Peripartum hysterectomy refers to surgical removal of the pregnant or recently pregnant uterus. Most procedures follow delivery and are prompted by pregnancy or delivery complications. However, the term also includes hysterectomy with the pregnancy in situ, which is much less frequently performed. Radical hysterectomy early in the second trimester for cervical cancer is one example.
This chapter focuses on peripartum hysterectomy including cesarean hysterectomy and postpartum hysterectomy. These procedures are indispensable for management of intractable obstetric hemorrhage unresponsive to other treatment. In the puerperium, advanced uterine infection with necrosis is another indication.
Peripartum hysterectomy frequently is lifesaving and should be within the capabilities of all obstetric consultants. That said, hysterectomy in these circumstances can be a formidable operation, particularly when performed for a life-threatening emergency. Skills necessary for its performance are best acquired from an experienced mentor.
Prior to the 19th century, cesarean delivery was uniformly fatal. Thus, peripartum hysterectomy was developed in the late 18th century to improve survival rates. Until that time, bleeding and infections were untreatable complications. Anesthetics were limited, and surgical antisepsis was virtually nonexistent. Moreover, most surgeons lacked the expertise to perform such massive pelvic surgery. Unfortunately, many graduating obstetrician-gynecologists also lack the technical skills needed to perform this operation, and thus further mentoring is essential.
The evolution of peripartum hysterectomy can be divided into epochs before and after the description of hysterectomy technique by Eduardo Porro in 1876. Until the early 20th century, pelvic deformities from nutritional deficiencies or infectious diseases were common. Examples are rachitis (rickets) from vitamin D deficiency and tuberculosis. Women in that era had no reliable contraception, and mothers with a very small or distorted pelvis often labored to exhaustion and died along with their fetus. Some attendants used fetal destructive operations to attempt to save the mothers, who often had extensive pelvic soft tissue injuries if they survived.
Joseph Cavallini of Florence developed the concepts that enabled the development of obstetric hysterectomy. In 1768, he disproved the prevailing idea that the uterus was an essential organ for life by removing the uterus successfully in pregnant and nonpregnant animals (Durfee, 1969). Investigators in Germany and England in the early 1800s concluded that abdominal delivery in animals was less dangerous if they removed the uterus after delivery (Young, 1944). These experiments prepared the way for safe cesarean delivery and for obstetric hysterectomy.
The earliest documented human peripartum hysterectomy was performed in 1868 by Horatio Robinson Storer of Boston (Bixby, 1869). Storer was among the first specialists in diseases of women, and he was confronted by a woman whose labor was obstructed by a large uterine tumor. The baby was already dead, but the tumor prevented any fetal destructive procedures. Using chloroform for anesthesia, Storer performed cesarean delivery, and because of life-threatening ...