الفهرس 
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Abstract
There is a rise in multiple repeat CSs with associated complications. Increasing rate and number of cesarean deliveries are known to be associated with maternal & fetal risks.
Therefore, the purpose of this study was to evaluate the outcome of repeated selective cesarean deliveries conducted at one Eyptian hospital ,Beni-suef university hospital, and to find out whether the outcome is affected by increasing number and repetition of cesarean deliveries including maternal morbidity (occurrence of complications) in comparison to primary cesarean delivery.
This study comprised 300 parturient women admitted to the casualties unit of department of obstetrics and gynecology at Beni-suef university hospital and admitted for selective cesarean delivery during the period of research from August 2020 to August 2021 to evaluate the maternal and perinatal outcome of pregnancy in those who had history of previous repeated cesarean deliveries and to find out whether the outcome is affected by increasing number and repetition of cesarean deliveries.
This study included 3 groups of pregnant women who had gestational age beyond 28 weeks: first group )control group ( included 100 normal pregnant women with primary cesarean delivery, second group included 100 parturient women with previous one cesarean delivery, and the third group included 100 parturient women with previous two or more cesarean deliveries.
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results of the current study revealed that approximately, more than half of cases included in the current study [n=177(59%)] had an age ranged from 25-29 years, and followed by the age group between 20 and 24 years of age as 21% of participants (n=63) have been falling in this age group. .Also 48 (16%) of participants were found between 30 and 34 years, and 12 (4%) were falling in the age group (34-39) years.
from our work, maternal age at delivery was a strong risk factor for emergency CS among women who delivered by CS more than once as there was statistically significant increase in the age of pregnant women who had more than two caesarian section than others as the mean age was 25.6± 3.02 years, 26.49 ± 2.65 years, and 29.45 ± 3.8 years in control group, patients with one prior caesarian section, and patients with more than one prior CS groups (P<0.001).
Furthermore, this study has consistently found an association between the increase in BMI and increase in number of CS as the mean BMI of control cases was 26.4 ± 3.6 kg/m2 while the mean BMI of patients with one prior caesarian section and patients with more than one prior CS groups was 28.93 ± 2.9 kg/m2, and 31.09±2.4kg/m2; respectively. Maximum incidence of CS was done among obese patients.
In addition, our results show that the mean of gestational age at delivery was significantly lower in patients who had more than one previous CS than those with one previous CS and controls (35.41 ± 1.78 vs. 36.59±1.47 and 37.3±1.58; respectively) (P=0.001). Compared to nearly three-quarters (73%) of controls
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who were term pregnancy, about a third (35%) of those who had history of more than one prior CS gave birth after 37 weeks of gestation. The rest cases were premature delivery. Amongst cases that had more than one prior CS, only nine (9%) gave birth below 33 weeks of gestation compared to none of controls.
Furthermore, in our study, consultant and specialist are more likely to perform cesarean section (CS) operation than senior resident to patients with more than one previous CS. In group 3, professional staff members were more involved in surgical intervention than the other 2 groups (P <0.001).
Regarding type of anesthesia utilized, 86.3% of our cases were operated under spinal anesthesia. Remaining 13.7% cases operated under general anesthesia. Thus spinal anesthesia is the most common in emergency caesarean section.
In the group with prior more than 1 CS slightly higher percentage of general anesthesia but without statistically significant difference (P=0.117).
The present study indicated that Incidence of placenta previa and accreta were significantly increased between women who having a previous cesarean delivery (P≤0.001). Incidence of placenta previa and accreta was 4% and 1% in women with one prior cesarean delivery and 16% and 9% in women with at more than one prior cesarean delivery. Problems difficulty to reach the abdominal cavity due to either adhesion with peritoneum due to scar adhesion detected in only 9% of cases with more than one previous CS. Adhesion with omentum observed in 33 of all pregnant mothers (11%); 29 women of them included in group 3 with history of more than one previous
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CS, 3 cases belonged to group 2 with one previous CS and the rest case in control group. Also, adhesion with bowel were observed in 15 cases (5%); 10 cases were included to group 3 that had history of more than one previous CS, 4 cases belong to group 2 with one previous CS and the rest case in control group. Furthermore, difficulty to reach the LUS due to adhesion with bladder was noticed in 32 cases (10.7%), 28 of them included in group 3 with history of more than one previous CS and the remaining 4 cases belongs to group 2 with one previous CS. Among post-operation complications that detected only in pregnant women with previous history of more than one CS but not in other groups were hysterectomy (10%) and bowel injury (3%).
In our study the higher incidence of placenta previa and accreta in the cases with prior CS coincided with more intraoperative complications (bleeding, operation time, blood transfusion, hysterectomy and post-operative analgesic in that group (p value <0.001) as previous history of repeated CS had significantly higher estimated blood loss (P<0.001) it was 496.59±82.09, 567.4±114.7, and 780±166.3 in controls, patients with previous history of one CS and those with repeated CS.The present study showed that number of cases needed intra-operative blood transfusion was greater in women with previous history of more than one CS (22%) than women with history of one CS (6%) and controls (3%) and significant increase in the incidence of post-operative blood transfusion in pregnant women with previous history of more than one CS (11%) compared to those with history of one CS (4%) and controls (2%).
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Furthermore, our results revealed that operation time was significantly longer in patients with multiple repeated CS (59.35 ±7.12 min) than those with history of one prior CS (45.1 ± 6.38 min) and controls (40.36 ± 4.9 min), (P < 0.001). In addition, time to regaining bowel movement was significantly longer in patients with multiple repeat SC (7.05 ± 1.5 hrs) than those with history of one prior CS (6.57±1.1 hrs) and controls (6.42±1.1 hrs), (P < 0.001). Also the present study showed that patients with multiple repeat CS stay at hospital longer than both those with history of one prior CS and controls (1.72 ± 1.17 days vs. 1.23±0.4 days and 1.18±0.39 days); respectively (P<0.001).
Regarding neonatal outcomes in our study, there was statistical significant decrease of neonatal birth weight in group 3 (2255±476.7 g) when compared with newborns of women with history of one prior CS (2962.55±550.7 g) as well as newborns of control group (3231.7±389 g) (P<0.001). A total of 33 neonates were admitted to the neonatal Intensive Care Unit (NICU) following CS delivery. The number of neonates admitted to the NICU was higher in group 3 than that in other two groups but without significant difference (P=0.057). There was increase in rate of neonatal death in third group (4%) than that in group 2 (1%) and control group (0%), but without significant difference (P=0.071). The mean Apgar score in control group, patients with one prior caesarian section, and patients with more than one prior CS groups was 7.84 ± 1.3, 7.77± 1.29, and 6.94± 1.7; respectively. The mean Apgar score was significantly lower for women with more than one prior CS compared with others (P<0.001).The present study showed that gestational age at delivery, time of operation,
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estimated blood loss, neonatal birth weight, presence of either placental previa or placental accretia, and NICU admission were strongly correlated with a low Apgar score (P<0.05).