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Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy
Research
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OBSTETRICS
Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy Anthony N. Imudia, MD; Deslyn T. G. Hobson, MD; Awoniyi O. Awonuga, MBBS; Michael P. Diamond, MD; Ray O. Bahado-Singh, MD OBJECTIVE: We sought to determine whether emergent cesarean su-
pracervical hysterectomy is associated with reduced risk of complications compared to total hysterectomy. STUDY DESIGN: We conducted a cohort study of 150 women who un-
derwent 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 hysterecto-
mies 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. Key words: emergent cesarean hysterectomy, intraoperative and postoperative complications, supracervical hysterectomy, total hysterectomy
Cite this article as: Imudia AN, Hobson DTG, Awonuga AO, et al. Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy. Am J Obstet Gynecol 2010;203:221.e1-5.
E
mergent 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 From the Divisions of Reproductive Endocrinology and Infertility (Drs Awonuga and Diamond) and Maternal–Fetal Medicine (Dr Bahado-Singh), Department of Obstetrics and Gynecology (all authors), Wayne State University School of Medicine/ Detroit Medical Center, Detroit, MI. Presented orally at the National Medical Association Scientific Assembly, Las Vegas, NV, July 25-29, 2009, and was selected as the OB/GYN Forum second-prize paper. Received Oct. 7, 2009, revised Jan. 18, 2010, accepted April 8, 2010. Reprints: Anthony N. Imudia, MD, Hutzel Women’s Hospital, 3980 John Rd., 7 Brush North (Box 165), Detroit, MI 48201. [email protected]. 0002-9378/$36.00 © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.04.007
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.1 Despite the lack of blood products, intravenous fluids, and antibiotics, the Porro operative technique subsequently decreased maternal mortality to 58%.2 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 artery3,4 and the possibility of subsequent cervical malignancy, necessitating regular cytologic evaluations.5,6 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.
M ATERIALS AND M ETHODS 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.7,8 Maternal characteristics such as age, parity, gestational age, race, type
SEPTEMBER 2010 American Journal of Obstetrics & Gynecology
221.e1
Research
Obstetrics
www.AJOG.org
TABLE 1
Maternal demographic characteristics, risk factors, and indications of patients who had total and supracervical hysterectomies during emergent cesarean hysterectomy Type of cesarean hysterectomy performed Variables
Total (n ⴝ 80)
Supracervical (n ⴝ 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
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
5.4 ⫾ 2.7
5.8 ⫾ 3.2
.15
Nonwhites
80.0% (64)
71.4% (50)
.25
Whites
20.0% (16)
28.6% (20)
Medicaid
65.0% (52)
61.4% (43)
Private
35.0% (28)
38.6% (27)
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
Gravidity
................................................................................................................................................................................................................................................................................................................................................................................
Race
...........................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Type of insurance
.74
...........................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Smoking
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
Results are mean ⫾ SD and frequency. Imudia. Determinants and complications of ECH: SH vs TH. Am J Obstet Gynecol 2010.
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 car221.e2
diomyopathy 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.
R ESULTS There were a total of 211,304 deliveries with 45,195 (21.4%) cesarean operations
American Journal of Obstetrics & Gynecology SEPTEMBER 2010
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). The operative variables such as total operating time, estimated blood loss, the number of units of blood transfused, and preoperative and postoperative hemoglobin were not different between the patients in the 2 groups (Table 2). In all, 61 patients (87.1%) and 72 patients (90%) received blood transfusion in the SH and TH group, respectively. Overall, the commonest complications encountered during and after ECH were postoperative fever (44%), disseminated intravascular coagulopathy (22.7%), surgical
Obstetrics
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Research
TABLE 2
Operative variables and complications in patients who had total and supracervical hysterectomies during emergent cesarean hysterectomy Type of cesarean hysterectomy performed Variables
Total (n ⴝ 80) 173.6 ⫾ 80.7
Total operating time, min
Supracervical (n ⴝ 70) 170.9 ⫾ 76.1
P value .38
................................................................................................................................................................................................................................................................................................................................................................................
Estimated blood loss, mL
3000 (900–21,500)
2500 (1000–10,900)
.20
................................................................................................................................................................................................................................................................................................................................................................................
Preoperative hemoglobin, g/dL
10.9 ⫾ 1.6
10.8 ⫾ 1.6
.98
Postoperative hemoglobin, g/dL
9.0 ⫾ 1.8
8.9 ⫾ 1.7
.61
Blood transfused, U
5.5 (0–28)
4.0 (0–32)
.16
No. of days in ICU
1.0 (0–47)
1.0 (0–40)
.60
Hospital stay, d
5.0 (3–47)
4.0 (0–46)
.09
15.0% (12)
15.7% (11)
.90
8.8% (7)
10.0% (7)
.80
Febrile morbidity
47.5% (38)
40.0% (28)
.24
DIC
25.0% (20)
20.0% (14)
.56
Reexploration
17.5% (14)
15.7% (11)
.83
Cuff bleeding
6.3% (5)
5.7% (4)
.89
Depression
8.8% (7)
5.7% (4)
.54
Pulmonary complications
5.0% (4)
10.0% (7)
.35
56.3% (45)
51.4% (36)
.62
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
Urologic injury
................................................................................................................................................................................................................................................................................................................................................................................
Bowel injury
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
Any complication
................................................................................................................................................................................................................................................................................................................................................................................
Results are mean ⫾ SD, median (range), and frequency. DIC, disseminated intravascular coagulopathy; ICU, intensive care unit. Imudia. Determinants and complications of ECH: SH vs TH. Am J Obstet Gynecol 2010.
reexploration (16.7%), urologic injury (15.3%), and bowel injury (9.3%). There were no statistically significant differences in the above postoperative complication rates, the number of days spent in the intensive care unit, and the total hospital stay between the 2 groups (Table 2). Dividing the study period into 3 equal groups of 6 years each (1991–1996, 1997–2002, and 2003–2008), it was evident there was a significant decline in the relative frequency of TH. The percentage of patients undergoing TH declined from 71.4% in the first period to 55.6% in the second period (P ⫽ .11) and to 23.8% in the third period (P ⬍ .0001). The decline between the second and third period (55.6% vs 23.8%) was also statistically significant (P ⫽ .004). There were no statistically significant differences in the risk factors, indications for ECH, operative variables, and complications rates during these 3 periods between the patients in the 2 groups (data not shown).
C OMMENT Our data demonstrate that obstetricians are now performing more SH than TH during ECH. The ratio of TH to SH performed in our institution in 2 different periods (1991–1997 and 2003–2008) was completely reversed, with 3 of 4 ECH performed in the later years of our study being SH. A similar trend was also reported by Yoong et al9 who analyzed 18 ECH performed over a 20-year period. Of the ECH in the first 10 years of their study, 75% were TH while only 40% of the cases in the last 10 years were TH.9 The explanation for this trend is likely to be the general notion that SH is faster and associated with fewer complications;3,10 however, these assertions were not validated by the findings in this study. Those who advocate that TH be performed when ECH becomes necessary suggest that the procedure avoids hemorrhage from the cervical branch of the uterine artery and ensures removal of abnormal adherent placentation if it in-
volves the lower uterine segment.3,4,11-14 In the study by Zelop et al,14 all the 3 patients with persistent surgical bleeding requiring reexploration underwent SH. Others have also suggested that TH would reduce the possibility of cervical stump malignancy and hence the need for regular cytology.5,6 The risk factors, indications, as well as the complications encountered during and after ECH in this study were independent of the type of hysterectomy performed (Table 2), which is in agreement with some other studies that are smaller than ours.15-17 Although there was a trend toward patients who underwent SH staying 1 day less in the hospital than those who had TH, this difference was not significant (P ⫽ .09). Forna et al18 stated that patients with TH had longer hospitalization stays than those who had SH in their study. However, the reasons for this difference were not addressed, and there were no data available regarding the proportion of patients in each
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Obstetrics
group for us to make direct comparison with our study. Kastner et al15 reported a trend toward more surgical intensive care unit admissions and postoperative complications in patients who underwent TH. However, only 9 patients underwent TH in their study, 8 (88.9%) of whom required a blood transfusion. Contrary to our findings, Lau et al19 reported that the incidence of urinary tract injury was higher (25%) in patients who underwent TH compared to those who had SH (12.5%). Nevertheless, this was a smaller series (n ⫽ 36) and their surgical approach was TH in 81% of the cases and SH in only 19% of the cases. Others20,21 argue that SH should be performed because it preserves bladder and sexual function, and is associated with reduced surgical and postoperative complications. However, recent data fail to support these common beliefs.22-26 The patients who underwent SH in our series were approximately 3 years older than those who had TH (P ⫽ .03), however, the reason for this difference is unclear. Given that no advantage can be attributed to the performance of SH in our large series and those of others,15-17 TH remains an option because of the economic implication associated with future health care surveillance issues such as the need for Pap smears. ECH is now often performed before patients severely deteriorate, and in settings in which blood and blood products, antibiotics, and intensive care units are readily available, which was the setting in which the data for this article were generated. It is recognized that in other settings with limited availability of these resources, that the findings of this article may be less relevant and SH may still represent a better option when patients are in extremis, especially when blood and/or blood products are unavailable or the performance of TH is not technically feasible. There were some limitations in our study. First, ours was a historical cohort and thus does not provide direct insight into some of the clinical decision-making process that took place in the management of these women, including the decision to perform a TH or SH. In addition, we have not addressed the individual surgeons’ experience, surgical 221.e4
www.AJOG.org approach preference, as well as intraoperative consultation to gynecology oncologist for any of the cases, all of which could bias the results of our study. Also, this study is from a single institution in 1 geographic location, and thus may not be representative to all facilities and regions of the country or indeed the world. Because our institution is a referral center and the study population was from multiple providers, our results may be biased. It should be kept in mind that due to the very high-risk nature of our pregnant population, one would have expected clearer demarcation of the alleged benefits of SH such as reduced operative time and postoperative complications; these were not in evidence. Our study is currently one of the largest series on ECH in the literature, and clearly invalidates the general notion that SH per se is quicker and safer than TH. Total hysterectomy is safe and is not associated with increase risk compared to SH. Given that TH may obviate the need for annual cervical cytologic evaluation and the possibility of future cervical cancer, consideration should be given to the performance of TH in patients requiring ECH. It is possible that we have not been able to show a difference because of type II error. Based on the difference in the proportion of our TH vs SH groups (53% vs 47%), we calculated that we needed 1132 patients in each group for a 2-tailed test, an alpha value of 0.05, and 80% power to show a difference. Therefore, reports from other institutions on this subject are warranted to confirm our article. f REFERENCES 1. Todman D. A history of cesarean section: from ancient world to the modern era. Aust N Z J Obstet Gynaecol 2007;47:357-61. 2. Earhart AD. The Porro procedure: steps toward decreasing post-cesarean mortality. Prim Care Update Ob Gyns 2003;10:120-3. 3. Chestnut DH, Eden RD, Gall SA, Parker RT. Peripartum hysterectomy: a review of cesarean and postpartum hysterectomy. Obstet Gynecol 1985;65:365-70. 4. Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol 1985;66:353-6. 5. Barclay DL. Cesarean hysterectomy: thirty years’ experience. Obstet Gynecol 1970;35: 120-31.
American Journal of Obstetrics & Gynecology SEPTEMBER 2010
6. Thonet RG. Obstetric hysterectomy–an 11year experience. Br J Obstet Gynaecol 1986; 93:794-8. 7. Imudia AN, Awonuga AO, Dbouk T, et al. Incidence, trends, risk factors, indications for, and complications associated with cesarean hysterectomy: a 17-year experience from a single institution. Arch Gynecol Obstet 2009; 280:619-23. 8. Imudia AN, Awonuga AO, Dbouk T, et al. Lack of racial disparity in the clinical determinants and outcomes of cesarean hysterectomy. J Natl Med Assoc 2009;101:565-8. 9. Yoong W, Massiah N, Oluwu A. Obstetric hysterectomy: changing trends over 20 years in a multiethnic high risk population. Arch Gynecol Obstet 2006;274:37-40. 10. Roopnarinesingh R, Fay L, McKenna P. A 27-year review of obstetric hysterectomy. J Obstet Gynaecol 2003;23:252-4. 11. Chanrachakul B, Chaturachinda K, Phuapradit W, Roungsipragarn R. Cesarean and postpartum hysterectomy. Int J Gynaecol Obstet 1996;54:109-13. 12. Eltabbakh GH, Watson JD. Postpartum hysterectomy. Int J Gynaecol Obstet 1995;50: 257-62. 13. Engelsen IB, Albrechtsen S, Iversen OE. Peripartum hysterectomy–incidence and maternal morbidity. Acta Obstet Gynecol Scand 2001;80:409-12. 14. Zelop CM, Harlow BL, Frigoletto FD Jr, Safon LE, Saltzman DH. Emergency peripartum hysterectomy. Am J Obstet Gynecol 1993;168: 1443-8. 15. Kastner ES, Figueroa R, Garry D, Maulik D. Emergency peripartum hysterectomy: experience at a community teaching hospital. Obstet Gynecol 2002;99:971-5. 16. Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol 1993;168:879-83. 17. Zeteroglu S, Ustun Y, Engin-Ustun Y, Sahin G, Kamaci M. Peripartum hysterectomy in a teaching hospital in the eastern region of Turkey. Eur J Obstet Gynecol Reprod Biol 2005; 120:57-62. 18. Forna F, Miles AM, Jamieson DJ. Emergency peripartum hysterectomy: a comparison of cesarean and postpartum hysterectomy. Am J Obstet Gynecol 2004;190:1440-4. 19. Lau WC, Fung HY, Rogers MS. Ten years experience of cesarean and postpartum hysterectomy in a teaching hospital in Hong Kong. Eur J Obstet Gynecol Reprod Biol 1997;74:133-7. 20. Munro MG. Supracervical hysterectomy: a time for reappraisal. Obstet Gynecol 1997;89: 133-9. 21. Thakar R, Manyonda I, Stanton SL, Clarkson P, Robinson G. Bladder, bowel and sexual function after hysterectomy for benign conditions. Br J Obstet Gynaecol 1997;104:983-7. 22. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total versus sub-
Obstetrics
www.AJOG.org total abdominal hysterectomy. N Engl J Med 2002;347:1318-25. 23. Learman LA, Summitt RL Jr, Varner RE, et al. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Obstet Gynecol 2003; 102:453-62.
24. Thakar R, Sultan AH. Hysterectomy and pelvic organ dysfunction. Best Pract Res Clin Obstet Gynaecol 2005;19:403-18. 25. Weber AM, Walters MD, Schover LR, Church JM, Piedmonte MR. Functional outcomes and satisfaction after abdominal hysterectomy. Am J Obstet Gynecol 1999;181:530-5.
Research
26. Roussis NP, Waltrous L, Kerr A, Robertazzi R, Cabbad MF. Sexual response in the patient after hysterectomy: total abdominal versus supracervical versus vaginal procedure. Am J Obstet Gynecol 2004;190:1427-8.
SEPTEMBER 2010 American Journal of Obstetrics & Gynecology
221.e5
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OBSTETRICS
Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy Anthony N. Imudia, MD; Deslyn T. G. Hobson, MD; Awoniyi O. Awonuga, MBBS; Michael P. Diamond, MD; Ray O. Bahado-Singh, MD OBJECTIVE: We sought to determine whether emergent cesarean su-
pracervical hysterectomy is associated with reduced risk of complications compared to total hysterectomy. STUDY DESIGN: We conducted a cohort study of 150 women who un-
derwent 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 hysterecto-
mies 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. Key words: emergent cesarean hysterectomy, intraoperative and postoperative complications, supracervical hysterectomy, total hysterectomy
Cite this article as: Imudia AN, Hobson DTG, Awonuga AO, et al. Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy. Am J Obstet Gynecol 2010;203:221.e1-5.
E
mergent 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 From the Divisions of Reproductive Endocrinology and Infertility (Drs Awonuga and Diamond) and Maternal–Fetal Medicine (Dr Bahado-Singh), Department of Obstetrics and Gynecology (all authors), Wayne State University School of Medicine/ Detroit Medical Center, Detroit, MI. Presented orally at the National Medical Association Scientific Assembly, Las Vegas, NV, July 25-29, 2009, and was selected as the OB/GYN Forum second-prize paper. Received Oct. 7, 2009, revised Jan. 18, 2010, accepted April 8, 2010. Reprints: Anthony N. Imudia, MD, Hutzel Women’s Hospital, 3980 John Rd., 7 Brush North (Box 165), Detroit, MI 48201. [email protected]. 0002-9378/$36.00 © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.04.007
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.1 Despite the lack of blood products, intravenous fluids, and antibiotics, the Porro operative technique subsequently decreased maternal mortality to 58%.2 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 artery3,4 and the possibility of subsequent cervical malignancy, necessitating regular cytologic evaluations.5,6 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.
M ATERIALS AND M ETHODS 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.7,8 Maternal characteristics such as age, parity, gestational age, race, type
SEPTEMBER 2010 American Journal of Obstetrics & Gynecology
221.e1
Research
Obstetrics
www.AJOG.org
TABLE 1
Maternal demographic characteristics, risk factors, and indications of patients who had total and supracervical hysterectomies during emergent cesarean hysterectomy Type of cesarean hysterectomy performed Variables
Total (n ⴝ 80)
Supracervical (n ⴝ 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
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
5.4 ⫾ 2.7
5.8 ⫾ 3.2
.15
Nonwhites
80.0% (64)
71.4% (50)
.25
Whites
20.0% (16)
28.6% (20)
Medicaid
65.0% (52)
61.4% (43)
Private
35.0% (28)
38.6% (27)
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
Gravidity
................................................................................................................................................................................................................................................................................................................................................................................
Race
...........................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Type of insurance
.74
...........................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Smoking
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
Results are mean ⫾ SD and frequency. Imudia. Determinants and complications of ECH: SH vs TH. Am J Obstet Gynecol 2010.
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 car221.e2
diomyopathy 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.
R ESULTS There were a total of 211,304 deliveries with 45,195 (21.4%) cesarean operations
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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). The operative variables such as total operating time, estimated blood loss, the number of units of blood transfused, and preoperative and postoperative hemoglobin were not different between the patients in the 2 groups (Table 2). In all, 61 patients (87.1%) and 72 patients (90%) received blood transfusion in the SH and TH group, respectively. Overall, the commonest complications encountered during and after ECH were postoperative fever (44%), disseminated intravascular coagulopathy (22.7%), surgical
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TABLE 2
Operative variables and complications in patients who had total and supracervical hysterectomies during emergent cesarean hysterectomy Type of cesarean hysterectomy performed Variables
Total (n ⴝ 80) 173.6 ⫾ 80.7
Total operating time, min
Supracervical (n ⴝ 70) 170.9 ⫾ 76.1
P value .38
................................................................................................................................................................................................................................................................................................................................................................................
Estimated blood loss, mL
3000 (900–21,500)
2500 (1000–10,900)
.20
................................................................................................................................................................................................................................................................................................................................................................................
Preoperative hemoglobin, g/dL
10.9 ⫾ 1.6
10.8 ⫾ 1.6
.98
Postoperative hemoglobin, g/dL
9.0 ⫾ 1.8
8.9 ⫾ 1.7
.61
Blood transfused, U
5.5 (0–28)
4.0 (0–32)
.16
No. of days in ICU
1.0 (0–47)
1.0 (0–40)
.60
Hospital stay, d
5.0 (3–47)
4.0 (0–46)
.09
15.0% (12)
15.7% (11)
.90
8.8% (7)
10.0% (7)
.80
Febrile morbidity
47.5% (38)
40.0% (28)
.24
DIC
25.0% (20)
20.0% (14)
.56
Reexploration
17.5% (14)
15.7% (11)
.83
Cuff bleeding
6.3% (5)
5.7% (4)
.89
Depression
8.8% (7)
5.7% (4)
.54
Pulmonary complications
5.0% (4)
10.0% (7)
.35
56.3% (45)
51.4% (36)
.62
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Urologic injury
................................................................................................................................................................................................................................................................................................................................................................................
Bowel injury
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
Any complication
................................................................................................................................................................................................................................................................................................................................................................................
Results are mean ⫾ SD, median (range), and frequency. DIC, disseminated intravascular coagulopathy; ICU, intensive care unit. Imudia. Determinants and complications of ECH: SH vs TH. Am J Obstet Gynecol 2010.
reexploration (16.7%), urologic injury (15.3%), and bowel injury (9.3%). There were no statistically significant differences in the above postoperative complication rates, the number of days spent in the intensive care unit, and the total hospital stay between the 2 groups (Table 2). Dividing the study period into 3 equal groups of 6 years each (1991–1996, 1997–2002, and 2003–2008), it was evident there was a significant decline in the relative frequency of TH. The percentage of patients undergoing TH declined from 71.4% in the first period to 55.6% in the second period (P ⫽ .11) and to 23.8% in the third period (P ⬍ .0001). The decline between the second and third period (55.6% vs 23.8%) was also statistically significant (P ⫽ .004). There were no statistically significant differences in the risk factors, indications for ECH, operative variables, and complications rates during these 3 periods between the patients in the 2 groups (data not shown).
C OMMENT Our data demonstrate that obstetricians are now performing more SH than TH during ECH. The ratio of TH to SH performed in our institution in 2 different periods (1991–1997 and 2003–2008) was completely reversed, with 3 of 4 ECH performed in the later years of our study being SH. A similar trend was also reported by Yoong et al9 who analyzed 18 ECH performed over a 20-year period. Of the ECH in the first 10 years of their study, 75% were TH while only 40% of the cases in the last 10 years were TH.9 The explanation for this trend is likely to be the general notion that SH is faster and associated with fewer complications;3,10 however, these assertions were not validated by the findings in this study. Those who advocate that TH be performed when ECH becomes necessary suggest that the procedure avoids hemorrhage from the cervical branch of the uterine artery and ensures removal of abnormal adherent placentation if it in-
volves the lower uterine segment.3,4,11-14 In the study by Zelop et al,14 all the 3 patients with persistent surgical bleeding requiring reexploration underwent SH. Others have also suggested that TH would reduce the possibility of cervical stump malignancy and hence the need for regular cytology.5,6 The risk factors, indications, as well as the complications encountered during and after ECH in this study were independent of the type of hysterectomy performed (Table 2), which is in agreement with some other studies that are smaller than ours.15-17 Although there was a trend toward patients who underwent SH staying 1 day less in the hospital than those who had TH, this difference was not significant (P ⫽ .09). Forna et al18 stated that patients with TH had longer hospitalization stays than those who had SH in their study. However, the reasons for this difference were not addressed, and there were no data available regarding the proportion of patients in each
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group for us to make direct comparison with our study. Kastner et al15 reported a trend toward more surgical intensive care unit admissions and postoperative complications in patients who underwent TH. However, only 9 patients underwent TH in their study, 8 (88.9%) of whom required a blood transfusion. Contrary to our findings, Lau et al19 reported that the incidence of urinary tract injury was higher (25%) in patients who underwent TH compared to those who had SH (12.5%). Nevertheless, this was a smaller series (n ⫽ 36) and their surgical approach was TH in 81% of the cases and SH in only 19% of the cases. Others20,21 argue that SH should be performed because it preserves bladder and sexual function, and is associated with reduced surgical and postoperative complications. However, recent data fail to support these common beliefs.22-26 The patients who underwent SH in our series were approximately 3 years older than those who had TH (P ⫽ .03), however, the reason for this difference is unclear. Given that no advantage can be attributed to the performance of SH in our large series and those of others,15-17 TH remains an option because of the economic implication associated with future health care surveillance issues such as the need for Pap smears. ECH is now often performed before patients severely deteriorate, and in settings in which blood and blood products, antibiotics, and intensive care units are readily available, which was the setting in which the data for this article were generated. It is recognized that in other settings with limited availability of these resources, that the findings of this article may be less relevant and SH may still represent a better option when patients are in extremis, especially when blood and/or blood products are unavailable or the performance of TH is not technically feasible. There were some limitations in our study. First, ours was a historical cohort and thus does not provide direct insight into some of the clinical decision-making process that took place in the management of these women, including the decision to perform a TH or SH. In addition, we have not addressed the individual surgeons’ experience, surgical 221.e4
www.AJOG.org approach preference, as well as intraoperative consultation to gynecology oncologist for any of the cases, all of which could bias the results of our study. Also, this study is from a single institution in 1 geographic location, and thus may not be representative to all facilities and regions of the country or indeed the world. Because our institution is a referral center and the study population was from multiple providers, our results may be biased. It should be kept in mind that due to the very high-risk nature of our pregnant population, one would have expected clearer demarcation of the alleged benefits of SH such as reduced operative time and postoperative complications; these were not in evidence. Our study is currently one of the largest series on ECH in the literature, and clearly invalidates the general notion that SH per se is quicker and safer than TH. Total hysterectomy is safe and is not associated with increase risk compared to SH. Given that TH may obviate the need for annual cervical cytologic evaluation and the possibility of future cervical cancer, consideration should be given to the performance of TH in patients requiring ECH. It is possible that we have not been able to show a difference because of type II error. Based on the difference in the proportion of our TH vs SH groups (53% vs 47%), we calculated that we needed 1132 patients in each group for a 2-tailed test, an alpha value of 0.05, and 80% power to show a difference. Therefore, reports from other institutions on this subject are warranted to confirm our article. f REFERENCES 1. Todman D. A history of cesarean section: from ancient world to the modern era. Aust N Z J Obstet Gynaecol 2007;47:357-61. 2. Earhart AD. The Porro procedure: steps toward decreasing post-cesarean mortality. Prim Care Update Ob Gyns 2003;10:120-3. 3. Chestnut DH, Eden RD, Gall SA, Parker RT. Peripartum hysterectomy: a review of cesarean and postpartum hysterectomy. Obstet Gynecol 1985;65:365-70. 4. Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol 1985;66:353-6. 5. Barclay DL. Cesarean hysterectomy: thirty years’ experience. Obstet Gynecol 1970;35: 120-31.
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6. Thonet RG. Obstetric hysterectomy–an 11year experience. Br J Obstet Gynaecol 1986; 93:794-8. 7. Imudia AN, Awonuga AO, Dbouk T, et al. Incidence, trends, risk factors, indications for, and complications associated with cesarean hysterectomy: a 17-year experience from a single institution. Arch Gynecol Obstet 2009; 280:619-23. 8. Imudia AN, Awonuga AO, Dbouk T, et al. Lack of racial disparity in the clinical determinants and outcomes of cesarean hysterectomy. J Natl Med Assoc 2009;101:565-8. 9. Yoong W, Massiah N, Oluwu A. Obstetric hysterectomy: changing trends over 20 years in a multiethnic high risk population. Arch Gynecol Obstet 2006;274:37-40. 10. Roopnarinesingh R, Fay L, McKenna P. A 27-year review of obstetric hysterectomy. J Obstet Gynaecol 2003;23:252-4. 11. Chanrachakul B, Chaturachinda K, Phuapradit W, Roungsipragarn R. Cesarean and postpartum hysterectomy. Int J Gynaecol Obstet 1996;54:109-13. 12. Eltabbakh GH, Watson JD. Postpartum hysterectomy. Int J Gynaecol Obstet 1995;50: 257-62. 13. Engelsen IB, Albrechtsen S, Iversen OE. Peripartum hysterectomy–incidence and maternal morbidity. Acta Obstet Gynecol Scand 2001;80:409-12. 14. Zelop CM, Harlow BL, Frigoletto FD Jr, Safon LE, Saltzman DH. Emergency peripartum hysterectomy. Am J Obstet Gynecol 1993;168: 1443-8. 15. Kastner ES, Figueroa R, Garry D, Maulik D. Emergency peripartum hysterectomy: experience at a community teaching hospital. Obstet Gynecol 2002;99:971-5. 16. Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol 1993;168:879-83. 17. Zeteroglu S, Ustun Y, Engin-Ustun Y, Sahin G, Kamaci M. Peripartum hysterectomy in a teaching hospital in the eastern region of Turkey. Eur J Obstet Gynecol Reprod Biol 2005; 120:57-62. 18. Forna F, Miles AM, Jamieson DJ. Emergency peripartum hysterectomy: a comparison of cesarean and postpartum hysterectomy. Am J Obstet Gynecol 2004;190:1440-4. 19. Lau WC, Fung HY, Rogers MS. Ten years experience of cesarean and postpartum hysterectomy in a teaching hospital in Hong Kong. Eur J Obstet Gynecol Reprod Biol 1997;74:133-7. 20. Munro MG. Supracervical hysterectomy: a time for reappraisal. Obstet Gynecol 1997;89: 133-9. 21. Thakar R, Manyonda I, Stanton SL, Clarkson P, Robinson G. Bladder, bowel and sexual function after hysterectomy for benign conditions. Br J Obstet Gynaecol 1997;104:983-7. 22. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total versus sub-
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www.AJOG.org total abdominal hysterectomy. N Engl J Med 2002;347:1318-25. 23. Learman LA, Summitt RL Jr, Varner RE, et al. A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes. Obstet Gynecol 2003; 102:453-62.
24. Thakar R, Sultan AH. Hysterectomy and pelvic organ dysfunction. Best Pract Res Clin Obstet Gynaecol 2005;19:403-18. 25. Weber AM, Walters MD, Schover LR, Church JM, Piedmonte MR. Functional outcomes and satisfaction after abdominal hysterectomy. Am J Obstet Gynecol 1999;181:530-5.
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