Emergency Peripartum Hysterectomy During COVID-19 Pandemic

Objective To evaluate women undergoing emergency peripartum hysterectomy (EPH) during COVID-19 pandemic regarding their sociodemographic features, indications, intraoperative and postoperative complications, and assess their health problems related to a traumatic birth. Methods This was a retrospective review of EPH cases operated from March 2020 to March 2021 in terms of demographic characteristics, intraoperative, and postoperative outcome variables. Results During the specified time period, there were nine cases of EPH. All patients were young with ages ranging from 25 to 31 years; all were unbooked having unplanned pregnancies and presented at varying gestational ages. Six out of nine cases (66.67%) had previously scarred uterus with five women having morbidly adhered placenta. A total of 77.78% (seven out of nine) patients referred to our centre with high-risk factors. Five out of nine women (55.56%) needed ICU care. Seven out of nine women (77.78%) had live births and two of these infants died. The guilt of losing the baby, lethargy, worries related to feminity and sexual health, and flashbacks of ICU stay were major concerns. Conclusion The morbidly adhered placenta was the primary cause of EPH in our study cohort. Preventive psychological session should be an integral part of postpartum follow-up visits for any women with traumatic childbirth.


Introduction
The COVID-19 pandemic has grossly affected the lives of people throughout the world [1]. The Indian Government announced a nationwide lockdown in the initial phase starting from 23rd March 2020 as a preventive step to minimize its spread [2]. Major changes were made in various Government policies especially involving the health system. Though health facilities continued to provide their essential services, elective surgeries had to be curtailed to divert the hospital resources in managing the COVID-19 pandemic. In association with FOGSI (Federation of Obstetricians and Gynaecologists of India), the Ministry of Health and Family Welfare issued guidelines to provide uninterrupted health facilities to pregnant women considering them to be a high-risk group [3]. Despite this, evidence suggested a sharp decline in acceptability of essential maternal health care during the strict lockdown [4]. Restrictions on travel, fear of being exposed to COVID-19 infection, and limited health facilities in low resource areas further minimized antenatal visits. This neglected health check-up status resulted in many women attending labour stages with high-risk factors, making them prone to labour complications and emergency surgery.
Labour and childbirth induce an array of emotions in the parturient ranging from joy and happiness to pain and grief in the event of a traumatic birth [5]. Every woman enters the delivery room with the hope of experiencing joy and pride with her motherly instinct [6]. But at times, this joyous event can result in a negative emotional experience in sadness, emptiness, and a sense of worthlessness [7][8][9]. Emergency peripartum hysterectomy (EPH) is one such life event wherein the parturient can severely affect her physical, emotional, and psychological health. Literature suggests that one in 1000 women globally have EPH [10,11].
Little is known about the emotional and psychological effects of caesarean hysterectomy. The patient population herein is a young woman, already in a fragile state of mind, and subjecting her to this traumatic life event can harm her state of mind. Traumatic childbirth experience is known to be associated with posttraumatic stress disorder (PTSD) [12].
Moreover, the present pandemic scenario may also affect her emotional and social functioning. With the emergence of the COVID-19 pandemic, every new patient in our hospital is a COVID suspect unless the report comes out negative. Hence, pregnant women needing immediate delivery without her COVID test reports undergo necessary care in COVID suspect area with an undertaking of being getting COVID infection from other patients in the same room if any of them comes positive for infection. This itself adds to her stress. With this aim in mind, we planned to evaluate women undergoing EPH during the COVID-19 pandemic regarding their sociodemographic features, indications, intraoperative and postoperative complications, and assess their health problems related to a traumatic birth. This review is unique because it is the first article reviewing the details of EPH cases with a focus on their self-related health issues related to a traumatic birth.

Materials And Methods
This was a retrospective review of EPH cases conducted in the Department of Obstetrics and Gynaecology at a tertiary care centre from Uttarakhand, India. Being a referral centre, we receive many high-risk patients in critical condition. From March 2020 to March 2021, we encountered nine cases of emergency peripartum hysterectomy. This study was approved by the Institutional Ethical Committee of All India Institute of Medical Sciences, Rishikesh vide letter number AIIMS/IEC/21/405. COVID-19 pandemic badly affected health systems all over the world and our institute was also one of them. All elective facilities were shut and visits were mostly restricted for emergency needs. This institute caters to the hilly population and nationwide lockdown resulted in difficult transportation even at times of emergency. We started telemedicine facilities to continue providing routine antenatal care thereby restricting routine physical visits for low-risk women. Emergency services were running taking all COVID precautions. For every unbooked case or referred case, the reason for delay was noted. For cases undergoing EPH, we evaluated the case files from hospital records and noted the number of antenatal visits, a referral from other centre, sociodemographic parameters such as age, parity, period of gestation, planned/unplanned pregnancy status, presenting complaints, reasons for the delay in seeking medical help, imaging findings, mode of delivery, and operative variables like indication for EPH, type of uterine incision, intraoperative findings, blood loss, number of blood and blood components transfused, maternal ICU admission, and duration of hospital stay. Infant characteristics in terms of live birth, birth weight, neonatal ICU admission, and period of separation from baby were all recorded in the proforma. Details regarding their self-reported health issues related to traumatic birth were also recorded from their case files (when they came for follow-up visit at six weeks).

Statistical analysis
Baseline demographic characteristics, intraoperative, and postoperative outcome variables of all cases of EPH were noted in a tabular form. Descriptive statistics were used to calculate simple frequency, percentage, and proportion.

Results
During the specified period, we had nine cases of emergency peripartum hysterectomy. Table 1 shows the baseline demographic characteristics of the study sample with reasons for the delay in seeking a health care facility. All patients were young, with ages ranging from 25 to 31 years. All of these were unbooked having unplanned pregnancies and presented at varying gestational ages. Six out of nine cases (66.67%) had previously scarred uterus. Case number 8 presented at day 2 of puerperium with placenta accreta and postpartum hemorrhage with puerperal sepsis. Seven out of nine cases (77.78%) were referred cases. One of the women was referred with COVID positive status.   Table 2 shows the intraoperative and postoperative findings of EPH cases. Case number 1-3 had central placenta praevia (Figures 1-3). Case 4 had a massive postpartum haemorrhage and bleeding continued despite stepwise devascularisation. In the 5th case, the foetal head was deeply impacted in the pelvis and had extension of uterine incision into broad ligaments and inferiorly into the vagina. Despite best possible efforts to repair the extensions with step-wise devascularisation, bleeding continued resulting in a need for hysterectomy. The sixth case presented with frank haematuria with decreasing haemoglobin (9 to 6 gm%) levels and a history of on and off bleeding per vaginum. Cystoscopy showed bladder filled with clots but complete removal of clots was not possible due to large clots. Placental infiltration was also seen. Case 7 presented in haemorrhagic shock with ruptured rudimentary horn pregnancy (Figure 4). Case 8 and 9 had massive postpartum bleeding with gaped caesarean scar and atonic uterus respectively ( Figure 5). Bladder densely adhered to lower uterine segment with tortuous vessels. Placenta bulging through lower uterine segment and seen covered with peritoneum ( Figure 1     As seen in Table 5, all these women reported some health issues post-hysterectomy during their six-week follow-up. The guilt of losing the baby, lethargy, worries related to feminity and sexual health, and flashbacks of ICU stay were significant concerns.

Discussion
Emergency peripartum hysterectomy (EPH) is an obstetric procedure performed in a crisis as last-resort, life-saving surgery, typically following intractable postpartum hemorrhage [13,14]. EPH is classified as severe maternal morbidity, or even near-miss maternal mortality, due to the surgical intervention, intubation, blood transfusions, and critical care transfer associated with it [15]. The purpose of this study was to analyse women undergoing EPH during the COVID pandemic in terms of their sociodemographic features, indications, intraoperative and postoperative complications, neonatal parameters, concerns, and worries related to traumatic childbirth. To date, no studies focussing on the demographic details and causes of emergency peripartum hysterectomy during the COVID-19 pandemic are recorded in the literature.
The memories of childbirth last a lifetime, and every woman cherishes and discusses them with her friends and family members. A bad experience can make her lose confidence in the health system. This pandemic has created a sense of insecurity with concerns of vertical transmission in obstetric patients. Pregnant women have become extremely cautious in seeking health facilities to avoid being getting exposed unless deemed necessary. Lockdown travel restrictions have resulted in women avoiding routine check-ups. Despite centres running telemedicine facilities, many high-risk factors get missed due to a lack of physically examining pregnant women. Such women usually present in labor with high-risk factors, often in subcentres or similar hospitals wherein there is a shortage of skilled healthcare workers, requiring referrals to higher facilities.
Goyal et al. [16] evaluated their experience of the COVID-19 pandemic on maternal health due to delay in seeking health care. They found that around 32.5% of pregnant women had fewer antenatal visits during the pandemic. The primary reasons for the delay in seeking help were quoted as strict lockdown resulting in lack of transportation facilities (50.9%) and fear of getting COVID infection in 33.4%. In our study, all women were unbooked, with 77.78% (seven out of nine) referred to our centre with high-risk factors. The primary indication of EPH in our study sample was obstetric haemorrhage due to morbidly adherent placenta. A transfundal uterine incision, when feasible, was preferred compared to a lower segment incision in emergencies wherein the diagnosis of morbidly adherent placenta was made preoperatively. Five women had morbidly adhered placenta and had massive blood loss during caesarean section necessitating emergency hysterectomy despite step-wise systematic devascularisation. No definite guidelines exist for the step at which hysterectomy becomes mandatory, and this is primarily a subjective decision. In a 26-year review of around 56 cases of EPH from a tertiary centre in Kuwait, the authors found that almost 37% of cases had at least one previous caesarean section [17]. In our cohort of EPH cases, we had 66.67% cases with a previously scarred uterus. With rising caesarean section rates, there is a definite rise in incidences of the adhered placenta, leading to an increase in cases of EPH [18]. Though this can be prevented if diagnosed early due to advancements in early detection by doppler sonography in conjunction with magnetic resonance imaging, hysterectomy is often the only resort when a patient presents in labour.
EPH is associated with massive blood loss. The mean blood loss in our cohort was 2.83 ± 1.34 as compared to 3467 ± 2110 in a study by Chibber et al. [17]. Five women required intensive care unit (ICU) support owing to massive blood loss. None of the women died in our study, unlike two maternal deaths in the study by Chibber et al. [17]. Neonatal outcome was poor in our study sample, with two early neonatal deaths amongst seven live births.
These women were asked to mention their significant concerns after stabilisation and discharge from ICU. The primary concerns were mostly related to the health of the newborn child and husband. Zanardo et al. suggested pregnant women delivering during this COVID-19 pandemic as a vulnerable group need careful follow-up to improve psychological wellbeing [19]. Traumatic childbirth may further aggravate the emotional health of such women. In our cohort of nine cases of EPH, problems related to physical exertion, loss of feminity, and guilt of losing a child were the main issues. Health care providers often miss this aspect of postpartum care as women hardly speak about their emotional health, especially in rural areas. By identifying the experience and sequelae of EPH, health care providers can better understand the concerns of these women and add to women's satisfaction and mental health. Here lies the importance and need for a preventive psychological session for a woman with a traumatic birth.
A major strength of this study is its unique nature in identifying the sociodemographic risk factors of EPH during the COVID pandemic and addressing the self-reported health issues on the postpartum visit. The study could have been better if we had used some standard questionnaire to address post-traumatic stress disorder and depression and identify those at risk for stress and depression, but being a retrospective study, we lagged in this aspect. Future research is needed to address the gap in knowledge on EPH in terms of experience and its sequelae.
Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethical Committee of All India Institute of Medical Sciences Rishikesh issued approval AIIMS/IEC/21/405. This study was approved by Institutional Ethical Committee of All India Institute of Medical Sciences, Rishikesh vide letter number AIIMS/IEC/21/405. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: No conflict of interest exists for this article.