Cesarean Section. Impact on Postpartum Recovery, Subsequent Pregnancy and Delivery

Sammanfattning: Women are at increased risk of complications after Cesarean section (CS) postpartum and in subsequent pregnancy and delivery. The overall aim of the thesis was to evaluate complications after CS, outline options for their management and to assess strategies to increase the rate of vaginal deliveries after CS (VBAC).Paper I was a prospective study where women were offered to have an additional appointment with an obstetrician supplemented by ultrasound examination 6-9 months after CS (n=147) to evaluate whether this appointment may reduce the levels of anxiety postpartum. In Paper II a case of a successful expectant management of Cesarean scar heterotopic pregnancy was reported. Paper III was a retrospective study included all cases of Cesarean scar and other non-tubal ectopic pregnancies managed between 2010-2018 (n=39) to evaluate the success rate and complications of different treatment regimens and to determine predictive factors for treatment failure. In Paper IV pregnant women with one previous CS in their first or third trimester participated in the study (n=87) to determine their level of knowledge regarding risks and benefits of CS and VBAC. Paper V included women with one previous CS who delivered during two periods: 2005-2008 (n=792) and 2013-2016 (n=1225), to compare the rate of VBAC, maternal and perinatal outcomes between the two cohorts.Paper I, the appointment with the obstetrician supplemented by ultrasound examination significantly reduced the levels of anxiety in women after CS. In Paper II and III, it was shown that conservative treatment may be the first option for consideration in non-tubal ectopic pregnancies and even expectant management is possible in small non-viable Cesarean scar pregnancies. The presence of fetal heartbeat and -hCG levels at diagnosis may be used for prediction of treatment failure. In Paper IV it was found that the level of knowledge about risks and benefits of VBAC increased in the third trimester of pregnancy compared to the first trimester. Nevertheless, women reported to get insufficient information even at the end of pregnancy. Paper V revealed that an appropriate management of women with one previous CS might increase VBAC rate without negative impact on maternal or perinatal outcomes. The results of the research might help to develop educational programs for women with previous CS, establish clinical guidelines for management of complications after CS such as postpartum anxiety and Cesarean scar pregnancy, and improve the interaction between ultrasound department, antenatal units and delivery ward to provide better support to women.