Katherine M. Johnson
Scott A. Shainker
Peripartum hysterectomy is defined as the removal of the uterus ± cervix at the time of delivery or in the immediate postpartum period, defined as 6 weeks postpartum (1).
This procedure is often required in the setting of refractory postpartum hemorrhage (PPH) in an emergent setting. It is also often performed nonemergently in a scheduled fashion, commonly in the setting of placenta accreta spectrum.
In the midst of a PPH, the patient typically has signs of acute blood loss, including tachycardia, hypotension, pallor, altered mental status, and decreased urine output.
Ongoing vaginal bleeding is usually present but can be concealed in the setting of a closed cervix after cesarean delivery. In this scenario, a large hematometra develops.
The uterus itself is often atonic, which can be appreciated directly in the setting of an open abdomen at time of cesarean delivery or can be ascertained through an abdominal examination after vaginal birth with the fundus palpated well above the umbilicus.
In rare cases, the uterus may have ruptured into the broad ligament or into one of the other retroperitoneal spaces, and the blood loss may be initially concealed.
The differential diagnosis for PPH includes uterine atony, retained products of conception, coagulopathy, uterine rupture and abnormal placentation; in addition to vulvar and vaginal hematoma, which are discussed elsewhere. Abnormal placentation includes placenta previa and placenta accreta spectrum.
The leading cause of peripartum hysterectomy is abnormal placentation, with uterine atony following closely behind (2).
PPH is first treated with uterine massage and evacuation of the uterus, as well as drainage of the urinary bladder if a catheter is not already in place.
Next, uterotonics are used, typically first with oxytocin, followed by carboprost, methylergometrine, and misoprostol.
Tranexamic acid (TXA) should be administered soon after diagnosis of PPH in addition to uterine massage and uterotonics. TXA has been shown to decrease the likelihood of death from bleeding in the setting of PPH, although its use may not decrease the chance of peripartum hysterectomy (3). Intrauterine balloon tamponade is often used in the setting of PPH; this has been shown to decrease the need for blood transfusion, peripartum hysterectomy, and intensive care unit (ICU) admission (4).
Uterine artery embolization can also be used to assist in the treatment of PPH in a hemodynamically stable patient.
Packed red blood cells and other blood products are often needed in the setting of PPH, particularly as coagulopathy prevents adequate treatment of uterine atony. The transfusion of blood along with appropriate blood products is preferred over large-volume crystalloid transfusion which may exacerbate dilutional coagulopathy. Blood and blood products accomplish both missions of addressing hypovolemic and anemic shock and reestablishing normal or maintaining functional coagulation.
Conservative operative techniques, such as curettage to remove products of conception, compressive sutures such as B-lynch and Cho stitches, and uterine artery ligature (e.g., O’Leary stitch) are often attempted prior to proceeding with hysterectomy.
IMAGING AND OTHER DIAGNOSTICS
Bedside ultrasound can be helpful in identifying retained products of conception, as well as hematometra, both common causes of PPH. In addition, free fluid in the abdomen and significant retroperitoneal collections can also be identified in expert hands.
Aside from the scheduled peripartum hysterectomy for placenta accreta spectrum (covered in Chapter 4.9), peripartum hysterectomy is almost always performed emergently.
Risk factors for peripartum hysterectomy include cesarean delivery in the index pregnancy, as well as a history of prior
cesarean deliveries (2). Placenta previa and placenta accreta spectrum are both independent risk factors for peripartum hysterectomy (2,5).
In addition to cesarean delivery and abnormal placentation, increasing maternal age, artificial reproductive technologies (curettage and hysteroscopy, embryo transfer), stillbirth, antepartum hemorrhage, fibroids, pelvic irradiation, and placental abruption have been identified as risk factors for peripartum hysterectomy; hemorrhage risk assessment should be performed for all patients presenting in labor (6,7).
Once PPH is identified, resources should be marshaled to provide optimal care, including a multidisciplinary team (7,8). This may include mobilizing additional surgical assistance and expertise, as well as activating massive transfusion protocols.
Preoperative antibiotics are recommended. A first-generation cephalosporin should be used and re-dosed after 4 hours or after an estimated blood loss of >1,500 mL.
There are no specific recommendations for antibiotics for cesarean hysterectomy, but it is reasonable to follow the American College of Obstetricians and Gynecologists (ACOG) cesarean section recommendations and modify as appropriate (9):
Administer as soon as possible after the incision.
Weight-adjusted dosing (IV route)
Normal body mass index (BMI) (weight ≤80 kg)—1 g of cefazolin
Obese: BMI ≥30 or weight ≥80 kg—2 g of cefazolin
In cases of suspected or proven allergy (anaphylaxis, angioedema, respiratory distress, or urticaria)
900 mg of clindamycin and 5 mg/kg of aminoglycoside
Some hospitals may standardize a 2-g cefazolin dose for all patients.
For nonobstetric patients, consensus opinion is 2 g of cefazolin for patients ≥80 kg and 3 g of cefazolin for patients ≥120 kg. Data are however conflicting on 2- versus 3-g cefazolin dosing in the obstetric population. Many agree that increasing the dose to 2 g for ≥80 kg is a reasonable recommendation and that the benefit of increasing to 3 g for ≥120 kg is not yet established.
There is evidence that azithromycin may be an alternative or adjunct to first-generation cephalosporins. Adding 500 mg of azithromycin, infused over 1 hour, “may be considered.”
Obesity and post-cesarean hysterectomy or postpartum hysterectomy prophylaxis:
Consider a postoperative oral regimen in obese individuals who may not have received IV azithromycin. This may be 500-mg oral cephalexin and 500-mg metronidazole every 8 hours for 48 hours.
Long procedure >2 drug half-lives (>4 hours for cefazolin from the time of dose)
Administer additional intraoperative dose of the same antibiotic.
Excessive blood loss >1,500 mL
Administer additional intraoperative dose of the same antibiotic.
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If available, a bipolar vessel-sealing device may reduce surgical bleeding and the need for massive transfusion. Although such devices have not been shown to decrease complications or length of postoperative hospital stay (10), in some cases, they may help with the management of highly friable vascular areas by allowing slow desiccation of the tissue and sealing of the vessels, thereby avoiding the need to place needles through tissue and create vascular pedicles.
Peripartum hysterectomy often occurs emergently, and access to bipolar vessel-sealing devices may be limited. The procedure can be accomplished with a standard hysterectomy technique (e.g., clamps and suture).
Primary goals include removal of the uterus expeditiously without damage to surrounding organs, and thus attention should be paid to the course of the ureters as much as possible.
Typically, the patient is positioned in the supine position because the procedure often immediately follows cesarean delivery.
Low lithotomy position (Figure 4.7.1) can be helpful to access the cervix if needed, to evaluate ongoing vaginal bleeding during the surgery, to delineate posterior and anterior vaginal fornix anatomy using vaginally placed instruments (i.e., end-to-end anastomosis [EEA] sizer), and to facilitate pre-/postoperative cystourethroscopy when indicated. A further advantage is that an assistant can be placed between the patient’s legs.
Peripartum hysterectomy may be performed as a planned procedure or as an emergent procedure. It may also be performed either after vaginal birth or after cesarean delivery.
In the setting of an unplanned hysterectomy, the delivery has often already occurred and most typically an incision on the abdomen has already been made. The most common type of abdominal incision for cesarean delivery is the Pfannenstiel incision, although a vertical midline incision may also have been made (Figure 4.7.2). A peripartum hysterectomy can be accomplished through either incision.
If a hysterectomy is planned, this is often owing to preoperative concern for placenta accreta spectrum. In this scenario, a vertical midline incision is often recommended. Surgical management of placenta accreta spectrum is discussed in Chapter 4.9.
Adequate visualization is best accomplished through the use of a self-retaining retractor such as a Bookwalter device (Figure 4.7.3) or Balfour retractor.
Figure 4.7.1. Low lithotomy position, using Allen stirrups. (Reprinted with permission from Morrow CP, Curtin JP, eds. Gynecologic Cancer Surgery. Churchill Livingstone; 1996.)
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