Peripartum Hysterectomy

Key points

• Emergency hysterectomy in the peripartum period is often performed for life-threatening obstetric complications.
• Peripartum hysterectomy is related to significant maternal mortality and morbidity.
• Has incidence, management and outcomes of women who have undergone peripartum hysterectomy changed significantly since the previous UKOSS study 2005-6?

Surveillance period

1st August 2024 - 31st July 2025

Background

Maternal deaths from haemorrhage have increased over the last triennium, with no significant improvement observed in the last decade.¹ This has been attributed to several factors including the rising caesarean section rate, since women with a history of caesarean birth are at an increased risk of hysterectomy.² Hysterectomy during pregnancy is performed as a life-saving intervention in cases of potentially lethal obstetric haemorrhage, when other medical or surgical conservative treatments fail. MBRRACE-UK has reinforced existing national guidance for early recourse to hysterectomy if conservative medical and surgical interventions to control haemorrhage prove ineffective.^1,3

UKOSS last studied peripartum hysterectomy in 2005-6 and the incidence at this time was 4.1 cases per 10,000 births.⁴ This data contributed to an international study (INOSS) on peripartum hysterectomy which revealed a prevalence ranging from 2.6 per 10,000 in Denmark to 10.7 per 10,000 in Italy.⁵ In the UK, the leading causes were uterine atony (53%) and placenta accreta spectrum disorders (38%). For every one woman that died frollowing peripartum hysterectomy, a further 150 experienced severe morbidity.

There have been dramatic changes in clinical guidance and pathways since the previous UKOSS study. For example, the introduction of specialist services for women with abnormally invasive placentation in England in 2019, the addition (tranexamic acid) and removal (FVIIa) of recommended pharmaceutical management, and guidance on the administration of blood products (RCOG Greentop³). There have been no high-quality large scale observational studies of peripartum hysterectomy in the UK since the previous publication therefore the impact of these changes on the incidence of hysterectomy and its complications are unknown.

This study will determine the national incidence of peripartum hysterectomy in the UK and identify the extent to which previous caesarean section is a risk factor in this population. This will enable appropriate future service planning, provide accurate information which can be used when counselling women about the risks associated with caesarean section, and provide a baseline incidence against which future trends can be monitored if caesarean delivery rates continue to rise nationally. Further description about the management of obstetric haemorrhage prior to hysterectomy and in relation to outcomes for mother and baby will facilitate understanding of current practice in comparison to national guidance and has the potential to inform practice.

Objective

To use the UK Obstetric Surveillance System (UKOSS) to determine the incidence of peripartum hysterectomy in the UK and describe the management of obstetric haemorrhage prior to hysterectomy and examine subsequent management and outcomes.

Research questions

• What is the incidence of peripartum hysterectomy in the UK?
• What is the incidence of planned hysterectomy during pregnancy in the UK?
• What is the incidence of postnatal hysterectomy in the UK?
• Which demographic and pregnancy factors are associated with increased risk of hysterectomy?
• What are the indications for peripartum hysterectomy in the UK?
• What is current managment of postpartum haemorrhage prior to peripartum hysterectomy in the UK?
• What are the outcomes for mother and baby following hysterectomy during pregnancy or in the postnatal period?

Case definition

Any woman undergoing surgical removal of the uterus during pregnancy or within 42 days of the end of pregnancy.

Controls: Two controls will be requested for every case reported. The controls will be the two women who delivered at the hospital immediately before the case.

Funding

The principal researcher is funded by the public health specialist registrar training scheme of the London deanery and a Clinical Fellowship from the Nuffield Department of Population Health, University of Oxford. Administrative costs will be funded from Professor Kinght's NIHR Senior Investigator award.

Ethics committee approval

This study has been approved by the London Brent REC (Ref. Number: 10/H0717/20).

Investigators

Nicola Vousden and Marian Knight, NPEU, University of Oxford

Sample Data Collection Forms

Peripartum Hysterectomy_Case_Sample dcf

Peripartum Hysterectomy_Control_Sample dcf

References

1. Knight M, Bunch K, Felker A, Patel R, Kotnis R, Kenyon S, Kurinczuk JJ (Eds) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers' Care Core Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019-21. Oxford: National Perinatal Epidemiology Unit: University of Oxford; 2023.

2. Marshall NE, Fu R, Guise JM. Impact of multiple ceaesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol. 2011;205(3):262.e1-8.

3. Royal College of Obstetricians and Gynaecologists. Prevention and Management of Postpartum Haemorrhage. BJOG: An International Journal of Obstetrics & Gynaecology. 2017;124(5):e106-e49.

4. Knight M, Kurinczuk JJ, Spark P, Brocklehurst P. Caesarean delivery and peripartum hysterectomy. Obstetrics and gynecology. 2008L;111(1):97-105.

5. Kallianidis AF, Maraschini A, Danis J, Colmorn LB, Deneux-Tharaux C, Donati S, et al. Epidemiological analysis of peripartum hysterectomy across nine European countries. Acta Obstet Gynecol Scand. 2020;99(10):1364-73.