Emergency hysterectomy in a tertiary care hospital: Indications, surgical outcomes and challenges: A 2year retrospective descriptive cross-sectional study

  • Pan African Medical Journal, Volume 37, Year 2020

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Study Justification:
– Emergency hysterectomy is a life-saving procedure for life-threatening obstetric hemorrhage and other gynecological emergencies.
– Understanding the indications, surgical outcomes, and challenges of emergency hysterectomy in a tertiary care hospital is crucial for improving patient care and outcomes.
– This study aims to provide valuable insights into the prevalence and management of emergency hysterectomy, which can inform clinical practice and policy decisions.
Study Highlights:
– The study analyzed data from 146 emergency hysterectomies performed over a two-year period.
– The main indication for emergency hysterectomy was primary postpartum hemorrhage (73.28%).
– Other indications included uterine perforation with necrosis (8.9%), secondary postpartum hemorrhage (4.8%), choriocarcinoma and pelvic abscess (2.74% each), and broad ligament hematoma (2.06%).
– Uterine atony (54.20%) was the most common indication for emergency hysterectomy due to primary postpartum hemorrhage.
– The majority of surgeries (91.78%) were total abdominal hysterectomies, while 8.22% were subtotal hysterectomies.
– Intraoperative complications were rare, with bowel injury (2.04%), bladder injury (0.68%), and maternal death (0.68%) being the most frequent.
– Skilled doctors above the level of a Specialist performed most of the surgeries (89.73%).
Recommendations for Lay Reader and Policy Maker:
– Improve timely referral of patients to tertiary centers for prompt management of obstetric and gynecological emergencies.
– Enhance access to blood products to ensure adequate supply during emergency hysterectomies.
– Strengthen training programs for healthcare professionals to enhance surgical skills in emergency hysterectomy.
– Promote awareness and education on the prevention and management of primary postpartum hemorrhage, including uterine atony and ruptured uterus.
– Develop protocols and guidelines for the management of emergency hysterectomy to ensure standardized and optimal care.
Key Role Players:
– Obstetricians and gynecologists
– Surgeons
– Anesthesiologists
– Nurses and midwives
– Hospital administrators
– Policy makers and government officials
Cost Items for Planning Recommendations:
– Training programs for healthcare professionals
– Blood product procurement and storage
– Equipment and surgical instruments
– Medications and anesthesia supplies
– Development and dissemination of educational materials
– Implementation of protocols and guidelines
– Monitoring and evaluation of interventions

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is a retrospective descriptive cross-sectional study, which provides valuable information on the indications, surgical outcomes, and challenges of emergency hysterectomy in a tertiary care hospital. The study setting is clearly described, and the study population is well-defined. Data collection and analysis methods are also explained. However, the abstract lacks information on the sample size and the statistical methods used for data analysis. Additionally, the abstract does not mention any limitations of the study. To improve the evidence, the authors could provide more details on the sample size, statistical analysis, and limitations of the study.

Introduction: emergency hysterectomy (EH) remains a life-saving procedure in cases of lifethreatening obstetric hemorrhage and other gynaecological emergencies. We aim to determine the indications, surgical outcomes and challenges of EH in our tertiary centre. Methods: an ethically approved retrospective descriptive cross-sectional study on all EHs performed at a tertiary hospital during the period of 1st January 2018 to 31st December 2019 was conducted. Medical records of eligible patients were retrieved, reviewed and analysed using frequencies and percentages and then summarized in tables. Results: there were 146 EHs over the two year period. The age of participants ranged from 19 to 59 years, with a mean of 34.3 years (SD = 6.06). SD: standard deviation.The main indication for EH was primary postpartum haemorrhage (PPH): 73.28% (n = 110/146). The other indications were uterine perforation with necrosis: 8.9% (n = 13/146), secondary postpartum haemorrhage: 4.8% (n = 7/146), choriocarcinoma and pelvic abscess: 2.74% (n = 4/146) each and broad ligament haematoma: 2.06% (n = 3/146). There were 3.42% (n = 5/146) which were classified as ‘others **’: two cases of ovarian cyst torsion; one case of placental site tumour; one case of incomplete septic abortion; one case of bulky multinodular fibroid uterus with severe unremitting lower abdominal pain.The most common indication for the subgroup of hysterectomy due to PPH was uterine atony 54.20% (n = 60/110), followed by ruptured uterus20.56% (n = 23/110) and then, morbidly adherent placenta 14.95% (n = 16/110). Placenta accreta constituted 62.5% (n = 10/16) of the morbidly adherent placenta.There were 91.78% (n=134/146) total abdominal hysterectomies and 8.22% (n = 12/146) subtotalhysterectomies. About eighty percent 79.45% (n = 116/146) of the surgeries required general anaesthesia, 15.07% (n = 22/146) required regional anaesthesia whilst 5.48% (n = 8/146) were started as regional anaesthesia but were converted to general anaesthesia.There were no associated intraoperative complications in 96.60% (141/146) of the cases. The most frequent intraoperative complications included bowel injury 2.04% (3/146), bladder injury 0.68% (1/146) and maternal death 0.68% (1/146).Twoof the three bowel injuries required bowel resection and anastomosis. Most of the surgeries 89.73% (n = 131/146) were performed by skilled doctors above the level of a Specialist. Major challenges faced include delayed referral of patients to the tertiary centre for prompt management and lack of quick access to blood products. Conclusion: emergency hysterectomy is performed in women who are relatively young with primary postpartum haemorrhage as the commonest indication but there are other nonobstetric indications for this emergency surgery. Though a challenging procedure, it is safe in the hands of a skilled surgical team.

Study setting: this retrospective descriptive cross-sectional study was conducted at the Obstetrics and Gynaecology Department of Komfo Anokye Teaching Hospital (KATH), Kumasi. KATH is a 1300 bed capacity hospital and is the second largest tertiary hospital in Ghana serving as the major referral centre for the middle and northern sectors of Ghana. It is also designated as a training and teaching facility for the Kwame Nkrumah University of Science and Technology School of Medicine and Dentistry (KNUST/KSMD), Kumasi, and offers specialised or scientific clinical care, research and teaching. Study population: the scope of this study was limited to women who underwent emergency hysterectomy (EH) (obstetric and non-obstetric) over the period 1st January 2018 to 31st December 2019. The emergency obstetric hysterectomies (EOH) were the emergency hysterectomies performed for hemorrhage unresponsive to other therapeutic interventions at the time of delivery (cesarean section or vaginal delivery) or subsequently within the defined period of puerperium (42 days). Study design and data collection: the medical records (theatre and case notes) of all women who underwent emergency hysterectomy during the study period were retrieved, reviewed and analyzed. A data capture form (proforma), designed for the purpose of this study was used to capture the data. A research assistant (a Resident in the department) was taken through training to ensure data extraction was efficient. Data extraction was conducted by the research assistant and the corresponding author. Included in the study were women who underwent emergency hysterectomy in the Obstetrics and Gynaecology Directorate of Komfo Anokye Teaching Hospital (KATH), Kumasi over the period 1st January 2018 to 31st December 2019. Excludedfrom the study were women who underwent emergency hysterectomy outside KATH, women who had elective hysterectomy at KATH and women who meet the inclusion criteria but have incomplete medical records. Information extracted from the medical records included socio-demographic data and surgical information: mainly age, indication for the hysterectomy, type of hysterectomy (total or subtotal). Other data were any additional procedures performed, intraoperative complications, the type of anaesthesia used and the grade of the main operator/surgeon. Data analysis: the data collected was coded and entered into a pre-designed data collection proforma. No patient identifiable information was documented. The information was then entered onto a Microsoft Excel Spread sheet. The data was then cleaned and those with incomplete data excluded. The final data was then analysed using STATA version 10. The data was password protected and accessible to only the investigators. The analysis was focused on the indications and surgical outcomes of the hysterectomy.In computing the sociodemographic and surgical characteristics of the study participants, measures of central tendencies (mean, standard deviation) were used while frequencies and percentages were used to compute continuous variables and then summarized in tables. Ethical clearance: ethical clearance was obtained from the Institutional Review Board for Research and Development (IRB/ R&D) of the Okomfo Anokye Teaching Hospital.

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Based on the provided information, it seems that the study is focused on analyzing emergency hysterectomy procedures performed at a tertiary care hospital in Ghana. The study aims to determine the indications, surgical outcomes, and challenges associated with emergency hysterectomy.

To improve access to maternal health, some potential recommendations based on the findings of this study could include:

1. Strengthening referral systems: Addressing the issue of delayed referral by improving communication and coordination between primary healthcare facilities and tertiary care centers. This could ensure that pregnant women with complications are promptly referred to the appropriate level of care.

2. Enhancing blood transfusion services: Given the reported challenge of lack of quick access to blood products, efforts could be made to improve blood transfusion services at the tertiary care hospital. This may involve establishing blood banks, ensuring an adequate supply of blood products, and implementing efficient systems for blood transfusion.

3. Training healthcare providers: Since the majority of surgeries were performed by skilled doctors above the level of a Specialist, it may be beneficial to provide training and capacity-building opportunities for healthcare providers at all levels. This could help improve the availability of skilled surgeons and enhance the quality of emergency obstetric care.

4. Increasing awareness and education: Conducting awareness campaigns and educational programs targeted at both healthcare providers and the community can help raise awareness about the signs and symptoms of obstetric emergencies. This could lead to early recognition and timely referral, ultimately improving maternal outcomes.

5. Strengthening data collection and analysis: Continuously collecting and analyzing data on emergency hysterectomy procedures can provide valuable insights into the trends, causes, and outcomes of obstetric emergencies. This information can guide evidence-based decision-making and help identify areas for improvement in maternal healthcare services.

It is important to note that these recommendations are based on the limited information provided and should be further evaluated and tailored to the specific context and needs of the healthcare system in Ghana.
AI Innovations Description
Based on the provided description, the recommendation to improve access to maternal health based on the study findings could include the following:

1. Strengthening referral systems: Address the challenge of delayed referral by improving communication and coordination between primary healthcare facilities and tertiary care hospitals. This can ensure that pregnant women with complications are promptly referred to the appropriate level of care for timely management.

2. Enhancing blood transfusion services: Improve access to blood products by establishing blood banks or blood transfusion services within or in close proximity to tertiary care hospitals. This can help address the challenge of limited availability of blood products during emergency hysterectomies and other obstetric procedures.

3. Training and capacity building: Provide training and continuous professional development opportunities for healthcare providers, particularly in the management of obstetric emergencies and surgical procedures. This can help ensure that skilled doctors are available to perform emergency hysterectomies and other life-saving interventions.

4. Community education and awareness: Conduct community outreach programs to raise awareness about the importance of antenatal care, early recognition of complications, and timely referral to appropriate healthcare facilities. This can help empower women and their families to seek timely and appropriate care during pregnancy and childbirth.

5. Research and quality improvement: Encourage further research and quality improvement initiatives to identify and address the underlying causes of obstetric emergencies leading to emergency hysterectomies. This can help inform evidence-based interventions and strategies to prevent or manage these complications more effectively.

It is important to note that these recommendations should be tailored to the specific context and healthcare system of the setting in question.
AI Innovations Methodology
Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can improve access to maternal health by allowing pregnant women in remote areas to consult with healthcare professionals through video calls or phone calls. This can help in providing timely advice, monitoring, and support during pregnancy.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources related to maternal health can empower pregnant women with knowledge and enable them to make informed decisions. These apps can provide information on prenatal care, nutrition, exercise, and track important milestones during pregnancy.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in underserved areas can improve access to maternal health services. These workers can also help in identifying high-risk pregnancies and referring them to appropriate healthcare facilities.

4. Transportation solutions: Lack of transportation is a major barrier to accessing maternal health services in many areas. Implementing transportation solutions such as ambulances or mobile clinics can ensure that pregnant women can reach healthcare facilities in a timely manner, especially during emergencies.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population that will benefit from the innovations, such as pregnant women in rural areas or low-income communities.

2. Collect baseline data: Gather data on the current access to maternal health services in the target population, including factors such as distance to healthcare facilities, availability of healthcare professionals, and utilization rates of maternal health services.

3. Introduce the innovations: Implement the recommended innovations, such as telemedicine services, mHealth applications, community health worker programs, or transportation solutions, in the target population.

4. Monitor and collect data: Continuously monitor the implementation of the innovations and collect data on key indicators, such as the number of telemedicine consultations, app usage rates, community health worker activities, and transportation utilization.

5. Analyze the data: Analyze the collected data to assess the impact of the innovations on improving access to maternal health services. This can include measuring changes in utilization rates, reduction in travel time, increase in knowledge and awareness, and improvement in health outcomes.

6. Evaluate and refine: Evaluate the effectiveness of the innovations and identify areas for improvement. Refine the interventions based on the findings to optimize their impact on improving access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommended innovations and assess their effectiveness in improving access to maternal health services.


Statistics:
Citations: 1
Identifiers:
DOI: 10.11604/pamj.2020.37.106.25393
Research Areas:
Cancer, Community Interventions, Health System and Policy, Maternal and Child Health, Sexual and Reproductive Health, Technology and Innovations, Violence and Injury, Workforce
Study Countries:
Ghana
Study Design:
Cohort Study, Cross Sectional Study, Grounded Theory
Study Approach:
Mixed-methods, Quantitative, Systematic Review
Participants Gender:
Female
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