Incidence, Indications, and Predictors of Adverse Outcomes of Postpartum Hysterectomies: 20-Year Experience in a Tertiary Care Centre

Objective: Postpartum hysterectomy is an uncommon yet serious obstetric procedure associated with maternal morbidity and mortality. The objectives of our study were to assess the incidence of and indications for PH and to identify predictors of massive hemorrhage and coagulopathy. Methods: We conducted a retrospective cohort study on all cases of PH performed at the Jewish General Hospital, McGill University, between 1992 and 2011. Data were collected from individual patient charts and logistics regression models were used to evaluate predictors of adverse events. Results: Over a 20-year study period, there were 76 938 live births and 67 postpartum hysterectomies for an overall incidence of 0.87/1000. Although overall PH rates increased over time predominantly because of increasing rates of planned PH for placental abnormalities, there was a decrease in unplanned emergency postpartum hysterectomies. The main indications for PH were abnormal placentation (64.2%) and postpartum hemorrhage (26.9%). In adjusted analysis, the risk of requiring massive blood transfusion was increased when PH was performed after vaginal delivery or Caesarean section (OR 102.1; 95% CI 4.22 to 2468) and in association with postpartum hemorrhage (OR 9.1; 95% CI 1.3 to 64.3). The risk of massive hemorrhage was lower if occlusive balloons were placed antenatally in the uterine arteries (OR 0.13; 95% CI 0.03 to 0.68) and if PH was performed by a dedicated experienced surgeon (OR 0.23; 95% CI 0.06 to 0.86). Conclusion: Although overall rates of PH are increasing, antenatal recognition of placental pathologies have resulted in fewer postpartum hysterectomies being done as emergencies. The use of occlusive balloons in the uterine arteries and having the procedure performed by a dedicated surgeon skilled in performing postpartum hysterectomy can reduce overall serious morbidity.