ANALYSIS OF 18 CASES OF OBSTETRIC HYSTERECTOMY

ANALYSIS OF 18 CASES OF OBSTETRIC HYSTERECTOMY

K R Chaudhari*, M N Vaswani**
*Lecturer, KEM Hospital, **Professor, Nair Hospital, Mumbai.

Obstetric hysterectomy was originally evolved as surgical attempts to manage life threatening obstetric haemorrhage and infection. An obstetric hysterectomy is reserved for management of cases where other measures have failed but its performance should not be delayed until the patient is too far deep in trouble. It is the last resort to save the mother’s life but reproductive capability is to be sacrificed however if timely performed procedure will help in reducing the maternal mortality.
INTRODUCTION

Obstetrics is “Bloody Business”. Even though the maternal mortality rate has been reduced dramatically by hospitalization for delivery and the availability of blood for transfusion, death from haemorrhage remains prominent in the majority of mortality reports.

Obstetrical haemorrhage is most likely to be fatal to mother in circumstances in which blood or blood components are not available immediately. The establishment and maintenance of facilities that allow prompt administration of blood are absolute requirement for acceptable obstetrical care.

This is retrospective analysis of 18 cases of obstetric hysterectomy performed at KEM Hospital over a period of two years from January 1998 to December 1999. The incidence of obstetric Hysterectomy following vaginal delivery was 14% and that caesarean hysterectomy was .88%. The commonest indication was atonic PPH 44.4% of cases. Maternal mortality was 5.5% and perinatal mortality was 11.1%.

MATERIAL AND METHODS Each case record is analysed in detail as regard to incidence, age, parity, registration, antenatal high risk factors, indication of obstetric hysterectomy and type of obstetric hysterectomy.

The incidence of obstetric hysterectomy in our series was 14% of a total of 12347 vaginal deliveries and .88% following caeserean section.

The majority of patients in our study were in age group of 30 to 35 yrs.

TABLE 1

Incidence

Number Hysterectomy %

Vaginal delivery 12347 8 .14%

Caesarean section 1857 6 .88%

TABLE 2

Age

Age (years) No. of cases %

20-25 6 33.3

25-30 4 22.2

30-35 7 38.8

35-40 1 5.5

TABLE 3

Parity

Parity No. of cases %

Primi 3 16.6

Second 5 27.7

Third 4 22.2

Fourth 5 27.7

Multi 1 5.5

On studying the obstetric status, it is observed that incidence of obstetric hysterectomy was more in multiparous patients as compared to primiparous specially para 2 or more. Atonic PPH being more common as indication.

TABLE 4

No. of cases %

Booked 8 44.5

Unbooked 10 55.5

Out of 18 cases only 8 cases were registered. 10 were unregistered. 4 patients were delivered outside and came with retained placenta, DTC, sepsis. All emergency admissions were with prolonged labour as the major predisposing cause.

TABLE 5

Antenatal risk factors

No. of cases %

Previous caesarean section 2 11.1

Grand multiparity 3 16.6

Placenta previa 4 22.2

Abruptio placentae 1 5.5

Antenatal high risk factors were previous LSCS in 11.1% cases, grand multiparity in 16.6% and placenta previa in 22.2% cases and abruptio placenta in 5.5% cases underwent obstetric hysterectomy for uncontrolled haemorrhage.

TABLE 6

Indications

No. of cases %

Atonic PPH 8 44.4

Rupture uterus 4 22.2

Placenta accreta 1 5.5

Secondary haemorrhage 2 22.2

Due to sepsis

Placenta previa 2 22.2

Abruptio placentae 1 5.5

Two cases of placenta previa and one case of abruptio placenta underwent obstetric hysterectomy for uncontrolled haemorrhage.

Eight cases of atonic PPH-5 following vaginal delivery and 3 following caesarean section were submitted to hysterectomy.

One case of placenta accreta referred from private hospital with profuse bleeding and was subjected to hysterectomy after failed manual removal of placenta.

Four obstetric hysterectomy were performed in cases of rupture uterus. Out of which two had previous scar and were given trial of labour. Two cases had emcredil instillation done for second trimester abortion.

Two patients were subjected to obstetric, because of secondary haemorrhage (vaginal) due to sepsis.

TABLE 7

Type of obstetric hysterectomy

No. of cases %

Subtotal 16 88.8

Total 2 11.1

88.8% of cases were subtotal and only 11.1% cases were total obstetric hysterectomy.

TABLE 8

Intervention to arrest haemorrhage

Number

Blood 18

Dopamine 2

PGF2 8

Internal iliac artery 6

Internal iliac embolisation 2

All cases were liberally transfused with blood which include whole blood, fresh frozen plasma.

Two patients were on dopamine drip.Inj. PGF2 was used in 8 patients.

Ligation of internal iliac artery was tried in primi patients with atonic PPH prior to obstetric hysterectomy but proved to be unsuccessful.

Two patients had to be transferred to medical intensive care unit for want of critical care.

In two patients internal iliac artery embolization done prior to obstetric hysterectomy.

TABLE 9

Morbidity and Mortality

Infection 8 44.4

Bladder injury 1 5.5

Maternal death 1 5.5

Infective morbidity was noted in 44.4% and all cases were anaemic. Intra operative bladder injury occurred in one case of placenta accreta.

There was one maternal mortality in case of DIC due to severe blood loss. Perinatal losses in 2 cases of rupture uterus.

DISCUSSION

Hysterectomy as a method of treatment is a radical procedure. The obstetric future of patient is sacrificed. All the obstetric hysterectomy were performed as emergency operation as a last resort. Other conventional methods were tried in young and low parity group but when one is forced to decide upon hysterectomy, it is wise to perform it timely, before patient’s condition further deteriorate. This will definitely help in reducing maternal mortality.

Complications during hysterectomy decrease with skill and experience of the surgeon. At times the performance of this procedures may be the difference between life and death for the patient. Hysterectomy was performed to prevent death from haemorrhage and sepsis after vaginal delivery and caesarean section.

Surgical technique of obstetric hysterectomy is very different from hysterectomy in non pregnant patient. The highest incidence of obstetric hysterectomy was following PPH due to placenta previa this falls in to category of unpreventable emergencies. Atonic PPH can be prevented by meticulous monitoring of patients upto third stage of labour and optimum and timely use of uterotonic agents. Rupture of uterus can be prevented by regular antenatal check ups and vigilant monitoring in labour.

REFERENCES

Warren C Plauche. Caeserean hysterectomy indications, technique and complications. clinical Obst and Gynaec 1986; 29 : 2.

Rupture Uterus V. Kamal Jayram. Journal of Obst Gynaec of India 1988.

DW Strudee, et al. Caesarean and post partum hysterectomy. British Journal of Obst and Gynaec 1986; 48.

Role of Emergency hysterectomy Obst. The Journal of Obst and Gynaec of India 1998; 48.

DV Strudee, et al. Caesarean and Post partum hysterectomy. Progress in Obst and Gynaec 1987; 6 : 195.

To Section TOC

TABLE 1
Incidence
	Number	Hysterectomy	%
Vaginal delivery	12347	8	.14%
Caesarean section	1857	6	.88%

TABLE 2
Age
Age (years)	No. of cases	%
20-25	6	33.3
25-30	4	22.2
30-35	7	38.8
35-40	1	5.5

TABLE 3
Parity
Parity	No. of cases	%
Primi	3	16.6
Second	5	27.7
Third	4	22.2
Fourth	5	27.7
Multi	1	5.5

TABLE 5
Antenatal risk factors
	No. of cases	%
Previous caesarean section	2	11.1
Grand multiparity	3	16.6
Placenta previa	4	22.2
Abruptio placentae	1	5.5

TABLE 6
Indications
	No. of cases	%
Atonic PPH	8	44.4
Rupture uterus	4	22.2
Placenta accreta	1	5.5
Secondary haemorrhage	2	22.2
Due to sepsis
Placenta previa	2	22.2
Abruptio placentae	1	5.5

TABLE 7
Type of obstetric hysterectomy
	No. of cases	%
Subtotal	16	88.8
Total	2	11.1

TABLE 8
Intervention to arrest haemorrhage
	Number
Blood	18
Dopamine	2
PGF2	8
Internal iliac artery	6
Internal iliac embolisation	2

TABLE 9
Morbidity and Mortality
Infection	8	44.4
Bladder injury	1	5.5
Maternal death	1	5.5