Prolonged operative time of repeat cesarean is a risk marker for post-operative maternal complications

Risk factors for relaparotomy after a cesarean delivery: a case-control study

BACKGROUND

Relaparotomy following a cesarean delivery (CD) is an infrequent complication, with inconsistency regarding risk factors and indications for its occurrence. We therefore aimed to determine risk factors and indications for a relaparotomy following a CD at a single large tertiary center.

METHODS

A retrospective case-control single-center study (2013-2023). We identified all women who had a relaparotomy up to six weeks following a CD (study group). Maternal characteristics, obstetrical and surgical data were compared to a control group in a 1:2 ratio. Controls were women with a CD before and immediately after each case in the study group, who did not undergo a relaparotomy. Included were CDs occurring after 24 gestational weeks. CD performed at different centers and indications for repeat surgery unrelated to the primary surgery (e.g., appendicitis) were excluded. Logistic regression was used to adjust for potential confounders.

RESULTS

During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD, and 130 patients (0.46%) underwent a relaparotomy. Relaparotomies following a CD occurred during the first 24 h, the first week, and beyond the first week, in 59.2%, 33.1%, and 7.7% of cases, respectively. In the multivariable logistic regression analysis, relaparotomy was significantly associated with Mullerian anomalies (aOR 3.33, 95%CI 1.08-10.24, p = 0.036); uterine fibroids (aOR 3.17, 95%CI 1.11-9.05,p = 0.031); multiple pregnancy (aOR 4.1, 95%CI 1.43-11.79,p = 0.009); hypertensive disorders of pregnancy (aOR 3.46, 95%CI 1.29-9.3,p = 0.014); CD during the second stage of labor (aOR 2.54, 95%CI 1.15-5.88, p = 0.029); complications during CD (aOR 1.62, 95%CI 1.09-3.21,p = 0.045); and excessive bleeding during CD or implementation of bleeding control measures (use of tranexamic acid, a hemostatic agent, or a surgical drain) (aOR 2.23, 95%CI 1.29-4.12,p = 0.012). Indications for relaparotomy differed depending on the time elapsed from the CD, with suspected intra-abdominal bleeding (36.1%) emerging as the primary indication within the initial 24 h.

CONCLUSION

We detected several pregnancy, intrapartum, and intra-operative risk factors for the need for relaparotomy following a CD. Practitioners may utilize these findings to proactively identify women at risk, thereby potentially reducing their associated morbidity.

Prolonged operative time of cesarean is a risk marker for subsequent cesarean maternal complications

PURPOSE

Prolonged cesarean operative time (OT) is a well-established proxy for post-operative maternal complications. We aimed to study whether prolonged OT may serve as a proxy for maternal complications in the subsequent cesarean delivery.

METHODS

A retrospective cohort study of women who underwent cesarean delivery between 2005 and 2019. Parturients who had two subsequent cesarean deliveries were included and those with Placenta Accreta Syndrome (PAS) were excluded. Prolonged operative time was defined as the duration of cesarean delivery above 60 min. Univariate analyses were followed by multivariate analysis (adjusted Odds Ratio (aORs); [95% Confidence Interval]).

RESULTS

A total of 5163 women met the inclusion and exclusion criteria of which 360 (7%) had prolonged operative time. Prolonged operative time of a cesarean section in the index pregnancy was significantly associated in the subsequent cesarean delivery with the following: Prolonged operative time, intra-operative blood loss > 1000 ml, postpartum hemorrhage, blood products transfusion, injuries to the urinary system in the subsequent delivery, and hysterectomy. Multivariate analysis revealed that prolonged OT in the index delivery was associated with composite adverse maternal outcome (aOR 1.46 [1.09-1.95]; P = 0.01) and blood products transfusion (aOR 2.93 [1.90-4.52]; P < 0.01) in the subsequent delivery.

CONCLUSION

Prolonged operative may serve as a proxy for adverse maternal outcomes, mostly blood products transfusion, in the subsequent cesarean delivery among women undergoing repeat cesarean delivery.

Repeat low order caesarean delivery, risk factors for complications: A retrospective, longitudinal study

One-third of cesarean deliveries (CDs) are repeat operations, of which the majority are low-order, second (CD2) and third (CD3). The study objectives were to identify risk factors for a complicated maternal CD among women undergoing a repeat low-order CD and to develop a predictive model for at-risk women. A retrospective longitudinal follow-up study was conducted in a single medical center, during 2005-2016. Women who underwent both CD2 and CD3 at the site were included. Those with placenta accreta or a caesarean hysterectomy were excluded. A composite complicated maternal CD was defined by either uterine rupture/dehiscence, blood transfusion, relaparotomy, admission to the intensive care unit or prolonged operative time >90th percentile. Data was analyzed comparing between CD2 to CD3, each woman served as her own control. Univariate analysis followed by a multivariate logistic regression modeling were performed with an OR of 95% CI defining significance. The study group comprised of 1,331 women. A complicated CD occurred in 159 (12%) vs. 226 (17%) of CD2 vs. CD3 respectively, (p<0.001). Women with a complicated CD2 were at higher risk for complications in CD3, aOR 2.3 (95% CI 1.5, 3.3). Sub-Saharan African origin and preterm delivery at CD3 were both risk factors for a complicated CD3, aOR 3.7 (95% CI 1.9, 7.3) and aOR 1.7 (95% CI 1.1, 2.7), respectively. The multivariate regression model included 1328 cases, was statistically significant, χ2(7) = 50.760, p <0.001, explained 6.3% of the variance of composite complicated maternal CD3 and correctly classified 82.9% of cases. Although a complicated CD2, Sub-Saharan African origin and preterm delivery are risk factors for maternal complications in CD3, it is hard to predict which specific women will experience complications. Sensitivity, specificity, positive and negative predictive value of a complicated CD2 for detecting complications in CD3 were 21%, 90%, 30% and 85% respectively.

Delayed versus early umbilical cord clamping for near-term infants born to preeclamptic mothers; a randomized controlled trial

OBJECTIVE

This study aims to assess delayed versus early umbilical cord clamping in preeclamptic mothers undergoing scheduled caesarean delivery regarding the maternal intra-operative blood loss and neonatal outcomes.

METHODS

A clinical trial was conducted on 62 near-term preeclamptic mothers (36-38⁺⁶ weeks) who were planned for caesarean delivery. They were randomly assigned into two groups. The first group was the early cord clamping (ECC) group (n= 31), in which clamping the umbilical cord was within 15 seconds, while the second group was the delayed cord clamping (DCC) group (n= 31), in which clamping the umbilical cord was at 60 seconds. All patients were assessed for intra-operative blood loss and incidence of primary postpartum haemorrhage (PPH). Otherwise, all neonates were assessed for APGAR scores, the need for the neonatal intensive care unit (NICU) admission due to jaundice, and blood tests (haemoglobin, haematocrit. and serum bilirubin).

RESULTS

There was not any significant difference between the two groups regarding the maternal estimated blood loss (P=0.673), the rates of PPH (P=0.1), post-delivery haemoglobin (P=0.154), and haematocrit values (P=0.092). Neonatal outcomes also were showing no significant difference regarding APGAR scores at the first minute (P=1) and after 5 minutes (P=0.114), day 1 serum bilirubin (P=0.561), day 3 serum bilirubin (P=0.676), and the rate of NICU admission (P=0.671). However, haemoglobin and haematocrit values were significantly higher in the DCC group than in the ECC group (P<0.001).

CONCLUSION

There is no significant difference between DCC and ECC regarding maternal blood loss. However, DCC has the advantage of significantly higher neonatal haemoglobin.

TRIAL REGISTRATION

It was first registered at ClinicalTrials.gov on 10/12/2019 with registration number NCT04193345.

Prevalence and Associated Factors for Post-Caesarean Delivery Blood Transfusion in Eastern Sudan: A Cross-Sectional Study

Background

Obstetric haemorrhage is a leading cause of maternal mortality and morbidity worldwide. Caesarean delivery (CD) is associated with significant blood loss, which may require blood transfusions. This study aimed to determine the prevalence and associated factors for post-CD transfusion.

Methods

A cross-sectional study was conducted in Gadarif maternity hospital, eastern Sudan, from March to September 2020. Sociodemographic, obstetric and clinical data, including pre- and postoperative haemoglobin levels, were collected. A multivariate logistic regression analysis was performed.

Results

A total of 539 women were enrolled in the study; the median (interquartile range) age of these women was 28.0 (8.0) years. The overall post-CD transfusion rate was 8.2%. Emergency CD (adjusted odds ratio [AOR]=2.57, 95% confidence interval [CI]=1.25‒5.28) and antepartum haemorrhage (AOR=44.70, 95% CI=11.18‒178.76) were associated with increased risk of post-CD blood transfusion. Preoperative haemoglobin (AOR=0.48, 95% CI=0.36‒0.64) and rural residence (AOR=0.45, 95% CI=0.22‒0.93) were associated with reduced risk for post-CD blood transfusion.

Conclusion

The overall prevalence of post-CD transfusion in this part of Sudan is 8.2%. Women with emergency CD, low preoperative haemoglobin levels and antepartum haemorrhage were at higher risk for post-CD transfusion. Risk identification and correction of antenatal anaemia can reduce the hazard of blood transfusion among CD women.

Reloadable Stapler Use during Peripartum Hysterectomy for Placenta Accreta Spectrum: A Novel Surgical Technique and Case Series

OBJECTIVE

This study aimed to describe a novel surgical technique for the management of antenatally suspected placenta accreta spectrum (PAS).

STUDY DESIGN

This is a retrospective, case series of patients with suspected PAS undergoing peripartum hysterectomy with a reloadable articulating stapler at a tertiary care center.

RESULTS

Eighteen patients with antenatally suspected PAS were identified and underwent peripartum hysterectomy with the aid of a reloadable stapler. Mean gestational age at delivery was 34^4/7 ± 1^1/7 weeks. Mean total operative time (skin-to-skin) was 117.3 ± 39.3 minutes, and 79.8 ± 19.8 minutes for the hysterectomy. Mean blood loss for the entire case was 1,809 ± 868 mL. Mean blood loss for the hysterectomy was 431 ± 421 mL. Mean units of intraoperative red blood cells transfused was 3 ± 1 units. Mean units of postoperative red blood cells transfused was 1 ± 0.5 units. Five cases were complicated by urological injury (two intentional cystotomies). Four patients were admitted to the intensive care unit (ICU) for a mean of ≤24 hours. Mean postoperative LOS was 4.11 ± 1.45 days. Three patients had final pathology that did not demonstrate PAS while four were consistent with accreta, six increta, and five percreta.

CONCLUSION

Use of a reloadable articulating stapler device as part of the surgical management of antenatally suspected PAS results in a shorter operative time (117 ± 39 minutes vs. 140-254 minutes previously reported), lower average blood loss (1,809 ± 868 mL vs. 2,500-5,000 mL previously reported) and shorter LOS (4.11 ± 1.45 days vs. 9.8 ± 13.5 days previously reported) compared with traditional cesarean hysterectomy. The reloadable stapling device offers an advantage of more rapidly achieving hemostasis in the surgical management of PAS.

KEY POINTS

· PAS is associated with severe maternal morbidity.. · Decreased operative time and blood loss have many clinical benefits.. · Reloadable stapler use for PAS decreases operative time.. · Reloadable stapler use for PAS decreases operative blood loss..

Relaparotomy post-cesarean delivery: characteristics and risk factors

PURPOSE

Relaparotomy following cesarean delivery (CD) is performed at a rate of 0.2-1% of CD. The objective of the present study was to identify risk factors for relaparotomy following CD, and to examine whether there is a difference in the risk of relaparotomy between CD performed during different hours of the day.

METHODS

A retrospective study on all CD over 10 years compared pregnancies that underwent laparotomy within 1 week following CD to those that did not.

RESULTS

Sixty-four patients underwent relaparotomy out of 24,239 CDs (0.26%). In univariate analysis, relaparotomy was significantly associated with pregnancies following assisted-reproductive-technologies odds ratio (OR) 95% confidence interval (CI) 3.15 (1.90-5.22), hypertensive disorders of pregnancy OR 3.05 (1.62-5.72), twin pregnancies OR 95% CI 3.78 (2.21-6.48), preterm deliveries OR 95% CI 2.44 (1.46-4.10), placenta previa OR 95% CI 6.41(2.55-16.09) and urgent CD 1.74 (1.06-2.86), especially during the second-stage of labor OR 95% CI 2.73 (1.34-5.54). The time of day of CD did not influence the rate of relaparotomy. In a multivariable-regression analysis, the adjusted odds ratio for relaparotomy was 10.24 in CD due to placenta previa, and 5.28 in CD performed at the second-stage of delivery. At relaparotomy, active bleeding was found in 50 patients (78.1%), nearly half received packed cells, 12.5% developed consumptive coagulopathy, and 17.2% needed hospitalization in the intensive care unit. 6.3% underwent a second relaparotomy, mainly due to bleeding.

CONCLUSION

Placenta previa, and urgent CDs mainly those performed at the second stage of labor are risk factors for relaparotomy after CD.

Incidence and OR team awareness of "near-miss" and retained surgical sharps: a national survey on United States operating rooms

INTRODUCTION

A retained surgical sharp (RSS) is a never event and defined as a lost sharp (needle, blade, instrument, guidewire, metal fragment) that is not recovered prior to the patient leaving the operating room. A "near-miss" sharp (NMS) is an intraoperative event where there is a lost surgical sharp that is recovered prior to the patient leaving the operating room. With underreporting of such incidents, it is unrealistic to expect aggressive development of new prevention and detection strategies. Moreover, awareness about the issue of "near-miss" or retained surgical sharps remains limited. The aim of this large-scale national survey-based study was to estimate the incidence of these events and to identify the challenges surrounding the use of surgical sharps in daily practice.

METHODS

We hypothesized that there was a larger number of RSS and NMS events than what was being reported. We survived the different OR team members to determine if there would be discordance in reported incidence between groups and to also evaluate for user bias. An electronic survey was distributed to OR staff between December 2019 and April 2020. Respondents included those practicing within the United States from both private and academic institutions. Participants were initially obtained by designating three points of contact who identified participants at their respective academic institutions and while attending specialty specific medical conferences. Together, these efforts totaled 197 responses. To increase the number of respondents, additional emails were sent to online member registries. Approximately 2650 emails were sent resulting in an additional 250 responses (9.4% response rate). No follow up reminders were sent. In total, there were 447 survey responses, in which 411 were used for further analysis. Thirty-six responses were removed due to incomplete respondent data. Those who did not meet the definition of one of the three categories of respondents were also excluded. The 411 were then categorized by group to include 94 (22.9%) from anesthesiologist, 132 (32.1%) from resident/fellow/attending surgeon and 185 (45%) from surgical nurse and technologist.

SURVEY

The survey was anonymous. Participants were asked to answer three demographic questions as well as eight questions related to their personal perception of NMS and RSS (Fig. 1). Demographic questions were asked with care to ensure no identifiable information was obtained and therefore unable to be traced back to a specific respondent or institution. Perception questions 4-6 and 11 were designed to understand the incidence of various sharp events (e.g. lost, retained, miscounted). Questions 7 and 10 were dedicated to understanding time spent managing sharps and questions 8 and 9 were dedicated to understanding the use x-ray and its effectiveness.

RESULTS

Overall, most of each respondent group reported 1-5 lost sharp events over the last year. Roughly 20% of surgeons believed they never had a miscounted sharp over the last year, where only 5.3% of anesthesiologist reported the same (p = 0.002). Each group agreed that roughly 4 lost events occur every 1000 surgeries, but a significant difference was found between the three groups regarding the number of lost sharps not recovered per 10,000 surgeries with anesthesiologist, surgeon and nurse/technologist groups estimating 2.37, 2.56 and 2.94 respectively (p = 0.001). All groups noted x-ray to offer poor effectiveness at 26-50% with 31-40 min added for each time x-ray was used. More than half (56.8%) of surgeons reported using x-ray 100% of the time when managing a lost sharp whereas anesthesiologists and nurses/technologists believe it is closer to 1/3 of the time. An average of 21-30 min is spent managing each NMS, making a lost sharp event result in up to 70 min of added OR time.

CONCLUSIONS

"Near-miss" and RSS are more prevalent than what is reported in current literature. Surgeons perceive a higher rate of success in retrieving the RSS when compared to anesthesiologists and OR nurses/technologists. We recognize several challenges surrounding "near-miss" and never events as contributing factors to their underreported nature and the higher degree of surgeon recall bias associated with these events. Additionally, we highlight that current methods for prevention are costly in time and resources without improvement in patient safety. As NMS and RSS have significant health system implications, a strong understanding of these implications is important as we strive to improve patient safety.

Safety and feasibility of trial of vaginal labor after cesarean section: A retrospective study

By observing and analyzing the success rate of Tai'an City central hospital TOLAC and VBNC and various indicators after delivery, we make sure whether TOLAC is safe and feasible to be promoted in Tai'an area.Between January and December 2017, data of 144 cases undergoing TOLAC, 152 cases undergoing VBNC, 152 cases undergoing RCS and 142 case undergoing PCS in Tai'an City Central Hospital were retrospectively analyzed. The success rate of vaginal delivery, labor time, 24 hours postpartum hemorrhage, hospital stay, Apgar score of newborns and puerperal morbidity were observed.Primary study outcomes: The success rates of the TOLAC and VBNC groups were 93.06% and 93.42%, respectively, where the difference was not statistically significant (P = .901). Secondary study outcomes: There were no significant differences in labor time (P = .0249), amount of 24 hours postpartum hemorrhage (P = .206), Apgar score of newborns (P = .582), hospital stay (P = .194) and puerperal morbidity (P = .942) between the VBAC group and VBNC group. There were statistically significant differences in amount of 24 hours postpartum hemorrhage (P < .001), hospital stay (P < .001) and puerperal morbidity (P = .018), but no difference in Apgar score of newborns (P = .228) between the VBAC group and RCS group. There were significant differences in operation time (P = .011), amount of 24 hours hemorrhage (P = .001), hospital stay (P = .001) and puerperal morbidity (P = .041), but no significant difference in Apgar score of newborns (P = .300) between the RCS and PCS groups.The TOLAC is as safe and feasible as VBNC, and more favorable to the safety of mother and fetus than RCS in Tai'an area.

Perioperative Complications of Hysterectomy After a Previous Cesarean Section: A Systematic Review and Meta-Analysis

Background

With increasing rates of cesarean sections (CS), the number of hysterectomies performed among women with a previous CS is on the rise.

Objective

To provide the association between the odds of complications following a hysterectomy performed later in life and a previous CS.

Search strategy

A comprehensive search was performed using major electronic databases, ie, MEDLINE, Scopus, ISI Web of Science, from their inception to April 2019.

Selection criteria

Analytical studies, irrespective of language or publication status, were included.

Data collection and analysis

Outcomes were extracted in duplicate. The methodological quality of the included studies was independently evaluated by two review authors. A three-level meta-analysis was applied for outcomes with dependent effect sizes.

Main results

Twenty-six studies were included involving 54,815 women. The odds of the following complications were increased in women with a previous CS: urinary tract injury (pooled unadjusted odds ratio (OR)=3.15, 95% CI=2.01-4.94, 15 studies, 33,902 women, and pooled adjusted OR=2.21, 95% CI=1.46-3.34, 3 studies, 31,038 women), gastrointestinal tract injury (pooled unadjusted OR=1.73, 95% CI=1.19-2.53; 7 studies, 30,050, and pooled adjusted OR=1.83, 95% CI=1.11-3.03, 1 study, 25,354 women), postoperative infections (pooled unadjusted OR=1.44, 95% CI=1.22-1.71, 6 studies, 37,832 women), wound complications (pooled unadjusted OR=2.24, 95% CI=1.94-2.57, 9 studies, 37,559 women), reoperation (pooled unadjusted OR=1.46, 95% CI=1.19-1.78, 2 studies, 9,899 women), and blood transfusion (pooled unadjusted OR=1.35, 95% CI=1.03-1.76, 7 studies, 13,430 women).

Conclusion

Previous CS increases risks of various complications following hysterectomy. This information reminds the gynecologists to be aware of the associations between previous CS and potential complications among women undergoing hysterectomy.

Prospero registration number

CRD42018085061.