Complications due to adhesion formation following cesarean sections: a review of deliveries in three cases

Prenatal Detection and Conservative Management of Uterine Scar Dehiscence in Patient with Previous Uterine Rupture and Multiple Surgeries-A Case Report

Uterine rupture is a rare and life-threatening condition. It usually occurs in patients with uterine scars (most commonly for a previous myomectomy or caesarean section), but it can also affect an unharmed uterus. This complication is more frequent in the third trimester and during delivery. There is not yet a recognised method of prediction of uterine rupture and the ultrasound features still need a consensus. In this article, we have reported a case of uterine dehiscence diagnosed by a pelvic ultrasound and magnetic resonance (MRI) at 24 weeks of gestation. The finding was confirmed intraoperatively at the caesarean section at 29 weeks of gestation. The 40-year-old patient has had a previous pregnancy complicated by uterine rupture at 22 weeks of gestation, following six previous abdominal surgeries for stage IV endometriosis, diffuse and nodular adenomyosis, and pelvic adhesion syndrome. The early detection of uterine dehiscence allowed us to prolong the pregnancy and perform a subsequent fertility-sparing surgery, reducing maternal and neonatal morbidity and mortality. Our case report proves that women with severe endometriosis/adenomyosis are at a high risk of uterine rupture and scar dehiscence. The antenatal ultrasound can describe a uterine dehiscence (even in asymptomatic patients) and prevent complications.

Cesarean Section Complications Followed by Bladder Cystotomy and Gross Hematuria Due to Unknown Dense Scar Tissue

Adhesions formed from previous Cesarean section (C-section) are a significant risk factor for bladder injury. We present a case of a 43-year-old pregnant woman who underwent a C-section and experienced severe complications due to adhesions and incisional dehiscence from a previous Cesarean delivery 11 years earlier. Several surgical and non-surgical interventions as radiologic tests, cystotomy, blood transfusion, cystogram, and others were necessary to resolve the issues followed by the Cesarean delivery. It is important for clinicians caring for women undergoing both primary and subsequent Cesarean sections to consider and mitigate risk factors for adhesion development.

Caesarean Section on Maternal Request: An Italian Comparative Study on Patients' Characteristics, Pregnancy Outcomes and Guidelines Overview

In recent years, the rate of caesarean sections has risen all over the world. Accordingly, efforts are being made worldwide to understand this trend and to counteract it effectively. Several factors have been identified as contributing to the selection of caesarean section (CS), especially an obstetricians' beliefs, attitudes and clinical practices. However, relatively few studies have been conducted to understand the mechanisms involved, to explore influencing factors and to clearly define the risks associated with the caesarean section on maternal request (CSMR). This comparative study was conducted to elucidate the factors influencing the choice of CSMR, as well as to compare the associated risks of CSMR to CS for breech presentation among Italian women. From 2015 to 2018, a total of 2348 women gave birth by caesarean section, of which 8.60% (202 women) chose a CSMR. We found that high educational attainment, use of assisted reproductive technology, previous operative deliveries and miscarriages within the obstetric history could be positively correlated with the choice of CSMR in a statistically significant way. This trend was not confirmed when the population was stratified based on patients' characteristics, obstetric complications and gestational age. Finally, no major complications were found in patients that underwent CSMR. We believe that it is essential to evaluate patients on a case-by-case basis. It is essential to understand the personal experience, to explain the knowledge available on the subject and to ensure a full understanding of the risks and benefits of the medical practice to guarantee the patients not only their best scientific preparation but also human understanding.

Prevalence of adhesions and associated postoperative complications after cesarean section in Ghana: a prospective cohort study

BACKGROUND

The global increase in Cesarean section rate is associated with short- and long-term complications, including adhesions with potential serious maternal and fetal consequences. This study investigated the prevalence of adhesions and association between adhesions and postoperative complications in a tertiary referral hospital in Accra, Ghana.

METHODS

In this prospective cohort study, 335 women scheduled for cesarean section at Korle-Bu Teaching Hospital in Accra, Ghana were included from June to December 2015. Presence or absence of adhesions was recorded and the severity of the adhesions was scored using a classification system. Associations between presence and severity of adhesions, postoperative complications, and maternal and infant outcomes at discharge and 6 weeks postpartum were assessed using multivariate logistic and linear regression analysis.

RESULTS

Of the participating women, 128 (38%) had adhesions and 207 (62%) did not. Prevalence of adhesions increased with history of caesarean section; 2.8% with no CS but may have had an abdominal surgery, 51% with one previous CS, 62% with >1 CS). Adhesions significantly increased operation time (mean 39.2 (±15.1) minutes, absolute adjusted difference with presence of adhesions 9.6 min, 95%CI 6.4-12.8), infant delivery time (mean 5.4 (±4.8) minutes, adjusted difference 2.4 min, 95%CI 1.3-3.4), and blood loss for women with severe adhesions (mean blood loss 418.8 ml (±140.6), adjusted difference 57.6 ml (95%CI 12.1-103.0). No differences for other outcomes were observed.

CONCLUSION

With cesarean section rates rising globally, intra-abdominal adhesions occur more frequently. Risks of adhesions and associated complications should be considered in counseling patients for cesarean section.

Indications for and Risks of Elective Cesarean Section

BACKGROUND

Rates of cesarean section have risen around the world in recent years. Accordingly, much effort is being made worldwide to understand this trend and to counteract it effectively. A number of factors have been found to make it more likely that a cesarean section will be chosen, but the risks cannot yet be clearly defined.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed, Scopus, and DIMDI databases, as well as on media communications, analyses by the German Federal Statistical Office, and guidelines of the Association of Scientific Medical Societies in Germany (AWMF).

RESULTS

The increased rates of cesarean section are thought to be due mainly to changed risk profiles both for expectant mothers and for their yet unborn children, as well as an increase in cesarean section by maternal request. In 1991, 15.3% of all newborn babies in Germany were delivered by cesarean section; by 2012, the corresponding figure was 31.7%, despite the fact that a medical indication was present in less than 10% of all cases. This development may perhaps be explained by an increasing tendency toward risk avoidance, by risk-adapted obstetric practice, and increasing media attention. The intraoperative and postoperative risks of cesarean section must be considered, along with complications potentially affecting subsequent pregnancies.

CONCLUSION

Scientific advances, social and cultural changes, and medicolegal considerations seem to be the main reasons for the increased acceptibility of cesarean sections. Cesarean section is, however, associated with increased risks to both mother and child. It should only be performed when it is clearly advantageous.

Prior cesarean section is associated with increased preeclampsia risk in a subsequent pregnancy

Background

To evaluate the impact of a prior cesarean section on preeclampsia risk in a subsequent pregnancy.

Methods

Study data were collected from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service for 2006–2010. Patients who had their first delivery in 2006 and subsequent delivery between 2007 and 2010 in Korea were enrolled. The overall incidence of preeclampsia during the second pregnancy was estimated and to evaluate the risk of preeclampsia in the second pregnancy, a model of multivariate logistic regression analysis was performed with preeclampsia as the final outcome

Results

The risk of preeclampsia in any pregnancy was 2.17%; the risk in the first pregnancy was 2.76%, and that in the second pregnancy was 1.15%. During the second pregnancy, the risk of preeclampsia was 13.30% for women who had developed preeclampsia in their first pregnancy and 0.85% for those who had not. In the entire population, prior cesarean section was associated with preeclampsia risk in their subsequent pregnancy (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.13–1.41). Among women with and without preeclampsia in their first pregnancy, a prior cesarean section was associated with preeclampsia risk in their second pregnancy (OR, 1.35; 95% CI, 1.09–1.67; OR, 1.23; 95% CI, 1.08–1.40, respectively).

Conclusions

Our study showed that cesarean section in a first pregnancy was associated with increased preeclampsia risk in the second pregnancy. These results provide physicians with a preeclampsia risk evaluation method for a second pregnancy that they may aid counseling in patients.

[Post-cesarean parietal scar characteristics are predictive of pelvic adhesions. A prospective cohort study]

OBJECTIVE

To investigate whether abdominal scar characteristics could predict the incidence and severity of intra-abdominal adhesions found at repeat cesarean delivery.

PATIENTS AND METHODS

Prospective cohort study including 151pregnant women with at least one previous cesarean delivery and who delivered abdominally in the department of obstetrics and gynaecology of Farhat Hached teaching hospital-Sousse-Tunisia, during 6 months. Abdominal scar characteristics were studied. The main outcome measure(s) were the incidence and severity of intra-abdominal adhesions. Statistical analysis was performed using SPSS 18.0.

RESULTS

Of 151 women enrolled into this trial, 111 (73.5%) had adhesions, 57 (37.8%) had dense adhesions. Of all the abdominal scar characteristics studied, a depressed scar was associated with an increased incidence of both dense and filmy intra-abdominal adhesions and frozen pelvis if compared of women who did not have a depressed scar (P<10(-4) ; RR=7.6; IC=2.98-19.45). A number of previous cesarean section equal or more than 2 was also correlated with an increased incidence of severe intra-abdominal adhesions and frozen pelvis if compared with women who had only one previous cesarean section (P=0.002; RR=2.53; IC=1.16-5.56).

DISCUSSION AND CONCLUSION

A depressed abdominal scar of a previous cesarean delivery and a number of previous cesarean sections are significantly correlated with the incidence and severity of intra-abdominal adhesions.

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 abdominal adhesions and their prevention in gynaecological surgery: II. How can they be prevented?]

This paper is the second of a two-part publication. The initial paper provided a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. There is rising evidence that surgeons can take important steps to reduce the burden of adhesions. In this second paper, we review the various strategies to reduce the impact of adhesions, improve surgical outcomes and provide some practical proposals for action on adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be considered for use particularly in high-risk surgery and in patients with adhesiogenic conditions. Further research into new strategies to prevent adhesions more effectively through an improved surgical environment, new and combination devices and pharmacological agents should be encouraged. Formal recommendations would ensure better prioritisation of adhesion-reduction within the French health system. Patients should also be better informed of the risks of adhesions.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: I. What should you know?]

Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.

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.