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

Abstract

Background. Peripartum hysterectomies are lifesaving procedures but definitions vary. Indications are variable and dependant on resources and geographical factors. Objectives. To evaluate the incidence, aetiology and complications associated with peripartum hysterectomies in a tertiary hospital in South Africa. Methods. A retrospective audit at an academic referral centre over a 5-year period from February 2009 to March 2014 was performed.Procedures from a gestation of 24 weeks until 6 weeks postpartum were included. Results. One hundred and sixty cases met inclusion criteria. Nine case records were unavailable. The incidence was 2.77 per 1 000 deliveries. Main indications were sepsis (60, 39.7%), atony (24, 15.9%), morbidly adherent placenta (21, 13.9%), tears (14, 9.3%), uterine rupture (8, 5.3%), placenta praevia (7, 4.6%) and unclassified bleeding (6, 4.0%). There were 6 maternal deaths. Five related to sepsis and one to hypovolaemic shock. One hundred and thirty-eight (91.4%) women required high or intensive care admission. Conclusion. Sepsis is an important aetiology for peripartum hysterectomies, particularly in southern Africa. The high rate of sepsis may be due to HIV infection, low socioeconomic standards, late diagnosis, limited access to healthcare, sterility issues and differences in the definition and inclusion criteria used for a peripartum hysterectomy. A peripartum hysterectomy is a lifesaving procedure usually performed as an emergency that can be associated with significant morbidity and mortality.[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.[12] The varying definitions make it difficult to compare incidences and aetiology. If a short time period after delivery is used, complications related to sepsis and delayed haemorrhage may be underestimated.Peripartum hysterectomies complicate about 1 in 1 000 pregnancies.[23] The incidence is lower in higher-resource settings. 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 Thail...

Acute Villitis and Intravascular Microorganisms in Fetal Vessels: A Case Report and Literature Review of an Unusual Histopathological Finding

“…On the contrary, in low-income countries, feto-maternal sepsis remains a relatively usual indication for hysterectomies, which along with uterine rupture and intractable postpartum haemorrhage complicates at least 2.8 every 1,000 pregnancies. 13 – 15 However, histopathological analysis of the uterus, placenta and fetus remains a relatively uncommon event in these settings which limits our understanding of the true incidence of acute villitis associated with intravascular microorganisms and leads to potential reporting bias. 16 …”

Clinical and Sociodemographic Characteristics Associated with Emergency Peripartum Hysterectomy due to Puerperal Sepsis in Malawi

“…Recent studies in South Africa found that puerperal sepsis was a primary indication for emergency peripartum hysterectomy in up to 46% of cases. 4 , 9 , 10 A standard protocol guiding emergency peripartum hysterectomy secondary to puerperal sepsis remains unclear and there is a scarcity of recent literature regarding clinical course and outcomes in settings with limited access to antibiotics. As a result, the incidence of emergency peripartum hysterectomy is greatly influenced by clinical impression and factors such as delayed recognition of puerperal sepsis, availability of adequate antibiotics, and delays in transfer to specialist care at the tertiary center.…”