Epidemiological analysis of peripartum hysterectomy across nine European countries

Abstract

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high‐resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. Material and methods We performed a descriptive, multinational, population‐based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0‐10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4‐12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (ρ = 0.67, P < .05). Conclusions Prevalence of peripartum hysterectomy may vary considerably between high‐income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine‐fold increased risk of peripartum hysterectomy.

The Italian Obstetric Surveillance System: Implementation of a bundle of population-based initiatives to reduce haemorrhagic maternal deaths

“…We asked Italian clinicians to respond to the high haemorrhagic MMR, act in light of the knowledge gained through the ItOSS surveillance and move beyond the numbers. The population-based approach and the adoption of shared SMM definitions among the countries participating in the INOSS [ 21 ] led to robust epidemiologic data allowing for SMM incidence rates estimates and international comparisons [ 22 , 23 ].…”

Incidence, Management and Outcomes in Women Undergoing Peripartum Hysterectomy in a Tertiary Care Centre in India

“…For all other cases of haemorrhage, IIL was done when bleeding was refractory to medical methods, uterine artery ligation, or compression sutures. In the future, these cases will be encountered on a frequent basis, hence all obstetricians must develop the necessary training and skill to perform IIL [21][22][23][24]. We did not use balloon tamponade due to acuteness of event (PPH), and recombinant activated factor VII due to its unavailability at our center.…”

“…Worldwide, there has been a shift in the primary indication of PRH from uterine atony to MAP [ 12 , 20 ]. Our study showed MAP as the most common cause and intractable hemorrhage due to uterine atony as a second most common cause of PRH [ 21 , 22 ]. There are variations in definitions of uterine atony in different studies [ 21 - 23 ].…”

Surgical Treatment of Early Postpartum Hemorrhage Caused by Lower Uterine Segment Atony

“…Physiological mechanisms that limit postpartum blood loss are: contractions of the myometrium and local spreading of decidual hemostatic factors which cause clotting. The pathogenesis of most cases of PPH is a disturbance in one or both mechanisms [1][2][3][4][5][6]. The most common cause of PPH in more than 50% of cases is uterine atony, lack of effective contraction of the uterus after the delivery.…”

“…Peri and postpartum hysterectomy is being mainly performed due to the heavy bleeding mainly caused by uterine atony or invasive malplacentation. Cesarean section and vaginal birth after cesarean section are associated with nine-old increased risk of peripartum hysterectomy [1,2,3,4].…”