Peripartum hysterectomy: Two years experience at Nelson Mandela Academic hospital, Mthatha, Eastern Cape South Africa

Abstract

Background: Obstetric haemorrhage is the leading direct cause of maternal mortality in South Africa. Objective: To determine the incidence, indications, associations and maternal outcomes of emergency peripartum hysterectomies. Methods: A descriptive and retrospective analysis of patients who had peripartum hysterectomy between 1 st February 2007 and 31 st January 2009 in Nelson Mandela Academic Hospital at Mthatha city. Results: The incidence of 0.95% of peripartum hysterectomies (n=63 or 9.5/1000 births) increased with the increasing maternal age from 0.121% at age of less than 20 years to 0.5% at age more or equal to 30 years. Similarly the incidence increased with parity from 0.332% for Primiparity to 0.468% at parity of four or more. The indications for the operation were uterine atony 19/63 (30.2%), secondary haemorrhage/puerperal sepsis 17/63 (27%) and ruptured uterus 16/63 (23.4%). The main intra operative complication was haemorrhage 13/63 (20.6%). Repeat laparotomy was done in 10/63 (15%) of patients due to haemorrhage. Admission to intensive care unit was 25/63 (39.7%). The case specific mortality rate was of 19 % (n=12). The main causes of death were hypovolaemic shock and septicemia. Conclusion: The incidence of peripartum hysterectomies was high and was associated with ruptured uterus and puerperal sepsis which are preventable.

Clinical analysis of 52 obstetric hysterectomies

“…The literature offers varying reports on PH rates, with the lowest (0.02%) in Ireland and the highest (0.95%) in RPA [4,12]. Data about other countries include 0.024% for Denmark, 0.041% for UK, and 0.146% for the Czech Republic [13][14][15].…”

Sepsis: Primary indication for peripartum hysterectomies in a South African setting

“…In a large review from the USA the incidence was 0.77 per 1 000 deliveries [10] while African countries have reported higher incidences ranging from 4.34 to 9.5 per 1 000 deliveries. [9,14,17,19] Lack of antenatal and peripartum care due to limited resources, a high burden of HIV infection and a delay in recognising complications may be reasons for the higher incidences.In high-resource settings complications of placentation are the most common indication for hysterectomy. [5][6][7][8]11,12,22,24,25] In middle-income countries the aetiology is variable, with studies from Turkey, India and Thailand showing similar indications to high-resource settings but with higher rates of uterine rupture.…”

“…In a large review from the USA the incidence was 0.77 per 1 000 deliveries [10] while African countries have reported higher incidences ranging from 4.34 to 9.5 per 1 000 deliveries. [9,14,17,19] Lack of antenatal and peripartum care due to limited resources, a high burden of HIV infection and a delay in recognising complications may be reasons for the higher incidences.…”

“…The morbidly adherent placenta was the least common indication. [9] In a review of cases from Durban, uterine rupture and sepsis made up 56% of the indications, [29] and a study from Pretoria reported that puerperal sepsis was the second most common indication after ruptured uteri and accounted for 33% of peripartum hysterectomies. [31] Observational data in our department at Tygerberg Hospital, a tertiary referral centre in Cape Town, suggested that sepsis was a common indication.…”

“…[1] Despite many publications, the definition of a peripartum hysterectomy remains vague. Definitions include a hysterectomy performed within 24 hours of delivery, [2][3][4][5] a hysterectomy performed within the same hospitalisation, [6][7][8][9][10] a hysterectomy performed within 72 hours of delivery, [11] a hysterectomy performed within 1 month of delivery [12,13] to a hysterectomy performed within 6 weeks of delivery. [14] Some even limit the definition to a hysterectomy performed for uncontrolled haemorrhage only [4,[15][16][17][18][19][20][21][22] and exclude cases of infection.…”