Cắt tử cung trong sản khoa

Cắt tử cung trong sản khoa I. Đại cương II. Chỉ định III. Kỹ thuật IV. Biến chứng V. Kết luận Đại cương Danh pháp: cesarian hysterectomy, peripartum or obstetric hysterectomy Afaf R.A. Alsayali, DGO; Salah M.A. Baloul, MRCOG(EMERGENCY OBSTETRIC HYSTERECTOMY: 8YEAR REVIEW AT TAIF MATERNITY HOSPITAL, SAUDI ARABIA) Cắt tử cung trong sản khoa được áp dụng từ thế kỷ 19, nhằm làm giảm tỉ lệ tử vong và bệnh xuất trong sản khoa trong mổ lấy thai. Các chỉ định thường gặp:nhiễm trùng huyết, băng huyết sau sanh. Vài thập niên sau , các chỉ định thường là: đờ tử cung,vỡ tử cung, nhau cài răng lược, ảnh hưởng bởi các tiêu chuẩn về thực hành và chất lượng chăm sóc tiền sản. Mổ lấy thai làm tăng nguy cơ nhau cài răng lược, vỡ tử cung

Cắt tử cung sản khoa I II III IV V Đại cương Chỉ định Kỹ thuật Biến chứng Kết luận Đại cương Danh pháp: cesarian hysterectomy, peripartum or obstetric hysterectomy Afaf R.A Alsayali, DGO; Salah M.A Baloul, MRCOG( EMERGENCY OBSTETRIC HYSTERECTOMY: 8-YEAR REVIEW AT TAIF MATERNITY HOSPITAL, SAUDI ARABIA) Cắt tử cung sản khoa áp dụng từ kỷ 19, nhằm làm giảm tỉ lệ tử vong bệnh xuất sản khoa mổ lấy thai Các định thường gặp:nhiễm trùng huyết, băng huyết sau sanh Vài thập niên sau , định thường là: đờ tử cung,vỡ tử cung, cài lược, ảnh hưởng tiêu chuẩn thực hành chất lượng chăm sóc tiền sản Mổ lấy thai làm tăng nguy cài lược, vỡ tử cung PPH was the commonest indication (60%) Ruptured uterus is the second most common indication in our study accounting for 36.58% of cases Incidence reported by Mantri et al is 67.2%, and by Ambiye and Venkatraman 67.8% Allahabadia et al reported a lower incidence of 20%.The mortality amongst our patients was 9.7% comparable to 9.3% reported by Ambiye and Venkatraman Mantri et al reported 14% mortality and Allahabadia and Vaidya 632% Sturdee and Rushton reported no mortality in their series of 47 cases.( Emergency obstetric hysterectomy Kant Anita, Wadhwani Kavita Escorts Hospital and Research Centre, Faridabad - 121 001.) Chỉ định - Cắt tử cung để cầm máu trường hợp chảy máu từ tử cung nguyên nhân sản khoa hay nguyên nhân phụ khoa mà biện pháp điều trị nội khoa khơng có kết - Cắt tử cung thương tổn tử cung như: rau bong non, vỡ tử cung, tử cung nhiễm khuẩn nặng (nhiễm khuẩn huyết, viêm phúc mạc), thủng tử cung, rau cài lược, u xơ tử cung to mổ lấy thai - Chú ý: trường hợp có định cắt tử cung cấp cứu mà người bệnh tình trạng chống phải khẩn trương tiến hành hồi sức thực phẫu thuật (Yduocvn.com) Phẫu thuật viên Bác sĩ chuyên khoa sản hay bác sĩ huấn luyện, đào tạo kỹ thuật cắt tử cung Chuẩn bị - Người bệnh: giải thích lý phải phẫu thuật đồng ý phải ký giấy cam đoan, sát khuẩn vùng bụng, vùng vệ, đặt ống thông tiểu trước tiến hành phẫu thuật - Phương tiện, dụng cụ: dụng cụ cắt tử cung (có đủ kẹp động mạch tử cung), thuốc hồi sức, dịch truyền thay máu máu có Qui trình kỹ thuật cắt tử cung cấp cứu 4.1 Mở bụng theo đường từ bờ xương vệ đến rốn, qua da, cân, tới phúc mạc Mở phúc mạc thành phía cao gần sát rốn dần xuống để tránh gây thương tổn cho bàng quang Khẩn trương đặt vải xung quanh mép vết mổ, chèn gạc kỹ đẩy ruột lên cao nhằm bộc lộ rõ vùng tiểu khung nơi có tử cung 4.2 Kiểm tra tử cung tạng xung quanh Nếu bộc lộ tử cung khỏi ổ bụng qua vết mổ Quan sát tổn thương tử cung: + Nếu có tổn thương chảy máu dùng loại kẹp thích hợp nhanh chóng cầm máu tạm thời + Nếu tử cung nhiễm khuẩn nặng không cặp kẹp có vào thân tử cung để tránh mủ tử cung chảy vào khoang bụng + Trường hợp thủng tử cung nạo cần kiểm tra kỹ quai ruột mạc nối tìm tổn thương phối hợp với thủng tử cung để xử trí + Sau tiến hành bước khác 4.3 Giải phóng hai cánh bên tử cung Bắt đầu cặp dây chằng tròn hai kẹp có mấu, hai kẹp cách khoảng 1cm Cắt hai kẹp Nếu bảo tồn buồng trứng dùng hai kẹp cặp tiếp dây chằng tử cung - buồng trứng gần tử cung cắt hai kẹp Nếu không bảo tồn buồng trứng dùng hai kẹp cặp dây chằng thắt lưng - buồng trứng cắt hai kẹp Chỉ cắt hai buồng trứng có thương tổn hay người bệnh cao tuổi Tuy nhiên để lại hai buồng trứng phẫu thuật khó đơi chút Khâu lại cuống mạch tiêu Riêng cuống mạch phần phụ nên khâu buộc hai lần dễ bị tụt gây chảy máu sau mổ 4.4 Kẹp cắt động mạch tử cung Dùng kẹp to có kéo tử cung lên cao để bộc lộ hai cuống động mạch tử cung Cặp động mạch tử cung vị trí ngang với đoạn tử cung tương ứng eo tử cung khơng có thai, kẹp kìm vào tận tử cung Chú ý đến niệu quản cách cổ tử cung 1,5cm phía ngồi Cắt động mạch tử cung Khâu buộc không tiêu, nên làm hai lần cho cuống mạch Lần lượt cắt hai cuống mạch tử cung hai bên 4.5 Cắt khâu lại tử cung Cắt tử cung mức ngang đoạn (tương ứng eo tử cung khơng có thai) Khâu ép mép trước với mép sau mỏm cắt tiêu để cầm máu Nên dùng mũi khâu rời bảo đảm cầm máu chắn Các mũi khâu cách khoảng 1cm vừa 4.6 Kiểm tra cầm máu cẩn thận cuống mạch mỏm cắt Chú ý xem tình trạng huyết áp người bệnh thời điểm kiểm tra cầm máu Sau tiến hành phủ phúc mạc tiêu với mũi khâu vắt để che kín mỏm cắt cuống mạch 4.7 Lau, rửa ổ bụng (viêm phúc mạc) Rút bỏ hết gạc chèn Đếm kiểm tra cẩn thận toàn số gạc bỏ Đóng bụng lớp Chỉ đặt ống dẫn lưu trường hợp cần thiết Tai biến xử trí tai biến - Chảy máu sau mổ tuột cuống mạch, chảy máu từ mỏm cắt khâu cầm máu khơng tốt, rối loạn đơng máu Biểu chống tụt huyết áp, tình trạng thiếu máu cấp, ổ bụng có dịch phải mổ lại để cầm máu đồng thời với việc hồi sức tích cực, điều chỉnh rối loạn đơng máu, bồi phụ thể tích tuần hồn - Máu tụ ngồi phúc mạc khơng kiểm sốt tốt tình trạng cầm máu Thường cần theo dõi điều trị nội khoa, hồi sức tuần hồn khơng thấy khối máu tụ to lên khơng cần mổ lại - Gây thương tổn đường tiết niệu chủ yếu thương tổn bàng quang niệu quản Phải mổ lại để phục hồi thương tổn chẩn đoán - Viêm phúc mạc sau mổ cắt tử cung cấp cứu Phải tiến hành hồi sức, điều trị kháng sinh phối hợp, liều cao mổ lại để rửa ổ bụng, dẫn lưu - Mạch máu nuôi tử cung động mạch tử cung nhánh động mạch hạ vị dài 13- 15cm, lúc đầu chạy thành chậu bên phải, sau hướng xuống vào chui vào vùng dây chằng rộng bắt chéo mặt trước niệu quản cách cổ tử cung 1,5cm, sau bắt chéo niệu quản động mạch chạy sát eo tử cung quặt ngược lên chạy dọc bờ tử cung tới sừng tử cung động mạch tử cung bắt chéo phía sau dây chằng tròn quặt ngang ngồi chạy vòi trứng tiếp nối động mạch buồng trứng Trên đường phân nhánh bên nhánh cùng: - Nhánh niệu quản - Nhánh bàng quang- âm đạo - Nhánh cổ tử cung - âm đạo - Nhánh tử cung chạy xiên xoắn ốc vào lớp tử cung - Nhánh đáy tử cung phát triển nhiều có thai rau thường bám đáy tử cung + Tĩnh mạch: - Tĩnh mạch lớp nông chạy động mạch tử cung với động mạch bắt chéo mặt trước niệu quản - Tĩnh mạch lớp sâu sau niệu quản nhận máu bàng quang âm đạo hai tĩnh mạch nông sâu đổ vào tĩnh mạch hạ vị - Bạch mạch: Tạo thành hệ thống chi chít dây chằng rộng đổ vào hai nhóm mạch nhóm hạch cạnh động mạch chủ bụng nhóm hạch dọc theo động mạch hạ vị - Thần kinh có nhiều nhánh tách từ đám rối hạ vị chạy theo dây chằng tử cung đến eo tử cung chi phối tử cung cổ tử cung PERIPARTUM HYSTERECTOMY T F Baskett HYSTERECTOMY Emergency peripartum hysterectomy is an unequivocal marker of severe maternal morbidity and ‘near-miss’ mortality1,2 Reviews of published data in the past 25 years show a variable incidence, from one in 3313 to one in 6978 deliveries4 In developed countries, the incidence is approximately one in 2000 deliveries,with one population-based study in a Canadian province showing an incidence of 0.53 per 1000deliveries2.Because of the increasing Cesarean section rate world-wide and the concomitant rise in placenta previa and placenta previa accreta,the incidence of emergency peripartum hysterectomy is rising in many countries For example,in Canada from 1991 to 2000 the rate rose from 0.26/1000 deliveries to 0.46/1000 deliveries (relative risk 1.76; 95% confidence interval 1.48–2.08)5 Compared to vaginal delivery,emergency hysterectomy and delivery by Cesarean section are strongly associated6,7 In addition, a recent study has shown that multiple pregnancy had a six-fold increased risk of emergency peripartum hysterectomy compared to ingleton pregnancies8 Within this group,higher-order multiple pregnancies (triplets and beyond) had an almost 24-fold increased risk of hysterectomy8 It seems logical to conclude that the increase in multiple pregnancy rates associated with assisted reproductive technology provides a further contribution to the rising peripartum hysterectomy rates.Maternal mortality rates associated with emergency hysterectomy range from to 30%, with the higher rates in regions with limited medical and hospital resources9 How valid these rates are today is unclear, as they were calculated more than a decade ago Nonetheless,even in countries with low maternal mortality rates, associated maternal morbidity can be high due to hemorrhage, blood transfusion, disseminated intravascular coagulation, infection and potential injury to the adjacent lower urinary tract7,10,11 This chapter describes mergency hysterectomy in the immediate postpartum period following vaginal or Cesarean delivery INDICATIONS By far the most common indication for hysterectomy is hemorrhage associated with the following conditions7,9–20 Abnormal placentation In developed countries, placenta previa, with or without associated accreta, is the most common indication for hysterectomy This is due to the rising incidence of these conditions associated with the increasing number of women previously delivered by Cesarean section Despite the fact that numerous other techniques aimed at preserving the uterus have been proposed and are discussed in other chapters in this book, hysterectomy is used to stem the sometimes frightening hemorrhage associated with placenta previa or accreta in the majority of hospitals.In addition, on rare occasions, abruptio placentae, particularly of the concealed variety,may be associated with such a degree of extravasation of blood into and through the full thickness of the myometrium (Couvelaire uterus) as to make it unresponsive to oxytocic drugs, so necessitating hysterectomy It must be emphasized, however, that in the majority of cases of abruptio placentae with Couvelaire uterus the response to oxytocic drugs is 312 appropriate and the hemorrhage is due to disseminated intravascular coagulation rather than failure of the uterus to contract Uterine atony As outlined elsewhere in this book (Chapter 27),the range of modern oxytocic drugs has greatly improved the management of uterine atony Nonetheless, there are cases in which the uterus is refractory to all applications of such agents This is most commonly found in the prolonged,augmented and/or obstructed labor: simply stated, the exhausted and infected uterus may respond poorly to oxytocic agents The majority of these cases occur at the time of Cesarean section for dystocia or cephalopelvic disproportion Uterine rupture The most common cause of complete uterine rupture is within a previous Cesarean section scar If the rupture is extensive and hemorrhage cannot be contained by suture of the ruptured area, then hysterectomy may be necessary In addition, rupture of the intact uterus can occur in multiparous women in response to inappropriate use of oxytocic agents in the first and second stages of labor Uterine trauma Traumatic rupture, that is, perforation or laceration of the uterus, can occur with a variety of obstetric manipulations, including internal version and breech extraction in bstructed labor;instrumental manipulation, such as the classical application of the anterior blade of Kielland’s forceps; manual exploration of the uterus and manual removal of the placenta or its fragments after obstructed labor with a ballooned and thin lower uterine segment; and during curettage for secondary postpartum hemorrhage Cesarean section in the second stage of labor with the fetal head deeply impacted in the vagina may be associated with lateral traumatic extension of the lower uterine segment incision into the major vessels21 On rare occasions, the extent of this tear may necessitate hysterectomy, especially if one or both uterine arteries is lacerated and a hematoma obscures the surgical repair External traumas, such as assault, a fall or motor vehicle accident, are relatively rare causes of uterine perforation and rupture Sepsis In the era of modern antibiotics, sepsis is not a common reason for emergency hysterectomy.However, it still may be necessary in cases with extensive uterine sepsis, particularly with clostridial infections and myometrial abscess formation, in which antibiotic treatment fails to control the sepsis Other septic causes of secondary postpartum hemorrhage include Cesarean scar infection and necrosis, arteriovenous fistula formation secondary to uterine trauma and infection, and endomyometritis associated with hemorrhage All may rarely require hysterectomy SURGICAL PRINCIPLES Although the technique of obstetric hysterectomy is similar in principle to that of abdominal hysterectomy in gynecology, numerous anatomical and physiological changes in pregnancy create potential surgical difficulties (1) The uterine and ovarian vessels are enlarged and distended, often markedly so, and the adjacent pelvic tissues are edematous and friable (2) Abdominal entry may have been via Pfannestiel or lower midline incision,depending on the urgency and speed required (3) Maneuvers to obtain immediate hemostasis will depend on the cause of the hemorrhage In cases of uterine rupture,Green– Armytage clamps or sponge forceps can be used to compress the bleeding edges of torn uterine muscle The uterus should be eventrated from the abdominal wound The structures of the adnexa on each side are pulled laterally by an assistant and the surgeon applies straight clamps adjacent to the top sides of the are quite revalent in rural India The present study was carried out to find out the risk factors leading to peripartum hysterectomy.Methods A retrospective analysis of 30 cases of emergency peripartum hysterectomy was done over a period of years from January 1999 to December 2003 All the risk factors, indications for hysterectomy, fetal and maternal outcome, and operative and postoperative complications were analyzed Most of these cases were referred from periphery to our tertiary institute Observations There were 30 cases of cesarean hysterectomy amongst 9526 deliveries over the years giving an incidence of 0.31% The youngest woman to undergo hysterectomy was 22 years old and the oldest was 40 years old.Twenty one (70%) of the women were in the age group of 26 to 35 years, three (10%) were primigravidas, 15 (50%) were primiparas and 12 (36%) were multiparas.Seventeen women (56.6%) belonged to poor socioeconomic status Twelve (40%) were booked cases who paid regular visit to the hospital and had pregnancy complications like placenta previa and fibroid uterus Eighteen (16%) were unbooked and all 505 of them reported were referred from periphery in /unstable condition with rupture uterus and absent fetal heart All the 18 had preoperative hemorrhagic shock and three of them developed renal failure All the booked patients were clinically stable Indications Rupture uterus was the most common indication for cesarean hysterectomy seen in 18 (60%) women, all of whom were referred from peripheral rural areas within a radius of 15 to 18 km Out of these 18 cases, seven had previous one cesarean section and were handled by dais with oxytocin abuse, five were in obstructed labor,and six had prolonged and intravenous oxytocin administration by the dai There were three cases of bladder rupture among the 18 with rupture uterus and all the three had a scarred uterus In cases with previous lower segment cesarean section rupture had occurred along the line of previous incision and had extended laterally into the broad ligament Of the remaining 11cases of uterine rupture, five had vertical tear on the left side extending upto the vaginal portion of the cervix,and in six cases left side of the uterus was involved with broad igament hematomas and massive hemoperitoneum with the uterus lying on one side and /the fetus lying high up in the abdominal cavity often below the diaphragm.Morbidly dherent placenta was the second most common indication in six (20%) women Two of them had previous one cesarean section, one had placenta previa with previous one lower segment cesarean section, two had placenta accreta, and one had history of manual removal of placenta in previous pregnancy.Atonic postpartum hemorrhage was the third indication in three (10%) women with placenta previa All of them were booked cases, and had major degree type IV placenta previa There was one (3.3%) case of traumatic postpartum hemorrhage due to extension of previous uterine incision which ended in cesarean hysterectomy There were two (6.6%) cases of fibroid uterus complicating pregnancy that were taken up for elective cesarean section with concurrent hysterectomy.There were three maternal deaths, one because of disseminated intravascular coagulation and two because of irreversible hemorrhagic shock and renal failure, in cases who had rupture bladder There was 60% fetal mortality all of it in the 18 patients of rupture uterus with fetus death Thus in the rupture uterus group there was 100% fetal mortality In 29 cases, subtotal hysterectomy was done and in one case total hysterectomy was performed In two cases of cesarean section uterine artery ligation followed by internal iliac artery ligation was performed to control hemorrhage but ultimately hysterectomy had to be done In three cases bladder repair was done Number of blood transfusions required ranged form to 11 depending upon the blood loss Postoperative Complication: Nineteen patients had febrile morbidity, four had paralytic ileus, six had wound infection, two had endotoxic shock, two had renalfailure, one had deep vein thrombosis and 13 had urinaryinfection Such a high maternal morbidity is self explanatory Table Reported incidences of obstetric hysterectomy Author Incidence Mesleh et al (1998) 0.03% Bakshi and Meyer (2002) 0.27% Kastner et al (2002) 0.14% Mukherjee et al (2002) 0.15% Sheiner et al (2003) 0.048% Baskett (2003) 0.53% Parmeshwari Devi et al (2004)7 0.07% Sahu et al (2004) 0.20% Kwee et al (2005)9 0.03% Kant and Wadhwani (2005) 10 0.26% Present study 0.31% Discussion Peripartum hysterectomy is a major operation almost always an emergency one with significant blood loss and high maternal and fetal morbidity and mortality Our incidence of 0.31% is comparable to other studies as shown Table Ours is a tertiary institute for referral and most of the cases are referred late The rupture uterus is the most common indication in our study The comparison of indications in various studies is shown in Table Peripartum hysterectomy 506 Table Reported indications Gupta Mukherjee Kastner Baskett Sahu Praneshwari Kwee Kant Present and et al et al (2003) et al Devi et al and study Ganesh et al Wadhwani (1994) 11 (2002) (2002) (2004) (2004) (2005) (2005) 10 (2005) Rupture uterus — 38.3% — — 38.8% 23% — 36.58% 60% Morbidly adherent — 8.4% 48.9% 50% 13.88% 26.9% 50% 12.19% 20% placenta Atonic PPH — 10.3% 29.8% 32.8% — 19.2% 27% 41.46% 10% Traumatic PPH 39.4% 6.5% 4.3% — — 7.6% — — 3.3% Pregnancy with — 0.9% — — — — — — 6.6% fibroid uterus The second most common indication is morbidly adherent placenta followed by atonic PPH, traumatic PPH and term pregnancy with fibroid uterus Rupture uterus is a serious obstetric emergency with high maternal and perinatal mortality Though a common obstetric problem in developing country, it is preventable Occurrence of uterine rupture is significantly associated with grand multiparity, scarred uterus, lack of antenatal care, unsupervised labor at home, injudicious use of oxytocin, and low socioeconomic status of the women These factors are largely preventable Postoperative complications like febrile morbidity, paralytic ileus, wound infection,endotoxic shock renal failure and deep vein thrombosis are common because of prolonged labor intrauterine manipulations, and dormant sepsis4,5,7,8,10,12.No maternal deaths were reported by Basket6, and Mesleh et al1 while 10% maternal deaths were reported by others 5,9,10 Emergency obstetric hysterectomy is no doubt a life saving procedure for managing life threatening obstetric hemorrhage and uterine rupture This is one situation when the surgeon is in a dilemma, in deciding about emergency hysterectomy, as a last resort to save the life of the mother, the fetus being already lost and the mother still young, often a primigravida or of low parity with no living child This operation should be made rarer by good antenatal care, of active anagement of labor, early recognition of complications and timely performance of cesarean section when indicated But every obstetrician should be conversant with obstetric hysterectomy References Mesleh R, Ayoub H, Algwiser A et al Emergency peripartum hysterectomy J Obstet Gynaecol1998;18:533-7 Bakshi S, Meyer BA Indications for and outcomes of emergency peripartum hysterectomy A five-year review J Reprod Med 2000;45:733-7 Kastner ES, Figueroa R, Garry D et al Emergency peripartum hysterectomy: experience at a community teaching hospital Obstet Gynecol 2002;99:971-5 Mukherjee P, Mukherjee G, Das C Obstetric hysterectomy – A review of 107 cases J Obstet Gynecol India 2002;52:34-6 Sheiner E, Levy A, Katz M et al Identifying risk factors for peripartum cesarean hysterectomy A population based study J Reprod Med 2003;48:622-6 Baskett TF Emergency obstetric hysterectomy J Obstet Gynaecol 2003;23:3535 Praneshwari Devi RK, Singh NN, Singh D Emergency obstetric hysterectomy J Obstet Gynecol India2004;54:343-5 Sahu L, Chakravertty B, Panda S Hysterectomy for obstetric emergencies J Obstet Gynecol India2004;54:34-6 Kwee A, Bots ML, Visser GH et al Emergency peripartum hysterectomy A prospective study in The Netherlands Eur J Obstet Gynecol Reprod Biol2006;124:187-92 10 Kant A, Wadhwani K Emergency obstetric hysterectomy J Obstet Gynecol India 2005;55:132-34 11 Gupta U, Ganesh K Emergency hysterectomy in obstetrics: review of 15 years Asia Oceania J ObstetGynaecol 1994;20:1-5.Marwaha Parveen et al Articles Peripartum hysterectomy: a ten-year experience at a tertiary care hospital in a developing country Ferha Saeed MBBS FCPS * Roha Khalid MBBS Abdullah Khan MBBS * MD Shazia Masheer MBBS FCPS Javed H Rizvi MBBS FACS * * Department of Obstetrics and Gynecology, Aga Khan University Hospital, Karachi; Medical College, Aga Khan University Hospital, Karachi, Pakistan Correspondence to: Shazia Masheer, Department of Obstetrics and Gynecology, Aga Khan University Hospital, Karachi, Pakistan Email: shazia.masheer@aku.edu Acute bleeding after delivery can be a life-threatening complication Emergency hysterectomy is usually undertaken as a last resort This study was conducted in order to estimate the incidence, indications, risk factors and complications associated with peripartum hysterectomy performed at a tertiary care hospital We retrospectively analysed 39 of 45 cases of emergency peripartum hysterectomy performed at the Aga Khan University Hospital from 1997–2006 Peripartum hysterectomy was defined as one performed for a haemorrhage after delivery which is unresponsive to other treatments The most frequent indications for peripartum hysterectomy were morbidly adherent placenta (46%) and uterine atony (23%) The duration of surgery was shorter (P = 0.045) but the complications were higher (P = 0.029) in total compared with subtotal hysterectomies Our results suggest that caesarean deliveries are associated with an increased risk for peripartum hysterectomy, which is of concern given the increasing rate of caesarean deliveries Subtotal hysterectomy is a reasonable alternative in emergency obstetric hysterectomy Department of Epidemiology, University of Washington, Seattle, Washington, USA bodelon@u.washington.edu Obstetrics and Gynecology [2009, 114(1):115-23] Type: Journal Article Abstract Highlight Terms Gene Ontology(1) Diseases(6) OBJECTIVE: To identify factors associated with peripartum hysterectomy performed within 30 METHODS: This was a population-based case-control study using Washington State birth certifi and mode of delivery and 95% confidence intervals (CIs) were computed RESULTS: There were 896 hysterectomies Incidence rates ranged from 0.25 in 1987 to 0.82 per not As compared with vaginal delivery, vaginal delivery after cesarean (27 cases compared with CONCLUSION: Incidence rates of peripartum hysterectomy are increasing over time The most LEVEL OF EVIDENCE: II Current studies Peripartum hysterectomy Background Severe obstetric haemorrhage is a leading cause of severe maternal morbidity in Australia and remains a cause of maternal death One-off studies on peripartum hysterectomy have shown that the incidence is increasing1 and that there is an association between prior caesarean delivery and the need for peripartum hysterectomy.2 The caesarean section rate in Australia continues to increase, with the most recent figures showing that over 30% of women gave birth by this mode in 2005, compared with less than 20% in 1996.3 There is an urgent need to explore the epidemiology and management of peripartum hysterectomy in Australia Research Questions What is the current incidence of peripartum hysterectomy in Australia? What are the risk factors for peripartum hysterectomy in Australia? How is severe obstetric hemorrhage resulting in peripartum hysterectomy managed in Australia? What are the outcomes for both the woman and the infant when a pregnancy results in peripartum hysterectomy in Australia? Method Prospective, case-control study using monthly negative surveillance system of all birthing services in Australia (>50 births) – AMOSS Nominated clinicians and midwives within each maternity unit will be e-mailed a simple tick-box to indicate whether a case occurred or whether there is ‘nothing to report’ If a case arose, the reporting clinician will complete a case form using the secure web-based data system The clinician/midwife will also complete two control forms using the secure web-based data system Only non-identifiable data will be collected Surveillance Period January 2010 - June 2011 Case Definition The cases will be all women in Australia identified as having a peripartum hysterectomy using the following definition: EITHER any woman whose pregnancy terminates and who has a hysterectomy in the same clinical episode or within six weeks postpartum when the indication for hysterectomy is related to the pregnancy e.g secondary postpartum haemorrhage OR any woman giving birth and undergoing a hysterectomy in the same clinical episode or within six weeks postpartum when the indication for hysterectomy is related to the birth e.g secondary postpartum haemorrhage Control Selection The two births immediately prior to the case, in the same hospital Study Size The study will run for 18 months The estimated sample size for this time duration is 330 cases based on the Victorian obstetric haemorrhage and associated hysterectomy study conducted for the years 1999 – 2002.1 The incidence of peripartum hysterectomy was shown to be increasing consistently over these years, with 48 hysterectomies performed in Victoria in 2002, from a pool of 61 959 maternities; 7.7 per 10,000 maternities This is a larger sample estimate than that made based on the UKOSS results: between 100 and 130 cases based on the UKOSS results of 4.1 (95%CI 3.6 to 4.5) per 10,000 maternities.2 References Haynes, K., C Stone, and J King, Major Conditions Associated with Childbirth in Australia: Obstetric Haemorrhage and Associated Hysterectomy 2004, Department of Human Services: Melbourne Knight, M., et al., Cesarean delivery and peripartum hysterectomy Obstetrics & Gynecology, 2008 111(1): p 97-105 Laws, P.J., et al., Australia's mothers and babies 2005, in Perinatal statistics series no 20 Cat no PER 40 2007, AIHW National Perinatal Statistics Unit: Sydney EDITORIAL COMMENT Peripartum Hysterectomy Risk Factors in Taiwan Ming-Jie Yang, Peng-Hui Wang* Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, National Yang-Ming UniversityHospital, and Institute of Clinical Medicine, National Yang-Ming University School ofMedicine, Taipei, Taiwan, R.O.C.© 2010 Elsevier Taiwan LLC and the Chinese Medical Association All rights reserved *Correspondence to: Dr Peng-Hui Wang, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan, R.O.C E-mail: phwang@vghtpe.gov.tw ● Received: March 28, 2010 ● Accepted: May 25, 2010 In addition, nearly half of all deliveries (46.7%) in this study were by cesarean section,5 which may also be a risk factor, although the authors did not mention it The presence of an attendant at every birth and access to emergency obstetric care are key to reducing maternal morbidity and mortality in the developing world,although esource-rich countries have a rising cesarean section rate with its consequent effect on the incidence of abnormal placentation and its link with peripartum hysterectomy.9 In fact, cesarean section is the single most important factor resulting in peripartum hysterectomy,because women undergoing primary cesarean section had the highest peripartum hysterectomy rate, with an adjusted odds ratio of 12.13 (95% confidence interval, 8.30– 17.14), compared with women undergoing vaginal delivery.2 The risk from primary cesarean section is even more severe than that of repeated cesarean sections This may indicate that the incidence of peripartum hysterectomy may increase significantly in the near future; if the age of women during pregnancy continues to increase, the primary cesarean section rate will continue to rise References Wise A, Clark V Challenges of major obstetric haemorrhage.Best Pract Res Clin Obstet Gynaecol 2010;24:353– 65 Jou HJ, Hung HW, Ling PY, Chen SM, Wu SC Peripartum hysterectomy in Taiwan Int J Gynaecol Obstet 2008;101:269–72 Turner MJ Peripartum hysterectomy: an evolving picture IntJ Gynaecol Obstet 2010;109:9–11 Ozden S, Yildirim G, Basaran T, Gurbuz B, Dayicioglu V.Analysis of 59 cases of emergent peripartum hysterectomies during a 13year period Arch Gynecol Obstet 2005;271:363–7 Yalinkaya A, Guzel AI, Kangal K Emergency peripartum hysterectomy:16-year experience of a medical hospital J Chin MedAssoc 2010;73:360–3 Leridon H, Slama R The impact of a decline in fecundity and of pregnancy postponement on final number of children and demand for assisted reproduction technology Hum Reprod2008;23:1312– Schmidt L Should men and women be encouraged to start childbearing at a younger age? Expert Rev Obstet Gynecol 2010;5:145–7 Cheng MH, Wang PH Placentation abnormalities in the pathophysiology of preeclampsia Expert Review Mol Diagn2009;9:37–49 Hsu TY Abnormal invasive placentation—placenta previa increta and percreta Taiwan J Obstet Gynecol 2009;48:1–2.400 Abstract The aim of this study was to estimate incidence, indications and complications of peripartum hysterectomy in Apex Hospital of the Kashmir valley We analyzed 100 cases of emergency cesarean hysterectomies performed in our hospital from January 2001 to December 2002 The incidence of emergency hysterectomy was 2.6 per thousand deliveries Most common indication for emergency hysterectomy was uterine rupture (30%), followed by placenta previa (25%), uterine atony (21%) and placenta increta/accerta/percreta (8%) Majority of uterine rupture cases were late referrals from rural areas The commonest postoperative complication was fever (27%), followed by lower respiratory tract infection (10%), wound infection (8%), and bladder injury (8%) Maternal mortality following emergency hysterectomy was 3%, and the cause of death was related to complications like shock, septicemia and disseminated intravascular coagulation (DIC) Introduction Emergency hysterectomy is carried out as life saving procedure Even today, 8-10% of maternal mortality, in developing countries, directly occurs due to massive obstetrical hemorrhage Emergency peripartum hysterectomy that occurs after vaginal delivery, or at the time of cesarean births, is usually reserved for situations where conservative measures not control hemorrhage Most common indication for emergency peripartum hysterectomy has been uterine atony and uterine rupture2,3 Recently the most common reported indication is placenta accerta, and is most likely related to increase in number of cesarean deliveries observed over the past two decades , , , , The purpose of our study was to estimate incidence, indications, and postoperative complications associated with emergency hysterectomy in this part of the world Methods The present prospective study was carried out in Lalla-Ded Hospital, which is one of the main hospitals associated to Government Medical College Srinagar, Kashmir and is the only referral maternity care hospital at present catering the whole Kashmir valley A random sample of first 100 women who underwent caesarean hysterectomy for various indications between January 2001 to December 2002 was studied Maternal characteristics like age, parity, residence, and any previous cesarean delivery were recorded The indication for surgery, type of hysterectomy, postoperative complications, any need for blood transfusion, and pregnancy outcome were obtained Data thus collected was subjected to appropriate statistical analysis Results From January 2001 to December 2002, 45460 normal vaginal deliveries, 10139 cesarean deliveries, and 146 emergency cesarean hysterectomies were performed We analyzed 100 randomly selected samples out of 146 cases of emergency cesarean hysterectomy The incidence of emergency cesarean hysterectomy was 2.6 per thousand deliveries A total of 36% patients were from urban areas while 64% belonged to rural areas (Table 1) Table 1: Incidence of cesarean hysterectomies The proportion of patients requiring emergency hysterectomy increased from 5% in 20-24 years age group to 42% in 35-39 years, and then showed decline at or above 40 years (Table 2) Of the patients who underwent emergency cesarean hysterectomy, 64 were of Para (40%) and para (24%); parity distribution showed a fall in the number of hysterectomies from 40% in Para to 2% in Para (table3) There were 3% primigravida who underwent cesarean emergency hysterectomy Table 2: Age distribution of patients requiring emergency hysterectomy (n=100) The most common indication for emergency cesarean hysterectomy was rupture of the uterus (30%), all the cases being rural referrals, followed by placenta previa (25%), atonic uterus (21%), accidental hemorrhage (12%), and placenta increta/acreta (8%) Table 3: Parity distribution of patients who underwent emergency Cesarean hysterectomy (n=100) In 97% of cases subtotal hysterectomy was carried out, whereas 3% patients required total hysterectomy Average length of hospital stay in those patients who underwent cesarean hysterectomy was 10-15 days Table 4: Indications for emergency hysterectomy (n=100) Fever was the most common complication (27%), followed by urinary tract infection (12%), bladder injury (8%), wound infection (8%), lower respiratory tract infection(10%), and life threatening septicemia (1%) Perinatal mortality was 43%, and maternal mortality was 3% in present study Discussion Cesarean hysterectomy has undergone tremendous change, both in terms of the indications and frequency of the procedure Obstetric cesarean hysterectomy is mostly done for indications deemed to be serious and life threatening to the patient, and not amenable to conservative management Present study describes maternal mortality, morbidity, etiology, and fetal outcome of 100 patients who underwent cesarean hysterectomy in our hospital in a period of about years There were a total of 45460 vaginal deliveries, 10139 cesarean deliveries, and 146 emergency cesarean hysterectomies The incidence of cesarean hysterectomy was 2.62 per thousand deliveries The rate is higher than that in the earlier studies conducted by Chestnut et al1 where 44 hysterectomies in 36561 deliveries were reported between 1963 and 1983 for a rate of 1.2 per thousand Clark et al identified 70 hysterectomies in 68653 deliveries between 1978 and 1982 for a rate of 1.02 per thousand; where as Zelop et al described 117 hysterectomies in 75650 deliveries between 1983 and 1991 at a rate of 1.55 per thousand However these are published rates of institutions within the United States Gupta et al described 169 emergency hysterectomies out of 100,000 deliveries between January 1976 to December 1980, giving a rate of 1.69 per thousand Our study revealed an incidence rate of 2.6 per thousand deliveries which is higher than that in studies mentioned above This increase in incidence can be attributed to more frequent referrals from rural areas in our setting Patients who underwent emergency cesarean hysterectomy belonged more often to a rural area (64%) than to an urban location (36%) Up to 60% of patients undergoing cesarean hysterectomy were in age group of 30 to 36 years, 42% of 35 to 39 years, and 10% of 40 years of age or greater Similar trends were observed by Gupta in 1992 , where the number of patients requiring hysterectomy at 40 years of age or above, fell from 13.7% to 5.7% Maximum number of patients belonged to Para (40%) and Para (24%), as these patients are at more risk of complications associated with pregnancy Barclay 10 in 1975 showed that 82.6% of patients undergoing cesarean hysterectomy were Para or greater ; our results run in conformity The most common cause of emergency peripartum hysterectomy was uterine rupture (30%), followed by placenta previa (25%) and uterine atony (21%) Majority of ruptured uterus cases were late referrals from rural areas and rural hospitals Gupta et al showed an incidence of 42% of uterine rupture in patients undergoing cesarean hysterectomy, slightly higher than our study Standee and Ruston 11 in 1983 reported an incidence of 17.14% uterine rupture, 14.29% uterine atony, 48.7% placenta previa in patients undergoing cesarean hysterectomy Chestnul et al found that the major indication for cesarean hysterectomy was uterine rupture followed by uterine atony and placenta accereta Clark et al reported uterine atony (43%) to be the most common cause of emergency peripartum hysterectomy However, Stanco et al found later that most common cause of emergency peripartum hysterectomy was placenta accrete (50%), followed by uterine atony (21%) Zelop et al also found placenta accrete (64%) and uterine atony as most common indications for emergency peripartum hysterectomy Conclusion: Present study highlights various areas for overall improvement in health care which will lead to decline in emergency hysterectomy These include refreshing courses for multipurpose workers in identifying high risk pregnancies and their timely referral, upgrading of Primary Health Centers (PHCs) and ambulance facilities, posting of qualified and specialist surgeons, proper mechanism of referral to a higher hospital, round the clock obstetric services at the PHCs, and creation of first referral units (FRUS) These first as well as second line referrals need to be upgraded for providing basic and comprehensive obstetric care as scheduled in India Reproductive and Child Health Programme II (RCH-II) Acknowledgements We greatly acknowledge the guidance and cooperation of our following esteemed teachers that made our study completed successfully: Correspondence to Dr Tasleema Chesti, Professor Department of Gynecology and Obstetrics, Government Medical College Srinagar Dr AM Hashia Professor and Head, Department of Anesthesia and Critical Care Medicine, Government Medical College Srinagar References Sanjay B Rao, PK Shah, S Dholakia, N Shreyan, N Vanjara Emergency hysterectomy: The Hobson's choice in Massive Atonic Postpartum Hemorrhage (s) Chestnut DH, Eden RD, Gall SA, Parker RT Peripartum hysterectomy: A review of cesarean and postpartum hysterectomy Obstet Gynecol 1985; 65: 365-70 (s) Clark SL, Yeh SY, Phelan JP, Bruce S, Paul RH Emergency hysterectomy for obstetrical hemorrhage Obstet Gynecol 1984; 64: 376-80 (s) Stanco LM, Schrimmer DB, Paul RH, Mishell DR Emergency peripartum hysterectomy and associated risk factors Am J Obstet Gynecol 1993; 168: 879-83 (s) Zelop CM, Harlow BL, Frigoletto FD, Safon LE, Saltzman Dh Emergency peripartum hysterectomy Am J Obstet Gynecol 1993; 168: 1443-48 (s) Rates of cesarean delivery- United States 1991 MMWR 1993; 42: 285-89 (s) Clarke SL, Koonings PP, Phelan JP Placenta previa/accrete and prior cesarean section Obstet Gynecol1985; 66:89-92 (s) Miller DA, Chollet JA, Goodwin TM Clinical risk factors for placenta previa-placenta accrete Am J Obstet Gynecol 1997; 177: 210-14 (s) Gupta U, Anjana Changing trends in emergency hysterectomy in obstetric practice in a large teaching hospital The Journal of Obstetrics and Gynecology of India.42; 2: 169-73 (s) 10 Barclay DL, Hawkins BL, Freuh DM Elective cesarean hysterectomy - a five year comparison with cesarean section Am J Obstet Gynecol 1976; 124: 900-93 (s) 11 Strudee DW, Ruston D Cesarean and postpartum hysterectomy , 1968-1983 Br J Obstet & Gynecol 1986; 93: 270-74 (s) This article was last modified on Fri, 13 Feb 09 13:32:57 -0600 This page was generated on Sun, 07 Nov 10 04:59:19 -0600, and may be cached Department of Medicine and Public Health, University of Bologna, Bologna, ITALIE (2) National Perinatal Epidemiology Unit, University of Oxford, Oxford, ROYAUME-UNI (3) Department of Obstetrics and Gynecology, University of Bologna, Bologna, ITALIE Résumé / Abstract Objective To estimate the incidence of peripartum hysterectomy in an Italian Region (EmiliaRomagna) and investigate its association with cesarean delivery Design Population-based retrospective study using hospital discharge records Setting All public and private hospitals in Emilia-Romagna region, Italy Population A total of 151,494 women delivering between 2003 and 2006, 131 of whom had a peripartum hysterectomy Methods Peripartum hysterectomy was defined as a hysterectomy performed at the time of delivery or afterwards during the same hospitalization Incidence rates were calculated by type of delivery Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated with logistic regression to evaluate the association between peripartum hysterectomy and delivery type Main outcome measures Incidence rates of peripartum hysterectomy by type of delivery; odds of peripartum hysterectomy after primary or repeat cesarean compared with vaginal delivery without previous cesarean Results A total of 131 peripartum hysterectomies were performed among 151,494 deliveries (0.86/1,000 deliveries; 95% CI 0.72-1.03) with 20.7% primary and 9.6% repeat cesarean deliveries Women undergoing a primary caesarean delivery were more likely to have a peripartum hysterectomy than women having a vaginal delivery who had never had a cesarean delivery (OR 6.48; 95% CI 4.16-10.07) Women undergoing a repeat caesarean delivery were also at increased risk (OR 3.69; 95% CI 2.11-6.46) Conclusions In this population, primary and repeat cesarean deliveries are associated with an increased risk of peripartum hysterectomy These results are of particular concern given the steady increase in the cesarean delivery rate in many countries The pathological mechanism of this association requires further investigation Revue / Journal Title Acta obstetricia et gynecologica Scandinavica ISSN 0001-6349 CODEN AOGSAE ... Chỉ định - Cắt tử cung để cầm máu trường hợp chảy máu từ tử cung nguyên nhân sản khoa hay nguyên nhân phụ khoa mà biện pháp điều trị nội khoa khơng có kết - Cắt tử cung thương tổn tử cung như:... sau mổ 4.4 Kẹp cắt động mạch tử cung Dùng kẹp to có kéo tử cung lên cao để bộc lộ hai cuống động mạch tử cung Cặp động mạch tử cung vị trí ngang với đoạn tử cung tương ứng eo tử cung khơng có... rau bong non, vỡ tử cung, tử cung nhiễm khuẩn nặng (nhiễm khuẩn huyết, viêm phúc mạc), thủng tử cung, rau cài lược, u xơ tử cung to mổ lấy thai - Chú ý: trường hợp có định cắt tử cung cấp cứu mà