Cesarean section and the risk of emergency peripartum hysterectomy in high-income countries: a systematic review

Arch Gynecol Obstet. 2015 Dec;292(6):1201-15. doi: 10.1007/s00404-015-3790-2. Epub 2015 Jun 24.


Introduction: Our objective was to determine the incidence and mortality rates associated with emergency peripartum hysterectomy, factors that lead to uncontrolled hemorrhage and emergency peripartum hysterectomy, and to determine the relationship between cesarean section and risk of emergency peripartum hysterectomy.

Materials and methods: Studies published between January 1, 2000 and December 31, 2012 were identified using PubMed, OVID and Web of Science databases. Studies were included if they reported incidence rates for emergency peripartum hysterectomy, factors that lead to hemorrhage and emergency peripartum hysterectomy, or the association of emergency peripartum hysterectomy with cesarean section in high-income countries.

Results: Four hundred and fifty-one studies were identified, and 52 were included. The incidence of emergency peripartum hysterectomy ranged from 0.20 to 5.09 per 1000 deliveries with a median incidence rate of 0.61 per 1000 deliveries. These rates have increased over time. Rates varied by region/country, specifically with the United States reporting higher rates than North American, Asian, Oceania, and European countries. The most common factor leading to emergency peripartum hysterectomy was placental abnormalities. Both cesarean section and prior cesarean section were strong risk factors for emergency peripartum hysterectomy with higher risks conferred for each additional cesarean section. The mean percentage of maternal deaths for EPH survivors was 3.0 %.

Conclusion: Given the association of cesarean section with emergency peripartum hysterectomy, the increased risk of emergency peripartum hysterectomy should be factored into the decision of whether to proceed with cesarean delivery, particularly for women who desire more children.

Keywords: Cesarean section; Emergency hysterectomy; Maternal morbidity; Maternal mortality.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Adult
  • Cesarean Section / adverse effects
  • Cesarean Section / statistics & numerical data*
  • Delivery, Obstetric
  • Developed Countries*
  • Emergency Treatment / statistics & numerical data*
  • Female
  • Humans
  • Hysterectomy / adverse effects
  • Hysterectomy / statistics & numerical data*
  • Incidence
  • Maternal Mortality
  • Peripartum Period
  • Postpartum Hemorrhage / surgery*
  • Pregnancy
  • Risk Factors