Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England,

DOI: 10.1111/1471-0528.12076 www.bjog.org Urogynaecology Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002 2008 A Pradhan, a DG Tincello, b R Kearney a a Department of Obstetrics and Gynaecology, Addenbrooke s Hospital, Cambridge, UK b Reproductive Science Section, CSMM, University of Leicester, Leicester, UK Correspondence: Dr A Pradhan, Department of Obstetrics and Gynaecology, Addenbrooke s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK. Email: swatash@yahoo.com Accepted 5 October 2012. Published Online 27 November 2012. Objective To report the numbers of patients having childbirth after pelvic floor surgery in England. Design Retrospective analysis of Hospital Episode Statistics data. Setting Hospital Episode Statistics database. Population Women, aged 20 44 years, undergoing childbirth after pelvic floor surgery between the years 2002 and 2008. Methods Analysis of the Hospital Episode Statistics database using Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) code at the four-character level for pelvic floor surgery and delivery, in women aged 20 44 years, between the years 2002 and 2008. Main outcome measures Numbers of women having delivery episodes after previous pelvic floor surgery, and numbers having further pelvic floor surgery after delivery. Results Six hundred and three women had a delivery episode after previous pelvic floor surgery in the time period 2002 2008. In this group of 603 women, 42 had a further pelvic floor surgery episode following delivery in the same time period. The incidence of repeat surgery episode following delivery was higher in the group delivered vaginally than in those delivered by caesarean (13.6 versus 4.4%; odds ratio, 3.38; 95% confidence interval, 1.87 6.10). Conclusions There were 603 women having childbirth after pelvic floor surgery in the time period 2002 2008. The incidence of further pelvic floor surgery after childbirth was lower after caesarean delivery than after vaginal delivery, and this may indicate a protective effect of abdominal delivery. Keywords Childbirth, Hospital Episode Statistics, pelvic floor surgery. Please cite this paper as: Pradhan A, Tincello D, Kearney R. Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002 2008. BJOG 2013;120:200 204. Introduction Surgery for pelvic organ prolapse and urinary incontinence is now a common procedure, with women having a 12.2% lifetime risk of undergoing surgery for pelvic organ prolapse or urinary incontinence. 1 A study from Australia has shown that the lifetime risk of surgery for pelvic organ prolapse is 19%. 2 The increasing incidence of pelvic floor surgery is most probably a result of a combination of factors, including growing awareness of the availability of surgical interventions to correct prolapse and incontinence, the introduction of minimally invasive procedures and greater expectations of a better quality of pelvic floor health. Pelvic floor procedures, including those utilising synthetic materials, are predicted to increase over the next 40 years, including in women of childbearing age who may undergo these procedures prior to completion of their family. 3 Pregnancy and childbirth have been identified as the most significant risk factors in the occurrence of pelvic floor dysfunction. 4 7 Vaginal delivery has been reported to increase the incidence of subsequent prolapse by up to 10- fold. 5,8 However, the role of childbirth in the recurrence of pelvic floor dysfunction has not been studied in detail. At present, there is a lack of published data on the outcome of women delivering after surgery for prolapse or incontinence. There are published case reports of women delivering vaginally or by caesarean following prolapse and incontinence surgery. There is no information available regarding the incidence of childbirth following pelvic floor procedures and, in particular, the incidence of repeat pelvic floor surgery following delivery. Therefore, there is insufficient information to counsel women on the safety of childbirth after pelvic floor procedures and the impact of further childbirth on the outcome of the original procedure. 200 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Childbirth after pelvic floor surgery In addition, there is inadequate information available to counsel women on the mode of delivery after pelvic floor surgery. This article reports the numbers of women giving birth after pelvic floor surgery in England as identified by Hospital Episode Statistics data, and presents the modes of delivery in this group and the numbers of repeat pelvic floor surgery episodes. Methods Hospital Episode Statistics is an online database of all episodes of admission to NHS hospitals in England, as well as all NHS-funded inpatient care provided by independent treatment centres. On this database, any procedure or intervention performed is recorded using the Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) code. To obtain a comprehensive list of all procedures, we used the OPCS-4 codes at the four-character level. OPCS-4 codes consist of a letter followed by three numbers. The letters denote the 24 chapters of the classification each chapter dealing with a different part or system of the body. Further details of these codes are freely available on the website www. hesonline.nhs.uk. The Hospital Episode Statistics extract of records supplied to Public Health Observatories by the NHS Information Centre for Health and Social Care was used to identify women aged 20 44 years who had: (1) any record of pelvic floor procedures using the OPCS-4 codes (any procedure position) and (2) record of a delivery episode using OPCS-4 codes (any procedure position). The age group 20 44 years was chosen as being the group most likely to include women who had not completed their childbearing at the time of pelvic floor surgery. The records covered the financial years 2002 2008. The data field EXTRACT_HESID was used to identify women who had undergone both a pelvic floor procedure and a delivery episode, and to prevent double counting of women who may have had more than one pelvic floor procedure. EXTRACT-HESID is the unique identifier that allows the data analyst to link individual patient s episodes of care without having to access patient identifiable information, and further explanation of this is available on the previously mentioned Hospital Episode Statistics website. Records were grouped by type of procedure and by method of delivery. Reporting of data was as described in the Hospital Episode Statistics protocol to ensure that no individuals could be identified. 9 Codes for all operations for urinary incontinence involving the bladder neck and urethra were included, e.g. suprapubic sling (M521), colposuspension of bladder neck (M523), introduction of tension-free vaginal tape (M534), etc. For prolapse, we included all operations via the abdominal or vaginal route with or without a hysterectomy and use of mesh, e.g. anterior and posterior colporrhaphy (P231), vaginal hysterocolpectomy (Q083), sacrocolpopexy (P242), anterior colporrhaphy with mesh reinforcement (P236), repair of vault of vagina with mesh using abdominal approach (P245), etc. Results Between 2002 and 2008, there were 340 539 pelvic floor surgery episodes recorded. In women between the ages of 20 and 44 years, there were 63 892 episodes recorded (Figure 1 and Table 1). There was an increase in the number of episodes of pelvic floor surgery for the age group 20 44 years from 7285 in 2002 to 9829 in 2008, with a noticeably high number of procedures in the year 2004. During this time period, 603 women between the ages of 22 and 44 years were reported to have had a delivery episode after pelvic floor surgery. Table 2 shows the number of deliveries annually following pelvic floor surgery. There were 671 delivery episodes recorded in 603 women. Two-thirds of women were delivered by caesarean section after pelvic floor surgery (Table 3). Of the 603 women who delivered a baby following pelvic floor surgery, 42 had a subsequent episode of pelvic floor surgery within the same time period, 2002 2008. These 42 women, each having one previous pelvic floor surgery episode, collectively went on to have 53 delivery episodes and a further 50 subsequent pelvic floor surgery episodes between them. Twenty eight (66%) of these 42 women had undergone a previous surgery for prolapse and 14 (33%) a previous surgery for urinary incontinence prior to the delivery. Twenty of these 53 delivery episodes were by caesarean and 33 were by vaginal delivery. Thirteen episodes of further surgery for prolapse and seven episodes of further surgery for urinary incontinence were recorded in the group of women having the 20 episodes of caesarean delivery. Seventeen episodes of further surgery for prolapse and 13 episodes of further surgery for urinary incontinence were number 16,000 14,000 12,000 10,000 8000 6000 4000 2000 0 7285 7668 14424 7644 8020 9022 number 9829 2002 2003 2004 2005 2006 2007 2008 Year Figure 1. Number of episodes of pelvic floor surgery per year in women between the ages of 20 and 44 years. ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 201

Pradhan et al. Table 1. Annual number of episodes of pelvic floor surgery during 2002 2008 according to age group Age group (years) Number of episodes of pelvic floor surgery per age category in the years 2002 2008 20 24 39 46 70 39 49 47 70 360 25 29 228 232 372 196 212 282 365 1887 30 34 1105 1043 1790 878 913 896 1033 7658 35 39 2418 2503 4718 2459 2443 2782 2915 20,238 40 44 3495 3844 7474 4072 4403 5015 5446 33,749 Total 7285 7668 14,424 7644 8020 9022 9829 63,892 Table 2. Women undergoing pelvic floor surgery who had undergone at least one subsequent delivery episode in the same time period, 2002 2008 (age group, 20 44 years) One delivery episode 93 106 107 104 89 35 7 541 (89.7%) Two delivery episodes 21 15 11 6 2 1 0 56 (9.2%) Three delivery episodes 2 2 1 0 0 1 0 6 (0.9%) Total number of women 116 123 119 110 91 37 7 603 Total number of delivery episodes 141 142 132 116 93 40 7 671 Table 3. Type of delivery episode following an episode of pelvic floor surgery, 2002 2008 Caesarean delivery 103 86 88 89 57 23 4 450 (67%) Normal delivery 34 53 40 25 31 13 2 198 (29.5%) Instrumental delivery 4 3 4 2 5 4 1 23 (3.4%) Total number of women 116 123 119 110 91 37 7 603 Total number of delivery episodes 141 142 132 116 93 40 7 671 recorded in the group of women having the 33 episodes of vaginal delivery. The incidence of repeat surgery episode following delivery episode was higher in the group delivered vaginally (30 of 221) than in those delivered by caesarean (20 of 450) [13.6 versus 4.4%; odds ratio (OR), 3.38; 95% confidence interval (CI), 1.87 6.10]. Discussion This study uses Hospital Episode Statistics data from 2002 to 2008 for 603 women who delivered after pelvic floor surgery, and reports that the incidence of repeat pelvic floor surgery is higher following vaginal delivery than following caesarean delivery. To the best of our knowledge, this is the first paper to report repeat pelvic floor surgery following delivery in women of reproductive age having pelvic floor surgery in England. There is a paucity of data on women who deliver after pelvic floor surgery, both with regard to the safety of the delivery and the outcome of pelvic floor function. Of the women who had a further birth following surgery, two-thirds were delivered by caesarean. We do not have any information on the reasons for this, but it is likely that this was a recommendation to prevent the recurrence of the original pelvic floor disorder. In the largest published case series of 89 women who conceived following colporrhaphy, 24 had a caesarean section to preserve pelvic floor function. At 6 8 weeks postpartum, there was recurrence of symptoms in 7% of women and, at 1 year postpartum, 22% had symptoms sufficiently severe to require further surgery. In this case series, caesarean section failed to prevent recurrence, with nine of the 25 (36%) 202 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

Childbirth after pelvic floor surgery delivered abdominally suffering recurrence at 5 years, compared with seven of the 49 (14%) delivered vaginally. 10 A small series of six vaginal deliveries following uterosacral sacrospinous suspension for prolapse reported one patient suffering from a recurrence requiring further surgery. 11 In a review of the literature of pregnancy and delivery after midurethral sling procedures, 24 cases were cited, with 12 delivering vaginally, 11 delivering by caesarean and one ongoing pregnancy. This showed that 10 of the 12 delivered vaginally and nine of the 11 delivered by caesarean were continent at 2 36 months, giving a recurrence of 20%. 12 A recent systematic review of outcomes of pregnancy following surgery for stress urinary incontinence showed that the incidence of postpartum stress urinary incontinence ranged from 5 to 18% after caesarean delivery and 20 to 30% after vaginal delivery. 13 The authors commented on the limited studies available in the literature, and only in the form of case reports, case series and physicians surveys, and stated that a formal analysis between the risk after caesarean and vaginal delivery could not be performed with the limited data available. In the data presented here, the need for further surgery was 6.96%, which is lower than that cited by the other studies. From the data presented, caesarean delivery does not appear to be entirely protective of the need for further surgery, because 4.4% of women had a further surgery episode recorded. Vaginal delivery appears to be associated with a higher likelihood of further surgery, with the risk of having repeat surgery after previous vaginal delivery being three times greater than after previous caesarean delivery: OR, 3.38 (95% CI, 1.87 6.10). Our study is limited by the retrospective nature of data collection. The Hospital Episode Statistics database also has limitations in terms of the use of appropriate codes for various procedures. It is not possible to ascertain whether the group of women who had repeat surgery did so for a recurrence of the previous condition in the same operated compartment, or whether they developed a new symptom, for example a rectocele requiring surgery, having had previous anterior compartment surgery. Detailed individual data to assess the type of procedure performed before and after childbirth for each individual woman are not available as a result of suppression of small numbers according to the Hospital Episode Statistics protocol. In addition, we used repeat surgery as a surrogate marker of the recurrence of pelvic floor dysfunction. This is likely to be an underestimate of recurrence as it does not include women who were operated on after 2008, or who are symptomatic but who have not had further surgery. We have not reported on the incidence of repeat surgery in women who did not deliver, as we wished to report data specifically on women who delivered after surgery. The Hospital Episode Statistics data show that many women are undergoing pelvic floor procedures during reproductive age. Only 0.9% of these women had a delivery after pelvic floor surgery in the short time period between 2002 and 2008. Many gynaecologists would discuss with women the option of deferring surgery until their childbearing is completed, because of concerns regarding the recurrence risk of pelvic floor dysfunction if women give birth after a pelvic floor procedure. However, in some cases, it is not acceptable to the woman to suffer symptoms until she completes her family, or a further pregnancy may be unplanned. There is also uncertainty as to whether a caesarean section will prevent further recurrence of the prolapse or urinary incontinence. This article provides data on women in England who delivered following pelvic floor surgery between 2002 and 2008. Further prospective studies are required to investigate the role of pregnancy and delivery in the recurrence of prolapse and incontinence. Conclusions There were 603 women having childbirth after pelvic floor surgery in the time period 2002 2008. The incidence of further pelvic floor surgery after childbirth was lower after caesarean delivery than after vaginal delivery, and this may indicate a protective effect of abdominal delivery. Disclosure of interests AP and RMK have no disclosure of interests. DGT has received a grant for other studies from Ethicon and is a consultant for Ethicon and Pfizer. DGT has no conflict of interest regarding this article. Contribution to authorship AP analysed the data and wrote the manuscript. RMK and DGT contributed to the conception and design, analysis of the data and writing of the manuscript. Details of ethics approval This study was approved as a service evaluation by Addenbrooke s Hospital R&D Department and the Patient Safety and Audit Department, and they confirmed that it did not need formal ethics approval as no individual patient identifiable information was accessed by the data. Funding No funding was obtained and needed for this study. Acknowledgements We thank Dr Sian Evans, Kirsty Smith and Alan Warn (Institute of Public Health, Cambridge, UK) for their help with data collection and analysis. & ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 203

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