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Caesarean Section: Short- and long-term maternal complications
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Obstetrik & gynekologi.
2017 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
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.

Ort, förlag, år, upplaga, sidor
Uppsala: Acta Universitatis Upsaliensis, 2017. , s. 61
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1358
Nyckelord [en]
adhesion, caesarean section, extremely preterm birth, gynaecologic surgery, organ injury, uterine rupture, trial of labour
Nationell ämneskategori
Reproduktionsmedicin och gynekologi
Forskningsämne
Obstetrik och gynekologi
Identifikatorer
URN: urn:nbn:se:uu:diva-327934ISBN: 978-91-513-0041-2 (tryckt)OAI: oai:DiVA.org:uu-327934DiVA, id: diva2:1134412
Disputation
2017-10-06, Föreläsningssalen Biblioteket, Falu Lasarett, Falun, 13:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2017-09-15 Skapad: 2017-08-18 Senast uppdaterad: 2017-10-17
Delarbeten
1. The risk of uterine rupture is not increased with single- compared with double-layer closure: a Swedish cohort study
Öppna denna publikation i ny flik eller fönster >>The risk of uterine rupture is not increased with single- compared with double-layer closure: a Swedish cohort study
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2015 (Engelska)Ingår i: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 122, nr 11, s. 1535-1541Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

OBJECTIVE:

To compare single- with double-layer closure of the uterus for the risk of uterine rupture in women attempting vaginal birth after one prior caesarean delivery.

DESIGN:

Cohort study.

SETTING:

Sweden.

POPULATION:

From a total of 19 604 nulliparous women delivered by caesarean section in the years 2001-2007, 7683 women attempting vaginal birth in their second delivery were analysed.

METHODS:

Data from population-based registers were linked to hospital-based registers that held data from maternity and delivery records. Logistic regression was used to estimate the risk of uterine rupture after single- or double-layer closure of the uterus. Results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).

MAIN OUTCOME MEASURE:

Uterine rupture.

RESULTS:

Uterine rupture during labour occurred in 103 (1.3%) women. There was no increased risk of uterine rupture when single- was compared with double-layer closure of the uterus (OR 1.17; 95% CI 0.78-1.76). Maternal factors associated with uterine rupture were: age ≥35 years and height ≤160 cm. Factors from the first delivery associated with uterine rupture in a subsequent delivery were: infection and giving birth to an infant large for gestational age. Risk factors from the second delivery were induction of labour, use of epidural analgesia, and a birthweight of ≥4500 g.

CONCLUSIONS:

There was no significant difference in the rate of uterine rupture when single-layer closure was compared with double -layer closure of the uterus.

Nationell ämneskategori
Reproduktionsmedicin och gynekologi
Identifikatorer
urn:nbn:se:uu:diva-232789 (URN)10.1111/1471-0528.13015 (DOI)000362752100020 ()25088680 (PubMedID)
Forskningsfinansiär
VetenskapsrådetSvenska läkaresällskapet
Tillgänglig från: 2014-09-25 Skapad: 2014-09-25 Senast uppdaterad: 2017-12-05Bibliografiskt granskad
2. Maternal complications in settings where two-thirds of extremely preterm births are delivered by cesarean section
Öppna denna publikation i ny flik eller fönster >>Maternal complications in settings where two-thirds of extremely preterm births are delivered by cesarean section
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2017 (Engelska)Ingår i: Journal of Perinatal Medicine, ISSN 0300-5577, E-ISSN 1619-3997, Vol. 45, nr 1, s. 121-127Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Objective: To investigate the maternal complications associated with cesarean section (CS) in the extremely preterm period according to the gestational week (GW) and to indication of delivery. Study design: This is a retrospective case-referent study with a review of medical records of women who delivered at 22-27 weeks of gestation (n = 647) at two level III units in Sweden. For abdominal delivery, gestational length was stratified into 22-24 (n = 105) and 25-27 (n = 301) weeks. For comparison, data on women who underwent a CS at term were identified in a register-based database. Results: The rate of CS in extremely preterm births was 62.8%. There was no difference in the complication rates, but types of incisions other than the low transverse incision were required more often at 22-24 (18.1%) weeks than at 25-27 GWs (9.6%) (P = 0.02). Major maternal complications occurred in 6.6% compared with 2.1% in the extremely preterm and term CS, respectively (P < 0.01). A maternal indication of extremely preterm CS increased the risk of complications. Conclusions: Almost two-thirds of the births at 22-27 GWs had an abdominal delivery. No increase in short-term morbidity was observed at 22-24 weeks compared to 25-27 weeks. CS performed extremely preterm had more major complications recorded than cesarean at term. The complications are driven by the underlying maternal condition.

Nyckelord
Cesarean section, extremely preterm birth, post-operative complications, pregnancy complications
Nationell ämneskategori
Pediatrik Reproduktionsmedicin och gynekologi
Identifikatorer
urn:nbn:se:uu:diva-317691 (URN)10.1515/jpm-2016-0198 (DOI)000393201100016 ()27768584 (PubMedID)
Forskningsfinansiär
Vetenskapsrådet
Tillgänglig från: 2017-03-17 Skapad: 2017-03-17 Senast uppdaterad: 2017-11-29Bibliografiskt granskad
3. Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study.
Öppna denna publikation i ny flik eller fönster >>Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register study.
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2018 (Engelska)Ingår i: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 125, nr 5, s. 597-603Artikel i tidskrift (Refereegranskat) 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.

Nyckelord
Adhesions, adhesive disease, caesarean section, gynaecologic surgery
Nationell ämneskategori
Reproduktionsmedicin och gynekologi
Identifikatorer
urn:nbn:se:uu:diva-327111 (URN)10.1111/1471-0528.14708 (DOI)000428368900022 ()28444984 (PubMedID)
Forskningsfinansiär
Vetenskapsrådet, 2012-00087
Tillgänglig från: 2017-08-03 Skapad: 2017-08-03 Senast uppdaterad: 2018-06-20Bibliografiskt granskad
4. Effect of remote cesarean delivery on complications during hysterectomy: a cohort study
Öppna denna publikation i ny flik eller fönster >>Effect of remote cesarean delivery on complications during hysterectomy: a cohort study
2017 (Engelska)Ingår i: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 217, nr 5, s. 564.e1-564.e8, artikel-id S0002-9378(17)30863-3Artikel i tidskrift (Refereegranskat) 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.

Nyckelord
Adhesive disease, adhesions, cesarean section, complications, endometriosis, hysterectomy
Nationell ämneskategori
Reproduktionsmedicin och gynekologi
Identifikatorer
urn:nbn:se:uu:diva-327110 (URN)10.1016/j.ajog.2017.07.021 (DOI)000414073300012 ()28735704 (PubMedID)
Forskningsfinansiär
Vetenskapsrådet, 2012-00087
Tillgänglig från: 2017-08-03 Skapad: 2017-08-03 Senast uppdaterad: 2018-02-16Bibliografiskt granskad

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