Expert: Catherine Beier MS CBE - 3/26/2009

Question
Hello, I have had 4 c-sections within 5 years, and I am now pregnant with my 5th child. My youngest is 3 1/3 years old. What exactly are the risks involved after so many c sections so close together? What is the percentage of the risk of my uterus rupturing?

Also during my 3rd pregnancy my bladder fused to my uterine wall which they fixed, does this add any additional risks?

And what precautons should I take during this pregnancy? will I need to go on bed rest at some point?

juliet


Answer
Juliet,

Unfortunately, there are many risks associated with that many c-sections.  Fortunately, with more than two years since your last c-section, it does help lower the risk of uterine rupture.

The main risks of repeat c-sections for you are placental problems, such as placenta accreta (the placenta attaches too far into the uterine wall, requiring surgical removal), uterine rupture (which although scary, rarely leads to maternal or fetal death), hysterectomy and adhesions (when internal organs attach to the uterus at the scar - which you've already had).

The risks for the baby include being twice as likely to experience respiratory distress at birth as well as twice the risk of developing asthma by age 8.

A study that examined risks after multiple c-sections (http://www.ncbi.nlm.nih.gov/pubmed/16738145) found that after 5 c-sections, placenta accreta was present in 2.33% vs 0.24% for a first c-section.  

Hysterectomy was required in 3.49% of 5th c-sections vs. 0.65% of first c-sections.  

Adhesions, which you've already experienced, are much more common after 3+ c-sections and are likely to recur.

Another study (http://www.ncbi.nlm.nih.gov/pubmed/16501678) found significant risks of uterine rupture and other complications after 3+ c-sections.

While the risks increase, bed rest does little to decrease them. It's often suggested, but has not been shown to improve outcomes for mothers or babies.  Often, doctors suggest it rather than saying there's nothing they can do to lessen the risks.

The main risks come from the trauma to your uterus and how thick the uterine wall is near the incision.  As your pregnancy progresses, this increases the strain on your uterus which can cause a rupture at any time during your pregnancy, not just if you went into labor.

In terms of precautions, there is little you can do to lessen the risks since your uterus has sustained the trauma of multiple surgeries.  

You can limit the amount of heavy lifting you do as well as making sure to carefully ensure you eat a healthy diet to maintain a healthy pregnancy.  Since you've had more than two years since your last c-section, you've given your uterus some time to heal and recover, so this is a factor in your favor for preventing complications with this pregnancy.


Best,
Catherine