Emergency Peripartum Hysterectomy in Pakistan Railway Teaching Hospital Rawalpindi: Eleven Years Review

Emergency Peripartum Hysterectomy [EPH] is a major surgical procedure. There appears to be a rise in the rate of emergency peripartum hysterectomy [EPH] in the developed world. Peripartum hysterectomy is high risk but a life saving operation. It is usually associated with significant maternal and fetal morbidity and mortality. Obstetricians should identify patients at risk and anticipate the complications, as early intervention and proper management results in optimal outcome. To determine the incidence, indications, risk factors, complications and management of EPH over the last eleven years. A descriptive study. All cases of EPH performed in the period between January 2001 and December 2011 were included in the study. Study was conducted at Railway Teaching Hospital, Rawalpindi [in northern Pakistan]. Data of all the cases of EPH cases operated during the study period was collected from the hospital obstetric record. Data of basic demographics, mode of delivery, maternal and fetal outcome along with associated complications was collected and entered into the Statistical Package for Social Sciences version 14.0 [SPSS Inc., Chicago, IL, USA] for further analysis. Indications, pre-op planning, type of operation, emergency decision, blood loss, transfusion, complications, were compared and cross-tabulated. Statistical analysis included: Chi-square and Fisher exact tests, where appropriate, and two-sample t test. Total deliveries were 13560 in 11 years. Twenty Six EPH cases were performed among deliveries, giving an incidence of 1.8 per 1000 deliveries i.e. one in 566 deliveries. The indications were uterine atony [34.61%], ruptured uterus [23.07%] and cervical/vaginal tears [11.53%], placenta praevia [11.53%], invasive placental adhesion [accreta, increta, percreta [11.53%]]. A significant association between previous uterine surgery and abnormal placentation was shown [p=0.02], especially those with previous caesarean [p=0.003]. One maternal and six perinatal mortalities were recorded. Four perinatal deaths were of non-booked patients, handled by traditional birth attendants/private clinics. Out of two perinatal deaths of booked patients, one was pre-term and other was delivered by forceps. Maternal morbidity was prevalent, including twenty three intensive care admissions, three disseminated intravascular coagulopathies, three bladder injuries, three re-explorations, multiple blood, FFPs and platelet transfusions, two pulmonary embolism and one cardio- respiratory failure. Maternal death was of non-booked patient with previous scar, home delivery, uterine rupture and brought to hospital with un-recordable BP and very weak pulse. Incidence of peri-partum hysterectomy is increasing. It is a major operation, and almost always an emergency with significant blood loss. An early decision should be made to save life of the patient and prevent complications. The most important risk factor for peripartum hysterectomy in our patients is hemorrhage, most notably caused by uterine atony, uterine rupture, placenta previa and abnormally adherent placenta