Emergency hysterectomy in a tertiary care hospital: indications, surgical outcomes and challenges: a 2-year retrospective descriptive cross-sectional study

Abstract

Introduction: emergency hysterectomy (EH) remains a life-saving procedure in cases of life-threatening obstetric hemorrhage and other gynaecological emergencies.We aim to determine the indications, surgical outcomes and challenges of EH in our tertiary centre.

Methods: an ethically approved retrospective descriptive cross-sectional study on all EHs performed at a tertiary hospital during the period of 1^st January 2018 to 31^st December 2019 was conducted. Medical records of eligible patients were retrieved, reviewed and analysed using frequencies and percentages and then summarized in tables.

Results: there were 146 EHs over the two year period. The age of participants ranged from 19 to 59 years, with a mean of 34.3 years (SD = 6.06). SD: standard deviation.The main indication for EH was primary postpartum haemorrhage (PPH):73.28% (n = 110/146). The other indications were uterine perforation with necrosis: 8.9% (n = 13/146), secondary postpartum haemorrhage: 4.8% (n = 7/146), choriocarcinoma and pelvic abscess: 2.74% (n = 4/146) each and broad ligament haematoma: 2.06% (n = 3/146). There were 3.42% (n = 5/146) which were classified as ‘others **’: two cases of ovarian cyst torsion; one case of placental site tumour; one case of incomplete septic abortion; one case of bulky multinodular fibroid uterus with severe unremitting lower abdominal pain.The most common indication for the subgroup of hysterectomy due to PPH was uterine atony 54.20% (n = 60/110), followed by ruptured uterus20.56% (n = 23/110) and then, morbidly adherent placenta 14.95% (n = 16/110). Placenta accreta constituted 62.5% (n = 10/16) of the morbidly adherent placenta.There were 91.78% (n=134/146) total abdominal hysterectomies and 8.22% (n = 12/146) subtotalhysterectomies. About eighty percent 79.45% (n = 116/146) of the surgeries required general anaesthesia, 15.07% (n = 22/146) required regional anaesthesia whilst 5.48% (n = 8/146) were started as regional anaesthesia but were converted to general anaesthesia.There were no associated intraoperative complications in 96.60% (141/146) of the cases. The most frequent intraoperative complications included bowel injury 2.04% (3/146), bladder injury 0.68% (1/146) and maternal death 0.68% (1/146).Twoof the three bowel injuries required bowel resection and anastomosis. Most of the surgeries 89.73% (n = 131/146) were performed by skilled doctors above the level of a Specialist. Major challenges faced include delayed referral of patients to the tertiary centre for prompt management and lack of quick access to blood products.

Conclusion: emergency hysterectomy is performed in women who are relatively young with primary postpartum haemorrhage as the commonest indication but there are other non-obstetric indications for this emergency surgery. Though a challenging procedure, it is safe in the hands of a skilled surgical team.