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This thesis presents an update on maternal mortality in the Netherlands, and its association with mode of birth. Additionally, the second part demonstrates the differences in maternal morbidity, in particular peripartum hysterotomy, between European high-income countries as well as worldwide.

Objective To identify changing trends in peripartum hysterectomy (PH), both elective. cesarean hysterectomy and emergency cesarean hysterectomy, at a single training and research hospital over the last 17 years in Istanbul, Turkey. Materials and methods A retrospective cohort study was performed between January 2001 and September 2017. The records of all patients who had PH at Kanuni Sultan Suleyman Training and Research Hospital were analyzed. Results There were 243 cases of PH during the study period. A total of 266,386 births occurred, of which 60.1% were vaginal deliveries and 39.8% were cesarean sections. The incidence of PH increased from 0.67 per 1000 deliveries to 1.14 per 1000 deliveries during 2001–2008 and 2009–2017, respectively, with an overall incidence of 0.91 per 1000 deliveries during the 17 years. The main indication for PH changed significantly during this time from uterine atony (57.1%) to placenta accreta spectrum (85%). About 37% of women who underwent PH had at least one previous cesarean delivery during 2001–2008, whereas that percentage increased to 95.4% during 2009–2017. Conclusion Placenta accreta spectrum was the leading cause of PH and was associated with significant maternal morbidity and mortality.

Objective To describe the characteristics and outcomes of prelabour uterine ruptures. Design Descriptive study based on population data from the Medical Birth Registry of Norway, the Patient Administration System and medical records. Sample Maternities with uterine rupture before start of labour in Norway during the period 1967-2008 (8 complete ruptures among 2 334 712 women with unscarred uteri, and 22 complete and 45 partial ruptures among 121 085 women with scarred uteri). Method We measured the rate of perinatal deaths and peripartum hysterectomy following ruptures. In addition, we studied the characteristics of ruptures. Results The eight complete ruptures in women with unscarred uteri were associated with trauma from traffic accidents (n = 3; 37.5%), previous curettage (n = 3; 37.5%) and congenital uterine malformations (n = 2; 25%), resulting in seven perinatal deaths and two hysterectomies. The 22 complete ruptures in scarred uteri were mostly outside the lower uterine segment (n = 17; 72.7%). Abnormally invasive placenta (AIP) and previous rupture were present in four (18.2%) and three women (13.6%), respectively. They resulted in nine perinatal deaths (39.1%) and two hysterectomies (9.1%). The 45 partial ruptures involved mostly scars in the lower uterine segment (n = 39; 86.7%). None of them resulted in perinatal death or hysterectomy. Perinatal deaths have decreased dramatically in recent years, despite increasing prelabour rupture rates. Conclusion Although complete uterine ruptures before labour start were rare, they often resulted in catastrophic outcomes, such as perinatal death. Scars outside the lower segment were associated with a higher percentage of catastrophic prelabour ruptures compared with scars in the lower segment (Video S1). Tweetable abstract Complete prelabour uterine ruptures were rare, but resulted in high perinatal deaths, especially if they were in scars outside the lower segment.

BACKGROUND Caesarean section delivery, in spite of its popularity has its short- and long-term complications like infections, haemorrhage, adhesions, abnormal placentation, uterine rupture and hysterectomy. Many studies have shown an increasing incidence of abnormal placentation which includes placenta previa, placenta accreta, placenta increta and placenta percreta to be related with the rising trend of caesarean section delivery. Again, abnormal placentation is a life-threatening condition often associated with massive postpartum haemorrhage and in recent studies it is the most common indication for peripartum hysterectomy. Deliveries by caesarean section are also increasing in our institute. METHODS In this hospital based cross-sectional study, 91 peripartum hysterectomy cases received in the Department of Pathology, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, during a ten-year study period (January, 2009 to December, 2018) were included in the study. The gross and microscopic histopathological findings were statistically analysed in relation to age, parity, number of previous caesarean sections using SPSS software. Significance of the risk of abnormal placentation between cases of previous caesarean section and vaginal deliveries was evaluated by chi-square test (p-value of ≤ 0.05) and odds ratio (OR). RESULTS During the ten years study period, 91 peripartum hysterectomy cases were selected and studied. The overall rate of peripartum hysterectomy was 1.27 per 1000 births. The age of the cases ranged from 20 to 45 years and 81.3 % were multiparous (parity two and above). The main pathological lesions were abnormal placentation- 41 (45.05%), ruptured uterus- 16 (17.58%), uterine atony- 21 (23.07%) and retained product of conception- 13 (14.28%). In 32 (35.16%) cases, there was history of previous caesarean section once in 14 and twice in 18, of which 23 (71.88%) cases had abnormal placentation pathology comprising of placental praevia 12 (37.50%), placental accreta 4 (12.5%), placental increta 5 (15.62%) and 2 (6.25%) placental percreta. CONCLUSIONS Abnormal placentation which includes placenta praevia, placenta accreta, placenta increta and placenta accreta is one of the most important causes of intractable postpartum haemorrhage necessitating a peripartum hysterectomy. Previous caesarean delivery has a 5.82 times higher risk of developing placentation abnormalities in subsequent pregnancies than previous vaginal delivery.

Introduction Emergency peripartum hysterectomy (EPH) is a foremost operation and is perpetually implemented in the presence of life intimidating hemorrhage during or immediately after abdominal or vaginal deliveries. The aim of this study was to review cases managed at the Department of Gynecology and Obstetrics at Jordan University Hospital (JUH). Material and methods All women who underwent EPH due to any cause in the period from January 2010, to December 2017 were included in the study. Data were collected retrospectively using the patients' files namelessly. Main measures: age, gravidity, parity, number of previous cesarean sections, previous uterine surgeries, indication for hysterectomy, complications, antepartum bleeding and the need for blood transfusion. Results In total, 74 cases of EPH were managed during the study period. The incidence of EPH ranged from 0.24 to 8.7 per 1000 deliveries. EPH was found to be more common following cesarean sections than vaginal deliveries. The prime indication was abnormal placentation, uterine atony, and uterine rupture. The risk factors included previous cesarean sections, scarred uteruses, multiparity, older age group. Maternal morbidity ranged from 26.5 to 31.5% and mortality from 0 to 12.5% with a mean of 4.8%. Conclusions EPH is the most demanding obstetric surgery performed in very tiresome circumstances of life threatening hemorrhage. The indication for EPH in recent years has changed from outdated uterine atony to abnormal placentation. Antenatal eagerness of the risk factors, engrossment of proficient obstetricians at an early stage of management and a prompt hysterectomy after adequate resuscitation would go a long way in tumbling morbidity and mortality.

Introduction: Placenta accreta is the most common cause of bleeding leading to peripartum hysterectomy, and therefore, due to the importance of accreta in the mortality and morbidity of pregnant women, the correct diagnosis of the patient's final outcome is important. Therefore, this study aimed to evaluate the sensitivity, specificity, and accuracy of sonography diagnosis in the evaluation of placenta accreta by examining the two-dimensional (2D) and color Doppler sonography findings. Materials and Methods: Sonography was done for detection of accreta from pregnant women who were suspicious of placenta accreta in the third trimester of pregnancy. They were evaluated to confirm placenta histology for accreta and clinical examination after cesarean surgery at Maternity Ward, Ahvaz Imam Khomeini Hospital. Then they were evaluated as an overview and for the lack of accreta sonography findings. The data collected were analyzed by SPSS V 24. Results: About 58 patients (55.8%) of 103 pregnant mothers suspected of accreta with anterior placenta with an average age of 32.9 years after cesarean section were clinically extraordinarily positive and 45 patients (43.3%) were negative. The overall sensitivity and specificity of sonography for the detection of accreta placenta were 97.7% and 86.2%, respectively, which were most sensitive to diffuse and focal lacunar flow (100%) and the least sensitivity (33.3%) was observed for bladder wall interruption. Accuracy, positive predictive value, and negative predictive value of sonography for the diagnosis of accreta placenta with at least one diagnostic criteria were 91.2%, 84.6%, and 98.3%, respectively. Conclusion: Sonography, as an affordable and inexpensive diagnostic method, can be worthy by examining placenta for the detection of accreta, which can increase the diagnostic accuracy when combining 2D criteria with color Doppler.

Background and Objectives: Emergency peripartum hysterectomy (EPH) is a life-saving surgical procedure performed when medical and surgical conservative measures fail to control postpartum hemorrhage. The objective of this study was to estimate the incidence of EPH and to determine the factors leading to this procedure and the maternal outcomes. Materials and Methods: A retrospective cohort study with all cases of EPH performed at Filantropia Clinical Hospital in Bucharest between January 2012 and May 2021. Results: There were 36 EPH, from a total of 36,099 births recorded. The overall incidence of EPH was 0.99 per 1000 deliveries, most cases being related to placenta accreta spectrum disorder and uterine atony. Conclusions: Peripartum hysterectomy is associated with an important maternal morbidity rate and severe complications. Efforts should be made to reduce the number of unnecessary cesarean deliveries.

Background Emergency peripartum hysterectomy is a life-saving procedure which involves the surgical removal of uterus and is usually performed for uncontrollable maternal haemorrhage when all other conservative management has failed. The aim of this study was to determine the incidence, indication, risk factors and perinatal/maternal outcome related to EPH performed in Mendefera Regional Referral Hospital Methods Case-control study was carried out in women, who underwent EPH over a period of almost 8 years. Controls were women, who had spontaneous vaginal delivery or were delivered by Caesarean section, without EPH. The findings were analyzed using Stata 14. Results During the study period, there were a total of 15,527 deliveries and 31 cases of emergency peripartum hysterectomies, giving an incidence of 2 per1000 deliveries. The mean age, parity, and hospital stay of the cases was 31.5, 4.0 and 5.5 respectively. The main indications for the procedure were uterine atony (38.7%) and uterine rupture (25.8%). Factors showing a significant association with EPH were: being 40 + years of age (OR 10.6; 95%CI 1.5–76.1), being grand multiparous (OR 8.0; 95%CI 2.1–30.4) and CS on the index pregnancy (OR 16.6; 95%CI 7.80-35.95). Subtotal hysterectomy was performed in majority (74%) of cases. The case fatality rate and stillbirth rate was 13% and 34.4% respectively. Conclusion The incidence of EPH in our institution is very high and fetal outcome was poor. The commonest indication for EPH was severe hemorrhages most notably caused by uterine atony or uterine rupture, which are largely preventable.

Postpartum hemorrhage (PPH) affects approximately 14 million women yearly, accounts for 25% of delivery-related deaths in the world and is the main cause of emergency peripartum hysterectomy. Traditionally, PPH is defined as at least 500 mL of blood loss after vaginal delivery or 1000 mL of blood loss after cesarean-section. However, several authors have suggested a simpler definition to include women who experience hemodynamic instability after birth regardless of amount of blood loss. Secondary PPH is defined as bleeding that occurs after 24 hours to 12 weeks from delivery, and can fail medical management. It is imperative that the clinical team recognize the signs and symptoms of secondary PPH and, if necessary, consult the interventional radiology service for a minimally invasive option of uterine artery embolization, which has shown up to 95% success rate.

Purpose: To define the frequency, significant factors and causes that necessitated peripartum hysterectomies. Material and Methods: We studied retrospectively and prospectively 21 patients who underwent peripartum hysterectomies at “Nadezhda” Women’s Health Hospital between January 2013 and July 2019. Results: The frequency of peripartum hysterectomy was 1.96/1000 deliveries, and 95 % of them were performed during or after a cesarean birth. The intrapartum ones were carried out mainly because of uterine atony or abnormal insertion of the placenta. The interventions made in the early postoperative period were undertaken in cases of severe pelvic inflammations and postoperative hematomas. Conclusion: Patients undergoing cesarean section are at risk for peripartum haemorrhages, which are associated with many risk factors: previous cesarean section and other interventions such as myomectomy, placenta praevia.

Aim Severe acute maternal morbidity (SAMM) is a state of the woman, when she nearly died, but survived. The aim of study was to find out the exact incidence of SAMM in Slovakia, establishment of functional surveillance system and improve quality of health care. Materials and methods The regular annual analyses of SAMM cases in Slovakia from January 1st 2012 to December 31st 2016. Observed SAMM included: peripartum haemorrhage, peripartum hysterectomy, uterine rupture, abnormally invasive placenta, HELLP syndrome, eclampsia, sepsis, transport to intensive care unit or anaesthesiology and non-fatal amniotic fluid embolism. Results The response rate of questionnaires was 84.8 %. The overall confirmed incidence of SAMM was 6.35/1,000 births (95% CI 6.03-6.67). The most often causes of SAMM were: peripartum haemorrhage (2.1/1,000 births), transport to intensive care unit or anaesthesiology (1.46/1,000 births), peripartum hysterectomy (0.84/1,000 births) and HELLP syndrome (0.63/1,000 births). The average age of women with SAMM was 30.3 years (14-46) and average parity was 1.16 (0-15). Conclusion The incidence of SAMM and especially incidence of peripartum haemorrhage and peripartum hysterectomy in Slovakia is one of the highest in Europe. To decrease incidence and improve management and outcome of patients, regular audit of SAMM is needed (Tab. 3, Fig. 2, Ref. 30).

Background Peripartum hysterectomy (PRH) is the surgical removal of the uterus performed in obstetrical complications such as uncontrolled postpartum haemorrhage (PPH), unrepairable uterine rupture, and sepsis. Its incidence has increased in recent years. The objective of this study was to review all the cases of PRH in a tertiary care teaching hospital over three years (January 2017-December 2019) to determine its incidence and analyse clinico-demographic characteristics in these women. Method All women undergoing PRH from January 2017 to December 2019 were included in the study. Data were collected retrospectively from medical records, of patients who underwent a PRH at the time of delivery, or within 24 hours, or performed any time before discharge from the same hospitalization and obstetric event. The total number of deliveries including caesarean and vaginal deliveries were recorded. Main outcome measures were the incidence of PRH, indication for hysterectomy, management option used, maternal outcomes (PPH, bladder injury and maternal death) and fetal outcomes (stillbirth). Results There were a total of 3904,4 deliveries; 27,337 vaginal and 11,697 caesarean sections in three years. A total of 50 patients underwent a PRH. The incidence of PRH in our study was 1.3 per 1,000 deliveries and 3.5/1,000 caesareans, respectively. PRH was found to be more common following cesarean sections than vaginal deliveries (odds ratio 22.86 [95% CI: 8.16 to 63.98]). Morbid adherent placenta (MAP) (n=30, 62%) was the most common indications of PRH. Seven (15%) women had PRH due to uterine rupture. Twenty-seven women of the 30 women (90%) with the MAP had a previous caesarean delivery. The case fatality rate per hysterectomy was 4%. Stillbirth rate (SBR: n=8,16%) among women having PRH was seven-fold higher than overall SBR in our country. Conclusion There has been a rise in MAP as an indication of PRH in our study for a decade in comparison to uterine atony. Caesarean delivery is a significant risk factor for PRH. Previous caesarean section and major placenta previa were common occurring obstetric risk factors present in the MAP in our cohort. Our maternal mortality in PRH was low and the stillbirth rate was high when compared with national data.

Introduction Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy. Material and methods We merged data from nine nationwide or multi-regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated. Results A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births. Conclusions Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life-saving procedure is associated with substantial adverse maternal and neonatal outcome.

Caesarean section, the most commonly performed surgical operation in the world, is an operative technique by which a foetus is delivered through an incision in the uterus. It is now a safer procedure than in previous years. This chapter discusses the incidence, classification and indication for caesarean section. It describes the management of caesarean section in labour, surgical techniques of caesarean section and management of commonly associated complications in developing countries. This chapter highlights factors to justify the choice of anaesthesia for caesarean section and lists risk management issues in caesarean section. This chapter further discusses the growing prevalence of caesarean delivery and consequent challenges of peripartum (caesarean/postpartum) hysterectomy in the presence of life-threatening bleeding due to placental accreta/percreta that obstetricians now face. The indications for the perimortem caesarean section are also discussed. Obstetricians need to consider long-term reproductive outcomes when contemplating primary caesarean delivery without sound medical indications. This chapter seeks to encourage them to take adequate measures towards the birth of healthy babies and the well-being of mothers.

Introduction Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. Material and methods We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. Results A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (rho = 0.67, P

Cesarean Hysterectomy refers to emergency peripartum hysterectomy - EPH, which is performed as a life-saving procedure in cases of continual obstetric hemorrhage secondary to uterine atony, uterine rupture, placental disorders, fibroids, and lacerations during cesarean section - CS or vaginal parturition. Emergency peripartum hysterectomy - EPH, although rare in modern obstetrics, remains a life- saving procedure in cases of severe hemorrhage. In contemporary obstetrics, the overall incidence of severe postpartum hemorrhage was reported to occur in 6.7/1,000 deliveries worldwide. It is one of the leading causes of maternal mortality and morbidity and represents the most challenging complication that an obstetrician will face. The incidence of peripartum hysterectomy in the literature is reported as 0.24, 0.77, 2.3, and 5.09 per 1,000 deliveries by many authors mentioning a few; Sakse et al., White- man et al., Bai et al., and Zeteroglu et al., respectively. Nevertheless, there is a lack of Albanian data on EPH. To our knowledge, there is no Portuguese information on postpartum hemorrhage and EPH, which does not mean that we do not have such obstetrical complications and therefore such emergency intervention. This paper’s intention is to bring awareness of such catastrophic obstetrical complications especially in young primigravida and primipara women.

Objectives: Peripartum hysterectomy is a dramatic obstetric surgery that is performed in emergency life saving situations or as an elective procedure in morbidly adherent placenta (MAP). Recently peripartum hysterectomy is performed more for MAP than obstetrics haemorrhage. The procedure is associated with significant morbidity and mortatlity. We report the demographic details of all patients who underwent peripartum hysterectomy over the period of one year in a tertiary care unit. Methodology: A retrospective case note analysis were done from 1st June 2014 to 1st June 2015 at De Soysa Hospital for Women among all the mothers who had an emergency and elective peripartum hysterectomies. Results: Eleven women had peripartum hysterectomies. Seven were due to MAP (63%). The rest were due to major post partum haemorrhage, which could not be managed medically, or with other surgical interventions. All women were multiparas and there were no maternal deaths during the study period. Nine patients had elective caesarean section (either lower segment or upper segment) and two delivered vaginally. Out of seven women with MAP five had planned peripartum hysterectomies and two were managed expectantly with methotrexate, which failed due to secondary haemorrhage. All patients had intensive care support after the surgery. All patients were managed in the multidisciplinary settings. Conclusion: Evaluation of peripartum hysterectomy aids in the understanding of severe maternal morbidity which allowing for better resource utilization. Multidisciplinary team approach would results good maternal and fetal outcomes in peripartum hysterectomy cases.

BACKGROUND Emergency peripartum hysterectomy (EPH) is a life-saving obstetric procedure reserved for conditions where medical treatment and conservative surgery have failed. EPH is associated with significant morbidity and mortality. AIM To examine the incidence, indications, risk factors, maternal and neonatal outcomes of EPH in a tertiary hospital in Western Australia (WA). METHODOLOGY A retrospective case-note analysis of all cases of EPH performed at King Edward Memorial Hospital in WA between the years 2006 and 2016. The incidence, indications, risk factors, maternal and neonatal outcomes were reviewed. All cases were ascertained via our hospital obstetric database. RESULTS A total of 72 cases of EPH were identified among 64 999 births. The incidence of EPH in WA was 1.1 per 1000 deliveries. Abnormal placentation was the main indication for EPH accounting for 66.7% of cases. Among women undergoing an EPH, 22.2% had a history of one previous caesarean section and 33.3% had two or more caesarean sections, respectively. Maternal morbidity was significant. There was one cardiac arrest secondary to hypovolaemia, and 84% of the women received blood transfusions with more than half of these women meeting the criteria for massive transfusion protocol (≥4 units of packed red cells). Urinary tract injury and venous thromboembolism were some of the other complications among our cohort of women. CONCLUSION EPH is associated with significant morbidity. Our study identifies abnormal placentation as the leading cause of EPH.

Background Peripartum hysterectomy can cause significant morbidity and mortality. Most studies of peripartum hysterectomy are from high income countries. This cohort study examined risk factors for peripartum hysterectomy using data from Africa, Asia, Europe and the Americas. Methods We used data from the World Maternal Antifibrinolytic (WOMAN) trial carried out in 193 hospitals in 21 countries. Peripartum hysterectomy was defined as hysterectomy within 6 weeks of delivery as a complication of postpartum haemorrhage. Univariable and multivariable random effects logistic regression models were used to analyse risk factors. A hierarchical conceptual framework guided our multivariable analysis. Results Five percent of women had a hysterectomy (1020/20,017). Haemorrhage from placenta praevia/accreta carried a higher risk of hysterectomy (17%) than surgical trauma/tears (5%) and uterine atony (3%). The adjusted odds ratio (AOR) for hysterectomy in women with placenta praevia/accreta was 3.2 (95% CI: 2.7–3.8), compared to uterine atony. The risk of hysterectomy increased with maternal age. Caesarean section was associated with fourfold higher odds of hysterectomy than vaginal delivery (AOR 4.3, 95% CI: 3.6–5.0). Mothers in Asia had a higher hysterectomy incidence (7%) than mothers in Africa (5%) (AOR: 1.2, 95% CI: 0.9–1.7). Conclusions Placenta praevia/accreta is associated with a higher risk of peripartum hysterectomy. Other risk factors for hysterectomy are advanced maternal age, caesarean section and giving birth in Asia.

Objective: To determine the incidence, demographic data, risk factors, indications, outcome and complications of emergency peripartum hysterectomy (EPH) performed in two major tertiary care hospitals in Dubai, and to compare the results with the literature. Materials and Methods: The records of all women who underwent EPH from January 2000 to December 2015 in two major tertiary care hospitals in Dubai were accessed and reviewed. Maternal characteristics, hysterectomy indications, outcomes, and postoperative complications were recorded using descriptive statistics to describe the cohort. Results: There were 79 EPH out of 168.293 deliveries, a rate of 0.47/1000 deliveries. The most common indications for hysterectomy were abnormal placentation (previa and/or accreta) and uterine atony. The majority of hysterectomies were subtotal (70%). The complications were dominated by massive transfusion, urinary tract injuries, one case of maternal death, and one case of neonatal death. Conclusion: The main indication for EPH was abnormal placentation in scarred uterus and uterine atony. The major method of prevention of EPH is to assess women’s risks and to reduce the number of cesarean section deliveries, by limiting the rate of primary cesareans. This is challenging in the United Arab Emirates (UAE) where the culture is for high gravidity and high parity. Recommendations to act to reduce primary and repeated cesareans should be included on the national agenda in UAE.

Aims: To determine the incidence and risk factors of women undergoing peripartum hysterectomy at BPKIHS, Dharan.Methods: A descriptive study was conducted for all women undergoing peripartum hysterectomy in two years from July 2012 to June 2014.Various maternal characteristics including demographic data, previous obstetric details, antepartum, intrapartum and postpartum data were collected and analysed.Results: There were 29 cases of peripartum hysterectomy among 19,539 births in 2 yrs (1.48 per 1000 births). Indications for peripartum hysterectomy were uterine rupture (65.5%), morbid adherence of the placenta (13.8%) and uterine atony (12.9%). Previous caesarean section was identified as independent risk factor with relative risk of 1.8 (95% CI 1.3-2.5, p< 0.003). Maternal morbidity was significant with febrile morbidity and urinary tract injury among the most common complications.Conclusions: Uterine rupture causing severe haemorrhage was the commonest indication for peripartum hysterectomy. Timely intervention reduces the peripartum maternal and perinatal morbidity and mortality.

BACKGROUND Emergency Peripartum Hysterectomy (EPH) implies removal of uterus at the time of delivery or in the immediate postpartum period, usually carried out as a last resort in uncontrollable life-threatening obstetric haemorrhage. Recent studies show an increase in these procedures being done for abnormal placentation, which refers to both placenta praevia and morbidly adherent placenta praevia or accreta. The aim of the study is to determine the incidence, indications, risk factors and complications of Emergency Peripartum Hysterectomy (EPH). MATERIALS AND METHODS This is a retrospective case series involving detailed examination of the case records of patients for 3 years who had emergency peripartum hysterectomy between January 2013 and December 2015 in the Department of Obstetrics and Gynaecology, Government Medical College, Kozhikode. We analysed the incidence, indications, risk factors, type of hysterectomy and the complications of emergency peripartum hysterectomy. RESULTS There were 49,125 deliveries of which 65.22% were vaginal and 34.78% were by caesarean section. Hundred and five women underwent emergency peripartum hysterectomy giving an incidence of 2.1 per 1000 deliveries. The indications of EPH were mainly placenta previa with prior caesarean section. Morbidly adherent placenta was seen in 60 of the 63 (60%) cases followed by atonic PPH (19%) and rupture uterus (10.47%). There were two cases of maternal death. Inadvertent cystotomy was the most important complication in our series (6.66%). Sixty nine (65.7%) had previous delivery by caesarean section and 74 (70.4%) women delivered by caesarean section. CONCLUSION Morbidly adherent placenta in women with prior CS was the most common indication to perform emergency peripartum hysterectomy. Timely decision for hysterectomy significantly reduced the maternal morbidity and is a lifesaving procedure.

Introduction: Emergency peripartum hysterectomy (EPH) is a major surgical venture performed in the setting of life threatening hemorrhage during or immediately after abdominal and vaginal deliveries. In developing countries, 8-10% of maternal mortality directly occurs due to massive obstetrical hemorrhage. Most common indication for emergency peripartum hysterectomy has been uterine atony and uterine rupture. The decision to perform an emergency hysterectomy on a young woman especially one with low parity poses a dilemma for the obstetrician particularly in our society. Objective: To estimate incidence, indications and postoperative complications associated with emergency hysterectomy at Maternal and Child Health Training Institute (MCHTI), Azimpur, Dhaka. Materials and Methods: This is a retrospective study and registration numbers of all women who underwent emergency peripartum hysterectomy were indentified. With the numbers, the case notes were retrieved from the medical records department for in-depth study. Information abstracted included the socio-demographic characteristics of the patients, indications for the hysterectomy, type of hysterectomy performed, booking status of patients, mode of delivery, gestational age at delivery and maternal outcome were recorded in a pre-designed data form. The data were analyzed using simple proportion, rates and tables. Results: There were 18 cases of emergency peripartum hysterectomies performed during the study period of January 2011 to December 2013 (incidence 1.26/1000 deliveries). Commonest age of the middle group was 29-34 years. Ruptured uterus was the commonest indication (9 cases, 50%) and other indications were uterine atony/ PPH (8 cases, 44.44%), placenta praevia (1 case, 5.56%). Subtotal abdominal hysterectomy was done in 17(94.44%) cases whereas total abdominal hysterectomy in 01(5.56%) cases. This emergency procedure was associated with significant number of intraoperative and postoperative complications, However maternal and perinatal outcome was satisfactory. Conclusion: EPH remains an essential life saving procedure and its incidence continues to remain high in our community when compared with developed countries. Effective antenatal care, identification of patients at risk, enhancement of blood transfusion facilities together with improvement of surgical skills are important to reduce the incidence of peripartum hysterectomy as well as morbidity and mortality. Journal of Armed Forces Medical College Bangladesh Vol.13(1) 2017: 106-110

Abnormally implanted, invasive, or adherent placenta has become one of the most serious problems in obstetrics, comprising a leading cause of maternal hemorrhage, the most common cause of peripartum hysterectomy and an increasingly important contributor to cesarean delivery morbidity. Currently, up to 3 in 1000 pregnancies in the USA are complicated by placenta accreta, increta, or percreta, and the incidence is increasing in parallel with the rising cesarean delivery rate. Yet, despite the high morbidity and mortality associated with placenta accreta, consensus guidelines are lacking regarding the management of women with this condition.

Background and Aims: Peripartum hysterectomy is associated with significant maternal morbidity and mortality. We reviewed all peripartum hysterectomies at our institute over a 1-year period. The aim of this study was to determine the incidence, surgery and anesthesia-related issues of peripartum hysterectomies and to compare outcomes of emergency and electively planned peripartum hysterectomies. Material and Methods: This was a retrospective analysis of records of women who underwent emergency or elective peripartum hysterectomy in a tertiary care hospital. The study included all women who underwent peripartum hysterectomy in a teaching hospital and referral institute in North India over a span of 1 year (April 1, 2014, to March 31, 2015). Association of variables was based on Chi-square test, Fisher's exact test, and comparison on “t” statistics (normal distribution) and Mann–Whitney (nonnormal distribution). Results: Forty women underwent peripartum hysterectomy during the study period. The incidence was 6.9/1000 deliveries. In 16 (40%) cases, peripartum hysterectomy was planned electively while emergency hysterectomy was done in 24 (60%) cases. Main indications of peripartum hysterectomies were placenta accreta (60%), atonic postpartum hemorrhage (PPH) (27.5%), and uterine rupture (7.5%). Intensive care management was required in 35% women postoperatively. The common maternal complications were febrile morbidity, bladder injury, disseminated intravascular coagulation, and wound infection. There were 4 maternal deaths following emergency peripartum hysterectomy done for atonic PPH whereas no mortality occurred in elective hysterectomy group. Conclusions: The most common indication for peripartum hysterectomy was placenta accrete. Electively planned peripartum hysterectomies with a multidisciplinary team approach had better outcomes and no mortality as compared to emergency peripartum hysterectomies.

Background The incidence of peripartum hysterectomy (PH) shows fifty-fold variation worldwide (0.2–10.5/1000 deliveries) and risk factors include advancing maternal age and parity, previous caesarean section (CS) and abnormal placentation. Objectives In this first national study of PH in Ireland, our objectives were threefold: to describe the national trend in PH incidence over 15 years since 1999; to assess risk of PH associated with morbidly adherent placenta (MAP), placenta praevia and postpartum haemorrhage (PPH) during 2005–2013; and to describe the causes, interventions and outcomes of PH cases during 2011–2013. Study design For the 15-year time-trend analysis, PH cases and denominator data were extracted from Ireland’s Hospital In-Patient Enquiry database. Multivariate Poisson regression analysis assessed risk of PH associated with MAP, placenta praevia and PPH. In collaboration with the 20 Irish maternity units we carried out a three-year national clinical audit of severe maternity morbidity. PH was a notifiable morbidity and the audit included detailed review of MOH cases. Results In 1999–2013 there were 298 PH cases, a rate of 0.32/1000 deliveries. During the period 2005–2013, the PH rate was 50 times higher in deliveries involving PPH, 100 times higher with placenta praevia and 1000 times higher with MAP. During the clinical audit (2011–2013) there were 65 PH cases, a rate of 0.33/1000 deliveries, increasing with advancing age and parity. The reporting of abnormal placentation, primarily the co-occurrence of placenta praevia and MAP, was linked with previous CS. Fifty-six of the 65 cases suffered MOH, most commonly associated with placenta praevia, MAP and uterine atony. Prophylactic and therapeutic uterotonic agents were appropriately used in the majority of cases. Conclusions The incidence of PH in Ireland has been consistently low over 15 years, averaging one case every 3000 deliveries. The recognised risk factors of MAP, placenta praevia and PPH were independently associated with PH, with MAP being by far the strongest predictor. The vast majority of PH cases in our clinical audit were associated with MOH. Some deficiencies were noted in antenatal care, in certain elements of treatment and clinical governance protocols but adherence to guidelines was generally high.

Placenta percreta is a rare condition during pregnancy in which the abnormal presentation of placenta penetrates the uterine wall and invades into the surrounding organs including bowel and bladder. With the increasing rate of cesarean sections, the incidence of placenta percreta has also increased. This is a condition which gives rise to a major obstetric hemorrhage, peripartum hysterectomy, and maternal and fetal morbidity and mortality. This case report presents a successful obstetric and anesthetic management of a patient with preoperatively diagnosed placenta percreta.

Abnormal invasion of placenta or placenta accreta spectrum disorders refer to the penetration of the trophoblastic tissue through the decidua basalis into the underlying uterine myometrium, the uterine serosa or even beyond, extending to pelvic organs. It is classified depending on the degree of invasion into placenta accreta (invasion 50% of the myometrium) and percreta (invading the serosa and adjacent pelvic organs). Clinical diagnosis is made intra-operatively; however, the confirmative diagnosis can only be made after a histopathological examination. The incidence of abnormal invasion of placenta has increased worldwide, mostly as a consequence of the rise in caesarean section rates, from 1 in 2500 pregnancies to 1 in 500 pregnancies. The importance of the disease is due to the increased maternal and foetal morbidity and mortality. Foetal implications are mainly due to iatrogenic prematurity, while maternal implications are mostly the increased risk of obstetric haemorrhage and surgical complications. The average blood loss is 3000–5000 mL, and up to 90% of the patients require a blood transfusion. An accurate and timely antenatal diagnosis is essential to improve outcomes. The traditional management of abnormal invasion of placenta has been a peripartum hysterectomy; however, the increased incidence and the short- and long-term consequences of a radical approach have led to the development of more conservative techniques, such as the intentional retention of the placenta, partial myometrial excision and the ‘Triple P procedure’. Irrespective of the surgical technique of choice, women with a high suspicion or confirmed abnormally invasive placenta should be managed in a specialist centre with surgical expertise with a multi-disciplinary team who is experienced in managing these complex cases with an immediate availability of blood products, interventional radiology service, an intensive care unit and a neonatal intensive care unit to optimize the outcomes.

The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians’ understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.