Peripartum Hysterectomy
Todd Boren
Sarah Boyd
Stephen DePasquale
C. David Adair
INTRODUCTION AND HISTORICAL PERSPECTIVE
Puerperal, obstetric, or peripartal hysterectomy implies the surgical removal of the uterus of a patient that is either currently or recently pregnant. The technique was advanced in the late 19th century as means to address infection, hemorrhage, and facilitation of indicated cesarean delivery, all of which carried an almost uniform outcome of maternal death. Earlier, the surgical removal of the problematic uterus was the only way to save a mother. With the advent of modern antisepsis, anesthesia, blood transfusion capability, and antibiotics, both hysterectomy and subsequently an evolution to true cesarean delivery became a reality. Since the advent of the newfound safe cesarean delivery, the need for hysterectomy was largely relegated to a lifesaving intervention for treatment of hemorrhagic complications.
With an improved surgical armamentarium and safe cesarean delivery, obstetric hysterectomy significantly decreased in its utilization during most of the 20th century. This was due largely to an increase in cesarean delivery being accomplished with the retention of the recently gravid uterus with excellent safety and ease. The timeliness of this chapter serves us well to reflect upon the recent increased rate of obstetric hysterectomy. The increased rate may largely be associated with the morbidly adherent placenta which occurs mainly from prior cesarean delivery. While the obstetrician is well versed on the technique of hysterectomy, the obstetric hysterectomy requires special attention to anatomical distortion due to pregnancy or its complications such as uterine rupture and tears, blood volume and flow aberrations commonly associated with hemorrhage secondary to either uterine atony or morbid adherence of the placenta. This is particularly of concern with the US cesarean section rates approaching one in three births and increasing likelihood of repeat cesarean once the first one has been performed. These procedures lead to significant increased risks of hemorrhagic complications and morbid adherence of the placenta. The surgical approach and management of these cases require special preparation, technique, and both intra- and post-op care provision.
Planned Versus Unplanned Peripartum Hysterectomy
The peripartum hysterectomy can be challenging. To ensure optimal patient outcomes, our opinion is that planned or anticipated procedures should be scheduled in centers accustomed to level one trauma, generally consistent with a maternal level of care 3 or 4.1 A multidisciplinary operative team, with adequate intensive care support for
postoperative management is critical. Ideally, these patients, if diagnosed with abnormal placentation prior to delivery, are transferred to the appropriate higher-level care center. Preoperative surgical planning includes the assembly of the proper team and availability of multiple units and types of blood products with a massive transfusion protocol in place.
postoperative management is critical. Ideally, these patients, if diagnosed with abnormal placentation prior to delivery, are transferred to the appropriate higher-level care center. Preoperative surgical planning includes the assembly of the proper team and availability of multiple units and types of blood products with a massive transfusion protocol in place.
If the need for cesarean hysterectomy is unexpectedly required, one of the most urgent portions of the procedure is to make the decision to proceed to hysterectomy prior to development of a consumptive coagulopathy. Once the decision and hysterectomy are required, efficiently expediting the procedure will minimize blood loss and improve patient outcomes.
PREOPERATIVE SURGICAL PLANNING
Indications for peripartum hysterectomy include uterine hemorrhage, abnormal placentation, infection, uterine anomalies, uterine rupture, and rarely malignancy. The procedure may be anticipated and planned accordingly as an indicated elective procedure or it may be emergent in nature, thus largely unplanned.
The most common indication for a planned peripartum hysterectomy is the spectrum of abnormal placentation; previa, placenta accreta, increta, or percreta (see Chapter 4, Abnormal Placentation after Cesarean Delivery). Approximately 60% of patients with abnormal placentation will require a hysterectomy at time of delivery.2 The incidence of placenta accreta has increased significantly over the past several decades with the main risk factors including prior cesarean section and placental previa.3
The most common indication for an emergent peripartum hysterectomy is severe uterine hemorrhage due to uterine atony or abnormal placentation the latter of which accounts for 30% to 50% of peripartum hysterectomies3,4,5,6,7 (Figure 8-1). Less frequently, a pelvic abscess following cesarean delivery can result in a peripartum hysterectomy
(Figure 8-2). The peripartum hysterectomy differs from a hysterectomy done for gynecologic indications in several ways. In pregnancy, the uterus receives approximately 20% of the cardiac output resulting in dilated and tortuous blood vessels as well as varices in the vesicouterine space and mesosalpinx. Disruption of these friable vessels can result in significant hemorrhage and a compromised operative field. The peripartum cervix is often soft and difficult to palpate accurately. This may result in unintended retention of portions of cervical or endometrial tissue. Tissue integrity in the pelvis is commonly compromised due to edema and inflammation resulting in shearing of clamped blood vessels. Cognizance of these pregnancy-induced influences and anticipation of managing potential complications can lead to improved outcomes.
(Figure 8-2). The peripartum hysterectomy differs from a hysterectomy done for gynecologic indications in several ways. In pregnancy, the uterus receives approximately 20% of the cardiac output resulting in dilated and tortuous blood vessels as well as varices in the vesicouterine space and mesosalpinx. Disruption of these friable vessels can result in significant hemorrhage and a compromised operative field. The peripartum cervix is often soft and difficult to palpate accurately. This may result in unintended retention of portions of cervical or endometrial tissue. Tissue integrity in the pelvis is commonly compromised due to edema and inflammation resulting in shearing of clamped blood vessels. Cognizance of these pregnancy-induced influences and anticipation of managing potential complications can lead to improved outcomes.
 FIGURE 8-1 Ultrasound demonstration of morbidly adherent placentation. Arrowheads indicate sonolucencies seen in PAS; arrow indicates placenta bulging into bladder; and asterisk indicates bladder. (From Doubilet PM, Benson CB, Benacerraf BR. Wolters Kluwer Health and Pharma. 2018.) |
 FIGURE 8-2 Postcesarean delivery abscess. (From Sweet RL, Gibbs RS. Atlas of Infectious Diseases of the Female Genital Tract. Philadelphia: Lippincott Williams & Wilkins; 2005.) |
Facility and Team
Ideally, the location where a peripartum hysterectomy takes place should be such that all necessary resources are present and easily accessible. Typically, a level 3 or level 4 maternal facility are where these resources are readily available and include adequately trained anesthesia staff capable of medically managing massive hemorrhage, intensive care services, adequate blood product availability, and appropriate ancillary staff such as experienced surgical technicians and nurse circulators paired with a dedicated team of consultative services, such as maternal fetal medicine, gynecologic oncology, urology, trauma surgery, vascular surgery, and interventional radiology. A separate dedicated team should be available to manage blood product transfusion in the appropriate proportions with activation of a massive blood transfusion protocol when needed. A massive blood transfusion protocol with a separate member of the team will ensure correct and accurate ratio of blood product replacement. Every attempt should be made preoperatively to attain adequate intravenous access. Significant fluid shifts often occur during a peripartum hysterectomy in the form of crystalloid and blood product infusion as well as intra-and postoperative blood loss and third spacing. Therefore, adequate hemodynamic monitoring is critical, and as such, if a peripartum
hysterectomy is planned, placement of an arterial line and a central line prior to starting the procedure is essential. When a peripartum hysterectomy becomes a necessity as a result of unexpected hemorrhage, then central venous access should be attained as quickly as possible; hence the need for experienced and qualified anesthesia personnel.
hysterectomy is planned, placement of an arterial line and a central line prior to starting the procedure is essential. When a peripartum hysterectomy becomes a necessity as a result of unexpected hemorrhage, then central venous access should be attained as quickly as possible; hence the need for experienced and qualified anesthesia personnel.
Operative Suite and Equipment
Preoperative planning for a peripartum hysterectomy should ensure appropriate and adequate equipment availability to manage every possible outcome that may occur. Adequate preoperative preparation is just as important as intraoperative skill and judgment and every effort should be made to have the entire team assembled and available prior to incision.
Surgical illumination of the operative suite is critical and should be fully equipped with proper overhead lighting.
Surgeon mounted headlamps aid greatly in proper visualization of pelvic structures and are particularly useful when significant bleeding is encountered.
Authors use a self-retaining retractor, such as the Bookwalter retractor, which facilitates adequate visualization.
Electrocautery and a vessel-sealing device such as a LigaSure Impact Open Sealer/Divider (Medtronic, Boulder, Colorado) should be available (Figure 8-3).
Authors find that the utilization of Zeppelin clamps during the hysterectomy minimizes the potential for tissue or blood vessel slippage.
Equipment for urological evaluation and management should be readily available to facilitate stent placement or evaluate for suspected urinary tract injury including a cystoscope, ureteral stents, and fluoroscopy.
Interventional radiology suite may prove to be invaluable for preoperative placement of vascular catheters or postoperative embolization.
Hemostatic agents can be very useful in the setting of peripartum hemorrhage or disseminated intravascular coagulopathy. Evesil and Arista secondary to their effectiveness and ease of application or similar products should be made immediately available. These agents have proven to be of great assistance in our collective experience.
Suture offerings of various size and material should be available. We prefer to utilize either Monocrylor Vicryl sutures. Both offer excellent tensile strength and provide the surgeon with minimal tissue shearing.
Large bore drains may be considered, as it may inform the postoperative care team early warning of bleeding persistence or recurrence. A 19 French round Blake drain(s) usually proves more than adequate.
 FIGURE 8-3 LigaSure Impact Open Sealer/Divider. (© Medtronic, Boulder, Colorado) |
CHOICE OF SKIN INCISION IN PERIPARTUM HYSTERECTOMY
When the indication for peripartum hysterectomy arises and a Pfannenstiel incision has been made, our approach is to extend the incision by either dividing the rectus muscles (Maylard incision) or performing a Cherney incision as outlined below. Conversion of a Pfannenstiel incision to either a Maylard or Cherney incision should provide more than adequate exposure to perform all aspects of a peripartum hysterectomy. We feel it is imperative to emphasize this, as inadequate exposure can result in injury to pelvic structures and delayed hemostasis.
Procedure for Converting from Pfannenstiel Incision to a Maylard Incision:
With the Maylard approach, an Army-Navy retractor can be placed underneath the rectus muscle between the posterior aspect of the muscle and the peritoneum.
Using electrocautery, the muscle is then divided. The inferior epigastric artery becomes more lateral in the rectus muscle as you approach the pubic symphysis. Identification of this artery is paramount, and it is either ligated with a suture ligature or a vessel sealer prior to transection.
Note of caution: if the inferior epigastric artery is inadvertently lacerated, it can retract into the muscle making it very recalcitrant and very difficult to control bleeding.
Closure of the Maylard incision is accomplished by reapproximating the inferior and superior ends of the rectus muscle belly with two 2-0 PDS sutures on each side placed in a horizontal mattress fashion.
Closure of the peritoneum may decrease the risk of the bowel attaching to exposed muscle as well in this particular situation.
The fascia can then be closed over the top of the reapproximated muscle ends with #1 PDS suture in a running fashion.
Procedure for Converting from a Pfannenstiel Incision to a Cherney Incision:
The lateral margins of the skin incision should extend out several centimeters.The insertions of the rectus muscle tendons to the pubic symphysis should be identified.
The rectus muscle tendons are then transected at their midpoint with electrocautery. Just lateral to the rectus muscle tendon, the inferior epigastric artery emerges from the lateral aspect of the rectus muscle.
Prior to mobilizing the rectus muscles superiorly, the inferior epigastric arteries must be either ligated with suture and divided or alternatively transected with a commercially available vessel-sealing device.
The rectus muscles can then be mobilized superiorly and a generous peritoneal incision can be made.
Following closure of a Cherney incision, one should reattach the inferior and superior ends of the rectus tendons with two horizontal mattress sutures on each tendon using a 2-0 PDS suture.
CHOICE OF UTERINE INCISION
During a cesarean section, a transverse uterine incision is typically performed to decrease the risk of uterine rupture in subsequent pregnancies and to allow for the possibility of future vaginal deliveries. In general, the authors prefer a uterine vertical incision in cases where a peripartum hysterectomy is anticipated. In cases of known abnormal placentation, the authors prefer a fundal incision, starting at the superior aspect of the uterus and carrying the incision over the fundus and ending on the posterior aspect of the uterus with delivery of the fetus through the open fundus. This technique often avoids disruption of the pathologically adherent placenta during fetal delivery and in turn minimizes blood loss prior to the hysterectomy portion of the procedure. If hysterectomy is planned or likely secondary to abnormal placentation, prior knowledge of placentation is critical. Equally important is to not disrupt the placenta, in an effort aimed at attempting to minimize blood loss. Customization of the uterine incision is based on a preoperative ultrasound to confirm location of the placenta, again in an attempt to minimize potential for placenta disruption.
A recent report by Belfort et al., describes a technique using a GIA stapler to make the hysterotomy.8
New Technique Using a GIA Stapler to Make the Hysterotomy (Figures 8-4 and 8-5)
Four sutures are placed at right angles to each other through the myometrium creating an avascular window through which electrocautery is used to dissect down to the amniotic sac.
The plane between the amniotic sac and myometrium is bluntly dissected in the direction of the intended hysterotomy incision, and one arm of the GIA stapler is guided along this plane.
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