Cesarean Section Leading to Cesarean Hysterectomy Case File

Cesarean Section Leading to Cesarean Hysterectomy Case File

Eugene C. Toy, MD, Edward Yeomans, MD, Linda Fonseca, MD, Joseph M. Ernest, MD

Case 6

A 38-year-old African American woman, G7P6006, presents to triage at 40 weeks of gestation by last menstrual period because of painful contractions. She denies bleeding or leakage of amniotic fluid. All six of her previous pregnancies resulted in term vaginal deliveries. Vital signs are normal, height is 5 ft 4 in and weight is 190 lb (86 kg). Her fundal height is 47 cm, fetal heart tones are detected at 160 beats per minute and presentation cannot be ascertained on abdominal examination. Cervical examination reveals a bulging bag of water, dilation of 6 cm, complete effacement, and no presenting part in the pelvis. A bedside ultrasound is performed which indicates excessive amniotic fluid and a cephalic presentation. During the ultrasound examination the patient’s membranes rupture spontaneously followed by vaginal passage of copious amounts of amniotic fluid and a prolapsed umbilical cord. An emergency cesarean delivery under general anesthesia results in the birth of a 4500 g male infant. After the placenta is removed, the uterus is flaccid and bleeding is brisk. There is no response to massage, bimanual uterine compression, and a variety of uterotonic agents. Blood loss is estimated at 2000 cc and bilateral uterine artery ligation produces no improvement. Blood pressure is now 80/40 mm Hg, pulse is 120 per minute, and typespecific blood has been requested.

➤ What is the most likely diagnosis?

➤ What is your next step?

➤ What are the complications of the next step?

ANSWERS TO CASE 6:

Cesarean Section Leading to Cesarean Hysterectomy

Summary: A 38-year-old G7P6006 at term, with polyhydramnios, who underwent an emergency cesarean delivery for cord prolapse after spontaneous rupture of membranes in labor. She experienced severe intraoperative blood loss leading to hemodynamic instability. Conservative treatment measures did not resolve the problem.

➤ Most likely diagnosis: Uterine atony refractory to conservative management.

➤ Next step: Proceed with cesarean hysterectomy.

➤ Potential complications: Urinary tract injury, high likelihood of transfusion, loss of fertility, admission to intensive care, death.

ANALYSIS

Objectives

1. Appreciate that both primary and repeat cesarean delivery are strong risk factors for cesarean hysterectomy.
2. Be familiar with the leading indications for cesarean hysterectomy.
3. Consider the ways in which proper performance of cesarean hysterectomy may enable the operator to avoid the known complications of the procedure.

Considerations

A 38-year-old grand multipara with polyhydramnios undergoes spontaneous rupture of membranes and cord prolapse necessitating an emergent cesarean delivery under general anesthesia with delivery of a macrosomic infant. Each entry in bold in the previous sentence is a risk factor for uterine atony and combining such factors, as in the case presented, markedly increases the risk. Intraoperatively, when the expected uterine atony and hemorrhage is encountered, conservative management fails to reduce the bleeding. To prevent further morbidity or mortality a cesarean hysterectomy is performed.

APPROACH TO

Cesarean Section Leading to Cesarean Hysterectomy

DEFINITIONS

CESAREAN DELIVERY: A surgical incision through the abdominal wall (laparotomy) and uterus (hysterotomy) performed to deliver a fetus.

CESAREAN HYSTERECTOMY: An abdominal hysterectomy performed at the time of a cesarean delivery.

PERIPARTUM HYSTERECTOMY: A more inclusive term encompassing hysterectomy performed at the time of either cesarean or vaginal delivery or in the immediate postpartum period.

UTERINE ATONY: Inadequate contractility of the postpartum uterus leading to hemorrhage from the placental implantation site. Blood flow to this site averages 600 mL/min at term.

POLYHYDRAMNIOS: A term that is used to describe excessive amniotic fluid volume. Quantitatively, an amniotic fluid index above 24 cm, or above the 95th percentile for gestational age, or a maximum vertical pocket greater than 8 cm have each been used to define excessive fluid; sometimes only a qualitative assessment of too much fluid is used.

CLINICAL APPROACH

Safe cesarean childbirth is one of the greatest medical advances of the 20th century. Advances in anesthesia, broad-spectrum antibiotics, safe blood transfusion, and improved operative technique have resulted in incredibly low maternal mortality related to cesarean delivery. Ironically, it is the safety of the procedure that has contributed to unprecedented high rates in the United States and around the world.

The incidence of cesarean has increased in the United States from 5.5% in 1970 to its present rate of almost 32%. There are a myriad of “reasons” for this increased rate including lower tolerance for risks, high false-positive rate for detection of fetal hypoxia, increased use of electronic fetal monitoring, increased use of epidural anesthesia, decrease in VBACs, fear of litigation, patient choice, and physician convenience.1

Overall maternal mortality is extremely uncommon (< 10 deaths/100,000 live births) in the United States, but even here cesarean birth carries two to four times the risk for mortality compared to vaginal delivery. This risk notwithstanding, cesarean deliveries have been credited with saving the lives of some mothers and many infants. The case of cord prolapse presented in this case exemplifies the lifesaving nature of an emergency cesarean delivery for the infant. The indication for cesarean in our case is inarguable, but too often the indications are flimsy, and the serious risks of the procedure including hysterectomy and death are underemphasized. Of note, cesarean delivery is associated with a fivefold increase in pulmonary embolism compared to vaginal delivery. For a detailed discussion of cesarean delivery indications and technical considerations the reader is referred to standard texts on obstetrics. The remainder of this section outlines the clinical approach to cesarean hysterectomy.

The incidence of cesarean hysterectomy is 4 to 8/10,000 births; if peripartum hysterectomies are considered (see under “Definitions”), then the frequency will be slightly higher. Two recent reports examined the relationship of cesarean delivery to cesarean hysterectomy.2,3 Compared with controls, women who had a peripartum hysterectomy were three times more likely to have had a previous cesarean section and the risk increased to 18 times for two or more prior cesareans. Even if one considers only cesarean delivery in the current gestation, the risk of hysterectomy is still seven times higher than after vaginal delivery.

Most peripartum hysterectomies are performed because of life-threatening hemorrhage. A smaller number are performed for concurrent gynecologic conditions such as leiomyomata or cervical dysplasia; these are classified as indicated nonemergency procedures. Relatively few are performed electively. In one series, hemorrhagic complications leading to cesarean hysterectomy included uterine atony 53%, abnormally adherent placenta 39%, uterine rupture 8%, and irreparable extension of the uterine incision 6%.2 However, the majority of recent reports cite placenta accreta and its variants as the most frequent condition requiring hysterectomy.4 If, as in our case, the indication is uterine atony, the initial management is aimed at preserving the uterus with medical measures, surgical measures, or both. In our case uterine artery ligation was the only surgical method attempted. Hypogastric artery ligation is not used often and is of uncertain value. Uterine suturing methods like the B-Lynch stitch may be useful in primiparous women or those of low parity, but choosing hysterectomy without such measures in a grand multipara is defensible. When placenta accreta is the indication, for example, in women with three or more prior cesareans and a placenta previa in the current gestation, proceeding with planned cesarean hysterectomy may be advisable and results in less blood loss.5

Peripartum hysterectomy is associated with considerable morbidity and mortality. Average blood loss in an emergency hysterectomy is 2500 +/−1300 mL. An adequately trained operator, experienced anesthesia personnel, and immediate availability of blood products are all essential to optimize outcomes. Technically, good exposure, extensive mobilization of the urinary bladder, careful attention to vascular pedicles, and constant traction on the uterus will minimize blood loss and avoid damage to adnexal structures and adjacent organs. If brisk bleeding is occurring then rapidly clamping and dividing the vessels supplying the uterus down to and including the uterine arteries has merit.6 The surgeon can later return to suture ligate all the pedicles once the uterus has been devascularized.6 Occasionally, the cervix is not safely approachable due to previous scarring and a supracervical hysterectomy may be chosen; significant blood loss may dictate this choice. Often, the cervix can be isolated and removed without adding substantially to the risk of the operation. Once the specimen has been removed, the instillation of sterile milk (infant formula is useful) into the maternal bladder through an indwelling Foley catheter may be advisable to confirm bladder integrity. Some surgeons would opt for cystoscopy to inspect the ureteral orifices and examine the bladder. Cesarean hysterectomy is almost always performed on relatively young women, so particular attention must be paid to preserving the ovaries.

Cesarean hysterectomy is a formidable surgical procedure, especially in the setting of massive hemorrhage. Some of the complications of cesarean hysterectomy and their approximate frequencies are presented in Table 6–1.7 It is highly desirable for residency training programs to provide young physicians with the opportunity to participate in a few of these cases under controlled circumstances to avoid having them encounter their first emergency after training is completed. In those cases where hemorrhage is anticipated, calling in experienced assistance or transfer of the woman to a tertiary center are both prudent options.

Surgical Technique

The surgical technique for a hysterectomy performed after delivery (cesarean hysterectomy) is similar to that of an abdominal hysterectomy performed unrelated to recent delivery. One of the hardest components of performing a

Table 6–1 COMPLICATIONS OF CESAREAN HYSTERECTOMY
COMPLICATION	FREQUENCY (%)
RBC transfusion	84
Transfusion of other blood products	34
Admission to ICU	25-30
Postoperative fever	11
Unplanned removal of one ovary	5-15
Bladder injury	5-8
Subsequent laparotomy	4-8
Ureteral injury	3-7
Maternal death	2

hysterectomy after delivery is making the decision to perform the procedure if it was not planned previously. Delay in decision can lead to increased risk of additional hemorrhage and use of blood products in some cases.

As for all surgical procedures, exposure is crucial. The uterus should be elevated from the abdominal cavity to allow for exploration posteriorly, laterally, and caudally to review the anatomy and clear the gutters of blood and debris. Also, in keeping the uterus elevated on traction, this can decrease blood loss. If the placenta is still intact and there is suspicion of placenta accreta, one should evaluate the entire external uterine serosa to ensure that there is no evidence of percreta into surrounding organs, such as posteriorly to the bowel, caudally into the bladder, or laterally into the uterine vessels or otherwise. If so, additional consultation with a specialist in general surgery, urology, or vascular surgery, respectively may be beneficial. Some would advocate conservative surgery, leaving the placenta in place to avoid causing excessive bleeding from the placental site or myometrium if it is still in place at the time of investigation. The body of evidence that supports such an approach is limited.

If visualization of the ureters is difficult, then palpation is essential to ensure safety of placement of clamps to try to decrease the risk of ureteral injury. Due to the relatively young age of women undergoing hysterectomy after delivery, it is advisable to retain ovaries if possible.

The uterine incision can be quickly reapproximated. The round ligament is identified, doubly clamped, and ligated allowing for separation of the broad ligament in order to skeletonize the uterine arteries and their branches as quickly as possible. The ligation of the round ligament should be performed close to the uterus (Figure 6–1). The anterior leaf of the broad ligament should be extended to the vesicouterine serosa. The uterine arteries and associated veins can be tortuous and dilated at the time of a postpartum hysterectomy. One must ensure that the bladder has been dissected far enough away from the lower portion of the uterus to allow for the clamping, suturing, and ligation of the uterine artery. (Figures 6–2 and 6–3). Some advocate placing a clamp on the uterus itself to control back-bleeding.

Once hemostasis is obtained, attention can then be turned back to the utero-ovarian area (Figures 6–4 and 6–5).

The ovary needs to be elevated to allow for evaluation of the utero-ovarian area which often involves congested vessels during pregnancy. The posterior leaf of the broad ligament is perforated inferior to the fallopian tube, uteroovarian ligaments, and their associated vessels which can be dilated significantly. Double clamping is advisable using first a free tie followed by suture ligation of the utero-ovarian pedicle. Attention can then be turned back to the area of the uterine cervix and bladder. In some cases it is safer and medically indicated to excise the uterus at the level of the internal cervical os; however, in other cases, a total abdominal hysterectomy is feasible. If a supracervical hysterectomy is performed, a series of interrupted figure-of-eight sutures on the cervical stump can decrease bleeding and help with healing. If the cervix is removed, then the cuff should be reapproximated to the

Figure 6–1. The round ligaments are clamped, ligated, and transected bilaterally. (Reproduced,with permission, from Cunningham FG,Leveno KJ,Bloom SL,et al. Williams Obstetrics. 23rd ed.New York,NY:McGraw-Hill; 2010.)

Figure 6–2. The bladder is dissected sharply from the lower uterine segment. (Reproduced,with permission, from Cunningham FG,Leveno KJ,Bloom SL,et al. Williams Obstetrics. 23rd ed.New York,NY:McGraw-Hill; 2010.)

Figure 6–3. The uterine artery and veins on either side are doubly clamped immediately adjacent to the uterus and divided. (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 23rd ed. New York, NY: McGraw-Hill; 2010.)

Figure 6–4. The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tube, utero-ovarian ligament, and ovarian vessels. (Reproduced,with permission, from Cunningham FG,Leveno KJ,Bloom SL,et al. Williams Obstetrics.23rd ed.New York,NY:McGraw-Hill; 2010.)

Figure 6–5. The utero-ovarian ligament and fallopian tube is clamped and cut bilaterally. (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 23rd ed.New York,NY:McGraw-Hill; 2010.)

uterosacral ligaments to reduce the risk of future vaginal vault prolapse. The uterosacral sutures should be held during continued progression of removal of the cervix so that the uterosacral ligaments can easily be identified at time of cuff closure. As in total abdominal hysterectomies unrelated to delivery, a curved clamp is placed across the lateral vaginal fornices immediately below the level of the cervix so that the tissue can be incised superiorly to the clamp to allow removal of the cervix and uterus. The angles of the lateral vagina are then reapproximated to the uterosacral ligaments that were previously held. The cuff is then closed in a series of interrupted figure-of-eight sutures or with a running-locked suture technique.

If there is any concern for bladder injury, the bladder can be filled with sterile milk (infant formula is suitable) via the Foley catheter. We recommend filling with at least 300 mL of fluid to ensure there is no leakage. If there is any question of ureteral injury, a small cystotomy can be performed in the dome of the bladder after IV infusion of indigo carmine to evaluate bilateral spill from both ureters or transurethral cystoscopy could be performed but would require some repositioning of the patient.

Irrigation of the abdominal cavity should be performed at the completion of the procedure prior to closure of the fascia and abdominal cavity.

Comprehension Questions

6.1 A 34-year-old woman at 35 weeks’ gestation is being counseled about her condition and possible complications. Hemorrhage and the need for hysterectomy are explained. The patient asks what is the likelihood for hysterectomy. Which of the following causes of obstetrical hemorrhage is MOST likely to lead to cesarean hysterectomy?

A. Placenta accreta

B. Uterine atony

C. Placental abruption

D. Uterine rupture

6.2 A 32-year-old woman has just delivered vaginally, and profuse vaginal bleeding is encountered. The uterus is noted to be boggy. Which of the following is the best therapy for this patient?

A. Intravenous misoprostol

B. Bakri intrauterine balloon

C. Oral ergot alkaloid

D. Uterine curettage

6.3 Which of the following complications is most frequently encountered with a cesarean hysterectomy?

A. Need for transfusion of blood products

B. Urinary tract injury

C. Endometritis

D. Maternal death

ANSWERS

6.1 A. Placenta accreta complicates about 1 in 500 pregnancies and is increasing remarkably with the increase in cesarean delivery.

6.2 B. Uterine atony may be treated early on with uterine massage and pharmacological agents. Rectal or oral misoprostol can be used and intramuscular prostaglandin is an option. Oral ergot alkaloids are not absorbed quickly enough to be useful in the face of hemorrhage. An intrauterine balloon has been shown to be useful in postpartum hemorrhage due to uterine atony. When these conservative measures are not effective, then surgery is indicated.

6.3 A. Transfusion is the only logical choice and it is required in over 75% of emergency cases. Urinary tract injury occurs in up to 5% of cases. Death is uncommon and there is no endometrium remaining to get infected.

Clinical Pearls

See US Preventive Services Task Force Study Quality levels of evidence in Case 1

➤ Despite a careful examination of risk factors, a substantial number of women who undergo cesarean hysterectomy cannot be identified preoperatively (Level II).

➤ Women with a peripartum hysterectomy are 10 times more likely to have had one or more previous cesarean section (Level II).

➤ A diagnosis of hemorrhage is listed in the discharge of about 70% of peripartum hysterectomy patients (Level II).

➤ Cesarean hysterectomies are most often performed for uterine atony or abnormally adherent placenta. The latter is particularly concerning in light of the increasing cesarean delivery rate in contemporary obstetric practice (Level II).

➤ Hemorrhage, infections, and bladder injury are the most common complications of a peripartum hysterectomy. The integrity of the bladder should be evaluated, especially in patients with a previous cesarean section (Level II).

➤ After one previous cesarean section the risk of serious complications such as placenta previa, placenta accreta, uterine rupture increases in a subsequent pregnancy. Thus, every effort must be made to limit primary cesarean deliveries to those with a valid clinical indication (Level III).

REFERENCES

1. Sachs BP, Kobelin C, Castro MA, Frigoletto F. The risks of lowering the cesareandelivery rate. N Engl J Med. 1999;340:54-57. 

2. Knight M, Kurinczuk JJ, Spark P, Brocklehurst P. Cesarean delivery and peripartum hysterectomy. Obstet Gynecol. 2008;111:97-105. 

3. Whiteman MK, Kuklina E, Hillis SD, et al. Incidence and determinants of peripartum hysterectomy. Obstet Gynecol. 2006;108:1486-1492. 

4. Flood, KM, Said S, Geary M, et al. Changing trends in peripartum hysterectomy over the last 4 decades. Am J Obstet Gynecol. 2009;200:632.e1-632.e6. 

5. Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta accreta. BJOG. 2009;116:648-654. 

6. Plauche WC. Cesarean Hysterectomy: Indications, technique, and complications. Clin Obstet Gynecol. 1986;29:318-328. 

7. Shellhaas CS, Gilbert S, Landon MB, et al. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol. 2009;114:224-229.

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