Peripartum hysterectomy

Question 1

Definition

Answer 1

A hysterectomy performed immediately following, or within 24 hours of, delivery

Question 2

Incidence

Answer 2

0.2 to five per 1000 deliveries

95% following caesarean

Question 3

Most common causes

Answer 3

- Abnormal placentation (morbidly
adherent placenta 55%, and placenta
praevia 20%)
- Uterine atony
- Uterine scar rupture

Question 4

Risk factors

Answer 4

• Caesarean delivery (past and present)
• AMA
• multiparity,
• multiple gestation,
• GDM
• infection
• previous uterine surgery

Question 5

When to consider CS hysterectomy

Answer 5

• Bleeding refractory to conservative
  measures
• Suspected accreta
• Uterine rupture.

Question 6

Initial management if considering hysterectomy

Answer 6

• Aortocaval compression to allow resuscitative efforts to catch up
• Decision made by senior clinician, ideally after second opinion

Question 7

Procedure

Answer 7

Skin incision – both midline and
low transverse can be used. Midline
incision preferred
• Avoid the placenta; if there is a known
praevia and accreta, consider a
classical uterotomy incision
• Close uterotomy incision following
delivery. Adherent placentas should be
left in situ
• Careful bladder dissection off anterior
lower uterine segment
o Sharp dissection should be
performed to minimize bladder
injury and bleeding. Aim 1–2 cm
below the cervico-vaginal junction
o Understand ureteric anatomy
• Round ligament identification, double
clamped laterally
• Utero-ovarian ligament. Special care is
needed as vessels are often dilated and
tissues can tear easily. Ovaries almost
always preserved
• Identify the uterine vessels. Three
clamps can be used for extra security,
two on the active vessel side and one
on the uterine side
• Supra-cervical (subtotal) hysterectomy
can be performed at this stage.
• Cardinal ligaments. Clamp, cut and
ligate in 1–1.5 cm tissue sections until
the external os is reached. Continuous
careful inspection of bladder and ureters
• Clamp across vaginal angle and
uterosacral ligament, enter vaginal
mucosae anteriorly, just below cervix
and remove uterus. Secure vaginal
vault angles and cardinal ligaments
• There are no specific guidelines for
closure of vaginal vault. Continuous or
interrupted sutures
• Consider perioperative
thromboprophylaxis and antibiotic
cover
• Haemostatic agents should be
considered if required. Agents such
as FloSeal, Fibrillar, Surgicel may
be effective; however, none replace
meticulous surgical technique
• Subtotal hysterectomy is thought to
be faster, associated with less blood
loss, less bladder/ureteric injury and
is often the procedure of choice in
haemodynamically unstable patients

Question 8

Why is a peripartum hysterectomy more complicated than a standard hysterectomy?

Answer 8

• Distended soft cervix – difficult to identify the internal os
• Engorged and dilated pelvic blood vessels – increase risk of bleeding
• Friable and oedematous tissue – increase bleeding
• Large bulky uterus – obscure operating field
• Potentially unstable patient

Question 9

Consequences of peripartum hysterectomy

Answer 9

• prolonged hospital stay,
• ICU/HDU admission,
• increased surgical complications such as ureteric
  injury (6% to 15%),
• coagulopathy,
• massive transfusion,
• sub-fertility,
• emotional response and need for psychological support
• Mortality 2-15%