Risk Factors for Re-laparotomy After Cesarean Section and Associated Maternal Mortality and Near-miss Events at KNH an Exploratory Case-control Study

Abstract

Background Cesarean section (CS) delivery is on the rise worldwide and now accounts for more than one in five deliveries, this trend is expected to rise and by 2030 nearly 29% of total deliveries are likely to be through CS. In LMIC maternal mortality following CS delivery is 100 times higher than in HIC. One of the short-term and rare complications of CS is re-laparotomy after CS (R-LACS). There are few studies on R-LACS in obstetric literature. In Kenya, there is no study that looked at R-LACS, its therefore necessary to study the risk factors for R-LACS and associated maternal mortality(MM) and near-miss event(MNM) in the Kenyan content so as to improve the quality of care for CS patients and to reduce MM and MNM event associated with R-LACS. Objectives: To determine risk factors for re-laparotomy after cesarean section and associated maternal mortality and near-miss events at KNH between 1st of January 2012 to 31st of December 2021. Methodology: This was an exploratory case-control study(1:2 ratio). The data obtained were analyzed using SPSS version 26. We used Chi-square test of association/Fisher’s exact test and independent samples T-test/Mann Whitney U test for categorical and continuous variables respectively, to determine the risk factor for R-LACS. A binary logistic regression was then carried out for each significant factor. Finally, all the significant risk factors were modeled using a backward stepwise multivariable logistic regression. This yielded the adjusted odds ratios with their corresponding 95% confidence intervals for the significant risk factors for re-laparotomy following CS delivery. The maternal mortality and near-miss events were summarized using frequency(n) and percentages and then compared between the 2 groups (cases and controls group) using Chi-square test of association/fisher’s exact test. Binary, as well as multivariable logistic regression, was carried out. Results: During the study period, 82 patients who underwent re-laparotomy following CS delivery were compared to 164 patients who did not undergo re-laparotomy after CS at KNH. The mean age for the cases was 31± 6.6 years versus 29 ± 5.9 years for the controls, which was statistically with a p-value of 0.022. Age above 35 years was associated with higher odds of R-LACS as compared to age less than 25 years, with OR 2.52 (95% CI =1.09-5.80). In backward stepwise multivariable logistic regression we noted; history of one previous scar (aOR = 2.91(95% CI 1.01- 8.43), fetal macrosomia (aOR = 7.08 ( 95% CI 1.27-39.42), Preeclampsia with severe features (aOR = 9.17( 95% CI 2.58-32.55), long operative duration of index CS delivery ( aOR = 4.00(1.14-14.06),PPH ( aOR19.31(95% CI 6.57-56.75),adhesions(aOR 3.65(95% CI 1.45-9.18) and need for blood transfusion (aOR 42.75(95% CI 10.33-177.01) to be independent risk factor for R-LACS. There were 4% (3cases) of maternal mortality in patients who underwent R-LACS versus none in those who did not undergo re-laparotomy after CS. 60% of patients who underwent R-LACS experienced MNM events as opposed to only 2% in the control group. 11% of the cases experienced more than three MNM events,while none in the control group. Patients who underwent R-LACS had higher odds of experiencing MNM events as compared to those who did not undergo re-laparotomy, with aOR= 81.81(95% CI 23.64-283.17)...