{"paper_id":"2e0a6d75-48a2-4ec4-b519-fb3785bff4b9","body_text":"~ 13 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2019; 3(4): 13-17 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2019; 3(4): 13-17 \nReceived: 09-05-2019 \nAccepted: 13-06-2019 \n \nDr. Kothapalli Indira Surya Kumari \nM.D Assistant Professor, \nObstetrics & Gynaecology, \nRangaraya Medical College \nKakinada, Andhra Pradesh, India \n \nDr. Palavalasa Manasa \nPost graduate in Obstetrics and \nGynaecology Rangaraya Medical \nCollege Kakinada, Andhra \nPradesh, India \n \nDr. Siva Ranjani Priya Paul \nPost Graduate in Obstetrics and \nGynaecology, Rangaraya Medical \nCollege, Kakinada, Andhra \nPradesh, India \n \nDr. G Soumini  \nFICOG, Professor, Obstetrics & \nGynaecology Obstetrics and \nGynaecology, Rangaraya Medical \nCollege, Kakinada, Andhra \nPradesh, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorrespondence \nDr. G Soumini \nFICOG Professor, Obstetrics & \nGynaecology Obstetrics and \nGynaecology, Rangaraya Medical \nCollege, Kakinada, Andhra \nPradesh, India \n \nClinical study on hysterectomy for AUB as surgical \nmanagement at tertiary care centre GGH, Kakinada \n \nDr. Kothapalli Indira Surya K umari, Dr. Palavalasa Manasa, Dr. Siva \nRanjani Priya Paul and Dr. G Soumini \n \nDOI: https://doi.org/10.33545/gynae.2019.v3.i4a.284  \n \nAbstract \nObjectives: Hysterectomy is most common gynaecological surgery next to cesarean section.  This study \nhas been designed to identify the indications and methods  of hysterectomy for  Abnormal uterine bleeding \n(AUB) based on PALM – COEIN classification, with the histopathological correlation in a tertiary care \nhospital. \nMethodology: This is the retrospective study based on patient’s case records,  admitted between 20 15 – \n2018 in obstetrics and gynaecology department , Government G eneral hospital, Rangaraya Medical \nCollege, Kakinada. 100 AUB patients who have undergone hysterectomy , are categorised as per methods \nand indications as PALM – COEIN classification were selec ted for study. Data recorded before and after \noperation in the case sheets , entered in excel sheet,  analysed with SPSS  version16 for statistical \nsignificance.  \nResults: In the present study of n= 100 subjects who were treated with hysterectomy for AUB were  \nstudied. Total abdominal hysterectomy (TAH) was the most common method and Leiomyoma (75%) of the \nuterus found to be major indication of hysterectomy followed by endometrial  dysfunction, polyp , \nadenomyosis, malignancy. Mean duration of hospital stay was 7  to 8 days. Most common postoperative \ncomplication was wound infections followed by fever and urinary tract infections. There was no mortality. \nConclusion: Total abdominal hysterectomy was the most common method of hysterectomy. Most common \nindication for hysterectomy as per PALM – COEIN classification is leiomyoma.  Post-operative \ncomplications were more with TAH. \n \nKeywords: Hysterectomy, PALM – COEIN classification, postoperative complication \n \nIntroduction  \nHysterectomy word derived from Greek hysteron - “uterus”, ektome – “cutting out of “is the \nsurgical removal of uterus. Despite emerging medical and surgical therapies,  AUB remains a \ncommon medical problem among women. However with emergence of effective medical  and \nconservative treatment for benign cond itions it is now posing a question mark regarding the \njustification of hysterectomy. Hysterectomy represents the most common gynaecological \nprocedure in the world and a third of 60 -year-old women underwent this surgery  [1] Its \neffectiveness in improving AU B symptoms, being curative and definitive, is well recognized  \nThough a number of minimally invasive surgical options for hysterectomy are available, because \nof their restricted availability , poor knowledge, high cost, need for follow up, limit them from \nbeing widely used. Therefore, hysterectomy either vaginal or abdominal still remains  the widely \naccepted and practised treatment of choice for majority of gynaecological diseases. According to \nMagon et al . [2] hysterectomy is a surgery which has been used and  misused, underused and \nabused at different times in gynaecology. The modern trend in approaching AUB is related to \nthe reduction of the global number of hysterectomies. A conservative surgical management of \nthis common symptom is mandatory independently f rom the need of pregnancies. Conservative \nendoscopic surgery and medical treatment of AUB are now facilitated by the use of the PALM -\nCOEIN classification PALM COEIN classification system is the basic system that comprises 4 \ncategories, defined by visually objective structural criteria (PALM: polyp, adenomyosis, \nleiomyoma, malignancy and  hyperplasia), that are unrelated to structural anomalies (COEIN: \ncoagulopathy, ovulatory dysfunction, endometrial, iatrogenic) and one reserved for entit ies that \narenot yet classified (N).  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 14 ~ \nThis retrospective study was done  to determine indications  of \nhysterectomy as per PAL M COEIN classification , presenting \nsymptoms, associated comorbiditi es, methods of  hysterectomy \nand postoperative complications. We want to stress on fact that \nthe uterus not be considered for child bearing purposes only, as \nafter hysterectomy females suffer from various psychosexual \ndysfunctions. It may have a significant  impact on women’s \npersonal, social, physical, and quality of life with significant \nfinancial burden to the country’s economy [3]. \n \nMethods \nThis retrospective study was performed in the department of \nobstetrics and gynaecology , Rangaraya medical college,  \nGovernment general hospital, Kakinada on 100 inpatients from \n2015 to 2019 of 3 ½ year period. This is a tertiary level teaching \ninstitute catering to the needs of adjoining rural population in \neast Godavari district, South India. All women [reproductive age \nto post -menopausal] who underwent hysterectomy with or \nwithout salpingo- oophorectomy were included in this study. All \npatients are included in PALM- COEIN classification. \n \nInclusion criteria \nAll non-obstetric causes,  hysterectomies for Abnormal  uterine \nbleeding. \n \nExclusion criteria \nContains obstetric hysterectomies, pelvic organ prolapse and \nother indications like mass per abdomen, malignancies without \nAUB. \nBaseline data were collected from inpatient files from \ngynaecology ward to determine the indication for surgery , \ndistribution according to age, associated comorbidities , post-\noperative complications. \nStructured history followed  by general physical, systemic and \ngynecological examination was carried out. On gynecological \nexamination, external g enitalia, cervix, uterus and adnexa were \nassessed. A pelvic ultrasound was done to assess uterus and \nadnexa for any pat hology. Endometrial biopsy done,  mode of \nhysterectomy assessed and done. The gross and microscopic \nfindings of the hysterectomy samples we re obtained were \nsubjected to histopathology . The causes were categorized \naccording to PALM group were classified as per the structural \nabnormality noted  (FIGO Classification ) [4, 5] and clinical \ndiagnosis was then correlated  with histopathology. The COEIN \ngroup stands for coagulopathy, ovulatory disorders, endometrial, \niatrogenic, not otherwise classified and related to non – \nstructural etiologies that cannot be assessed by imaging or \nhistopathology [3]. The present classification system not designed \nto replace those of WHO, FIGO for categorizing the endometrial \nhyperplasia and neoplasia  [6, 7]. The lesions are usually benign \nbut a small miniority may have atypical or malignant features [8, \n9]. The COEIN  group were classified where no  structural \nalterations were appreciated. The systamic disorders of \nhemostasis ( Coagulopathies) should be screened for using a \nstructural history [10]. Coagulopathy was labelled for all  known \ncases of coagulation. Bleeding time, clotting time was done for \nall cases . Prothrombin time , activated partial  thromboplastic \ntime were done  whenever required . Ovulatory disorder was  \ndefined as unpredictable timing and variable amount of  \nbleeding. Endometrial  disorders were re fered to  causes where \npredictable or cyclical pattern was observed. Iatrogenic category \nwas categorized by onset of symptomes  following use of  \nhormonal contraceptive device/method in the preceding 3 \nmonths [11]. \n \nResults  \nDuring the study period,  a total of 100 women of  age 25 – 60 \nwho underwent for  hysterectomy were assessed.  Mean age for \noverall hysterectomy was 43.71 years with 1SD 7.11 years.  \n \nTable 1: Characteristics of participants [n=100] \n \nAge in years number % \n<30 1 1 \n30- 39 19 19 \n40-49 59 59 \n50-59 18 18 \n>60 3 3 \n \nTable 1 shows the participant characteristics.  Almost more than \nhalf of the women around 59 are in the age group between  40-\n49. Around 19 are between 30-39. Around 18 are near \nmenopausal age  that is between  50-59. Very less are post \nmenopause that is only 3 members.  59 % of the women  \nundergoing hysterectomy were in the age group of 40 -49 years. \nTable 4 Shows Indications of hysterectomy according to PALM \n– COIEN classification.  In this majority  of patients have \nstructural abnormalities. Of this  maximum no of patients had \nleiomyoma that is 57 patient s. Remaining have other structural \ncauses like polyp for 8 patients, adenomyosis for 5 patients, \nmalignancy for 5  patients. Of non-structural causes endometrial \ncauses are 23, ovarian dysfunction for 2 members as shown in \ntable 6, Figure 1.\n \nTable 2: Distribution of menstrual complaints and duration \n \n Number Duration 1-3 months 3-6 months 6-12 months >12 months \nMenorrhagia 81 45 15 11 10 \nPolymenorrhagia 1 - 1 - - \nMetrorrhagia 7 2 4 1 - \nPostmenopausal bleeding 5 5 - - - \nmenometrorrhagia 6 4 2 - - \n \nTable 2:  shows distribution of menstrual complaints and \nduration. Almost  81 patients have  complaints of menorrhagia \nwere maximum members fall under the range of1 to 3 months \ni.e. 45 patients. 10 patients are with duration  >12 months. Post-\nmenopausal bleeding present for 5 patients. Inter menstrual \nbleeding present for 7 patients. With a period of 3 to 6  months \nfor most of them that is 4 patients. 81% of the women came with \nchief complaint of menorrhagia figure 1.  \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 15 ~ \n \n \nFig 1: Diagrammatic representation of chief complaints of patients\n \nTable 3: Presentation of AUB \n \nPresentation Number of cases Presentation Number of cases \nMenorrhagia 81 Poly menorrhea 1 \nPain abdomen metrorrhagia 6 Irregular cycles 3 \nMenorrhagia mass abdomen 2 Dischargeper vegina 2 \nPost-menopausal bleeding 5   \n \nTable 3,  shows presentation of AUB with or without pain \nabdomen. AUB with pain  abdomen only for 6  patients, \nremaining are with other complaints. \nUltra sound findings & HPE of patients. Of these majority of the \npatients have fibroid uterus that is 42 patients. Very less patients \nhave malignancy that is 5 patients. Adenomyosis is present for 5 \npatients. Bulky uterus for 14  patients. Polyp for 8  patients. \nThickened endometrium for 14  patients, rest of the cases are  \nnon-structural causes. \n \nTable 4: Case distribution according to indications of hysterectomy \n \nIndication Number of cases \nPolyp 8 \nAdenomyosis 5 \nAuba-E 23 \nOvarian dysfunction 2 \nFibroid 57 \nCa. endometrium 5 \n \nTable 4 shows indications of hysterectomy. In this  majority of \ncases are  fibroid 57 , AUB  E 23 , polyp  8, adenomyosis 5, ca.  \nendometrium 5, and ovarian dysfunction 2. \n \nTable 5: Patients categorised into PALM - COIEN classification \n \nStructural causes Non-structural causes \np-polyp- 8 C- coagulopathy -0 \nA – adenomyosis - 5 O - ovarian dysfunction - 2 \nL - leiomyoma - 57 E - endometrial causes -23 \nM- malignancy - 5 I -Iatrogenic - 0 \n N - not yet classified -0 \n \nTable 5 shows indications of hysterectomy according to PALM \n– COIEN classification. \n \n  \nPalm       Coein \n \nFig 2: Shows indications of hysterectomy according to PALM – COIEN classification \n \nIn this majority of patients have structural abnormalities. Of this  \nmaximum number of patients had leiomyoma that is 57 patients. \nRemaining have other structural causes like polyp for 8 patients. \nAdenomyosis for 5 patients, malignancy for 5  patients. Of non-\nstructural causes endometrial causes are 23, ovarian dysfunction \nfor 2 patients. As in Table 5. There were 21 patients. Who were \nmanaged with medical treatment but bleeding not subsided with  \nAnti-fibrinolytics and Harmones but recurred after stoppage.  No \nsurgical management prior to surgery not done. \nMethod of hysterectomy  is more of TAH. In this series , 61 are \nunderwent for TAH with BSO,  31 underwent only for TAH, 2 \nunderwent for lap assisted vaginal hysterectomy, one for \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 16 ~ \nVaginal Hysterectomy., Radical hysterectomy 2,  modified \nradical hysterectomy 2,  extended TAH+BSO 2.Mean age for \nTAH is 41.5years,  TAH + BSO i s 44.2 years,  for radical \nhysterectomy mean age is maximum that is 57 years as shown in \nFigure 3. \n \n \n \nFig 3: Shows patient underwent for which type of hysterectomy \n \nThe percentage of  postoperative complications of the patients \nunderwent total abdominal hysterectomy.in this 6% of the \npatients have urinary tract infection , 12 % had  fever and 13% \nhad wound infections . These wound infections were observed \npost operatively due to pre -existing malnutrition , anaemia \nassociated diabetes mellitus. Wound infection s are most \ncommon in age group 45 years. There was no mortality. \n \nDiscussion \nSurgical management should be considered for patients who are \nnot clinically stable, are not suitable for medical management, or \nhave failed to respond appropriately to medical ma nagement12. \nAUB remains a common medical  problem among women \ndespite emerging medical and surgical therapies  in the present \nstudy (n= 100) who  underwent hysterectomies for AUB were \nanalysed for methods and indications of hysterectomy. AUB is \nreported to occur in 9 to 14 % women between menarche and \nmenopause [18]. In India, the reproductive  prevalence of AUB is \naround 17.9% [19]. Thus, the impac t of this condition on the \npublic health and health care costs is significant.  Because \nmedical therapies for AUB have significant failure rates or side \neffects, surgical  treatment by hysterectomy remains a major \ntherapeutic option for chronically symptomat ic women. \nMahoney and colleagues report it is indication for two  thirds of \nhysterectomies and nearly 25%  of gynaecologic operations.  \nAntifibrinolytic drugs,  such as tranexamic acid,  work by \npreventing fibrin degradation  and are effective treatments for \npatient with chronic  AUB. They have been shown to reduce \nbleeding in these patients by 30-55% [15, 16]. In our study medical \ntreatment used for 21% over 6 to 12 months. Combined OCs and \noral progestins , taken in multi dose regimens , also are \ncommonly used  for acute AUB. One study  compared \nparticipants who underwent therapy with  OCs administered \nthree times daily for 1 week with those underwent therapy for  I \nweek for  the treatment  acute AUB [17]. The patient age range \nfrom 30 to 60 years with mean age 43.71 yea rs with 1 SD  of \n7.11 years.  Of this for TAH  is 41.5 years and TAH + BSO is \n44.2 years. This is correlate with study of Whiteman MK et al: \naccording to this study highest rate of hysterectomy between \nages of 40-49 with an average of 46.1 years [20]. \nThe most  common indication was  leiomyomas according to \nPALM- COIEN classification.  Structural causes were  carried \nmore incidence about 75 % in our study. Non -structural causes \ncarried 25% studies using sonological or histological \nexamination11. Our study was most similar with Gimmbel H, et \nal and Leung PL, et al in the study most common indication for \nhysterectomy was fibroid uterus [n=688 (73.7%)]  [21]. Most \ncommon complaint was menorrhagia. In relation to menorrhagia \n9% were  detected as polyp, 4% as adenomyosis,  47% as \nleiomyoma, only 2% carried malignancy. Other most common is \nendometrial causes followed by other structural causes like \npolyp and adenomyosis. Endometrial carcinoma was  present in \n5% of study.  According to Chanderdeep Sharma, et al AUB is \nmost common cause of TAH [22] with prevalence of 8.8%. These \nwere underwent radical hysterectomy with mean age of 57 \nyears. In our study endometrial  causes are most common in age \ngroup 40- 49 years. Endometrial causes were most common in \nthe age group 50-60 [13, 14]. \nPostoperative complications are UTI, fever , wound infections \nand wound dehiscence. Wound infections. UTI present in 6%, \nfever in 12 % , wound infections in 1 3% of total number of \npatients. These are mainly related to preoperative malnutrition \ncomorbidities like diabetes millet  us. There was no mortality  \nThis study wants to highlight the fact that reporting of all total \nhysterectomies are to  have clear cut indications of PALM - \nCOIEN classification.as any surgical procedure hysterectomy is \nalso associated with risk factors , thus indications should be \ncarefully evaluated and other minimally invasive methods or \nlong acting medical methods can be tried if availab le alon with \npatient follow up. \n \nConclusion \nHysterectomy is one of the most common gynaecological \nsurgeries. TAH was more common.  As per PALM - COIEN \nclassification leiomyomas are most common in structural causes \nfollowed by polyps and adenomyosis . In non -structural causes \nendometrial dysfunction is most common  indication. Inspite of \ntechnological advancements of medical and minimally invasive \nsurgical procedures, still hysterectomy is the preferred procedure \nfor AUB due to structural lesions. \n \nReferences \n1. Manyonda I. 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