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Articulo de FR de HPP de China 2014 PDF
Articulo de FR de HPP de China 2014 PDF
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Original article
Risk factors associated with emergency peripartum hysterectomy
Jin Rong, Guo Yuna and Chen Yan
Keywords: emergency peripartum hysterectomy; postpartumhemorrhage; placenta accrete; previous cesarean delivery;
tocolytic
Background Use of an emergency peripartum hysterectomy (EPH) as a lifesaving measure to manage intractable
postpartum hemorrhage (PPH) appears to be increasing recently around the world, and the indications for EPH have
changed. The object of this study is to identify risk factors associated with EPH.
Methods We conducted a case-control study of 21 patients who underwent EPH because of intractable PPH between
January 1, 2005 and June 30, 2013, at the International Peace Maternity and Child Health Hospital Shanghai Jiao Tong
University, School of Medicine (IPMCH). The parametric t-test, chi-square tests and Logistic regression models were used
for analysis to identify the risk factors. The results were considered statistically signicant when P<0.05.
Results There were 89178 deliveries during the study period. Twenty-one women had an EPH, with an incidence of
24 per 100000 deliveries. The loss of blood during postpartum hemorrhage of the EPH group was (5 060.73 032.6)
ml, and that of the control group was (2040.8723.5) ml. There was a significant difference of PHH between the
EHP group and the control group (P=0.001). Independent risk factors for EPH from a logistic regression model were:
disseminated intravascular coagulation (DIC) (OR: 9.9, 95% CI 2.834, P=0.003), previous cesarean section (OR: 5.27;
95% CI: 1.4817.9, P=0.009), placenta previa (OR: 6.9; 95% CI 1.62.9, P=0.008), the loss of PPH (OR: 1.001; 95% CI
1.0011.002, P=0.002), placenta accreta (OR: 68; 95% CI 10456, P=0.004), the use of tocolytic agents prenatally (OR:
6.55, 95%CI 1.3432.1,P=0.049), and fetal macrosomia (OR: 6.9, 95% CI 1.2538, P=0.049).
Conclusion Significant risk factors of EPH are DIC, placenta previa, PPH, previous cesarean delivery, and placenta
accrete, the use of tocolytic agents prenatally, and fetal macrosomia.
Chin Med J 2014;127 (5): 900-904
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Table 1. Measurement analysis of variances
Characteristics
Age (years)
Gravidity
Parity
Gestational age(week)
The length of stay at the hospital after delivery (days)
The loss of postpartum hemorrhage (ml)
The time postpartum hemorrhage (hours)
Birth weight (g)
EPH (n=21)
35.1004.146
3.7602.071
1.8100.62
36.2382.119
9.8605.141
5060 7603132.624
0.3811.359
2891.000745.049
Non-EPH (n=69)
32.1204.858
2.3501.315
1.3900.647
37.7102.184
7.3904.694
2140.800723.574
1.7394.391
3140.840578.760
P values
0.522
0.000*
0.010*
0.008*
0.042*
0.000*
0.167
0.110
4.76%).
Difference of PPH between EHP group and the
control group
As shown in Figure 2, the loss of blood during postpartum
hemorrhage in the EHP group was (5060.73032.6) ml,
the loss of blood during postpartum hemorrhage of the EHP
group was (2040.8723.5) ml. There was a significant
difference of blood loss due to PPH between the EHP group
and the control group (P=0.001). The results indicated that
Table 2. Logistic regression analysis of risk factors for PPH and EPH
Items
Previous cesarean section
Using tocolytic agents prenatal
GDM
Placenta previa
Placenta accreta
Placental abruption
DIC
Macrosomia
Uterine artery embolization
Intrauterine packing with gauze,
Ligation for ascending branch of uterine artery
B-lynch suture
PPH
OR (95% CI)
23.8 (3.9144.0)
2.5 (0.512.5)
0.3 (0.032.6)
5.4 (1.518.6)
18.5 (3.889.5)
1.3 (0.115.4)
36.7 ( 7.3183.9)
4.0 (0.742.8)
1.0 (0.14.2)
3.0 (0.99.0)
7.9 (1.251.7)
34.1 (4.8241.0)
P values
0.001
0.26
0.28
0.001
0.001
0.86
0.001
0.12
0.9
0.052
0.03
0.001
EPH
OR (95% CI)
5.27 (1.4817.9)
6.55 (1.3432.1)
1.09 (0.171.69)
6.9 (1.629)
68 (10456)
1.34 (0.117.1)
9.9 (2.834)
6.9 (1.2538)
2.85 (0.238)
1.0 (0.33.3)
4.2 (0.822)
3.0 (0.713)
P values
0.009
0.049
0.002
0.008
0.004
0.82
0.003
0.049
0.61
0.99
0.15
0.21
Control variables includes age, gestational weeks and parity. The loss of postpartum hemorrhage was separated into high and low level by 3 000 ml.
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delivery rate in the Unite State was 33% during the period
from 19942007,14 and at the Mayday Hospital, UK it had
risen from 16% in 1989 to 18% in 1998 and 23% in 2008.19
In recent years, because of advance surgical skills and
anesthetic facilities, almost all people believe undergoing a
cesarean section is a no risk, no pain and quick surgery, and
the selective cesarean section has become the first choice of
the majority of pregnant Chinese women. To some extent,
the high rate is due to the low proportion of analgesia labor
and one-child family planning policy. All EPH cases in our
study were performed after cesarean deliveries, but none
was selective cesarean section.
Compared with vaginal delivery, cesarean delivery has
been shown to be associated with higher maternal and
neonatal complications and healthcare costs. In addition,
studies have reported that cesarean delivery is associated
with an increased risk for EPH.14,20 This may be a result
of the associated risk factors for cesarean delivery such as
placenta previa, placenta accreta, or dystocia. Selo-Ojeme et
al21 demonstrated that cesarean delivery was an independent
risk factor for EPH. Nevertheless, in the present study,
it is not cesarean section but previous cesarean section
that was an independent risk factor for EPH and PPH. In
modern obstetrics, due to perfection of surgical skills and
anesthesia, and comprehensive perioperative assessment
and nursing, primary cesarean section has become a lowrisk surgery. However, in a subsequent pregnancy, the
previous cesarean section may have changed normal
anatomy, which increased the risk of placenta previa,
placenta accreta, dystocia and surgical injury, therefore,
increased the incidence of EPH. The safety of vaginal birth
after cesarean delivery (VBAC) remains controversial,
yet the risks were much greater in women who attempted
VBAC and failed. The VBAC rate has decreased markedly
in the United States in recent years.11 Only one EPH case in
the present study who underwent EPH because a ruptured
uterus failed to VBAC. The present analysis does not
calculate VBAC as a risk factor for EPH. However, women
and their prenatal care providers should assess the risks and
benefits rigorously at different stages of pregnancy when
they plan to try VBAC.
In the present study, the use of prenatal tocolytic agents, a
previously undocumented factor, was an independent risk
factor for EPH (OR 6.55 (1.3432.1), P=0.049), but not for
PPH (OR 2.5 (0.512.5), P=0.26). It is obvious that EPH
and PPH are not parallel indicators. For a patient, deciding
on EPH requires comprehending many factors, not just
consideration of the amount of PPH. With an increased
incidence of placenta previa and placenta accrete, tocolytics
with various mechanisms of action such as ritodrine (Anpo),
magnesium sulfate, and oxytocin inhibitors (Atosiban),
have been used to treat vaginal bleeding due to placenta
previa in middle and terminal pregnancy. A substantial
proportion of cases of placenta previa need emergency
surgery because of antenatal bleeding, and there is no time
to stop using the tocolytics before surgery. However, from
our study, we were unable to draw conclusions as to when
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