NEW YORK (Reuters Health) – Peripartum hysterectomy is associated with significantly more complications and deaths compared to nonobstetric hysterectomy, a new study confirms.

“We knew that peripartum hysterectomy was associated with significant morbidity and mortality, but this is one of the first studies to directly compare peripartum and nonobstetric hysterectomy and we were surprised by the magnitude of differences seen between the two procedures,” first author Dr. Jason D. Wright from Columbia University College of Physicians and Surgeons in New York City told Reuters Health by e-mail.

“The mortality of peripartum hysterectomy is more than 25 times that of hysterectomy performed outside of pregnancy,” he and his colleagues report in the June issue of Obstetrics & Gynecology. They did not expect the “dramatically increased mortality rate” in the peripartum group, Dr. Wright told Reuters Health.

Using the National Inpatient Sample, Dr. Wright’s team identified 4,967 women who underwent peripartum hysterectomy and 578,179 who had nonobstetric hysterectomy. The most common indications for peripartum hysterectomy were placenta accreta (36%) and uterine atony (31%).

About one third of peripartum hysterectomies were subtotal (34%) compared with 9% of nonobstetric procedures.

According to the investigators, peripartum hysterectomy was linked to a higher rate of injuries to the bladder (9% vs 1%) and the ureter (0.7% vs 0.1%). Rates of reoperation (4% vs 0.5%), wound complications (10% vs 3%) and venous thromboembolism (1% vs 3%) were all higher with peripartum hysterectomy compared with nonobstetric hysterectomy. The same was true for perioperative cardiovascular, pulmonary, gastrointestinal, renal and infectious complications.

These morbidity rates with peripartum hysterectomy are not surprising given the often emergent nature and the difficulty of the surgery, the researchers note in their report.

“Somewhat surprising,” however, was the finding that women with uterine atony who had peripartum hysterectomy had the highest rates of reoperation, postoperative hemorrhage, and wound complications, as well as cardiovascular and pulmonary complications. “Why these complications are more common in women with uterine atony and without placenta accreta is not intuitively clear,” the investigators said.

Forty-six percent of women who had peripartum hysterectomies received a transfusion, compared with only 4% of those who had nonobstetric hysterectomy. Women who had peripartum hysterectomy stayed an average of 8.7 days in the hospital compared with 2.9 days for the nonobstetric group.

Perioperative mortality in the peripartum and nonobstetric groups was 1% and 0.04%, respectively. In multivariate analysis, the odds ratio of death for peripartum compared with nonobstetric hysterectomy was 14.4.

“Given the significant morbidity and mortality associated with peripartum hysterectomy, efforts to reduce that morbidity are clearly needed,” Dr. Wright said. “All physicians and hospitals systems should be prepared to manage women who require peripartum hysterectomy. Institutional protocols and training have been shown to reduce the complications associated with obstetric hemorrhage and should be in place in all institutions.”

“For those women who are at highest risk for requiring postpartum hysterectomy consideration should be given to referral to a tertiary center with experience in the management of obstetric hemorrhage,” Dr. Wright said. [email]

Results of a second study by the same team of authors, published in the same issue of the journal, suggest that mortality is lower when obstetric hysterectomy is done at high-volume centers.

After adjusting for clinical and demographic factors that influence the morbidity and mortality of peripartum hysterectomy, maternal mortality was 71% lower (odds ratio, 0.29) in women treated at high-volume centers (5 to 7 procedures/year) versus low-volume centers (1 to 2 procedures/year).

References:

http://journals.lww.com/greenjournal/Abstract/2010/06000/Morbidity_and_Mortality_of_Peripartum_Hysterectomy.14.aspx

http://journals.lww.com/greenjournal/Abstract/2010/06000/Regionalization_of_Care_for_Obstetric_Hemorrhage.15.aspx

Obstet Gynecol 2010;115:1187-1193,1194-1200.