Maternal Morbidity with Repeated Cesarean Deliveries

Rebecca Klahr; Kevin Cheung; Emily S. Markovic; Mackenzie Naert; Andrei Rebarber; Nathan S. Fox

doi:10.1055/s-0041-1736183

American Journal of Perinatology, Table of Contents

Am J Perinatol 2023; 40(13): 1431-1436
DOI: 10.1055/s-0041-1736183

Original Article

Maternal Morbidity with Repeated Cesarean Deliveries

Rebecca Klahr

¹Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York

,

Kevin Cheung

¹Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York

,

Emily S. Markovic

¹Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York

,

Mackenzie Naert

¹Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York

,

Andrei Rebarber

¹Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York

²Maternal Fetal Medicine Associates, PLLC, New York, New York

,

Nathan S. Fox

¹Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York

²Maternal Fetal Medicine Associates, PLLC, New York, New York

› Author Affiliations

Abstract

Objective This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice.

Study Design Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used.

Results A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001).

Conclusion Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population.

Key Points

Maternal morbidity increase with each CD.
Absolute adverse outcomes remains low in highest order CDs.
In women without placenta previa, there is no added morbidity with additional CDs.

Keywords

repeat cesarean - maternal morbidity - multiparity - grand multiparity - uterine window

Full Text

References

References
1 Osterman MJK. Recent trends in vaginal birth after cesarean delivery: United States, 2016-2018. NCHS Data Brief 2020; (359) 1-8
2 Silver RM, Landon MB, Rouse DJ. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
3 Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol 2011; 205 (03) 262.e1-262.e8
4 Fox NS, Gerber RS, Mourad M. et al. Pregnancy outcomes in patients with prior uterine rupture or dehiscence. Obstet Gynecol 2014; 123 (04) 785-789
5 Macones GA, Cahill A, Pare E. et al. Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?. Am J Obstet Gynecol 2005; 192 (04) 1223-1228 , discussion 1228–1229
6 Guise JM, Eden K, Emeis C. et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep) 2010; (191) 1-397
7 Oben A, Ausbeck EB, Gazi MN. et al. Association between number of prior cesareans and early preterm delivery in women with abnormal placentation. Am J Perinatol 2021; 38 (04) 326-331
8 Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006; 107 (04) 771-778
9 Ananth CV, Smulian JC, Vintzileos AM. The association of placenta previa with history of cesarean delivery and abortion: a metaanalysis. Am J Obstet Gynecol 1997; 177 (05) 1071-1078
10 Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstet Gynecol 2002; 99 (06) 976-980
11 Miller ES, Nielsen C, Zafman KB, Fox NS. Optimal timing of delivery in women with higher order cesareans: a cohort study. Am J Perinatol 2018; 35 (12) 1154-1158
12 Kok N, Wiersma IC, Opmeer BC, de Graaf IM, Mol BW, Pajkrt E. Sonographic measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor in women with previous Cesarean section: a meta-analysis. Ultrasound Obstet Gynecol 2013; 42 (02) 132-139