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Perioperative Management of Peripartum Hysterectomy at Duke University Hospital: A Retrospective Review
Abstract Number: S-49
Abstract Type: Original Research
Introduction: Peripartum hysterectomy is associated with significant morbidity and mortality. Nationwide the incidence of parturients undergoing hysterectomy has been steadily increasing, but the perioperative management of these patients has not been well described. The purpose of this retrospective study was to identify the perioperative management of patients undergoing peripartum hysterectomy at Duke University Hospital in order to develop an effective protocol for management of these patients at our institution.
Methods: We identified patients admitted to the Duke Birthing Center at Duke University Hospital between January 1, 2003 and September 26, 2012 who had a peripartum hysterectomy from the electronic anesthesia database. Patient characteristics, indication for hysterectomy, anesthesia technique, estimated blood loss, blood product utilization, need for invasive monitoring, interventional radiology procedures and frequency of post operative ventilation and ICU admission were analyzed. Data were summarized as median (IQR) or n (%).
Results: We have identified 43 patients to date. 77% (33/43) of patients who underwent peripartum hysterectomy were multiparous women and 51% (22/43) had a history of prior cesarean section. Abnormal placentation and uterine atony accounted for 67% (29/42) of patients. The anesthetic technique fell into 3 major categories: 28% (12/43) were performed under neuraxial anesthesia only, 14% (6/43) were performed under general anesthesia (GA) and 58% (25/43) were converted from a regional anesthetic for vaginal or cesarean delivery to a GA for hysterectomy. 86% (37/43) of patients had an arterial line and 40% (17/43) had central venous access established intraoperatively. The median estimated blood loss was 3500 ml (2750, 5000 ml). 97% (42/43) of patients required transfusion of blood products intraoperatively. The median intraoperative PRBC transfusion was 5 units (3,12 units) and the median intraoperative FFP transfusion was 2 units (2,9 units). Platelets were administered to 40% (17/43) while 35% (15/43) received cryoprecipitate intraoperatively. 12% (5/43) of patients received factor VII and 9% (4/43) of patients required a vascular interventional radiology procedure in addition to a hysterectomy to control bleeding. At the conclusion of the operative procedures 50% (21/42) of patients required postoperative ventilation and 57% (24/42) were admitted to the ICU. There was one intraoperative death from uncontrolled bleeding.
Summary: Our findings highlight the significant transfusion requirements for peripartum hysterectomy patients and the variability in perioperative anesthetic technique. These differences in anesthesia technique are likely based on the urgency of the hysterectomy and anticipated blood loss. Based on the significant resources required, successful management of these patients requires a carefully coordinated multidisciplinary approach which we have implemented at our institution.