Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review.

OBJECTIVE: To describe factors leading to and outcomes after emergency postpartum hysterectomy for uncontrolled postpartum hemorrhage.

DATA SOURCES: Searches were conducted up to August 2009 using the PubMed, MEDLINE, EMBASE, and Cochrane Library databases, using the following medical subject heading and text words: "postpartum bleeding," "postpartum hysterectomy," "uterine atony," "cesarean hysterectomy," "placenta accreta," "increta," "percreta," and "placenta previa."

METHODS OF STUDY SELECTION: Studies were reviewed if they included cases of emergency postpartum hysterectomy performed at the time or within 48 hours of delivery, described factors leading to uncontrolled postpartum hemorrhage, enrolled women who delivered after 24 weeks of gestation, and reported data as proportional rates in tables or text. Studies were excluded if they analyzed hysterectomy performed after 48 hours of delivery or electively for an associated gynecologic condition, enrolled a small sample size (fewer than 10 patients), were conducted in underdeveloped countries, reported data in graphs or percentages, or did not include the actual numbers of patients.

TABULATION, INTEGRATION, AND RESULTS: Twenty-four articles that included 981 cases of emergency postpartum hysterectomy were retrieved. Study characteristics and quality were recorded for each study. Demographic maternal characteristics, previous uterine surgery, conservative procedures to prevent emergency postpartum hysterectomy, type of hysterectomy (total or subtotal), factors leading to emergency postpartum hysterectomy, and maternal morbidity and mortality related to emergency postpartum hysterectomy were abstracted, presented as proportional rates (percentage), and integrated with meta-analysis techniques. The maternal morbidity rate was 549 (56.0%) of 981, and 428 (44.0%) of 981 women required blood transfusion. The maternal mortality rate was 26 (2.6%) of 981 cases. The type of hysterectomy was specified in 601 (61.2%) of 981 cases of emergency postpartum hysterectomy (total hysterectomies, 314 of 601 [52.2%]; subtotal hysterectomies, 287 of 601 [47.8%]). Additional surgery was required in 103 (10.5%) of 981 of cases.

CONCLUSION: Women at highest risk of emergency hysterectomy are those who are multiparous, had a cesarean delivery in either a previous or the present pregnancy, or had abnormal placentation.