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Caesarean Section: Short- and long-term maternal complications
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Caesarean section is a common major surgical procedure and long-term complications have not been fully investigated. By longitudinal population based register studies, based on National health registers and medical data records, maternal complications after caesarean delivery at subsequent labour (N=7 683), among extremely preterm births (N=406), and at remote gynaecologic surgery (N=25 354) were explored.

In Paper I, uterine closure was investigated in respect to uterine rupture in a subsequent delivery after caesarean section. Uterine rupture occurred in 1.3 % of women with a previous caesarean section. There was no increased risk of uterine rupture with single compared with double layers for closure of the uterus (adjusted Odds Ratio 1.17, 95 % CI 0.78-1.70). Modifiable risk factors of uterine rupture in a trial of labour after caesarean section included induction of labour and use of epidural analgesia.

In Paper II, maternal outcomes and surgical aspects of caesarean section in the extremely preterm period were assessed. Maternal complications were more frequently reported in extremely preterm- compared with term caesarean delivery. No increase in short-term morbidity was observed at 22-24 compared with 25-27 gestational weeks, but uterine corporal incisions were performed more frequently (18.1 % vs. 9.6 %, p=0.02).

Furthermore, risk factors for abdominal adhesions after caesarean section and organ injury in remote gynaecologic surgery were analysed (Paper III and IV). Numbers of prior caesarean sections were the most important factor for formation of adhesions. Advanced maternal age, obesity, infection and delivery year 1997-2013 were factors associated with adhesions in conjunction with caesarean section. Organ injury occurred in 2.2 % of women undergoing benign hysterectomy. A history of caesarean section increased the risk (adjusted Odds Ratio 1.74, 95 % CI 1.41-2.15), but was only partly explained by the presence of adhesions. The organ affected depended on medical history; prior caesarean predisposed for bladder injury, prior bowel/pelvic surgery for bowel injury and endometriosis was associated with ureter injury at time of hysterectomy. In conclusion; data from National health registers indicates that caesarean delivery is associated with long-term complications, although the absolute risk of severe complications for the woman is low.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. , 61 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1358
Keyword [en]
adhesion, caesarean section, extremely preterm birth, gynaecologic surgery, organ injury, uterine rupture, trial of labour
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
URN: urn:nbn:se:uu:diva-327934ISBN: 978-91-513-0041-2 (print)OAI: oai:DiVA.org:uu-327934DiVA: diva2:1134412
Public defence
2017-10-06, Föreläsningssalen Biblioteket, Falu Lasarett, Falun, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2017-09-15 Created: 2017-08-18 Last updated: 2017-10-17
List of papers
1. The risk of uterine rupture is not increased with single- compared with double-layer closure: a Swedish cohort study
Open this publication in new window or tab >>The risk of uterine rupture is not increased with single- compared with double-layer closure: a Swedish cohort study
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2015 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 122, no 11, 1535-1541 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

To compare single- with double-layer closure of the uterus for the risk of uterine rupture in women attempting vaginal birth after one prior caesarean delivery.

DESIGN:

Cohort study.

SETTING:

Sweden.

POPULATION:

From a total of 19 604 nulliparous women delivered by caesarean section in the years 2001-2007, 7683 women attempting vaginal birth in their second delivery were analysed.

METHODS:

Data from population-based registers were linked to hospital-based registers that held data from maternity and delivery records. Logistic regression was used to estimate the risk of uterine rupture after single- or double-layer closure of the uterus. Results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).

MAIN OUTCOME MEASURE:

Uterine rupture.

RESULTS:

Uterine rupture during labour occurred in 103 (1.3%) women. There was no increased risk of uterine rupture when single- was compared with double-layer closure of the uterus (OR 1.17; 95% CI 0.78-1.76). Maternal factors associated with uterine rupture were: age ≥35 years and height ≤160 cm. Factors from the first delivery associated with uterine rupture in a subsequent delivery were: infection and giving birth to an infant large for gestational age. Risk factors from the second delivery were induction of labour, use of epidural analgesia, and a birthweight of ≥4500 g.

CONCLUSIONS:

There was no significant difference in the rate of uterine rupture when single-layer closure was compared with double -layer closure of the uterus.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-232789 (URN)10.1111/1471-0528.13015 (DOI)000362752100020 ()25088680 (PubMedID)
Funder
Swedish Research CouncilSwedish Society of Medicine
Available from: 2014-09-25 Created: 2014-09-25 Last updated: 2017-12-05Bibliographically approved
2. Maternal complications in settings where two-thirds of extremely preterm births are delivered by cesarean section
Open this publication in new window or tab >>Maternal complications in settings where two-thirds of extremely preterm births are delivered by cesarean section
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2017 (English)In: Journal of Perinatal Medicine, ISSN 0300-5577, E-ISSN 1619-3997, Vol. 45, no 1, 121-127 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To investigate the maternal complications associated with cesarean section (CS) in the extremely preterm period according to the gestational week (GW) and to indication of delivery. Study design: This is a retrospective case-referent study with a review of medical records of women who delivered at 22-27 weeks of gestation (n = 647) at two level III units in Sweden. For abdominal delivery, gestational length was stratified into 22-24 (n = 105) and 25-27 (n = 301) weeks. For comparison, data on women who underwent a CS at term were identified in a register-based database. Results: The rate of CS in extremely preterm births was 62.8%. There was no difference in the complication rates, but types of incisions other than the low transverse incision were required more often at 22-24 (18.1%) weeks than at 25-27 GWs (9.6%) (P = 0.02). Major maternal complications occurred in 6.6% compared with 2.1% in the extremely preterm and term CS, respectively (P < 0.01). A maternal indication of extremely preterm CS increased the risk of complications. Conclusions: Almost two-thirds of the births at 22-27 GWs had an abdominal delivery. No increase in short-term morbidity was observed at 22-24 weeks compared to 25-27 weeks. CS performed extremely preterm had more major complications recorded than cesarean at term. The complications are driven by the underlying maternal condition.

Keyword
Cesarean section, extremely preterm birth, post-operative complications, pregnancy complications
National Category
Pediatrics Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-317691 (URN)10.1515/jpm-2016-0198 (DOI)000393201100016 ()27768584 (PubMedID)
Funder
Swedish Research Council
Available from: 2017-03-17 Created: 2017-03-17 Last updated: 2017-11-29Bibliographically approved
3. Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study.
Open this publication in new window or tab >>Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study.
Show others...
2017 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528Article in journal (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVE: The aim of the study was to evaluate the association between abdominal adhesions at the time of gynaecologic surgery and a history of caesarean delivery, and to investigate obstetric factors contributing to adhesion formation after caesarean section (CS).

DESIGN: Longitudinal population-based register study.

SETTING: Sweden.

POPULATION: Women undergoing benign hysterectomy and/or adnexal surgery in Sweden, 2000-2014, with a previous delivery during 1973-2013 (n = 15 479).

METHODS: Information about abdominal adhesions during gynaecological surgery, prior medical history, pregnancies and deliveries were retrieved from Swedish National Health and Quality registers.

MAIN OUTCOME MEASURES: Adhesions.

RESULTS: In women with previous CS, adhesions were present in 37%, compared with 10% of women with no previous CS [odds ratio (OR): 5.18, 95% confidence interval (CI): 4.70-5.71]. Adhesions increased with the number of caesarean sections: 32% after one CS; 42% after two CS and 59% after three or more CS (P < 0.001). Regardless of the number of CS, factors at CS such as age ≥35 years (aOR: 1.28, 95% CI: 1.05-1.55), body mass index (BMI) ≥30 [adjusted OR (aOR): 1.91, 95% CI: 1.49-2.45] and postpartum infection (aOR: 1.55, 95% CI: 1.05-2.30) increased the risk of adhesions.

CONCLUSIONS: Presence of adhesions in abdominal gynaecological surgery is associated with women's personal history of caesarean delivery. The number of caesarean sections was the important predictor of adhesions; advanced age, obesity and postpartum infection further increased the incidence.

TWEETABLE ABSTRACT: Repeat caesarean, age, obesity and infection increased the risk of pelvic adhesions after caesarean section.

Keyword
Adhesions, adhesive disease, caesarean section, gynaecologic surgery
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-327111 (URN)10.1111/1471-0528.14708 (DOI)28444984 (PubMedID)
Available from: 2017-08-03 Created: 2017-08-03 Last updated: 2017-08-18
4. Effect of remote cesarean delivery on complications during hysterectomy: a cohort study.
Open this publication in new window or tab >>Effect of remote cesarean delivery on complications during hysterectomy: a cohort study.
2017 (English)In: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, S0002-9378(17)30863-3Article in journal (Refereed) Epub ahead of print
Abstract [en]

BACKGROUND: Cesarean section is frequently performed worldwide, and follow-up studies reporting complications at subsequent surgery are warranted.

OBJECTIVES: The aim of the study was to investigate the association between a previous abdominal delivery and complications during a subsequent hysterectomy, and to estimate the fraction of complications driven by the presence of adhesions.

STUDY DESIGN: This was a longitudinal population based register study of 25354 women undergoing a benign hysterectomy at 46 hospital units in Sweden 2000-2014.

RESULTS: Adhesions were found in 45 % of the women with a history of cesarean delivery. Organ injury affected 2.2 %. The risk of organ injury (aOR 1.74, 95 % CI 1.41-2.15) and post-operative infection (aOR 1.26, 95 % CI 1.15-1.39) was increased with prior cesarean section, irrespective of whether adhesions were present or not. The direct effect on organ injury by a personal history of cesarean delivery was estimated to 73 %, and only 27 % was mediated by the presence of adhesions. Previous cesarean was a predictor of bladder injury (aOR 1.86, 95 % CI 1.40-2.47) and bowel injury (aOR 1.83, 95 % CI 1.10-3.03) but not ureter injury. A personal history of other abdominal surgeries was associated with bowel injury (aOR 2.27, 95 % CI 1.37-3.78), and the presence of endometriosis increased the risk of ureter injury (aOR 2.15, 95 % CI 1.34-3.44).

CONCLUSIONS: Prior cesarean delivery is associated with an increased risk of complications during a subsequent hysterectomy, but the risk is only partly attributable to the presence of adhesions. Previous cesarean delivery and presence of endometriosis were major predisposing factors of organ injury at the time of the hysterectomy whereas background and perioperative characteristics were of minor importance.

Keyword
Adhesive disease, adhesions, cesarean section, complications, endometriosis, hysterectomy
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-327110 (URN)10.1016/j.ajog.2017.07.021 (DOI)28735704 (PubMedID)
Available from: 2017-08-03 Created: 2017-08-03 Last updated: 2017-08-18

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