European Journal of Cardiovascular Medicine

A Caesarean Section (CS) is a significant procedure commonly performed in obstetric practice ⁽¹⁾. It serves as a life-saving intervention when warranted and helps to avert complications for both mothers and newborns, including the risk of neonatal death. The frequency of CS is escalating due to various factors such as maternal traits (age extremes, obesity, etc.), requests from mothers, labor induction, and the use of epidural anaesthesia ^(2-4). The World Health Organization suggests that the ideal rate for CS should be between 10-15% ⁽⁵⁾; however, despite the fact that CS rates have surpassed 20%, this increase has not correlated with a decrease in maternal or neonatal mortality rates ⁽⁶⁾.

Although there have been advancements in techniques such as blood transfusions, anaesthesia, and routine antibiotic administration ⁽²⁾, caesarean sections, similar to other surgical procedures, come with both short-term and long-term complications. The risk of maternal mortality associated with caesarean delivery is three times higher than that of vaginal delivery ⁽⁷⁾. One of the immediate complications that may arise is the necessity for re-laparotomy following a caesarean section ⁽¹⁾. Re-laparotomy is defined as an abdominal surgery conducted after an initial procedure within a 60-day period, with decisions based on the patient’s overall response to surgical stress ⁽⁸⁾.

Re-laparotomy post-caesarean section is regarded as a near-miss event that carries significant consequences for the patient ⁽⁹⁾; some studies indicate that maternal mortality rates after such procedures range between 2.9% and 33% ^{(1, 10, 11)}. Thus, re-laparotomy after a caesarean section necessitates sound clinical judgment and early identification of patients who may need this procedure, as it could be the final and sole option to save the patient's life ⁽¹²⁾.

Some reasons for re-laparotomy after a caesarean section include intra-abdominal haemorrhage, hemodynamic shock, and postpartum hemorrhage ^{(1, 13, 14)}. In 2018, Gedikbasi et al pointed out that only three descriptive studies on re-laparotomy following CS were available in the literature ⁽¹⁾. Given the limited number of studies published on this topic, the current study intends to explore the risk factors and maternal outcomes within our tertiary care facility. This prospective research will identify the factors and risk scenarios linked to re-laparotomy post-CS, enabling medical professionals to address these issues and encouraging obstetricians to exercise greater caution during the initial surgery to minimize the need for secondary surgical interventions and associated morbidities.

OBJECTIVES:

1. To assess the various risk factors in mothers requiring re-laparotomy after caesarean section in our hospital during the given period.
2. To evaluate maternal outcomes in this study in terms of mortality and morbidit.

Study Design: A prospective observational study.   

Study area: Department of Obstetrics and Gynecology, R.G.KAR Medical College and Hospital, Kolkata.   

Study Period: December, 2022 to May, 2024 (18 months)  

Study population: All women undergoing re-laparotomy after caesarean section deliveries in the stipulated time frame in R.G.KAR Medical College and Hospital, Kolkata. 

Sample size: The study consisted of a total of 40 subjects. 

If we consider 95% confidence interval and 5% error then considering

Prevalence of re-laparotomy after caesarean section as 2.3%, the sample size is calculated from the following formula of descriptive study:

N = (Z 1-alpha/2)2 x P x Q/L2

= (1.96x1.96) ×2.3×97.9/5×5

= 36

Adding 10% drop out rate, sample size = 36+10%= 40

Sampling method: convenience sampling method.   

Inclusion criteria: All patients requiring re-laparotomy after caesarean section deliveries in our hospital.

Exclusion criteria: Patients not willing to participate in the study.

Ethical consideration: Institutional Ethical committee permission was taken before the commencement of the study.

Study tools and Data collection procedure:

STUDY VARIABLES:

For maternal outcomes and risk factors, the following would be assessed:

1. Age of the patient
2. Booking status of the patient
3. Gravida
4. Parity
5. Present Obstetric history
6. past obstetric history
7. Preexisting medical disorders
8. Indication of Primary CS who underwent re-laparotomy
9. Indications of re-laparotomy
10. Procedures at re-laparotomy
11. Time interval between primary CS and re-laparotomy
12. Management after re-laparotomy following caesarean section
13. Duration of hospital stay
14. Final outcome after re-laparotomy

OUTCOME DEFINITION AND PARAMETERS:

Maternal Mortality: The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes.

Near Miss (Severe Acute Maternal Morbidity): A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy.

Maternal Morbidity:

1. Stay in HDU/CCU
2. Blood and blood products use
3. Dialysis
4. Pyrexia
5. Wound dehiscence
6. Discharge

Data were collected in details by history taking, antenatal card, hospital records, hospital admission records, case sheets, examination and daily regular observation of the patients. Collected data were recorded in a pretested case report proforma. Analysis was to be done in the form of percentages and represented as tables and figures where necessary.

STATISTICAL ANALYSIS:

The data are tabulated in Microsoft excel and analyzed with IBM SPSS V.24 software. The continuous variables are presented with mean ± standard deviation. The categorical variables are presented with frequency and percentage. The results have been presented with appropriate tables and diagrams.

Table 1. Distribution of Maternal age

the distribution of maternal age among 40 individuals reveals that the majority (50.0%) are aged between 26-30 years. This is followed by 37.5% of mothers who are between 20-25 years old, and a smaller proportion (12.5%) are older than 30 years. The average age is 26.87 years, with a standard deviation of 3.55 years. Booked cases account for 27.5%, while referred cases make up 72.5%.

The distribution of the period of gestation indicates that 30% of deliveries occurred before 37 weeks. 37.5% of deliveries occurred at 37 weeks. The remaining 32.5% of deliveries occurred after 37 weeks. The mean period of gestation was 37.1 weeks with a standard deviation of 1.5 weeks.

The parity of the mothers, with a majority (55.0%) being primiparous. Multiparous mothers with two, three, and four previous deliveries account for 22.5%, 12.5%, and 10.0% respectively. Majority of the patients were obese 2(30%, obese 1 (25%) and overweight (20%). the vast majority of pregnancies (90.0%) were conceived spontaneously, with only 10.0% resulting from in vitro fertilization (IVF). 27.5% of women had previous 1 caesarean section, 25.5% had previous vaginal deliveries, 22.5% of women had previous 2 caesarean sections and 25.0% had no previous delivery.

Table 2. Distribution of Pre-existing medical disorders

The most common issues were pregnancy-induced hypertension (PIH) present in 20.0% and gestational diabetes mellitus (GDM) in 12.5%. Hypothyroidism was noted in 10.0% of the cases. Notably, 22.5% had no significant pre-existing medical conditions.

Out of 11 relaparotomies done in our institution, 81.8% were performed by surgeons up to the level of senior residents (including Junior Residents) while only 18.2% were performed by consultants. out of 11 re-laparotomies that occurred in our institution in the stipulated time period, 8 cases (72.73%) were after Emergency CS and 3 cases (27.27%) were after elective CS.

Table 3. Distribution of Indication of CS

The most common reasons were obstructed labor (20.0%) and post-caesarean section with such as scar tenderness (27.5%), repeat caesarean section with such as scar tenderness (22.5%) and non-progress of labor (10.0%).

Table 4. Distribution of Time period between CS and Relaparotomy

The highest percentage, 25%, of patients underwent relaparotomy within less than 6 hours of CS. This is followed by 22.5% of patients who had the procedure between 6 and 12 hours after CS. A smaller proportion, 15%, had relaparotomy within 12 to 24 hours, and 17.5% between 24 and 72 hours. Finally, 20% of patients underwent relaparotomy more than 72 hours after CS.

The most common indication was postpartum haemorrhage (PPH) due to an atonic uterus, accounting for 30% of cases. Rectus sheath hematoma was the second most common indication, comprising 25% of cases. Secondary PPH and hemoperitoneum each accounted for 12.5% of the indications. Burst abdomen and broad ligament hematoma were each responsible for 7.5% of the relaparotomies. Bladder injury and suspected intestinal injury were the least common indications, each making up 2.5% of the cases.

Among the booked cases most of the re-laparotomies were performed due to PPH (atonic uterus) (45.45%) followed by rectus sheath hematoma and broad ligament hematoma. Among the referred cases, most of the re-laparotomies were performed due to rectus sheath hematoma (27.59%) followed by PPH (24.14%0 and hemoperitoneum (13.79%).

Table 5. Distribution of Procedures during relaparotomy

The most frequent procedure was drainage of blood clots from the undersurface of the rectus sheath and peritoneal cavity, performed in 25% of the cases. Hypogastric artery ligation was performed in 17.5% of cases, while bilateral uterine artery ligation along with ligation of the utero-ovarian anastomosis near the cornu was performed in 15% of the cases. Resuturing of the uterine incision line was carried out in 12.5% of cases. Obstetric hysterectomy accounted for 10% of the procedures. Repair of burst abdomen was performed in 7.5% of the cases. Several procedures, each performed in 2.5% of the cases, included drainage of bladder base hematoma, re-ligation of the tubectomy site, decompression of the large gut, and evacuation of broad ligament hematoma.

Regarding blood transfusion, where 37.5% of patients received a combination of packed red blood cells (PRBC), fresh frozen plasma (FFP), and random donor platelets (RDP). Only PRBC was used in 30.0% of cases.

Table 6. Distribution of Outcome

Most patients were shifted to high- dependency units (HDU) (52.5%), while 30.0% were moved to general wards. Unfortunately, 7.5% of the patients died.

Table 7: Maternal Mortality following Re-laparotomy

3 cases died after the procedure. Causes were hemorrhagic shock, coagulation profile, and multi-organ failure respectively.

Table 8. Distribution of post-operative complications

Postoperative complications, with 65.0% of patients experiencing no significant complications. However, 10.0% had wound dehiscence, and various combinations of sepsis, anuria, and hypovolemic shock were noted in smaller proportions.

Table 9. Distribution of Duration of Hospital stay

Most patients (60.0%) stayed for 11-20 days, with a mean duration of 17.58 days. A smaller number stayed less than 10 days (12.5%) or more than 30 days (10.0%).

During the stipulated 18 months of my study there were total 15281 deliveries in our institution, among which there were 9047 caesarean section deliveries (59.2%). My study constituted of 40 cases of re-laparotomy after caesarean section, however referred cases (72.5%) formed the majority of my study population.

In 11 cases of re-laparotomy where primary CS was performed in our institution, 8 cases (72.73%) had undergone emergency CS; while 27.27% had undergone elective CS. A study by Reddy et al in 2016 also found that 90.5% who underwent re-laparotomy had an emergency CS, whereas only two had an elective CS (41).Among the 11 booked cases, in nine cases 81.82%) of re-laparotomy , the primary CS were performed by doctors up to the level of senior resident(including junior resident); whereas in two cases (18.18%) of re- laparotomy, the primary CS were done by consultants in case of which re-laparotomy had to be done due to burst abdomen.

My study reveals that majority (50%) patients are aged between 26-30 years, this is followed by 37.5% of mothers who are between 20-25 years old, and a smaller proportion (12.5%) are older than 30 years of age. The average age is 26.87 +3.55 years. Similarly, a study by Khan et al in 2015 found that the majority cases of re-laparotomy patients (92.6%) were between the age group of 20-35 years. ⁽¹⁴⁾; while in a study by Biswas et al ⁽¹⁵⁾ the mean age of the patients requiring re-laparotomy was 25 years with range being 15 to 35 years. Another study by Reddy et al ⁽¹⁶⁾ in 2016 found that the mean age group was 20 to 35 years which is the normal reproductive age group.

Majority of patients (37.5%) were delivered at 37 weeks of gestation, whereas 32.5% deliveries occurred after 37 weeks of gestation. And 30% deliveries occurred before 37 weeks of gestation. A study by Raagab et al ⁽⁴⁾ in 2014 also found that average week of gestation is 36-76 weeks. In my study, majority of the patients were obese class two (30%) (BMI >30kg/m2) required re-laparotomy after CS; whereas 25% were in Obese class one group (BMI=25-29.9 kg/m2). A study by Amikam et al ⁽¹⁷⁾ in 2024 found that mean BMI of the patients requiring re- laparotomy was 23.9+4.7 Kg/m2.

Majority of the patients in my study was primi-parous (55%), whereas only 10 % (4/40) was multipara mothers. A study by Reddy et al ⁽¹⁶⁾ in 2016 found that most of the cases were multipara except for 3 who were in their first parity, which was different from my study. Majority of patients who underwent re-laparotomy conceived spontaneously (90%) with only 10 % cases were resulted from IVF (In vitro fertilization). Most of the patients (27.5%) undergoing re-laparotomy after caesarean section had previous one caesarean section (Post C/S); whereas 25% cases had previous vaginal deliveries and 22.5% women had previous two caesarean section (Repeat C/S). A study by Seal SL et al in 2007 similarly found most of the cases who underwent re-laparotomy after CS had one previous CS ⁽¹³⁾.

Majority of my study population had Pregnancy Induced Hypertension (20%) as pre-existing medical comorbidity; whereas 12.5% patients had Gestational Diabetes Mellitus (GDM). Many of my study population had PIH, Pre -eclampsia (mild or severe), GDM, Hypothyroidism, Obstetric cholestasis; but the most common comorbidity present was severe pre- eclampsia. 22.5% of my study population had no significant medical comorbidity. In most of the cases (40%) the primary caesarean section was performed in private set up followed by other govt. facilities (32.5%; 13/40); in our institution total 11 cases (27.5%) patients required re-laparotomy after caesarean section.

My study revealed that the most common indication of primary caesarean section was Post CS with scar tenderness (27.5%;11/40) followed by Repeat CS with scar tenderness (22.5%; 9/40). Obstructed labor was the indication of primary caesarean section in 20% cases; whereas CS done due to non- progress of labor in 10% cases. In case of remaining 20% study population, the indications of caesarean section were GDM with fetal distress (5%), Abruptio placentae (5%), Placenta previa (5%) and CPD (Cephalo-Pelvic Disproportion (5%).  

In my study, majority of cases (25% underwent re-laparotomy within 6 hours of primary CS, whereas 22.5% cases underwent re-laparotomy between 6-12 hours, a smaller proportion (15%) had undergone re-laparotomy within 12-24 hours, 17.5% cases had undergone re- laparotomy in 24-72 hours and lastly 20% cases underwent the procedure in more than 72 hours after primary CS .A study by Reddy ⁽¹⁶⁾ et al in 2016 also found that most of the cases(80.9%) required re-laparotomy within 24 hours of primary CS, while 1 case required re-laparotomy after 72 hours. Similarly, a study by Seal SL ⁽¹³⁾ in 2007 also found that most of the cases underwent re-laparotomy within 6 hours of primary CS.

My study found that most common indication of re-laparotomy after caesarean section was PPH (Post-Partum Hemorrhage) due to atonic uterus i.e.,30% cases, followed by Rectus Sheath Hematoma (25%). There were 5 cases of hemoperitoneum (12.5%) and 5 cases of secondary PPH (12.5%) for which re-laparotomy after caesarean section was needed. Among the remaining cases, 3 cases (7.5% required re-laparotomy due to burst abdomen a, 3 cases (7.5%) required re-laparotomy due to broad ligament hematoma, 1 case (2.5%) due to bladder injury and only 1 case (2.5%) required re-laparotomy due to suspected intestinal injury. A study by Reddy et al ⁽¹⁶⁾ in 2016 revealed that atonic PPH was leading cause of re- laparotomy after CS followed by rectus sheath hematoma; which is almost similar findings as of my study. Another study by Seal SL ⁽¹³⁾ in 2007 found that PPH was the commonest reason for need of re-laparotomy after CS followed by rectus sheath hematoma (27.3%); which was quite similar to my study. A study by Kundu G et al ⁽¹⁸⁾ also found that PPH (both primary and secondary) was a major indication of doing re-laparotomy after CS. In contrary to this, a study by Ragaab et al ⁽⁴⁾ in 2014 found that intra-peritoneal hemorrhage was the main indication of doing re-laparotomy after CS.

In cases of PPH due to atonic uterus, initially to control hemorrhage, oxytocics such as oxytocin, methergin and prostaglandin injections were given; blood transfusion was also done. In cases of secondary PPH, injectable antibiotics were also given to the patients. When the conservative management failed to control PPH, surgical interventions were undertaken. Hypogastric artery ligation was done in seven cases (17.5%); whereas B/L uterine artery ligation along with ligation of utero-ovarian anastomosis near uterine cornu was performed in 15% of cases. In cases of secondary PPH, wound debridement and re- suturing of uterine cut margins were done; Re-suturing of uterine incision line was done in five cases (12.5%).

Drainage of blood clots from undersurface of rectus sheath was done in case of rectus sheath hematoma in 10 cases (10%). The peritoneal cavity was opened and inspected routinely. Obstetric hysterectomy was done in four cases (10%) of secondary PPH. A study by Gedikbasi et al ⁽¹⁾ in 2008 also revealed five cases of subtotal hysterectomy following re-laparotomy after CS. Re-laparotomy after CS required due to burst abdomen in three cases (7.5%), where repair of anterior abdominal wall was done.

Other procedures during re-laparotomy were 4 (10%) which includes: one case (2.5%) needed drainage of bladder base hematoma and bladder injury repair; one case (2.5%) required re-ligation of tubectomy site; one case (2.5%) required drainage of bladder base hematoma and one case (2.5%) required resection and anastomosis of small gut. The patients who underwent re-laparotomy after CS had received different combination of blood and blood products. Most of the cases (37.5%) had (PRBC+FFP+RDP) transfusion, while in 12.5% cases patients received the combination of PRBC, FFP, RDP and cryoprecipitate. Among the remaining cases, 30% received only PRBC transfusion, whereas 20 % patients received both PRBC and FFP.

Out of 40 patients who required re-laparotomy after CS, 12 patients (30%) were shifted to general ward and discharged; 21 patients (52.5%) were shifted to HDU (High Dependency Unit) then recovered and subsequently discharged. Only four patients (10%) required CCU admission and recovered. Maternal death occurred only in three cases (7.5%). Maternal death occurred due to following reasons: one case died due to hemorrhagic shock within four hours of re- laparotomy who underwent re-laparotomy for PPH due to atonic uterus, whose indication of primary CS was obstructed labor. one case died due to coagulation failure within two hours of re-laparotomy who underwent re-laparotomy due to hemoperitoneum, whose indication of primary CS was abruptio placentae; and lastly one case died due to multi organ failure and sepsis within four days after re-laparotomy who underwent re- laparotomy due to rectus sheath hematoma and whose indication for primary CS was obstructed labor. A study by Seal SL ⁽¹³⁾ in 2007 found eight cases of maternal death following re-laparotomy after CS.

My study revealed, in most of the patients (60%) the average duration of hospital stay was 11-20 days; whereas in cases of only four patients (10%), the average duration of hospital stay was >30 days due to requirement of dialysis, secondary suturing. Mean duration of hospital stay was 17.58+7.47 days.

Finally, it can be concluded that exposure to CS is itself a definitive risk factor with complications such as need of re-laparotomy which is done as a procedure in cases of near miss fatality of mother. Every effort must be made to make the procedure safe. If the personnel and adequate blood products are available, re-laparotomy should not be delayed for the management of intractable hemorrhage and unstable vital signs after CS. Strict post -operative vigilance and timely intervention can reduce both maternal morbidity and mortality.

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