Peripartum Hysterectomy Complications

Peripartum (emergency or planned) hysterectomy is removal of the uterus at or within 24 hours (some definitions up to 6 weeks) of delivery, performed for life threatening haemorrhage or sepsis. Incidence is about 0.2 to 1 per 1,000 deliveries (higher in settings with high caesarean rates).

Indications: uterine atony (about 20 to 40%), placenta accreta spectrum (about 30 to 50% and rising), uterine rupture, praevia and abruption, extension of uterine incision, uterine infection with necrosis, and refractory bleeding. It carries high morbidity (about 50 to 60% have at least one complication) and mortality (about 0.5 to 3%).

Complications:

• Haemorrhage and coagulopathy: massive transfusion, DIC, dilutional coagulopathy, hypothermia and acidosis (lethal triad), transfusion reactions, TRALI, TACO, hypocalcaemia and hyperkalaemia
• Urinary tract injury: bladder injury (about 5 to 15% in accreta cases) and ureteric injury (about 1 to 3%), vesicovaginal or ureterovaginal fistula
• Bowel injury, vascular injury, nerve injury
• Infection: wound infection, pelvic abscess, vaginal cuff cellulitis, sepsis, necrotising fasciitis
• Venous thromboembolism (high risk: surgery, haemorrhage, transfusion, sepsis)
• Organ dysfunction: acute kidney injury, ARDS, cardiac failure, hepatic dysfunction, Sheehan syndrome
• Abdominal wall: dehiscence, haematoma, incisional hernia, and adhesions
• Psychological: grief, depression, PTSD, loss of fertility, body image issues
• Surgical menopause if oophorectomy performed

• Persistent haemodynamic instability, ongoing bleeding (abdominal distension, drain output, falling haemoglobin), oliguria, and haematuria suggesting urological injury
• Postoperative fever, abdominal pain, ileus, foul discharge or wound infection
• Leaking urine per vagina (fistula, days to weeks later), flank pain and hydronephrosis (ureteric ligation or injury)
• Dyspnoea, chest pain, leg swelling (venous thromboembolism, pulmonary oedema, transfusion related lung injury)
• Bruising, mucosal bleeding (coagulopathy)
• Low mood, anxiety, intrusive memories

• Postoperative monitoring: vital signs, urine output, drain volume, blood count, coagulation tests (fibrinogen, PT, aPTT), lactate, electrolytes (potassium, calcium, magnesium), renal and liver function, and arterial blood gas
• Imaging: ultrasound or CT abdomen and pelvis with contrast for haematoma, abscess, bowel injury; CT urogram (delayed phase) or cystogram for urinary tract injury; CT pulmonary angiography for PE; chest radiograph for pulmonary oedema or ARDS
• Creatinine of drain fluid and urea for urine leak confirmation
• Wound swabs and blood cultures for infection
• Screening for depression and PTSD

• Prevention: early decision for hysterectomy in refractory haemorrhage (before coagulopathy develops), senior surgeon and anaesthetist, planned accreta management with multidisciplinary team, ureteric stents when anatomy is distorted, and cell salvage.
• Intraoperative: damage control surgery (rapid haemostasis, pelvic packing, temporary closure, return in 24 to 48 hours), correction of the lethal triad, massive transfusion protocol (red cells, plasma and platelets 1:1:1), tranexamic acid, fibrinogen replacement, calcium, and active warming.
• Early recognition and repair of urinary tract injury: bladder repair in two layers with 3-0 absorbable suture and catheter drainage for 10 to 14 days (cystogram before removal); ureteric injury repaired by stenting, reimplantation (ureteroneocystostomy), or nephrostomy; urology involvement.
• Postoperative ICU care: ventilatory and haemodynamic support, renal protection, and nutritional support.
• Infection: broad spectrum antibiotics (piperacillin tazobactam 4.5 g IV every 6 hours, or meropenem), source control (drainage of abscess, debridement), and culture directed therapy.
• Thromboprophylaxis: enoxaparin 40 mg daily (adjust for weight and renal function; 40 mg twice daily for BMI above 40) started 12 to 24 hours after surgery once bleeding is controlled, combined with compression stockings, and continued for 6 weeks postpartum (10 days minimum).
• Fistula: continuous catheter drainage for small bladder fistulas; surgical repair after 3 to 6 months (or earlier for clean fistulas).
• Endocrine: assess and replace for Sheehan syndrome (hydrocortisone, levothyroxine) if features; hormone replacement therapy if bilateral oophorectomy in young women.
• Psychological support, debriefing, and counselling on fertility options (surrogacy, oocyte retrieval when ovaries retained).
• Follow up in a postnatal clinic and long term review for pelvic floor, bladder, and bowel function.