title: Cesarean section and the risk of emergency peripartum hysterectomy in high-income countries: a systematic review.
abstract: BACKGROUND
  Our objective was to determine the incidence and mortality rates associated with emergency peripartum hysterectomy, factors that lead to uncontrolled hemorrhage and emergency peripartum hysterectomy, and to determine the relationship between cesarean section and risk of emergency peripartum hysterectomy.
  
  
  METHODS
  Studies published between January 1, 2000 and December 31, 2012 were identified using PubMed, OVID and Web of Science databases. Studies were included if they reported incidence rates for emergency peripartum hysterectomy, factors that lead to hemorrhage and emergency peripartum hysterectomy, or the association of emergency peripartum hysterectomy with cesarean section in high-income countries.
  
  
  RESULTS
  Four hundred and fifty-one studies were identified, and 52 were included. The incidence of emergency peripartum hysterectomy ranged from 0.20 to 5.09 per 1000 deliveries with a median incidence rate of 0.61 per 1000 deliveries. These rates have increased over time. Rates varied by region/country, specifically with the United States reporting higher rates than North American, Asian, Oceania, and European countries. The most common factor leading to emergency peripartum hysterectomy was placental abnormalities. Both cesarean section and prior cesarean section were strong risk factors for emergency peripartum hysterectomy with higher risks conferred for each additional cesarean section. The mean percentage of maternal deaths for EPH survivors was 3.0 %.
  
  
  CONCLUSIONS
  Given the association of cesarean section with emergency peripartum hysterectomy, the increased risk of emergency peripartum hysterectomy should be factored into the decision of whether to proceed with cesarean delivery, particularly for women who desire more children.
authors.affiliation: Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612, USA. delacruz@alumni.upenn.edu.
authors.forename: Cara Z
authors.initials: CZ
authors.lastname: de la Cruz
authors.affiliation: Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612, USA.
authors.forename: Erika L
authors.initials: EL
authors.lastname: Thompson
authors.affiliation: Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL, 33612, USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: O'Rourke
authors.affiliation: Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL, 33612, USA.
authors.forename: Wendy N
authors.initials: WN
authors.lastname: Nembhard
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000009:adverse effects / Q000706:statistics & numerical data*; D036861:Delivery, Obstetric; D019049:Developed Countries; D004638:Emergency Treatment / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects / Q000706:statistics & numerical data*; D015994:Incidence; D008428:Maternal Mortality; D058725:Peripartum Period; D006473:Postpartum Hemorrhage / Q000601:surgery*; D011247:Pregnancy; D012307:Risk Factors
keywords: Cesarean section; Emergency hysterectomy; Maternal morbidity; Maternal mortality