Risk of Adhesions After Cesarean Section
Cesarean sections significantly increase the risk of abdominal adhesions, with incidence rates of 37% in women with previous C-section compared to 10% in women without prior C-section (odds ratio: 5.18). 1
Incidence and Risk Factors
The risk of adhesions increases with the number of cesarean deliveries:
- 32% after one cesarean section
- 42% after two cesarean sections
- 59% after three or more cesarean sections 1
Additional factors that increase adhesion risk following cesarean section include:
- Advanced maternal age (≥35 years) - 28% increased risk
- Obesity (BMI ≥30) - 91% increased risk
- Postpartum infection - 55% increased risk 1
Clinical Consequences
Adhesions following cesarean sections can lead to significant complications:
- Increased operating time during subsequent surgeries
- Longer time to delivery in repeat cesarean sections
- Higher risk of bladder injury during repeat procedures 2
- Chronic pelvic pain (as seen in "captive uterus syndrome") 3
- Potential for partial uterine dehiscence 4
- Increased risk of bowel obstruction 5
Prevention Strategies
Several approaches can reduce adhesion formation after cesarean section:
Surgical Technique Modifications:
- Meticulous surgical technique
- Gentle tissue handling
- Minimizing tissue ischemia and desiccation
- Careful hemostasis
- Avoiding powdered gloves 4
Adhesion Barriers:
- Hyaluronate carboxymethylcellulose (Seprafilm®) has shown effectiveness in reducing adhesions and risk of reoperations for adhesive small bowel obstruction (relative risk 0.49) 5
- Icodextrin 4% solution (Adept®) can be used in both open and laparoscopic surgery 5
- Oxidized regenerated cellulose (Interceed®) may have limited use in cesarean sections as it requires complete hemostasis 6
Surgical Approach:
- Laparoscopic approaches when appropriate may reduce adhesion formation compared to open procedures 5
Detection of Adhesions
Clinical signs of adhesions following cesarean section may include:
- Chronic pelvic pain
- Subinvoluted uterus
- High fixed cervix on examination
- Ultrasound findings showing points of traction and irregular uterine border 3
Treatment
For patients with symptomatic adhesions following cesarean section:
- Laparoscopic adhesiolysis is the primary treatment for symptomatic adhesions
- In severe cases with chronic pain, hysterectomy may be considered 3
- Using adhesion barriers during adhesiolysis can help prevent recurrence 5
Clinical Pitfalls and Considerations
- Delayed diagnosis of adhesions is a common cause of malpractice claims, highlighting the importance of timely diagnosis 5
- The risk of adhesion-related complications is lifelong, not just limited to the immediate postoperative period 5
- Adhesion barriers should be considered particularly in patients at high risk for adhesions or those planning future pregnancies 6
- Complete evaluation of chronic pelvic pain following cesarean section should include consideration of adhesions as a potential cause 3