Emergency peripartum hysterectomy is usually performed during childbirth or postpartum in conditions of uncontrollable massive hemorrhage or life-threatening sepsis. It is a relatively uncommon procedure in this age of modern obstetrical care. The characterization of emergency peripartum hysterectomy worldwide was done in a systematic review and meta-analysis published in the journal Obstetrics and Gynecology.¹

Through this, the researchers aimed to determine the incidence (overall and country-wise) of emergency peripartum hysterectomy across countries based on income levels. They also attempted to explore the differences in its indications, risk factors, outcomes and management, which were also the secondary outcomes of the meta-analysis. A total of 154 studies were selected after a comprehensive search of PubMed, Medline, Embase, Cochrane Library, ClinicalTrials.gov, Web of Science and Emcare databases up to December 10, 2021.

Analysis of data revealed that 14,409 emergency peripartum hysterectomies were performed in 17,127,499 births in 42 countries. The overall pooled incidence of hysterectomy, which was the primary outcome, was found to be 1.1 per 1,000 births. Predictably, high-income countries had the lowest incidence of emergency peripartum hysterectomy at 0.7 per 1000 births compared to lower middle-income countries at 3 per 1000 births.

Overall, the most common indication of emergency postpartum hysterectomy was identified as placental pathology at 38% followed by uterine atony (27.0%) and uterine rupture (21.2%). When indications were assessed according to income levels, placental pathology (48.4%) was the commonest indication in high-income countries, whereas among the lower middle-income countries, uterine rupture (44.5%) was the most frequent indication. Almost half (49.8%) of the participants had a history of previous cesarean section; 51% had undergone ≥2 cesarean births.

To avoid hysterectomy, uterotonics were used in 17% women: 53.2% women received oxytocin, 44.6% prostaglandins and 17.3% were given ergometrine. In majority of women (80.5%), surgical measures were adopted, most common being compressive methods in 62.6%: bimanual compression in ~99%, vaginal or uterine packing in 20.5%, uterine balloon tamponade in 16.3% and uterine compression sutures in 14.3% women.

Maternal case fatality rate was significantly higher among women from the lower middle-income countries at 11.2 per 100 emergency peripartum hysterectomies performed. In high income countries, the maternal case fatality rate was just 1.0 per 100 emergency peripartum hysterectomies done.

Febrile morbidity occurred in 29.7% women. Other common complications were hematologic (such as bleeding, hypovolemic shock, anemia, coagulopathy) in 27.5% and infections (such as septicemia, thrombophlebitis, UTIs) in ~13%.

These findings point out the significant differences in the incidence as well as indications of emergency peripartum hysterectomy among different income settings. The risk of having an emergency peripartum hysterectomy was higher among women in low income countries including higher odds of experiencing the associated morbidity and mortality. The commonest indication globally was a placental pathology including placenta accreta spectrum, placenta previa, combined placental pathology, or placental abruption. Cesarean section is a significant risk factor for placenta accreta spectrum. While the overall incidence was little over 1 per 1000 births, the authors conclude that “the frequency of emergency peripartum hysterectomy is likely to increase in light of increasing cesarean delivery rates”.

As per the WHO, the caesarean section rate for any country should be between 10% and 15%. The National Family Health Survey (NFHS)-5 (2019-21) shows that the percentage of cesarean births in India has increased from 17.2% in NFHS-4 (2015-16) to 21.5% in the current fifth NFHS. The percentage of cesarean births in the private health facilities has gone up to 47.4% in the NFHS-5 from 40.9% in NFHS-4. Cesarean rates in government hospitals have also increased from 11.9% to 14.3%. While there are several reasons why cesarean delivery may be chosen over a vaginal birth, nevertheless, attempts must be made to reduce the rising cesarean delivery rates.

Reference

1. Kallianidis AF, et al. Incidence, indications, risk factors, and outcomes of emergency peripartum hysterectomy worldwide: a systematic review and meta-analysis. Obstet Gynecol. 2023 Jan 1;141(1):35-48. doi: 10.1097/AOG.0000000000005022.