title: Potentially Avoidable Peripartum Hysterectomies in Denmark: A Population Based Clinical Audit.
abstract: OBJECTIVE
  To audit the clinical management preceding peripartum hysterectomy and evaluate if peripartum hysterectomies are potentially avoidable and by which means.
  
  
  METHODS
  We developed a structured audit form based on explicit criteria for the minimal mandatory management of the specific types of pregnancy and delivery complications leading to peripartum hysterectomy. We evaluated medical records of the 50 Danish women with peripartum hysterectomy identified in the Nordic Obstetric Surveillance Study 2009-2012 and made short narratives of all cases.
  
  
  RESULTS
  The most frequent indication for hysterectomy was hemorrhage. The two main initial causes were abnormally invasive placenta (26%) and lacerations (26%). Primary atony was third and occurred in 20%. Before hysterectomy another 26% had secondary atony following complications such as lacerations, retained placental tissue or coagulation defects. Of the 50 cases, 24% were assessed to be avoidable and 30% potentially avoidable. Hysterectomy following primary and secondary atony was assessed to be avoidable in 4/10 and 4/13 cases, respectively. Early sufficient suturing of lacerations and uterine ruptures, as well as a more widespread use of intrauterine balloons alone or in combination with uterine compression sutures (the sandwich model), could presumably have prevented about one fourth of the peripartum hysterectomies.
  
  
  CONCLUSIONS
  More than 50% of peripartum hysterectomies seem to be avoidable by simple measures. In order to minimize the number of unnecessary peripartum hysterectomies, obstetricians and anesthesiologists should investigate individual cases by structured clinical audit, and disseminate and discuss the results for educational purposes. An international collaboration is warranted to strengthen our recommendations and reveal if they are generally applicable.
authors: Department of Obstetrics, Rigshospitalet Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark.
authors: Lotte Berdiin
authors: http://orcid.org/0000-0001-7570-2822
authors: LB
authors: Colmorn
authors: Department of Obstetrics and Gynecology, Holbæk Hospital/University of Copenhagen, Holbæk, Denmark.
authors: Lone
authors: L
authors: Krebs
authors: Department of Obstetrics, Rigshospitalet Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark.
authors: Jens
authors: J
authors: Langhoff-Roos
mesh_terms: D000328:Adult; D002585:Cesarean Section; D054869:Clinical Audit; D015331:Cohort Studies; D003718:Denmark; D005260:Female; D006801:Humans; D007044:Hysterectomy; D009774:Obstetrics; D058725:Peripartum Period; D010920:Placenta / Q000293:injuries; D010922:Placenta Diseases / Q000453:epidemiology / Q000601:surgery; D006473:Postpartum Hemorrhage / Q000453:epidemiology / Q000601:surgery*; D011247:Pregnancy; D014593:Uterine Inertia / Q000453:epidemiology / Q000601:surgery*; D014597:Uterine Rupture / Q000453:epidemiology / Q000601:surgery*; D014599:Uterus / Q000601:surgery