Long-term morbidity of peripartum hysterectomy: A systematic review.

Abstract

Background: Surgical removal of the uterus during pregnancy or immediately post-partum is called peripartum hysterectomy. It can be pre-planned as an elective or performed as an emergency life-saving procedure for severe hemorrhage. Although rare, it is a catastrophic event leading to severe maternal morbidity and a prolonged recovery period. Besides the well-documented acute and subacute sequelae, perpartum hysterectomy may produce long-lasting physical, social, and psychological impacts.

Objectives: Long-term complications of peripartum hysterectomy have barely been explored or recognized. The scattered information gathered from studies involving different corners of the world has yet to be synthesized or organized into coherent clusters of evidence. Therefore, the current study aims to fill the research gap by synthesizing the best available evidence, triggering the adoption of better management strategies.

Search strategy: We searched the Embase, PubMed, Science Direct, and Cochrane Library databases. Study selection was conducted using the semi-automated tool Rayyan.

Selection criteria: Full-text articles published up to April 22, 2024 on randomized controlled trials, qualitative studies, cohort studies, case-control studies, cross-sectional studies, and case reports in the English language reporting long-term complications of peripartum hysterectomy were included, while review articles, book chapters, and studies reporting poor neonatal outcomes were excluded.

Data collection and analysis: Data were extracted under three broad themes: long-term quality of life, psychological outcomes, and women's experiences. Data synthesis involved a thematic analysis. Study quality assessment was conducted using the Newcastle-Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) tools. Meta-analysis was not performed due to the qualitative nature of the evidence and the heterogeneity of study outcomes.

Main results: There were no randomized controlled trials. Eighteen studies were analyzed (eight cohorts, one case-control, one case report, one cross-sectional, and seven qualitative) with 503 peripartum hysterectomy women. Overall, all the included studies showed solid methodological quality. Peripartum hysterectomy led to profound psychological impacts, including post-traumatic stress disorder (PTSD), depression, anxiety, and grief, with a fluctuating course over several months to decades. Peripartum hysterectomy significantly impaired quality of life, with declines in physical functioning, social functioning, and general mental health domains, which lasted several months to a few years. Self-narrations of women revealed breastfeeding issues, delayed emotional reactions, poor bonding with the infant, feelings of maternal failure, regrets for the loss of fertility, ongoing traumatic memories, persistent pain, dyspareunia, marital insecurity, and lack of family support, with some issues haunting them even decades later.

Conclusions: Traditional puerperium follow-up schedules do not meet the needs of women recovering from peripartum hysterectomy. The present study provides insights into the long-term physical, psychological, and social consequences of peripartum hysterectomy, prompting healthcare professionals to look for those actively. It may lead to early recognition of the complications, resulting in better patient-centered care and improved quality of life. Further, well-designed studies are warranted to raise awareness, plan appropriate interventions, and introduce follow-up guidelines.