explored. Its  associations with mode of delivery were similarly reviewed. Patients were also divided into two 
groups, namely: those having PH and those having other interventional management. Causes, mode of delivery, complications, and management successes in the two groups were compared. Significant factors and causes were also analysed in detail for two time periods, namely: 1998-2004 and 2005-2012.
Results: During the 14-year period (1998 to 2012), a total of 76,145 mothers underwent delivery. Among these, 75 (0.099% or 1 per 1000) patients underwent a PH or other interventional management as a treatment for postpartum haemorrhage; 47 (0.062% or 0.62 per 1000) had a PH. Analysis of these 47 patient’s records showed that abnormal placentation including placenta praevia and morbidly adherent placenta were the main prevailing causes (57.4%). In this group, undergoing a Caesarean section (76.6%) was more prevalent than vaginal delivery (23.4%). While morbidly adherent placenta (odds ratio [OR]=15.3; 95% confidence interval [CI], 1.9-122.8; p<0.001), classical Caesarean section (OR=2.3; 95% CI, 1.3-7.4; p=0.006), and previous Caesarean section (OR=4.4; 95% CI, 1.3-14.8; p=0.01) were significantly associated with having a PH when compared to mothers who underwent other interventional management. Among those who had Caesarean section as the mode of delivery, elective operations
(OR=4.8; 95% CI, 1.0-24.2; p=0.04) and those having repeat Caesarean sections (OR=4.1; 95% CI, 1.2-15.1;
p=0.02) were also more likely to have a PH. There were also significance in the amount of packed cells (PH vs. non-PH: 16.4 units vs. 10.2 units; p=0.037) and fresh frozen plasma (9.0 units vs. 5.2 units; p=0.046) transfused. Those patients who had a uterine or internal iliac artery embolisation (OR= –3.3; 95% CI, -1.2 to -9.0; p=0.018), and/or uterine compression sutures (OR = –3.7; 95% CI, -1.1 to -4.3; p=0.014) were less likely to need a PH, particularly those caused by uterine atony. In the past 14 years, PHs have a 3.0-fold increase after adjustment for the rise of total delivery numbers. Among those who had a PH, Caesarean section (4.3-fold, p<0.001), previous Caesarean section (6.4-fold, p<0.001), and abnormal placentation (6.0-fold, p<0.001) were the main contributing causes and factors for such increase.
Conclusions: This paper reinforces the need for obstetricians to be made aware of the seriousness of maternal morbidity and mortality associated with a PH which is on the rise. Much of this increase was due to the leading causes and factors which were Caesarean sections, previous Caesarean sections, and abnormal placentation. As most of these causes are known factors associated with a Caesarean section, these data provide further impetus to control the rapidly increasing Caesarean section rate including those on request alone. In addition, when interventional management for postpartum haemorrhage is inevitable, methods such as uterine compression sutures and arterial embolisation should be used at an earlier stage especially if the cause was due to uterine atony.