DISCUSSION
The present study showed that the most common indication for PPH was
placental invasion anomalies. The planned peripartum hysterectomies
provided lower morbidities and better neonatal outcomes compared to
emergent cases whereas the emergent peripartum hysterectomies needed
higher blood product requirements.
The incidence of PPH varies in a wide range. In a large-scaled
meta-analysis, the incidence was found as 0.9 per 1000
deliveries6. A retrospective cohort study from
Pakistan showed higher incidence as 4.01 per 1000
deliveries12. We have also observed PPH yielding an
incidence of 1.7 per 1000 deliveries in a previous study from our
tertiary center13. There are several studies that
assessed the peripartum hysterectomies and the incidence may change
among countries and centers whether they have sufficient antenatal care
for pregnancies. In some studies from Turkey, the incidence of PPH was
established between 0.3 and 5.38 per 1000 deliveries7,14-17. Sharma et al. found much higher incidence as
6.9 per 1000 deliveries3. Our incidence was similar to
the previous literature and accordance with another Turkish studies. The
most common indication was uterine atony in the
past7,8. However, the main indication has been evolved
over recent years from uterine atony to abnormal
placentation18. The rising cesarean delivery rates may
result to the placental pathologies so it increases the rates of
peripartum hysterectomy6,19-21. Van den Akker et al.
evaluated approximately 8 million deliveries and they reported that
placental abnormalities were the most common indication for PPH and
followed by uterine atony6. In a recent study, Kazi
found that emergent peripartum hysterectomy was performed for hemorrhage
primarily due to uterine atony12. Senturk et al. put
forward that the incidence of PPH was higher in the east of Turkey and
the main indication was uterine atony and rupture17.
The increasing use of uterotonics and cesarean rate may explain the
conversion of main indication from uterine atony to abnormal invasive
placentation for PPH3,6,19,22-24. The morbidly
adherence of placenta become prominent as an indication especially in
planned cesarean hysterectomy3. Briery et al. reported
that uterine atony was responsible in over half of the patients for
emergent peripartum hysterectomy and placenta accreata was the second
frequent indication in this group11. In a
retrospective study, Sharma et al. showed that placenta accreata was
found in all of elective peripartum hysterectomy
patients3. We found similar results in accordance to
the recent literature. The cesarean rate has incrased over the years and
this rate was observed as 63.6% in our study population. Therefore, the
placental abnormalities consisted of 56% of patients. We have also
determined that the reason of peripartum hysterectomy was only abnormal
placental pathologies in planned hysterectomy group. We have performed
total abdominal hysterectomy(63.6%) for patients and there was no
significant differences between emergent and planned hysterectomy group
in terms of surgical type. Subtotal hysterectomy is more desirable for
surgeons because removal of the cervix may be difficult due to possible
dilated cervix in the peripartum hysterectomy cases. Total abdominal
hysterectomy was performed more frequently in our study. Some studies
demonstrated that subtotal abdominal hysterectomy is more suitable
especially in placental invasion abnormalities, and the morbidities was
lower than total abdominal hysterectomy cases7,20.
However, some researchers proposed to make total abdominal hysterectomy
if the patient status is in good condition and they indicated that total
abdominal hysterectomy should be considered to prevent hemorrhage from
the cervix5,8.
It was established that intra-operative bleeding was higher in emergent
peripartum hysterectomy group compared to scheduled
cases8,11. In a recent prospective-cohort study, Seoud
et al. have observed lower intra-operative bleeding in elective surgery
group and they also found that lower blood prodcuts were transfused in
the elective cases25. In parallel with the higher
blood loss, the transfused blood products increase in peripartum
hysterectomies. In our study, we observed that red blood cell
transfusion was given to all of the patients in the emergent group,
although 83.9% of the patients needed to get transfusion in the planned
surgery group(p=0.014). We have also determined that lower fresh frozen
plasma transfusion was required in the planned hysterectomy cases. Wei
et al. showed the red blood cell transfusion with a rate of
95%26. Sak et al. found that the red blood cell was
transfused to 62.2% of the placenta accreata
patients27. Briery et al. compared the transfusion of
red blood cell between emergent and planned cesarean hysterectomies and
they observed 66% vs. 33% transfusion rate with a mean transfused
units of 4.5 vs 1.6, respectively(p<0.05)11.
A prospective-cohort study has also found that elective surgery was
associated with lower blood transfusion rate compared to emergent
cases25. In another retrospective study, authors have
demonstrated lower post-operative hemoglobin values in the emergent
surgery but it did not reach any significance(7.8±1.6 vs. 8.9±2.2,
p=0.08)3. Our study also showed significanly lower
hemoglobin levels in the emergent perpiartum hysterectomy group. The
transfused units of red blood cell and fresh frozen plasma were higher
in the emergent group. Similar to our study, Seoud et al. established
that the transfusion rate and mean transfused units were higher in the
emergent casses25. We have also analyzed the
difference between pre-operative and post-operative hemoglobin levels
and it revealed lower differences in the planned surgery compared to
emergent cases. The higher complication rate is expected in the emergent
cases than scheduled surgery. The bladder injury that is the most common
complication was observed as 3-20% in several
studies3,7,12,17,23. A higher incidence of bladder
injury(27.2%) was stated in our study in reference to the literature.
The planned hysterectomy groups had higher bladder injury rate than
emergent group but not significantly. We thought that the higher rate
may be related to the higher incidence of abnormal placental invasion in
planned surgery group. Briery et al. showed higher incidence of
post-operative complications in the emergent cesarean
hysterectomy11. Two studies 11,25have established that the number of hospital stays were similar between
groups but Pettit et al. have found fewer hospital duration in the
planned surgery28. We have also reported slightly
higher hospital duration in emergent hysterectomy group, but it did not
differ significantly similar to the literature findings.
The neonatal outcomes are important in the peripartum hysterectomies. In
emergent situations, these outcomes may be affected negatively, so we
can improve the neonatal outcomes by performing planned peripartum
hysterectomies in selected patients with proper timing. Seoud et al.
demonstrated similar birth weight and apgar scores among elective and
emergent cases25. Pettit et al. also compared the
neonatal outcomes and showed similar apgar scores between emergent and
planned surgeries28. Otherwise, they found higher
gestational weeks and birth weight in the planned hysterectomy. Briery
et al. obtained that the patients underwent planned cesarean
hysterectomy had higher gestational weeks, higher fetal birth weight and
apgar scores compared to emergent group, but not
significantly11. On the contrary, we have observed
that the gestational weeks, and birth weight were higher in the emergent
peripartum hysterectomy cases significantly. We also reported that the
apgar scores were significantly higher in the planned surgery although
the gestational week and birth weight were lower than the emergent
surgery group. It may be associated that we administered antenatal
corticosteroids to all of the planned surgery prior to the delivery.
The emergent peripartum hysterectomy is a life-saving procedure but it
has some post-operative problems. Thus, the planned peripartum
hysterectomy may improve the maternal and neonatal outcomes and
decreases the complication rates. The prenatal diagnosis of the abnormal
placental invasion become significant for performing scheduled surgery
in these cases. One third of the placental accreata cases that
antenatally diagnosed still delivered in an unplanned
manner28. We think that it is not possible to avoid
the emergent cases completely. The ideal delivery time for suspected
abnormal placentation cases is still controversial. There was more
optimal outcomes in the placenta accreata cases that delivered at the 34
gestational weeks29. American College of Obstetrics
and Gynecology(ACOG) recently recommended delivery time at 34 weeks to
35 weeks 6 days especially in suspected case for placenta
accreata30. ACOG also suggests to make the deliveries
of placenta accreata cases with expert team in a tertiary
center10.
The main limitation of our study was the retrospective nature. The datas
of the study population covers a very wide time interval, so the uterine
atony was more in the old datas and placental pathologies were more
prominent in the recent datas. It might make a selection bias for our
study. However, the present study comprehensively compared the emergent
and planned peripartum hysterectomies and the sample size of the study
was enough according to the previous studies. One of the limitations is
the lack of information about the expertise level of surgeons in both
study groups. Another important limitation is that we compared the
different indications between emergent and planned surgeries such as
uterine atony and placental invasion anomalies; since in uterine atony,
anatomy is not distorted than placental invasion anomalies.
In conclusion; we showed that antenatally planning of the peripartum
hysterectomy improved the maternal and neonatal outcomes. Prenatal
diagnosis of suspected cases provide some modifications to the surgeons
during the surgery. According to the above ACOG recommendations, we make
an effort to diagnose the suspected cases antenatally and we also
currently perform the planned peripartum hysterectomies at 34 weeks to
35 weeks 6 days with an expert multi-disciplinary team. Further
prospective studies are needed to investigate the correlation of planned
peripartum hysterectomy with perinatal outcomes.