Peripartum Hysterectomy in the UK: Management and Outcomes of the Associated Hemorrhage

Peripartum hysterectomy is usually performed in the presence of life-threatening obstetrical hemorrhage, and as such is considered to be a “near miss” event. This population-based descriptive study, based on the United Kingdom Obstetric Surveillance System (UKOSS), examined the causes, management, and outcome of peripartum hysterectomy and associated hemorrhage in all 229 hospitals in the United Kingdom having consultant-led maternity units. A total of 315 women had peripartum hysterectomy in order to control bleeding during a 12-month period in 2005 and 2006. Hemorrhage was ascribed to uterine atony in 53% of cases and to a morbidly adherent placenta in 39%. One-third of women had 2 or more causes of bleeding, including 30 who had both uterine atony and placenta accreta. Uterine ruptures numbered 26. Four in every 5 women had a cesarean delivery, while 16% had spontaneous, and 4% assisted vaginal delivery. Four women who had hysterectomy following bleeding that reportedly was due only to uterine atony received no uterotonic drugs, and 18 others—nearly one-fourth of the total—received only one such drug. Twenty-three of 91 women whose bleeding was due solely to placenta accreta also received no uterotonic drugs, and 16 received no other treatment at all. Fifty women were ineffectively managed before hysterectomy with a B-Lynch or other brace suture, 28 with activated factor VII, and 9 with arterial embolization. Nearly 20% of women had damage to other structures, and the same proportion required further surgery. Just under 19% of patients had other severe morbidity. Bladder damage was more likely to occur in women with placenta accreta than in those with uterine atony. Outcomes did not differ significantly between women having total and those having subtotal hysterectomy. Two women died, for a case fatality rate of 0.6%. Nearly 85% of women were admitted to intensive care for a median of 2 days.