Review
Prevalence, Indications, Risk Indicators, and
Outcomes of Emergency Peripartum
Hysterectomy Worldwide
A Systematic Review and Meta-analysis
Thomas van den Akker, MD, PhD, Carolien Brobbel,
and Kitty W. M. Bloemenkamp, MD, PhD
OBJECTIVE: To compare prevalence, indications, risk
indicators, and outcomes of emergency peripartum
hysterectomy across income settings.
DATA SOURCES: PubMed, MEDLINE, EMBASE, Clinical-
Trials.gov, and Cochrane Library databases up to March
30, 2015.
METHODS OF STUDY SELECTION: Studies including
emergency peripartum hysterectomies performed within
6 weeks postpartum. Not eligible were comments, case
reports, elective hysterectomies for associated gyneco-
logic conditions, studies with fewer than 10 inclusions,
and those reporting only percentages published in
languages other than English or before 1980. Interstudy
heterogeneity was assessed by x2 test for heterogeneity;
a random-effects model was applied whenever I2
exceeded 25%.
TABULATION, INTEGRATION, AND RESULTS: One
hundred twenty-eight studies were selected, including
7,858 women who underwent emergency peripartum
hysterectomy, of whom 87% were multiparous. Hyster-
ectomy complicated almost 1 per 1,000 deliveries (range
0.2–10.1). Prevalence differed between poorer (low and
lower middle income) and richer (upper middle and high
income) settings: 2.8 compared with 0.7 per 1,000 deliv-
From the Departments of Obstetrics and Clinical Epidemiology, Leiden
University Medical Center, Leiden, and the Department of Obstetrics,
Wilhelmina Children’s Hospital Birth Center, University Medical Center
Utrecht, Utrecht, the Netherlands.
The authors thank J. W. M. Plevier for her help with the literature search.
Corresponding author: Thomas van den Akker, MD, MSc, MPhil, PhD,
Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2,
2333ZA Leiden, the Netherlands; e-mail: t.h.van_den_akker@lumc.nl.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2016 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/16
VOL. 128, NO. 6, DECEMBER 2016
Copyright ª by The American College of Obstetricians
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MD, Olaf M. Dekkers, MD, PhD,
eries, respectively (relative risk 4.2, 95% confidence
interval [CI] 4.0–4.5). Most common indications were
placental pathology (38%), uterine atony (27%), and uter-
ine rupture (26%). Risk indicators included cesarean
delivery in the current pregnancy (odds ratio [OR]
11.38, 95% CI 9.28–13.97), previous cesarean delivery
(OR 7.5, 95% CI 5.1–11.0), older age (mean difference
6.6 years between women in the case group and those
in the control group, 95% CI 4.4–8.9), and higher parity
(mean difference 1.4, 95% CI 0.7–2.2). Having attended
antenatal care was protective (OR 0.12, 95% CI 0.06–
0.25). Only 3% had accessed arterial embolization to
prevent hysterectomy. Average blood loss was 3.7 L.
Mortality was 5.2 per 100 hysterectomies (reported range
0–59.1) and higher in poorer settings: 11.9 compared
with 2.5 per 100 hysterectomies (relative risk 4.8, 95%
CI 3.9–5.9).
CONCLUSION: Emergency peripartum hysterectomy is
associated with considerable morbidity and mortality
and is more frequent in lower-income countries, where it
contains a higher risk of mortality. A (previous) cesarean
delivery is associated with a higher risk of emergency
peripartum hysterectomy.
(Obstet Gynecol 2016;128:1281–94)
DOI: 10.1097/AOG.0000000000001736
P
eripartum hysterectomy was invented to manage
life-threatening obstetric hemorrhage and uterine
sepsis and was first performed successfully by Porro in
1871.1 By the 1950s, it had become an elective pro-
cedure (including for sterilization) and became contro-
versial as a result of the risk of blood loss and urinary
tract injury.2,3 Today, emergency peripartum hyster-
ectomy is performed as a life-saving operation only.
The term includes hysterectomies after cesarean deliv-
ery as well as vaginal delivery.
OBSTETRICS & GYNECOLOGY 1281
 Need for hysterectomy may change over time
and is context-specific. Availability of blood trans-
fusion and other interventions (eg, uterotonic agents,
B-Lynch sutures, and arterial embolization) may
have reduced need. Contrastingly, increasing cesar-
ean delivery rates globally may lead to a higher
incidence of placental pathology and therefore
hysterectomy.4–11 In the face of unremitting hemor-
rhage, obstetricians face a dilemma: perform the
procedure (balancing risks of surgery and possible
desire of the woman to preserve fertility) or delay
while attempting other therapies that may result in
severe morbidity or death.
Rossi et al12 published the first systematic
review on emergency peripartum hysterectomy in
2010. They included studies performed in high-
income settings for obstetric hemorrhage. The pro-
cedure is, however, performed for a wider range of
indications and across all income settings. Knowl-
edge of differences across settings could stimulate
quality improvement.
We have three purposes: first, to estimate and
compare prevalence of emergency peripartum hyster-
ectomy across different income settings; second, to
determine indications, risk indicators, and outcomes;
and third, to compare associated factors and outcomes
between income settings.
SOURCES
A systematic search of the PubMed, MEDLINE,
EMBASE, ClinicalTrials.gov, and Cochrane Library
databases up to March 30, 2015, was undertaken with
help from a qualified librarian (Appendix 1, available
online at http://links.lww.com/AOG/A884). Referen-
ces were searched to track additional studies. Publica-
tions not in English and before 1980 were excluded.
Full-text articles not available digitally or in our univer-
sity library were retrieved from elsewhere if the journal
had an impact factor above one in April 2015 as in-
dexed by the Science Citation Index. Preferred Report-
ing Items for Systematic Reviews and Meta-Analyses
was applied (http://www.prisma-statement.org).
STUDY SELECTION
Study selection was performed independently by two
of the authors (C.B. and T.v.d.A.). Every article in
which emergency peripartum hysterectomy was per-
formed within 6 weeks postpartum for acute obstetric
conditions was eligible. Although definitions varied
between studies, we included papers as long as the
postpartum interval did not exceed 6 weeks. Only
studies that allowed for differentiation between elec-
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tive and emergency hysterectomies were included
(with exclusion of elective gynecologic procedures).
For analysis of risk factors and outcomes, we
included controlled studies. The control group
included all women who delivered during the same
period as women in the case group within a specific
study and did not undergo emergency peripartum
hysterectomy.
Cohort, case–control, or cross-sectional studies
were eligible if data were reported in tables or text.
Excluded were comments, case reports, personal
communications, studies with sample size below 10,
or reporting only percentages without the possibility
to extract absolute numbers.
Quality assessment of studies was performed
using an adaptation of the Newcastle-Ottawa scale.13
Selection bias was considered if cases were not con-
secutively or randomly sampled from a defined hos-
pital or region over a defined period of time (cohort
studies) or if controls were not from the same source
population as cases (case–control studies). In cohort
studies, selection bias was considered if the cohort was
not representative of the pregnant population the
cohort was taken from, if nonexposed and exposed
cohorts were from different populations, or if the
outcome of interest was already present at onset.
Information bias was considered if case or cohort
definition was inadequate, meaning that postpartum
interval, gestational age at delivery, or indications for
hysterectomy were not specified.
Estimating prevalence was considered more reli-
able in population-based compared with hospital-
based studies to avoid bias based on referral of
complex patients to tertiary hospitals or omission of
those women with home deliveries.
Confounding was considered when confounders
were not adequately identified. Maternal age, parity,
ethnicity, number of previous births, gestational age,
multiple pregnancy, and mode of delivery were
considered potentially relevant confounders.
Data extraction was done by two of the authors
(T.v.d.A. and C.B.). Multiple studies published by the
same author(s) were checked for overlap of included
participants. Each country was classified as low (Gross
National Income per capita $1,025 U.S. or less), lower
middle ($1,026–4,035), upper middle ($4,036–
12,475), or high-income ($12,476 or greater).14 Statis-
tical analysis was performed using SPSS 16.0 and
meta-analysis using RevMan 5.3.
Prevalence was extracted from each study. Stud-
ies reporting only cesarean or postpartum hysterecto-
mies without a denominator were excluded from
prevalence estimation. Proportions were pooled in
OBSTETRICS & GYNECOLOGY
a fixed-effect analysis. Proportions per income setting
were compared by relative risk calculation. A differ-
ence was considered significant if the 95% confidence
interval (CI) of the relative risk did not encompass 1.
Maternal characteristics included age, parity, ges-
tational age, antenatal care registration, and previous
uterine surgery. Obstetric characteristics included:
mode of delivery, indications for hysterectomy, and
hysterectomy type (subtotal compared with total
abdominal). Placenta accreta, increta, and percreta were
pooled as “abnormally invasive placenta.”15 Preventive
measures included medical interventions and mechani-
cal measures. Complications were grouped by type.
Maternal outcomes included duration of sur-
gery, postoperative care, blood loss and transfusion,
complications, and maternal mortality. Perinatal
mortality was used as neonatal outcome. Some
studies reported other neonatal outcomes but these
varied greatly between studies and were therefore
not included.
Main indications for hysterectomy were estimated
per income setting and compared using x2 test for
linear trend with prevalence in low-income settings
as baseline. Registration for antenatal care, hysterec-
tomy type, blood transfusion, and maternal and peri-
natal mortality was also compared. Differences were
considered significant if the P value was ,.05.
Studies using women in a control group were
included to determine risk indicators if these were
reported in at least three studies. Interstudy hetero-
geneity was assessed using x2 test for heterogeneity.16
A random-effect model was applied whenever the I2
statistic exceeded 25%. Pooled odds ratio (OR) with
95% CI was calculated for categorical variables. Con-
tinuous variables were examined with estimation of
pooled mean difference and 95% CI (inverse variance
weighting).
RESULTS
Inclusion is summarized in Fig. 1. One hundred
twenty-nine articles with collectively 7,858 women
were selected (Appendix 2, available online at
http://links.lww.com/AOG/A884); 193 (2.5%) were
women from low income,17,18 2,022 (25.7%) from
lower middle income,6,19–55 1,406 (17.9%) from upper
middle income,5,9,56–80 and 4,237 (53.9%) from high-
income settings.1,4–6,9,10,17–50,51–90,91–110,111–139 Two
studies were analyzed as one (same sample),4,113 so
the total number of papers was considered 128.
In 58 of 128, case definitions were incom-
plete.1,6,17,19,20,23–29,31,33,34,37,38,40,41,43,45–53,57,58,60,62,
64,72,78,83,86,87,93,94,96,105–109,112,114,118–121,126–128 All
others used a complete definition, but these
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varied widely. In nine studies, cases were
defined as women who underwent emergency
peripartum hysterectomy within 6 weeks postpar-
tum,32,59,70,84,99,113,116,117,139 in 45 within 24 hours
postpartum,5,9,18,22,30,35,36,39,42,54,55,61,63,67–69,71,73–77,
79–82,90–92,95,97,98,100,103,104,111,115,122–124,129,130,133,135–137
and in 17 within another time range (but within 6
weeks).10,21,44,56,65,66,85,88,89,101,102,110,125,131,132,134,138
Twenty-seven studies only included patients after
24 weeks of gestation1,5,20,30,61,64–66,80,82,87,90,91,93,94,
97–102,108,117,121,126,129,135 and nine after any gesta-
tional age.4,23,29,34,46,47,51,113,131,139 All other studies
used other cutoffs or did not report any. In three,
indications for emergency peripartum hysterectomy
were not mentioned, but these explicitly excluded
women with elective hysterectomies and were there-
fore selected.17,70,88
Study period was clearly defined in all studies.
One study used random21; all others used consecutive
sampling. In all controlled studies, controls were from
the same source population as cases.
Eleven studies were population-based4,10,59,76,88,
101,103,104,107,113,125,139 and 117 were hospital-based
(four multicenter).57,65,80,90
Five case–control studies reported multivariate
analysis.4,88,119,126,138 Confounders mentioned were
maternal age, parity, and gestational age. Two men-
tioned analysis of confounding but no multivariate
analysis.87,110
All but three studies88,89,118 mentioned preva-
lence of emergency peripartum hysterectomy; four
were excluded from prevalence estimation, because
these reported only cesarean21,71,79 or postpartum136
hysterectomies. As a result, 6,796 emergency peripar-
tum hysterectomies performed in 7,858,250 deliveries
were included for estimation of prevalence: overall
weighted mean prevalence 0.9 per 1,000 deliveries.
Prevalence in low and lower middle income settings
was much higher than in upper middle and high-
income settings: 2.8 compared with 0.7 per 1,000
deliveries (relative risk 4.2, 95% CI 4.0–4.5). Preva-
lence ranged from 0.2 in Norway,100 Denmark,125 Ire-
land,132 and Turkey75 to 10.1 per 1,000 deliveries in
India.34 Fig. 2 shows weighted mean prevalence per
country.
Maternal age ranged from 1185 to 54117 years,
mean age from 26.299 to 37.9126 years, and mean
gestational age from 34.4124 to 39.077 weeks (weighted
mean 37.0 weeks of gestation).
Parity was mentioned in 82 studies for 5,432
women,19–21,23,24,56,58,60,86–88,90,92–96 of whom 4,738
(87.2%) were multiparous. Weighted mean parity
was 4.0 (range 1.173 to 9.557).
Emergency Peripartum Hysterectomy Worldwide 1283
Fig. 1. Flowchart showing selection of studies included in the meta-analysis.
van den Akker. Emergency Peripartum Hysterectomy Worldwide. Obstet Gynecol 2016.

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Fig. 2. World map showing prevalence of emergency peripartum hysterectomy per country. Image created using
mapchart.net.
van den Akker. Emergency Peripartum Hysterectomy Worldwide. Obstet Gynecol 2016.

Registration for antenatal care was mentioned in
38 studies for 1,946 women19,20,24–31,60,65,66,83,98;
1,230 (63.2%) were unregistered.
Prior uterine surgery was assessed in 75 studies
for 4,289 women20,22,27,28,56,60,61,64–66,81–87,90,93,95–
99,101,102,104,105,108,110: 1,988 (46.4%) had undergone
previous cesarean delivery (of whom 53.3% two or
more cesarean deliveries) and 474 (11.1%) other uter-
Type of hysterectomy was not reported or
unknown in 2,763 (35.2%) women. In the remaining
5,095 (64.8%), there were 2,601 (51.1%) total abdom-
inal and 2,494 (48.9%) subtotal hysterectomies.
Measures to treat hemorrhage (and prevent hyster-
ectomy) were given in 37 studies for 2,155
women.5,10,26,58,60,61,64,66,70,74,75,80,84,85,87,92,93,95,97,100,102,
104,105,111,113,116,117,119,123,125,126,129,133,136–139 Oxytocin

ine surgery. Previous abortions or miscarriages were
mentioned in six studies for 440 women, of whom 174
(39.5%) had either.22,70,105,112,119,121
Four studies were excluded from analysis of
mode of delivery in the index pregnancy, because
these reported cesarean21,71,79 or postpartum136
hysterectomies only. Mode of delivery was either
not reported or unknown in 1,413 (18.4%) women.
Of the 6,279 (81.6%) remaining women, 4,739
(75.5%) delivered by cesarean and 1,540 (24.5%)
vaginally.
The most common indication was placental
and ergometrine were given to 1,846 (85.7%) women
and prostaglandins to 843 (39.1%). The most common
mechanical measures to prevent hysterectomy were
compressive measures (balloon tamponade, compres-
sive sutures, bimanual compression, and packing,
33%); embolization using interventional radiology was
performed in only 3% (Table 3).
Additional surgical or interventional radiology
procedures, during or after hysterectomy, were men-
tioned in 70 studies for 3,703 women
(Table 4).1,5,6,9,10,17–19,22,23,34,40,43,48–50,54,57,60–62,66,67–
71,73,78–80,84–87,90–92,95,97–103,105,106,111,113,114,116,117,120–

pathology (Table 1). Some women had more than 123,125,126,128–130,132,133,135,138,139

one indication. The three most common indications
(placental pathology, uterine atony, and uterine rup-
ture) were stratified according to income setting and
all differed significantly (Table 2). Placental pathology
was most common in high income (47.6% compared
with 37.6% in other settings, P,.01) and uterine rup-
Weighted mean operative time was 150.5 mi-
nutes; operative time ranged from 4580 to 48068
and mean time per study from 8064 to 21079 mi-
nutes. Of 2,024 women, 920 (45.5%) were admitted
into an intensive care unit postoperatively.10,17,22,24,30,32,
33,36,41,64,70,72,84,86,87,97,98,104–106,109,111,113,116,117,120,121,123,

ture in lower middle income settings (53.5% com- 127,133–135,137 Weighted mean stay at intensive care unit

pared with 25.7% in other settings, P,.01). was 2.5 days (range/study 1.733 to 3.872). One woman

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Table 1. Indications for Emergency Peripartum cells (weighted mean 8.1 units/person)1,17,22,23,
Hysterectomy 25,26,28,30–43,48,50,51,56,59–61,65–68,72,75–77,79,80,82–86,89–
95,97–99,104–106,108,111,113,114,116,121–124,126,127,129–131,133–
Prevalence 136,138,139; highest number of units of packed red
Indication (n56,765)
blood cells given to one woman was 232.84 Of
Placental pathology 2,542 (38) all women, 53.7% were given fresh frozen
Abnormally invasive placenta 1,276 (19) plasma,17,76,93,104,114,121,126,138,139 41.1% plate-
Placenta previa 650 (10) lets,104,132,138,139 17.3% fibrinogen, 60,139 14.7% cry-
Combined or unspecified placental 517 (8)
oprecipitate,104,138 8.7% recombinant factor
pathology
Placental abruption or couvelaire uterus 99 (1) VIIa,84,113,116,117,125,139 and 2.4% prothrombin
Uterine atony 1,819 (27) complex.116,139 Tranexamic acid was mentioned
Uterine rupture* 1,740 (26) in one study,100 given to 27.3% of women. Use of
Unspecified hemorrhage 352 (5) intraoperative blood salvage was mentioned in one
Infection† 129 (2)
study,104 given to 10.3%.
Cervical tear or laceration 85 (1)
Leiomyomas or myomas with major 56 (1) The number of women who received packed red
obstetric hemorrhage blood cells was mentioned for 165 of 193 (85.5%)
Disseminated intravascular coagulation 30 (,1) women from low income, 1,215 of 2,022 (60.1%) from
Hematoma‡ 26 (,1) lower middle income, 621 of 1,406 (44.2%) from
Abnormal pregnancy§ 12 (,1)
upper middle income, and 2,382 of 4,237 (56.2%)
Otherk 33 (,1)
Unknown 126 (2) from high-income settings. The proportions of women
who received packed red blood cells were 47.9% in
Data are n (%).
Percentages are for all 6,765 women and exceed 100% because low, 99.4% in lower middle, 94.7% in upper middle,
some had more than one indication. and 89.5% in high-income settings. Number of packed
* Includes both uterine rupture and extension of uterine incision. red blood cells packed red blood cells per person was
†
Includes endometritis, pelviperitonitis, chorioamnionitis, gangre-
nous uterus, puerperal sepsis, pelvic abscess, and hemorrhage mentioned for 28 of 193 (14.5%) women from
‡
due to resulting from these infections. low income, 684 of 2,022 (33.8%) from lower middle
Includes broad ligament, retroperitoneal, and unspecified hema- income, 661 of 1,406 (47.0%) from upper middle
toma.
§
Includes abdominal, cervical, molar, and ruptured cornual income, and 2,462 of 4,237 (58.1%) from high-income
k
pregnancy. settings. Number of packed red blood cells per person
Includes avulsion of uterine artery, uterine inversion, septic increased with increasing income setting (weighted
abortion, termination of pregnancy with perforation and heavy
bleeding, malignancy with hemorrhage, and sterilization. means 2.4 and 9.5 units per person in low- and high-
income settings, respectively). Women in the case
group lost more blood (mean difference 2.7 L, 95% CI
2.2–3.2, P,.01) and received red blood cell transfu-
stayed in the intensive care unit for 50 days.84 Hospital sion much more often (98/107 [91.6%] compared with
stay ranged from 15,22,63,78 to 24078 days with a weighted 1,315/146,348 [0.9%], P,.01, OR 650.37, 95% CI
mean of 10.7. 330.03–1,281.65).
Weighted mean estimated blood loss was 3.7 L; All but 1841,52,54,59,69,72,74,76,77,81,88,89,108,112,119,122,
highest reported blood loss in one woman in Hong 124,134 studies mentioned complications of emergency

Kong, who delivered by cesarean, was 40 L68; 4,006 peripartum hysterectomy, available for 5,704 (72.6%)
of 4,383 (91.4%) women received packed red blood women (Table 5). Maternal mortality was given in all

Table 2. Indications per Income Setting

Income Setting Placental Pathology Uterine Atony Uterine Rupture No. of Women

Low income 7 (25) 10 (36) 7 (25) 28

Lower middle income 403 (20) 349 (17) 1,077 (53) 2,022
Upper middle income 527 (39) 424 (32) 262 (20) 1,345
High income 1,605 (48) 1,036 (31) 394 (12) 3,370
Total 2,542 (38) 1,819 (27) 1,740 (26) 6,765
Data are n (%) unless otherwise specified.
Percentages are for all women per income setting.
x2 test for linear trend: x25399.59, P,.01; x2598.51, P,.01, x251,055.7, P,.01, respectively, for each column.

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Table 3. Mechanical Measures to Prevent Table 5. Complications After Emergency
Emergency Peripartum Hysterectomy Peripartum Hysterectomy

Measure Prevalence (n52,155) Complication Prevalence (n55,704 Women)

Compression* 702 (33) Hematologic* 1,477 (26)

Uterine balloon tamponade 179 (8) Febrile morbidity 1,071 (19)
Uterine compression sutures† 178 (8) Genitourinary† 570 (10)
Bimanual compression 170 (8) Wound‡ 566 (10)
Vaginal or uterine packing 167 (8) Infection§ 564 (10)
Artery ligation‡ 499 (23) Pulmonaryk 171 (3)
Fundal massage 210 (10) Renal¶ 149 (3)
Suturing of placental bed§ 166 (8) Gastrointestinal# 148 (3)
Curettage 114 (5) Thromboembolic** 57 (1)
Uterine artery embolization 62 (3) Cardiovascular†† 54 (1)
Manual removal of placentak 45 (2) Psychologic disturbance 54 (1)
Other¶ 120 (6) Neurologic‡‡ 7 (,1)
Data are n (%). Endocrinologic§§ 7 (,1)
Percentages are for all 2,155 women. Otherkk 71 (1)
* Including eight patients in whom compression was unspecified. UTI, urinary tract infection; RTI, respiratory tract infection.
†
Includes B-Lynch procedure and other or unspecified procedures. Data are n (%).
‡
Includes ligation of the uterine, ovarian, internal iliac, and Percentages are for all 5,704 women.
hypogastric arteries. * Includes bleeding, anemia, hypovolemic shock, hematomas, and
§
Includes suturing of bleeding points and cervical lacerations. coagulopathy.
k
Includes examination under anesthesia. †
Includes bladder or ureteric injury, fistula, incontinence, and
¶
Includes placenta left in utero, intraabdominal packing, internal urine retention.
iliac artery balloon placement, hot saline packs, lower segment ‡
Includes dehiscence, hematoma, infection or sepsis, and inci-
belt, securing of uterine angles, and unspecified measures. sional hernia.
§
Includes septicemia (pelvic, subphrenic, vaginal cuff) abscess,
thrombophlebitis, RTI, UTI, and peritonitis.
k
but five70,85,111,112,126 studies: 397 of 7,643 women Includes atelectasis, pneumothorax, pulmonary edema, pleural
died; mortality rate was 5.2 per 100 hysterectomies. effusion, acute respiratory distress syndrome, and ventilation
requirement.
Maternal mortality was reported for 193 of 193 ¶
Includes acute renal failure, hydronephrosis, oliguria, and hyper-
(100%) women from low income, 2,022 of 2,022 albuminosa.
#
(100%) from lower middle income, 1,345 of 1,406 Includes paralytic ileus, jaundice, liver dysfunction, ascites,
bowel injury, and intestinal obstruction.
(95.7%) from upper middle income and 4,078 of **
Includes deep vein thrombosis; pulmonary, air, amniotic fluid
4,237 (96.2%) from high-income settings. Mortality embolism.
††
was higher in low and lower middle income settings Includes cardiac arrest, myocardial infarction, heart failure, and
cardiomyopathy.
compared with upper middle and high-income settings: ‡‡
Includes stroke, seizure, and coma.
§§
11.9 compared with 2.5 per 100 hysterectomies (rela- Includes Sheehan syndrome and premature ovarian failure.
kk
tive risk 4.8, 95% CI 3.9–5.9). The maternal mortality Includes prolonged pain, reactive splenomegaly, multiorgan
failure, compartment syndrome, bed sores, anaphylactic shock,
rate was highest in lower middle income (12.1%) and and cortical blindness.
lowest in high-income settings (1.4%). Maternal mor-
tality rates ranged from none in some countries to
Perinatal mortality was given in 78 studies.1,5,6,9,10,18–
59.1%20 in one study from Nigeria (Fig. 3). 25,27–29,31–35,37,39–45,48–50,52,54,56–63,66,67,69,71,72,74–76,78,80–
82,84,85,92,94,97,100,102–104,106,107,109,114,116,117,120–122,124,129,

Table 4. Procedures in Addition to Hysterectomy 130,132,135,136 Overall perinatal mortality rate was 33.4%

(range none in several high-income countries to

Prevalence (n53,703 87.1%44). Perinatal mortality was mentioned for 28 neo-
Procedure Women) nates from low income, 1,669 from lower middle
Relaparotomy 333 (9) income, 1,052 from upper middle income, and 1,012
Salpingo-oophorectomy 214 (6) from high-income settings. Perinatal mortality was high-
Bladder or ureteral repair 110 (3) er in low and lower middle income settings compared
Artery ligation or embolization 30 (1) with upper middle and high-income settings: 56.5 com-
Other* 18 (,1)
pared with 14.5 per 100 children (relative risk 3.9,
Data are n (%). 95% CI 3.5–4.3). Perinatal mortality rate was highest
Percentages are for all 3,703 women.
* Includes abdominal packing, bowel repair, appendectomy, in lower middle income (57.2%) and lowest in high-
uterine curettage, and unspecified procedures. income settings (5.6%).

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Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Fig. 3. World map showing maternal mortality after emergency peripartum hysterectomy. Image created using
mapchart.net.
van den Akker. Emergency Peripartum Hysterectomy Worldwide. Obstet Gynecol 2016.
The maternal mortality rate was higher among
women who underwent hysterectomy (21/1,033
[2.03%]) compared with women who did not
(49/157,528 [0.03%], P,.01, OR 34.08, 95% CI
3.94–295.07). The perinatal mortality rate was higher
among women who underwent hysterectomy (19/107
[17.8%]) compared with women who did not (1,131/
112,553 [1.0%], P,.01, OR 15.09, 95% CI 6.10–37.37).
Antenatal care registration was mentioned for 165
of 193 (85.5%) women from low income, 1,319 of
2,022 (65.2%) from lower middle income, 326 of
1,406 (23.2%) from upper middle income, and 136
of 4,237 (3.2%) from high-income settings. The pro-
portion of unregistered women was highest in lower
middle income (930/1,319 [70.5%]) and lowest in
high-income settings (43/136 [31.6%]).
Hysterectomy type was mentioned for 193 of 193
(100%) women from low income, 1,916 of 2,022
(94.8%) from lower middle income, 994 of 1,406
(70.7%) from upper middle income, and 1,992 of
4,237 (47.0%) from high-income settings. Subtotal
hysterectomies were most common in lower middle
income (61.3%) and least common in low-income
settings (9.3%): 46.6% and 42.1% in upper middle
income and high-income settings, respectively.
Most studies mentioned mode of deliv-
ery.10,24,31,56,59,61,63,64,66,67,85–88,90–98,102–104,110,112,113,115–
117,119 Some mentioned other risk indicators. Women in
1288 van den Akker et al Emergency Peripartum Hysterectomy Worldwide
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
the case group were older (mean difference 6.63 years,
95% CI 4.41–8.85, P,.01), had higher parity (mean dif-
ference 1.41, 95% CI 0.65–2.18, P,.01), and lower ges-
tational age at delivery (mean difference 1.99 weeks,
95% CI 0.78–3.20, P,.01). Other pooled ORs are listed
in Table 6 and funnel plots for risk factors in Appendix 3
(available online at http://links.lww.com/AOG/A884).
DISCUSSION
This is a comprehensive review of emergency peripar-
tum hysterectomy worldwide. Prevalence decreased with
increasing income setting. Marked differences between
individual countries may be the result of varying
cesarean delivery rates, definitions, settings (population-
compared with hospital-based), and availability of other
treatments. Maternal mortality after hysterectomy was
high, particularly in lower income settings.
We could not differentiate between deaths attrib-
utable directly to the hysterectomy itself or the
underlying pathology, which led to the hysterectomy.
Surgical complications may be aggravated by placen-
tal pathology distorting lower uterine segment and
pelvic anatomy and increased blood supply to pelvic
organs during pregnancy.140 Prematurity likely results
from conditions leading to hysterectomy, particularly
those causing antepartum hemorrhage.
The high multiparity rate confirms that post-
partum hemorrhage increases in high parity,141 a risk
OBSTETRICS & GYNECOLOGY
Table 6. Odds Ratios for the Association Between Risk Indicators and Emergency Peripartum
Hysterectomy

Risk Indicator (No. of Studies Emergency Peripartum I2

Included) Hysterectomy Controls (%) OR (95% CI) P

Registered for antenatal care (5) 86/196 (44) 77,758/87,375 (89) 81 0.12 (0.06–0.25) ,.01
Primiparity (11) 275/1,633 (17) 184,019/309,977 (59) 77 0.16 (0.10–0.24) ,.01
Multiple pregnancy (7) 102/1,466 (7) 2,752/158,478 (2) 15 3.26 (2.49–4.27) ,.01
Preeclampsia (3) 108/1,034 (10) 3,696/116,230 (3) 90 3.13 (1.01–9.70) .05
Placenta previa (10) 551/1,730 (32) 3,245/225,681 (1) 89 68.48 (34.48–136.01) ,.01
Abnormally invasive placenta (4) 175/494 (35) 8/22,151 (,1) 0 495.71 (81.95–2,998.44) ,.01
Uterine atony (3) 331/1,027 (32) 119/21,293 (1) 97 115.43 (6.27–2,126.29) ,.01
Uterine rupture (6) 236/1,473 (16) 164/40,961 (,1) 88 183.06 (48.18–695.45) ,.01
Previous cesarean delivery (15) 566/1,126 (50) 38,350/396,833 (10) 81 7.51 (5.12–11.02) ,.01
Previous curettage (6) 168/649 (26) 169/1,278 (13) 57 2.15 (1.41–3.30) ,.01
Cesarean delivery (64) 3,057/4,099 (75) 721,133/3,546,951 (20) 82 11.38 (9.28–13.97) ,.01
Assisted vaginal delivery; of all 90/366 (25) 538/3,458 (16) 84 2.29 (1.02–5.14) .04
vaginal deliveries (3)
Induction of labor (4) 104/531 (20) 204/1,158 (18) 90 1.29 (0.46–3.64) .63
OR, odds ratio.
Data are n/N (%) unless otherwise specified.

factor for uterine atony atony.5 One explanation for
decreased risk of hysterectomy in nullipara is absence
of prior cesarean delivery. The association between
(previous) cesarean delivery and hysterectomy is con-
sistent with previous studies.7,110,142,143 Countries
with high cesarean delivery rates had higher hysterec-
tomy prevalence figures (eg, Italy 1.5 and the United
States 1.3/1,000 deliveries) compared with those with
lower rates (eg, the Netherlands 0.3/1,000). Com-
pared with vaginal delivery in unscarred uteri, vaginal
birth after cesarean delivery and repeat cesarean
delivery carry higher risks of hysterectomy (OR
11.91, 95% CI 4.21–33.68 and OR 4.59, 95% CI
2.65–7.93, respectively).143
Indications for cesarean delivery may be the same
as for hysterectomy such as abnormally invasive
placentation. Many of these are not detected before
delivery, so that hysterectomy could not be antici-
pated.15 Only three studies mentioned inclusion of
anticipated hysterectomies, for 22 women on-
ly.109,132,139 Clinical outcomes in these women may
be better, because blood products and experienced
staff could be more readily available.144 Rising cesar-
ean delivery rates and introduction of uterotonics may
explain why placental pathology has replaced atony
as the most common indication.8,108,145–147
Uterine rupture was the most common indication
in lower middle income settings, probably as a result
of higher rates of obstructed labor, lack of labor
monitoring, and perhaps more trials of labor after
cesarean delivery. However, a policy of vaginal birth
after cesarean delivery is justified because cesarean
deliveries carry significant additional risks.148
Although having registered for antenatal care is
associated with a reduced risk of hysterectomy,
unregistered women are likely overreported: it was
often impossible to distinguish “truly” unregistered
from referred patients who received antenatal care
outside the center of surgery.45
Few cases had accessed arterial embolization
despite reported high success rates.139,149,150 An
inverse relation between prevalence of embolization
and hysterectomy has been described.151
The proportion of women receiving blood trans-
fusion was highest in lower middle income settings,
where fewer preventive measures are available. Par-
adoxically, packed red blood cells per person
increased with increasing income setting, expressing
limited availability of blood for transfusion in lower
income settings.152
Our meta-analysis has the advantage of a large
number of included patients. Nonetheless, caution
should be exercised in interpreting findings. First, the
cutoff at which hysterectomy is considered life-saving
is subjective. Second, there is risk of publication bias.
Third, varying pooled samples had to be used. Fourth,
conclusions about prevalence are difficult, because
few studies were population-based. Fifth, women from
low-income settings were underrepresented. Sixth,
skills and experience of treating clinicians were
generally not specified and may have influenced
results. Seventh, multivariable analysis was impossible
in absence of individual data. Eighth, measures to
prevent hysterectomy depend on cause of bleeding,
but this was often not specified. Ninth, it is unknown
whether complications resulted from bleeding that led

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Copyright ª by The American College of Obstetricians

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to hysterectomy or from the hysterectomy itself.
Finally, the cohort of women in low-income settings
may include individuals who were in a personal high-
income bracket, just like the other way around.
Several recommendations follow. First, we sug-
gest defining emergency peripartum hysterectomy as
an emergency hysterectomy performed within 6
weeks postpartum, because most cases can be related
to the delivery.32,59,70,84,99,113,116,117,139 Second, larger
population-based studies are needed to make state-
ments with more vigor, for instance through the
International Network of Obstetric Surveillance Sys-
tems.153 Universal criteria, as promoted by Core Out-
comes in Women’s Health Initiative, would greatly
facilitate these.154 Third, our results stress the impor-
tance of avoiding unnecessary cesareans, particularly
in the first pregnancy. Fourth, additional research is
needed to compare hysterectomy in elective com-
pared with emergency cesarean, to help differentiate
whether the indication for cesarean delivery or the
procedure itself is responsible for the risk increase.
Fifth, precautions should be taken for women at high
risk of placental pathology, as identified by history
(previous cesarean delivery and placenta previa) or
ultrasonography and magnetic resonance imaging.132
Finally, only with improved obstetric care around the
world will emergency peripartum hysterectomy and
associated suffering be prevented.
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