Impact of previous caesarean section on outcomes of first and second trimester surgical abortion: A systematic review and meta-analysis

Abstract

It is unclear whether previous caesarean section (CS) increases the risk of complications during surgical abortion. To compare surgical abortion complication rates in women with a history of previous CS to those without previous CS. Four databases were systematically searched in July 2024. Primary studies in English reporting on surgical abortion complications in women with and without a history of previous CS were included. Overall complications and major complications were compared between women with and without previous CS using a random effects meta-analysis. Sub-analyses were performed in women with > 1 previous CS, and incidence of emergency hysterectomy. Certainty of evidence was assessed using GRADE. Ten retrospective cohort studies with 3123 women with and 14,514 without a previous CS were included in the meta-analysis. The overall incidence of major complications from surgical abortion was 0.9 %. Previous CS was associated with an increase in overall complications (OR = 2.00, CI 1.32-3.04, p = 0.001) and major complications (OR = 2.82, CI 1.83-4.36, p < 0.00001). Major complications included haemorrhage requiring transfusion, uterine perforation and unplanned laparoscopy/laparotomy, while minor complications included cervical laceration and the need for repeat evacuation. There were no cases of uterine rupture during pre-procedural cervical ripening. Hysterectomy was an exceptionally rare occurrence (0.05 %); low-quality evidence from seven studies showed an association between history of CS and need for emergency hysterectomy (OR = 8.73, CI = 1.83-41.61, p = 0.007). The quality of the evidence was judged to be very low to medium mainly due to risk of bias of the included studies. While major surgical complications of surgical abortion are rare, women with a prior history of CS were more than twice as likely to experience a complication.