Hesselman Susanne, Högberg Ulf, Jonsson Maria
Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Center for Clinical Research Dalarna, Falun, Sweden.
Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
Am J Obstet Gynecol. 2017 Nov;217(5):564.e1-564.e8. doi: 10.1016/j.ajog.2017.07.021. Epub 2017 Jul 21.
Cesarean delivery is performed frequently worldwide, and follow-up studies that report complications at subsequent surgery are warranted.
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.
This was a longitudinal population-based register study of 25354 women who underwent a benign hysterectomy at 46 hospital units in Sweden 2000-2014.
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).
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.
剖宫产在全球范围内频繁进行，因此有必要开展后续手术并发症的随访研究。
本研究旨在调查既往剖宫产与后续子宫切除术中并发症之间的关联，并估计由粘连导致的并发症比例。
这是一项基于人群的纵向登记研究，纳入了2000年至2014年在瑞典46家医院接受良性子宫切除术的25354名女性。
有剖宫产史的女性中，45%发现有粘连。2.2%的女性发生器官损伤。既往有剖宫产史会增加器官损伤风险（校正比值比，1.74；95%置信区间，1.41 - 2.15）和术后感染风险（校正比值比，1.26；95%置信区间，1.15 - 1.39），无论是否存在粘连。既往剖宫产史对器官损伤的直接影响估计为73%，仅27%由粘连介导。既往剖宫产史是膀胱损伤（校正比值比，1.86；95%置信区间，1.40 - 2.47）和肠损伤（校正比值比，1.83；95%置信区间，1.10 - 3.03）的预测因素，但不是输尿管损伤的预测因素。既往有其他腹部手术史与肠损伤相关（校正比值比，2.27；95%置信区间，1.37 - 3.78），子宫内膜异位症的存在增加了输尿管损伤的风险（校正比值比，2.15；95%置信区间，1.34 - 3.44）。
既往剖宫产与后续子宫切除术中并发症风险增加相关，但该风险仅部分归因于粘连的存在。既往剖宫产史和子宫内膜异位症的存在是子宫切除术中器官损伤的主要易感因素，而背景和围手术期特征的重要性较小。
