Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section

Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound

INTRODUCTION AND OBJECTIVE

Cesarean section (CS) is the most common operation in obstetrics, with rising incidence in most countries. As a result of this operation late scar dehiscence may occur, which may lead to uterine rupture in a subsequent pregnancy. In this case series we have described sonographic detection of scar dehiscence after CS and feasibility of vaginal or combined laparoscopic and vaginal scar excision and uterine repair.

METHODS

Five consecutive patients underwent vaginal or laparoscopic assisted vaginal approach for repair of suspected scar dehiscence following CS, during a 5 year period. In all cases, transvaginal sonography detected suspicious features of scar dehiscence over the anterior uterine wall. Except of one, all patients had reported recurrent pelvic pain and/or irregular menstrual bleedings. Furthermore all patients planned for a further pregnancy.

RESULTS

Resection of the uterine defect and re-constitution of the uterine wall was successfully achieved in all five patients. There were no intra-operative complications and none of the patients required blood transfusion. The mean operation time was 117 min (27-192). Presence of scar tissue was confirmed on histology in all specimens. Four patients remained free of symptoms with no evidence of recurrent scar dehiscence on sonography over a median follow up of 30 months (3-46). One patient had an uneventful pregnancy 24 months after scar removal and was delivered by repeat CS at 39 weeks' gestation.

CONCLUSION

Patients with a history of CS should undergo transvaginal sonography of the scar region in order to detect latent scar dehiscence in combination with uterine wall thinning prior to planning further pregnancy. In suspected cases, a combined laparoscopic - vaginal or vaginal approach can be employed to repair the defect.

WHO systematic review of maternal mortality and morbidity: the prevalence of uterine rupture

OBJECTIVE

To determine the prevalence of uterine rupture worldwide.

DESIGN

Systematic review of all available data since 1990.

SETTING

Community-based and facility-based reports from urban and rural studies worldwide. Sample Eighty-three reports of uterine rupture rates are included in the systematic review. Most are facility based using cross-sectional study designs.

METHODS

Following a pre-defined protocol an extensive search was conducted of 10 electronic databases as well as other sources. Articles were evaluated according to specified inclusion criteria. Uterine rupture data were collected along with information on the quality of reporting including definitions and identification of cases. Data were entered into a database and tabulated using SAS software.

MAIN OUTCOME MEASURES

Prevalence of uterine rupture by country, period, study design, setting, participants, facility type and data source.

RESULTS

Prevalence figures for uterine rupture were available for 86 groups of women. For unselected pregnant women, the prevalence of uterine rupture reported was considerably lower for community-based (median 0.053, range 0.016-0.30%) than for facility-based studies (0.31, 0.012-2.9%). The prevalence tended to be lower for countries defined by the United Nations as developed than the less or least developed countries. For women with previous caesarean section, the prevalence of uterine rupture reported was in the region of 1%. Only one report gave a prevalence for women without previous caesarean section, from a developed country, and this was extremely low (0.006%).

CONCLUSION

In less and least developed countries, uterine rupture is more prevalent than in developed countries. In developed countries most uterine ruptures follow caesarean section. Future research on the prevalence of uterine rupture should differentiate between uterine rupture with and without previous caesarean section.

The benefits and risks of inducing labour in patients with prior caesarean delivery: a systematic review

OBJECTIVE

To evaluate the risks and benefits of inducing labour in women with a prior caesarean delivery.

DESIGN

Systematic review.

SAMPLE

Pregnant women with prior caesarean delivery.

METHODS

Studies were identified using MEDLINE, EMBASE, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Abstracts of Reviews of Effectiveness, reference lists and experts.

MAIN OUTCOME MEASURES

All studies reporting data for outcomes in women with induced labours and prior caesarean were eligible. Methodologic quality was evaluated using the criteria of the U.S. Preventive Services Task Force and the NHS Centre for Reviews and Dissemination. We assigned studies good, fair or poor rating.

RESULTS

We reviewed 162 full text articles, identified 14 fair-quality studies, and found no good-quality studies. Compared with spontaneous labour, induction was more likely to result in caesarean delivery. Of women undergoing spontaneous labour, 20% had a caesarean (range 11-35%) compared with 32% receiving oxytocin (range 18-44%). In studies of PGE2, spontaneous labour resulted in caesarean delivery in 24% (range 18-51%) compared with 48% with PGE2 (range 28-51%). There was a non-significant increase in uterine ruptures among those induced compared with spontaneous labours. There were no maternal deaths; other maternal complications were infrequently reported. Only four studies reported on infant deaths; other infant outcomes were inadequately reported.

CONCLUSION

Women with a history of caesarean attempting trial of labour who require induction have a higher rate of caesarean delivery and have a slightly elevated risk of rupture compared with similar women with spontaneous labour. More consideration is needed for potential confounders: dose, reasons for induction and appropriate comparison groups.

Factors influencing repeat caesarean section: qualitative exploratory study of obstetricians' and midwives' accounts

OBJECTIVE

To explore the views of health professionals on the factors influencing repeat caesarean section.

DESIGN

Qualitative study involving semi-structured interviews with professionals who care for women in pregnancy and labour.

SETTING

Acute hospital trust with two maternity units and community midwifery service, Leicestershire, UK.

SAMPLE

Twenty-five midwives and doctors.

METHODS

Interviews with professionals were undertaken using a prompt guide. All interviews were audiotaped and transcribed verbatim. Analysis was based on the constant comparative method, assisted by QSR N5 software.

MAIN OUTCOME MEASURES

Identification of factors influencing professional decision making about repeat caesarean section.

RESULTS

Decision making in relation to repeat caesarean is a complex process involving several parties. Professionals identify the relevance of evidence for decision making for repeat caesarean. However, professionals feel that following strict protocols is of limited value because of the perceived substandard quality of evidence in this area, other external pressures and the contingent, unique and often unanticipated features of each case. Professionals also perceive that the organisation of care plays an important role in rates of repeat caesarean.

CONCLUSIONS

Decision making for repeat caesarean is a social practice where standardised protocols may have limited value. Attention needs to be given to the multiple parties involved in the decision-making process. Reflective practice, opinion leadership and role modelling may offer ways forward but will require evaluation.

Emergency peripartum hysterectomy: A prospective study in The Netherlands

OBJECTIVE

To determine the incidence, indication, association with caesarean section (CS) and outcome of emergency peripartum hysterectomy (EPH) in The Netherlands.

STUDY DESIGN

All 100 Dutch obstetric departments were asked to participate in a prospective nationwide registration of EPH between 1 April 2002 and 1 April 2003. For every case, a form with questions about obstetrical history, current pregnancy and delivery, maternal and neonatal outcome was completed.

RESULTS

Eighty-nine (89%) hospitals participated and registered in total 48 EPH. The estimated incidence of EPH is 0.33/1000 births. The main indication for EPH was placenta accreta (50%), followed by uterine atony (27%). There were two maternal deaths (4%). Severe maternal morbidity included: urinary tract injury 15%, relaparotomy 25%, transfusion >10 units red blood cells 67%, intensive care admission 77%. Both previous CS and CS in the index pregnancy were associated with a significant increased risk of EPH. The number of previous CS was related to an increased risk of placenta accreta, from 0.19% for one previous CS to 9.1% for four or more previous CS.

CONCLUSION

Emergency peripartum hysterectomy is associated with a high incidence of maternal morbidity and a case fatality rate of 4%. It is significantly related to CS in index or previous pregnancy. Placenta accreta is the most common indication to perform a peripartum hysterectomy.

Mode of delivery and problems in subsequent births: a register-based study from Finland

OBJECTIVE

The purpose of this study was to investigate the effects of delivery on problems in subsequent births.

STUDY DESIGN

This was a cohort study that used register data for 73,104 mothers who had their first birth from 1987 to 1989 and subsequent births from 1987 to1998. Three analyses were performed: (1) examination of second births by mode of delivery in the first birth, with adjustment for confounders, (2) same parameter, with exclusion of women with persistent problems, and (3) examination of third births for women with a first birth vaginal delivery.

RESULTS

More complications and poorer infant outcome were found at later births when the first or second birth was by cesarean delivery than after a first spontaneous vaginal delivery, even when women with persistent problems were excluded. Women with instrument first births had a similar rate of complications in the second birth to women with spontaneous vaginal births, but some infant outcomes were poorer.

CONCLUSION

Problems that are subsequent to cesarean delivery are unlikely to be explained entirely by indications for cesarean delivery.

Evidence-based vaginal birth after Caesarean section

Caesarean section rates are rising globally. Whether vaginal birth after Caesarean (VBAC) is safe and under what circumstances is increasingly important. This chapter reviews the literature about the risks of VBAC, patient and management factors that may alter risk, and discusses ongoing research as well as suggestions for improving future research.

Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study

OBJECTIVE

To determine the factors associated with an increased risk of perinatal death related to uterine rupture during attempted vaginal birth after caesarean section.

DESIGN

Population based retrospective cohort study.

SETTING

Data from the linked Scottish Morbidity Record and Stillbirth and Infant Death Survey of births in Scotland, 1985-98.

PARTICIPANTS

All women with one previous caesarean delivery who gave birth to a singleton infant at term by a means other than planned repeat caesarean section (n = 35 854).

MAIN OUTCOME MEASURES

All intrapartum uterine rupture and uterine rupture resulting in perinatal death (that is, death of the fetus or neonate).

RESULTS

The overall proportion of vaginal births was 74.2% and of uterine rupture was 0.35%. The risk of intrapartum uterine rupture was higher among women who had not previously given birth vaginally (adjusted odds ratio 2.5, 95% confidence interval 1.6 to 3.9, P < 0.001) and those whose labour was induced with prostaglandin (2.9, 2.0 to 4.3, P < 0.001). Both factors were also associated with an increased risk of perinatal death due to uterine rupture. Delivery in a hospital with < 3000 births a year did not increase the overall risk of uterine rupture (1.1, 0.8 to 1.5, P = 0.67). However, the risk of perinatal death due to uterine rupture was significantly higher in hospitals with < 3000 births a year (one per 1300 births) than in hospitals with >or= 3000 births a year (one per 4700; 3.4, 1.0 to 14.3, P = 0.04).

CONCLUSION

Women who have not previously given birth vaginally and those whose labour is induced with prostaglandin are at increased risk of uterine rupture when attempting vaginal birth after caesarean section. The risk of consequent death of the infant is higher in units with lower annual numbers of births.