Prevalence, Indications, Risk Indicators, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis.
To compare prevalence, indications, risk indicators, and outcomes of emergency peripartum hysterectomy across income settings.



PubMed, MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases up to March 30, 2015.



Studies including emergency peripartum hysterectomies performed within 6 weeks postpartum. Not eligible were comments, case reports, elective hysterectomies for associated gynecologic conditions, studies with fewer than 10 inclusions, and those reporting only percentages published in languages other than English or before 1980. Interstudy heterogeneity was assessed by χ test for heterogeneity; a random-effects model was applied whenever I exceeded 25%.



One hundred twenty-eight studies were selected, including 7,858 women who underwent emergency peripartum hysterectomy, of whom 87% were multiparous. Hysterectomy complicated almost 1 per 1,000 deliveries (range 0.2-10.1). Prevalence differed between poorer (low and lower middle income) and richer (upper middle and high income) settings: 2.8 compared with 0.7 per 1,000 deliveries, respectively (relative risk 4.2, 95% confidence interval [CI] 4.0-4.5). Most common indications were placental pathology (38%), uterine atony (27%), and uterine rupture (26%). Risk indicators included cesarean delivery in the current pregnancy (odds ratio [OR] 11.38, 95% CI 9.28-13.97), previous cesarean delivery (OR 7.5, 95% CI 5.1-11.0), older age (mean difference 6.6 years between women in the case group and those in the control group, 95% CI 4.4-8.9), and higher parity (mean difference 1.4, 95% CI 0.7-2.2). Having attended antenatal care was protective (OR 0.12, 95% CI 0.06-0.25). Only 3% had accessed arterial embolization to prevent hysterectomy. Average blood loss was 3.7 L. Mortality was 5.2 per 100 hysterectomies (reported range 0-59.1) and higher in poorer settings: 11.9 compared with 2.5 per 100 hysterectomies (relative risk 4.8, 95% CI 3.9-5.9).



Emergency peripartum hysterectomy is associated with considerable morbidity and mortality and is more frequent in lower-income countries, where it contains a higher risk of mortality. A (previous) cesarean delivery is associated with a higher risk of emergency peripartum hysterectomy.
Departments of Obstetrics and Clinical Epidemiology, Leiden University Medical Center, Leiden, and the Department of Obstetrics, Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, Utrecht, the Netherlands.
Thomas
T
van den Akker
Carolien
C
Brobbel
Olaf M
OM
Dekkers
Kitty W M
KWM
Bloemenkamp
D002585:Cesarean Section / Q000706:statistics & numerical data; D019049:Developed Countries / Q000706:statistics & numerical data*; D003906:Developing Countries / Q000706:statistics & numerical data*; D004630:Emergencies; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data*; D008423:Maternal Age; D058725:Peripartum Period; D010922:Placenta Diseases / Q000601:surgery; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data; D015995:Prevalence; D065840:Protective Factors; D012307:Risk Factors; D014592:Uterine Hemorrhage / Q000601:surgery*; D014593:Uterine Inertia / Q000601:surgery; D014597:Uterine Rupture / Q000601:surgery