الفهرس 
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Abstract
Enhancing maternal and perinatal health in underdeveloped nations is heavily reliant on bolstering healthcare systems. Maternal mortality is a significant health measure in both developing and developed nations. The reflection of these characteristics encompasses a woman’s social and economic standing, as well as her nutritional condition throughout both her youth and adulthood. Moreover, maternal mortality serves as an indicator of the availability and effectiveness of antenatal care and delivery services, as well as the quality of these systems.
Common factors leading to maternal death in underdeveloped nations include haemorrhage, sepsis, problems arising from unsafe abortions, uteroplacental apoplexy, hypertensive disorders throughout pregnancy, and obstructed labour. Postpartum haemorrhage is a prominent factor contributing to maternal illness and mortality on a global scale. Peripartum hysterectomy is often done as a last resort when severe obstetric haemorrhage does not respond to other therapies. This procedure serves as an indication of severe postpartum haemorrhage. This technique is linked to significant maternal morbidity and leads to infertility.
Emergency peripartum hysterectomy (EPH) refers to the surgical removal of the uterus during childbirth or shortly after(within 6 weeks postpartum). The surgery is mostly performed as a life-saving measure for cases of ongoing obstetric haemorrhage caused by uterine atony, placental abnormalities, uterine rupture, lacerations after caesarean section, or fibroids. The first caesarean subtotal hysterectomy, performed with success resulting in the survival of both the mother and baby, was a notable advance. Subsequently, the procedure has seen enhanced safety due to advancements in surgical methodologies, anaesthesia administration, blood transfusion protocols, and antibiotic use. The indications for EPH have broadened to include both emergency and non-emergency issues, including elective hysterectomy during childbirth.
The occurrence of EPH, whether via vaginal or caesarean births, varies between 0.4 and 2.5 per 1,000 deliveries in the present day. The prevalence and causes of EPH fluctuate significantly across developing and developed nations owing to disparities in healthcare facilities. In industrialised countries, the primary reason for the rising number of caesarean sections and the related risks of abnormal placentation is the most frequent explanation. On the other hand, in poorer nations, unsupervised pregnancies and complex obstetric problems in women who have not received antenatal care are increasingly widespread. The frequency of peripartum hysterectomy is increasing due to several causes, including inadequate prenatal care, the presence of untrained and unsupervised delivery attendants, low levels of literacy, poverty, and limited transportation facilities. These issues persist despite efforts such as the Millennium Development Goals.
The incidence of risk factors for conditions that result in peripartum hysterectomy has grown due to changes in the characteristics of the birthing population and obstetric techniques. The primary factor leading to the unmanageable bleeding requiring an emergency peripartum hysterectomy (EPH) has changed since the 1980s. Abnormal placentation has surpassed uterine atony and rupture, mostly owing to improved care of uterine atony, decreased occurrence of uterine rupture, and the rising global rate of caesarean sections.
Additional risk factors linked to EPH include older maternal age, multiparous women, and multiple pregnancies. The incidence of emergency postpartum hysterectomy may be influenced by the growing number of caesarean deliveries and the expanding population of individuals with a scarred uterus, which might indirectly lead to a higher occurrence of emergency postpartum hysterectomy and its associated problems. Obstetricians are confronted with a difficult decision when deciding whether to adopt a cautious or assertive strategy in managing this situation. They must carefully consider the woman’s want to maintain her ability to have children, while also taking into consideration the potential danger of serious health problems or even death for the mother if emergency postpartum hysterectomy is delayed.
The significant occurrence of unbooked patients in developing nations, who undergo labour and delivery without proper supervision in health facilities, can be attributed to socio-cultural obstacles, low levels of literacy, female socioeconomic disadvantage, poverty, limited access to health facilities, and the utilisation of spiritual homes as maternity centres due to the belief that pregnancy complications are caused by spiritual attacks. Conversely, in developed nations with high rates of adult literacy, most patients are scheduled and give birth in well-equipped healthcare facilities staffed by competent professionals. These nations may have a reduced incidence of emergency peripartum hysterectomy due to factors such as the empowerment of women in terms of their socioeconomic status, the availability of sufficient critical obstetric care facilities, a high prevalence of contraceptive use, and a preference for having a modest family size.
The timing of a hysterectomy is crucial for achieving the best possible result, and it should neither be done too early nor too late. Obstetricians must strike a balance between dedicating excessive time to useless alternative procedures and opting for a definitive and life-saving hysterectomy. Procrastination may result in more bleeding and possibly dangerous consequences such as disseminated intravascular coagulation, significant loss of blood volume, inadequate oxygen supply to tissues, abnormally low body temperature, and acid buildup in the body, all of which further worsen the patient’s condition.
Delays in performing the emergency peripartum hysterectomy sometimes contribute to the high maternal mortality associated with this procedure. Delays include the patient’s failure to promptly get treatment during an obstetric emergency, as well as the wait in accessing a healthcare institution after making the decision to seek medical attention.
The objective of the present research was to ascertain the risk variables and outcomes associated with emergency peripartum hysterectomy (EPH) patients at Minia Maternity University Hospital.
This retrospective study was carried out in the Department of Obstetrics and Gynaecology, Faculty of Medicine, Minia University, specifically at the Minia Maternity University Hospital. The study period was from January 2021 until December 2022. During this time, a total of 74 emergency peripartum hysterectomies were done.
Summary of our results:
• According to the official statistics from Minia University Hospital, there were a total of 21,978 childbirths throughout the research period. Out of these, 74 cases (0.33%) required Emergency Peripartum Hysterectomy (EPH). The significance of this incidence rate lies in its ability to give a crucial assessment of the prevalence of EPH in the hospital’s obstetric care. The incidence rate of 0.33%, which corresponds to about 3.3 occurrences of EPH per 1,000 births, provides vital information on the hospital’s efficacy in managing delivery and its strategy for reducing such complications.
• According to EPH data, indications of EPH were abnormal placentation (PAS) in 49 (66.22%) patients, primary postpartum haemorrhage (PPH) and uterine atony occurred in 10 (13.51%) patients, secondary PPH occurred in 4 (5.41%) patients, ruptured uterus occurred in 6 (8.11%) patients, infections and sepsis occurred in 4 (5.41%) patients, and invasive mole was observed in 1 (1.35%) patient.
• The anaesthesia used was mostly general anaesthesia with endotracheal tube (ETT) in 70 (94.59%) patients, spinal anaesthesia in 2 (2.7%) patients, and spinal anaesthesia converted to general anaesthesia in 2 (2.7%) patients.The research included participants aged 19 to 42 years, with a mean age of 31.7 years and a standard deviation (SD) of 4.85 years. Regarding reproductive history, the median number of parity was 4, with an interquartile range (IQR) of 3 to 5. Likewise, the median number of the total number of pregnancies (gravidity), which includes both current and past pregnancies, was 5, with an interquartile range of 4 to 6.
• The mode of delivery was caesarean section (CS) in 67 patients, spontaneous vaginal delivery (SVD) in 6 patients, and vaginal birth after caesarean (VBAC) in 1 patient.
• Among the multigravida patients, only 1 (1.49%) had a caesarean section (CS) in their prior pregnancy.
• Among patients who had 1 previous CS, 10 (14.93%) had another CS in their current pregnancy.
• Among patients who had 2 previous CS, 11 (16.42%) had a CS in their current pregnancy.
• Among patients who had 3 previous CS, 14 (20.9%) had a CS in their current pregnancy.
• Among patients who had 4 or more previous CS, 32 (47.76%) had a CS in their current pregnancy.
• In terms of neonatal outcome, 10 neonates (14.71%) required admission to the Neonatal Intensive Care Unit (NICU), 48 newborns (70.59%) were discharged from the hospital, 8 neonates (11.76%) had intrauterine foetal demise (IUFD), and 2 neonates (2.94%) had an END.
• The haemoglobin levels were considerably reduced after the surgery compared to before the surgery (P value=0.002).
• The blood units varied from 1 to 17, with an mean value (± standard deviation) of 6.08 (±3.04). The FFP units varied from 1 to 6, with a mean value of 2.79 and a standard deviation of 1.37.
• Bladder injury was observed in 23 (31.08%) patients, while right adnexectomy was performed in 4 (5.41%) patients. Left adnexectomy was carried out in 1 (1.35%) patient, and DIC-related bleeding occurred in 1 (1.35%) patient. Ureteric injury was observed in 2 (2.7%) patients, and serosal intestinal injury occurred in 1 (1.35%) patient.
• Six patients (8.11%) had mortality.