Peripartum hysterectomy for management of hemorrhage
- Daniela A Carusi, MD, MSc
Daniela A Carusi, MD, MSc
- Assistant Professor of Obstetrics & Gynecology
- Harvard Medical School
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Howard T Sharp, MD
Howard T Sharp, MD
- Section Editor — Gynecologic Surgery
- Professor and Vice Chair for Clinical Activities
- Department of Obstetrics and Gynecology
- University of Utah Health Sciences Center
Peripartum hysterectomy can be defined as a hysterectomy performed at the time, or within 24 hours, of delivery. Another definition is a hysterectomy performed any time from delivery to discharge from the same hospitalization.
The procedure may be emergent or planned. The most common indication for emergent procedures is severe uterine hemorrhage that cannot be controlled by conservative measures. Such hemorrhage is most commonly due to abnormal placentation or uterine atony, with each accounting for 30 to 50 percent of peripartum hysterectomies [1-4]. Other potential causes of severe intrapartum or postpartum uterine hemorrhage include uterine rupture, leiomyomas, and laceration of uterine vessels. Planned peripartum hysterectomy may be performed in patients with an antepartum diagnosis of placenta accreta or stage IA2 and IB1 cervical carcinoma. Infection appears to be an important contributor to peripartum hysterectomy. Not only is severe postpartum pelvic infection a potential indication for the procedure, but uteri removed for atony also show a relatively high rate of infection and inflammation on pathologic analysis .
In emergency situations, a sequence of conservative measures to control uterine hemorrhage should be attempted before resorting to more radical surgical procedures (table 1). If an intervention does not succeed, the next treatment in the sequence should be swiftly instituted. Conservative measures should be employed with the goal of avoiding the morbidity and sterilization that comes with hysterectomy. For those patients who inevitably require hysterectomy, immediate performance of the procedure (without using multiple conservative measures) leads to a lower transfusion requirement and possibly less morbidity . Moreover, there is increased blood loss with increased duration of time before performance of hysterectomy. Thus, conservative measures should be used in quick succession, and preparation for hysterectomy should begin promptly in cases of massive hemorrhage or maternal instability. (See "Overview of postpartum hemorrhage".)
The obstetrician should be prepared for the potential need to perform emergent peripartum hysterectomy, especially in patients with significant risk factors or heavy postpartum bleeding. Hysterectomy is not commonly performed on labor and delivery units; depending on local operating room resources, a general operating room may be necessary. An institution-specific labor and delivery unit checklist of equipment, other supplies, and action items that will be needed in the event of emergent hysterectomy can be helpful (table 2).
Preoperative risk assessment — Sometimes the obstetrician can anticipate the possible need for peripartum hysterectomy based on the patient’s risk factors. This enables patient preparation and counseling in the antenatal period, detailed surgical planning, and possibly avoidance of an emergency procedure. This is true primarily for women with abnormal placentation.
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- SURGICAL PLANNING
- Preoperative risk assessment
- Patient counseling
- Scheduling delivery of patients at high risk for cesarean hysterectomy
- Total versus supracervical hysterectomy
- Placement of hypogastric artery balloon catheters
- Preoperative preparation
- OPERATIVE PROCEDURE
- Key points
- Incision and delivery
- - Evaluation of bladder and ureteral integrity
- - Inspection and closure
- CONTROL OF PERSISTENT PELVIC BLEEDING
- Hemostatic agents
- Pelvic packing
- POSTOPERATIVE CARE
- Bladder care
- SUMMARY AND RECOMMENDATIONS