Obstetric Hysterectomy

Indications & Urgency - Code Red Reasons

• Primary: Uncontrollable Postpartum Hemorrhage (PPH)
  • Uterine atony: refractory to uterotonics, massage, tamponade, uterine artery ligation.
  • Placenta Accreta Spectrum (PAS): accreta, increta, percreta.

    ⭐ Placenta Accreta Spectrum (PAS) is the leading indication for peripartum hysterectomy in many developed countries, especially with rising caesarean section rates.

  • Uterine rupture: complete or complex.
  • Irreparable uterine/cervical trauma: e.g., extensive lacerations.
• Other Critical:
  • Severe uterine sepsis/necrosis: e.g., chorioamnionitis unresponsive to broad-spectrum antibiotics.
  • Uterine neoplasia: discovered incidentally during CS, requiring definitive management.
• Urgency (Code Red):
  • Life-threatening, ongoing hemorrhage despite all conservative measures.
  • Persistent, profound hemodynamic instability (refractory shock).

Timing, Types & Team - Hysterectomy Huddle

• Timing of Obstetric Hysterectomy:
  • Elective: Planned for conditions like placenta accreta spectrum (PAS) diagnosed antenatally.
  • Emergency: Life-saving for uncontrolled postpartum hemorrhage (PPH), uterine rupture, intractable uterine atony.
• Types:
  • Total Abdominal Hysterectomy (TAH): Removal of uterine body and cervix. Most common.
  • Subtotal/Supracervical Hysterectomy (STAH): Uterine body removed, cervix preserved.
    • Advantages: Potentially faster, ↓ blood loss, ↓ risk of urinary tract injury.
    • Disadvantages: Risk of cyclical bleeding from stump, future cervical stump pathology (e.g., malignancy).
• Team (Hysterectomy Huddle - multidisciplinary approach):
  • Senior/Experienced Obstetrician (Primary Surgeon)
  • Assistant Surgeon(s)
  • Senior Anesthesiologist (experienced in obstetric emergencies)
  • Scrub Nurse & Circulating Nurse
  • Blood Bank: Crucial for timely blood products; activate Massive Transfusion Protocol (MTP) if anticipated.
  • Neonatal Team: If delivery is part of the procedure or recent.

⭐ Subtotal hysterectomy may be preferred in emergencies due to shorter operative time and potentially less blood loss, but carries a risk of future cervical stump issues (e.g., cyclical bleeding, malignancy).

Surgical Technique - Navigating Red Sea

• Core Aim: Rapid hemorrhage control. Experienced surgeon & team vital.
• Incision: Midline vertical for optimal access & speed.
• Uterus: Enlarged, hypervascular; gentle handling crucial.
• Critical Steps:
  • Ureteric Vigilance: Identify early. ⚠️ High injury risk.
  • Vascular Pedicles:
    • Swift, secure double clamping. Use large clamps.
    • Suture ligate (e.g., Vicryl No. 1).
  • Bladder Flap: Careful dissection due to ↑vascularity.
  • Procedure Type:
    • Subtotal (Supracervical): Faster, ↓blood loss; often emergency choice.
    • Total: For cervical issues or definitive care.
  • Hemostasis: Absolute priority. Consider packing/drains.
  • MTP: Activate Massive Transfusion Protocol early.

⭐ Systematic devascularization, including ligation of uterine arteries and potentially ovarian arteries (if bleeding persists from above), is a cornerstone of managing hemorrhage during obstetric hysterectomy.

Complications & Outlook - Post-Op Perils

• Major Risks & Complications:
  • Hemorrhage: Primary concern, often the indication.
  • Urinary Tract Injury: Bladder/ureter damage.

    ⭐ Injury to the urinary tract, particularly the bladder or ureters (risk ~1-2%), is a significant morbidity; ureters are most vulnerable near the uterine artery ligation site or at the pelvic brim.

  • Bowel/Nerve Injury: Less frequent.
  • Infection: Wound, pelvic, UTI.
  • Thromboembolism: DVT/PE.
  • Febrile morbidity.
• Late Sequelae:
  • Adhesions, bowel obstruction.
  • Fistula formation (e.g., vesicovaginal).
  • Vault prolapse.
  • Psychological impact (loss of fertility).
• Prognosis:
  • Maternal mortality: Low, but ↑ vs. non-obstetric cases.
  • Recovery: Generally good if complications managed promptly.

High‑Yield Points - ⚡ Biggest Takeaways

• Primary indication: Uncontrollable PPH, especially from placenta accreta spectrum (PAS) or uterine atony.
• An emergency life-saving measure when conservative PPH treatments fail.
• Total hysterectomy preferred; subtotal is quicker in dire emergencies.
• Key goals: Secure uterine/ovarian arteries; activate massive transfusion protocol.
• Major risks: Hemorrhage, ureteric/bladder injury, sepsis.
• Risk factors: Prior C-sections, placenta previa, grand multiparity, uterine rupture.
• Causes permanent sterility; counsel pre-operatively if possible.