Cesarean Hysterectomy

Cesarean hysterectomy refers to removal of the uterus at the time of cesarean delivery. It is a technically challenging procedure owing to the anatomic and physiologic changes of pregnancy, including a massive increase in blood flow to the uterus at term. The surgery’s dramatic nature stems from the fact that it is frequently performed in emergent, unplanned situations when a mother’s life is in danger and because it permanently ends future fertility. The procedure is unfortunately becoming more common largely owing to the rising primary cesarean delivery rate in the United States.

Postpartum hysterectomy refers to hysterectomy done either after vaginal delivery or cesarean delivery skin closure after cesarean section, whereas cesarean hysterectomy is done in the same surgical case as cesarean delivery. Postpartum hysterectomies are largely unplanned and often done on an emergent basis for obstetric hemorrhage or undiagnosed abnormal placentation. See the image below.

The uterus consists of 3 layers: endometrium (the inside lining), myometrium (muscular layer, the bulk of the uterine weight), and serosa (thin surface covering, separating the uterus from other organs). See the images below.

Normally, the placenta attaches to the uterus via specialized endometrium for the exchange of various nutrients between mother and fetus during pregnancy. Once the fetus delivers, the placenta separates and the uterus contracts down and shrinks in size. Cessation of bleeding requires the myometrial layer to contract down tightly to close off the special uterine vessels (spiral arteries) that grew during pregnancy and to decrease the surface area exposed on the inside of the uterus where the placenta was attached (placental bed).

The most common indication for cesarean hysterectomy is abnormal placentation, ^[1] which is most commonly diagnosed when the placenta fails to separate from the underlying tissue. Various degrees of abnormal placentation are noted: placenta accreta (adherence of the placenta to myometrium), increta (invasion through myometrium), and percreta (invasion all the way through the myometrium into serosa, frequently into the bladder). Risk factors for abnormal placentation include prior cesarean delivery, placenta previa, and prior uterine surgery including myomectomy (fibroid removal) and curettage (see the image below).

Abnormal placentation may be suspected prior to delivery based on ultrasonography or MRI or based on risk factors, but it can also be encountered unexpectedly at delivery. More than half of cases of placenta previa-accreta are not diagnosed before delivery. ^[2]

Another indication for cesarean hysterectomy is postpartum hemorrhage, ^[3] which most commonly results from uterine atony (failure of the uterus to contract into a firm muscle after delivery of the placenta). Several uterotonic medications are available to control obstetric hemorrhage, and several procedures may be used when medications fail, such as balloon tamponade (ie, Bakri balloon) as well as bilateral uterine artery ligation (ie, O’Leary sutures) or compression sutures (eg, B-Lynch suture. If these measures fail and the mother continues to hemorrhage, hysterectomy is often the next step.

Bilateral internal iliac (hypogastric) artery ligation may also be attempted prior to performing a hysterectomy or to control continued bleeding after a hysterectomy; however, this procedure is difficult and requires a highly skilled surgeon. Uterine artery embolization, performed by interventional radiology, is another option that may be considered to reduce bleeding in a stable patient if facilities are available.

An uncommon indication for cesarean hysterectomy is cancer, such as cervical cancer and endometrial cancer. ^[4] Cervical cancer is one of the most common cancers diagnosed in pregnancy ^[1] and is managed either with radiation, chemotherapy, or surgery, and in certain instances, a gynecologic oncologist may advise hysterectomy at the time of cesarean delivery to minimize the number of times a woman is under anesthesia and also remove the cancer in a timely fashion.

The only absolute contraindication to cesarean hysterectomy is refusal of the procedure by the mother. This is rare as most cases are done for emergent or life-saving reasons.