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INCIDENCE |
NUMBER (N) = 3411 |
PERCENTAGE (%) |
Incidence of Normal delivery
|
1365 |
40.01% |
Incidence of Caesarean Delivery |
2046 |
59.98% |
Incidence of obstetric hysterectomy |
18 |
0.52% |
Incidence of obstetric hysterectomy followed vaginal delivery |
5 |
0.14% |
Incidence of obstetric hysterectomy followed caesarean section |
7 |
0.20% |
Incidence of obstetric hysterectomy due to ectopic pregnancy |
3 |
0.087% |
TABLE 2
MATERNAL PROFILE
There was a high association of age see in our study. Majority women belonged to 26 -30 years of age .
MATERNAL AGE DISTRIBUTION IN EMERGENCY HYSTERECTOMY
AGE (yrs.) |
PARITY
|
||||||
0 |
1 |
2 |
3 |
4 |
5 |
TOTAL |
|
<20 |
- |
- |
- |
- |
- |
- |
0 |
21-25 |
- |
- |
- |
1 |
- |
- |
1 |
26-30 |
2 |
1 |
2 |
1 |
- |
- |
6 |
31-35 |
- |
1 |
3 |
- |
1 |
- |
5 |
36-40 |
- |
1 |
1 |
- |
- |
- |
2 |
41-45 |
1 |
- |
- |
- |
- |
1 |
1 |
>46 |
2 |
- |
- |
- |
- |
- |
2 |
Total |
5 |
3 |
6 |
2 |
1 |
1 |
18 |
TABLE: 3
RISK FACTORS
The reason for this non -uniform distribution of parity with caesarean hysterectomy is due to presence of high risk factors, elderly IVF pregnancies, ectopic pregnancy and other confounding factors such as low socioeconomic status, poor general condition, massive hemorrhage and severe anemia.
RISK FACTORS ASSOCIATED WITH OBSTERICS HYSTERECTOMY
RISK FACTORS |
NUMBER |
PERCENTAGE(%) |
Age > 35 years |
11 |
61.11% |
History of myomectomy |
03 |
16.66% |
History of previous LSCS (adherent placenta) |
03 |
16.66% |
IVF conception |
05 |
27.77% |
Multiple pregnancy |
02 |
11.11% |
Accidental hemorrhage |
03 |
16.66% |
Traumatic |
01 |
5.55% |
Where:
LSCS-lower segment Caesarean section
IVF in vitro fertilization
TABLE 4
INDICATIONS FOR OBSTETRIC HYSTERECTOMY
In our study most common indication for obstetrical hysterectomy was atonic PPH (27.77%) followed by rupture uterus 22.22%.
INDICATIONS FOR OBSTETRIC HYSTERECTOMY
INDICATIONS |
NUMBER (N) |
PERCENTAGE (%) |
Traumatic PPH |
1 |
5.55% |
Atonic PPH |
5 |
27.77% |
Rupture uterus |
4 |
22.22% |
Ectopic pregnancy |
3 |
16.66% |
Placenta percreta |
3 |
16.66% |
Carcinoma in situ |
1 |
5.55% |
Molar gestation |
1 |
5.55% |
Total |
18 |
100% |
Where: (PPH : post partum hemorrhage)
TABLE 5
TYPE OF HYSTERECTOMY
In our study most common type of hysterectomy performed was total abdominal hysterectomy (66.66%) and 33.33% patients underwent subtotal hysterectomy.
TYPE OF HYSTERECTOMY
TYPE OF HYSTERECTOMY |
NUMBER (N) N=18 |
PERCENTAGE (%) |
Subtotal hysterectomy |
6 |
33.33% |
Total hysterectomy |
12 |
66.66% |
TABLE 6
POST OPERATIVE COMPLICATIONS
Amongst the post operative complications, the most common post operative complication in our study was haemorrhagic shock seen in (61.11%) patients followed by cases having bladder injury (27.77%), DIC (22.22%), acute renal failure(16.66%), paralytic ileus (16.66%) whereas, 16.66% patients had breast engorgement, wound infection (11.11%), 11.11% patients had septicemia and 16.66% was the documented maternal mortality rate.
POSTOPERATIVE COMPLICATIONS
CAUSES |
NUMBER (N) N= 18 |
PERCENTAGE (%) |
Breast engorgement |
3 |
16.66% |
Wound infection |
2 |
11.11% |
Bladder injury |
5 |
27.11% |
Septicemia |
2 |
11.11% |
Maternal mortality |
3 |
16.66% |
DIC |
4 |
22.22% |
Hemorrhagic Shock |
11 |
61.11% |
Paralytic Ileus |
3 |
16.66% |
Acute renal failure |
3 |
16.66% |
Where: DIC (disseminated intravascular coagulopathy)
DISCUSSION
Incidence of obstetrical hysterectomy in our study within 2 years of duration was 0.52% which was slightly higher to the studies conducted by Praneshwari et al4, Sturdee and Rushton5, Chew and Bishwas6, Gupta et al7 who reported an overall incidence of 0.0779%. 0.05%. 0.0392% and 0.26% each respectively. It may due to the fact that most of the deliveries at our tertiary care belong to high risk group and referral (referral cases high). (TABLE 1)
There was a high association of age see in our study but there was no significant difference seen in primi and multiparas in our study. Mean age of women who underwent obstetric hysterectomy at our centre was 35.44 years (TABLE 2). Study conducted by Najam R8 et al revealed 29% cases with parity >5. The reason for this non -uniform distribution of parity with caesarean hysterectomy is due to presence of high risk factors, elderly IVF pregnancies, ectopic pregnancy and other confounding factors such as low socioeconomic status, poor general condition, massive hemorrhage and severe anemia (TABLE 3).
In our study incidence of normal delivery was 40.01% and caesarean section was 59.98%. Whereas, incidence of obstetric hysterectomy followed by vaginal delivery was 0.14% and obstetrical hysterectomy followed by caesarean section was 0.20%. These results were slightly at a higher range as compared 0.0106%, 0.039% and 0.33%, 0.45% respectively reported by Praneshwari et al4and Pawar and Shroti et al9(TABLE 1).
In our study most common indication for obstetrical hysterectomy was atonic PPH (27.77%) followed by rupture uterus 22.22%, all ruptures are seen in previous scar uterus either scar due to myomectomy or due to Caesarean section no cases of rupture seen due to obstructed labour this could be due decreasing home delivery by untrained persons and promotion and practice of hospital deliveries. which was similar to the incidence found by Praneshwari et al4 (19.2%), Allahbadiya and Vaidya10 (16%), Kant Anita et al2(41.46%), Agashe and Marathe11 (60%) and Mantri et al13 (67.2%). Second most common indication in our study was rupture uterus (23.22%) which was similar to the study conducted by Praneshwari et al4(23%), Allahbadiya and Vaidya 10(20%) and Kant Anita2 (36.58%). In our study other indications seen were placental causes such as placenta increta and percreta(16.66%), ectopic pregnancy(16.66%), traumatic PPH (5.55%) and molar gestation (5.55%)(TABLE 4).
In our study maternal mortality was seen in (3/18) patients i.e (16.66%) cases. Similar results were found by Agashe and Marathe11 (14%). Whereas, Praneshwari et al4 found no maternal mortality in relation to obstetric hysterectomy.
In our study most common type of hysterectomy performed was total abdominal hysterectomy (66.66%). But subtotal hysterectomy is usually preffered as it is less time consuming surgery and it gives a better outcome in a moribund patient. But in indications like placenta previa and adherent placenta total abdominal hysterectomy is the ideal treatment as it removes the placental bed in the lower uterine segment. At our centre 33.33% patients underwent subtotal hysterectomy which was also seen by Praneshwari et al4 and Mrinalini et al12 (40%).(TABLE 5)
Amongst the post operative complications, the most common post operative complication in our study was haemorrhagic shock seen in (61.11% )followed by cases having bladder injury (27.77%), DIC (22.22%), acute renal failure(16.66%), paralytic ileus (16.66%) whereas, 16.66% patients had breast engorgement, wound infection (11.11%) and 11.11% patients had septicaemia. Whereas, Praneshwari et al4 found vesicovaginal fistula after subtotal hysterectomy which was done due to ruptured uterus which was followed by prolonged obstructed labor. Whereas, Kant Anita1 found post operative shock, pyrexia, paralytic ileus and wound infection as common post operative complications. They were mainly due to prolonged labour, intrauterine manipulations and sepsis. Nazam R8 reported 2 cases which had septic shock and 1 case in their study had DIC.(TABLE 6)
CONCLUSION
As life-saving procedure to deal with obstetric complication when medical and conservative surgical procedure fail emergency hysterectomy are performed. Elderlygravida with IVF pregnancy, history of previous LSCS(with adherent placenta) and history of myomectomy are risk factor for peripartum hystrectomy. These cases should be dealt cautiously and should be handled at tertiary centres. Impact of risk factors can be further studied by longerer duration of study. As a method of treatment it is a radical procedure, though it has a definite role in the management of life threatening obstetric hemorrhage or ruptured uterus. On one hand it is the last resort to save a mother's life, and on the other hand, the reproductive capability of a mother is sacrificed and leads to both surgical morbidity and psychological impact on women health.
Up gradation of the peripheral health centers and the timely referral of high risk parturients to higher centers can decline the rate of peripartum complications and improve maternal care and wellbeing. Emergency hysterectomy leads to psychological stress due to perceived loss off emininity, cessation of menstruation and reproductive ability. Psychological counselling and support therefore plays an important role in postoperative patients.
Acknowledgement:
Would like to thanks and acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Funding: No funding sources
Conflict of interest: None declared
References:
BIBLIOGRAPHY
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