Effect of remote cesarean delivery on complications during hysterectomy: a cohort study

BACKGROUND: Cesarean delivery is performed frequently worldwide, and follow-up studies that report 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 that are driven by the presence of adhesions. STUDY DESIGN: This was a longitudinal population-based register study of 25354 women who underwent 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% of the women. The risk of organ injury (adjusted odds ratio, 1.74; 95% confidence interval, 1.41-2.15) and postoperative infection (adjusted odds ratio, 1.26; 95% confidence interval, 1.15-1.39) was increased with previous cesarean delivery, 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 delivery was a predictor of bladder injury (adjusted odds ratio, 1.86; 95% confidence interval, 1.40-2.47) and bowel injury (adjusted odds ratio, 1.83; 95% confidence interval, 1.10-3.03), but not ureter injury. A personal history of other abdominal surgeries was associated with bowel injury (adjusted odds ratio, 2.27; 95% confidence interval, 1.37-3.78), and the presence of endometriosis increased the risk of ureter injury (adjusted odds ratio, 2.15; 95% confidence interval, 1.34-3.44). CONCLUSION: Previous 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.