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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Glaze S, Ekwalanga P, Roberts G, et al. Peripartum hysterectomy: 1999 to 2006. Obstet Gynecol 2008; 111:732.
- Bodelon C, Bernabe-Ortiz A, Schiff MA, Reed SD. Factors associated with peripartum hysterectomy. Obstet Gynecol 2009; 114:115.
- Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review. Obstet Gynecol 2010; 115:637.
- Flood KM, Said S, Geary M, et al. Changing trends in peripartum hysterectomy over the last 4 decades. Am J Obstet Gynecol 2009; 200:632.e1.
- Hernandez JS, Nuangchamnong N, Ziadie M, et al. Placental and uterine pathology in women undergoing peripartum hysterectomy. Obstet Gynecol 2012; 119:1137.
- Knight M, UKOSS. Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage. BJOG 2007; 114:1380.
- Fitzpatrick KE, Sellers S, Spark P, et al. The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study. BJOG 2014; 121:62.
- Giambattista E, Ossola MW, Duiella SF, et al. Predicting factors for emergency peripartum hysterectomy in women with placenta previa. Arch Gynecol Obstet 2012; 285:901.
- Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997; 177:210.
- Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226.
- Whiteman MK, Kuklina E, Hillis SD, et al. Incidence and determinants of peripartum hysterectomy. Obstet Gynecol 2006; 108:1486.
- Imudia AN, Awonuga AO, Dbouk T, et al. Incidence, trends, risk factors, indications for, and complications associated with cesarean hysterectomy: a 17-year experience from a single institution. Arch Gynecol Obstet 2009; 280:619.
- Knight M, Kurinczuk JJ, Spark P, et al. Cesarean delivery and peripartum hysterectomy. Obstet Gynecol 2008; 111:97.
- Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol 2011; 117:331.
- Wright JD, Devine P, Shah M, et al. Morbidity and mortality of peripartum hysterectomy. Obstet Gynecol 2010; 115:1187.
- Imudia AN, Hobson DT, Awonuga AO, et al. Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy. Am J Obstet Gynecol 2010; 203:221.e1.
- Tan CH, Tay KH, Sheah K, et al. Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta. AJR Am J Roentgenol 2007; 189:1158.
- Shrivastava V, Nageotte M, Major C, et al. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol 2007; 197:402.e1.
- Ballas J, Hull AD, Saenz C, et al. Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: a management paradox. Am J Obstet Gynecol 2012; 207:216.e1.
- Salim R, Chulski A, Romano S, et al. Precesarean Prophylactic Balloon Catheters for Suspected Placenta Accreta: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:1022.
- Carnevale FC, Kondo MM, de Oliveira Sousa W Jr, et al. Perioperative temporary occlusion of the internal iliac arteries as prophylaxis in cesarean section at risk of hemorrhage in placenta accreta. Cardiovasc Intervent Radiol 2011; 34:758.
- Milne ME, Yazer MH, Waters JH. Red blood cell salvage during obstetric hemorrhage. Obstet Gynecol 2015; 125:919.
- Albright CM, Rouse DJ, Werner EF. Cost savings of red cell salvage during cesarean delivery. Obstet Gynecol 2014; 124:690.
- Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta accreta. BJOG 2009; 116:648.
- Wright JD, Bonanno C, Shah M, et al. Peripartum hysterectomy. Obstet Gynecol 2010; 116:429.
- Duenas-Garcia OF, Goldberg JM. Topical hemostatic agents in gynecologic surgery. Obstet Gynecol Surv 2008; 63:389.
- Achneck HE, Sileshi B, Jamiolkowski RM, et al. A comprehensive review of topical hemostatic agents: efficacy and recommendations for use. Ann Surg 2010; 251:217.
- Gabay M. Absorbable hemostatic agents. Am J Health Syst Pharm 2006; 63:1244.
- Berrevoet F, de Hemptinne B. Use of topical hemostatic agents during liver resection. Dig Surg 2007; 24:288.
- Finan MA, Fiorica JV, Hoffman MS, et al. Massive pelvic hemorrhage during gynecologic cancer surgery: "pack and go back". Gynecol Oncol 1996; 62:390.
- Dildy GA, Scott JR, Saffer CS, Belfort MA. An effective pressure pack for severe pelvic hemorrhage. Obstet Gynecol 2006; 108:1222.
- Ghourab S, Al-Nuaim L, Al-Jabari A, et al. Abdomino-pelvic packing to control severe haemorrhage following caesarean hysterectomy. J Obstet Gynaecol 1999; 19:155.
- Awonuga AO, Merhi ZO, Khulpateea N. Abdominal packing for intractable obstetrical and gynecologic hemorrhage. Int J Gynaecol Obstet 2006; 93:160.
- Howard RJ, Straughn JM Jr, Huh WK, Rouse DJ. Pelvic umbrella pack for refractory obstetric hemorrhage secondary to posterior uterine rupture. Obstet Gynecol 2002; 100:1061.
- Burchell RC. The umbrella pack to control pelvic hemorrhage. Conn Med 1968; 32:734.
- PARENTE JT, DLUGI H, WEINGOLD AB. Pelvic hemostasis: a new technic and pack. Obstet Gynecol 1962; 19:218.
- Cassels JW Jr, Greenberg H, Otterson WN. Pelvic tamponade in puerperal hemorrhage. A case report. J Reprod Med 1985; 30:689.
- Robie GF, Morgan MA, Payne GG Jr, Wasemiller-Smith L. Logothetopulos pack for the management of uncontrollable postpartum hemorrhage. Am J Perinatol 1990; 7:327.
- Hallak M, Dildy GA 3rd, Hurley TJ, Moise KJ Jr. Transvaginal pressure pack for life-threatening pelvic hemorrhage secondary to placenta accreta. Obstet Gynecol 1991; 78:938.
- Briery CM, Rose CH, Hudson WT, et al. Planned vs emergent cesarean hysterectomy. Am J Obstet Gynecol 2007; 197:154.e1.
- Shellhaas CS, Gilbert S, Landon MB, et al. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol 2009; 114:224.
- 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