Bilateral Ovarian Necrosis after Emergency Peripartum Hysterectomy: Lessons from a Rare Complication

Abstract

Introduction: Emergency peripartum hysterectomy (EPH) is a life-saving intervention for severe postpartum haemorrhage unresponsive to conservative management. Although uncommon, ovarian necrosis following EPH can result in irreversible gonadal damage and premature ovarian insufficiency (POI).

Aim & Objective: To report an exceptionally rare case of bilateral ovarian necrosis following EPH due to inadvertent ligation of the infundibulopelvic ligaments, highlighting the importance of preserving ovarian vascular supply during emergency obstetric surgery.

Case Presentation: A 19-year-old primiparous woman underwent emergency caesarean section complicated by severe postpartum haemorrhage, necessitating subtotal hysterectomy at a peripheral hospital. She was referred to a tertiary care centre on postoperative day two with oliguria and subsequently developed acute kidney injury requiring haemodialysis. Persistent postoperative fever and imaging findings suggestive of bilateral adnexal masses prompted exploratory laparotomy. Intraoperative examination revealed bilateral ovarian and fallopian tube necrosis secondary to inadvertent ligation of the infundibulopelvic ligaments during the initial surgery. Bilateral salpingectomy and excision of necrotic ovarian tissue were performed.

Results: Postoperative hormonal evaluation demonstrated markedly elevated follicle-stimulating hormone levels, consistent with premature ovarian insufficiency. The case highlights the severe reproductive and endocrine consequences of compromised ovarian perfusion following emergency obstetric surgery. Early recognition of persistent fever and adnexal abnormalities facilitated definitive surgical management.

Conclusion: Bilateral ovarian necrosis following EPH is an exceptionally rare but serious complication. Meticulous identification and preservation of the infundibulopelvic ligaments and ovarian vascular pedicles are essential during emergency obstetric procedures. Prompt evaluation of postoperative fever and adnexal abnormalities may enable timely intervention. Awareness of this complication is crucial to preventing irreversible ovarian damage and its long-term endocrine consequences.

REFERENCES

1. World Health Organization. WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage. Geneva: World Health Organization; 2023:1-31. https://doi.org/10.1186/isrctn92079573
2. Guidelines for prevention and treatment of postpartum hemorrhage. Zhonghua Fu Chan Ke Za Zhi. 2023;58:401-409.
3. Kallianidis AF, Rijntjes D, Brobbel C, Dekkers OM, Bloemenkamp KWM, van den Akker T. Incidence, indications, risk factors, and outcomes of emergency peripartum hysterectomy worldwide: a systematic review and meta-analysis. Obstet Gynecol. 2023;141(1):35-48. https://doi.org/10.1097/aog.0000000000005022
4. Coulam CB, Adamson SC, Annegers JF. Incidence of premature ovarian failure. Obstet Gynecol. 1986;67:604–606.
5. Li M, Zhu Y, Wei J, Chen L, Chen S, Lai D. The global prevalence of premature ovarian insufficiency: a systematic review and meta-analysis. Climacteric. 2023;26(2):95-102. https://doi.org/10.1080/13697137.2022.2153033
6. Rebar RW. Premature ovarian failure. Obstet Gynecol. 2009;113:1355-1363.
7. Vujovic S. Aetiology of premature ovarian failure. Menopause Int. 2009;15:72-75. https://doi.org/10.1258/mi.2009.009020
8. Panay N, Anderson R, Nappi R, et al. Premature ovarian insufficiency: an International Menopause Society White Paper. Climacteric. 2020;23(5):426-446. https://doi.org/10.1080/13697137.2020.1804547
9. Howard-Anderson J, Ganz PA, Bower JE, Stanton AL. Quality of life, fertility concerns, and behavioral health outcomes in younger breast cancer survivors: a systematic review. J Natl Cancer Inst. 2012;104:386-405. https://doi.org/10.1093/jnci/djr541
10. Rocca WA, Gazzuola-Rocca L, Smith CY, et al. Accelerated accumulation of multimorbidity after bilateral oophorectomy: a population-based cohort study. Mayo Clin Proc. 2016;91(11):1577-1589. https://doi.org/10.1016/j.mayocp.2016.08.002
11. Webber L, Davies M, Anderson R, et al. European Society for Human Reproduction and Embryology (ESHRE) Guideline Group on POI. ESHRE guideline: management of women with premature ovarian insufficiency. Hum Reprod. 2016;31(5):926-937. https://doi.org/10.1093/humrep/dew027
12. Armeni E, Paschou SA, Goulis DG, Lambrinoudaki I. Hormone therapy regimens for managing the menopause and premature ovarian insufficiency. Best Pract Res Clin Endocrinol Metab. 2021;35(6):1-11. https://doi.org/10.1016/j.beem.2021.101561