Mortality and morbidity after emergency peripartum hysterectomy in a provincial referral hospital in Papua New Guinea: A seven-year audit.

BACKGROUND: Emergency peripartum hysterectomy (EPH) is a life-saving surgical procedure performed at the time of caesarean section or within 24 h of vaginal delivery and is usually a procedure of last resort in obstetric haemorrhage when other interventions fail. AIM: To investigate the incidence, indications, risk factors and complications of EPH in a provincial referral hospital in Papua New Guinea (PNG). MATERIALS AND METHODS: This was a seven-year retrospective observational study investigating the rate of EPH at a provincial hospital between January 2012 and December 2018. Patient medical records that included socio-demographics, obstetric risk factors, indications for EPH and maternal and perinatal outcomes were reviewed. RESULTS: Of the 19 215 deliveries during the study period, 26 women had EPH, giving an incidence of 1.35 per 1000 deliveries. The majority of women (18/26) were referred from peripheral health facilities. Overall, 21 women survived and five died (mortality index, 19%). Uterine rupture was the most common indication for EPH (13/26), and it was associated with a high maternal death rate of 15.4% (2/13) and significantly higher perinatal deaths when compared to babies born to mothers with other indications (13/13 (100%) versus 5/13 (38.5%); P = 0.002). Neonates born to mothers with uterine atony were more likely to survive (8/11 (72.7%) versus 0/15 (0%); P < 0.001), although maternal mortality was higher at 27.3% (3/11). CONCLUSION: Uterine rupture and uterine atony after prolonged labour are common indications of EPH and associated with significant maternal and perinatal mortality. Improving pre-hospital management of prolonged labour remains critical in PNG.

Safety and effectiveness of oral misoprostol for induction of labour in a resource-limited setting: a dose escalation study.

BACKGROUND: Oral misoprostol as an induction of labour (IOL) agent is rapidly gaining popularity in resource-limited settings because it is cheap, stable at ambient temperatures, and logistically easier to administer compared to dinoprostone and oxytocin. We aim to investigate the safety and effectiveness of a regimen of oral misoprostol in Papua New Guinean women undergoing IOL. METHODS: As part of a prospective dose escalation study conducted at Modilon Hospital in Papua New Guinea, women with a singleton pregnancy in cephalic presentation and an unfavourable cervix who gave written informed consent were administered oral misoprostol, commencing at 25mcg once every 2 h for 4 doses and increased to 50mcg once every 2 h for 8 doses within 24 h. The primary outcomes studied were i) the proportion of women delivering within 24 h of oral misoprostol administration, and ii) rates of maternal and perinatal severe adverse events. RESULTS: Of 6167 labour ward screened admissions, 209 women (3%) fulfilled the study inclusion criteria and underwent IOL. Overall, 74% (155/209 [95% confidence interval 67.6-79.9]) delivered within 24 h. Most women (90%; 188/209; 95% CI [84.9-93.5]) delivered vaginally with 86% (180/209) having a good outcome for both the mother and baby. Of the 10% (21/209) who failed IOL and underwent caesarean section, a significant proportion of their babies were admitted to special-care nursery compared to babies delivered vaginally (20/21 [95%] versus 8/188 [4%]; Fisher Exact test P < 0.001), but their perinatal mortality rate was not significantly higher (1/21 [5%] versus 2/188 [1%]; P = 0.30). The only maternal death was not study related and occurred in a patient with post-partum haemorrhage, 15 h post-delivery. CONCLUSION: The oral misoprostol regimen for IOL described in the present study is safe, effective and logistically feasible to administer in a resource-limited setting.