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Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Obstetrics.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
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2018 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 125, no 5, p. 597-603Article in journal (Refereed) Published
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.

Place, publisher, year, edition, pages
2018. Vol. 125, no 5, p. 597-603
Keywords [en]
Adhesions, adhesive disease, caesarean section, gynaecologic surgery
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:uu:diva-327111DOI: 10.1111/1471-0528.14708ISI: 000428368900022PubMedID: 28444984OAI: oai:DiVA.org:uu-327111DiVA, id: diva2:1129449
Funder
Swedish Research Council, 2012-00087Available from: 2017-08-03 Created: 2017-08-03 Last updated: 2018-06-20Bibliographically approved
In thesis
1. Caesarean Section: Short- and long-term maternal complications
Open this publication in new window or tab >>Caesarean Section: Short- and long-term maternal complications
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. p. 61
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1358
Keywords
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:nbn:se:uu:diva-327934 (URN)978-91-513-0041-2 (ISBN)
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

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Hesselman, SusanneHögberg, UlfJonsson, Maria

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