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Mahindra MP, Sampurna MTA, Mapindra MP, Putri AMS, Krisbiyantoro A, Aryananda RA. Factors affecting elective cesarean section in women with multiple pregnancy in Caruban, Indonesia. F1000Res 2023; 9:1481. [PMID: 38107345 PMCID: PMC10724646 DOI: 10.12688/f1000research.27292.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 12/19/2023] Open
Abstract
Background: Caesarean sections have become the most popular method for delivering twin babies because of the safety concerns associated with a natural birth. This study aims to identify the maternal characteristics and obstetric parameters that serve as risk factors influencing caesarean delivery in twin pregnancies by comparing women delivering via caesarean section and vaginal birth. Methods: A retrospective chart review design was used to analyse 47 women with multiple pregnancies from the medical records at a primary referral hospital in East Java, Indonesia. Women delivering vaginally were then compared with women who underwent a caesarean section to identify any differences between the groups. Results: In our study, more women delivered by caesarean section (n=35) than by vaginal birth (n=12). Women were more likely to undergo a caesarean section if they had a previous history of undergoing a caesarean section (OR 16.5; 95% CI 1.91-142.49; p=0.02). Similar to previous studies, we found that foetal malpresentation significantly increase the risk of caesarean delivery (OR 8.25; 95%CI 0.95-71.09; p=0.03), while labour augmentation decrease the likelihood of caesarean section (OR 0.20; 95% CI 0.49-0.81; p=0.03). There was also a significant older patients in the caesarean section groups (OR 1.26; 95% CI 1.09-1.45 ; p=0.00). Conclusions: The percentage of multiple pregnancies delivered via caesarean section is quite high. Other larger cohort study are warranted, since many factors were involved in the decision of caesarean section.
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Affiliation(s)
- Muhammad Pradhiki Mahindra
- Maternal-Fetal Medicine Department, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, WC1E 6AU, UK
| | - Mahendra Tri Arif Sampurna
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Surbaya, East Java, 60115, Indonesia
| | - Muhammad Pradhika Mapindra
- Neonatology Department, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, WC1E 6AU, UK
| | - Apriska Mega Sutowo Putri
- Faculty of Medicine, Sebelas Maret University, Surakarta, East Java, 57126, Indonesia
- Caruban General Hospital, Madiun, East Java, 63153, Indonesia
| | - Aries Krisbiyantoro
- Faculty of Medicine, Sebelas Maret University, Surakarta, East Java, 57126, Indonesia
- Caruban General Hospital, Madiun, East Java, 63153, Indonesia
| | - Rozi Aditya Aryananda
- Department of Obstetrics and Gynecology, Airlangga University, Subaya, East Java, 60115, Indonesia
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Levin G, Yagel S, Schwartz A, Many A, Rosenbloom J, Yinon Y, Meyer R. Trial of labor after cesarean in twin gestation with no prior vaginal delivery - evidence from largest cohort reported. Int J Gynaecol Obstet 2022; 159:229-236. [PMID: 34995363 PMCID: PMC9544935 DOI: 10.1002/ijgo.14090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/07/2021] [Accepted: 01/06/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To investigate trial of labor after cesarean (TOLAC) success rates in twin gestations with no prior vaginal delivery. METHODS A retrospective study of women with twin gestations who underwent a TOLAC and had no prior vaginal delivery during 2011-2020. TOLAC success and failure groups were compared. RESULTS Of 675 twin gestations with a history of cesarean delivery and no prior vaginal delivery, 83 (12.3%) elected to undergo a TOLAC and 26 (31.3%) succeeded. Two (7.7%) women delivered by cesarean for the second twin after vaginal delivery of the first twin. Epidural analgesia was positively associated with TOLAC success (odds ratio [OR] 4.31, 95% confidence interval [CI] 1.56-11.94, P = 0.004). Uterine rupture occurred in two patients (3.5%) of the TOLAC failure group. The proportion of cases with low Apgar score (<7) at 5 min was higher in the TOLAC success group (4 [15.4%] versus 1 [1.8%]; OR 10.1, 95% CI 1.07-96.22, P = 0.032) and the neonatal composite adverse outcome rate was lower in this group (OR 0.22, 95% CI 0.07-0.69, P = 0.009). CONCLUSION TOLAC in women with twins with no prior vaginal delivery is associated with a low success rate. No independent predictors of successful TOLAC were identified.
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Affiliation(s)
- Gabriel Levin
- ¹Department of Obstetrics and GynecologyHadassah‐Hebrew University Medical CenterJerusalemIsrael
- Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Simcha Yagel
- ¹Department of Obstetrics and GynecologyHadassah‐Hebrew University Medical CenterJerusalemIsrael
- Faculty of MedicineHebrew UniversityJerusalemIsrael
| | - Anat Schwartz
- Department of Obstetrics and GynecologyTel‐Aviv Sourasky Medical CenterTel‐AvivIsrael
- Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Ariel Many
- Department of Obstetrics and GynecologyTel‐Aviv Sourasky Medical CenterTel‐AvivIsrael
- Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Joshua I. Rosenbloom
- ¹Department of Obstetrics and GynecologyHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Yoav Yinon
- Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
- Department of Obstetrics and GynecologyChaim Sheba Medical CenterRamat‐GanIsrael
| | - Raanan Meyer
- Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
- Department of Obstetrics and GynecologyChaim Sheba Medical CenterRamat‐GanIsrael
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3
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Hochler H, Tevet A, Barg M, Suissa-Cohen Y, Lipschuetz M, Yagel S, Aviram A, Mei-Dan E, Melamed N, Barrett JFR, Fox NS, Walfisch A. Trial of labor of vertex-nonvertex twins following a previous cesarean delivery. Am J Obstet Gynecol MFM 2022; 4:100640. [PMID: 35398584 DOI: 10.1016/j.ajogmf.2022.100640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Maternal and neonatal outcomes of trial of labor after cesarean delivery of twins are similar to those of singleton trials of labor after cesarean delivery. However, previous studies did not stratify outcomes by second-twin presentation on admission to labor. OBJECTIVE To examine maternal and neonatal outcomes following trial of labor after cesarean delivery in twins with vertex-nonvertex presentation. STUDY DESIGN A retrospective multicenter study was conducted including data on deliveries occurring between the years 2005 and 2020. We included trials of labor after a previous cesarean delivery (at ≥320/7 weeks' gestation) of twin gestations with a vertex-presenting first twin on admission to labor. The exposed group was defined as deliveries with a nonvertex second twin at admission to labor, whereas the comparison group included deliveries with a vertex second twin at admission. Only parturients who attempted vaginal delivery were included. Cases of prelabor fetal death of either twin or major fetal anomalies were excluded. The primary outcome was uterine rupture. RESULTS A total of 236 twin trials of labor after cesarean delivery were included, of which 128 involved nonvertex second twins and 108 a second vertex twin. Uterine rupture rates were comparable between the groups (1/128 [0.9%] vs 1/108 [0.8%]; P=1.000). Successful trial of labor after cesarean delivery of both twins occurred in 76.6% of the exposed group vs 81.5% of the comparison group, whereas cesarean delivery of both twins was performed in 21.9% of the exposed group vs 17.6% of the comparison group (P=.418; odds ratio, 1.32; confidence interval, 0.7-2.5). Two cases of cesarean delivery of the second twin occurred in the exposed group and 1 in the comparison group (1.6% vs 0.9%, respectively, P=1.000). There was no difference between the groups in maternal outcomes, including rates of postpartum hemorrhage, blood transfusion, placental abruption, thromboembolic events, and maternal fever. Neonatal outcomes were also comparable between the groups, including rates of intensive care admission and low (≤7) 5-minute Apgar scores. CONCLUSION Our data show that trial of labor after cesarean delivery of noncephalic second twins holds favorable maternal and neonatal outcomes, comparable with those of vertex-vertex trials of labor after cesarean delivery. Second-twin noncephalic presentation should not discourage parturients and caregivers from considering trial of labor after cesarean delivery if desired.
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Affiliation(s)
- Hila Hochler
- Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (Drs Hochler, Suissa-Cohen, Lipschuetz, Yagel, and Walfisch).
| | - Aharon Tevet
- Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel (Dr Tevet); Department of Obstetrics and Gynecology, Shaare-Zedek Medical Center, Jerusalem, Israel (Drs Tevet and Barg)
| | - Moshe Barg
- Department of Obstetrics and Gynecology, Shaare-Zedek Medical Center, Jerusalem, Israel (Drs Tevet and Barg)
| | - Yael Suissa-Cohen
- Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (Drs Hochler, Suissa-Cohen, Lipschuetz, Yagel, and Walfisch)
| | - Michal Lipschuetz
- Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (Drs Hochler, Suissa-Cohen, Lipschuetz, Yagel, and Walfisch)
| | - Simcha Yagel
- Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (Drs Hochler, Suissa-Cohen, Lipschuetz, Yagel, and Walfisch)
| | - Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Mei-Dan, and Melamed)
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Mei-Dan, and Melamed); Department of Obstetrics and Gynecology, North York General Hospital, University of Toronto, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Mei-Dan, and Melamed)
| | - Jon F R Barrett
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett)
| | - Nathan S Fox
- Maternal Fetal Medicine Associates PLLC, New York, NY (Dr Fox); Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Dr Fox)
| | - Asnat Walfisch
- Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (Drs Hochler, Suissa-Cohen, Lipschuetz, Yagel, and Walfisch)
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Mei-Dan E, Jain V, Melamed N, Lim KI, Aviram A, Ryan G, Barrett J. Directive clinique no 428 : Prise en charge de la grossesse gémellaire bichoriale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:835-851.e1. [DOI: 10.1016/j.jogc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mei-Dan E, Jain V, Melamed N, Lim KI, Aviram A, Ryan G, Barrett J. Guideline No. 428: Management of Dichorionic Twin Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:819-834.e1. [PMID: 35798461 DOI: 10.1016/j.jogc.2022.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To review evidence-based recommendations for the management of dichorionic twin pregnancies. TARGET POPULATION Pregnant women with a dichorionic twin pregnancy. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline may improve the management of twin pregnancies and reduce neonatal and maternal morbidity and mortality. EVIDENCE Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (e.g., twin, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for women with twin pregnancies. SUMMARY STATEMENTS RECOMMENDATIONS.
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Amikam U, Hiersch L, Barrett J, Melamed N. Labour induction in twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2021; 79:55-69. [PMID: 34844886 DOI: 10.1016/j.bpobgyn.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 01/21/2023]
Abstract
Medically-indicated deliveries are common in twin pregnancies given the increased risk of various obstetric complications in twin compared to singleton pregnancies, mainly hypertensive disorders of pregnancy and foetal growth restriction. Due to the unique characteristics of twin pregnancies, the success rates and safety of labour induction may be different than in singleton pregnancies. However, while there are abundant data regarding induction of labour in singleton pregnancies, the efficacy and safety of labour induction in twin pregnancies have been far less studied. In the current manuscript we summarize available data on various aspects of labour induction in twin pregnancies including incidence, success rate, prognostic factors, safety and methods for labour induction in twins. This information may assist healthcare providers in counselling patients with twin pregnancies when labour induction is indicated.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jon Barrett
- Departments of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada.
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Lopian M, Kashani-Ligumski L, Cohen R, Assaraf S, Herzlich J, Lessing JB, Perlman S. Twin TOLAC is an independent risk factor for adverse maternal and neonatal outcome. Arch Gynecol Obstet 2021; 304:1433-1441. [PMID: 33877401 DOI: 10.1007/s00404-021-06062-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/31/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine factors associated with a successful twin trial of labor after Cesarean delivery (TOLAC). METHODS A retrospective cohort study was conducted at a single medical center in a population highly motivated for TOLAC (> 80%). The effect of maternal demographic and obstetric characteristics on the likelihood of twin TOLAC success was analyzed. Maternal complications and combined adverse outcome (uterine rupture, Apgar < 7 at 5 min, and umbilical cord pH < 7.1) were compared between singleton and twin TOLAC groups. RESULTS Ninety-five women with a twin gestation and one previous Cesarean delivery comprised the study group. Five thousand seven hundred and three women with a singleton gestation and one previous Cesarean delivery comprised the control group. 30.5% and 83% of women with twin and singleton gestation, respectively, underwent a trial of labor. Women in the twin TOLAC group were significantly less likely to succeed and less likely to have a spontaneous unassisted vaginal delivery compared to women in the singleton TOLAC group. Maternal age less than 35 years, parity greater than two, and at least one previous VBAC increased the likelihood of TOLAC success. Statistically significant differences were found between the twin TOLAC and the singleton TOLAC group for uterine rupture, maternal complications, and for combined adverse outcome. CONCLUSIONS Twin TOLAC is not common, even in parturients highly motivated for TOLAC. Our results demonstrate that even in a selected population, women undergoing twin TOLAC are less likely to have a successful spontaneous vaginal delivery and have a higher risk for uterine rupture, maternal complications, and combined adverse perinatal outcome than women undergoing TOLAC with a singleton gestation. Demographic and obstetric risk factors were identified which can aid the attending obstetrician in the counseling of these challenging cases.
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Affiliation(s)
- Miriam Lopian
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, 17 Harav Povarski Street, Bnei Bark, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Lior Kashani-Ligumski
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, 17 Harav Povarski Street, Bnei Bark, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronnie Cohen
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, 17 Harav Povarski Street, Bnei Bark, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Assaraf
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, 17 Harav Povarski Street, Bnei Bark, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacky Herzlich
- Department of Pediatrics, Mayanei Hayeshua Medical Center, Bnei Brak, Israel.,Department of Neonatology, Tel Aviv Sourasky Medical Center, Lis Hospital for Women, Tel Aviv, Israel
| | - Joseph B Lessing
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, 17 Harav Povarski Street, Bnei Bark, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Perlman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Rabin Medical Center, The Helen Schneider Hospital for Women, Petach Tikva, Israel
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8
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Baradaran K. Risk of Uterine Rupture with Vaginal Birth after Cesarean in Twin Gestations. Obstet Gynecol Int 2021; 2021:6693142. [PMID: 33868405 PMCID: PMC8032534 DOI: 10.1155/2021/6693142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/24/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Women with a previous cesarean delivery may attempt a subsequent vaginal birth or repeat cesarean. Vaginal birth after cesarean carries a greater risk of uterine rupture, defined as the disruption of all uterine layers, resulting in maternal-fetal morbidity or mortality. It is unclear how the risk of uterine rupture compares in patients with twin gestations who undergo different delivery methods. OBJECTIVE The purpose of this systematic review is to determine if there is an increased risk of uterine rupture in patients with twin gestations attempting vaginal birth after cesarean (VBAC) versus planned repeat cesarean delivery (PRCD). Study Design. PubMed, Cochrane Library, and CINAHL were searched systematically. Eligible studies were prospective and retrospective studies that evaluated the incidence of uterine rupture in twin pregnancies that attempted VBAC or PRCD. Data were manually extracted from these studies, and the number of events in each group was used to calculate an odds ratio (OR) and 95% confidence interval (CI). RESULTS 4 retrospective studies were included with a total of 7699 participants, 2305 of whom attempted VBAC and 5394 underwent PRCD. The absolute risk of uterine rupture in the VBAC and PRCD groups was 0.87% and 0.09%, respectively. The rate of uterine rupture was significantly higher in the VBAC group than in the PRCD group (OR: 9.43; CI: 3.54-25.17). CONCLUSION Although VBAC is associated with higher rates of uterine rupture in twin pregnancies when compared with PRCD, the absolute risk of uterine rupture is low in both groups. Depending on individual risk factors, vaginal birth may be offered as a safe option to women with twin pregnancies and a history of cesarean delivery.
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Affiliation(s)
- Kimya Baradaran
- Master of Science in Physician Assistant Studies, Dominican University of California, San Rafael, CA 94901, USA
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9
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Bart Y, Mohr-Sasson A, Mazaki-Tovi S, Kalter A, Shapira M, Sivan E, Hendler I. The effect of polyhydramnios on the success of trial of labor after cesarean delivery (TOLAC): A retrospective cohort. Eur J Obstet Gynecol Reprod Biol 2020; 253:187-190. [PMID: 32890818 DOI: 10.1016/j.ejogrb.2020.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/29/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Prediction of success of trial of labor after cesarean delivery (TOLAC) is of major importance. We investigated the impact of polyhydramnios on the success rate of TOLAC. STUDY DESIGN A retrospective cohort study of all women with singleton pregnancies ≥ 34th weeks of gestation who underwent TOLAC after one previous cesarean delivery, between 2011 and 2016 in a single tertiary care center. Polyhydramnios was defined as amniotic fluid index ≥ 240 mm. Primary outcome was defined as the rate of successful TOLAC. RESULTS 31,245 women gave birth during the study period, of them 1637 (5.3 %) women underwent TOLAC and met inclusion criteria. 39 (2.4 %) women with polyhydramnios were compared to a control group of 1598 (97.6 %) women with amniotic fluid index < 240 mm. Polyhydramnios significantly reduced the rate of successful TOLAC: 69.2 % (27/39) in the study group compared to 85.8 % (1371/1598) in the control group (P = 0.009). In a subgroup analysis based on amniotic fluid index, women with AFI > 270 mm had substantially lower TOLAC success rate [9/19 (47.4 %) vs 18/20 (90 %); P = 0.006]. There was no difference in the rate of uterine rupture between the groups (0/39 (o%) vs 9/1598 (0.56 %); P = 0.64). Logistic regression analysis revealed that polyhydramnios remained significantly associated with higher rates of cesarean delivery [OR 3.09 (95 % CI, 1.37-6.98)] after adjustment for confounding factors. CONCLUSION Polyhydramnios was associated with significantly reduced TOLAC success rate with no statistical difference in the rate of uterine rupture. This information should be considered in physician counseling.
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Affiliation(s)
- Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Kalter
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moran Shapira
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Sivan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Hendler
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Risager JK, Uldbjerg N, Glavind J. Cesarean scar thickness in non-pregnant women as a risk factor for uterine rupture. J Matern Fetal Neonatal Med 2020; 35:389-394. [PMID: 31992102 DOI: 10.1080/14767058.2020.1719065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Whether there is an association between residual myometrial thickness (RMT) after cesarean section (CS) and the risk of uterine rupture (UR) or uterine scar dehiscence at the subsequent delivery has been sparsely investigated.Materials and methods: Our cohort included 149 women with a first CS in whom we measured RMT by transvaginal ultrasonography 6-15 months after their delivery. We did a follow-up study on delivery outcomes in the women's subsequent births. The exposure was scar measurements in the non-pregnant uterus, and the primary outcome was a diagnosis of UR or dehiscence. We calculated likelihood ratios (LRs) with 95% confidence intervals of having UR or dehiscence with a thin RMT (<3 mm).Results: Among the 149 women, 39 had a repeat CS (14 scheduled and 25 unscheduled procedures), and within these, we found one woman with UR and five women with uterine dehiscence. The proportion of women with a thin RMT was significantly higher among cases (4/6) than in controls (4/33); the LR was 5.5 (95% CI 1.9-16.2).Conclusions: The results suggest a significant association between a thin RMT as measured by transvaginal ultrasonography in the non-pregnant uterus after a first scheduled CS and the risk of UR or dehiscence at a subsequent delivery.
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Affiliation(s)
- Johanne Koba Risager
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Glavind
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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11
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Shinar S, Agrawal S, Hasan H, Berger H. Trial of labor versus elective repeat cesarean delivery in twin pregnancies after a previous cesarean delivery-A systematic review and meta-analysis. Birth 2019; 46:550-559. [PMID: 31124186 DOI: 10.1111/birt.12434] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To perform a systematic review of success rates of trial of labor after cesarean (TOLAC) and maternal and neonatal outcomes in twin pregnancy versus elective repeat cesarean delivery (ERCD). METHODS We searched MEDLINE, EMBASE, and Web of Science from data inception to May 2018 with no language or regional restrictions, to identify all studies that compared twin TOLAC and ERCD for maternal and/or neonatal outcomes. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. We assessed the pooled relative risk and mean difference using a random-effects model. The pooled event rates for successful VBAC, cesarean delivery for twin B after vaginal delivery of twin A, and uterine rupture were determined. RESULTS Of the 841 citations identified, 10 were eligible for analysis (2336 TOLAC cases and 5763 ERCD cases). The pooled event rates for successful VBAC and uterine rupture during TOLAC were 72.2% (95% CI 59.7%-83.2%) and 0.87% (95% CI 0.51%-1.31%), respectively. TOLAC was associated with a significantly higher risk of neonatal death (RR 3.02 [95% CI 1.07-8.54]) with no significant differences in mean gestational age at birth, NICU admission rates, or 5-minute Apgar <7. Although the risk for maternal infectious morbidity was significantly lower with TOLAC (RR 0.48 [95% CI 0.25-0.90]), risks of uterine dehiscence, blood transfusions, and hysterectomy were comparable. CONCLUSIONS Twin TOLAC is associated with a relatively high rate of successful vaginal delivery and a low risk of uterine rupture. The finding of higher neonatal mortality rates may be influenced by prematurity, but requires further investigation.
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Affiliation(s)
- Shiri Shinar
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Swati Agrawal
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Haroon Hasan
- Epi Methods Consulting, Toronto, Ontario, Canada
| | - Howard Berger
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
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Trial of labor after cesarean delivery in twin gestations: systematic review and meta-analysis. Am J Obstet Gynecol 2019; 220:336-347. [PMID: 30465748 DOI: 10.1016/j.ajog.2018.11.125] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/01/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Trial of labor after cesarean is offered as a routine option for singleton gestations with previous cesarean delivery. However, adequate data are not available to determine whether the approach is equally valid in women with twin gestation. OBJECTIVE This systematic review and meta-analysis aimed to assess maternal morbidities associated with trial of labor after cesarean delivery in twin gestations. STUDY DESIGN Electronic databases were searched for cohort studies and randomized controlled trials evaluating the association between trial of labor after cesarean delivery in twin gestations and pregnancy outcomes. Maternal mortality and severe morbidities, such as uterine rupture and hysterectomy, were compared between women who had trial of labor and women who had a planned repeat cesarean delivery. Pooled odds ratios were calculated using a random-effects model. Additional analyses were performed to compare trial of labor after cesarean outcomes in singleton and twin gestations. RESULTS Eleven cohort studies including a total of 8209 twin gestations with previous cesarean delivery were included in the present study. Of these gestations, 2484 were intended for planned vaginal birth and 5725 were intended for planned repeat cesarean delivery. The rate of uterine rupture in twin gestations was higher in the trial of labor after cesarean group than the elective cesarean group (odds ratio, 10.09, 95% confidence interval, 4.30-23.69, I2 = 68%). However, no statistically significant difference was found in the rate of uterine rupture between twin and single gestations attempting trial of labor after cesarean delivery (odds ratio, 1.34, 95% confidence interval, 0.54-3.31, I2 = 0%). Women who attempted a trial of labor after cesarean delivery with twins did not have an increased risk of uterine scar dehiscence, hemorrhage, blood transfusion, or neonatal morbidity and mortality compared with elective repeat cesarean delivery. Patients with twins had similar rates of successful vaginal delivery as patients with singletons (odds ratio, 0.85, 95% confidence interval, 0.61-1.18, I2 = 36%). CONCLUSION This meta-analysis demonstrates that, although trial of labor with twins after previous cesarean delivery is associated with higher rates of uterine rupture compared with elective cesarean delivery, pregnancy outcomes and success rates are similar to a trial of labor after previous cesarean delivery in singleton gestations. Planned vaginal birth for women with twin gestation and previous cesarean delivery may be a safe alternative to a planned repeat cesarean.
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Vaginal Birth After Previous Cesarean Birth: A Comparison of 3 National Guidelines. Obstet Gynecol Surv 2018; 73:537-543. [PMID: 30265740 DOI: 10.1097/ogx.0000000000000596] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Vaginal birth after previous cesarean birth (VBAC) is a reasonable option for many women with previous cesarean delivery. Objective The aim of this study was to summarize evidence and compare recommendations from national guidelines regarding VBAC. Evidence Acquisition A descriptive review of 3 national guidelines on VBAC was conducted: Royal College of Obstetricians and Gynaecologists on "Birth After Previous Caesarean Birth," American College of Obstetricians and Gynecologists on "Vaginal Birth After Cesarean Delivery," and Society of Obstetricians and Gynaecologists of Canada on "Guidelines for Vaginal Birth After Previous Caesarean Birth." These guidelines were summarized and compared in terms of the recommended antenatal and intrapartum care of women. Recommendations and strength of evidence were also reviewed based on method of reporting. Results The variations mentioned on the different guidelines reflect the heterogeneity of the published data on the management of VBAC during the antenatal and intrapartum care. Conclusions Evidence-based medicine could support the conception of international recommendations for VBAC, which may improve both safety and efficacy of this procedure.
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Landon MB, Grobman WA. What We Have Learned About Trial of Labor After Cesarean Delivery from the Maternal-Fetal Medicine Units Cesarean Registry. Semin Perinatol 2016; 40:281-6. [PMID: 27210023 PMCID: PMC4983226 DOI: 10.1053/j.semperi.2016.03.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The cesarean delivery rate in the United States has risen steadily over the past 5 decades such that approximately one in three women now undergo cesarean section. The rise in repeat operations and accompanying decline in trial of labor after cesarean (TOLAC) have been major contributors to this phenomenon. The appropriate use of TOLAC continues to be a topic of interest with the recognition that most women with a history of prior cesarean are candidates for trial of labor. The NICHD MFMU Network Cesarean Registry conducted from 1999 to 2002 provided contemporary data concerning the risks and benefits of TOLAC, which in turn have helped inform practitioners and women considering their options for childbirth following cesarean delivery.
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Affiliation(s)
- Mark B. Landon
- The Ohio State University College of Medicine, Columbus OH,
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Abstract
BACKGROUND Twin pregnancies are associated with increased perinatal mortality, mainly related to prematurity, but complications during birth may contribute to perinatal loss or morbidity. The option of planned caesarean section to avoid such complications must therefore be considered. On the other hand, randomised trials of other clinical interventions in the birth process to avoid problems related to labour and birth (planned caesarean section for breech, and continuous electronic fetal heart rate monitoring), have shown an unexpected discordance between short-term perinatal morbidity and long-term neurological outcome. The risks of caesarean section for the mother in the current and subsequent pregnancies must also be taken into account. OBJECTIVES To determine the short- and long-term effects on mothers and their babies, of planned caesarean section for twin pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 November 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing a policy of caesarean section with planned vaginal birth for women with twin pregnancy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility, quality and extracted data. Data were checked for accuracy. For important outcomes the quality of the evidence was assessed using the GRADE approach. MAIN RESULTS We included two trials comparing planned caesarean section versus planned vaginal birth for twin pregnancies.Most of the data included in the review were from a multicentre trial where 2804 women were randomised in 106 centres in 25 countries. All centres had facilities to perform emergency caesarean section and had anaesthetic, obstetrical, and nursing staff available in the hospital at the time of planned vaginal delivery. In the second trial carried out in Israel, 60 women were randomised. We judged the risk of bias to be low for all categories except performance (high) and outcome assessment bias (unclear).There was no clear evidence of differences between women randomised to planned caesarean section or planned vaginal birth for maternal death or serious morbidity (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.67 to 1.11; 2844 women; two studies; moderate quality evidence). There was no significant difference between groups for perinatal or neonatal death or serious neonatal morbidity (RR 1.15, 95% CI 0.80 to 1.67; data for 5565 babies, one study, moderate quality evidence). No studies reported childhood disability.For secondary outcomes there was no clear evidence of differences between groups for perinatal or neonatal mortality (RR 1.41, 95% CI 0.76 to 2.62; 5685 babies; two studies, moderate quality evidence), serious neonatal morbidity (RR 1.03, 95% CI 0.65 to 1.64; 5644 babies; two studies, moderate quality evidence) or any of the other neonatal outcomes reported.The number of women undergoing caesarean section was reported in both trials. Most women in the planned caesarean group had treatment as planned (90.9% underwent caesarean section), whereas in the planned vaginal birth group 42.9% had caesarean section for at least one twin. For maternal mortality; no events were reported in one trial and two deaths (one in each group) in the other. There were no significant differences between groups for serious maternal morbidity overall (RR 0.86, 95% CI 0.67 to 1.11; 2844 women; two studies) or for different types of short-term morbidity. There were no significant differences between groups for failure to breastfeed (RR 1.14, 95% CI 0.95 to 1.38; 2570 women, one study; moderate quality evidence) or the number of women with scores greater than 12 on the Edinbugh postnatal depression scale (RR 0.95, 95% CI 0.78 to 1.14; 2570 women, one study; moderate quality evidence). AUTHORS' CONCLUSIONS Data mainly from one large, multicentre study found no clear evidence of benefit from planned caesarean section for term twin pregnancies with leading cephalic presentation. Data on long-term infant outcomes are awaited. Women should be informed of possible risks and benefits of labour and vaginal birth pertinent to their specific clinical presentation and the current and long-term effects of caesarean section for both mother and babies. There is insufficient evidence to support the routine use of planned caesarean section for term twin pregnancy with leading cephalic presentation, except in the context of further randomised trials.
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Affiliation(s)
- G Justus Hofmeyr
- Walter Sisulu University, University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Jon F Barrett
- Sunnybrook Health Sciences Centre60 Grosvenor StreetTorontoONCanadaM5S 1B6
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
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Risk factors predicting an emergency cesarean delivery for the second twin after vaginal delivery of the first twin. Arch Gynecol Obstet 2015; 292:531-6. [PMID: 25716669 DOI: 10.1007/s00404-015-3667-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 02/16/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate obstetrical risk factors predicting failure of vaginal delivery and an emergency cesarean section (CS) for the second twin after vaginal delivery of the first twin. In addition, the study was aimed to define perinatal outcomes of the second twin. STUDY DESIGN A retrospective study was conducted, comparing all deliveries of twins in which CS was performed for the second twin to those in which both twins were delivered vaginally during the years 1988-2010. Women with multiple gestations in which a CS was performed for both twins were excluded from the study. RESULTS During the study period, 1966 vaginal deliveries of the first twin were recorded; 192 involved emergency CS for the second twin. Risk factors for emergency CS of the second twin were preterm delivery, previous CS, placental abruption and breech presentation of the second twin. Perinatal outcomes did not differ between the groups. CONCLUSION Risk factors for emergency cesarean section of the second twin are preterm delivery, previous CS, placental abruption and breech presentation. Nevertheless, short-term perinatal outcomes are comparable to twins delivered vaginally.
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Wenckus DJ, Gao W, Kominiarek MA, Wilkins I. The effects of labor and delivery on maternal and neonatal outcomes in term twins: a retrospective cohort study. BJOG 2014; 121:1137-44. [PMID: 24575851 PMCID: PMC4108533 DOI: 10.1111/1471-0528.12642] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare maternal and neonatal outcomes in twins undergoing a trial of labor versus pre-labor caesarean. DESIGN Retrospective cohort study. SETTING 19 US hospitals from the Consortium on Safe Labor. POPULATION Of 2225 twin sets ≥36 weeks' gestation. METHODS Maternal (abruption, estimated blood loss, postpartum haemorrhage, transfusion, chorioamnionitis, hysterectomy, ICU admission, death) and neonatal outcomes (birth injury, 5-minute Apgar <7, NICU admission, RDS, TTN, sepsis, asphyxia, NICU length of stay, death) were compared between the trial of labour and pre-labour caesarean groups with univariate and multivariate logistic and linear regression analyses. Similar analyses were performed for actual delivery modes. MAIN OUTCOME MEASURES Maternal and neonatal outcomes. RESULTS Among the 2225 twin sets, 1078 had a trial of labour, and 65.9% of those delivered vaginally. There was an increased risk for postpartum haemorrhage [OR 2.5, 95% confidence interval (CI) 1.4-4.5] and blood transfusion (OR 1.9, 95%CI 1.2-3.2) for the trial of labour compared with pre-labour caesarean groups. Birth injury only occurred in the trial of labour group, 1% Twin A, 0.4% Twin B. Both twins had a higher risk of 5-minute Apgar <7 with trial of labour compared to pre-labour caesarean (A: OR 3.9, 95%CI 1.05-14.5; B: OR 3.9, 95%CI 1.3-12.3). CONCLUSION Term twins undergoing a trial of labour have increased maternal haemorrhage and transfusions along with neonatal birth trauma and lower Apgar scores, but these absolute neonatal occurrences were rare. Trial of labour in twins remains a safe and reasonable option in appropriately selected cases.
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Affiliation(s)
- Dalia J. Wenckus
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Illinois at Chicago
| | - Weihua Gao
- Center for Clinical and Translational Science, University of Illinois at Chicago
| | - Michelle A. Kominiarek
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Illinois at Chicago
| | - Isabelle Wilkins
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Illinois at Chicago
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Hammad IA, Chauhan SP, Magann EF, Abuhamad AZ. Peripartum complications with cesarean delivery: a review of Maternal-Fetal Medicine Units Network publications. J Matern Fetal Neonatal Med 2013; 27:463-74. [DOI: 10.3109/14767058.2013.818970] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Uterine rupture during attempted vaginal birth after cesarean is a rare, but serious complication and can result in death or long-term disability. Several factors can increase the risk of uterine rupture during vaginal birth after cesarean and adequate counseling is necessary. Current literature suggests that timely diagnosis and delivery of the fetus is necessary for optimal outcome.
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Affiliation(s)
- Calla M Holmgren
- Department of Maternal-Fetal Medicine, Intermountain Medical Center and Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Schmitz T. Situations cliniques particulières, maternelles ou fœtales, influençant le choix du mode d’accouchement en cas d’antécédent de césarienne. ACTA ACUST UNITED AC 2012; 41:772-81. [DOI: 10.1016/j.jgyn.2012.09.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
The aim of this article is to review current information regarding the management of twin gestations and discuss optimal pregnancy length and considerations regarding route of delivery. Limited data are available on the timing and mode of delivery for twins. For apparently uncomplicated twin pregnancies, current recommendations suggest the optimal length of gestation is 38 weeks for dichorionic diamniotic twins, 34-36 weeks for monochorionic diamniotic twins, and 32-34 weeks for monoamniotic twins. In general, vaginal trial of labor may be considered for cephalic-cephalic twins and in cases of cephalic-noncephalic twins where the provider's skills and experience allow. Cesarean is recommended in twin gestations with monoamnionicity, noncephalic presenting fetus, and those at high risk for combined vaginal-abdominal delivery. The optimal management of twin deliveries is controversial, with timing and mode of delivery dependent on multiple factors, including chorionicity, amnionicity, provider experience, and fetal presentation.
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Affiliation(s)
- Young Mi Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY 10065, USA.
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Abstract
BACKGROUND Twin pregnancies are associated with increased perinatal mortality, mainly related to prematurity, but complications during birth may contribute to perinatal loss or morbidity. The option of planned caesarean section to avoid such complications must therefore be considered. On the other hand, randomised trials of other clinical interventions in the birth process to avoid problems related to labour and birth (planned caesarean section for breech, and continuous electronic fetal heart rate monitoring), have shown an unexpected discordance between short-term perinatal morbidity and long-term neurological outcome. The risks of caesarean section for the mother in the current and subsequent pregnancies must also be taken into account. OBJECTIVES To determine the short- and long-term effects on mothers and their babies, of planned caesarean section for twin pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011). SELECTION CRITERIA Randomised trials comparing a policy of caesarean section with planned vaginal birth for women with twin pregnancy. DATA COLLECTION AND ANALYSIS Two researchers independently assessed eligibility, quality and extracted data. Data were checked for accuracy. MAIN RESULTS One small trial with unconfirmed allocation concealment compared caesarean section with planned vaginal birth in 60 women with vertex/non-vertex twin pregnancies. There were no differences in perinatal outcome. The trial was too small to exclude the possibility of clinically meaningful benefits of either approach. There is one additional trial currently ongoing. AUTHORS' CONCLUSIONS There is a lack of robust evidence to guide clinical advice regarding the method of birth for twin pregnancies. Women should be informed of possible benefits and risks of either approach, including short-term and long-term consequences for both mother and babies. Future research should aim to provide unbiased evidence, including long-term outcomes.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | | | - Caroline A Crowther
- ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia
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Vendittelli F, Rivière O, Crenn-Hébert C, Riethmuller D, Schaal JP, Dreyfus M. Is a planned cesarean necessary in twin pregnancies? Acta Obstet Gynecol Scand 2011; 90:1147-56. [PMID: 21426308 DOI: 10.1111/j.1600-0412.2011.01130.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Evaluation of elective cesarean section for twin delivery as a standard of care. DESIGN Historical cohort in a national database (2 597 twin pregnancies). SETTING France. SAMPLE Twins with first child in cephalic presentation. METHODS Decision analysis. MAIN OUTCOME MEASURES All neonatal complications, i.e. death, whether intrapartum or in the delivery room or the immediate postpartum period, or neonatal transfer to intensive (or special) care, or trauma, of one or both twins. RESULTS When we focused on neonatal complications for either or both twins, the strategy of planned vaginal delivery was preferable; the weight of its decision tree branch was lower than that for planned cesarean (26.5 vs. 31.7). If only twin 2 was considered, vaginal delivery was also preferred (weight of vaginal delivery=27.6 vs. 32.7 for planned cesarean). As long as the morbidity and mortality of twin 1 or twin 2 or both during a cesarean for twin 2 in the case of planned vaginal delivery does not exceed 31.5%, all else being equal, vaginal delivery should be preferred to a planned cesarean for twin 1 and twin 2. The two-variable sensitivity analysis confirmed the robustness of the results. CONCLUSIONS The results of our study do not support a policy of planned cesarean delivery for twin pregnancies at and after 34 weeks of gestation. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Françoise Vendittelli
- AUDIPOG (Association of Health Workers Using an Electronic File in Paediatrics, Obstetrics and Gynaecology), Medical University RTH Laennec, Lyon, France.
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Aaronson D, Harlev A, Sheiner E, Levy A. Trial of labor after cesarean section in twin pregnancies: maternal and neonatal safety. J Matern Fetal Neonatal Med 2010; 23:550-4. [PMID: 19658041 DOI: 10.3109/14767050903156700] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess maternal and perinatal morbidity in patients undergoing a trial of labor after cesarean section (TOLAC) in twin gestations. METHODS A retrospective study including all twin pregnancies with a single prior cesarean section was performed. Stratified analysis using a multiple logistic regression model was performed to control for confounders. Patients who had a clear medical indication for a cesarean section (i.e. previous corporeal cesarean section, breech or transverse presentation, placenta previa, placental abruption, and herpes infection) were excluded from the analysis. RESULTS During the years 1988-2007, 134 patients met the inclusion criteria. Of these, 25 patients underwent a trial of labor and the remaining 109 underwent a repeat cesarean delivery. There were no cases of uterine rupture, maternal mortality, or peripartum fever in our population. Higher rates of perinatal mortality were noted in patients undergoing a trial of labor (8% vs. 1.8%, p = 0.042, OR = 4.652, 95% CI = 1.122-19.286). However, a trial of labor was not found to be an independent risk factor for perinatal mortality after controlling for confounders such as gestational age, ethnicity, and fetal malformations (adjusted OR = 1.07, 95% CI = 0.07-15.95, p = 0.95). CONCLUSIONS A TOLAC is not associated with an increased risk for maternal morbidity, including uterine rupture. Nevertheless, in our population TOLAC was noted as a risk factor for perinatal mortality, although residual confounding cannot be excluded. Further prospective randomized studies should evaluate the safety of TOLAC in twin gestations to establish appropriate guidelines.
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Affiliation(s)
- Daniel Aaronson
- Faculty of Health Sciences, The Joyce and Irving Goldman Medical School, Ben-Gurion University of Negev, Be'er-Sheva, Israel
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Gregory KD, Fridman M, Korst L. Trends and patterns of vaginal birth after cesarean availability in the United States. Semin Perinatol 2010; 34:237-43. [PMID: 20654773 DOI: 10.1053/j.semperi.2010.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A review of the literature and analysis of the National Inpatient Sample Database was performed to describe the trends in vaginal birth after cesarean availability in the United States and the factors associated with changing use. Vaginal birth after cesarean increased after the first National Institutes of Health Consensus Conference on Cesarean Childbirth in 1981. It increased from 3% to a maximum rate of 28.3% in 1996. Despite studies reporting stable success rates of approximately 70% and low complication rates (<1%), concerns about patient safety and physician liability have led to more restrictive policies and a decrease in vaginal birth after cesarean use. The current rate is approximately 8.5%, and decreased rates have been noted for all age and ethnic groups. There is decreased use of vaginal birth after cesarean as the result of concerns about patient safety and physician liability, which has resulted in decreased availability.
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Affiliation(s)
- Kimberly D Gregory
- Department Obstetrics & Gynecology, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA.
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Vendittelli F, Accoceberry M, Savary D, Laurichesse-Delmas H, Gallot D, Jacquetin B, Lémery D. Quelle voie d’accouchement pour les jumeaux ? ACTA ACUST UNITED AC 2009; 38:S104-13. [DOI: 10.1016/s0368-2315(09)73567-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sentilhes L, Bouhours AC, Biquard F, Gillard P, Descamps P, Kayem G. Mode d’accouchement des grossesses gémellaires. ACTA ACUST UNITED AC 2009; 37:432-41. [DOI: 10.1016/j.gyobfe.2009.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Uterine rupture, whether in the setting of a prior uterine incision or in an unscarred uterus, is an obstetric emergency with potentially catastrophic consequences for both mother and child. Numerous studies have been published regarding various risk factors associated with uterine rupture. Despite the mounting data regarding both antepartum and intrapartum factors, it currently is impossible to predict in whom a uterine rupture will occur. This article reviews the data regarding these antepartum and intrapartum predictors for uterine rupture. The author hopes that the information presented in this article will help clinicians assess an individual's risk for uterine rupture.
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Affiliation(s)
- Jennifer G Smith
- Section on Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Abstract
A trial of labor and vaginal delivery are usually indicated in vertex-vertex twins. For vertex-nonvertex twins, vaginal birth is preferred, with the second twin being delivered by breech extraction, unless it is significantly larger than the first. Cesarean delivery is indicated if the first twin is nonvertex and for all cases of monoamniotic or potentially viable conjoined twins. There is a limited role for trial of labor after cesarean delivery in twin gestations. In my opinion, combined vaginal-cesarean birth is the riskiest method for mother and infants and should be avoided if possible.
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Affiliation(s)
- Dwight P Cruikshank
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Abstract
Given the high national rate of cesarean delivery in current obstetric practice, patients considering vaginal birth after cesarean (VBAC) in subsequent pregnancies are frequently encountered. A recently growing body of literature on VBAC has produced concrete evidence to define the VBAC-associated risks and identify factors influencing success. An evidence-based approach can guide practitioners and patients through the complex counseling, decision-making, and management issues when considering VBAC delivery.
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Affiliation(s)
- Alison G Cahill
- Department of Obstetrics and Gynecology, Washington University, St Louis, Missouri, USA.
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Bibliography. Current world literature. Women's health. Curr Opin Obstet Gynecol 2006; 18:666-74. [PMID: 17099340 DOI: 10.1097/gco.0b013e328011ef42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ford AAD, Bateman BT, Simpson LL. Vaginal birth after cesarean delivery in twin gestations: a large, nationwide sample of deliveries. Am J Obstet Gynecol 2006; 195:1138-42. [PMID: 17000246 DOI: 10.1016/j.ajog.2006.06.036] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2006] [Revised: 06/06/2006] [Accepted: 06/09/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the maternal morbidity associated with attempted vaginal birth after cesarean (VBAC) in twin gestations using a large, nationwide sample of deliveries. STUDY DESIGN Data for this study were obtained from an administrative dataset, the Nationwide Inpatient Sample, a representative sample of discharges from non-Federal hospitals, for the years 1993 to 2002. Patients admitted nonemergently for the delivery of twin gestations who had a history of previous cesarean delivery were selected. Patients that either delivered vaginally or who had discharge codes that indicated labor before cesarean delivery were defined as the trial of labor group, while patients who had a cesarean delivery without discharge codes that indicated labor were defined as the elective cesarean group. Various complications of delivery were analyzed for each group. RESULTS We identified 4705 women who underwent an elective cesarean delivery and 1850 women who underwent a trial of labor. For women who had a trial of labor, 836 (45.2%) delivered vaginally. The rate of uterine rupture was higher in the trial of labor group than in the elective cesarean group (0.9% vs 0.1%, P < .001), and the rate of wound complications was lower (0.6% vs 1.3%, P < .02). The rates of other complications including hysterectomy, transfusion, major postpartum infection, thromboembolism, uterine dehiscence, and pelvic hematoma were not significantly different between the 2 groups. CONCLUSION Our study showed a significantly higher rate of uterine rupture in the trial of labor group that is similar to the rates reported for trial of labor after cesarean in singleton pregnancies.
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Affiliation(s)
- Abigail A D Ford
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Abstract
PURPOSE OF REVIEW The increasing rates of primary caesarean section are likely to contribute to a rise in the incidence of uterine rupture in developed countries. Uterine rupture continues to be an important cause of maternal death in less and least developed countries. Recent publications adressing the diagnosis, aetiology and management of primary caesarian section are reviewed. RECENT FINDINGS Uterine rupture is commonly associated with vaginal birth after caesarean section, although the absolute risk varies according to previous obstetric history, gestational age, and induction of labour. Quantification of risk for a range of circumstances allows informed counselling of pregnant women. Imaging techniques may improve the early detection of uterine dehiscence but in the acute setting abnormal fetal heart rate patterns provide early diagnostic information. The scale of the problem in less and least developed countries is sobering and maternal mortality can be determined by the ability to access basic obstetric care. SUMMARY Uterine rupture remains one of the most frightening complications in obstetric care. The risk of its occurrence is likely to increase for many parous women, placing the emphasis on counselling and early prediction and prevention wherever possible.
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Affiliation(s)
- Deirdre J Murphy
- Division of Maternal and Child Health Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
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Affiliation(s)
- Mary Anne Carroll
- Division of Maternal-Fetal Medicine, University of Texas Health Science Center Houston, Houston, Texas 77030, USA.
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