Essai de travail en cas de césarienne antérieure

Trial of labour versus elective caesarean delivery for estimated large for gestational age foetuses after prior caesarean delivery: a multicenter retrospective study

BACKGROUND

Lower rates of successful trial of labor after cesarean (TOLAC) in association with fetal macrosomia were previously reported. This study aimed to compare TOLAC to elective caesarean delivery (CD) in women with estimated fetal weight large for gestational age (eLGA) and a prior CD. Primary outcome was to analyse the mode of delivery in case of TOLAC. Secondary outcome was to compare maternal and foetal morbidity.

METHODS

We conducted a retrospective, descriptive, multicentric, cohort study in five maternity units between January and December 2020. Inclusion criteria were: women with a single prior CD and eLGA or neonatal weight > 90th percentile with singleton pregnancy and gestational age ≥ 37 weeks.

MAIN OUTCOME MEASURES

rate of vaginal delivery, maternal and fetal morbidity including: shoulder dystocia, neonatal hospitalization, fetal trauma, neonatal acidosis, uterine rupture, 3^rd and 4^th perineal tears, post-partum hemorrhage, and a need for blood transfusion.

RESULTS

Four hundred forty women met inclusion criteria, including 235 (53.4%) eLGA. 170 (72.3%) had a TOLAC (study group) and 65 (27.7%) an elective CD (control). 117 (68.82%) TOLAC had a vaginal delivery. No significant differences were found between the two groups in the rates of: postpartum haemorrhage, transfusion, Apgar score, neonatal hospitalization, and foetal trauma. Cord lactate was higher in the case of TOLAC (3.2 vs 2.2, p < 0.001). Median fetal weight was 3815 g (3597-4085) vs. 3865 g (3659-4168): p = 0.068 in the study vs. controls group respectively.

CONCLUSION

TOLAC for eLGA fetuses is legitimate because there is no difference in maternal-fetal morbidity, and the CD rate is acceptable.

[Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]

OBJECTIVES

To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche.

METHODS

Review of the literature, critical reflection, and pragmatic advice.

RESULTS

There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases.

CONCLUSIONS

A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.

[Labour in women with scarred uterus in the Democratic Republic of the Congo: trial of scar and factors influencing the outcome]

OBJECTIVE

Our study aims to identify risks factors associated with failed trial of scar and to set a predictive score of labour in women with scarred uterus in the Democratic Republic of the Congo.

METHODS

We conducted a multicenter cross-sectional analytic study of patients with scarred uterus in four maternity units in the Democratic Republic of the Congo (DRC) from 1 January to 31 December 2013. Logistic regression model was used to identify factors associated with failed trial of scar. We set a predictive score based on this model in order to predict trial of scar failure in maternity units in the DRC. ROC curve was used to assess the ability of the set score to identify patients at risk for trial of scar failure. The cut off point for the predictive score was determined on the basis of the Youden-index-based optimal sensitivity and specificity. All the tests in our study were carried out by using a significance threshold of α=0.05.

RESULTS

Two explanatory factors in trial of scar failure were retained. They were the socio-demographic factor (maternal age) and three obstetric factors (fundal height, fetal presentation and premature rupture of membranes). Predictive score was set to predict trial of scar failure. This score was determined based on four elements: maternal age, evaluation of the gestational sac on admission, fundal height and fetal presentation. The minimum score was set at 4 and the maximum score was set at 16. The threshold value was set at 7. A total score greater than or equal to 7 reflects a risk of trial of scar failure.

CONCLUSION

We set a predictive score to predict trial of scar failure. This score was determined based on four elements: maternal age, evaluation of the gestational sac on admission, fundal height and fetal presentation. A total score greater than or equal to 7 reflects a risk of trial of scar failure.