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Peripartum hysterectomy for management of hemorrhage

Author
Daniela A Carusi, MD, MSc
Section Editors
Charles J Lockwood, MD, MHCM
Howard T Sharp, MD
Deputy Editor
Kristen Eckler, MD, FACOG

INTRODUCTION

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 [5].

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 [6]. 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".)

SURGICAL PLANNING

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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Literature review current through: Nov 2016. | This topic last updated: Thu Apr 14 00:00:00 GMT 2016.
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