Improving outcomes for peripartum hysterectomy: Still a long way to go!

Despite advances in science and technology, obstetric hemorrhage tops the list of direct cause of maternal death, accounting for 25% of all maternal deaths.[1,2] Ninety-nine percent burden of such fatalities is borne by developing countries.[1] Aggressive antenatal and obstetric management can be very effective in preventing such deaths. Maternal mortality rate has therefore been considered as a sentinel indicator of the quality of a health-care delivery system.[1] Endorsing the views of WHO, the authors of the present study have aptly pointed out that “near-miss” events such as peripartum hysterectomy (PH) should rather be scrutinized.[1,3]

PH is considered “one of the most devastating” complications in obstetrics.[4,5] Edward Porro reported the first successful case report of PH more than a century ago for severe postpartum hemorrhage (PPH). Since then, advances in the management of PPH including obstetric, interventional, and transfusion medicine have improved outcomes and reduced its indications, more so in developed country.[4]

The rate of PH in the present study was 6.9/1000 deliveries with a mortality rate of 10%, which is higher than that reported for our country (2.6/1000 births and 3%).[3,6] This is probably because of the small study period (1 year), the institute being a tertiary referral center receiving complicated cases from peripheral centers, and time lost in patient transfer leading to compromised state at presentation and delay in instituting treatment.

Uterine atony is responsible for 75%–90% of cases of PPH and has been the most common indication for PH in studies from developing countries.[4,5] Uterine atony did not appear on top of the list in this study and was the second most common cause of PH because recent advances in the management of PPH control atonic PPH in most cases and their center was a well-equipped one.

Abnormal placentation was the most common indication of PH in the present study and had swapped place with rupture uterus within two decades in their center.[6] The most alarming finding of their study was a sharp rise in the incidence of PH in their institute (0.2% vs. 0.7%).[3,6] This may be because of the ever-rising rate of cesarean section (CS) and increased maternal age in our country. Eighty-five percent of their patients had undergone a previous CS.[3] It has been reported that the incidence of PH after CS was 13 times the rate following vaginal delivery.[7] Furthermore, 40% PH were done as elective cases after being diagnosed as placenta accreta either on magnetic resonance imaging or on Doppler sonography. Outcomes of electively planned PH were predictably better (0% mortality) than emergency cases.[3] In case PPH is expected beforehand, the American College of Obstetricians and Gynecologists recommends prior preparation, e.g., patient counseling, multidisciplinary involvement, availability of adequate personnel, blood products, and cell salvage.[8]

General anesthesia has been the anesthetic modality of choice in all reported series (including the present one) till date.[3,6,9] Regional anesthesia is not ideal due to possible coagulopathy, hemodynamic instability, and uncertain duration of surgery. These patients are considered full stomach, so rapid sequence induction using ketamine as induction agent should be done. Invasive and minimally invasive hemodynamic monitoring devices may help in optimizing fluid management where available. If the mother is stable enough to be transferred to a radiology suite, embolization or angiographic occlusion with balloon catheters of hypogastric/common iliac arteries under fluoroscopic guidance may be considered to reduce blood loss. It may be inserted electively in cases diagnosed prior as placenta accreta. Studies have reported reduced transfusion requirements by the use of interventional radiology.[8]

The lethal triad of hypothermia, acidosis, and coagulopathy in massive transfusion patients should be diligently avoided by aggressive warming measures and early use of blood products. Drawing analogy from management of traumatic hemorrhage, early transfusion of fresh frozen plasma in a ratio of between 1:1 and 1:2 to packed red blood cells has been suggested for obstetric hemorrhage also.[8,9,10] The American Society of Anesthesiologists recommends the use of recombinant activated factor VII for controlling massive PPH when conventional measures have not been effective and before PH.[10] Antifibrinolytics such as tranexamic acid can also be used to decrease the need for further transfusion.[8,9,10] Intraoperative blood salvage has been recommended as safe if due precautions are taken.[8,9] Women who have a PH are also more likely to receive a blood transfusion (BT) (46% compared with 4% of women who had nonobstetric hysterectomies) and have longer hospital stay (mean of 8.7 vs. 2.9 days for nonobstetric hysterectomy).[7,8,9] In this study, all the patients in both groups required BT with 55% needing >5 units.[3]

A massive obstetric hemorrhage protocol should be available at every delivery unit. Prompt communication between anesthesiology, obstetrics–gynecology, nursing, laboratory, and hematology is essential. A five-step management plan for massive obstetric hemorrhage has been described:[11]

1. Organization of multidisciplinary team

2. Restoration of blood volume

3. Correction of coagulopathy

4. Hemodynamic and laboratory monitoring to assess response

5. Control of the etiology.

Conclusion

PPH is a preventable cause of maternal mortality and can result in the dreaded PH. Anesthesiologists play a key role in the management of massive hemorrhage by prompt recognition and aggressive management in perinatal, perioperative, and critical care unit. Alarming rise in rates of PH should be curbed at the earliest by appropriate surveillance and intervention from governmental and health-care bodies. Improved standards of antenatal care, wider availability, and application of advanced diagnostic modalities and multidisciplinary approach can improve outcomes of PH by anticipating and responding in a more planned and organized manner.