Emergency obstetrical hysterectomy in a low-income country: about 70 cases

 

Objective:

This study aimed to describe risk factors, indications, and complications of Emergency obstetric hysterectomy (EOH), and to determine the postoperative maternal prognosis.

Design:

This was a retrospective, single-centre, descriptive study conducted over a 17-year period, from January 2003 to December 2019 in Ben Arous regional hospital. 

Method:

We included patients with vaginal or caesarean delivery beyond 28 gestational weeks (GW), who had a severe postpartum haemorrhage, within 24 hours of delivery, requiring primary EOH or after the failure of conservative surgical treatment.

Results:

Seventy cases of EOH were enrolled. The rate of EOH was 1.3 ‰, i.e. one EOH per 769 deliveries. The mean age was 34.5 years (± 5.1). The most common risk factors were multiparity 51/70 (73%), caesarean delivery 47/70 (67%), and scarred uterus 41/70 (60%). The median delivery term was 38 GW and five days. The route of delivery was predominantly by cesarean section, with 67% of women. The rate of vaginal delivery was 33% including one instrumental delivery by forceps. The main symptom was heavy vaginal bleeding observed in 84% of patients (59/70). The average haemoglobin of our patients was 10.67 g/dl [±1.68]. 79% of patients required blood transfusion. 41 patients (59%) had an EOH after conservative treatment failure, and 29 patients (41%) required primary EOH. The first-line conservative treatment was in most cases uterine artery ligation (70%). The second-line conservative procedure was a triple Tsirulnikov ligation in 70% of cases, and bilateral hypogastric artery ligation in 30% of patients. In the third line, bilateral hypogastric artery ligation was performed in 5/27 patients (19%). The indications for EOH were multiple, dominated by placenta accreta in 27 patients (39%), followed by uterine inertia in 24 patients (34%), and uterine rupture in 11/70 (16%). The intraoperative morbidity rate was 34% (24/70). The most frequent complications were, in order of frequency, haemorrhagic shock 12/70 (17%), and bladder damage 4/70 (6%). Eleven patients (16%) were transferred to intensive care unit. The postoperative morbidity rate was 16%. These complications were dominated by acute renal failure 3/70 (4%) and haemorrhagic shock 3/70 (4%). There were six cases of maternal death (8%).

Conclusions:

Although conservative surgical techniques for the treatment of post-partum haemorrhage have considerably reduced the incidence of EOH, it remains , nevertheless, the unavoidable maternal life-saving procedure that any obstetrician may face.