Version May 2024
INTRODUCTION — Peripartum hysterectomy can be defined as a hysterectomy performed at the time, or within 24 hours, of delivery. Another definition is a hysterectomy performed any time from delivery to discharge from the same hospitalization. This topic will review the surgical planning, key operative points, and postoperative care for peripartum hysterectomy.
Related topics can be found separately and include:
●(See "Hysterectomy: Abdominal (open) route".)
●(See "Overview of preoperative evaluation and preparation for gynecologic surgery".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.
EPIDEMIOLOGY AND RISK FACTORS
●Incidence – Based on population-level data, the peripartum hysterectomy rate is approximately 1 per 1000 deliveries (eg, 0.1 percent) [1,2]. Incidence varies by setting. The highest incidence is reported in lower middle-income countries (3 in 1000 births, 95% CI 2.5-3.5) and the lowest incidence in high-income countries (0.7 in 1000 births, 95% CI 0.5-0.8 [2].
●Risk factors – In addition to abnormal placentation, other significant risk factors for peripartum hysterectomy include advanced maternal age and parity, previous cesarean delivery, multiple gestations, antepartum bleeding, preeclampsia, bleeding disorders, and the use of assisted reproductive technologies [2-10].
A meta-analysis of 154 studies that included over 14,400 emergency peripartum hysterectomies reported [2]:
•Most common overall indications – Placental pathology (38.0 percent, 95% CI 33.9-42.4), uterine atony (27.0 percent, 95% CI 24.6-29.5), and uterine rupture (21.2 percent, 95% CI 17.8-25.0).
•Lower middle-income settings – Uterine rupture (44.5 percent, 95% CI 36.6-52.7).
•High-income settings – Placental pathology (48.4 percent, 95% CI 43.5-53.4).
While most patients with these risk factors will not experience major hemorrhage or hysterectomy, patients who have multiple risk factors, a history of postpartum hemorrhage, or history of cesarean birth are most likely to benefit from delivering in a setting where hysterectomy is readily available if needed.
SURGICAL PLANNING — The procedure may be planned or performed in an emergency situation. The most common indication for emergency procedures is severe uterine hemorrhage that cannot be controlled by conservative measures. Such hemorrhage is most commonly due to abnormal placentation or uterine atony, with each accounting for 30 to 50 percent of peripartum hysterectomies [11-14]. Other potential causes include uterine rupture, leiomyomas, and laceration of uterine vessels [5,15]. Planned peripartum hysterectomy may be performed in patients with an antepartum diagnosis of placenta accreta, or more rarely for stage IA2 and IB1 cervical carcinoma or very large fibroids [16,17]. Infection appears to be an important contributor to peripartum hysterectomy. Not only is severe postpartum pelvic infection a potential indication for the procedure, but uteri removed for atony also show a relatively high rate of infection and inflammation on pathologic analysis [16].
The obstetrician should be prepared for the potential need to perform emergency peripartum hysterectomy, especially in patients with significant risk factors or heavy postpartum bleeding. Hysterectomy is not commonly performed on labor and delivery units; depending on local operating room resources, a general operating room may be necessary. An institution-specific labor and delivery unit checklist of equipment, other supplies, and action items for managing emergency hysterectomy is highly recommended and complies with the Hemorrhage Safety Bundle described by the United States National Partnership for Maternal Safety (table 1) [18].
In emergency situations, a sequence of conservative measures to control uterine hemorrhage is attempted before resorting to invasive or surgical procedures (table 2 and figure 1). If an intervention does not succeed, the next treatment in the sequence should be swiftly instituted. Conservative measures should be employed with the goal of avoiding the morbidity and sterilization that comes with hysterectomy. For those patients who inevitably require hysterectomy, immediate performance of the procedure (without using multiple conservative measures) leads to a lower transfusion requirement and possibly less morbidity [19]. Moreover, there is increased blood loss with increased duration of time before performance of hysterectomy. Thus, conservative measures should be used in quick succession, and preparation for hysterectomy should begin promptly in cases of massive hemorrhage or maternal instability. (See "Overview of postpartum hemorrhage".)
Preoperative risk assessment — Sometimes the obstetrician can anticipate the possible need for peripartum hysterectomy based on the patient's risk factors. This enables patient preparation and counseling in the antenatal period, detailed surgical planning, and possibly avoidance of an emergency procedure. This is true primarily for women with abnormal placentation.
Most patients with placenta accreta, increta, or percreta will undergo hysterectomy at delivery (79 of 133 patients [60 percent] in one study [20]). Placenta previa is associated with an approximately 5 percent risk of hysterectomy, usually in cases with placenta accreta [21]. The frequency of abnormal placentation rises substantially as the number of prior cesarean deliveries increases, as well as with maternal age [22]. (See "Placenta previa: Management" and "Placenta accreta spectrum: Management", section on 'Cesarean hysterectomy'.)
Even in the absence of abnormal placentation, cesarean delivery, as well as prior uterine surgery, appears to be a risk factor for peripartum hysterectomy [3,23,24]. In a population-based, case-control study, the risk of peripartum hysterectomy was lowest in women undergoing a first delivery that was vaginal (1 in 30,000) and highest in women with a history of two or more prior cesarean deliveries (1 in 220) [25]. In a study of 30,000 women undergoing cesarean delivery, the risk of peripartum hysterectomy was <1 percent for the first, second, or third cesareans; 2 to 4 percent for the fourth and fifth procedures; and 9 percent after six or more cesareans [23]. While abnormal placentation contributes to hysterectomy risk with repeat cesareans, it is unclear whether the increased risk with primary cesarean delivery relates to the surgery itself, or reflects the indication for cesarean. Indications such as abruption, infection, macrosomia, or multiple gestations are risk factors themselves for hemorrhage and/or uterine atony. Alternatively, providers may move more quickly to hysterectomy for management of hemorrhage in patients whose abdomen is already open. (See "Overview of postpartum hemorrhage", section on 'Physiologic mechanisms that limit postpartum blood loss' and "Overview of postpartum hemorrhage", section on 'Risk factors for PPH'.)
Patient counseling — Patients at risk for emergency peripartum hysterectomy should be counseled about the likelihood of the procedure and how the decision to proceed with hysterectomy will be made. Patients at risk and those with planned procedures should understand what the procedure involves, complications and outcomes of hysterectomy, and issues related to ovarian conservation. The patient should also be aware of the possible need for blood transfusion, mechanical ventilation, and recovery in an intensive care unit rather than a postpartum floor.
Scheduling delivery of patients at high risk for cesarean hysterectomy — Patients at high risk of needing cesarean hysterectomy should be scheduled for delivery at a time when surgical staff and resources are immediately available, preferably avoiding an emergency delivery after the onset of labor. Surgical scheduling and consultations should be arranged with appropriate ancillary staff, which may include high-risk anesthesiologists, interventional radiologists, gynecologic oncologists, and urologists, depending on the complexity of the case. The primary surgeon should have significant experience with pelvic surgery and hysterectomy. Transfer of care to a tertiary care center may be necessary if these resources are not locally available [26].
Total versus supracervical hysterectomy — In scheduled gynecologic surgery, there are no proven medical or surgical benefits of performing supracervical or subtotal hysterectomy if the cervix can be easily removed with the corpus . However in obstetric cases, supracervical hysterectomy may be preferable because removal of the cervix can be particularly challenging when the cervix is significantly dilated. In addition, supracervical hysterectomy may decrease total blood loss and operative time, which is important in the setting of severe acute hemorrhage. As a general guide, the cervix should be removed if cervical injury or bleeding is contributing to the hemorrhage, or if a previa/accreta may be invading the cervical stroma (often, this cannot be known with certainty until a pathologic analysis is performed). It is important to ensure that the entire placental bed has been removed in cases of placenta previa, which may require total hysterectomy or partial trachelectomy.
In a large study using data from the National Inpatient Sample, total hysterectomy was associated with more bladder and "other" (non-gastrointestinal, vascular, or ureteral) injuries, as well as more pulmonary complications and transfusion, but supracervical hysterectomy had higher rates of reoperation and perioperative death [27]. Although a retrospective cohort study reported no significant increase in complication rates when the cervix was removed after emergency cesarean delivery, surgical times were nearly identical with or without cervical removal, suggesting that the supracervical procedures may have been more complicated overall and that aborting cervical removal may have avoided excess morbidity [28]. A subsequent study focusing on peripartum hysterectomy reported higher rates of morbidity for total compared with supracervical approaches, although the study did not control for indication [29]. This study group recommended leaving the cervix if hemorrhage can be adequately controlled in this fashion.
Placement of hypogastric artery balloon catheters — The author does not place preoperative arterial catheters routinely before planned puerperal hysterectomies, given little evidence of benefit and concern for complications; however, practice patterns vary among providers. In selected cases, intraoperative uterine artery embolization may be helpful, although the benefits of this procedure are less clear when hysterectomy is to be performed [30]. (See "Placenta accreta spectrum: Management", section on 'Endovascular intervention for hemorrhage control'.)
Preoperative placement of balloon catheters in the hypogastric arteries has been proposed as a means of decreasing total intraoperative blood loss in patients at risk for severe postpartum hemorrhage. The balloons are generally placed by interventional radiologists under fluoroscopic guidance immediately prior to surgery and inflated following delivery or in the event of hemorrhage.
A meta-analysis of both observational and randomly assigned trials found no significant benefit to internal iliac balloon catheters prior to deliveries with placenta accreta spectrum [31]. Most published studies are observational and subject to significant confounding by surgical and patient characteristics [32-36]. A relatively large retrospective study that controlled for confounding with both propensity score matching and logistic regression reported no difference in morbid outcomes with or without the balloons [35]. Similarly, two randomized trials comparing accreta management with and without the balloons reported no significant difference in morbidity [37,38].
Significant catheter-related complications have been described. In one series (19 patients), 2 patients developed arterial thrombosis and 1 had an internal iliac arterial dissection (16 percent complication rate) [33]. In another study (59 patients), 1 patient developed a thrombosis and 1 had a catheter-site hematoma (4 percent complication rate). A third series of 21 patients who received common iliac balloons reported that 2 (9.5 percent) required postoperative arterial thrombectomies [39].
Placement of an aortic balloon catheter — As the effectiveness of internal iliac balloon occlusion may be limited by collateral pelvic circulation, some centers use a balloon placed in the distal aorta. This location will occlude most of the pelvic circulation and can be placed under either fluoroscopic or ultrasound guidance. A meta-analysis comparing 463 aortic balloon recipients with 268 control women showed a significant reduction in blood transfusion volume, hysterectomy rate, operative duration, and length of hospital stay in the balloon group [40]. A different series comparing over 300 cases of retrograde endovascular balloon occlusion of the aorta with 128 controls also reported decreased volumes of hemorrhage and blood transfusion [41]. The balloons were almost always inflated for less than 40 minutes; the overall complication was 0.6 percent. Complications such as aortic tears and iliac thromboses have been described, and the procedure should be performed by radiologists or surgeons with specialized training [42,43].
Preoperative preparation — Peripartum hysterectomy differs from hysterectomy in nonpregnant women in several important respects, most of which make the operation more difficult:
●The cervix may be quite soft and difficult to identify, especially if the patient has labored. In addition, the lower uterine segment may be highly developed and elongated, which may increase the risk of leaving endometrium behind with supracervical (subtotal) hysterectomy.
●Blood vessels throughout the pelvis are greatly dilated, and varices are often found in the mesosalpinx and vesicouterine space, increasing the risk of massive hemorrhage, which may obscure the operative field.
●The uterus is large and fills the pelvis.
●Tissue, including the vaginal cuff and broad ligament, may be friable and prone to tearing when clamped.
●The myometrium surrounding an invasive placenta (increta or percreta) may be very thin or absent, and placement of clamps on this tissue may lead to severe hemorrhage.
With these considerations in mind, the author makes the following preparations in patients at high risk of undergoing hysterectomy to prevent or control massive hemorrhage:
●Notify the anesthesia team in advance so anesthesia staff experienced with anesthetic management of massive hemorrhage and transfusion conduct the case. While epidural or combined spinal/epidural anesthesia is possible, general anesthesia should be immediately available [44].
●Assign surgical assistants familiar with hysterectomy, as well as experienced nursing staff and surgical technicians, or ensure that these personnel are readily available for staffing the case.
●Ensure adequate intravenous access with multiple large-bore lines, and possibly an arterial line, before surgery.
●Administer prophylactic antibiotics within one hour of skin incision to decrease the risk of postoperative infection (table 3). Intraoperative re-dosing is needed if blood loss exceeds 1500 mL or operative time exceeds four hours.
●Cross-match both packed red blood cells and plasma. In patients suspected of accreta, we have four units of both products immediately available and ask the blood bank to keep this amount available at all times as the products are transfused. For patients at lower risk for massive bleeding (such as those with large leiomyomas or prior classical cesarean delivery, myomectomy, severe adhesions, or placenta previa without prior cesarean delivery), the author has two units of blood immediately available, with more available for crossmatch, as needed. The blood bank should ensure the availability of cryoprecipitate and platelets, if required, and the facility should have a massive transfusion protocol in place. All centers that may provide peripartum hysterectomy should have a massive transfusion protocol in place and should perform periodic drills to simulate massive blood replacement [18].
●Confirm that appropriate instrumentation is available:
•Self-retaining retractor designed to give adequate lateral exposure (eg, Bookwalter or disposable self-retaining retractor)
•Sufficient number of pedicle clamps adequate to hold tissue without tearing or slippage (eg, Heaney, Rogers, or Zeppelin clamps)
•Electro-dissection unit
•Two suction devices
•Adequate number and types of sutures, including absorbable synthetic sutures of various sizes and delayed absorbable suture for a vertical fascial incision
•Disposable bipolar electrosurgical device (eg, LigaSure) can be very helpful to control back bleeding and manage hypervascularity during the dissection
•Atraumatic hemostatic clamps, such as ring or lung clamps
●Place a bladder catheter to drain urine and facilitate instillation of fluid to test bladder integrity, if required intraoperatively. Ureteral stents can be placed preoperatively, if the patient has an accreta or major adhesions with the need for parametrial dissection.
●Place a device for intermittent pneumatic compression to reduce the risk of deep vein thrombosis.
●Place the patient in lithotomy position using a boot-type stirrup, if possible, as this allows better assessment of intraoperative vaginal blood loss and allows ready access to the bladder or vagina from below. We advise placing a conical collection bag under the patient's buttocks, preferably with graduated markings to aid in blood loss quantification. Unscrubbed members of the operating room team should be assigned to quantify vaginal blood loss periodically. A scale may also be brought into the operating room for gravimetric blood loss assessment of soaked laparotomy sponges.
Prep the vagina with povidone-iodine. Before a planned total hysterectomy, some surgeons tag the external os with sutures (if no previa) or place a tagged (counted) sponge just beneath the cervix to aid intraoperative identification. Others have described placing a sponge stick or an end-to-end anastomosis sizer into the vagina, then directing it into the vaginal fornices intraoperatively to identify the upper vagina [45,46].
●Have patient- and fluid-warming devices available to avoid hypothermia, which should be anticipated in shock or massive transfusion.
●If available, consider using intraoperative cell salvage and autotransfusion of red blood cells. The procedure has been performed safely in hundreds of obstetric patients and appears to be cost-effective in the setting of anticipated gravid hysterectomy [47-49].
OPERATIVE PROCEDURE
Key points — This synopsis illustrates the key points of the more comprehensive discussion of the operative procedure that follows:
●In the setting of significant hemorrhage or an unstable patient, clamping or compressing the uterine blood supply takes precedence over adhesiolysis and retractor placement. Pedicles can be rapidly clamped and cut, and sutured later. When severe hemorrhage prohibits adequate visualization of the pelvis, the aorta can be compressed manually over the sacrum and the pelvis carefully packed until the bleeding slows. A trauma surgeon may be consulted, if available.
●When the patient is hemodynamically stable, obtaining adequate exposure and uterine traction will minimize vascular or ureteral injury.
●If the bladder does not reflect readily off the cervix, it may be opened at the dome. Palpation and inspection of the posterior bladder from the interior makes it easier to find the dissection plane between these two organs. In addition, the cervix may be fused to the bladder (especially in placental percreta), thus requiring resection of a portion of the bladder. Consultation with a gynecologic oncologist or urologist is warranted if the surgeon does not have sufficient experience with bladder surgery.
●Every attempt should be made to identify the ureter and avoid ligating it. However, control of hemostasis is more important than preserving the ureter intact. Ligation of one or both ureters can be reversed in a subsequent operation after hemostasis has been achieved and coagulopathy and hypovolemia have been corrected.
Incision and delivery — The author prefers a vertical skin incision to help ensure adequate exposure, specifically in cases of placenta accreta spectrum involving a prior low transverse hysterotomy. A Pfannenstiel incision may be appropriate in selected cases with an unscarred uterus or no placenta previa, and when exposure is expected to be adequate. If a transverse skin incision is performed, it should be as wide as possible, and the surgeon should be prepared to divide the rectus muscles (Maylard incision) or perform a Cherney approach if the incision does not provide adequate exposure.
A low transverse hysterotomy is acceptable if it is not over the placenta and can be made without causing excessive bleeding. Avoiding disruption of a known abnormally implanted anterior placenta or transection of large anterior fibroids is essential and is best accomplished through a classical (fundal) uterine incision. A high hysterotomy may also be preferable in the setting of large bladder varicosities or significant anterior adhesions. The hysterotomy can be made hemostatic rapidly using atraumatic hemostatic clamps or a single running layer with sturdy suture (eg, loop #1 polydioxanone [eg, PDS]) on a large needle.
With a fundal hysterotomy, a fetus in vertex or transverse lie is most easily delivered as a breech. Following delivery of the fetus, the placenta should be removed, if nonadherent, to allow maximal uterine contraction. Oxytocin is then given to maintain uterine tone until the blood supply is disconnected. Any adherent placenta should be left in place as removal can increase total blood loss [50]. (See "Placenta accreta spectrum: Management", section on 'Cesarean hysterectomy'.)
After delivery, placing the patient in Trendelenburg position, use of a self-retaining retractor, and packing the abdominal contents can facilitate visualization [51]. In addition, insertion of an intrauterine balloon or intrauterine packing for tamponade slows severe bleeding. The balloon or pack should be removed during the hysterectomy as bleeding is controlled surgically because lateral bulging may impede uterine artery and cardinal ligament dissection. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device".)
Hysterectomy — The technique should be simple enough to perform rapidly and should minimize the creation of dead space and raw surfaces because of the possibility of coexistent coagulopathy. When hemorrhage is severe, control of the uterine blood supply takes precedence over surgical dissection, and, in a hemodynamically unstable patient, this may require risking urinary tract, adnexal, or bowel injury.
The procedure is begun by using electro-dissection to lyse adhesions to the uterus. When the uterus is free, the fundus is extracorporealized, and an assistant maintains traction on the fundus until the uterus is removed. If the adhesions are highly vascular, early control of the uterine blood supply by dissecting and ligating the uterine arteries at their lateral edges may be preferable. This is particularly true with an anterior placenta accreta, as dissection of the vesicouterine space may lead to significant hemorrhage.
Each round ligament is doubly clamped laterally with curved clamps whose concave surface is directed medially. The tissue between the clamps is divided using Mayo scissors or electro-dissection, and each clamp is replaced with a suture ligature. The broad ligament is then opened, and the adnexal pedicles are isolated. The ovaries are almost always left in place, unless a severely adherent ovary necessitates a lengthy dissection during a hemorrhagic emergency. The fallopian tube and utero-ovarian ligament are then isolated and clamped. Placing clamps directly on the uterus may be inadvisable in the setting of hypertrophic vessels. In this circumstance, identifying and opening a clear space below each vascular bundle should be attempted. Each pedicle is then clamped with a vascular clamp, transected, and suture ligated. This should be done in a single bundle, if possible, but may require multiple pedicles on each side if the bundle is too large to ligate safely. In the presence of severe hemorrhage, however, the operation can be performed more rapidly if the pedicles are not sutured until all of the vascular structures to the uterine arteries have been clamped and divided. This requires a sufficient number of clamps to be available. Use of a bipolar ligature device, such as the LigaSure instrument, allows the procedure to be performed more rapidly, but we still prefer to secure the proximal pedicles with sutures after the blood supply has been controlled.
The posterior leaf of the broad ligament is then opened towards the cervix, dropping the ureters inferiorly and clearing the endopelvic fascia posterior to the uterine vessels. The uterine vessels are then skeletonized by carefully opening overlying tissue with cautery. If cesarean delivery was performed, the bladder flap may have been developed. Otherwise, the bladder may be released by gently spreading the tips of Metzenbaum scissors or a tonsil clamp in the vesicouterine peritoneum and using electro-dissection to transect the serosa. The vesicocervical space is developed and bladder pillars divided, but no further distally than will be necessary to allow exposure and clamping of the uterine vessels. Large varicosities in the vesicouterine space, as can be seen with placenta previa or accreta, may require bipolar coagulation or clamping with suture ligation. Gentle finger dissection may speed the procedure once good planes have been created, but blunt dissection with a sponge stick is inadvisable as massive bleeding or bladder laceration may result. If scarring has obliterated the vesicocervical space (as can occur after previous cesarean deliveries), sharp dissection with Metzenbaum scissors may be necessary to perform this dissection.
If a difficult or highly vascular dissection is anticipated, then it may be prudent to secure the uterine blood supply prior to completing the midline bladder dissection. This may be accomplished by opening the paravesical spaces and clearing the endopelvic fascia just medial to the ascending uterine vessels. This allows the arteries to be safely clamped and sutured with bladder adhesions undisturbed. These bladder adhesions can then be taken down sharply or with cautery after the majority of the uterine blood supply has been controlled. When there is concern for placental bladder invasion, a posterior approach to the dissection may be considered [45]. This involves opening the posterior vagina through the pouch of Douglas, then securing the uterosacral and cardinal ligaments and uterine arteries prior to developing the bladder plane from below.
The ureters are identified by visualizing them through the peritoneum of the posterior broad ligament, or by palpation when stented. If their position is in doubt, then the retroperitoneum should be opened further and the ureter directly visualized. Their position should be confirmed frequently during the procedure.
The uterine arteries may then be exposed by carefully dissecting the broad ligament. This often requires clamping or coagulating vessels within the ligament. Sequentially clamping and transecting the ascending uterine arteries, against the lateral uterus, may be most expedient, with the final pedicle containing the uterine vessels. However, caution should be used with a retained placenta accreta or percreta, in which case clamping of the vascular uterine tissue can lead to massive hemorrhage. In this circumstance, the uterine arteries should be dissected and identified lateral to the uterus, and clamped at their insertion. This requires identification of the ureters either visually or by palpation (in the case of stenting) as the arteries are clamped. At least one retrospective study has shown that preoperative ureteral stenting was associated with a significant reduction in early postoperative morbidity, possibly by facilitating the identification of the ureters or ureteral injury [50].
Once the major vessels have been ligated and the bladder has been displaced inferiorly, each cardinal ligament is divided in several bites by clamping close to the cervix with a straight clamp, dividing the tissue medially with scissors or a scalpel, and suturing the pedicle. After dissecting the upper cardinal ligaments, a supracervical hysterectomy can be performed by clamping the lateral cervical vessels and transecting the mid cervix with scissors or electrosurgery. After ligating the lateral vascular pedicles, the cervical edges are oversewn with figure-of-eight or running sutures. In the setting of a placenta previa, the excised boundary of the cervix should be examined to ensure that a cuff of clear endocervix lies beneath the placental bed.
Alternatively, if the cervix is to be completely removed, the cul-de-sac is examined to ensure that the rectal reflection is not abnormally high. The bladder is further reflected off the entire cervix and the proximal vagina. The cardinal ligaments are clamped and transected with incorporation of the lateral cervical vessels until the base of the cervix is reached. If the distal cervix is difficult to identify, the cervix may be transected above the level of vessel dissection and the uterine specimen removed. The external cervical os can then be palpated through this incision and used to define the distal limit of cardinal ligament dissection. The vaginal angle and uterosacral ligament on each side are clamped into a bundle with a curved clamp. The vagina is then severed with scissors medial to each clamp. Following this, each clamp is replaced with a suture ligature. The remainder of the vaginal cuff is closed with a running suture. Incorporating the peritoneum posteriorly may aid hemostasis. The suture should include approximately 10 mm of the upper vaginal cuff to avoid later bleeding or breakdown; in this process, it is important to avoid the bladder anteriorly.
Special considerations with placenta accreta spectrum — Due to hypervascularity of the lower uterine segment and high potential for placental disruption, more radical approaches have been described for cases of severe accreta spectrum (such as percreta) [45,52]. The author strongly advises the involvement of an experienced pelvic surgeon or gynecologic oncologist when managing these cases. If placenta percreta is unexpectedly encountered at the time of delivery, the obstetrician should consider aborting the procedure if possible or delivering the neonate through the uterine fundus and then closing the fundal incision without any placental disruption. The patient should then be carefully monitored in the operating room until surgical help or patient transfer can be arranged.
Evaluation of bladder and ureteral integrity — Integrity of the bladder can be confirmed by infusing 200 mL of saline mixed with two or three drops of methylene blue through the bladder catheter; extravasation of blue fluid signifies a leak. The ureters are inspected to determine that they are intact, peristalsing, and of normal caliber. If there is concern for ureteral injury, this may be tested by injecting one to two ampules (5 mL per ampule) of indigo carmine intravenously; blue urine will spill into the pelvis in 10 to 15 minutes if a ureter has been cut. This method is, however, unlikely to reveal ligation of the ureter. Cystoscopy or direct visualization of the ureters through a cystotomy (the latter requiring urine dye) demonstrate urine passing through both ureteral orifices. Absence of this finding suggests that one or both ureters are obstructed as a result of surgery. A ureteral stent can be passed through the ureteral orifice to localize the site of obstruction. (See "Urinary tract injury in gynecologic surgery: Identification and management".)
If a cystotomy has been created inadvertently or intentionally, it should be closed with two layers of absorbable synthetic suture. If the injury occurs at the level of the bladder trigone, stenting may be necessary, and urologic consultation is recommended. (See "Urinary tract injury in gynecologic surgery: Identification and management".)
Inspection and closure — The pelvis should be copiously irrigated and suctioned, and blood-soaked packs should be removed. Each vascular pedicle should be checked for hemostasis, as should the dissection sites. The abdomen is closed using any standard technique, after ensuring good hemostasis. No drains are necessary, unless there is concern for ongoing bleeding or persistent bladder leak.
PERSISTENT PELVIC BLEEDING — Bleeding in the deep pelvis may persist following hysterectomy.
Assess for coagulopathy — Ideally, coagulation is assessed with laboratory testing and, if abnormal, managed with transfusion of blood products, patient warming, and correction of acidemia and hypocalcemia. (See "Etiology and diagnosis of coagulopathy in trauma patients".)
Intraoperative testing options include:
●Direct observation of blood specimen – Prior to the return of the first set of laboratory studies, a red top tube of 5 mL blood can be observed for clotting. If the blood in the tube clots within 8 to 10 minutes and the clot remains intact, the patient likely has adequate fibrinogen stores. If the blood in the tube does not clot or an initial clot dissolves, it is likely that the patient is markedly deficient in key clotting factors.
●Viscoelastic testing – Some centers use point-of-care viscoelastic testing (POCVT) for more rapid coagulation testing and guidance on blood product replacement. One small trial reported decreased use of blood products when the POCVT-directed transfusion protocol was followed, but the difference was not significantly different in the intention-to-treat analysis [53]. A review of retrospective studies reported that POCVT may be linked to lower transfusion rates with postpartum hemorrhage, but larger well-controlled studies are needed to determine the utility and cost effectiveness of these methods [54].
Discussions of viscoelastic testing with thromboelastoplasty (TEG) and rotational thromboelastography (ROTEM) are presented in detail separately. (See "Platelet function testing", section on 'Viscoelastic testing (TEG and ROTEM)'.)
Surgical techniques — Surgical hemostasis may be achieved by placing running and figure-of-eight absorbable sutures in bleeding areas or with the direct application of cautery. If this does not control bleeding, hemostatic agents (table 4) and pelvic packing are the next steps. (See "Management of hemorrhage in gynecologic surgery", section on 'Prolonged pelvic packing' and 'Pelvic packing' below.)
Hemostatic agents — Small areas of low-volume bleeding can be treated with topical hemostatic agents [55,56]. Investigation of these agents has focused on vascular, cardiac, and hepatic surgery [57,58]. There are few high-quality data regarding treatment efficacy or use in obstetric and gynecologic surgery. Thus, choices are made based on surgeon preference, availability, and cost effectiveness (table 4). (See "Management of hemorrhage in gynecologic surgery", section on 'Topical hemostatic agents'.)
These agents should not be used for intravascular injection, in closure of skin incisions, or for treatment of bleeding from the endometrium. They also should not be used in infected tissue. If red blood cell salvage is being performed, it should be stopped as soon as hemostatic agents are placed in the pelvis and should not be resumed.
Pelvic packing — Packing is a last resort that usually succeeds in controlling low-pressure (microvascular or venous) bleeding confined to the pelvis [59]. There are multiple variations of this procedure; selection is based on surgeon preference and available materials. One approach is to tie Kerlix bandages together end-to-end to form one long strip for packing. If Kerlix is not available, dry laparotomy sponges may be used. The dry sponges are packed gently but firmly into the pelvis so that the pack fills all interstices, but does not abrade pelvic tissue. If the packing is successful, no blood will be seen seeping through or around the gauze after 10 minutes of observation. Alternate options include using gauze stuffed into an x-ray cassette drape, an inflated uterine balloon brought out through the vagina (picture 1), or an umbrella pack [60-69].
Most often, a temporary abdominal closure will be placed over the packings, possibly with the addition of a negative pressure wound system to remove fluids and avoid an abdominal compartment syndrome (see "Management of the open abdomen in adults")
These patients usually require intensive care unit admission to manage coagulopathy, ventilation, hypothermia, and metabolic abnormalities. (See "Management of hemorrhage in gynecologic surgery".)
Laparotomy is usually needed to remove the pack, or it may be removed through the vagina or another conduit. Postoperative fever is common, and broad-spectrum antibiotics are given until the packing is removed. Removal should take place under general anesthesia 36 to 72 hours after insertion. Bleeding may resume if the pack is removed too early or in the presence of coagulopathy, whereas pelvic infection is likely if removal is delayed [70].
COMPLICATIONS — The principal complications after peripartum hysterectomy are febrile morbidity, hemorrhage, urinary tract injury, coagulopathy, paralytic ileus or bowel obstruction, and reoperation. Emergency procedures are associated with a higher rate of complications than planned procedures [71]. Mortality should be <1 percent, though a global summary of emergency cases reported mortality rates ranging from 0 to 59 percent, with a composite rate of 5.2 percent [5,72]. The findings from several large series of peripartum hysterectomy are illustrated below:
●A prospective series by the Maternal-Fetal Medicine Units (MFMU) Network included 186 cesarean hysterectomies performed in 1999 and 2000 and reported the following complications and their frequencies: red blood cell transfusion (84 percent), transfusion of other blood products (34 percent), fever (11 percent), ileus (5 percent), exploratory laparotomy (4 percent), hospital readmission (4 percent), urinary tract infection (3 percent), cuff abscess (2.7 percent), maternal death (1.6 percent), bowel injury (1 percent), wound dehiscence (1 percent), pelvic or deep vein thrombosis (1 percent) [73].
●Data from the Nationwide Inpatient Sample (a random sample of 20 percent of hospital discharges in the United States) from 1998 to 2007 showed the following types and rates of complications in 4967 peripartum hysterectomies: transfusion (46 percent), infection (12 percent), wound complication (10 percent), bladder injury (9 percent), reoperation (4 percent), venous thromboembolism (1 percent); and intestinal, ureteral, or vascular injury (≤1 percent) [27]. Transfusion, infection, urinary tract injury, and reoperation were much more frequent than in nonobstetric hysterectomy.
●A review of six studies of peripartum hysterectomy reported the following ranges of complications: febrile morbidity (11 to 34 percent), cystotomy (6 to 29 percent), ureteral injury (2 to 7 percent), oophorectomy (6 percent), reoperation (4 to 33 percent), thromboembolism (1 to 4 percent), death (0 to 4.2 percent) [51].
POSTOPERATIVE CARE — Routine posthysterectomy and postpartum care is appropriate if the patient is stable. Patient-controlled analgesia (either intravenous or epidural) is preferable until she can take oral medicine. Wound care is conducted according to the surgeon's preference.
Enhanced Recovery after Surgery (ERAS) protocols are used for anticipated peripartum hysterectomy cases at the author's hospital in the same manner as for other scheduled cesareans [74]. Protocols can be modified based on an individual's postoperative status, but early oral intake and ambulation are encouraged when possible. (See "Cesarean birth: Preoperative planning and patient preparation".).
Prophylaxis — If the operation was clean contaminated, no postoperative antibiotics are indicated. Active infection should be treated appropriately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
Women undergoing peripartum hysterectomy are at moderate risk or high risk of postoperative thromboembolic disease, depending on individual risk factors; therefore, both mechanical and pharmacologic prophylaxis for deep venous thrombosis are suggested. Pharmacologic prophylaxis is initiated at least four hours postoperatively; timing depends on patient-specific factors in the balance between risk of bleeding and risk of venous thrombosis, and whether a neuraxial catheter is left in place after surgery is completed. Prophylaxis is discontinued when the patient is discharged, but may be prolonged in selected women at highest risk of venous thromboembolism, such as those who have had a previous thromboembolic event.
●(See "Venous thromboembolism in pregnancy: Prevention", section on 'Cesarean section'.)
●(See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Bladder care — If urinary stents were placed, they can be removed immediately postoperatively. The bladder catheter can also be removed within 24 hours postoperatively in stable patients who do not require monitoring hourly urinary output. However, if a cystotomy was repaired, then drainage is generally continued for 5 to 10 days. A large repair (>2 cm) should be evaluated with a cystourethrogram prior to discontinuing the catheter. (See "Urinary tract injury in gynecologic surgery: Identification and management".)
Diet — Clear liquids are ordered after surgery, and the diet is advanced with patient appetite and tolerance of oral intake. Nausea, anorexia, abdominal distention, or vomiting are signs of paralytic ileus. Mild symptoms can be managed with restriction of oral intake and intravenous fluids, while more severe vomiting should be evaluated radiographically. Confirmed ileus or partial obstruction should be treated with nasogastric suction with intravenous fluid and electrolyte repletion. (See "Postoperative ileus".)
Breastfeeding — Hemorrhage and hysterectomy are not contraindications to breastfeeding. Patients admitted to the intensive care unit may use a breast pump once they are extubated and stabilized. Early pumping is encouraged when the newborn is admitted to the neonatal intensive care unit. Breast milk output should be considered in the patient's fluid management, although this is usually not a concern by the time her milk supply develops. In the setting of a physically or psychologically difficult recovery, patients who are unwilling or unable to breastfeed should be supported.
Sheehan syndrome should be considered in women who fail to lactate postpartum or develop other manifestations of hypopituitarism. (See "Overview of postpartum hemorrhage", section on 'Long-term morbidity'.)
SUMMARY AND RECOMMENDATIONS
●Timing of hysterectomy – Timing is critical to an optimal outcome: hysterectomy should not be performed too early or too late. There is a relationship between the duration of time that passes prior to deciding to perform an emergency hysterectomy, the amount of blood loss, and the likelihood that the hysterectomy will be seriously complicated by coagulopathy, severe hypovolemia, tissue hypoxia, hypothermia, and acidosis, which further compromise the patient's status. (See 'Surgical planning' above.)
●Surgical planning – Anticipating the possible need for peripartum hysterectomy based on the patient's risk factors enables patient preparation and counseling in the antenatal period, detailed surgical planning, and possibly avoidance of an emergency procedure. (See 'Preoperative risk assessment' above and 'Scheduling delivery of patients at high risk for cesarean hysterectomy' above and 'Preoperative preparation' above.)
●Operative planning
•Vertical skin incision – A vertical skin incision is generally required for sufficient exposure. A Pfannenstiel incision may be acceptable in thin patients with no previa or large fibroids and at very low risk of having adhesions. A Pfannenstiel incision may also be appropriate when the placenta has previously been delivered, such as in cases of intractable uterine atony. (See 'Incision and delivery' above.)
•Adherent placenta – In the case of suspected placenta previa/accreta, the surgeon should take care to not disrupt the adherent placenta, which usually requires a fundal hysterotomy. (See 'Hysterectomy' above.)
•Supracervical hysterectomy – Supracervical hysterectomy is a reasonable option unless there is specific indication for removal of the cervix. (See 'Total versus supracervical hysterectomy' above.)
•Limited role of arterial balloon catheters – The author does not place preoperative arterial balloon catheters routinely before planned puerperal hysterectomies, given little evidence of benefit and concern for complications. (See 'Placement of hypogastric artery balloon catheters' above.)
●Key surgical points – Key points of the operative procedure include (see 'Key points' above):
•In emergency hemorrhage or an unstable patient, clamping the uterine blood supply takes precedence over adhesiolysis and packing. Pedicles can be rapidly clamped and cut, and sutured later.
•When the patient is hemodynamically stable, obtaining adequate exposure and uterine traction will minimize vascular or ureteral injury.
•It may be difficult to determine the boundary between the cervix and vagina as a dilated cervix is effaced and soft. Placing sutures, clips, or a ring forceps to "tag" the cervix reduces this problem. Before a planned total hysterectomy, the external os may be tagged with sutures (if no previa) or a tagged (counted) sponge, sponge stick, or end-to-end anastomosis sizer may be placed vaginally to aid intraoperative cervical and vaginal identification.
•If the bladder does not reflect readily off the cervix, it should be opened at the dome. Palpation and inspection of the posterior bladder from the interior makes it easier to find the dissection plane between these two organs. In addition, the cervix may be fused to the bladder (especially in placental percreta), thus requiring resection of a portion of the bladder. Consultation with a gynecologic oncologist or urologist is warranted if the surgeon does not have sufficient experience with bladder surgery.
•Every attempt should be made to identify the ureter and avoid ligating it. However, control of hemostasis is more important than preserving the ureter intact. Ligation of one or both ureters can be reversed in a subsequent operation after hemostasis has been achieved and coagulopathy and hypovolemia have been corrected.
●Plan for transfusion needs – Preparation should be made for massive transfusion and avoidance of coagulopathy. When bleeding cannot be stopped surgically, pelvic packing, temporary closure, and transfer to an intensive care unit may be necessary. This should usually proceed with the assistance of a general or trauma surgeon. (See 'Preoperative preparation' above and 'Persistent pelvic bleeding' above.)
●Complications – The principal complications of peripartum hysterectomy are hemorrhage, urinary tract injury, coagulopathy, and infection. (See 'Complications' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dr. Allan J Jacobs, who contributed to earlier versions of this topic review.
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