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Effect of remote cesarean delivery on complications during hysterectomy: a cohort 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, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna.
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.
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.
2017 (English)In: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 217, no 5, p. 564.e1-564.e8, article id S0002-9378(17)30863-3Article in journal (Refereed) Published
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.

Place, publisher, year, edition, pages
2017. Vol. 217, no 5, p. 564.e1-564.e8, article id S0002-9378(17)30863-3
Keywords [en]
Adhesive disease, adhesions, cesarean section, complications, endometriosis, hysterectomy
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:uu:diva-327110DOI: 10.1016/j.ajog.2017.07.021ISI: 000414073300012PubMedID: 28735704OAI: oai:DiVA.org:uu-327110DiVA, id: diva2:1129450
Funder
Swedish Research Council, 2012-00087Available from: 2017-08-03 Created: 2017-08-03 Last updated: 2018-02-16Bibliographically 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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