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Women undergoing hysterectomy were more likely to experience surgical complications if they had previously given birth via cesarean section, a large retrospective Danish cohort study found.

Higher rates of reoperation within 30 days and other perioperative and post-operative complications from a benign hysterectomy were seen in those with a history of C-section compared to women with vaginal deliveries, reported Sofie A. I. Lindquist, MD, of Aalborg University in Denmark, and colleagues.

Notably, women with one previous cesarean delivery who underwent a benign hysterectomy later in life had 31% increased odds of reoperation within 30 days (95% CI 3%-68%), after adjustment for other risk factors, the authors wrote in .

There was a trend toward possibly higher risk with multiple previous cesarean deliveries (adjusted OR 1.38, 95% CI 0.96-1.91).

Lindquist and colleagues argued that their results "support policies and clinical efforts to prevent cesarean deliveries that are not medically indicated," and suggested the risk may extend to other types of surgery besides hysterectomy.

"High prevalence of hysterectomy later in life makes this procedure a useful proxy for investigating long-term surgical complications associated with previous cesarean delivery," they wrote, adding that found prior cesarean deliveries may be related to a following a subsequent hysterectomy, such as lower urinary tract injuries, increased intraoperative and postoperative blood transfusion, and readmission within 30 days.

Lindquist and colleagues speculated that women with prior cesarean deliveries may need more frequent unplanned reoperation due to the of intra-abdominal adhesions, which "may complicate future surgery, leading to longer operating time and an increased risk of adverse events."

For the current study, they drew on national registry data for all Danish women who gave birth between January 1993 and December 2012, and underwent a benign, non-gravid hysterectomy from January 1996 to December 2012.

Overall, 7,685 women who had a hysterectomy were included. Of those, 5,267 had no previous cesarean delivery, 1,694 had one cesarean delivery and 724 had two or more cesarean deliveries. Mean age was 40 at the time of hysterectomy.

Laparotomy was the most common route of hysterectomy, (48%), followed by vaginal (33%) and laparoscopic (19%). However, the researchers noted vaginal hysterectomies were significantly more common among the group with no previous cesarean delivery. The most common indication for hysterectomy was a menstrual disorder (40%), followed by fibroids (26%) and pain (11%).

Overall, 5% of women had a reoperation within 30 days of hysterectomy, which increased with the number of previous cesarean deliveries (about 4% of women with no prior cesarean delivery versus about 6%-7% for women with previous cesarean deliveries). About 60% of these reoperations were for gynecological procedures, followed by 22% for gastrointestinal procedures, and 11% for urological procedures.

Examining perioperative and postoperative complications, about 12% of women experienced at least one surgical complication within 30 days. Bleeding, infection and perioperative lesions were the most common. There was a 30% increased risk of these complications among women with two or more cesarean deliveries (adjusted OR 1.30, 95% CI 1.02-1.65).

About 3% of women received a blood transfusion. Women with two or more cesarean deliveries 93% increased risk of needing a transfusion -- albeit with a wide confidence interval (adjusted OR 1.93, 95% CI 1.21-3.07). Lindquist and colleagues noted that previous laparoscopic surgery and laparoscopic route of hysterectomy also increased the risk of a blood transfusion.

Study limitations included its observational design and the risk of residual confounding. Also, the investigators had no access to data on BMI, despite controlling for obesity-related factors. The study only included women with a hysterectomy within 19 years of their first birth.

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