Wednesday, April 8, 2009

Hysterectomy risk with multiple cesarean deliveries

The fact that risks increase with multiple cesarean deliveries is well documented, and it is important that anyone considering choosing a planned cesarean delivery in preference to a trial of labor is aware of these increased risks. In fact, this is why the NIH, ACOG and others all stress that CDMR is not recommended for women planning large families.

One of the risks often cited with multiple surgeries is the chance of needing an emergency hysterectomy, and a recent Irish news article has highlighted this risk:

The Sunday Times' 'Caesarean link to surge in hysterectomies', on April 5, reports:

"The problem is caused where the placenta, or afterbirth, attaches too deeply into the wall of the womb. The risk of the condition is increased by the presence of scar tissue from previous caesareans. Doctors from the Rotunda, Holles Street and the Coombe hospitals analysed charts of all patients who had emergency hysterectomies after giving birth in the 40 years between 1966 and 2005. Of the 320 cases, 43 of them were due to placenta accreta. It accounted for only one in 20 emergency hysterectomies from 1966 to 1975 but 47% of those between 1996 and 2005 when almost half (20) the cases occurred. The caesarean rate rose from 6% to 19% over the same period and now stands at about one in four births."

It is similar to an article that appeared in January 2008 in Australia's The Age, 'Caesars raise risk of losing womb', which reported on research from the University of Oxford:

"For most women giving birth normally for the first time, a hysterectomy is rare - only one in 30,000 will need surgery to remove their womb because of bleeding complications. But the risk of having to undergo surgery to remove the womb rises in the subsequent pregnancy for those who had a caesarean. One in 1300 women who have had one previous caesarean will have a hysterectomy. If the woman has had two or more previous caesareans, the risk rises to one in 220. Researchers estimate that more than 80 women a year have been forced to have a hysterectomy in Britain as a result of having a caesarean. But with the popularity of the procedure on the rise this figure is likely to increase. The study of 775,000 women who gave birth in Britain between February 2005 and February 2006 also found that women with twin pregnancies, older mothers and those who already had three or more children were also at higher risk of needing a hysterectomy."

Limitations of the research
The main problem with the research cited above is that the nature of the primary cesarean deliveries (that occurred prior to the subsequent surgery in which the hysterectomy is required) are not specified.

In fact, all cesarean delivery types tend to be pooled together and then the health outcomes of their subsequent pregnancies are looked at together. This means that primary cesareans that may have been an emergency delivery (which has greater morbidity risks than a planned delivery) are treated the same as planned deliveries.

Therefore, healthy women choosing a planned primary cesarean delivery should not be criticized or deterred from making their valid decision on the basis of mixed data outcomes. Yes, they should be informed of the risk of subsequent placenta complications, but every effort should be made to evaluate how many hysterectomies occur in cesarean deliveries that follow primary planned surgeries - not primary emergency surgeries.

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