AN AUDIT OF INCIDENCE, INDICATIONS AND COMPLICATIONS RATE FOR CAESEREAN HYSTERECTOMIES IN A TERTIRARY CARE HOSPITAL

Abstract

Objective: Analysis of all caesarean hysterectomies, performed in gynecology unit 1 during one

year period, to find out its rate of incidence, indications and its morbidity, one of the largest

specialized healthcare care public hospitals in Lahore.

Methods: A retrospective observational study was conducted in the department of gynecology

and obstetrics Unit I, Sir Ganga Ram hospital, Lahore from June 2019 till June, 2020 including

all women who underwent caesarean hysterectomy. Data was abstracted from the medical record

and was entered and analyzed in SPSS version 21.0. The outcome was presented as frequency

and percentages for incidence, indications and complications.

Results: During the study period total deliveries were 5804 with 2979 were delivered through

caesarean section out of which 64 women underwent caesarean hysterectomy, resulting in an

incidence of 2.1%. Placenta accreta was found to be the most common indication for cesarean

hysterectomy. There were 7.4% (02) maternal deaths.

Conclusion: The rate of caesarean hysterectomy has increased markedly over a period of 1 year.

Increased caesarean rate is in fact a leading factor which requires adequate attention to help

reduce maternal and fetal abnormality not only from caesarean hysterectomies but also from

other preventable complications. There is further need of multicenter research to see the reasons

for increase in caesarean section rate in our hospitals.

Caesarean hysterectomy also known by some as peripartum hysterectomy or obstetric

hysterectomy is a procedure done to save maternal life in uncontrollable hemorrhage and few

elective indications. It can be planned but more often it is an emergency operation. It has caused

substantial morbidity and mortality worldwide. The incidence in literature for emergency

hysterectomy is 0.01 to 0.05 % 5

. In the past most of them were done to prevent sepsis, atony and

post-partum blood loss but currently most of them are carried out in emergency to control

hemorrhage. Caesarean hysterectomy once considered to be a rare procedure is on rise because

of increase in the rate of caesarean delivery which has resulted in increases incidence of

abnormal placentation (placenta accrete spectrum)8

.

Placenta accreta spectrum originally known as morbidly adherent placenta refers to the degree of

pathological adherence of placenta, including placenta increta, placenta accrete and placenta

percreta. The most preferred hypothesis regarding the etiology of placenta accrete spectrum is

that a defect of endometrial-myometrial interface leads to the failure of normal decidualization in

the area of uterine scar, which allows abnormally deep placental anchoring villi and trophoblastic

infiltration1

. Maternal morbidity and mortality can occur because of severe and sometimes lifethreatening hemorrhage, which often requires blood transfusion and is more likely to end up in

hysterectomy at the time of delivery or during the post-partum period. There are multiple risk

factors for abnormal placentation. The most common factor being the previous caesarean section

and the rise in the incidence of placenta accrete spectrum is directly proportional to the number

of prior caesarean sections.

Studies of caesarean hysterectomy are mostly reviews collected over a period of years. The

surgical indications and techniques have improved over time. These studies can have limited

impact to modern techniques. The purpose of this analysis was to estimate the frequency of

caesarean hysterectomy, its indications and associated complications over a period of 1 year in

our hospital to get a recent idea about the trends and to highlight avoidable factors and suggest

means to develop health care services to improve maternal and fetal well-being.

Materials and methods:

It was a retrospective observational study over a period of 1 year starting from July 1st 2019 till

30th June, 2020 conducted in gynecology and obstetrics unit 1 of Sir Ganga ram hospital,

Lahore. Data was taken from the medical record of the hospital. The 64 cases of caesarean

hysterectomy were analyzed from the medical record of labor ward. the information extracted

from the case notes include age, parity, gestational age, risk factors, indications, feto-maternal

complications (need of blood transfusions, visceral injury, need of re laparotomy, wound

dehiscence, mortality). The data was entered and analyzed in SPSS version 21.0 and presented as

frequency and percentages. Rates were calculated for incidence of hysterectomy, indications and

complications.

Results;

Out of a total number of 5804 deliveries during the study period, 2979 women underwent

caesarean deliveries with 64 patients having caesarean hysterectomies. The overall caesarean

section rate was 51.3% and caesarean hysterectomy rate turned out to be 2.1% with ratio of 1:46

caesarean hysterectomy in patients undergoing caesarean section.

Out of the 64 cases analyzed, most of the cases 95.3% (61) occurred in women aged 35 years and

below while the remaining 3 occurred in patients above 35 years. The distribution of parity in

our sample showed 31.2% (20) were in Para 3 group, primigravida were 7.8% (05), multipara

(Para 2 to 4) was 85% (55) and the grand multipara had 6.2% (04). In gestational age

presentation, 35.9% (24) women presented at term and 55.71% (40) at preterm (between 28 and

36 weeks. Risk factors encountered. 92.0% (59) cases were associated with scarred uterus with

the major contribution coming from previous caesarean scar, The least contributor was previous

myomectomy scar (no case 0 %). Other risk factors like previous placenta previa were not

encountered. (Table no: 1). The most common indication for caesarean hysterectomy in

descending order were placenta accrete spectrum followed by uterine rupture and atony. Total

abdominal hysterectomy was performed in most of the cases. The mean operative time was 2.23

+ .54 hours and maternal length of stay in the hospital on average was 5.47 + 1.71 days most of

women received general anesthesia from the outset.

Acute blood loss requiring blood transfusion was the most common complication. Almost all

patients required whole blood transfusion. FFPs were required by 42.9% (48) patients. Iatrogenic

bladder injury occurred in 8 cases. There were 7.4% (02) maternal deaths among the 64 women.

One mortality was due to underlying cardiac condition of aortic stenosis. (Graph no:1). The other

was attributed to amniotic fluid embolism. Both were previous caesarean deliveries and primary

indication for hysterectomy in each case was placenta accreta. The fetal birth weights showed

that 40.6% (26) were of normal birth weight (> 2.5 kg) and 59.3% (38%) babies were of low

birth weight (< 2.5 kg). (Table no: 2)