A Nationwide Population-Based Cohort Study of Peripartum Hysterectomy and Arterial Embolisation in Belgium: Results from the Belgian Obstetric Surveillance System
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Downloaded from http://bmjopen.bmj.com/ on November 12, 2017 - Published by group.bmj.com Open Access Research A nationwide population-based cohort study of peripartum hysterectomy and arterial embolisation in Belgium: results from the Belgian Obstetric Surveillance System Griet Vandenberghe,1 Marine Guisset,2 Iris Janssens,3 Virginie Van Leeuw,4,5 Kristien Roelens,1 Myriam Hanssens,2 Erika Russo,6 Joachim Van Keirsbilck,7 Yvon Englert,4,8 Hans Verstraelen1 To cite: Vandenberghe G, ABSTRACT Strengths and limitations of this study Guisset M, Janssens I, et al. A Objectives To assess the prevalence of major obstetric nationwide population-based haemorrhage managed with peripartum hysterectomy cohort study of peripartum ► This is a nationwide study of Belgian maternities, and/or interventional radiology (IR) in Belgium. To describe hysterectomy and arterial with excellent participation and response rates embolisation in Belgium: results women characteristics, the circumstances in which the (98.8%). The cases were collected on a monthly from the Belgian Obstetric interventions took place, the management of the obstetric basis using the standard methodology of obstetric Surveillance System. BMJ Open haemorrhage, the outcome and additional morbidity of surveillance systems. 2017;7:e016208. doi:10.1136/ these women. ► This study describes how women with major bmjopen-2017-016208 Design Nationwide population-based prospective cohort obstetric haemorrhage were managed with study. ► Prepublication history and peripartum hysterectomy and/or interventional additional material for this Setting Emergency obstetric care. Participation of 97% of radiology according to circumstances. paper are available online. To maternities covering 98.6% of deliveries in Belgium. ► The study lacks a perspective on the overall picture view these files please visit the Participants All women who underwent peripartum of postpartum haemorrhage in Belgium, namely the journal online (http:// dx. doi. hysterectomy and/or IR procedures in Belgium between total number of women suffering severe postpartum org/ 10. 1136/ bmjopen- 2017- January 2012 and December 2013. haemorrhage, near-misses or death due to 016208). Results We obtained data on 166 women who underwent postpartum haemorrhage. Received 14 March 2017 peripartum hysterectomy (n=84) and/or IR procedures ► The study lacks denominator data of the women with Revised 6 June 2017 (n=102), corresponding to 1 in 3030 women undergoing postpartum haemorrhage who were successfully Accepted 7 June 2017 a peripartum hysterectomy and another 1 in 3030 women managed with other second-line measures. being managed by IR, thereby preserving the uterus. Therefore we cannot draw conclusions on the failure Seventeen women underwent hysterectomy following IR rate of intrauterine balloon tamponade, haemostatic and three women needed further IR despite hysterectomy. brace suturing and ligation of the uterine arteries. Abnormal placentation and/or uterine atony were the reported causes of haemorrhage in 83.7%. Abnormally invasive placenta was not detected antenatally in 34% arterial embolisations performed in this study were of cases. The interventions were planned in 15 women. appropriate or preventable. Three women were transferred antenatally and 17 women postnatally to a hospital with emergency IR service. Urgent peripartum hysterectomy was averted in 72% BACKGROUND of the women who were transferred, with no significant Emergency peripartum hysterectomy is the difference in need for transfusion. IR procedures were single most dramatic procedure in modern able to stop the bleeding in 87.8% of the attempts. obstetrics. The procedure is stressful and Disseminated intravascular coagulation secondary to surgically challenging, inevitably causing major haemorrhage was reported in 32 women (19%). additional maternal morbidity and, not Conclusion The prevalence in Belgium of major obstetric haemorrhage requiring peripartum hysterectomy and/ least, infertility. It is listed by the WHO as an or IR is estimated at 6.6 (95% CI 5.7 to 7.7) per 10 000 identification criterion for maternal near- 1 For numbered affiliations see deliveries. Increased clinician awareness of the risk miss, a concept that, in view of the very end of article. factors of abnormal placentation could further improve low maternal mortality rates in developed 2 Correspondence to the management and outcome of major obstetric country settings, was introduced as an analyt- Griet Vandenberghe; haemorrhage. A case-by-case in-depth analysis is ical tool to address health system failures with griet. vandenberghe@ uzgent. be necessary to reveal whether the hysterectomies and the overall goal of improving obstetric care.3 Vandenberghe G, et al. BMJ Open 2017;7:e016208. doi:10.1136/bmjopen-2017-016208 1 Downloaded from http://bmjopen.bmj.com/ on November 12, 2017 - Published by group.bmj.com Open Access Substandard care in the management of major obstetric participating maternity unit was invited by monthly haemorrhage continues to be a critical cause of maternal mailing to report a selected number of rare obstetric death and severe maternal morbidity in developed coun- complications that had occurred in the preceding tries.4 5 Every obstetric practitioner needs to be trained month or, alternatively, to state that there was ‘nothing in the management of postpartum haemorrhage in order to report’. In the event of such a case being reported, to guarantee an immediate response and a multidisci- the contact person was asked to complete an extensive plinary team approach. Internationally recognised guide- data collection form. Confidentiality was guaranteed for lines6–8 indicate that one or more second-line measures, mother, provider and hospital, and person-identifiable including intrauterine (balloon) tamponade, haemostatic information was eliminated from data analysis. In cases of brace suturing, ligation of the uterine arteries and inter- incomplete reporting, the appointed contact person was ventional radiology (IR), should be available in hospitals encouraged repeatedly by email and phone to provide with delivery units and that obstetric practitioners should the missing data, up to 6 months following the date of the be familiar with these procedures. Notably, the early original report. involvement of an experienced senior obstetrician, hence The participation of 97% of Belgian maternity units appropriate clinical judgement, can save lives: the timely (n=110/113) was obtained, covering 98.6% of deliveries decision to turn to a hysterectomy can avoid further blood (n=248 681) in the 2-year study period. Belgium has a rela- loss, risk of disseminated intravascular coagulation (DIC), tively large number of tertiary referral centres providing additional morbidity and finally death.6 neonatal intensive care (n=19) along with a high concen- While emergency peripartum hysterectomy serves as tration of small-volume maternity units (more than half the ultimate response to major obstetric haemorrhage, of all units) in which there are fewer than 1000 annual resorting to IR procedures on the pathway towards hyster- births. All tertiary referral centres, as well as some of the ectomy can be both life-saving and fertility-preserving. IR larger non-tertiary maternity services, have an emergency in this context basically involves intra-arterial balloon IR service. In answer to an enquiry of B.OSS contact occlusion or arterial embolisation of the uterine or the persons, 40 maternity units (38%) declared they had an internal iliac arteries. Research publications on the effec- IR service available in the hospital, and a further seven tiveness of IR procedures in obstetric settings reporting units declared that they had an IR service available but high success rates of 85%–95% are accumulating.9–12 not 24/7 or that they could call on vascular surgeons for Success rates should be interpreted with caution, similar procedures. however, as they may be driven by ascertainment bias. IR is cautiously suggested in guidelines and recommenda- Study period tions6–8 13 14 describing its possible role in obstetric emer- The study was conducted between January 2012 and gency settings, but further evidence is awaited before firm December 2013. recommendations can be made. Yet in the UK a national recommendation was made to provide a network of emer- Case definition gency IR services available to all trusts with delivery units B.OSS aimed to collect all cases of peripartum hysterec- in response to a Healthcare Commission Investigation tomy and IR at any gestational age corresponding to the into maternal deaths.13 15 following definition: any woman giving birth to a fetus The aims of this study are to investigate the popula- or infant and undergoing a hysterectomy and/or IR tion-based prevalence of peripartum hysterectomy and procedure in the same clinical episode. Most peripartum the indications to proceed to this intervention, likewise hysterectomies are emergency, life-saving interventions the prevalence of major obstetric haemorrhage managed following vaginal or caesarean delivery, most commonly with IR in Belgium. Furthermore, we aim to describe the performed to manage major obstetric haemorrhage but characteristics of the women in Belgium who required occasionally because of a severe pelvic infection. Hyster- these interventions in order to treat or prevent major ectomy in the first or second trimester, termed abor- obstetric haemorrhage, the circumstances in which the tion hysterectomy, is occasionally