title: Population-based risk for peripartum hysterectomy during low- and moderate-risk delivery hospitalizations.
abstract: BACKGROUND
  Postpartum hysterectomy is an obstetric procedure that carries significant maternal risk that is not well characterized by hospital volume.
  
  
  OBJECTIVE
  The objective of this study was to determine risk for peripartum hysterectomy for women at low and moderate risk for the procedure.
  
  
  METHODS
  This population-based study used data from the Nationwide Inpatient Sample to characterize risk for peripartum hysterectomy. Women with a diagnosis of placenta accreta or prior cesarean and placenta previa were excluded. Obstetrical risk factors along with demographic and hospital factors were evaluated. Multivariable mixed-effects log-linear regression models were developed to determine adjusted risk. Based on these models receiver operating characteristic curves were plotted, and the area under the curve was determined to assess discrimination.
  
  
  RESULTS
  Peripartum hysterectomy occurred in 1 in 1913 deliveries. Risk factors associated with significant risk for hysterectomy included mode of delivery, stillbirth, placental abruption, fibroids, and antepartum hemorrhage. These factors retained their significance in adjusted models: the risk ratio for stillbirth was 3.44 (95% confidence interval, 2.94-4.02), abruption 2.98 (95% confidence interval, 2.52-3.20), fibroids 3.63 (95% confidence interval, 3.22-4.08), and antepartum hemorrhage 7.15 (95% confidence interval, 6.16-8.32). The area under the curve for the model was 0.833.
  
  
  CONCLUSIONS
  Peripartum hysterectomy is a relatively common event that hospitals providing routine obstetric care should be prepared to manage. That specific risk factors are highly associated with risk for hysterectomy supports routine use of hemorrhage risk-assessment tools. However, given that a significant proportion of hysterectomies will be unpredictable, the availability of rapid transfusion protocols may be necessary for hospitals to safely manage these cases.
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY. Electronic address: amf2104@columbia.edu.
authors.forename: Alexander M
authors.initials: AM
authors.lastname: Friedman
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Wright
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.
authors.forename: Cande V
authors.initials: CV
authors.lastname: Ananth
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY.
authors.forename: Zainab
authors.initials: Z
authors.lastname: Siddiq
authors.affiliation: Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY.
authors.forename: Mary E
authors.initials: ME
authors.lastname: D'Alton
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, and Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Bateman
mesh_terms: D000293:Adolescent; D000328:Adult; D016208:Databases, Factual; D005260:Female; D006760:Hospitalization; D006801:Humans; D007044:Hysterectomy; D008875:Middle Aged; D015999:Multivariate Analysis; D007744:Obstetric Labor Complications / Q000601:surgery*; D058725:Peripartum Period; D011247:Pregnancy; D012372:ROC Curve; D012044:Regression Analysis; D018570:Risk Assessment; D012307:Risk Factors; D055815:Young Adult
keywords: atony; hysterectomy; postpartum hemorrhage