The incidence of emergency obstetric hysterectomy in our study was 0.89%. Similar prevalence rates have been reported in two other maternity hospitals in Niger: 0.81% in Niamey[10] and 0.98% in Zinder[9]. The observed rate is higher than that reported in the majority of African studies, with a prevalence varying between 0.016 and 0.53% [3-12]. The incidence of emergency obstetric hysterectomy in Asian and European series was found to vary considerably, from 0.02% in Denmark, Ireland, Norway, and Turkey to 1.1% in India [13]. The highest incidence was observed in lower middle-income settings, as in our series and those of most African countries, with which we share the same social and health conditions. [4,13]. The lowest incidence was observed in high-income settings, which benefit from superior conditions for patient management, particularly due to the availability of modern methods for the management of postpartum haemorrhage. [13,14] In addition to the relatively low technical level of the maternity unit, other factors may contribute to the high frequency of emergency obstetric hysterectomy observed in our series. Firstly, the maternity unit is a referral facility, serving not only the urban community of Maradi but also neighbouring regions within a 125 km radius. Secondly, the peripheral hospitals are in a state of disrepair due to a lack of qualified personnel, appropriate medical equipment and essential pharmaceuticals.
In our series, the age group most affected was that comprising women aged 35-39, with an average age of 32.41 years. A similar trend has been documented by the majority of authors in the field, with mean ages ranging from 29.46 to 35.4 years. [4-15]. In a systematic review of the literature, which included 154 studies with 7,741 patients from 22 countries, Kallianidis et al. observed that the mean age was 32.1 years [13]. The mean parity in our series was 6.15 children. The largest proportion of women who expressed concern were those who had given birth more than five times (58.6%), followed by those who had given birth between four and five times (22.22%). The cohort of patients who had given birth to two to three children constituted 15.9% of the total, while those who had given birth only once represented only 4.6%. Our findings are in accordance with the data presented in the existing literature [13]. Several of studies have demonstrated that the prevalence of emergency obstetric hysterectomy rises markedly with increasing parity. [8,10,16,17]. Multiparity has been identified as an independent risk factor for emergency obstetric hysterectomy [4, 16]. Multiparity is a contributing factor to uterine fragility, which in turn increases the risk of uterine rupture, uterine atony and uterine inversion, as well as postpartum haemorrhage [17]. With regard to the mode of admission, medical evacuation (in utero transfer) was the predominant mode of admission for the majority of patients (95.82%). This is a contributing factor to the poor maternal-fetal prognosis observed in our patient cohort. Indeed, the suboptimal conditions of health evacuations in our regions (from villages to district hospitals, from neighbourhood maternity hospitals to the reference maternity hospital) and the considerable distances to travel to reach the reference maternity hospital contribute to delays in care, which frequently result in the ultimate intervention of emergency obstetric hysterectomy. A comparable result was observed in the majority of African studies [4, 7-12]. It is therefore crucial to implement effective measures to address the factors impeding these evacuations, namely the utilisation of healthcare services by parturients, prompt decision-making in emergency situations, the expeditious deployment of ambulances and the operational readiness of on-call teams in emergency departments. Furthermore, the establishment of a communication system, whether by telephone or radio, between the village health centres (CSIs) and the district hospitals, which are equipped with ambulances, would facilitate improved evacuation conditions between these two levels of healthcare. Furthermore, it is imperative that the patient's family should not be required to bear the financial burden of fuel costs, given the dearth of health insurance and mutual health insurance in our country. It is imperative that the community, the political authorities and donors assume a more active role, utilising a range of financial instruments, including the common fund, taxes, tontines, repayable loans and endowments. It is notable that a considerable number of evacuations are unpredictable (retroplacental heamatoma), and that obstetric emergencies (retroplacental heamatoma, eclampsia, uterine rupture, haemorrhagic placenta previa) are frequent. Furthermore, Niger remains one of the poorest countries in the world [4, 7]. In terms of obstetric follow-up, 22.2% of patients had no follow-up and 54.4% had attended three or fewer antenatal visits. A mere 23.4% of patients had attended at least four antenatal visits. This rate was not aligned with the World Health Organization (WHO) recommendations, which advise a minimum of four antenatal care visits during pregnancy, with an optimal number of eight ANC. Antenatal follow-up represents the optimal opportunity for the early identification and management of high-risk pregnancies. As is the case in the majority of series reported in the literature, the number of ANC was identified as a contributing factor in the occurrence of severe postpartum haemorrhage in our study. This is indicative of the quality of follow-up, compliance and accessibility of care provided to our patients, as evidenced in the literature [4, 7-9]. Indeed, certain aetiologies of postpartum haemorrhage can be effectively managed through the provision of high-quality antenatal care, particularly in cases of gravidic hypertension and its associated complications. It is imperative that increased public education, patient and community awareness, and continuing medical education for health staff (midwives, nurses and district doctors) be provided in our regions. The primary indications for evacuation among our patient cohort were obstructed labour (21.3%), uterine rupture (13.8%) and retroplacental haematoma (12.6%). In Mali, Fané et al. observed that 69% of patients were evacuated due to uterine rupture and 17% due to retroplacental haematoma [18]. Of the patients in the study, 49% had undergone caesarean section delivery. Some authors have suggested that caesarean sections may be associated with an increased risk of haemorrhage [4].
In our study, the indications for caesarean section themselves constituted risk factors for postpartum haemorrhage. In our study, the indications for emergency haemostasis hysterectomy were predominantly uterine rupture (64%), uterine atony (32.2%), and placenta accreta (2.5%).
Similarly, Oumarou et al. [9] observed a comparable trend in another Type II maternity hospital in Niger, with 68% uterine rupture and 32% uterine atony. Other authors have similarly identified uterine rupture as the primary indication for obstetric hysterectomy [10, 18-21]. Conversely, other authors posit that uterine atony represents the primary indication for emergency obstetric hysterectomy [8, 22, 23]. In the global literature, the most prevalent indications were identified as placental pathology (38.0%), uterine atony (27.0%), and uterine rupture (21.2%). The distribution of these indications exhibited considerable variation across income settings. In lower middle-income settings, the most common indication was uterine rupture (44.5%); in high-income countries, it was placental pathology (48.4%) [13]. The most frequently employed surgical technique in our study was total hysterectomy, accounting for 75.3% of cases, while subtotal hysterectomy was performed in 24.7% of cases. These figures are in close alignment with those reported in the recent literature. Indeed, globally, total hysterectomy was performed in 50.1% of cases, while subtotal hysterectomy accounting for the remaining 49.8% [13]. However, it is notable that total hysterectomy is a more prevalent procedure in underdeveloped countries, whereas subtotal hysterectomy is more common in developed countries [4, 9, 10]. This discrepancy can be attributed to the variation in the type of hysterectomy performed across different income settings. In low-income countries, total hysterectomy was conducted in 90.6% of cases, while in lower middle-income countries, it was performed in 36.3% of cases. In upper middle-income countries, the figure stood at 51.4%, and in high-income countries, it reached 56.9% [13]. In the medical literature, subtotal hysterectomy is described as the preferred surgical technique for the treatment of postpartum haemorrhage. Dissection is a more straightforward procedure, with a shorter operating time. Furthermore, the risk of utero-vesical lesions is reduced in cases of subtotal hysterectomy. However, the anatomical conditions present during pregnancy make it challenging to accurately determine the limits of the cervix, particularly during childbirth. However, it should be noted that subtotal hysterectomy does not always result in complete cessation of bleeding, particularly in cases of disseminated intravascular coagulation. In regions with limited resources, the continued bleeding from the cervix postoperatively can be fatal for the patient. This is due to the lack of availability of blood products and other haemostatic products. Consequently, total hysterectomy is the preferred surgical approach in underdeveloped countries. It is an effective method for stopping the bleeding and reducing the risk of reoperation. The management of postpartum haemorrhage in our department adheres to the current scientific standards and the available resources [4, 7, 9, 10]. Resuscitation involved the administration of crystalloid solutions while awaiting the arrival of whole blood. The quantity of blood products provided was not always aligned with the specific needs of each patient, but rather contingent on the availability of these resources. Prior to the decision to perform a hysterectomy, the procedure entailed three main steps: firstly, a uterine revision to confirm the absence of intrauterine contents and the integrity of the uterus; secondly, the repair of any lesions in the genital tract; and thirdly, the administration of uterotonics in conjunction with uterine massage in cases of uterine atony. The sole therapeutic agent employed was oxytocin, administered intravenously and/or intramuscularly. Misoprostol was administered rectally at a dosage of 800 mcg. It should be noted that parenteral prostaglandins are not available in Niger [4,7,9,10].
Despite our awareness of the effectiveness of this surgical technique, we did not attempt any form of vascular ligation in the course of our study. In Mali, the series by Camara et al. [8] describes the attempted use of triple vascular ligation as a first-line treatment in 3.96% of cases prior to hysterectomy. In the Tinusia series by Idriss Abidi et al. [12], uterine artery ligation was performed in 70% of cases, Tsirulnikov triple ligation in 70% of patients and bilateral hypogastric artery ligation in 30% of patients. In our department, as in other regions of Niger, the haemodynamic state of our patients, who were often admitted late, and the precarious conditions of intensive care did not allow for such a surgical option to be performed. Therefore, hysterectomy was the preferred option. In our series, hysterectomy was also the preferred option due to the lack of alternative treatments and the efficacy and rapidity of the procedure. Indeed, the procedure is straightforward and has the potential to be lifesaving, particularly in comparison to the hazardous and uncertain resuscitation procedures that may be required in a context of disseminated intravascular coagulation. Furthermore, in our developing and under-equipped country, there are no alternatives to radical surgery, such as conservative surgery and interventional radiology. (Complex logistics, training of radiologists, high cost of the procedure, patient admission methods) [4,10]. In terms of perinatal prognosis, the mortality rate was exceedingly high in our series (93.4%), with all cases classified as stillbirths. This elevated rate may be attributed to the underlying aetiological pathologies, the circumstances surrounding patient admission and the limited resuscitation resources available in our departments [4, 7, 9]. Our rate is comparable to those reported by Nayama et al. [10] and Oumarou et al. [9], who respectively reported 78.8% and 79% perinatal mortality in their series. However, Archana et al. [25] and Salih et al. [26] reported lower perinatal mortality rates of 18.18% and 25%, respectively. In our study, maternal morbidity was dominated by anaemia (48.1%), renal failure (5.06%), parietal suppuration (7.64%), vesico-vaginal fistula (3.79%), digestive fistula (1.25%) and evisceration (1.25%). Similar findings were reported by Dembele et al. [11] in Cameroon. In the series by Camara et al. [8] in Mali, the most prevalent forms of morbidity were oliguria (9%), parietal suppuration (7.9%), and post-transfusion reactions, including skin rash and hyperthermia (1.98%). In a recent systematic review of the international literature, the most commonly described complications were febrile morbidity (29.7%), haematological (27.5%), and infection (12.7%) [13].
The maternal lethality rate in our series was 10.9%. This rate is higher than those observed by certain authors, with a lethality varying between 2.95% and 9% (8, 11, 12, 15, 25, 26). However, other authors have reported a higher mortality rate, with figures ranging from 17.7% to 59.1% [11, 13, 27]. The highest maternal case fatality rate was reported in Nigeria, with 59.1% of cases undergoing hysterectomy resulting in death [13]. The literature indicates that the overall mortality rate is 3.2%. However, there is considerable variation in maternal case fatality rates across different income settings. The mean case fatality rates for low- and lower middle-income countries were 9.3% and 11.2%, respectively, while in upper middle- and high-income countries, the corresponding rates were 3.9% and 1.0%, respectively [13].
In the present study, the primary cause of maternal mortality was identified as haemorrhagic shock with disseminated intravascular coagulation, accounting for 61.54% of cases. This was likely exacerbated by the subsequent surgical procedure. Therefore, the absence of red blood cells, blood derivatives (fibrinogen) and macromolecules was a significant contributing factor to the mortality of our patients. It is imperative that maternity units are equipped with blood banks to compensate for the deficit of blood products and the time lost [4].