Objective
We sought to determine whether emergent cesarean supracervical hysterectomy is associated with reduced risk of complications compared to total hysterectomy.
Study Design
We conducted a cohort study of 150 women who underwent emergent cesarean hysterectomy at our medical center from 1991 through 2008. We compared the risk factors and indications, and intraoperative and postoperative complications associated with the 2 surgical procedures.
Results
During the study period, a total of 164 cesarean hysterectomies were performed; 91% (n = 150) of these cases were performed emergently of which 53.3% were total and 46.7% were supracervical. There was a significant decline in the relative frequency of total hysterectomy: 71%, 56%, and 24% during 1991–1996, 1997–2002, and 2003–2008, respectively ( P < .001). Risk factors, indications for surgery, operative variables, and postoperative complication rates were independent of the type of hysterectomy.
Conclusion
Using a cohort of 150 cases from our institution, we found no evidence of increased surgical time or complications associated with total hysterectomy.
Emergent cesarean hysterectomy (ECH) is performed for life-threatening obstetric complications during cesarean delivery or within 24 hours postpartum. The first successful cesarean hysterectomy was a supracervical procedure performed by an Italian obstetrician, Eduardo Porro, in 1876. Prior to the Porro procedure, maternal mortality following classic cesarean section was nearly 100%. Porro amputated the uterine corpus and sutured the cervical stump into the abdominal wall incision in an attempt to prevent life-threatening hemorrhage and infection. Despite the lack of blood products, intravenous fluids, and antibiotics, the Porro operative technique subsequently decreased maternal mortality to 58%. The Porro procedure was successfully performed with some modifications over the years, culminating in the modern-day supracervical hysterectomy (SH).
Obstetricians started performing total cesarean hysterectomy (TH) due to concerns about bleeding from the cervical branch of the uterine artery and the possibility of subsequent cervical malignancy, necessitating regular cytologic evaluations. Recently, there has been another shift toward preference for SH. This has been justified by the argument that SH is easier, faster, and associated with less blood loss and fewer complications compared with TH. These putative benefits remain unsubstantiated, however, and most of the recent studies comparing the 2 surgical approaches during ECH have been based on small numbers of patients.
The current study, based on 150 cases of ECH collected over a period of 18 years, represents one of the largest series in the literature. Our objective was to determine and compare the risk factors, indications, and the relative complications and associated benefits of the 2 different surgical approaches.
Materials and Methods
A retrospective analysis of all cases of cesarean hysterectomy was conducted after obtaining the appropriate institutional review board approval. Data were abstracted from the record of 164 patients who had cesarean hysterectomy from January 1991 through December 2008. In all, 150 of these were performed emergently and are the subject of this analysis. All the patients in this cohort were delivered by cesarean section and the procedure was performed primarily by the residents and maternal–fetal medicine fellows under the supervision of the attending physician on call (generalist or maternal–fetal medicine). Data from the first 17 years of this database (1991–2007) have been utilized for different analyses. Maternal characteristics such as age, parity, gestational age, race, type of insurance, body mass index, as well as the risk factors and the indications for ECH were recorded and compared according to the type of hysterectomy performed (TH vs SH).
The operative and postoperative characteristics such as operating time (defined as the start of the hysterectomy to the end of the procedure), preoperative and postoperative hemoglobin values, estimated blood loss, amount of blood transfused, febrile morbidity (defined as temperature >38°C or 100.4°F at least 6 hours apart, occurring after the first 24 hours of surgery), rates of disseminated intravascular coagulopathy (defined as the presence of peripartum hemorrhage and abnormal laboratory values; ie, prolongation of prothrombin and activated partial thromboplastin time and decreased platelet and fibrinogen; presence of 3 of 4 laboratory parameters confirmed the diagnosis of coagulopathy for the purpose of our study), cardiopulmonary complications (defined as acute respiratory distress syndrome, congestive heart failure, postpartum cardiomyopathy and pulmonary thromboembolism), and bowel and urologic injuries (defined as inadvertent bowel and bladder injury, ureter transection, or ligation during surgery) were compared by the type of hysterectomy performed.
The study period was divided into 3 periods of 6 years each and the trends in the type of hysterectomy performed and complication rates over these years were determined and compared. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS Inc, Chicago, IL) Version 15. Descriptive data were compared using independent t test and Mann-Whitney U test, while the Fisher’s exact test was used for categorical variables; a P value < .05 was considered statistically significant. Data are expressed as mean ± SD, median (range), and frequency.
Results
There were a total of 211,304 deliveries with 45,195 (21.4%) cesarean operations in the study period. Of the 164 cesarean hysterectomies performed, 91.5% (n = 150) were emergent and are the subject of this study. The overall proportion of TH and SH was 53.3% and 46.7%, respectively. The patients who underwent SH were on average 3 years older than those who had TH ( P = .001), other maternal demographic characteristics were not different between the 2 groups ( Table 1 ). In addition, risk factors and indications for surgery were not significantly different between the 2 groups ( Table 1 ).
| Type of cesarean hysterectomy performed | ||||
|---|---|---|---|---|
| Variables | Total (n = 80) | Supracervical (n = 70) | P value | |
| Maternal age, y | 30.4 ± 6.0 | 33.5 ± 4.9 | .03 | |
| Body mass index | 31.7 ± 6.8 | 32.9 ± 7.6 | .44 | |
| Gestational age, wk | 35.2 ± 4.6 | 36.0 ± 3.5 | .08 | |
| Gravidity | 5.4 ± 2.7 | 5.8 ± 3.2 | .15 | |
| Race | Nonwhites | 80.0% (64) | 71.4% (50) | .25 |
| Whites | 20.0% (16) | 28.6% (20) | ||
| Type of insurance | Medicaid | 65.0% (52) | 61.4% (43) | .74 |
| Private | 35.0% (28) | 38.6% (27) | ||
| Smoking | 7.5% (6) | 12.9% (9) | .29 | |
| Substance abuse | 13.8% (11) | 10.0% (7) | .62 | |
| Presence of comorbidity | 32.5% (26) | 42.9% (30) | .19 | |
| Prior cesarean section | 72.5% (58) | 81.4% (57) | .25 | |
| Placenta previa | 36.3% (29) | 35.7% (25) | .95 | |
| Placenta accreta | 56.3% (45) | 47.1% (33) | .33 | |
| Uterine atony | 27.5% (22) | 40.0% (28) | .12 | |
| Uterine rupture | 17.5% (14) | 17.1% (12) | .95 | |
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