Multiple repeat caesarean section: is it safe?

Limited efficacy with additional adverse effect of anti-adhesion barrier at primary cesarean section

BACKGROUND/PURPOSE

In our experience, adhesion after the primary CS is generally minimal or nonexistent. However, adhesion barriers users have experienced more febrile episodes that may require therapeutic antibiotics during the postcesarean period. We evaluated clinical efficacy of HA-CMC and ORC to prevent adhesion at secondary CS and the post-operative outcome at primary and secondary CS.

METHODS

This retrospective study includes 199 Asian women undergoing primary and secondary cesarean section between January1, 2011, and September 31, 2019. We used linear and logistic regression to analyze risk factors of postcesarean fever. An interaction term analysis was performed to examine the effect of surgical site infection risk factors and use of adhesion barrier on postcesarean fever rates.

RESULTS

We found that use of adhesion barrier at the primary cesarean section is associated with a significantly higher incidence of postcesarean fever (p = 0.045), which is an independent risk factor of postcesarean fever (adjusted hazard ratio (Adj-HR)= 3.53, 95% CI = 1.03-10.24, p = 0.045). The strongest risk factor for postcesarean fever is the use of anti-adhesion film during emergency cesarean section (p = 0.041). In the subgroup of labor before operation and emergency cesarean section, adhesion barrier user had significant higher risk of postcesarean fever than nonuser (p = 0.018, Adj-HR = 12.12, 95% CI = 1.53-95.78; emergency cesarean section: p = 0.016, Adj-HR = 12.71, 95% CI = 1.62-99.62).

CONCLUSION

Use of anti-adhesion films during emergency cases and with a significantly higher risk of postcesarean fever which potentially means increased risk of surgical site infection. Therefore, we do not suggest routine application of anti-adhesion films during cesarean deliveries especially in emergency cesarean section or in a woman having labor before operation.

Outcome of multiple cesarean sections in a tertiary maternity hospital in the United Arab Emirates: A retrospective analysis

TITLE

Outcome of multiple cesarean sections in a tertiary maternity hospital in the United Arab Emirates.

OBJECTIVE

To describe the operative outcomes, clinical findings, maternal morbidity and neonatal outcome associated with increasing numbers of cesarean deliveries.

DESIGN

Retrospective study.

SETTING

Corniche Hospital, Abu Dhabi, United Arab Emirates.

POPULATION

The study cohort was 1008 women giving birth by cesarean section who had previously undergone one or more cesarean sections, who had a singleton pregnancy, and who were not in labor.

METHODS

A retrospective study was undertaken over the one-year period from January 2016 to December 2016. Women were divided into five groups according to number of previous cesarean sections. The first group comprised of women who had one previous cesarean section, the second group women who had two previous cesarean sections, the third group consequently three previous cesarean sections and the fourth group four previous cesarean sections, whereas in the fifth group women had previously five or more previous cesarean sections. The maternal and neonatal outcomes of the groups were retrospectively evaluated.

RESULTS

The risks of placenta previa, placenta accreta, uterine dehiscence or rupture, postpartum hemorrhage, blood transfusion, bladder injury, lengths of operative time and hospital stay, and number of admissions to the high dependency unit increased with increasing numbers of previous cesarean sections. Women with five or more previous cesarean sections had a 10-fold increased risk of placenta previa (odds ratio [OR], 9.8; 95 % confidence interval [CI], 3.3-28.6), a 27 - fold increased risk of placenta accreta (OR, 26.5; 95 % CI, 4.2-166.3), and an 11-fold increased risk of uterine dehiscence or rupture (OR, 11.3; 95 % CI, 1.8-70.8).

DISCUSSION

The results of our study indicate that serious maternal morbidity increases with increasing numbers of previous cesarean sections. Women planning large families should consider the risks of repeat cesarean sections when contemplating elective primary cesarean delivery or attempted vaginal birth after one previous cesarean section.

Does an increased number of cesarean sections result in greater risk for mother and baby in low-risk, late preterm and term deliveries?

Objective:

To compare surgical complications and maternal and neonatal outcomes of low-risk, late preterm and term pregnant women who have had one or two previous cesarean sections (CSs) with those who have had three or more CSs.

Methods:

We conducted a retrospective study of 850 patients undergoing repeat CS at a tertiary level maternity hospital in Ankara, Turkey. Of those, 380 had previously undergone one or two CSs (Group-I: second or third CS) and 470 had previously undergone three or four CSs (Group-II: fourth or fifth CS). Outcomes and complications were compared between the groups.

Results:

The two groups were statistically significantly different in terms of maternal age, parity, body mass index, maternal weight gain during pregnancy, and length of hospital stay (all p<0.001). Although the prevalence of intraperitoneal adhesions and placenta previa was higher in Group-II than in Group-I (p<0.001), there was no statistically significant difference in terms of cesarean hysterectomy and adjacent organ injuries (p>0.05). There were also no significant differences between the groups in terms of neonatal outcomes (p>0.05).

Conclusion:

Although the increase in the number of CSs appears to be associated with intraperitoneal adhesions and placenta previa, adverse maternal and neonatal outcomes were not observed in those women with low-risk pregnancies who underwent CS for the fourth or fifth time. Therefore, fourth and fifth CSs may be considered relatively safe surgical procedures in this cohort.

Complications associated with higher order compared to lower order cesarean sections

Background: The rate of multiple cesarean sections is persistently on the rise because of cultural demands for large families, and multiple cesarean sections are an important cause of maternal morbidity and mortality.Objectives: This study was designed to detect the complications associated with higher order compared to lower order cesarean sections.Materials and methods: The hospitals record of women who had a cesarean section performed after three or more previous cesarean sections, and those who had a cesarean section for the second time over 2 years reviewed. Women with ≥3 cesarean sections admitted for elective cesarean section after 38 weeks' gestation, and those with ≥3 cesarean sections admitted in labor for emergency cesarean section were included in group 1. Women with history of previous one lower segment cesarean section (LSCS), who refused trial of labor and women with one LSCS who had an emergency cesarean section after failed trial of labor (TOL) were included in group 2. Antenatal, intraoperative, and postoperative data were reviewed. Statistical analysis done using SPSS version 20 (Chicago, Illinois, USA), to detect the complications associated with higher order compared to lower order cesarean sections. Primary outcome measures; complications associated with higher order compared to lower order cesarean sections. Secondary outcome measures; intraoperative, and postoperative complications.Results: Four hundred and fifty (450) women undergoing repeat cesarean section studied; 32.2% (145/450) had ≥3 previous cesarean sections (group 1), and 67.8% (305/450) had previous one cesarean section (group 2). In group 1, 77.2% (112/145) had previous three cesarean sections, 12.4% (18/145) had previous four cesarean sections, 9% (13/145) had previous five cesarean sections, and 1.4% (2/145) had previous six cesarean sections. The proportion of unbooked admission, and emergency cesarean sections were significantly high in group 2 compared to group 1 (11.1% (34/305) and 73.1% (223/305) versus 4.83% (7/145) and 40.7% (59/145); respectively) (p<.05, 95% CI; 0.1-0.2) and p<.01, 95% CI; 0.4-11.4; respectively. The risk of dense omental adhesions, and bladder injuries were significantly high in group 1 compared to group 2 (4.14% (6/145) and 1.38% (2/145) versus 0.66% (2/305) and 0% (0/305); respectively), (p=.01 (95% CI; 0.6-1.6) and p=.01 (95% CI; 0.5-5.5); respectively). Logistic regression analysis showed that the bladder injury was 5 times more (odds ratio 5.0 (95% CI; 0.035-711.8)) and the blood transfusion was 4.7 times more (odds ratio 4.7 (95% CI; 0.147-151.5)) in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference p=.52 and .38; respectively).Conclusion: The risk of dense omental adhesions and bladder injury was significantly high in women with previous ≥3 cesarean sections compared to women with previous one cesarean section. Logistic regression analysis showed that the bladder injury was five times more and the blood transfusion was 4.7 times more in women with >3 repeat cesarean sections compared to women with previous one cesarean section (insignificant difference).

Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section

PURPOSE OF INVESTIGATION

We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity.

MATERIALS AND METHODS

We analyzed intra-abdominal adhesions of 672 patients.

RESULTS

Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively.

CONCLUSIONS

Emergency operations and adhesions increased complications.

Are multiple repeated cesarean sections really as safe?

AIM

Surgical complications were compared between patients with three or less prior cesarean deliveries and four or more prior cesarean deliveries.

MATERIALS AND METHODS

Records of 120 patients who had undergone cesarean sections (CSs) in our Department of Obstetrics and Gynecology, between August and November 2015, were retrospectively studied. Cases were reviewed on the basis of age, type of operation, type of anesthesia, number of CSs, time of hospitalization, and intra-operative and post-operative complications.

RESULTS

Cesarean sections had been performed on 62 (51.7%) patients whose cesarean number was three or less, while 58 (48.3%) patients had multiple CSs four or more. Patients with four or more prior cesareans had an increased rate of intra-abdominal adhesions, compared with the other group. There was no significant difference in the gestational weeks, neonatal admission rate, incidence of cesarean hysterectomy, uterine scar rupture, placenta previa with placental invasion anomalies, bladder and bowel injuries, incidence of peripartum hemorrhage and blood transfusion rate between the two groups.

CONCLUSION

There is no greater risk of maternal complications in patients with four or more prior cesareans, excepting intra-abdominal adhesions.

Adhesion prevention after cesarean delivery: evidence, and lack of it

In spite of the recognized occurrence of cesarean-attributable adhesions, its clinical significance is uncertain. The presence of adhesions during a repeat cesarean section can make fetal extraction lengthy and the procedure challenging and may increase the risk of injury to adjacent organs. Two methods for adhesion prevention are discussed, peritoneal closure and use of adhesion barriers. Peritoneal closure appears to be safe in the short term. In the long term, conflicting evidence arise from reviewing the literature for possible adhesion reduction benefits. A systematic review of the literature on the use of adhesion barriers in the context of cesarean section yielded only a few studies, most of which are lacking in methodology. For now, it appears that the available evidence does not support the routine use of adhesion barriers during cesarean delivery.

Intra-operative complications increase with successive number of cesarean sections: Myth or fact?

Objective

To determine whether complications related to surgery increase with increasing number of cesarean sections (CSs) in upper segment placenta. To compare the complications in urgent and elective high order (4-6) repeat CSs.

Methods

A retrospective analysis of 519 women who underwent repeat CS was performed from January to December 2012. Women were divided into 3 groups: group 1 with previous 3 CS (n=325), group 2 with previous 4 CS (n=139), and group 3 with previous ≥5 CS (n=55).

Results

Statistically significant differences (P < 0.001) were observed among 3 groups, regarding mean gravidity, type of CS, midline incision and bilateral tubal ligation performed. The risks of severe intra-peritoneal adhesions, thin out lower uterine segment and bladder injury were significantly increased (P < 0.001) with increasing number of CS deliveries. Only one cesarean hysterectomy was done in group 1 due to post partum hemorrhage. No significant differences were found in blood loss, duration of surgery, post operative hospital stay as well as birth weight and Apgar scores of newborns. The elective and emergency CS groups of high order repeat CS had no remarkable differences in operative, post operative complications and fetal outcome.

Conclusion

Women with repeat CS are at increased risk of having multiple intra-operative surgical complications which increase with each subsequent CS. Pregnant women must be informed of the related risks which may affect counselling regarding possible tubal ligation.Women with repeat CS are at increased risk of having multiple intra-operative surgical complications which increase with each subsequent CS. Pregnant women must be informed of the related risks which may affect counselling regarding possible tubal ligation.

Adhesions following cesarean delivery: a review of their occurrence, consequences and preventative management using adhesion barriers

The objective of this article is to provide a comprehensive review of the occurrence and consequences of postoperative adhesions following cesarean delivery (CD), and an overview of the published clinical data on prevention in this setting using adhesion barriers. Adhesions occur frequently after CD and the incidence increases with each subsequent CD. Repeat CDs are complicated by adhesions, which increase operating time, time to delivery and risk of bladder injury. Clinical data on the efficacy of adhesion prevention strategies specific to the setting of CD are limited. Two small, nonrandomized studies found that the use of absorbable anti-adhesion barriers was associated with a significant reduction in adhesion formation and a shorter time to delivery at repeat CD, compared with no barrier use. Implications for practice and research are discussed. There is a significant need for well-controlled, randomized clinical studies investigating adhesion prevention in the labor and delivery setting.

Adhesions and perioperative complications of repeat cesarean delivery

The unprecedented high rate of cesarean delivery and the declining rate of vaginal birth after cesarean delivery make necessary awareness of the potential complications that are associated with repeat cesarean delivery. This article reviews the epidemiologic features of cesarean delivery and the perioperative risks that are associated with repeat cesarean delivery. These risks include increased adhesions, infections and wound complications, bleeding, bowel injury and obstruction, hysterectomy, operative time, hospital stay, and delays in delivery.

Postoperative adhesion development following cesarean and open intra-abdominal gynecological operations: a review

In this review, we discuss the pathophysiology of adhesion development, the impact of physiological changes associated with pregnancy on markers of adhesion development, and the clinical implications of adhesion development following cesarean delivery (CD). Although peritoneal adhesions develop after the overwhelming majority of intra-abdominal and pelvic surgery, there is evidence in the literature that suggests that patients having CD may develop adhesions less frequently. However, adhesions continue to be a concern after CD, and are likely significant, albeit on average less than after gynecological operations, but with potential to cause significant delay in the delivery of the baby with serious, lifelong consequences. Appreciation of the pathophysiology of adhesion development described herein should allow a more informed approach to the rapidly evolving field of intra-abdominal adhesions and should serve as a reference for an evidence-based approach to consideration for the prevention and treatment of adhesions.

Adhesion development and morbidity after repeat cesarean delivery

OBJECTIVE

The purpose of this study was to evaluate the development and implications of intraabdominal adhesions after repeat cesarean section delivery (CS).

STUDY DESIGN

We reviewed the charts of 1283 women who underwent repeat CS and 203 other women who underwent primary CS. Primary outcome measures were incidence and extent of adhesions, incision-to-delivery interval, and operating time.

RESULTS

No adhesions were found in primary CS. Compared with those women with a second CS (24.4%), significantly more women had adhesions after 3 CSs (42.8%; 95% confidence interval [CI], 0.84-0.99). Compared with a first CS (7.7 +/- 0.3 minutes), the delivery time was significantly longer at subsequent CSs (second CS, 9.4 +/- 0.1 minutes; 95% CI, 1-2; third CS, 10.6 +/- 0.3 minutes; 95% CI, 2-4; >or= 4 CSs, 10.4 +/- 0.1 minutes; 95% CI, 1-2). However, complication rates in those women with >or= 2 CSs were comparable with primary CS.

CONCLUSION

Increased adhesion development and a longer time to delivery were found with each subsequent CS.

Fatores médicos e não-médicos associados às taxas de cesariana em um hospital universitário no Sul do Brasil

O objetivo deste estudo foi descrever fatores associados ao aumento nas taxas de cesariana em um hospital universitário de 2002 e 2004, explorando a contribuição de fatores médicos e não-médicos para este aumento. Um estudo transversal investigou 2.905 partos ocorridos nos anos de 2002 (1.441) e 2004 (1.464). Diferenças nas razões de prevalência ajustadas pela regressão de Poisson e risco atribuível percentual foram estimados para a associação de cesariana com fatores sócio-demográficos; clínicos e reprodutivos; e do parto, institucionais e da prática obstétrica. As taxas de cesariana aumentaram de 28,4% em 2002 para 36,7% em 2004. Escolaridade materna elevada, hora do parto, presença de patologia e maior freqüência ao pré-natal foram os fatores que representaram a contribuição mais expressiva para o excesso em 2004, quando comparado a 2002. O aumento nas taxas de cesariana ao se comparar os dois anos pode ser atribuído, pelo menos em parte, a um crescimento nas indicações relativas e condições não-médicas.