Emergency obstetrical hysterectomy: subtotal or total hysterectomy?

 

Objective:

This study aimed to determine factors influencing the choice of Emergency obstetrical hysterectomy (EOH) type.

Design:

This was a retrospective, single-centre, descriptive, and analytical study conducted over a 17-year period, spanning from January 2003 to December 2019. 

Method:

70 patients were included in this study. They either have had a vaginal or caesarean delivery beyond 28 weeks of amenorrhoea, with severe postpartum haemorrhage within 24 hours of delivery requiring immediate EOH or after the failure of conservative surgical treatment. We compared data from patients who had a total EOH with those with a subtotal EOH to investigate factors influencing the choice of operative technique.

Results :

In our series, 41 patients (59%) had an EOH after the failure of conservative treatment, and 29 patients (41%) required an immediate EOH. Subtotal EOH (SEOH) was performed in 55 patients (79%), and 15 patients (21%) had total EOH (TEOH).

The mean age of patients in the SEOH group was 34.15 [±5.52], and 35.8 [±3.12] in the TEOH group (p=0.14).   Parity and socioeconomic level did not make a difference between the two groups. The use of TEOH was higher in patients with a scarred uterus (p=0.02, OR=5.8, and CI 95%=1.19-28.27).

In our series, uterine inertia was significantly associated with the SEOH group (p = 0.013; OR = 0.09 and CI 95% = 0.01 - 0.81). The other indications were the same between the two groups. There was no statistically significant difference in the incidence of complications between the SEOH and TEOH groups. The transfusion requirement in the SEOH group was not different from that in the TEOH group (p=0.246) (p=0.571). The mean operation time was significantly shorter for the SEOH group than for the TEOH group, 167.45 ±69.28 minutes versus 230 ±74.05 minutes, respectively (p<0.002).

Comparison of patients’ data by multivariate logistic regression analysis ruled out scar uterus and uterine inertia. It retained placenta accreta, and procedure duration as factors influencing the choice of hysterectomy type.

Conclusions 

The conflicting results in the literature regarding the superiority of subtotal hysterectomy over total hysterectomy may be explained by the randomisation, which is extremely difficult to consider in a life-threatening emergency. However, it seems more interesting to assume that it is the indication of the hysterectomy itself that guides the surgeon, according to his clinical appreciation and experience.