RESUMO
Objectives: To evaluate the surgical volume, surgical outcomes, and the evolving role of gynecologic oncologists in peripartum hysterectomies (PPH). Methods: We conducted an IRB-approved retrospective chart review of PPH cases performed at our institution from June 1, 2014, to June 30, 2021. Clinical-pathologic information was ed into a REDCap database. All analyses were conducted using STATA 17. Results: A total of 109 cases were performed over the 7-year period. Gynecologic oncologists (GYO) involvement in the cases increased from 33% in 2014 to 80% in 2021. The mean age was 36 (range: 23-47) years. Most patients were White (81/109, 74.3%), and the median BMI was 30.7 (range: 21-57) kg/m2. Surgical indications included placenta accreta syndrome (PAS) in 84 (77%) cases, uterine atony in ten (9.2%), uterine rupture in three (2.8%), malignancy in five (4.6%), and hemorrhage other than atony in seven cases (6.4%). Intraoperative complications included bladder injury (or intentional dissection) in eight (7.3%), ureter injury in four (3.7%), vascular injury in three (2.8%), and femoral pseudoaneurysm in one (0.9%) of the cases. Postoperative complications included urinary tract infection in 11 (10.1%), nerve injury in one (0.9%), surgical site infection in 13 (11.2%), and venous thromboembolism in five (4.6%) cases. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) usage started in 2019 with one case followed by six cases in 2020 (31.6%) and 3/16 cases in the first half of 2020 (15.8%). A higher REBOA usage in 2020 corresponded with blood products shortages during the COVID crisis.[Formula presented] Conclusions: Overall volume and complexity of peripartum hysterectomy are increasing. This trend is likely driven by an increased incidence of placenta accreta syndrome cases. Gynecologic oncologists are increasingly delegated as primary surgeons in many institutions. Fellowship training programs should strongly consider training in peripartum hysterectomy for trainees.
RESUMO
Case Report We report here a case of a 26-year-old woman at week 29 of a pregnancy who was transferred to our hospital for OBGYN care after on the same day she presented to an outside facility for one day of vaginal bleeding. At the transferring facility she was noted to be hypertensive with concerns for pre-eclampsia, acute kidney injury and non-reactive nonstress test. She had not had any pre-natal care or screenings done. Upon arrival she was normotensive but became obtunded and emergently taken to the OR. She was found to have a 50% placental abruption with uterine atony, hemorrhaging, and unfortunately fetal demise. She tested positive for SARS-CoV-2 on screening though she had no initial respiratory symptoms. Following extubation, she was noted to have very labored breathing, continued disorientation, and repeatedly stated that she was blind. She was subsequently re-intubated both to protect her airway and due to her work of breathing. Chest imaging showed bilateral patchy opacifications of her lungs and she was initiated on treatments for COVID19 pneumonia. She was lymphopenic at this time with an absolute lymphocyte count of 800 cells/mm. She had not been vaccinated against SARS-CoV-2. Over her hospitalization, she underwent extensive workup. For her complaints of vision loss she underwent ophthalmologic exam which did not find uveitis or other changes consistent with syphilis but rather for ischemic central retinal vein occlusions. She had persistent hypoxic respiratory failure and ultimately necessitated tracheostomy due to prolonged dependence of mechanical ventilation support. Approximately 1 month after her hospitalization, she developed a new left lower lung opacification as well as scattered tree-in-bud nodular findings on chest CT imaging. On bacterial and culture workup she grew methicillin-susceptible Staphylococcus aureus as well as Aspergillus species (identification still pending). She was treated with a short course of cefazolin for bacterial pneumonia and was started on a 3-month course of isavuconazonium sulfate for probable COVID-19-associated pulmonary aspergillosis (CAPA). After a two-month long hospitalization, she had gradual clinical improvement and was transferred to a skilled nursing facility for long-term care. In this case, the devastating impact of COVID-19 disease in a young, unvaccinated, and pregnant woman is clearly seen, as are multiple sequelae. She unfortunately lost her pregnancy and developed severe visual impairments and several opportunistic respiratory infections. Her placental abruption, ischemic retinal vein occlusions and pulmonary aspergillosis were all felt to be directly attributable to her COVID19 disease. The case presented here serves as a cautionary tale that even the young are at risk for severe COVID-19 disease. Healthcare professionals should continue to advocate for screening and vaccination for these high-risk individuals.