A retrospective study on the outcomes of peripartum hysterectomies for puerperal sepsis at Chris Hani Baragwanath Academic Hospital

Abstract

Background: Puerperal sepsis is a significant cause of maternal morbidity and mortality, especially in developing countries. Hysterectomy is often performed as a measure of source control for severe uterine infections when conservative treatment fails. The aim of this retrospective study was to examine the outcomes of peripartum hysterectomies performed for puerperal sepsis at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. Methods: A retrospective cross-sectional study was conducted between 1 January and 31 December 2019, on all women who underwent hysterectomies for puerperal sepsis. Data pertaining to demographics, surgical characteristics, microbiological cultures, organ dysfunction scores, and histopathological findings, were extracted from medical records. Women with miscarriages or pregnancies less than 24 weeks’ gestation were excluded. Statistical analysis included descriptive methods and comparative tests using Stata 15.0 software. Organ dysfunction scores were calculated using MODS, SOFA, and qSOFA systems. Ethical approval was obtained prior to conduction of the study. Results: During the study period, 33 hysterectomies were performed for puerperal sepsis, representing 0.17% of the 18,458 deliveries at the hospital. The median age of women was 28 years of age with a median gestational age at delivery of 38 weeks. The majority (88%) underwent total abdominal hysterectomies, while 12% had subtotal hysterectomies. Eighty eight percent of women underwent caesarean section for a fetal distress. The most common organisms cultured in intra-abdominal fluid were Acinetobacter baumannii (26%), Escherichia coli (19%), Klebsiella species (14%) and Enterococcus faecalis (14%). A. baumannii was the predominant pathogen in all four culture mediums. The most common antibiotics used in this hospital for treatment were resistant against most organisms. Women with higher MODS and SOFA scores predominantly cultured resistant organisms. A. baumannii was strongly associated with worse outcomes. Two women (6%) died due to complications of ongoing sepsis. Histological examination revealed that surgeons often underestimated the extent of necrosis (30%) and presence of pus (44%), highlighting the importance of histopathological evaluation for accurate diagnosis and management. Conclusion: This study highlights the rising antibiotic resistance which complicates treatment and emphasises the need for revision of antibiotic stewardship in puerperal sepsis management. Women with higher MODS and SOFA scores predominantly cultured resistant organisms. Further research is required to explore improving surgical recognition of uterine sepsis and whether a total abdominal hysterectomy is actually superior to a subtotal hysterectomy in women with puerperal sepsis.