Association of cesarean section and emergency peripartum hysterectomy: A review of the epidemiological evidence

Background: Increases in the incidence of emergency peripartum hysterectomy (EPH), a near-miss form of maternal morbidity, have been documented. Coupled with the rising cesarean section (c-section) rate, the study of the association of c-section and EPH is of great public health importance. Methods: Using Medline, 17 studies were selected after excluding those conducted in developing countries and those not in English. Results: In cross-sectional studies examining the risk for women having a c-section in the index pregnancy compared to having a vaginal delivery , the association with EPH ranged from adjusted relative risks (RR) of 9.47 (5.22-17.19) to 18.32 (10.26-32.71). Case-control studies found that cases (women who had EPH) had 11.6 (2.1-68.6) and 12.9 (5.2-32.3) greater odds of having had a c-section in the index pregnancy compared to controls (women who did not have EPH). In cross-sectional studies that examined the risk for women that had previous c-section compared to those with no prior c-section, the adjusted odds ratios ranged from 6.9 (3.7-12.8) to 10.78 (7.56-15.37) and one study reported a RR of 14.2 (6.37-31.5). In two case-control studies, cases had 3.52 (2.35-5.26) and 13.5 (2.7-65.4) greater odds of having had a prior c-section compared to controls. Four studies incorporated mode of delivery in the index pregnancy with the number of previous c-sections, generally finding a linear increase in the risk of EPH with each additional c-section. Conclusions: Regardless of study design or geographical location, all studies found a strong, statistically significant association of c-section and/or previous c-section with EPH.