ABSTRACT
Background: Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide. When bleeding and the resulting hemodynamic instability become refractory to medical and conservative surgical measures, peripartum hysterectomy (PH) is performed as a last-resort, life-saving intervention and is recognized as a maternal near-miss criterion. Severe PPH has also been linked to long-term cardiovascular risk. Romanian data on PH are limited to single-center reports. Objective: To estimate the prevalence of PH in Romanian tertiary maternity units and to describe its indications, the management preceding hysterectomy, and short-term maternal and neonatal outcomes. Methods: Retrospective multicenter study in six level III university maternity units (Brașov, Bucharest, Cluj-Napoca, Craiova, Iași, and Târgu Mureș) between 1 January 2019 and 31 December 2023. All hysterectomies performed during pregnancy or within 42 days postpartum were identified. Prevalence was expressed per 10,000 births; individual-level data were analyzed descriptively. Results: A total of 231 PH were performed among 88,932 births, corresponding to 26.0 per 10,000 births (95% CI 22.7–29.6), with center-specific rates ranging from 14 to 46 per 10,000. Individual-level data were available for 108 women: 93 (86.1%) underwent hysterectomy after caesarean delivery and 42 (38.9%) had a previous caesarean section. Placenta accreta spectrum disorders (~50%) and uterine atony (~30%) accounted for about 80% of indications. In 49 women (45.4%), hysterectomy was performed without previous conservative measures. Blood transfusion was required in 79% of cases; no maternal deaths occurred, whereas neonatal mortality was 12%. Conclusions: PH prevalence in Romanian tertiary units is approximately five times the pooled European population-based estimate and is driven mainly by caesarean-associated PAS disorders and uterine atony. The high proportion of primary hysterectomy suggests rapid hemodynamic deterioration and/or limited access to conservative options. A national obstetric surveillance system and structured long-term cardiovascular follow-up of survivors are warranted.