Peripartum cesarean hysterectomy: critical analysis of risk factors and trends over the years

Abstract

To investigate time trends and risk factors for peripartum cesarean hysterectomy. A population-based study comparing all deliveries that were complicated with peripartum hysterectomy to deliveries without this complication was conducted. Deliveries occurred during the years 1988-2007 at a tertiary medical center. A multiple logistic regression model was constructed to find independent risk factors associated with peripartum hysterectomy. Emergency peripartum cesarean hysterectomy complicated 0.06% (n=125) of all deliveries in the study period (n=211,815). The incidence of peripartum hysterectomy increased over time (1988-1994, 0.04%; 1995-2000, 0.05%; 2001-2007, 0.095%). Independent risk factors for emergency peripartum hysterectomy from a backward, stepwise, multivariable logistic regression model were: uterine rupture (OR=487; 95% CI 257.8-919.8, p<0.001), placenta previa (OR=66.4; 95% CI 39.8-111, p<0.001), postpartum hemorrhage (PPH) (OR=40.8; 95% CI 22.4-74.6, p<0.001), cervical tears (OR=22.3; 95% CI 10.4-48.1, p<0.001), second trimester bleeding (OR=6; 95% CI 1.8-20, p=0.003), previous cesarean delivery (OR=5.4; 95% CI 3.5-8.4, p<0.001), placenta accreta (OR=4.7; 95% CI 1.9-11.7, p=0.001), and grand multiparity (above five deliveries, OR=4.1; 95% CI 2.5-6.6, p<0.001). Newborns of these women had lower Apgar scores (<7) at 1 and 5 min (32.7% vs.4.4%; p<0.001, and 10.5% vs. 0.6%; p<0.001, respectively), and higher rates of perinatal mortality (18.4% vs. 1.4%; p<0.001) as compared to the comparison group. Significant risk factors for peripartum hysterectomy are uterine rupture, placenta previa, PPH, cervical tears, previous cesarean delivery, placenta accreta, and grand multiparity. Since the incidence rates are increasing over time, careful surveillance is warranted. Cesarean deliveries in patients with placenta previa-accreta, specifically those performed in women with a previous cesarean delivery, should involve specially trained obstetricians, following informed consent regarding the possibility of peripartum hysterectomy.