NEW YORK (Reuters Health) – Although the rate of hysterectomy after cesarean delivery has declined over the past decade, the procedure remains an “uncommon, but not rare” complication of pregnancy, occurring in 0.5% of cesarean deliveries, the results of a large, prospective study indicate. Most are emergent and are performed to control hemorrhage, the researchers report in the August issue of Obstetrics & Gynecology.

The investigators, led by Dr. Cynthia S. Shellhaus from The Ohio State University College of Medicine, Columbus, used the Cesarean Registry from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The researchers identified 39,244 women who underwent cesarean delivery at 13 academic medical centers between 1999 and 2000. The study cohort comprised 186 of these women (0.5%) who also required hysterectomy.

Dr. Shellhaus and associates observed a significant trend between the risk of hysterectomy and the number of prior cesareans deliveries, from 0.3% for a first cesarean to 2.9% for women with three or more prior procedures (p < 0.001 for trend). Nearly half (46%) occurred in patients who delivered at a gestational age less than 37 weeks. Overall, the primary indications for hysterectomy were placenta accreta (38%), in which a placenta adherent to the uterine wall could not be easily separated, and atony (34%) requiring oxytocic agents. Only 4% of all atony cases lead to hysterectomy, as opposed to 71% of all cases of placenta accreta. “With the decline in use of vaginal birth after cesarean in the past several years, accreta may rise in frequency as an indicator in the future,” the authors say. Other indications were cervical cancer, uterine rupture, and leiomyomas, as well as extensive adhesions, uterine artery laceration, inability to close the uterus, and uncontrolled bleeding. The most common complications were acute blood loss requiring transfusion (84%). Other complications included ileus, exploratory laparotomy, hospital readmission, cuff abscess, and bowel injury. Three women died. “The present analysis may serve as a reference to health care providers and women in determining risk for cesarean hysterectomy and its attendant complications,” Dr. Shellhaus and her associates conclude. Reference:
Obstet Gynecol 2009;114:224-229.