July Sept issue by MikeJenny


									Pak J Med Sci             July - September 2003             Vol. 19        No. 3      182 - 186

     Original Article

                             Dr. Sumera Tahir 1, Dr. Mahmood Aleem         2
                                                                               & Dr. Samina Akram   3

     Objectives: To analyze the maternal outcome of peripartum hysterectomy in badly handled cases with
     ruptured uterus and severe post partum haemorrhage.
     Design and Setting: A retrospective study carried out in Obstetric & Gynaecology Unit-II, Divisional
     Headquarter Hospital (D.H.Q.) Faisalabad over a period of two years.
     Subject: Thirty patients who underwent emergency peripartum hysterectomy during the study period
     of two years.
     Main Outcome Measures: Indications, associated maternal morbidity & mortality of peripartum
     Results: There were 30 cases of emergency peripartum hysterectomy over a period of two years. The
     most common indication was uterine rupture (42.9%), followed by uterine atony (26.6%). All women
     required blood transfusion, five (17%) developed coogulopathy, four (13.3%) had bladder injuries, two
     (6%) required salpingoophorectomy for uncontrolled adnexal bleeding and two (6%) patients underwent
     a repeat laparotomy for internal haemorrhage. Maternal mortality was 6% (n=2).
     Conclusion: Peripartum hysterectomy continues to have a high incidence in our community. High
     parity, illiteracy & ignorance coupled with inadequate maternity services, injudicious use of syntocinon,
     improper third stage management, abnormal placentation & uterine atony were identified as risk
     factors for emergency peripartum hysterectomy. An early decision of obstetrician can save blood loss
     & prevent complications.
     KEY WORDS: Peripartum hysterectomy, Abnormal placentation, Maternal morbidity & mortality.
     Pak J Med Sci     July - September 2003   Vol. 19   No. 3   182-186

1.   Dr. Sumera Tahir FCPS                                                           INTRODUCTION
     Assistant Professor Gynaecology & Obstetrics
2. Dr. Mahmood Aleem FRCOG                                            Obstetric hysterectomy refers to surgical re-
     Professor Gynaecology & Obstetrics Unit-II                     moval of the pregnant or recently pregnant
3. Dr. Samina Akram MBBS                                            uterus with the pregnancy insitu or due to
     Registrar Obs. & Gynae, Unit-II,
                                                                    complications of delivery. It is an indispens-
1-3. Divisional Headquarter Hospital
     Punjab Medical College,                                        able life saving tool for management of
     Faisalabad, Pakistan                                           intractable obstetric haemorrhage unrespon-
                                                                    sive to other treatment.
     Correspondence:                                                  In modern obstetrics the overall incidence is
     Dr. Sumera Tahir                                               0.05%1, but there is a considerable difference
     Assistant Professor Gynaecology & Obstetrics,                  in its incidence in different parts of the world
     Punjab Medical College,
     Divisional Headquarter Hospital,                               depending upon modern obstetrical services,
     Faisalabad, Pakistan                                           standard and awareness of antenatal care and
     E-mail: dr_sumera@hotmail.com                                  effectiveness of family planning activities of a
                                                                    given community. In Nigeria, the incidence is
*    Received for publication:      January 11, 2003
                                                                    1 in 349 2 and 1.3/1000 births in South
     Revision accepted:             April 28, 2003                  California3.
                                                                  Emergency peripartum hysterectomy
  Indications for emergency peripartum hys-          Indications of Hysterectomy
terectomy include uterine atony3,4,5. Ruptured         The most common indication for hysterec-
uterus is the second commonest with overall          tomy was ruptured uterus 43% (n=13). Uter-
incidence of 0.05%. It increases to 0.8% after       ine atony not responding to uterotonic agents
previous lower segment caesarean section6,7          was the indication in 27% (n=8). In five pa-
and 5% after classical section. It is responsible    tients (17%) it was abnormal placentation
for 5% maternal deaths in United States each         Table-III.
year8. Incidence in developing world is much
higher due to poor obstetric facilities though a                  Table – I: Age of Patients
definite statistical figure is not available. Ab-
normal placentation is increasing in frequency       No. of        Age of        Frequency      Percentage
as an indication. Recent studies show placenta       Groups       Patients                         (%)
accreta as one of primary indications9,10. Uter-     1            18   –   22         03          10.00
ine inversion is rare occurring in 1:640011 to       2            23   –   27         04          13.34
1:210012 deliveries. Sepsis is also a rare cause.    3            28   –   32         07          23.34
  Emergency peripartum hysterectomy in-              4            33   –   37         14          46.66
creases maternal morbidity and mortality. The        5            38   –   42         02          06.66
most frequent operative complications are
haemorrhage and urinary tract injuries. A com-       Total                            30         100.00
mon cause of peroperative haemorrhage is loss        Average age = 31 years
of control of a uterine artery or adnexal vascu-
                                                                Table – II: Parity Distribution
lar pedicle. Commonest postoperative compli-
cations are bleeding and infection.
                                                     No. of        Parity        Frequency      Percentage
                                                     Groups                                        (%)
                                                     1            00   –   02         02          6.66
  For this study thirty cases of peripartum hys-
                                                     2            03   –   05         05          16.66
terectomy were selected during a period of two
                                                     3            06   –   08         11          36.67
years, whether delivered inside or outside the
                                                     4            09   –   11         08          26.67
hospital. The patients and their family were
                                                     5            12   –   14         04          13.34
counseled regarding the potential need of emer-
gency hysterectomy and all of them signed an         Total                            30         100.00
informed consent. All patients received blood        Mean Parity = 07.00
transfusion and prophylactic antibiotic cover.
All patients were operated under general ana-               Table – III: Indications for Peripartum
esthesia. Operative complications were defined                            Hysterectomy
as vascular, bladder, uretral & bowel injuries.
  Post-operative complications were defined as       No. of Age of                     Frequ- Percentage
adverse events that occurred as a result of the      Groups Patients                    ency     (%)
procedure. All information was recorded on           1          Ruptured Uterus            13     43.00
proforma.                                            2          Uterine Atony              08     27.00
                                                     3          Placenta Accreta           05     17.00
                                                     4          Extended Uterine           02     07.00
Patient Characteristics                                         Incision
 The mean age of the patients was 31 years           5          External Cervical          01     03.00
with a range of 18 to 42 yeas (Table-I). The                    Tears
parity range was 0 to 14. Median parity was 7        6          Inverted Uterus            01     03.00
Table-II.                                            Total                                 30     100.00
                       Pak J Med Sci      Vol. 19   No. 3                       183
Sumera Tahir et al.
Type of Hysterectomy                                         damage to urinary tract were the most com-
  Total abdominal hysterectomy was per-                      mon complications.
formed in 25 patients (83.33%) while subtotal                  Average stay in hospital was 12 days
hysterectomy was done in 5 (16.67%) cases                    ranging from 7 to 21 as shown in Table-VI.
Table-IV.                                                    Average amount of blood transfused was 3.5
                                                             units as shown in Table-VII. There were
Preoperative & Postoperative Complications                   two maternal deaths (6.66%) as shown in
 As listed in Table-V haemorrhage and                        Table-VIII.

        Table – IV: Type of Hysterectomy                            Table – VI: Average Stay in Hospital

No. of Type of                   No. of    Percentage        No. of        Days            No. of        Percentage
Groups Hysterectomy              Cases        (%)            Groups                       Cases (f)         (%)

1          Total Abdominal 25                   83.33        1           07   –   09         06            20.00
           Hysterectomy                                      2           10   –   12         12            40.00
                                                             3           13   –   15         08            26.67
2          Sub-total                 5          16.67        4           16   –   18         02            06.66
           Abdominal                                         5           19   –   21         02            06.67
                                                             Total                           30           100.00
Total                             30            100          Average stay in hospital = 12 days

      Table – V: Operative and Post-operative                     Table – VII: Quantity of blood available
    complications of Peripartum Hysterectomy                                   for transfusion

No. of Complications                      No. of Percen-     No. of     Quantity of Blood       No. of     Percentage
Groups    Cases                           Cases tage (%)
                                                             Groups     Units (500ml/unit)    Patients (f)    (%)

         Intra Operative Complications
                                                             1                1~2                  08          26.67
1        • Urinary Bladder Injury          04     13.30
2        • Adnexal Bleeding                03     10.00      2                3~4                  16          53.33
3        • Retroperitoneal                 02     06.60
                                                             3                5~6                  04          13.33

         Postoperative Complications                         4                7~8                  02          06.67
4        • Coagulopathy                    05     16.60
                                                             Total                                 30          100.00
5        • ICU Admission                   04     13.30
                                                             Average blood transfusion = 3.5 units
6        • Pneumonia                       04     13.30

7        • Re Exploration                  03     10.00
                                                                      Table – VIII: Maternal mortality
                                                             Total No.        No. of                Mortality
8        • Vaginal Cuff Cellulitis         02     06.60
                                                             of Cases         Deaths              Percentage (%)
9        • Acute Renal Failure             04     13.30

10       • Urinary Tract Infection         12     40.10      30                    2                    6.66

11       • Wound Infection                 05     16.60      Maternal Mortality = 6.66%

                            Pak J Med Sci         Vol. 19   No. 3                      184
                                                                  Emergency peripartum hysterectomy
               DISCUSSION                           There were four cases (13%) of bladder injury.
                                                    Maternal mortality was 6% in contrast to
  This study shows uterine rupture as a major       Engelsen23, by Castaneda13 by Zelop CM5. They
indication for emergency peripartum hyster-         reported no maternal deaths in their recent
ectomy followed by uterine atony and abnor-         studies. The high morbidity and mortality is
mally adherent placenta. This is contrary to the    due to delays in onset of the patients’ problem
indications reported in studies from developed      and the arrival in tertiary referral center
countries where abnormal placentation is the        leading to irreparable loss.
primary indication10,13. As reported by Clark
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                           Pak J Med Sci         Vol. 19    No. 3                     186

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