Classification of haemorrhage
Peripartum hysterectomy is uncommon in modern obstetrics. It is mostly performed as an emergency procedure to control life-threatening haemorrhage. Despite recent technical advances in medicine, it is associated with high rates of morbidity and mortality. Peripartum hysterectomy constitutes a life-saving procedure.
- Postpartum haemorrhage
Peripartum hysterectomy can be defined as the removal of the corpus uteri alone or with the cervix at the time of a caesarean section or within the puerperium. The removal of the uterus at caesarean section is referred to as caesarean hysterectomy, while the removal after vaginal birth is called postpartum hysterectomy. The operation may be performed as an emergency or as a planned procedure [1,2].
Although uncommon in modern obstetrics, peripartum hysterectomy is one of the most devastating complications in obstetrics. It represents a catastrophic end to a pregnancy to all women in general and to those wanting to maintain their fertility in particular [3,4].
Despite advances in medicine and surgery, peripartum hysterectomy is associated with high rates of morbidity, near miss and mortality. It is mostly performed as an emergency procedure to control torrential life-threatening haemorrhage and remains a life-saving procedure [1,2,5].
Peripartum hysterectomy was proposed in 1768 by Joseph Cavallini in animal experiments. In 1823, James Blundell approved caesarean hysterectomy on a work based on rabbits. The first documented caesarean hysterectomy was performed by Horatio Storer in 1869. The patient died 68 h after surgery. In 1876, Eduardo Porro performed the first caesarean hysterectomy in which both the mother and baby survived. His patient was a 25-year-old primiparous dwarf. A constricting wire was passed around the cervix to control haemorrhage, and the uterus was excised. The abdominal wound was closed with silver wire. Various modifications followed, such as those of Godson in 1884 and Lawson in 1890 .
In modern obstetrics, there are considerable differences in the incidence of emergency peripartum hysterectomy in different parts of the world, with higher figures in low-resource countries, while developed countries generally report lower rates [7,8]. The variations may be related to the standard of antenatal care, unbooked emergencies, obstetric care, differing rates of caesarean delivery, different patterns of parity, maternal age and the earlier recourse to hysterectomy due to the lack of adequate blood and blood banking facilities. In addition, certain conservative procedures involving interventional radiology may not be available in most developing countries .
In a recent review of relevant articles in English literature, the incidence of emergency peripartum hysterectomy ranged from 0.24 to 8.7 per 1000 deliveries .
4. Risk factors
Emergency peripartum hysterectomy was found to be more common following caesarean section than vaginal deliveries. In addition, there is a significant association between emergency peripartum hysterectomy and previous caesarean section and placenta praevia. The risk of emergency peripartum hysterectomy increases with the number of previous caesarean sections. There is an increased incidence of previous caesarean section in patients with placenta praevia and in patients with adherent placenta [11-23].
To estimate the magnitude of increased maternal morbidity associated with increasing number of caesarean deliveries, Silver et al. in a prospective observational cohort of 30,132 women who had caesarean delivery without labour in 19 academic centres over 4 years found that placenta accreta was present in 15 (0.24 %), 49 (0.31%), 36 (0.57 %), 31 (2.13 %), 6 (2.33 %) and 6 (6.74 %) women undergoing their first, second, third, fourth, fifth and sixth or more caesarean deliveries, respectively. Hysterectomy was required in 40 (0.65 %) first, 67 (0.42 %) second, 57 (0.90 %) third, 35 (2.41 %) fourth, 9 (3.49 %) fifth and 8 (8.99 %) sixth or more caesarean deliveries. Furthermore, in women with praevia, the risk for placenta accreta was 3 %, 11 %, 40 %, 61 % and 67 % for first, second, third, fourth and fifth or more repeat caesarean deliveries, respectively .
The incidence of emergency peripartum hysterectomy is rising worldwide in view of the rising caesarean section rate and the concomitant rise in placenta praevia and placenta praevia accreta and multiple births .
Besides the predominant reported indications for emergency peripartum hysterectomy that include uterine atony, placenta praevia, placenta praevia accreta and uterine rupture, other reported risk factors include precipitate labour, induction, prolonged labour, dystocia, cephalopelvic disproportion, augmentation, foetal macrosomia, multiple pregnancy, retained products of conception, previous endometrial curettage, coagulopathy, thrombocytopenia, maternal obesity, advanced maternal age, previous primary postpartum haemorrhage, gestational diabetes and abruptio placentae, particularly the concealed variety that is associated with Couvelaire uterus. All were identified as independent risk factors for uterine atony [11-23].
Elective peripartum hysterectomy may be performed in patients with an antepartum diagnosis of placenta accreta or stage IA2 and IB1 cervical carcinoma . Severe postpartum infection unresponsive to medical therapy and placental site vessel subinvolution are other potential indications for the procedure [26,27].
5.1. Postpartum haemorrhage
Severe post partum haemorrhage remains a significant cause of maternal morbidity and mortality in both developed and developing countries [28,29]. The rate of postpartum haemorrhage requiring blood transfusion was reported to occur in 1.7% deliveries . Maternal complications of postpartum haemorrhage include hypovolaemic shock, disseminated intravascular coagulopathy (DIC), renal failure, hepatic failure and acute respiratory distress syndrome (ARDS) [31,32]. The most severe complication of haemorrhage is maternal death.
Haemorrhage, in general, is classified into four categories  (Table 1). Postpartum haemorrhage is measured by the loss of greater than 500 ml of blood following vaginal birth or 1000 ml of blood following caesarean section . Postpartum haemorrhage can be minor (500–1000 ml) or major (more than 1000 ml). Major postpartum haemorrhage could be divided to moderate (1000–2000 ml) or severe (more than 2000 ml). A blood loss of more than 2000 ml is regarded as ‘life threatening’.
|Blood loss (ml)||<750||750–1500||1500–2000||>2000|
|Blood loss (%)||<15 %||15–30 %||30–40 %||>40 %|
|Urine output (ml/hour)||>30||20–30||5–15||<5|
|Signs and symptoms||None||Fatigue, pallor||Confusion||Life threatening|
|Action: stop loss||Observe||IV fluid||Blood transfusion||Blood transfusion|
Haemorrhagic shock is a life-threatening condition that results when more than 20 % of the body’s blood is lost. Symptoms include anxiety, blue lips and fingernails, low or no urine output, profuse sweating, tachypnoea, dizziness, confusion, chest pain, loss of consciousness, hypotension, tachycardia and weak pulse .
A Cochrane review addressed the use of uterotonics in the third stage of labour. It indicated that, for women delivering vaginally, oxytocin 5 IU by intramuscular injection is the regimen of choice for routine prophylaxis against postpartum haemorrhage. In the context of caesarean delivery, oxytocin 5 IU by intravenous injection is the recommended routine for prophylaxis against postpartum haemorrhage; the drug should be given slowly to avoid the risk of profound hypotension .
|Oxytocin||IV||10–40 U in 1 L N saline||Continuous|
|Ergometrine*||IM||0.5 mg||Every 2–4 h|
|PGF2α**||IM or intra-myometrially||0.25 mg||Every 15–90 min. Max. 8|
|PGE2||Vaginal or rectal||20 mg||Every 2 h|
To arrest postpartum haemorrhage, algorithms have been proposed to aid its systematic management. Procedures for immediate management of postpartum haemorrhage include the use of pharmacological uterotonic drugs (Table 2), uterine massage or bimanual uterine compression on an empty bladder, the initiation of blood and blood components therapy (Table 3), repair of genital tract lacerations, evacuation of retained products of conception, the implementation of uterine or internal iliac arteries or anterior division of internal iliac arteries embolisation (Figure 1), uterine tamponade techniques (Table 4) (Figure 2), uterine compression sutures (Figure 3), systematic pelvic devascularisation (Figure 4), internal iliac artery ligation (Figure 5) and recombinant-activated factor VII for category III and IV postpartum haemorrhage [37-44] . Consideration should be given to the possibility that placenta praevia percreta may extend into the bladder and other pelvic organs. Clinicians need to be aware of the appropriateness and the timing of instituting interventions.
|Packed red cells||240 ml||RBC, WBC, plasma||Increase PCV 3 % points, Hb 1 g/dl|
|Platelets||50 ml||Platelets, RBC, WBC, plasma||Increase platelet 5,000–10,000/µl|
|Fresh frozen plasma||250 ml||Fibrinogen, antithrombin III, V, VIII||Increase fibrinogen by 10 mg/dl|
|Cryoprecipitate||40 ml||Fibrinogen, VIII, XIII, VWF||Increase fibrinogen by 10 mg/dl|
|Packing||4-inch gauze in 5 ml of sterile saline|
|Foley catheter||Insert one or more bulbs, instil 60–80 ml of saline|
|Tamponade balloon||Instil 300–500 ml of saline|
Postpartum haemorrhage is a leading indication for emergency peripartum hysterectomy. Peripartum hysterectomy is generally performed in the setting of category IV life-threatening haemorrhage during or after abdominal and vaginal deliveries that cannot be controlled by the above medical and conservative surgical measures.
5.2. Uterine rupture
Uterine rupture is associated with maternal and perinatal mortality and morbidity worldwide, particularly in developing countries. The most common cause of uterine rupture is tear of a previous caesarean section scar after a trial of labour in a patient with a previous caesarean section. Rupture of an unscarred uterus is rare. It may occur in obstructed, multiparous labour and in response to inappropriate use of oxytocic agents. Its incidence decreases with improvement in obstetric practice .
Traumatic rupture can occur with internal version, classical application of the anterior blade of Kielland’s forceps, manual removal of the placenta, manual exploration of the uterus and during curettage for secondary postpartum haemorrhage. Other causes of traumatic ruptures of the uterus are relatively rare and tend to occur at the fundus and usually result only from the most violent accidents .
5.3. Extension of the lower uterine segment incision
Caesarean hysterectomy may be necessary in cases of lateral extension of the lower uterine segment incision, when the caesarean section is performed with the foetal head deeply impacted in the pelvis in the second stage of labour. The tear may extend to branches of the uterine arteries. Haemostasis may be challenging; injuries to the ureters are possible. Broad ligament haematoma is not uncommon.
5.4. Uterine sepsis and placental site vessel subinvolution
Emergency peripartum hysterectomy may be necessary in cases of extensive uterine sepsis where antibiotic treatment is not effective and in the rare cases of placental site vessel subinvolution , in which uterine bleeding is protracted.
5.5. Abnormal placentation
The problems of uterine atony and uterine rupture have been greatly reduced through the use of potent uterotonic agents and the utilisation of modern obstetric care . With the rising caesarean section rate and the rising incidence of placenta praevia and accreta and the more severe forms of increta and percreta, associated with previous caesarean sections, recent studies have indicated a change in the trend towards abnormal placentation (Figure 6) as the most common indication for emergency and planned peripartum hysterectomy [48-50]. In the absence of risk factors, early diagnosis of placental abnormalities is difficult. Unfortunately, the diagnosis is frequently established only after unsuccessful removal of the placenta at delivery.
5.5.1. Ultrasonography in the diagnosis of abnormal placentation
For the antenatal diagnosis of placenta accreta, transvaginal and transabdominal ultrasonography are complementary diagnostic techniques. Transvaginal ultrasound is safe for patients with placenta praevia. Normal placentation is characterised by a hypoechoic boundary between the placenta and the bladder. Features suggestive of placenta accreta include thinning of the myometrium overlying the placenta (Figure 7), protrusion of the placenta into the bladder and irregularly shaped placental lacunae. The presence of lacunae ‘moth-eaten or Swiss cheese appearance’ within the placenta is predictive of placenta accreta (Figure 8). The use of colour Doppler, power Doppler or three-dimensional imaging may improve the diagnostic sensitivity (Figure 9), compared with that achieved by grayscale ultrasonography alone .
Overall, one study demonstrated that grayscale ultrasonography may be sufficient to diagnose placenta accreta, with a sensitivity of 91.4 % (95 % CI, 77.6–97.0 %), specificity of 95.9 % (95 % CI, 92.2–97.9 %), a positive predictive value of 80.0 % (95 % CI, 65.2–89.5 %) and a negative predictive value of 98.4 % (95 % CI, 95.5–99.5 %) . Another study concluded that ultrasound for the prediction of placenta accreta may not be as accurate as previously described, with reported sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 53.5 %, 88.0 %, 82.1 %, 64.8 % and 64.8 %, respectively .
5.5.2. Magnetic resonance imaging in the diagnosis of abnormal placentation
Magnetic resonance imaging (MRI) is considered to add little to the diagnostic accuracy of ultrasonography. However, when there are ambiguous ultrasound findings or a suspicion of a posterior placenta accreta, with or without placenta praevia, ultrasonography may be insufficient. In general, MRI may better outline the anatomy and degree of invasion (Figure 10) .
Controversy surrounds the use of gadolinium-based contrast enhancement even though it adds to the specificity of the placenta accreta diagnosis by MRI. The use of gadolinium contrast enables MRI to more clearly delineate the outer placental surface relative to the myometrium. However, it is recommended that intravenous gadolinium should be used only if absolutely essential .
6. Prophylactic arterial occlusion
Recently, prophylactic arterial occlusion has been described as a strategy to reduce bleeding during planned hysterectomy (Figure 11). The efficacy and safety of this procedure is unknown. One small-scale study suggested that the successful use of a staged embolisation hysterectomy procedure for placenta accreta is associated with decreased maternal morbidity . Another study using prophylactic intravascular balloon catheters did not benefit women with placenta accreta undergoing caesarean hysterectomy . The use of these procedures should not delay recourse to surgery.
Surgical planning is necessary. Once the decision is made to embark on surgical haemostasis, the most appropriate choice of procedure will depend on available resources and the expertise of available staff. Obstetricians should be prepared for the potential need to perform emergent peripartum hysterectomy. There is a high chance that a patient with uterine rupture, placenta accreta, increta or percreta will undergo hysterectomy . At least 4 U of blood and blood products must be made available in suspected cases of accreta.
The acute loss of blood and the unplanned nature of surgery render the conditions for postpartum haemorrhage less than ideal to perform the procedure. Peripartum hysterectomy is associated with increased rates of both intraoperative and postoperative complications. Compared with nonobstetric hysterectomy, peripartum hysterectomy is associated with higher rates of morbidity and mortality. The mortality of peripartum hysterectomy is more than 25 times that of hysterectomy performed outside of pregnancy, with the higher rates in regions with limited medical and hospital resources . Therefore, peripartum hysterectomy is considered a major dramatic life-saving surgical venture and represents the most challenging complication that an obstetrician will face.
Adequate resuscitation and prompt decision-making for hysterectomy would contribute to decreasing maternal morbidity and mortality, as timing is critical to an optimal outcome. It has been established that there is a relationship between the duration of time that passes prior to deciding to perform an emergency hysterectomy and the likelihood of coagulopathy, severe hypovolaemia, hypothermia and acidosis. Early recourse to hysterectomy is recommended, especially where bleeding is associated with placenta accreta or uterine rupture .
For peripartum hysterectomy, an experienced senior obstetrician with an experience in obstetric hysterectomy should be present at surgery. Of concern however is the limited experience of performing emergency hysterectomy among some obstetricians. Emergency peripartum hysterectomy being performed by an experienced surgeon is reported to significantly reduce maternal morbidity in general, operating time, number of units of blood transfusion and hospital stay in particular [60,61].
8. Other strategies for the management of abnormal placentation
Although hysterectomy has traditionally been advised for the management of placenta accreta, it is associated with considerable maternal morbidity and mortality. Therefore, new strategies have been attempted to manage this condition conservatively, so that fertility can be preserved and some of the complications of peripartum hysterectomy averted. Such strategies include leaving the placenta in situ, combined with uterine artery embolisation or uterine compression sutures, and the use of methotrexate to inhibit trophoblast growth. However, these conservative approaches may be limited by the high risk of bleeding, infection and poor placental absorption [62-64].
9. Transfusion-related acute lung injury as a major complication
Transfusion-related acute lung injury (TRALI) is a rare but potentially fatal complication of blood product transfusion, manifesting as acute respiratory distress syndrome (ARDS). It is characterised by acute respiratory distress following transfusion. All plasma-containing blood products have been implicated including rare reports of IVIG and cryoprecipitate. The symptoms typically develop during or within 6 h of a transfusion .
Transfusion-related acute lung injury patients present with the rapid onset of dyspnoea and tachypnoea. There may be associated fever, cyanosis and hypotension. Chest x-rays show bilateral patchy infiltrates, which may progress to the complete ‘white out’ oedema of acute respiratory distress syndrome.
It is hypothesised that transfusion-related acute lung injury may be precipitated by the infusion of donor antibodies directed against recipient leucocytes. The infusion of donor anti-HLA or anti-HNA antibodies is thought to directly cause complement activation, release of cytotoxic agents, endothelial damage and capillary leak. The majority of patients require ventilatory support .
Patients at high risk of caesarean hysterectomy should be scheduled for delivery at a time when appropriate ancillary staff with high-risk anaesthetists, interventional radiologists, urologists and resources is readily available. It is preferable to avoid emergency deliveries after the onset of labour, as the ancillary staff may not be available at a very short notice. Transfer of care to a tertiary care centre may be necessary if these resources are not locally available .
Patients at risk for peripartum hysterectomy should be counselled about the likelihood of the procedure, what the procedure involves, complications, issues related to ovarian conservation and possible need for recovery in an intensive care unit. Forward planning for delivery highlights the importance of antenatal checks and screening to minimise blood loss, morbidity and mortality. After the initial postoperative recovery, women should receive a comprehensive outline of events from experienced obstetricians .
The fertility-ending nature of emergency obstetric hysterectomy can be devastating as some women that receive an emergency peripartum hysterectomy are primigravid. After the initial postoperative recovery, those women should be comprehensively counselled.
11. Types of hysterectomy and anaesthesia
Peripartum hysterectomy may be either subtotal or total. It has been recommended that the decision on the type of hysterectomy should be individualised. Subtotal hysterectomy may be preferable because it may be technically easier with shorter operating time, less blood loss, less urological injury and low morbidity, added to the fact that the cervix may be difficult to identify, especially if the patient has laboured and whose cervix is fully effaced, dilated and soft. This is important in the setting of severe acute haemorrhage [67,68].
In cases of placenta praevia, where the entire placental bed has to be removed, and if the lower segment, cervix and paracolpos are involved in the haemorrhage, total hysterectomy will be necessary for haemostasis. Similar approach is adopted for cases of placenta praevia accreta that is invading the cervical stroma.
In the preoperative preparation for peripartum hysterectomy, in suspected cases of accreta, 4 U of both packed red blood cells and plasma have to be cross-matched. Cryoprecipitate and platelets should be available. General anaesthesia is considered to be more appropriate when there is continuing bleeding and the cardiovascular stability is compromised.
When the cardiovascular is stable and there is no evidence of coagulation failure, regional anaesthesia can be used. This may be particularly appropriate where a working epidural has been in place during labour. A vertical skin incision should be considered to provide better exposure.
The technique of peripartum hysterectomy is similar in principle to that of abdominal hysterectomy in gynaecology, except for the anatomical and physiological changes in pregnancy that render the uterine and ovarian vessels enlarged and distended and the pelvic tissues oedematous and friable.
12. Intraoperative and postoperative complications
In some cases of peripartum hysterectomy, traumatised tissues at the base of the pelvis may continue to bleed following surgery despite ligation of obvious bleeding pedicles. This bleeding is usually associated with disseminated intravascular coagulation (DIC). In such cases, the application of pelvic pressure packs may provide haemostasis until haematological stability is achieved. Vascular embolisation may be considered in the interim .
In general, emergency procedures are associated with a higher rate of postoperative complications than planned procedures. Furthermore, compared with nonobstetric hysterectomy, peripartum hysterectomy is accompanied by substantial morbidity and mortality. The principal complications are febrile episodes, haemorrhage, urinary tract injuries, coagulopathy, paralytic ileus or bowel obstruction, wound sepsis/dehiscence, vaginal cuff bleeding, pulmonary embolism and the need for re-exploration because of persistent bleeding.
13. Morbidity and mortality
In a population-based analysis to examine the morbidity and mortality of peripartum hysterectomy in comparison with nonobstetric hysterectomy, bladder and ureteral injuries were more common for peripartum hysterectomy, 9 % compared with 1 % and 0.7 % compared with 0.1 % respectively, (P<.001). Rates of reoperation (4 % compared with 0.5 %), postoperative haemorrhage (5 % compared with 2 %), wound complications (10 % compared with 3 %) and venous thromboembolism (1 % compared with 0.7 %) were all higher in women who underwent peripartum hysterectomy. In multivariable analysis, the odds ratio for death from peripartum compared to nonobstetric hysterectomy was 14.4 (95 % confidence interval 9.84–20.98) .
During peripartum hysterectomy, scarring from previous caesarean sections may obliterate the utero-vesical pouch and make the dissection of the bladder from the uterus injury prone. Furthermore, the ureters may be sectioned, clamped or stitched because of heavy bleeding that interferes with proper exposure. The reported incidence of urological injuries with peripartum hysterectomy is high . Within the context of the emergency situation and the available resources, it is best to diagnose and deal with any bladder or ureteric injury at the time of the hysterectomy. Any tear in the bladder should be repaired with two layers of 3/0 polyglactin (Vicryl) or equivalent suture. After repair of any bladder injury, the bladder can be filled with methylene blue or sterile milk to ascertain that this has been accomplished successfully. Perioperative cystoscopy with ureteral stent placement may be considered.
In the intraoperative stage of peripartum hysterectomy, the application of tourniquet around the uterine cervix can be attempted to reduce blood loss. This is facilitated by the use of transillumination, where the avascular spaces in the broad ligament, roughly opposite the level of a transverse lower caesarean incision, are identified and a catheter passed through on each side to encircle the lower uterine segment just above the cervix. The catheter should be twisted and tightly clamped. This would compress the uterine arteries. In addition, the application of straight clamps adjacent to the uterus to include the round ligaments, the Fallopian tubes and the utero-ovarian ligaments will serve to control the collateral blood flow to the uterus from the ovarian arteries. These two manoeuvres should occlude the main collateral ovarian and uterine artery supply to the uterus.
It is recommended that all pedicles should be doubly ligated in all types of hysterectomy. In peripartum hysterectomy, the vascular pedicles are particularly thick and oedematous. At first, a transfixing suture is applied, followed by an all encompassing ligature. Check should be made to ensure that there is no haematoma formation at the base of the pedicle.
In cases of hysterectomy for placenta praevia accreta, increta and percreta, the foetus is delivered through a classical uterine incision, and the intact placenta is left in situ while the hysterectomy is completed (Figure 12).
At caesarean hysterectomy, a finger can be placed through the uterine incision and the cervical rim palpated. It is the safest to enter the vagina posteriorly, identify the rim of the cervix and then proceed anteriorly.
In general, No. 1 polyglactin (Vicryl) or equivalent is used throughout the peripartum hysterectomy procedures. Perioperative antibiotic prophylaxis should be continued for 24–48 h. Both mechanical and pharmacologic prophylaxis for deep venous thrombosis should be instituted. Thromboprophylaxis with heparin should be started as soon as one is satisfied that haemostasis is secure, at least 4 h postoperatively. The ovaries are almost always conserved. Peripartum hysterectomy is not a contraindication to breastfeeding. Women may use a breast pump temporarily until they are fit enough to breastfeed .
For an optimal management strategy for placenta accreta, it has been suggested that avoiding attempted placental removal at caesarean hysterectomy in women with suspected placenta accreta is associated with reduced maternal morbidity. Furthermore, some studies have recommended that patients with placenta accreta, increta or percreta who have no attempt to remove any of their placentae, with the aim of conserving their uterus, have reduced levels of haemorrhage and a reduced need for blood transfusion [62-64].
To provide a standardised approach to patients with postpartum haemorrhage, it is recommended that each labour unit should have a protocol for cases with estimated blood loss exceeding 1000 ml. Management involves four components that must be initiated simultaneously: communication, resuscitation, arresting the bleeding and monitoring and investigation, for optimal patient care. The following is a general guide for the management of major postpartum haemorrhage of more than 1000 ml and continuing to bleed OR clinical shock.
Notify the senior obstetrician in charge, the department of anaesthesia, blood bank and laboratory.
Establish two 14-gauge intravenous canula access; 20 ml blood sample should be taken for full blood count, coagulation screen, urea and electrolytes and cross match (4 U).
For atony, administer oxytocin 10 IU by slow intravenous injection, followed by 40 IU in 500 ml of Hartmann’s solution or normal saline at 125 ml/hour. If no intravenous access, give 10 IU intramuscularly. Oxytocin may be combined with other pharmacological agents; ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension); carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 min to a maximum of eight doses (contraindicated in women with asthma); direct intramyometrial injection of carboprost 0.5 mg; misoprostol 1000 µg rectally (Table 2).
Initiate uterine massage and/or manual uterine compression.
Administer oxygen (10–15 l/min) by face mask or intubation, regardless of maternal oxygen concentration.
Transfuse blood as soon as possible. If cross-matched blood is still unavailable, give uncross-matched group-specific blood or ‘O RhD negative’ blood. Four units of fresh frozen plasma is given for every 6 U of red cells or prothrombin time/activated partial thromboplastin time more than 1.5 x normal (total 1 l). Platelet concentrates is administered if platelet count is less than 50 x 109/L and cryoprecipitate if fibrinogen is less than 1 g/L. The clinical picture should be the main determinant for the need for blood transfusion. Time should not be wasted waiting for laboratory results (Table 3).
Until blood is available, infuse up to 3.5 L of warmed crystalloid Hartmann’s solution (2 l) and/or colloid (1–2 l) as rapidly as required.
Inspect the vagina and cervix for lacerations and repair them as necessary; evacuate any retained products of conception.
If pharmacological measures fail to control the haemorrhage, initiate surgical haemostasis sooner rather than later. The following surgical interventions may be attempted, depending on clinical circumstances and available expertise:
For the constant and close monitoring and support, unstable patients may need to be catered for in an intensive care unit.
Common tests and their normal values include coagulation screen, electrolytes, liver function tests, acid-base and blood gases and kidney function tests (Table 5-9).
|Platelet count (Plt)||140–450 x 103/µL|
|Mean platelet volume (MPV)||7.4–10.4 fL|
|Prothrombin time (PT)||1–15 s|
|International normalised ratio (INR)||0.9–1.2|
|Activated partial thromboplastin time (APTT)||18–45 s|
|Thrombin clotting time (TCT)||11–18 s|
|Bleeding time||2–9 min|
|Sodium (Na)||135–147 mEq|
|Potassium (K)||3.5–5 mEq|
|Bicarbonate (HCO3)||24–30 mEq|
|Chloride (Cl)||100–106 mEq|
|ALT||5 to 56 U/L|
|AST||6 to 40 U/L|
|ALP||42 to 128 U/L|
|Total protein||35 to 84 g/L|
|Albumin||35 to 50 g/L|
|Globulins||25 to 35 g/L|
|Total bilirubin||0.1 to 1.0 mg/dL|
|Direct/conjugated bilirubin||0.0 to 0.4 mg/dL|
|GGT||9 to 48 U/L|
|LD||122 to 222 U/L|
|PT||9.5 to 13.8 s|
Reports of balloon tamponade describe the intervention as the ‘tamponade test’. Control of postpartum haemorrhage following inflation of the balloon indicates that laparotomy is not required. Continued postpartum haemorrhage following inflation of the balloon is an indication to proceed to laparotomy. This serves to affirm place of balloon tamponade as first-line procedure in the ‘surgical’ management of postpartum haemorrhage. The balloon should be left in place for 4–6 h, and, preferably, it should be removed during daytime hours. The balloon should be deflated and left in place for few minutes to ensure that bleeding does not reoccur [71,72].
The logistics for performing arterial occlusion or embolisation may not be readily available. This makes uterine balloon tamponade a more appropriate first-line treatment. Nevertheless, interventional radiology may be considered in cases of antenatal diagnosis of malplacentation, in the form of placenta praevia and placenta accreta, increta or percreta, where intra-arterial catheters, with the view of either occlusion or embolisation, can be placed prior to the performance of caesarean section. Follow-up studies of women who had undergone arterial embolisation or internal iliac artery ligation for control of postpartum haemorrhage suggest that these interventions do not impair subsequent menstruation, fertility and pregnancy outcomes [73,74].
|pH||Arterial||7.35 to 7.45|
|Venous||7.31 to 7.41|
|(H+)||Arterial||36 to 44 nmol/L|
|3.6 to 4.4 ng/dl|
|Base excess||Arterial and venous||-3 to +3 mEq/L|
|Oxygen partial pressure (pO2)||Arterial||10 to 14 kPa|
|75 to 105 mmHg|
|Venous||4.0 to 5.3 kPa|
|30 to 40 mmHg|
|Oxygen saturation (SpO2)||Arterial||94 to 100 %|
|Venous||Approximately 75 %|
|Carbon dioxide partial pressure (pCO2)||Arterial||4.4 to 6.0 kPa|
|33 to 45 mmHg|
|Venous||5.5 to 6.8 kPa|
|41 to 51 mmHg|
|Absolute content of CO2||Arterial||23 to 30 mmol/L|
|100 to 132 mg/dl|
|Bicarbonate (HCO3)||Arterial and venous||18 to 23 mmol/L|
|110 to 140 mg/dL|
|Standard bicarbonate (SBC)||Arterial and venous||21 to 28 mmol/L or mEq/L|
|134 to 170 mg/dL|
|Blood urea nitrogen (BUN)||6 to 20 mg/dL|
|Creatinine||0.6 to 1.3 mg/dL|
|Urine creatinine (24-hour sample)||500 to 2000 mg/day. 11 to 26 mg/kg weight|
|Creatinine clearance||88 to 137 ml/min|
It recommended that these postpartum guidelines should be implemented at an estimated blood loss well below approx 2000 ml as the aim is to prevent haemorrhage escalating to the point where it is life threatening. In the face of relentless bleeding, up to 1 L of fresh frozen plasma and 10 U of cryoprecipitate (two packs) may be given while awaiting the results of coagulation studies. Factor VIIa therapy may be used as an adjuvant to standard pharmacological and surgical treatments, in a dose of 90 µg/kg, which may be repeated within 15–30 min in the absence of clinical response. Fibrinogen should be above 1 g/L and platelets greater than 20 x 109/L before Factor VIIa is given.
These recommendations are primarily for clinicians working in specialist-led obstetric departments; they are less appropriate for settings where resources are limited. It is recommended that the main therapeutic goals of management of massive blood loss are to maintain:
Haemoglobin more than 8 g/dl
Platelet count more than 75 x 109/L
Prothrombin less than 1.5 x mean control
Fibrinogen more than 1.0 g/L
Intraoperative cell salvage for autologous red cell transfusion is being investigated for use in obstetrics. The insertion of a central line will provide a means of accurate central venous pressure (CVP) monitoring and act as a route for rapid fluid replacement. In addition to central venous pressure line, a direct arterial pressure line should be used for cardiovascular monitoring in cases of major haemorrhage.
Increasing caesarean rates would lead to an increase in the number of peripartum hysterectomies for abnormal placentation. Because serious maternal morbidity and mortality increases progressively with increasing number of caesarean deliveries, the number of intended family size should be considered when counselling regarding elective primary caesarean delivery and elective repeat caesarean operation versus a trial of labour [73-76].
Peripartum hysterectomy is a challenging procedure. Its role in modern obstetrics is evolving. Improving management of postpartum haemorrhage should decrease peripartum hysterectomy for uterine atony. Peripartum hysterectomy merits a multidisciplinary approach.
Smith J, Mousa HA. Peripartum hysterectomy for primary postpartum haemorrhage: incidence and maternal morbidity. J Obstet Gynecol. 2007;27:44-47.
Ribeiro F, Correia L, Paula T, Santana I, Vieira Pinto L, Borrego J, Jorge AF. Cervical cancer in pregnancy: 3 cases, 3 different approaches. J Low Genit Tract Dis. 2013;17:66-70.
Kwee A, Bots ML, Visser GH, Bruinse HW. Emergency peripartum hysterectomy: a prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol. 2006;124:187-192.
Elmir R, Schmied V, Wilkes L, Jackson D. Separation, failure and temporary relinquishment: women's experiences of early mothering in the context of emergency hysterectomy. J Clin Nurs. 2012;21:1119-1127.
Lim WH, Pavlov T, Dennis AE. Analysis of emergency peripartum hysterectomy in Northern Tasmania. Aust J Rural Health. 2014;22:235-240.
Umezurike CC, Adisa CA. Peripartum Hysterectomy. In: Al-Hendy A, Sabry M, editors. Hysterectomy. InTech Publishers; 2012. p. 83-102. DOI: 10.5772/34770, ch7
Umezurike CC, Feyi-Waboso PA, Adisa CA. Peripartum hysterectomy in Aba Southeastern Nigeria. Aust Zeal J Obstet Gynecol. 2008;48:580-582.
Whiteman MK, Kuklina E, Hillis SD, Jamieson DJ, Meikle SF, Posner SF, Marchbanks PA. Incidence and determinants of peripartum hysterectomy. Obstet Gynecol. 2006;108:1486-1492.
Bassey G, Akani CI. Emergency peripartum hysterectomy in a low resource setting: a 5-year analysis. Niger J Med. 2014;23:170-175.
Chawla J, Arora D, Paul M, Ajmani SN. Emergency Obstetric Hysterectomy: A Retrospective Study from a Teaching Hospital in North India over Eight Years. Oman Med J. 2015;30(3):181-186.
Selo-Ojeme DO, Bhattacharjee P, Izuwa-Njoku NF, Kadir RA. Emergency peripartum hysterectomy in a tertiary London hospital. Arch Gynecol Obstet. 2005;271:154-159.
Turner MJ. Peripartum hysterectomy: an evolving picture. Int J Gynecol Obstet. 2010;109:9-11.
Allam IS, Gomaa IA, Fathi HM, Sukkar GF. Incidence of emergency peripartum hysterectomy in Ain-shams University Maternity Hospital, Egypt: a retrospective study. Arch Gynecol Obstet. 2014;290:891-896.
Tikkanen M1, Paavonen J, Loukovaara M, Stefanovic V. Antenatal diagnosis of placenta accreta leads to reduced blood loss. Acta Obstet Gynecol Scand. 2011;90:1140-1146.
Hall T, Wax JR, Lucas FL, Cartin A, Jones M, Pinette MG. Prenatal sonographic diagnosis of placenta accreta--impact on maternal and neonatal outcomes. J Clin Ultrasound. 2014;42:449-455.
Baskett TF. Emergency obstetric hysterectomy. J Obstet Gynaecol. 2003;23:353–355.
Bakshi S, Meyer BA. Indications for and outcomes of emergency peripartum hysterectomy. A five-year review. J Reprod Med. 2000;45:733-737.
Glaze S, Ekwalanga P, Roberts G, Lange I, Birch C, Rosengarten A, Jarrell J, Ross S. Peripartum hysterectomy: 1999 to 2006. Obstet Gynecol. 2008;111:732-738.
Habek D, Becareviç R. Emergency peripartum hysterectomy in a tertiary obstetric center: 8-year evaluation. Fetal Diagn Ther. 2007;22:139–142.
Machado LS. Emergency peripartum hysterectomy: incidence, indications, risk factors and outcome. N Am J Med Sci. 2011;3:358–361.
Begum M, Alsafi F, ElFarra J, Tamim HM, Le T. Emergency peripartum hysterectomy in a tertiary care hospital in Saudi Arabia. J Obstet Gynaecol India. 2014;64:321-327.
Danisman N1, Kahyaoglu S, Celen S, Akselim B, Tuncer EG, Timur H, Kaymak O, Kahyaoglu I. The outcomes of surgical treatment modalities to decrease "near miss" maternal morbidity caused by peripartum haemorrhage. Eur Rev Med Pharmacol Sci. 2014;18:1092-1097.
Bateman BT, Mhyre JM, Callaghan WM, Kuklina EV. Peripartum hysterectomy in the United States: nationwide 14 year experience. Am J Obstet Gynecol. 2012;206:63.e1-8.
Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai B, Langer O, Thorp JM, Ramin SM, Mercer BM. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107:1226-1232.
Francois K, Ortiz J, Harris C, Foley MR, Elliott JP. Is peripartum hysterectomy more common in multiple gestations? Obstet Gynecol 2005;105:1369-372.
Anderson BL. Puerperal group A streptococcal infection: beyond Semmelweis. Obstet Gynecol. 2014;123:874-882.
Al-Mehaisen L, Al-Kuran O, Amarin ZO, Matalka I, Beitawi S, Muhtaseb A. Secondary postpartum haemorrhage following placental site vessel subinvolution: a case report. Arch Gynecol Obstet. 2008;278:585-587.
Weeks A. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG. 2015;122:202-210.
Amarin Z, Khader Y, Okour A, Jaddou H, Al-Qutob R. National maternal mortality ratio for Jordan, 2007-2008. Int J Gynecol Obstet. 2010;111:152-156.
Patterson JA, Roberts CL, Taylor LK, Ford JB. Reporting postpartum haemorrhage with transfusion: a comparison of NSW birth and hospital data. N S W Public Health Bull. 2014;24:153-158.
Sakse A, Weber T, Nickelsen C, Secher NJ. Peripartum hysterectomy in Denmark 1995–2004. Acta Obstet Gynecol Scan. 2007;86:1472–1475.
Teofili L, Bianchi M, Zanfini BA, Catarci S, Sicuranza R, Spartano S, Zini G, Draisci G. Acute lung injury complicating blood transfusion in post-partum haemorrhage: incidence and risk factors. Mediterr J Hematol Infect Dis. 2014;6:e2014069.
Cababas JG, Manning JE, Cairns CB. Fluid and Blood Resuscitation. In: Tintinalli UE, Stapczynski JS, John Ma O, Cline DM, Cydulka RK, Meckler JD, editors. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. McGraw-Hill: New York; 2004. p. 227, ch26.
Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125:5-12.
Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth. 2014;58:590-595.
British Medical Association; Royal Pharmaceutical Society of Great Britain. British National Formulary No. 57. London: BMJ Group and RPS Publishing [internet]. 2009 Available from http:// [www.bnf.org/bnf/bnf/57/4499.htm].
Hoffman MS, Karlnoski RA, Mangar D, Whiteman VE, Zweibel BR, Lockhart JL, Camporesi EM. Morbidity associated with nonemergent hysterectomy for placenta accreta. Am J Obstet Gynecol. 2010;202:e1-e5.
Wright JD, Devine P, Shah M, Gaddipati S, Lewin SN, Simpson LL, Bonanno C, Sun X, D'Alton ME, Herzog TJ. Morbidity and mortality of peripartum hysterectomy. Obstet Gynecol. 2010;115:1187-1193.
Clausen C, Stensballe J, Albrechtsen CK, Hansen MA, Lönn L, Langhoff-Roos J. Balloon occlusion of the internal iliac arteries in the multidisciplinary management of placenta percreta. Acta Obstet Gynecol Scand. 2013;92:386-391.
Agarwal N, Deinde O, Willmott F, Bojahr H, MacCallum P, Renfrew I, Beski S. A case series of interventional radiology in postpartum haemorrhage. J Obstet Gynaecol. 2011;31:499-502.
Hatfield JL, Brumsted JR, Cooper BC. Conservative treatment of placenta accreta. J Minim Invasive Gynecol. 2006;13:510-513.
Juneja SK, Tandon P, Mohan B, Kaushal S. A change in the management of intractable obstetrical haemorrhage over 15 years in a tertiary care center. Int J Appl Basic Med Res. 2014 Sep;4(Suppl 1):S17-9.
Boynukalin FK, Boyar H, Gormus H, Aral AI, Boyar N. Bilateral hypogastric artery ligation in emergency setting for intractable postpartum hemorrhage: a secondary care center experience. Clin Exp Obstet Gynecol. 2013;40:85-88.
Morel O, Perdriolle-Galet E, Mézan de Malartic C, Gauchotte E, Moncollin M, Patte C, Chabot-Lecoanet AC. Management of severe or persistent postpartum haemorrhage after vaginal delivery. J Gynecol Obstet Biol Reprod (Paris). 2014;43:1019-1029.
Berhe Y, Wall LL. Uterine rupture in resource-poor countries. Obstet Gynecol Surv. 2014;69:695-707.
Tweddale C. Trauma during pregnancy. Crit Care Nurs Q. 2006;29:53-67.
Brown G, Allen L, Torkelson A. Direct patient interventions that can reduce maternal mortality in developing countries: a systematic review. Fam Med. 2013;45:550-557.
Sakinci M, Kuru O, Tosun M, Karagoz A, Celik H, Bildircin FD, Malatyalioglu E. Clinical analysis of emergency peripartum hysterectomies in a tertiary center. Clin Exp Obstet Gynecol. 2014;41:654-658.
Wani RV, Abu-Hudra NM, Al-Tahir SI. Emergency peripartum hysterectomy: a 13-year review at a tertiary center in Kuwait. J Obstet Gynaecol India. 2014;64:403-408.
Bowman ZS, Eller AG, Bardsley TR, Greene T, Varner MW, Silver RM. Risk factors for placenta accreta: a large prospective cohort. Am J Perinatol. 2014;31:799-804.
Cheung CS, Chan BC. The sonographic appearance and obstetric management of placenta accreta. Int J Womens Health. 2012;4:587–594.
Chalubinski KM, Pils S, Klein K, Seemann R, Speiser P, Langer M, Ott J. Prenatal sonography can predict degree of placental invasion. Ultrasound Obstet Gynecol. 2013;42:518-524.
Bowman ZS, Eller AG, Kennedy AM, Richards DS, Winter TC 3rd, Woodward PJ, Silver RM. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol. 2014;211:177.e1-7.
Comstock CH, Bronsteen RA. The antenatal diagnosis of placenta accreta. BJOG. 2014;121:171-181.
Garcia-Bournissen F, Shrim A, Koren G. Safety of gadolinium during pregnancy. Can Fam Physician. 2006;52:309-310.
Angstmann T, Gard G, Harrington T, Ward E, Thomson A, Giles W. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet Gynecol. 2010;202:38.e1-9.
Shrivastava V, Nageotte M, Major C, Haydon M, Wing D. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol. 2007;197:402.e1-5.
Eltabbakh GH, Watson JD. Postpartum hysterectomy. Int J Gynecol Obstet. 1995;50:257-262.
Chestnut DH, Eden RD, Gall SA, Parker RT. Peripartum hysterectomy: a review of cesarean and postpartum hysterectomy. Obstet Gynecol. 1985;65:365-370.
Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study. BJOG. 2014;121:62-70.
Ibrahim M, Ziegler C, Klam SL, Wieczorek P, Abenhaim HA. Incidence, indications, and predictors of adverse outcomes of postpartum hysterectomies: 20-year experience in a tertiary care centre. J Obstet Gynaecol Can. 2014;36:14-20.
Torrenga B, Huirne JA, Bolte AC, van Waesberghe JH, de Vries JI. Postpartum monitoring of retained placenta. Two cases of abnormally adherent placenta. Acta Obstet Gynecol Scand. 013;92:472-475.
Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta accreta. BJOG. 2009;116:648-654.
Eller AG, Bennett MA, Sharshiner M, Masheter C, Soisson AP, Dodson M, Silver RM. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117:331-337.
Silver RM, Fox KA, Barton JR, Abuhamad AZ, Simhan H, Huls CK, Belfort MA, Wright JD. Center of excellence for placenta accreta. Am J Obstet Gynecol. 2014;20. pii: S0002-9378(14)02248-0.
de la Cruz CZ, Coulter ML, O'Rourke K, Amina Alio P, Daley EM, Mahan CS. Women's experiences, emotional responses, and perceptions of care after emergency peripartum hysterectomy: a qualitative survey of women from 6 months to 3 years postpartum. Birth. 2013;40:256-263.
Amarin Z. Subtotal Versus Total Abdominal Hysterectomy for Benign Gynecological Conditions. In: Al-Hendy A, Sabry M, editors. Hysterectomy. InTech Publishers; 2012. p. 23-29. DOI: 10.5772/34770, ch2.
Yoong W, Massish N, Oluwu A. Obstetric hysterectomy: changing trends over 20 years in a multiethnic high risk population. Arch Gynecol Obstet. 2006;274:37-40.
Izbizky G, Meller C, Grasso M, Velazco A, Peralta O, Otaño L, Garcia-Monaco R. Feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta. J Vasc Interv Radiol. 2015;26:162-169.
Olza-Fernández I, García-Murillo L, Palanca-Maresca I. Breastfeeding following emergency peripartum hysterectomy. Breastfeed Med. 2012;7:307-309.
Condous GS, Arulkumaran S, Symonds I, Chapman R, Sinha A, Razvi K. The ‘tamponade test’ in the management of massive postpartum haemorrhage. Obstet Gynecol. 2003;101:767-772.
Frenzel D, Condous GS, Papageorghiou AT, McWhinney NA. The use of the ‘tamponade test’ to stop massive obstetric haemorrhage in placenta accreta. BJOG. 2005;112:676-677.
Tadesse W, Farah N, Hogan J, D'Arcy T, Kennelly M, Turner MJ. Peripartum hysterectomy in the first decade of the 21st century. J Obstet Gynaecol. 2011;31:320-321.
Daskalakis G, Anastasakis E, Papantoniou N, Mesogitis S, Theodora M, Antsaklis A. Emergency obstetric hysterectomy. Acta Obstet Gynecol Scand. 2007;86:223-227.
Nizard J, Barrinque L, Frydman R, Fernandez H. Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum haemorrhage. Hum Reprod. 2003;18:844-848.
Salomon LJ, deTayrac R, Castaigne-Meary V, Audibert F, Musset D, Ciorascu R, et al. Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum Reprod. 2003;18:849-852.