Emergency Peripartum Hysterectomy

Peripartum Hysterectomy ​

• incidence : 0.24 to 8.9 per 1000 deliveries (1.2 to 2.7 per 1000 deliveries in USA, Europe <1)​
• after vaginal delivery : 0.1 to 0.3/1000​
• with CS:  0.2 to 8.7/1000 deliveries ​
• higher due to risk of placenta praevia with placenta acreta in repeat c-sections​
• uterine rupture : 114/1000 to 455/1000 

In most cases, severe PPH can be usually controlled with conservative management.  Therefore, the emergency peripartum hysterectomy is considered a “high risk, low incidence” event.  The incidence varies significantly with geographic location and depends on the ability of the unit to employ effective conservative measures.    Some cases are unpredictable. A patient’s history of previous cesarean section is the most important risk factor as it increases the risk of abnormal placentation and uterine rupture.​

Disclosures

• The following portion of the postpartum hemorrhage module is based on the powerpoint presentation authored by Dr. Kristin Hoffman and presented January 15, 2020 entitled “ Emergency Peripartum Hysterectomy:  Bloody Hell for Family Physicians” with the author’s permission ​
• The hysterectomy technique diagrams are from the textbook Williams Obstetrics 25th edition. ​

Anatomy

The uterus is well supplied with collateral blood supply with anastomotic connections from the:
a.  Ovarian artery
b.  Uterine artery​
c.  Vaginal artery​
d.  Internal pudendal artery​
Pulse pressure (and, therefore, blood loss) may be reduced with bilateral ligation of one or more of the sites indicated in the diagram above.  ​

The major portion of blood supply to the uterine corpus comes from the anastomoses of the ovarian and uterine arteries.  Therefore, ligation of these anastomotic sites is critical to the surgical management of postpartum hemorrhage.  Uterine artery ligation may be performed as an initial step before resorting to EPH.  However, it is faster and more effective to proceed directly to EPH if the patient is unstable.  The cervix is well supplied by the vaginal and internal pudendal arteries so will remain viable even if the remainder of the uterus is removed.  In a subtotal hysterectomy, the uterus is amputated at the level of its isthmus.  The uterine corpus is removed but cervix is left behind.​

Once the decision to proceed with EPH is made, four sites must be rapidly secured and divided in order to effectively control uterine bleeding (bilateral adnexal vessels and uterine arteries) as illustrated in this diagram.  It is important to observe what part of the uterus is bleeding.  If the bleeding is from the lower uterine segment, as it may be in the case of placenta acreta, securing the uterine and ovarian vessels may not control bleeding.  Hemorrhage from the lower segment or vaginal arteries must be addressed by placing lateral clamps caudad to the bleeding site. ​

Who is at increased risk?​

• Abnormal placentation (AP)​
• Uterine rupture​
• Uterine atony not responsive to conservative management

With access to optimal conservative management for PPH,  EPH due to uterine atony has become rarer.  In contrast, rising cesarean sections rates have increased the prevalence of abnormal placentation and uterine rupture.  ​

Abnormal Placentation​

• risk factors include placenta previa in a gravida with prior cesarean or other uterine surgery including myomectomy or D&C with placental implantation over the uterine scar. ​
• may be suspected prior to delivery and diagnosed with MRI or transvaginal ultrasound ​
• can occur unexpectedly at delivery​
• If the placenta does not detach with gentle traction, placenta acreta should be suspected and the anesthesiologist and family should be informed. Forcibly detaching an adherent placenta can have serious consequences usually involving heavy blood loss and damage to nearby organs. After recognizing that the placenta is not detaching, it is left inside the uterus and hysterectomy should proceed. ​

The possibility of abnormal placental adherence should be considered whenever the patient has a history of uterine surgery.  The most common scenario involves a combination of placenta previa and previous lower segment cesarean section.  This combination is the most likely to result in placenta acreta, increta or percreta because of the relatively thin myometrium in the lower uterine segment.  However, abnormal placentation can occur unexpectedly in the presence of placental implantation at the site of any previous uterine scar.​

Uterine rupture​

• risk factor : scarred uterus​
• VBAC​
• history of any uterine instrumentation ​
  • pregnancy termination, D&C, hysteroscopy, endometrial biopsy​
  • myomectomy​
  • IUCD ​

Uterine rupture typically occurs at the site of a uterine scar.  It is worth remembering that uterine perforation may have gone unrecognized at the time of previous instrumentation of the uterus.  A history of any uterine surgery or procedure is, therefore, important to consider. Often the patient presents with antepartum or intrapartum hemorrhage and emergency cesarean delivery can be performed and the rupture repaired.  If the baby has been delivered vaginally, the diagnosis is made by palpating the defect at the site of the uterine scar.​

Uterine Atony Not Responsive to Conservative Measures ​

In situations where conservative treatment is likely to fail or has failed, there should be no further delay in performing EPH as delay leads to increase in blood loss, transfusion requirement, operative time, DIC, and increased possibility of admission to ICU.​

Only absolute contraindication is refusal of the procedure by the mother​.

Lifesaving measures in any case of PPH depend on the surgeon’s ability to follow a strategic approach to diagnosis and management.  Always plan for the next step in case the bleeding is not responsive.​

Where

• Most appropriate medical facility – always transfer if possible​
• Communicate with local team: call for backup MD, RN, lab​
  • make a local to-do check list​
  • communicate early to referral center​
• Special equipment readily available and familiar to the team:​
  • Retractors including self-retaining Balfour, Bookwalter, Mobius ​
  • 8 heavy-duty clamps such as the curved Heaneys, Zepplins​
  • Delayed absorbable suture (0 or #1 polyglycolic suture or chromic)​

Ideally, anticipate failure of conservative measures, stabilize and transfer.  Early communication with the referral center and with the local team .  Assemble surgical equipment needed for EPH. ​

Blood?

• Bloodbank​
• Labs: CBC, coags, fibrinogen, lytes, Ca2+, Mg2+ (if available) (repeat as per blood loss)​
• RBCs/FFP in 1:1 ratio, platelets, cryoprecipate or human fibrinogen concentrate​

Estimate blood loss and replace.  Was the patient anemic to begin with? Are blood products readily accessible.  It is better to proceed with EPH sooner rather than later in the face of ongoing blood loss if adequate blood products are readily available.​

Anesthesiologist​

• adequate venous access ​
• may need conversion to GA (only if concerned) (airway oedema)​
• walk the thin line between hypovolemia and fluid overload​
• prepare for Massive Transfusion Protocol

Involve anesthesia early.  Be familiar with the Massive Transfusion Protocol (MTP) available at your site.​

Maintain perfusion but beware fluid overload.  Generally speaking young women of reproductive age are able to withstand a large loss of blood volume without hemodynamic compromise.  Devastating hemodynamic collapse then occurs precipitously.​

Anesthesia & Blood bank​
MT definition

• many definitions:
  • ​10 U or more RBCs over 24h
  • ​5 U over 3-4h​
  • 3 U over 1h​

Massive transfusion protocols are designed minimize the guess work in this emergency situation.​

Modified MTP​

• Order CBC, PT/PTT and keep monitoring q 30min(include fibrinogen, Ca2+, Mg2+ if available)​
• TXA​
• 1:1 RBC and FFP, warm, through rapid infuser​
• Use crossmatched blood as soon as available​
• RiaSTAP® if DIC​

Call Massive Transfusion Protocol (MTP) earlier rather than later. The most conservative approach is to start the MTP if the patient has lost more than 3 units of blood and has ongoing bleeding. ​

Lethal triad in hypovolemic shock may be aggravated by blood transfusion

1. Hypothermia – Not using blood and body warmer
2. Metabolic Acidosis – Additional lactic acidosis
3. Coagulopathy – Worsened by hypocalcemia

Technique – total hysterectomy

• Used routinely in an elective situation due to the potential risk of malignancy developing in the cervical stump and other associated problems such as bleeding or discharge associated with the residual cervical stump.
• Should be considered when active bleeding occurs from lower uterine segment (placenta praevia, placenta accreta) if bleeding not well controlled with clamping lateral vessels and placing deep hemostatic sutures in the cervical stump.

In an elective situation, a total hysterectomy is likely the best option and is the treatment of choice in the case of abnormal placentation in the lower segment.  However, in an emergency situation, subtotal hysterectomy is preferred as it is faster and likely safer. The cervical anatomy is distorted and more difficult to identify in a patient who has been in labour.  In the case of bleeding from the lower uterine segment, it may still be possible to control hemorrhage by placing clamps lateral to and below the site of bleeding site without removing the entire cervix.  

Technique – subtotal (supracervical) hysterectomy

Most common (53-80%) & safer than total hysterectomy for EPH

• less blood loss, less need for blood transfusion
• faster
• reduced intra and postoperative complications
• better choice for less skilled surgeons

Because EPH is so rarely performed, even in experienced hands the subtotal hysterectomy is preferable.  Faster control of hemorrhage can be achieved, thus reducing the need for further transfusion.  Generally speaking, complications such as injury to other organs are less common with supracervical hysterectomy as the bladder and ureters are further from the operative site.  

EPH Procedure Steps​

1. Place retractor and pack bowel into the upper abdomen​
2. Round ligaments & utero-ovarian ligaments are secured​
   1. Bilaterally, the round ligament is identified, clamped, divided, suture ligated. ​
   2. Bilaterally, free the ovaries from the uterus. Identify an avascular area in the broad ligament and perforate. Place 2 clamps through this hole, across the Fallopian tube and uteroovarian ligament. Cut and suture ligate. ​
3. Parametrial tissue: skeletonize sequentially up to the isthmus.​
4. Use firm upward traction on the cornua in order to elevate the uterine arteries away from the ureters  ​
5. Uterine artery and vein: bilaterally place a clamp towards the hysterotomy. Cut and suture ligate. ​
6. Amputate the uterine fundus by extending the anterior hysterotomy circumferentially. Close anterior and posterior together with hemolock technique as if repairing a c-section uterine incision. ​

Round Ligaments Secured

The uterus may be externalized for optimal visualization.  Clamps are placed across the cornua and the uterus is put on stretch.  The round ligaments are identified bilaterally clamped, cut and suture ligated.​

Create a window in the broad ligament​

The operator uses the index and middle finger to tent up an avascular area of the broad ligament in the space beneath the Fallopian tube and utero-ovarian ligament.  A small snip is made in the broad ligament to create a window.​

Division and ligation of Fallopian tube and utero-ovarian ligament​

Two clamps are placed across the Fallopian tube and utero-ovarian ligament with their tips protruding through the window in the broad ligament.  The pedicle is divided between the clamps and secured with a stitch.  The technique is repeated on the contralateral side.​

Posterior view of the uterus showing cross clamping of the uterine vessels​

The uterus is placed on further stretch in a cephalad direction in order to lift the uterine arteries away from the ureters.  The window in the broad ligament may be carefully enlarged to skeletonize the uterine vessels. The curved Heaney clamp is placed tight against the substance of the uterus taking the uterine vessels and surrounding tissue in a horizontal bite. ​

Anterior view of the uterus.  The uterine vessels are clamped.​

The uterine vessels are the most critical pedicles.  For that reason, double clamping is often performed to ensure excellent hemostasis.  A figure of eight suture (Heaney stitch) is placed distal to the most lateral of the two clamps. The assistant removes the lateral clamp while the surgeon snugs down the knot. The medial clamp may be flashed and the pedicle regrasped.  The pedicle is then ligated again with a free tie. In the diagram a third clamp has been applied to the uterus to decrease back bleeding.​

Clamps are placed slightly below the level of the hysterotomy incision and the uterine corpus amputated.​

The final set of clamps secure the angles of the hysterotomy incision.  The uterus is amputated by extending the hysterotomy incision to 360 degrees around the full circumference of the uterine isthmus.  The pedicles are secured with figure of 8 sutures. Suction and irrigation of the abdomen is performed.  If hemostatis is confirmed, closure proceeds. If the lower segment is bleeding more clamps may be applied closer to the cervix in order to address the bleeding site.​

The cervical stump is oversewn with running locked suture. ​

The anterior and posterior edges of cervical stump are oversewn with a running locked stitch.  Deep “figure of 8” sutures may also be placed deep in the substance of the stump to reinforce the closure and promote excellent hemostatis. ​

Closing Procedure

1. lace multiple deep, hemostatic sutures in the cervical stump​
2. Drape omentum over the stump (to prevent bowel adhesions). Consider placing a drain (don’t if DIC).​
3. Don’t close rectus muscle/peritoneum​
4. Fascia closed with delayed absorbable suture​
5. Closure to fat layer if 2cm or greater thickness (interrupted 2.0 plain gut)​
6. Staples for skin​

Complications

• infection (use prophylactic antibiotics)​
• bleeding​
• urinary tract injury to the bladder or ureters​
• DIC​
• VTE​
• (bowel injury)

Postoperative complications are significantly more common with emergency hysterectomy than elective surgery.  Massive hemorrhage is associated with a dramatic increase in surgical site infection so prophylactic antibiotics are a must.  Hemorrhagic shock, hemodilution and DIC deplete clotting factors and further impair coagulation.  Unfamiliar uterine anatomy in pregnancy, limited surgical visualization and rarity of EPH contribute to urinary tract injuries. Thrombotic events may still occur but the risk of ongoing bleeding generally precludes the use of anticoagulants.  Although bowel injury is still a potential concern in any surgery, it is most commonly associated with anatomical factors peculiar to the patient rather than related to PPH or EPH procedure itself.  For example, pelvic adhesions from previous abdominal surgery or endometriosis.     ​

Recommended Textbooks

1.  A Comprehensive Textbook of Postpartum Hemorrhage:  An Essential Clinical Reference for Effective Management 2ed. Global Library of Women’s Medicine (with Sapiens Publishing) 2012.
Open access available at www.glowm.com​

2. Williams Obstetrics 25th edition, Cunningham, Leveno, Bloom,Dashe, Hoffman, Casey, Spong eds, McGrawHill, 2018. Chapters on PPH and Cesarean Section/Hysterectomy​

Examples of PPH Kit / MHP

• AHS – Post-Partum Hemorrhage, Inpatient Maternal & Child Health
• http://cmajopen.ca/content/7/3/E546/T1.expansion.html​
• https://www.uptodate.com/contents/image?imageKey=OBGYN/110293​
• AIM – Obstetric Hemorrhage Patient Safety Bundle

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