Perinatal Morbidity & Mortality following repeat Cesarean section due to five or more previous Cesarean Section done in Tertiary centre in KSA

Objectives: To highlight and determine the maternal and neonatal outcome and associated risks for patients who have undergone their 6th and more caesarean sections. Design: Case control study. Setting: Tertiary Centre (Security Forces Hospital – Riyadh – Saudi Arabia). Patients: 80 patients selected to study group who have undergone their sixth and more caesarean sections in Security Forces Hospital. Between June 2006 and May 2010. This group was compared to 80 patients who have undergone their third to fi fth caesarean sections during the same time period and immediately following the studied case. Main outcome measured: Age and parity of women in study and the control group were correlated with the number of previous caesarean sections. Intra operative and post-operative maternal complications including presence and grade of adhesions, intra partum and postpartum hemorrhage, use of measurement and methods (both medical and surgical) to control bleeding such as Bakry balloon, Internal iliac artery ligation, etc., were highlighted. Bowel injury, blood transfusion, admission to surgical intensive care, incidence of placenta previa and accreta, post-operative complications like paralytic ileus, wound infection were also noted. Further, neonatal outcome including birth weight, Apgar score, and need for neonatal intensive care unit admission were reviewed. Results: Patients in the study group had higher incidence of extensive adhesions (41.25%) compared to (12.25%) in the control group. Bowel injury was (2.5%) in study group with none in the control group. The incidence of placenta previa was (8.75%) in the study group as compared to (2.5%) in the control group, with placenta accreta complicating (28.57%) of placenta previa seen only in the study group. Blood transfusion was higher in the study group (20%) as compared to (5%) in the control group. Neonatal admission to NICU was higher in the study group (27.5%) in comparison to the control group (12.5%). Also birth weight was lower in the study group. Conclusion: The more the number of caesarean sections, the more the maternal and neonatal morbidity. Patients should have proper counselling during antenatal follow up about the risks of repeated caesarean sections, and offered bilateral tubal ligation after the third or fourth caesarean sections. Research Article Perinatal Morbidity & Mortality following repeat Cesarean section due to fi ve or more previous Cesarean Section done in Tertiary centre in KSA Somia Osman, Gehan Farid* Reem Mohamed Kamal , Sarah Rabie Ali and Mohamed AH Swaraldahab Department of Obstetrics and Gynaecology, Security Forces Hospital, Saudi Arabia *Address for Correspondence: Gehan Farid, Department of Obstetrics and Gynaecology, Security Forces Hospital, Saudi Arabia, Email: Faridgi@yahoo.com Submitted: 10 July 2018 Approved: 30 July 2018 Published: 31 July 2018 Copyright: 2018 Osman S, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited Abbreviations: BTBlood Transfusion; C/SCaesarean Section; IIALInternal Iliac Artery Ligation; IUFDIntrauterine Fetal Death; PPHPostpartum Haemorrhage; NICUNeonatal Intensive Care Unit; NO.Number; RDSRespiratory Distress Syndrome; SICUSurgical Intensive Care Unit; TTN-Transient Tachypnae of Neonate How to cite this article: Osman S, Farid G, Kamal RM, Ali SR, Swaraldahab MAH. Perinatal Morbidity & Mortality following repeat Cesarean section due to fi ve or more previous Cesarean Section done in Tertiary centre in KSA. Clin J Obstet Gynecol. 2018; 1: 045-051. https://doi.org/10.29328/journal.cjog. 1001007 Introduction Higher order repeat caesarean sections is becoming a very common practice especially in the Middle East and more so in Saudi Arabia, where large families are desired due to social and cultural factors, thus putting the women at a signi icant risk of surgical and anesthetic complications of repeated caesarean sections. Repeat caesarean sections have become very common over past decade, due to improvement in the safety of anesthesia and the use of prophylactic Antibiotics and Anticoagulants which lead to an overall decrease in the maternal morbidity and mortality. There are few studies published in the literature regarding the associated risks with higher order repeated caesarean sections and patients with lower number of repeat caesarean sections (one, Perinatal Morbidity & Mortality following repeat Cesarean section due to fi ve or more previous Cesarean Section done in Tertiary centre in KSA Published: July 31, 2018 046 two, three and a maximum of four caesarean sections). Our study is one of fewer studies including the highest number of repeat caesarean sections including patients who have under gone six and more caesarean sections. The noted associated risks encountered with high order repeated caesarean sections, both maternal and neonatal , and which contradict with some other published data, encouraged us the conduct this study to highlight such morbidities in relation to the studied population in our institute. Material and Methods This is a case control study done on a total of 83 women who have undergone six or more caesarean sections in the department of Obstetrics and Gynecology at Security Forces Hospital – Riyadh – Saudi Arabia, between June 2006 and May 2010. Three of these patients were excluded from the analysis due to incomplete hospital records. This study group (cases) was matched to a control group of 80 women with previous two (46 patients), and three (26 patients) and four (8 patients) caesarean sections. The patient selected are those who had the caesarean section around the same period, and immediately following the studied case, controlled by the same maternal age and body mass index. The case records of the study and control groups were reviewed by the help of electronic medical record viewer chart in accordance to questionnaire set for each case and control which includes: 1. The patients’ characteristics include maternal age, weight, height, parity, gestational age, number of previous caesarean sections. 2. Intra operative and post-operative course including types of anesthesia, severity of adhesions which was subjectively graded by the operating surgeons according to the American Fertility Society Classi ication of Adnexal Adhesions, where ilmy and a vascular adhesions involving between 1 to 25% of a total area were classi ied as mild. Dense vascular adhesions which involved 26 to 50% of the pelvic areas were classi ied as moderate adhesions. Extensive adhesions where more than 50% of the area was involved were classi ied as severe. Estimated blood loss, the incidence of placental abnormalities, uterine ruptures whether complete or dehiscence were noted. Further bladder and bowel injury, blood transfusion, the use of antibiotics (intra and postoperative) were highlighted. The need for additional means to manage postpartum hemorrhage like internal iliac ligation, the use of Bakry Balloon, and internal iliac occlusion by catheter was also noted. This, in addition to admission to surgical intensive care unit. Post-operative complications including paralytic ileus, wound infection, urinary tract infection, chest infection, pyrexia and need for readmission were looked at, in addition to the length of stay. 3. Neonatal outcome including birth weight, Apgar score at ive minutes, admission to neonatal intensive care and mortality were also investigated. 4. Issues on contraception due to long term safety of the mother including intraoperative tubal ligation were noted.