Placenta Percreta And Its Successful Outcome: A Rare And Difficult Case Report And With Review Of Literature

Placenta Percreta is one of the most serious complications of placenta previa, the incidence of which has been on a rising trend and is frequently associated with severe obstetric hemorrhage usually necessitating hysterectomy. lacenta Previa complicates 0.3–0.5% of all pregnancies and is a major cause of third-trimester hemorrhage which is on the rise due to rise in incidence of cesarean sections. Significant maternal morbidity in form of increased incidence of fetal malpresentation, cesarean delivery, increased blood loss, and peripartum hysterectomy have been noted in cases of placenta previa and can lead to prolonged hospitalization in these women. Premature deliveries can occur which lead to higher admission to neonatal intensive care unit and stillbirths. (1).We present a case of placenta previapercreta in a case of previous cesarean section , managed excellently with a surgical expertise.

Placenta percreta: a rare presentation of obstetric emergency in second trimester

Incidence of adherent placenta is on the rise nowadays due to various reasons. Placenta percreta is seen in 5-7% of cases with adherent placenta, patients with morbidly adherent placenta are at increased risk for major obstetric hemorrhage, usually in the third trimester. Here we present an unusual case of placenta percreta presenting with obstetric emergency after trauma to abdomen in the second trimester. Emergency exploratory laparotomy was done for abruptio placentae with scar dehiscence at 20 weeks period of gestation. Consent for obstetric hysterectomy, if needed, was also taken. Intraoperatively, the placenta was found to be adherent to posterior wall of bladder. Emergency obstetric hysterectomy with bilateral internal iliac ligation with cystoscopy with detrusorrhaphy was done. Patient had an uneventful recovery. Multidisciplinary management with obstetricians, urologists and intensivist is presented hereed.

Impact of condom balloon tamponade on the rate of obstetric hysterectomy: a ten-year study

Background: The objective of this present study was to assess the efficacy of condom uterine balloon tamponade (C-UBT) in averting the obstetric hysterectomy (OH) in cases of major postpartum haemorrhage (PPH) over a period of 10 years.Methods: A retrospective cohort study from January 2010 to December 2019. A historical cohort was drawn from a group of women who had OH for major PPH between Jan 2010 to December 2014 (Group 1) whereas those from January 2015 to December 2019 were designated as Group 2. Total 305 C-UBT were used in the later period. Women who had OH at <28 weeks were excluded from the study. Primary outcome was to determine the efficacy of C-UBT in averting the risk of OH. Secondary objective was to determine the success rate of C-UBT after five years of useResults: Total 37463 births occurred from January 2010 to December 2014 and 38808 during January 2015 to December 2019. Cases of OH were 33 in the first five years period (Group 1) and 20 in the later (Group 2), p=<05, odds ratio=0.58 with 95% CI 0.335-1.019 favoring C-UBT.  After exclusion of rupture uterus and placenta accreta syndrome, OH for uterine atony alone were 22 (66.6%) for Group 1 and 08 (40%) for Group 2, P=0.01 odds ratio=0.350 (95% CI 0.156-0.788). No OH was done in group 2 for placenta previa. Efficacy of C-UBT was 96%.Conclusions: C-UBT is very safe, cheap and effective option for averting OH and associated physical, emotional and psychosocial morbidity.

Changing trends in uterine rupture audit, from the Institute of obstetrics and gynecology, modern government maternity hospital, Osmania medical college

Background: Between January 2001 to September 2003, 46,171 deliveries were recorded, the number of caesarean deliveries during this period of two years and nine months were 16,182 (35.04%).  Methods: An Audit from the Institute of obstetrics and gynecology, of uterine ruptures.Results: Total 81 cases of uterine rupture were managed at the Institute. Total number of scar ruptures managed were, 48/81 uterine ruptures. Five women had previous classical upper segment caesarean, and in previous lower segment caesarean section (LSCS), there were 43 cases of rupture uterus. In two cases following forceps delivery, traumatic uterine ruptures were recorded. Spontaneous ruptures were 31 during the study period. Bladder rupture occurred in 13 cases, 16.04% of uterine ruptures.  The fetal outcome in uterine ruptures 81 cases, live births were 19-23.45%. The number of vaginal births after caesarean section were 261, 215, 186 in the years 2001, 2002 and 2003 at the Institute of obstetrics and gynecology. The number of scar ruptures were 7/261, 9/215, 2/186 in the respective years. Hysterectomy was done in 43/81=53.08%. Rent repair of the uterine rupture was done in 38/81.Conclusions: An Audit from the Institute of obstetrics and gynecology, of uterine ruptures has provided the following data that gives an insight into the practice of obstetrics during the decade 2000 to 2010 in the teaching Institute.  Caesarean deliveries accounted for 35.04% of the total deliveries.  Repeat caesarean sections were 7105, 43.9%. The number of vaginal births after caesarean section (VBAC) were 662. Scar ruptures in VBAC were 18 /662-2.71%. The maternal mortality in MGMH study was 3/81 uterine ruptures-3.7%. Scar ruptures constituted, 48/81-59.25% of uterine ruptures. Trial of labor after caesarean (TOLAC) and VBAC are practiced in the teaching Institute.

Clinical profile of maternal deaths due to postpartum haemorrhage

Background: Postpartum haemorrhage is one of the dreadful complications that occur during delivery. It is often un-anticipated and occurs suddenly and un-expectedly. It is responsible for 20 percent of maternal deaths in developing countries. These deaths are largely preventable. The objective of the study was to find out the clinical profile, associated co-morbid conditions and contributory factors and treatment modalities used in the management.Methods: Retrospective observational study of maternal deaths due to postpartum haemorrhage (PPH) was carried out at tertiary care hospital. The data of maternal deaths for seven years from year 2013 to 2019 was reviewed, compiled and analyzed to draw conclusions.Results: There were 18 maternal deaths (19%) due to PPH out of total 86 maternal deaths. The average age of the woman who died due to PPH was 24 years. Ninety five percent of the cases of PPH were due to atonic uterus. Seventy percent of the cases had reported in advanced stage of shock with average blood loss of more than two to three litres. Poor general condition due to delay in reaching to tertiary care hospital was predominant feature. Sixty percent women underwent obstetric hysterectomy. Massive blood transfusion was given in fifty percent cases. Severe pregnancy induced hypertension, severe anaemia and severe concealed accidental haemorrhage were common associated factors in sixty percent of maternal deaths.Conclusions: Postpartum haemorrhage is still a common cause of maternal death. Early detection, prompt aggressive management, adequate blood replacement, use of uterine balloon tamponade and non-pneumatic anti-shock garment, timely transfer to higher centre and timely decision for surgical interventions can prevent maternal deaths.

A retrospective study of obstetric hysterectomy cases at tertiary care centre

Background: Postpartum haemorrhage (PPH) is a life-threatening condition. The objective of this study was to determine the incidence, demographic characteristics, indications, and feto-maternal outcomes associated with obstetric hysterectomy in a tertiary care centre.Methods: This is a retrospective analytical study conducted over a period of six years, from March 2014 to April 2020. A total of 68 cases of obstetric hysterectomy were studied at tertiary care centre in Ahmedabad, Gujarat, India.Results: Present study reported 68 obstetric hysterectomies per 44663 total deliveries (incidence - 0.15%), out of them 20 following 26446 vaginal deliveries (0.07%) and 48 following 18217 caesarean section (0.26%). Morbidly adherent placenta (29.41%) was the most common indication followed by atonic postpartum haemorrhage (25.00%) and uterine rupture (17.64%). The most frequent sequelae were disseminated intravascular coagulation (26.47%) and febrile morbidity (10.29%), maternal mortality was 16.17% whereas neonatal mortality was 26.47%.Conclusions: The incidence of obstetric hysterectomy has been found to be more following caesarean sections. There is a change in the indications of obstetric hysterectomy in the past two decades with placenta accreta spectrum being the commonest in present study. This is because of rising number of caesarean sections. Patients who underwent emergency obstetric hysterectomy due to atonic PPH had a higher mortality.

Espectro de placenta acreta, experiencia en un hospital peruano / Placenta accreta spectrum, experience in a Peruvian hospital

RESUMEN Introducción . El espectro de placenta acreta (EPA) se refiere a la gama de adherencias patológicas de la placenta al útero. Es considerado un problema de salud pública debido a su notable aumento en las últimas décadas y su asociación a morbimortalidad materna significativa, con riesgo elevado de hemorragia, transfusiones e histerectomía obstétrica. Objetivo . Conocer las características epidemiológicas, quirúrgicas y posquirúrgicas de las pacientes con espectro de placenta acreta. Métodos . Estudio descriptivo, retrospectivo de pacientes con espectro de placenta acreta atendidas en el Hospital San Bartolomé entre 2014 y 2018. Resultados . Se identificaron 36 casos de EPA con una tasa de 1,2/1 000 nacimientos. El 94% era multípara, 81% tuvo cirugía uterina previa, 61% tenía 35 o más años de edad y 47% poseía placenta previa, siendo la cesárea el antecedente quirúrgico uterino más frecuente con 72%. Se recurrió a procedimientos conservadores en 53% y a histerectomía en 47%. Hubo 53% de complicaciones postoperatorias, sin muerte materna. Conclusiones . En el presente estudio se halló que el espectro de placenta acreta estuvo significativamente asociado con la cesárea previa. Si bien hubo un número significativo de casos que se presentaron con hemorragia y choque hipovolémico, las intervenciones quirúrgicas oportunas y un banco de sangre bien provisto evitaron las muertes maternas. El manejo conservador del acretismo focal se mostró como alternativa válida para evitar la histerectomía y sus complicaciones.

ABSTRACT Introduction : Placenta accreta spectrum (PAS) refers to pathological adhesions of the placenta to the uterus. It is considered a public health problem due to its increase in recent decades, and it is associated with significant maternal morbidity and mortality and high risk of hemorrhage, blood transfusions and hysterectomy. Objective : To determine the epidemiological, surgical and post-surgical characteristics of patients with placenta accreta. Methods: Descriptive, retrospective study of patients with placenta accreta spectrum attended at San Bartolomé Hospital, Lima, Peru, between 2014 and 2018. Results : Thirty-six PAS cases were documented with a birth rate of 1.2/1 000; 94% occurred in multiparous women, 81% had previous uterine surgery including 26 (72%) with previous cesarean section; 61% were 35 years old or older, and 47% had placenta previa. Treatment was conservative in 53% of the cases, while hysterectomy was performed in 47%. There were post-surgical complications in 53%, without maternal deaths. Conclusions : In our study, placenta accreta spectrum was predominantly associated with previous cesarean sections. A considerable number of cases presented hemorrhage and hypovolemic shock. Timely surgical intervention and a well-supplied blood bank allowed conservative management in focal accretism as a valid alternative to hysterectomy and its complications.

Emergency obstetric hysterectomy: a two-year observational study at tertiary care center in Berhampur, Odisha, India

Background: Emergency obstetric hysterectomy is an unequivocal marker of severe maternal morbidity and, in many respects, the treatment of last resort for rupture uterus, severe postpartum hemorrhage (PPH) and other such life-threatening conditions. In no other gynaecological or obstetrical surgery is the surgeon in as much a dilemma as when deciding to resort to an emergency hysterectomy. On one hand it is the last resort to save a mother’s life, and on the other hand, the mother’s reproductive capability is sacrificed. This study is conducted with an aim to determine the frequency, demographic characteristics, indications, and feto-maternal outcomes associated with emergency obstetric hysterectomy in a tertiary care centre.Methods: We conducted a prospective, observational, and analytical study over a period of two years, from September 2017 till September 2019. A total of 56 cases of emergency obstetric hysterectomy (EOH) were studied in the Department of Obstetrics and Gynecology, MKCG Medical College, Berhampur.Results: The incidence of EOH in our study was 12 following vaginal delivery and 44 following caesarean section. The overall incidence was 56 per 21,128 deliveries. Uterine rupture (37.5%) was the most common indication followed by atonic postpartum hemorrhage (25%) and placenta accrete spectrum (10.7%). The most frequent sequelae were febrile morbidity (25.7%) and disseminated intravascular coagulation (21.4%). Maternal mortality was 17.1% whereas perinatal mortality was 51.7%.Conclusions: A balanced approach to EOH can prove to be lifesaving at times when conservative surgical modalities fail and interventional radiology is not immediately available. Our study highlights the place of extirpative surgery in modern obstetrics in the face of rising rates of caesarean section and multiple pregnancies particularly in urban settings in developing countries.

Histopathological examination of emergency obstetric hysterectomy specimens

Background: Obstetric hysterectomy is done as a lifesaving procedure in very trying circumstances of life threatening severe hemorrhage. The study was undertaken with the aim to evaluate the relative frequency of hysterectomy done for obstetric indication among the hysterectomy specimens and also to assess the histopathological findings in the hysterectomy specimens.Methods: The study was conducted at a tertiary care center over a period of two and half years. Consecutive specimens of hysterectomy done for obstetrical indication were included. Gross and microscopic findings noted and data analysed. The study was approved by the Institute Ethical Committee.Results: Of the total hysterectomy specimens received obstetrical hysterectomy comprised only 1.3%(12/915) of all the hysterectomies. Patient’s age ranged from 20-36 years; mean 28.6 years. Parity ranged from 1 to 5; mean 2. More multiparous women 91.7%(11/12) had hysterectomies as compared to primiparous 8.3%(1/12) cases                         (p value <0.0001). All patients had single pregnancy. All (100%) patients underwent surgery through abdominal route with subtotal hysterectomy with preservation of the bilateral adnexae undertaken in most (11/12; 91.7% cases). About 5(41.6%) cases hysterectomies were performed after previous caesarean section and had abnormal placentation. Histopathological examination revealed adherent placenta in 33.4%(4/12), endometritis in 25%(3/12), rupture in 25%(3/12) and histologically unremarkable in 16.6%(2/12) cases.Conclusions: Obstetric hysterectomy is an emergency lifesaving procedure done in situations of uncontrolled post-partum hemorrhage. In recent years with more number of caesarean sections the incidence of abnormal placentation has drastically increased, thus making adherent placenta as the most common histopathological finding.

Emergency obstretic hysterectomy: a retrospective study in a tertiary care center

Background: Obstetric hysterectomy remains a necessity in preventing maternal mortality in catastrophic rupture of the uterus or intractable postpartum hemorrhage when all the conservative management options fail. Uterine atony followed by abnormal placentation remains the primary indication of emergency obstratic hysterectomy worldwide. In majority of cases, anticipation, prompt resuscitation and earlier surgical intervention by skilled operator will reduce patient’s morbidity and mortality. The first successful operation was performed in 1876. The main objective of the study was to study frequency, indications and fetomaternal outcome of emergency obstetric hysterectomy in tertiary care center.Methods: Observational, retrospective and analytical study was done over 2 years from January 2017 to January 2019. A total of 11 cases of emergency obstretic hysterectomy (EOH) were recorded.Results: The overall incidence was 1.47 per 1000 deliveries. Atonic postpartum hemorrhage (54%) was the most common indication followed by placenta previa (18%) and placenta accreta (9%). Second gravida were mostly involved (45%) with previous LSCS (45%) as a common risk factor in commonest age group of 20-25 years (46%) amongst them. The most frequent squeal was disseminated intravascular coagulation (45%). Maternal mortality was nil while neonatal mortality being 9%. The decision of performing total or subtotal hysterectomy along with bilateral internal iliac ligation was influenced by patient’s condition.Conclusions: Emergency obstretic hysterectomy is the most demanding obstretic surgery performed in circumstances of life threatening hemorrhages where conservative surgical modalities fail and interventional radiology is not immediately available. Antenatal anticipation of the risk factors, involvement of experienced obstetrician at the early stage of management and prompt hystrectomy after adequate rescuitation will reduce fetomaternal mortality and morbidity.

A prospective study of indications and maternal outcome in case of emergency obstetric hysterectomy in a tertiary care hospital of Gujarat, India

Background: Obstetric hysterectomy was developed as a heroic operation arising out of necessity to control post-partum haemorrhage thereby reducing maternal mortality. The objectives of this study are to examine the incidence, indications, outcomes and complications of obstetric hysterectomy in a tertiary care hospital. It also aims to study the changing trends in incidence and indications in present day obstetric practice.Methods: This is a one-year study including 31 cases of obstetric hysterectomy performed in the Department of Obstetrics and Gynecology in a tertiary care hospital of Gujarat. Each case is analyzed, computed and tabulated as per standard proforma including clinical assessment, questionnaire, examination and investigations.Results: In present study 68% cases were in 21-30 years which is peak reproductive age. 55% patients were from rural areas and 52% cases were having three or more parity. The incidence of obstetric hysterectomy is 0.432% in both vaginal and cesarean deliveries i.e. 1 in 231 deliveries. Major indication for obstetric hysterectomy is morbidly adherent placenta 32% followed by atonic PPH 25.8% and ante partum hemorrhage in 22.58% due to increase in rate of cesarean sections. Most common complication is DIC and maternal mortality in around 16.12%.Conclusions: Obstetric hysterectomy is still a lifesaving surgery in modern day obstetrics. Quick decision for obstetric hysterectomy reduces maternal morbidity and mortality. Most of the morbidity is attributable to its indication and underlying disorder rather than the procedure itself.

Obstetric hysterectomy: a receding trend

Over 500,000 women die each year due to complications of pregnancy and childbirth, a number that has remained relatively unchanged since 1990, when the first global estimates of the burden of maternal mortality were developed. Hemorrhage due to uterine atony, adherent placenta and PPH are still the causes of maternal death in developing countries. Although advances have been made in the development of conservative medical and surgical treatment of obstetric haemorrhage like brace sutures, internal iliac artery ligation, selective arterial embolization etc emergency obstetric hysterectomy remains a lifesaving procedure in the management of intractable haemorrhage unresponsive to conservative management.

Factors associated with maternal near miss: A study from Kerala

Severe life-threatening situations leading to a 搉ear-miss� event may arise unexpectedly in pregnancy. Delay in seeking help, delayed access to care, and poor quality of emergency obstetric services can lead to undesirable outcomes. Women meeting the WHO 搉ear-miss� criteria were assessed using a cross-sectional study design. These women were interviewed to evaluate the circumstances leading to a near-miss event. Reasons for delays in getting proper care were studied using the �delays� model.� Thirty-two women met the criteria for 搉ear miss� during the 15-month study period, with a maternal near-miss incidence ratio of 9.27/1000 live births. One or more delays were identified in 21 (65.6%) near-miss cases. Delayed access to care was the most important factor for delay. A review of near-miss cases can be used to improve and optimize the existing obstetric services.

Frecuencia y factores asociados a la histerectomía obstétrica en un hospital de segundo nivel en México / Frequency and factors associated with obstetric hysterectomy in a second level hospital in México

INTRODUCCION La histerectomía obstétrica es procedimiento de urgencia para resolver una situación grave, su incidencia es de 5 a 15 por cada 1000 eventos obstétricos OBJETIVO GENERAL Determinar la frecuencia y factores asociados a la histerectomía obstétrica en un hospital de segundo nivel en México. METODOLOGIA Estudio descriptivo, transversal y retrospectivo en el periodo de Enero de 2014 a Diciembre del 2016, se incluyeron todos los casos de histerectomía posterior a un evento obstétrico, se estudiaron: edad, paridad, vía de interrupción del embarazo, antecedente de cesárea previa, indicaciones y complicaciones de la histerectomía, ingreso al servicio de terapia intensiva y mortalidad, el análisis se realizó con estadística descriptiva. RESULTADOS Durante el periodo de estudio, se atendieron 37 308 eventos obstétricos, efectuándose histerectomía obstétrica a 153 pacientes que representan el 0.57%, es decir, una HO por cada 243 embarazos. La edad promedio de quienes se les efectuó la histerectomía fue de 34 años de edad, siendo más frecuente en el grupo de mayores de 35 años, que habían tenido dos o tres embarazos previos. El antecedente de cesárea previa fue del 69.2%. La vía de interrupción del embarazo actual fue de cesárea en el 72.1%. La principal indicación fue la atonía uterina en 51 casos (33.3%). La complicación más frecuente fue la anemia aguda en el 83%. Hubo 1 muerte materna (0.6%). CONCLUSIONES La Histerectomía obstétrica es una cirugía de urgencia, por lo que se deben de identificar durante el control prenatal los factores asociados a las principales indicaciones de esta complicación.

INTRODUCTION Obstetric Hysterectomy (OH) is an emergency procedure to solve a life threatening condition, and its incidence is 5 to 15 per 1000 obstetric events. GENERAL OBJETIVE To determine the frequency and factors related with obstetric hysterectomy at a secondary hospital in Mexico. METHODOLOGY Descriptive, cross-sectional and retrospective study from January 2014 to December 2016 including all hysterectomy cases due to an obstetric event. Factors such as Age, number of deliveries, abortions, and previous cesarean sections, admission to the Intensive care unit, surgical indications, complications and mortality because of hysterectomy were analyzed thru descriptive statistics. RESULTS 37 308 obstetric events were registered and 153 were treated with Obstetric Hysterectomy representing 0.57% of the total, meaning one OH per every 243 pregnancies. The average age of those who had a hysterectomy was 28.5 years, and the procedure had its peak at the group of age older than 35 years who had had two or more pregnancies. The history of previous cesarean section was 39.2%. In 72.1% the pregnancy was terminated with a cesarean section. The main indication for hysterectomy was Uterine Atony in 33.3% (51 cases). The most frequent complication was acute anemia in 83%. There was a maternal death (0.6%). CONCLUSIONS Obstetric Hysterectomy is an emergency surgery, there are related factors that must be identified during the prenatal control to avoid this complication.

Tasa de hemorragia, histerectomía obstétrica y muerte materna relacionada / Rate of obstetric hemorrhage, obstetric histerectomy and related maternal death in Hospital Central Ignacio Morones Prieto

RESUMEN ANTECEDENTES: la hemorragia obstétrica sobreviene en 3% de los nacimientos y en Estados Unidos es responsable de 18% de las causas de muerte obstétrica. En 2012 fue la segunda causa de muerte materna en México. La predicción del riesgo de hemorragia es compleja porque solo 40% de las pacientes tiene algún factor de riesgo identificado. La conducta activa del tercer periodo del trabajo de parto es la única medida útil demostrada por diferentes estudios para prevenir la hemorragia. OBJETIVO: determinar la tasa de hemorragia e histerectomía obstétricas y muertes maternas relacionadas. MATERIALES Y MÉTODOS: estudio retrospectivo y descriptivo efectuado mediante el análisis de los expedientes clínicos de pacientes atendidas de parto o cesárea en el Hospital Central Ignacio Morones Prieto de San Luis Potosí, SLP, entre los meses de enero de 2011 a octubre de 2015, y que tuvieron hemorragia o histerectomía obstétricas. Criterios de inclusión: pacientes con diagnóstico de hemorragia e histerectomía obstétricas y muerte materna en este hospital. Criterios de exclusión: hemorragias o histerectomías efectuadas en otros hospitales y expedientes incompletos. RESULTADOS: se atendieron 27,158 nacimientos; de estos 19,569 por parto y 7,589 por cesárea (28%). Se registraron 657 casos de hemorragia (tasa 2.4) y 58 histerectomías obstétricas. Las principales causas de la hemorragia obstétrica fueron: atonía uterina (36.2%), acretismo placentario (32.7%) y placenta previa más acretismo placentario (12%). Hubo 125 ingresos a la unidad de cuidados intensivos por hemorragia obstétrica y una muerte materna relacionada. CONCLUSIONES: la tasa de hemorragia obstétrica de 2.4 es indicativa del incremento en el número de cesáreas y la consecuente asociación con el acretismo placentario que reemplazó a la atonía uterina como primera causa de histerectomía obstétrica.

ABSTRACT BACKGROUND: Obstetric hemorrhage occurs in 3% of births. It is responsible for 18% of causes of death in US. In 2012 was the second leading cause of maternal death in Mexico. There is difficulty in predicting the risk of bleeding because only 40% of patients have some risk factor identified. Active management of the 3rd period of labor has been the only useful measure demonstrated by different studies to prevent obstetric hemorrhage. OBJECTIVE: The aim was to determine the rate of obstetric hemorrhage, obstetric hysterectomy and maternal deaths related to our hospital. MATERIALS AND METHODS: A retrospective study conducting search of medical records of Central Hospital Ignacio Morones Prieto in San Luis Potosi, of women who childbirth attended or cesarean section from January 2011 to October 2015, which presented obstetric hemorrhage, and as hysterectomy for uterine atony. Having as inclusion criteria patients diagnosed with obstetric hemorrhage and obstetric hysterectomy performed in this hospital between the above dates. And searching the number of direct maternal deaths. Exclusion criteria hysterectomies performed in other hospitals and incomplete records. RESULTS: From January 2012 to December 2015 a total of 21.648 births were 19,569 births, 7,589 Caesarean sections, were treated a total of 657 obstetric hemorrhage were presented, with a rate of 2.4 obstetric hemorrhage during the study time. There were 53 obstetric hysterectomies. It is the main cause obstetric hemorrhage: 36.2% uterine atony, 32.7% placenta accreta, and 12% placenta accreta plus placenta praevia. There were 125 income Intensive Care Unit for Obstetric Hemorrhage and 1 maternal death related to it. CONCLUSIONS: The rate of obstetric hemorrhage HCIMP is 2.4 during the study time. The increase in the number of cesareans and subsequent association with acretism has been replacing the uterine atonia as first causa of obstetric hysterectomy in our hospital.

Histerectomía obstétrica en el Hospital General Dr. Aurelio Valdivieso, Oaxaca, México / Obstetric hysterectomy in a secondary hospital

Objetivo: Determinar la incidencia, principales indicaciones y complicaciones de la histerectomía obstétrica (HO) en un hospital de segundo nivel de atención a cuatro años de implementar el programa de prevención y manejo de la hemorragia obstétrica. Método: Estudio de tipo descriptivo de revisión de expedientes clínicos, de tipo transversal, analítico y retrospectivo. Resultados: Se hallaron 51 expedientes de pacientes a quiénes se realizó HO de enero de 2012 a noviembre de 2015. La prevalencia fue de 17,1/10.000 nacimientos, la incidencia por año fue de 1,7 (2012), 1,7 (2013), 1,4 (2014) y 1,9 (2015) por cada mil nacimientos respectivamente. La prevalencia de HO post-cesárea fue de 25,6/10.000 y en el post-parto de 10,6/10.000. Las variables que alcanzaron significancia entre cirugía programada y de emergencia fue pérdida sanguínea y necesidad de transfusiones sanguíneas. El procedimiento se asocia a anemia en el puerperio 7 veces más y las principales indicaciones para realizar el procedimiento fueron alteración de la adherencia placentaria e hipotonía. Conclusiones: El diagnóstico prenatal de anomalías en la adherencia placentaria, la mejor utilización de hemoderivados y la técnica quirúrgica ha eliminado la mortalidad materna por hemorragia obstétrica masiva en los últimos cuatro años en el Hospital General Dr. Aurelio Valdivieso.

Objective: To determine the incidence, main indications and complications of obstetric hysterectomy in a secondary hospital care to four years to implement the program of prevention and management of obstetric hemorrhage. Methods: Descriptive study of review of clinical records, transversal, analytical and retrospective. Results: 51 cases of patients who obstetric hysterectomy (OH) was held between January 2012 to November 2015. The prevalence was 17.1/10,000. The incidence per year was 1.7 (2012), 1.7 (2013), 1.4 (2014) and 1.9 (2015) per 1000 births, respectively. The prevalence of post-cesarean OH was 25.6/10,000 while postpartum OH was 10.6/10,000. The variables that reached significance between scheduled and emergency surgery was blood loss and need for blood transfusions. The procedure is associated with anemia in the postpartum period 7 times and the main indications for the procedure were alteration abnormal placental adhesion and uterine atony. Conclusions: The prenatal diagnosis of abnormal placental adhesion, better use of blood products and surgical technique has eliminated maternal mortality by massive obstetric hemorrhage in the last four years in the General Hospital Dr. Aurelio Valdivieso.

Placenta increta en cuerno uterino / Increta placenta in uterine horn

La placenta es un órgano materno fetal que tiene funciones importantes durante todo el embarazo y el desarrollo fetal. En ocasiones puede tener anormalidades anatómicas, estructurales, funcionales o asociadas con el sitio de implantación. Se presenta un caso de placenta increta en cuerno uterino, localización poco frecuente, como hallazgo transoperatorio en el curso de una operación cesárea que continua con una histerectomía obstétrica. Se muestran imágenes de la pieza quirúrgica, así como imágenes macro y microscópicas de anatomía patológica ilustrativas de tan infrecuente localización de este trastorno adherencial placentario. Con el objetivo de presentar un caso de placenta increta, en una localización poco frecuente como el cuerno uterino y revisar el tema se presentó un caso.

The placenta is a maternal fetal organ with important functions throughout pregnancy and fetal development. Sometimes it can develop anatomical, structural, or functional abnormalities, and sometimes these are associated with the implantation site. A case of placenta accreta in the uterine horn is presented. This is a rare location, as intraoperative finding during a Caesarean section followed by an obstetric hysterectomy. Illustrative images of the surgical specimen are shown as well as macro and microscopic pictures of pathology of such unusual location of this disorder. A case of increta placenta is presented in an unusual location such as uterine horn with the aim to review the issue.

Frequency, Indications and Maternal Outcome in Obstetric Hysterectomy in a Tertiary Care Centre in India.

The aim of present study is to review the frequency, indications, associated risk factors, maternal morbidity, maternal and fetal mortality associated with emergency obstetric hysterectomy in a tertiary care academic referral centre. A retrospective descriptive analysis from Jul 2005 to Jun 2010 was carried out in a tertiary care academic referral centre. Main outcome measures were frequency, indications, associated risk factors, maternal morbidity, maternal and fetal mortality associated with emergency obstetric hysterectomy. There were 41 cases of obstetric hysterectomy over the study period and the frequency of obstetric hysterectomy was 22.9/10,000 births. The incidence of hysterectomy for vaginal delivery was 0.017% and for caesarean section was 0.318%. Maximum number of patients (36.5%) were in the age group 26-30 years. 60.9% patients were antenatally unbooked emergency cases. It was most common in para two (46.3%) followed by para four or more (26.8). Main indications for obstetric hysterectomy were rupture uterus and postpartum haemorrhage (31.7% each) followed by morbidly adherent placenta (21.9%). All women required blood transfusion, 26 (63.42%) were anaemic, 5 (12.19%) required ICU stay. There was one maternal mortality and varied morbidity pattern. 12 fetal mortalities were noted, including 9 for uterine rupture, 2 for placenta previa in scarred uterus and one in obstructed labor case. Emergency obstetric hysterectomy still remains a life saving procedure and complications can be minimized by timely and thoughtful decision. Unnecessary delay or undue haste increase maternal morbidity.

Comportamiento epidemiológico de la histerectomía obstétrica / Epidemiological behavior of obstetric hysterectomy

Introducción: la histerectomía obstétrica es una medida quirúrgica drástica que se realiza en aquellas pacientes que no responden a otros procedimientos, frente a una hemorragia severa después de un parto o cesárea.Objetivos: caracterizar la distribución de un conjunto de variables en gestantes que requirieron una histerectomía obstétrica posparto, describir sus características clínicas y obstétricas e identificar las principales variables epidemiológicas en relación con el periparto y parto.Métodos: se realizó una investigación descriptiva, retrospectiva, de 19 gestantes a las cuales se les practicó histerectomía obstétrica por diferentes causas, atendidas en el Servicio de Partos del Hospital Ginecobstétrico Docente Ramón González Coro, en el período comprendido entre el 1ro. de enero de 2009 hasta el 31 de diciembre de 2010. Se utilizó la base de datos confeccionada a través del Sistema Microsoft Excel 2007. El estudio se efectuó conforme a las reglamentaciones y principios éticos existentes para la investigación en humanos y los estudios clínicos.Resultados: el mioma uterino se observó en el 26,3 porciento; el 31,6 porciento fueron nulíparas; predominó en pacientes con cesárea primitiva en un 42,1 porciento; el 66,7 porciento fue debido a atonía uterina y fue necesario el uso de prostaglandinas en el 31,6 porciento de los casos.Conclusiones: las complicaciones relacionadas con la cesárea y la atonía uterina siguen constituyendo las causas fundamentales de indicación de la histerectomía obstétrica

Introduction: obstetric hysterectomy is a surgical drastic measure performed in those patients who do not respond to other procedures, in case of severe bleeding after childbirth or caesarean.Objectives: to characterize the distribution of a set of variables in pregnant women requiring obstetric postpartum hysterectomy, to describe their clinical and obstetric characteristics and to identify key epidemiological variables relating to peri-delivery and delivery.Methods: a descriptive, retrospective study was conducted in 19 pregnant women who underwent obstetric hysterectomy for various reasons at the delivery service in Ramón González Coro Hospital, from 1st January 2009 to 31 December 2010. A database created through Microsoft Excel System 2007 was used. The study was conducted in accordance with existing regulations and ethical principles for human research and clinical studies.Results: uterine myoma was observed in 26.3 per cent, and it was predominant in patients with early cesarean in 42.1 per cent, 31.6 per cent were nulliparous, 66.7 per cent was caused by uterine atony and the use prostaglandin was necessary in 31.6 per cent of cases.Conclusions: complications associated with cesarean section and uterine atonies remain the root causes of obstetric hysterectomy indication

Obstetric hysterectomy: A life saving emergency.

Objective: To study the cases of obstetric hysterectomy performed over a period of 1 year (January 2008 to December 2008) in tertiary care center to estimate the incidence, indications, and maternal outcome following the procedure. Materials and Methods: A retrospective analysis of 20 cases of emergency obstetric hysterectomies performed during the study period. Results: During the study period, there were 11,356 deliveries and 20 emergency hysterectomies were done, giving an incidence of 0.17%. 75% cases were unbooked. Ruptured uterus was the most common indication for the procedure, followed by atonic Post-partum haemorrhage (PPH). Six out of 10 cases of rupture uterus had a previous cesarean delivery. Maternal mortality was 15% due to late referral. Conclusion: Emergency obstetric hysterectomy though a rare operation, still remains a life-saving procedure with which every obstetrician must be conversant. Regular antenatal care, identification of high-risk cases, and prompt referral can reduce the incidence of this operation.