Histerectomiile peripartum realizate electiv sau de urgență – experiența clinică a Spitalului Universitar de Urgență București

Introduction

In the context of obstetric emergencies, peripartum hysterectomy remains a highly invasive but sometimes indispensable procedure. It consists of surgically removing the uterus either during childbirth or in the early postpartum period, most often within the first 72 hours.

While rare, its application reflects the failure of all conservative approaches and underscores the severity of the underlying maternal complication. Peripartum hysterectomy refers to the surgical removal of the uterus performed during childbirth or in the immediate postpartum period, most often within the first 72 hours following delivery^(1,2). Unlike elective hysterectomy, which is usually scheduled for benign or malignant gynecological conditions, the peripartum variant arises in response to acute, life-threatening complications where uterine preservation is no longer a safe option⁽³⁾.

The timing of the procedure distinguishes it from conventional hysterectomy: it may be conducted intrapartum, such as during a caesarean delivery when hemorrhage becomes uncontrollable, or shortly after a vaginal birth, when bleeding persists despite all conservative measures^(2-4). In certain high-risk cases – particularly those involving placenta accreta spectrum (PAS) – the procedure can be anticipated and scheduled in advance as part of a multidisciplinary approach^(3-5).

Whether performed emergently or as a planned intervention, peripartum hysterectomy represents a pivotal step in the escalation of hemorrhage control. Its complexity extends beyond the surgical act, as it entails significant implications for maternal recovery and future fertility⁽⁶⁾.

Peripartum hysterectomy is an uncommon, but serious obstetric procedure, usually performed in the context of severe hemorrhage. Its incidence varies significantly between countries, with rates ranging from 0.7 per 1000 deliveries in high-income settings to over 3 per 1000 births in regions with limited access to emergency obstetric care^(7,8). In recent years, an upward trend has been documented, closely linked to the growing number of caesarean deliveries and the increasing incidence of placenta accreta spectrum disorders⁽⁸⁾. As prior uterine surgery becomes more frequent, especially caesarean section, the risk of abnormal placentation rises, making peripartum hysterectomy a more predictable intervention in certain high-risk cases⁽³⁾.

The most common indications for peripartum hysterectomy are related to severe obstetric hemorrhage that fails to respond to conservative measures. In clinical practice, the leading causes remain severe uterine atony, placenta accreta spectrum (PAS), and uterine rupture^(9-11).

PAS has become the predominant indication in scheduled hysterectomies, especially in patients with a history of multiple caesarean sections. In these cases, the abnormal adherence or invasion of the placenta prevents spontaneous separation, and any attempt to remove it can lead to uncontrollable bleeding. The management typically involves planned caesarean hysterectomy around 34 to 36 weeks of gestation, ideally performed in a tertiary center with multidisciplinary support^(10,12).

Uterine atony continues to be the main cause in emergency settings. Despite the use of uterotonics, uterine massage, balloon tamponade and compression sutures, some cases evolve into refractory hemorrhage. When bleeding persists despite maximal medical and conservative surgical efforts, hysterectomy becomes unavoidable. Atony is more frequently seen following vaginal deliveries but can also occur after caesarean sections, particularly in the setting of prolonged labor or uterine overdistension⁽¹¹⁾.

Uterine rupture, although less frequent, remains a critical emergency. It is commonly associated with a prior uterine scar and typically occurs during labor, particularly when a trial of labor after caesarean (TOLAC) is attempted without proper monitoring. Hysterectomy is often necessary when the rupture is extensive or when repair is not feasible due to ongoing hemorrhage^(9,13).

Additional indications include placenta praevia with persistent bleeding, traumatic uterine injury during fetal extraction or caesarean delivery and, in rare cases, severe uterine infection such as necrotizing endometritis or septic shock. The distribution of these etiologies often depends on the availability of skilled obstetric care, prenatal imaging and interventional alternatives^(13,14).

Peripartum hysterectomy is associated with significant maternal morbidity, with complications occurring both intra- and postoperatively. Massive hemorrhage is the most frequent intraoperative issue, often requiring transfusion of ≥4 units of packed red blood cells. In up to 10-15% of cases, especially in patients with placenta percreta or dense adhesions, bladder injury may occur. Ureteral injury is less common but remains a concern in difficult pelvic dissections⁽¹⁵⁾.

A particularly serious complication is disseminated intravascular coagulation (DIC), which may develop secondary to sustained hemorrhage and hypoperfusion. DIC significantly increases the risk of mortality, transfusion requirement and multi-organ dysfunction. Prompt recognition and aggressive replacement therapy (fibrinogen, platelets, FFP) are essential in these cases⁽¹⁶⁾.

Postoperatively, patients may develop wound infection, pelvic abscess, paralytic ileus, or venous thromboembolism. Admission to an intensive care unit is required in approximately 50% of cases, particularly when intraoperative instability, coagulopathy, or multiorgan support is necessary⁽¹⁵⁾.

Overall survival exceeds 99% in well-resourced settings; however, emergency hysterectomy, as opposed to planned procedures, is associated with higher rates of complications, prolonged hospitalization and reintervention. Permanent loss of fertility and the potential for delayed recovery emphasize the importance of early risk identification and management in specialized centers^(6,8,17).

Materials and method

We conducted a retrospective case series comprising 15 patients managed at the University Emergency Hospital Bucharest, Romania, between January 2024 and May 2025, all of whom underwent peripartum hysterectomy as the central focus of this study. Case selection was based on the availability of complete clinical documentation, and inclusion required a clearly documented obstetric indication for the procedure. The exclusion criteria included hysterectomies performed for non-obstetric indications and procedures carried out outside the defined puerperal period.

For each case, data were collected regarding maternal age at the time of delivery, gestational age, primary indication for hysterectomy, mode of delivery (caesarean section or vaginal birth), parity, estimated blood loss, transfusion requirements, admission to an intensive care unit (ICU), total length of hospital stay, and maternal outcome at discharge. All data were anonymized prior to analysis. Due to the relatively small sample size, only descriptive statistics were applied. The results are reported as absolute values and percentages.

Results

Between January 2024 and May 2025, a total of 15 patients underwent peripartum hysterectomy in our department (Figure 1). The median maternal age was 32 years old, with a range between 23 and 42 years old. As per the graphics below (Figure 2), the majority of patients (n=11; 73.3%) resided in urban areas, while the remaining four cases (26.7%) came from rural settings. The assessment of antenatal care revealed significant disparities: two patients (13.3%) received no prenatal care, six patients (40%) initiated follow-up during the first trimester, three patients (20%) in the second trimester, and four patients (26.7%) only in the third trimester (Figure 3). Regarding the mode of delivery, 14 patients (93.3%) underwent caesarean section, and one patient delivered vaginally. Fourteen births occurred in our department, while one patient was transferred from another maternity unit after delivery due to postpartum complications requiring surgical management.

During the same period, 2200 deliveries were recorded in our department, resulting in an estimated incidence of peripartum hysterectomy of 0.68%, equivalent to approximately 1 in 147 births.

The clinical indications for peripartum hysterectomy in this series were primarily related to severe obstetric hemorrhage. The most frequent underlying condition was placenta previa with abnormal placental adherence – suggestive of placenta accreta spectrum – identified in six cases (40%). Placenta praevia without invasion was noted in five patients (33.3%). Additional causes included uterine atony unresponsive to conservative measures in two patients (13.3%), abruptio placentae with massive hemorrhage in one case, and severe puerperal sepsis in one patient, requiring emergency hysterectomy for infection source control.

The estimated blood loss during surgery ranged from 2000 to 3800 mL, with a median of 2700 mL. Fourteen out of fifteen patients (93.3%) received blood transfusions. The transfusion volume varied, from two units of concentrated erythrocytes (CER) to a maximum of six CER and four units of fresh frozen plasma (FFP), depending on clinical severity. Admission to the intensive care unit (ICU) was required in 11 patients (73.3%), with durations ranging from zero to seven days. The median ICU stay was one day, with longer admissions noted in cases complicated by coagulopathy or severe hemorrhage. All patients survived and were discharged in good general condition. The total duration of hospitalization ranged from 5 to 28 days, with a mean hospital stay of 10 days. Extended stays were associated with postoperative complications such as sepsis, multiple transfusions, or prolonged ICU monitoring.

Discussion

This case series comprises 15 instances of peripartum hysterectomy managed over a 17-month period. The recorded incidence of 0.68% is relatively high when compared to previously reported data in the literature. However, this figure should be interpreted in the context of our institution’s role as a national referral center, where a substantial number of cases involving placenta praevia with abnormal placental adherence are routinely directed for specialized management. Moreover, antenatal care coverage remains below optimal standards in our region, with many pregnancies being inadequately monitored or not monitored at all. This may partially explain the elevated incidence observed. In our cohort, the most common indication for peripartum hysterectomy was placenta praevia, with or without associated abnormal placental invasion.

The diagnosis and management of placenta previa with abnormal placental adherence (such as placenta accreta, increta, or percreta) remain among the most challenging scenarios in obstetrics.

A multidisciplinary team is crucial to reduce perioperative risk and ensure continuity of care. Depending on the complexity of the case, the team may include an obstetrician, anesthesiologist, neonatologist, urologist, general surgeon, and interventional radiologist⁽¹⁵⁾. Intraoperatively, the main objectives are hemorrhage control and minimization of operative risks. Strategies may include early devascularization, avoidance of placental manipulation in PAS cases, use of intraoperative cell salvage, and close monitoring of hemostasis. In our hospital, all cases are managed by a multidisciplinary team, with access to all the necessary resources mentioned above⁽¹⁸⁾.

This integrated approach has allowed us to achieve consistently favorable outcomes. Accurate prenatal diagnosis and careful risk stratification are essential in reducing maternal morbidity associated with peripartum hysterectomy, as emphasized by clinical data from tertiary care centers^(6,13).

The elevated rate of ICU admission in our cohort (73.3%) reflects the clinical severity of major obstetric complications. This finding reinforces the notion that peripartum hysterectomy, when performed promptly and under optimal surgical conditions, serves as a critical, life-saving intervention in severe maternal morbidity.

The management of peripartum hysterectomy depends on the obstetric context and the underlying indication. In emergency situations, hysterectomy is indicated when hemorrhage cannot be controlled despite the use of conservative measures, such as uterotonic agents, uterine massage, intrauterine balloon tamponade, compression sutures and, where available, arterial embolization⁽¹⁴⁾. Once these options fail to achieve hemostasis, timely surgical intervention is essential to prevent coagulopathy and further complications⁽¹³⁾.

In planned cases, particularly those involving suspected placenta accreta spectrum (PAS), peripartum hysterectomy is typically performed in specialized centers with access to blood products, advanced anesthesia support, and surgical teams from other disciplines when needed^(8,10).

Preoperative planning includes detailed imaging (ultrasound and/or MRI), determination of the surgical approach and, in selected cases, placement of ureteral stents or prophylactic intravascular balloon catheters^(14,18,19).

In our patient cohort, only one hysterectomy was performed electively for a case of placenta praevia with abnormal placental adherence of the increta type. The patient had been closely followed from the first trimester within our department and benefited from both clinical and imaging-based diagnosis at an optimal stage. The case was managed under carefully planned multidisciplinary conditions, resulting in an uneventful postoperative course. The patient did not require ICU admission, being discharged on the fourth postoperative day.

Suboptimal antenatal care was frequently noted, with nearly half of the patients initiating follow-up only in the second or third trimester, and two patients receiving no prenatal surveillance. This highlights the critical role of early and structured antenatal care in preventing or preparing for obstetric complications. Additionally, the rate of caesarean delivery in this cohort (93.3%) reflects both the complexity of cases and the increased association between prior caesarean sections and abnormal placentation. The study is limited by its retrospective design and the relatively small sample size. However, the data offer valuable insight into the clinical burden of major obstetric hemorrhage and the resource-intensive nature of peripartum hysterectomy in a real-world setting.

Conclusions

Although considered rare interventions in developed countries, peripartum hysterectomies remain the ultimate life-saving option in selected complicated obstetric cases. In our study, despite the relatively small number of cases, we aimed to highlight our clinical experience by analyzing the most common indications, perioperative outcomes and maternal risk factors.   

Corresponding author: Diana Voicu E-mail: diana.voicu@umfcd.ro

All authors have participated equally in developing this study.

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.