Introduction
CS (CS) is defined as the delivery of the infant, alive or dead, after the period of viability, through an abdominal uterine incision.1 CS can be potentially lifesaving for the mother and fetus.2 Modern obstetrics practice, for medical, social, economic reasons has witnessed an increase in primary CS rates everywhere.3 The CS rate in India has increased from 17.2% to 21.5% from 2015-16 to 2019-20.4
Increasing rate of CS worldwide is concerning for public health and obstetricians as they can increase financial burden and can affect the maternal health when compared to vaginal delivery.5
CS have multiple complications like adhesions, abdominal pain, bladder damage, prolonged duration of surgery, postoperative bleeding, bowel obstruction, wound dehiscence, rupture, placenta accreta.2, 6 These complications make the procedure and foetal extraction more challenging, increasing the time to delivery, and increases the chances of bowel or bladder injury.7
Adhesions are one of the complications of CS that complicates future CS.3 Adhesions are defined as fibrous attachments developing between tissues and intra-abdominal organs following an inflammatory reaction of the peritoneum.3
This study aims to study the prevalence of intraabdominal adhesions in repeat CS and to evaluate the association between intraabdominal adhesions and maternal and fetal outcome.
Materials and Methods
Source of data
This study was performed among those pregnant women admitted at KIMS hospital in the Department of Obstetrics and Gynecology, and have had at least one CS in the past irrespective of the outcome/parity of the patient.
This observational study was conducted between January 2023 to June 2023 over 6 months in the department of Obstetrics and Gynecology, KIMS Hospital, Bangalore. The sampling method used was convenience sampling. Sample size of 70 was obtained as below.
Sample size estimation
Z(1-
P=0.62 [Based on the probability, that the most common type of complications in repeat CS patients were adhesions (62%) as per the findings from previous literature by Mercy A. Nuamah et al (2)]
Q=1-P
N = 64.14, rounded off to 70
Materials and Methods
After obtaining approval and clearance from the Institutional Ethics Committee, the data of the pregnant women fulfilling the inclusion criteria was enrolled for the study.
Basic data like age, gravidity, inter pregnancy interval, history of past surgeries was recorded.
ANC records and previous medical records were analysed.
Adhesions intraoperatively were assessed by a grading system according to Tulandi and Lyell as mentioned by Mercy A. Nuamah et al.2 in their prospective cohort study.
In their grading system (Table 1), adhesions were graded by their location, size and consistency. Flimsy adhesions are those that are transparent and easily dehisced. Flimsy adhesions more than 6 cm wide were allotted maximum of 4 points whereas dense adhesions which are difficult to separate were allotted 4 (if <3cm wide) and maximum of 16 (if >6cm wide) if adhesions present between uterus and bladder, abdominal fascia or omentum. Flimsy adhesion between omentum and abdominal fascia was allotted 2 points irrespective of size, and a dense adhesion was allotted 8 points. Similarly, a score was allotted for adhesions to other pelvic structures that interfere with the delivery as per the grading system.
Table 1
Annexure: Grading system
The duration of surgery was taken to be from the first skin incision till the placement of last skin suture.8
Outcomes measured were:
Data was entered in MS Excel and Statistical Analysis was done using Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 Released 2013. Armonk, NY: IBM Corp.
Descriptive analysis of all the explanatory and outcome parameters will be done using mean and standard deviation for quantitative variables, frequency and proportions for categorical variables.
Chi Square Test was used to observe for the association between patient characteristics, maternal & foetal complications based on the presence of Intra-abdominal adhesions and also based on the type of adhesion.
Mann Whitney Test was used to compare the mean duration of surgery and baby's birth weight based on the presence of Intra-abdominal adhesions and also based on the type of adhesion. The level of significance was set at P<0.05.
Results
The study included 70 pregnant patients admitted in KIMS hospital in Department of OBG, who underwent repeat CS at KIMS hospital.
The mean age distribution noted in the study subjects were 29.40±4.36 (21-41 years). (Table 2) The mean gestational age of the patients was 37-40 weeks period of gestation. The repeat CS were elective – 25 patients (35.7%) and emergency - 45 patients (64.3%).
Table 2
Distribution of age & gestational age among study subjects
|
Variable |
Category |
n |
% |
|
Age |
21-25 yrs. |
14 |
20.0% |
|
26-30 yrs. |
30 |
42.9% |
|
|
31-35 yrs. |
19 |
27.1% |
|
|
> 35 yrs. |
7 |
10.0% |
|
|
|
Mean |
SD |
|
|
Mean |
29.40 |
4.36 |
|
|
Range |
21 - 41 |
||
|
Gestational Age |
32-36 weeks |
17 |
24.3% |
|
37-40 weeks |
53 |
75.7% |
|
Among those who underwent repeat CS, adhesions were noted in 30 patients (42.9%) and no adhesions were there in 40 cases (57.1%). (Table 3)
Table 3
Prevalence of intra-abdominal adhesions among study subjects
|
Variable |
Category |
n |
% |
|
Intra-Abdominal Adhesion |
Present |
30 |
42.9% |
|
Absent |
40 |
57.1% |
|
|
Types of Adhesion |
Dense |
19 |
27.1% |
|
Flimsy |
11 |
15.7% |
Study subjects were compared based on the presence or absence of adhesions and patient characteristics and results were noted. In the age group </=30 years, adhesions were present in 17 patients (56.7%) and absent in 27 patients (67.5%). In the age group >30 years, adhesions were present in 13 patients (43.3%) and absent in 13 patients (32.5%). (Table 4)
In the group with gestational age between 32-36+6 weeks, 7 patients had adhesions (23.3%) and 10 patients (25%) did not have any adhesions. In term patients with gestational age between 37 – 40 weeks, 23 patients (76.7%) had adhesions and 30 patients (75%) had no adhesions. With respect to indication for surgery, in elective cases, 10 patients (33.3%) had adhesions and 15 patients (37.5%) had no adhesions. In emergency cases, 20 patients (66.7%) had adhesions and 25 patients (62.5%) had no adhesions. No statistically significant association was noted between patient characteristics like age, gestational age, indication of surgery and intra-abdominal adhesions prevalence. (Table 4)
Table 4
Association between prevalence of intra-abdominal adhesions and patients' characteristics using Chi square Test
Adhesions were categorized as flimsy and dense based on the Table 1 (annexure 1). Dense adhesions were noted intraoperatively between various structures in 19 patients (27.1%). Flimsy adhesions were noted in 11 patients (15.7%) intraoperatively. Around 40 patients (57.1%) did not have any adhesions. (Table 2)
On comparing the presence of adhesions and maternal outcome, atonic PPH (postpartum hemorrhage) was noted in 6 patients (20%) with adhesions and was managed medically. The subjects with adhesions showed significantly higher proportion of PPH in comparison to those without adhesions – 24 patients (80%). The difference in proportion between the subjects were statistically significant at p-value = 0.01. (Table 5) There was no statistically significant association noted between type of adhesion and maternal complications.
Table 5
Association between prevalence of intra-abdominal adhesions and maternal complications using Chi square Test
|
Variable |
Category |
Present |
Absent |
p-value |
||
|
n |
% |
n |
% |
|||
|
Postpartum Complication |
Atonic PPH |
6 |
20.0% |
0 |
0.0% |
0.01* |
|
None |
24 |
80.0% |
40 |
100.0% |
||
In this study, adhesion prevalence and their association with neonatal outcomes was compared. One neonate had low APGAR at 1 minute due to delay in extraction secondary to adhesiolysis. APGAR at 5 minutes was normal for all neonates. No statistically significant association was found between neonatal outcome and presence of adhesion.
The duration of surgery varied depending on the presence of adhesions during the repeat CS. The mean duration of surgery if adhesions were present was 126.83 minutes +/- 19.85 and was significantly higher in comparison to those without adhesions where it took 82.35 minutes +/- 12.82 for the CS. The mean difference in duration of surgery was statistically significant at p-value <0.001. (Table 6)
Table 6
Comparison of mean duration of surgery (in mins) based on the presence of Intra-abdominal adhesion using Mann Whitney Test
|
Variable |
Adhesion |
N |
Mean |
SD |
Mean Diff |
p-value |
|
Surgery Duration |
Present |
30 |
126.83 |
19.85 |
44.48 |
<0.001* |
|
Absent |
40 |
82.35 |
12.82 |
The mean duration of surgery also varied depending on the type of adhesion. In the group with dense adhesion, it took an average of 132.63 minutes +/- 21.88 for the repeat section, which was significantly higher than those with flimsy adhesions where it took an average of 116.82 minutes +/- 10.31 for the surgery. The mean difference in the surgery duration was statistically significant at p-value = 0.02. (Table 7)
Table 7
Comparison of mean duration of surgery (in mins) based on the type of intra-abdominal adhesion using Mann Whitney Test
|
Variable |
Adhesion |
N |
Mean |
SD |
Mean Diff |
p-value |
|
Surgery Duration |
Dense |
19 |
132.63 |
21.88 |
15.81 |
0.02* |
|
Flimsy |
11 |
116.82 |
10.31 |
The mean adhesion dimension noted in the group with dense adhesions intra operatively was 4.89 cm +/- 1.63 which was higher in comparison to the subjects with flimsy adhesion which was 3.27cm +/- 1.42. The mean adhesion dimension was statistically significant depending on the type of adhesion at p-value = 0.01. (Table 8)
Discussion
The rate of caesarean delivery has increased in the past, and the increase in primary CS and a decrease in the vaginal birth after caesarean section (VBAC) rate has led to an increase in repeat CS.9
The most common complication noted in repeat CS are adhesions to adjacent organs or fascia or abdominal wall most commonly between uterus and anterior abdominal wall, as noted in a study by Judith H Poole, that the uterus size prevents direct contact between incision site and intestines, causing adhesions commonly between uterus, bladder and omentum.10
Adhesions require surgical intervention and are thereby a significant burden to healthcare system as adhesiolysis and complications due to adhesions, require time and resources.11
The prevalence of adhesions noted in our study was 42.9%, which was lesser in comparison to a study done by Nuamah et al. which was 62%2 and a study conducted by Regmi DR, 82.6%.12
No difference was noted in the complications based on either elective or emergency repeat CS which was similar to a study done by Sharma et al.13
In our study we noted that the maternal and neonatal outcome can be affected as a perioperative consequence to adhesions. The factors noted were duration of surgery and extraction time especially when the repeat CS is indicated for foetal distress.
Maternal outcome noted in our study was atonic PPH in 6 patients (20%), which was higher than in the study done by Regmi et al. which was 8.2%.12 There was no statistically significant neonatal complication noted, but one neonate had a low one-minute APGAR due to delayed extraction secondary to adhesiolysis.
The duration of surgery was significantly increased due to the presence of adhesions and further increased in case of dense adhesions which was statistically significant. Dense adhesions were noted in 19 patients (63.3%) after one CS which was higher than that noted by R. Mooij et al. in their study, which was 56% after one CS.14 The mean increase in the duration noted between repeat section with adhesions and those without adhesions was 44.48 minutes which was similar as noted by Nuamah et al. in their study – 39.2 minutes2 and much higher than that noted by Manoj P et al. in their study which was approximately 24 minutes more with adhesions.15
Also, increased operative time even in Elective sections requires prolonged anaesthesia and can increase the chances of infection and increase blood loss as observed in other studies.2 In our study prolonged anaesthesia was noted. Postoperative infection risk was not included and no significant blood loss was noted intraoperatively.
The limitations of the study noted were, a prospective study could help follow up the patients to conclude on postoperative period complications, outcomes and quality of life. Another limitation noted was that, the inter pregnancy interval and adhesion association and the details of the previous CS like steps of the procedure, closure of peritoneum, type of suture material used, use of unpowdered or powdered gloves, duration of previous surgery could not be obtained to evaluate association and determine outcomes. In the present study, the CS was performed by both senior and junior surgeons, and the time taken for surgery may alter to some extent.
A prospective study overcoming the above limitations may help in identifying the contributing factors and help in preventing adhesions.
Conclusion
In our study the prevalence of intra-abdominal adhesions was 42.9%. There was a statistically significant association noted between presence of adhesions and maternal outcome which was noted here as atonic PPH intraoperatively among 6(20%) cases which was medically managed. Though one neonate had a low one-minute APGAR secondary to adhesiolysis in the repeat CS, no statistically significant association was noted with respect to neonatal outcome and adhesions. A significant association was noted in the duration taken for the surgery due to the presence of intra-abdominal adhesions where time taken was approximately more than 40 minutes. Further research can be conducted in a larger study group and with a prospective study design to evaluate other contributing factors.
Availability of Data and Materials
The electronic data set are available from the corresponding author on reasonable request.
Authors’ Contributions
Kiruthika T was responsible for correspondences and supervised data collection. Kiruthika T and Jayanthy T, co-designed the study and study procedures, analyzed data, designed the questionnaire. All authors participated in manuscript writing, reading and approval of final manuscript.
