Timing of delivery in women with prior uterine rupture: a decision analysis

Outcome of subsequent pregnancies in women with prior uterine rupture

OBJECTIVE

To report maternal and neonatal outcomes of subsequent pregnancies in a series of women with a prior uterine rupture.

METHODS

The records of all 103,542 deliveries (22,286 by cesarean section) performed in a single tertiary medical center from 2009 to 2021 were reviewed. Women with a prior uterine rupture, defined as a separation of the entire thickness of the uterine wall, with extrusion of fetal parts and intra-amniotic contents into the peritoneal cavity documented in the operative report of the previous cesarean delivery or laparotomy, were identified for inclusion in the study.

RESULTS

The cohort included 38 women with 50 pregnancies (50 neonates). Women had been scheduled for elective cesarean delivery at early term. Mean gestational age at delivery was 36 + 4 weeks (±5 days). In 7 pregnancies (14 %), spontaneous labor occurred before the scheduled cesarean delivery (at 36 + 6, 35 + 4, 35 + 3, 34 + 6, 34 + 3, 32 + 6 and 31 + 0 gestational weeks). A recurrent uterine scar rupture was found in 4 pregnancies (8 %), and uterine scar dehiscence, in 2 pregnancies (4 %), all identified during elective repeat cesarean delivery. In none of these cases was there a clinical suspicion beforehand; all had good maternal and neonatal outcomes. One parturient with placenta previa-accreta had a planned cesarean hysterectomy.

CONCLUSION

Women with prior uterine rupture have good maternal and neonatal outcomes in subsequent pregnancies when managed at a tertiary medical center, with planned elective term cesarean delivery, or even earlier, at the onset of spontaneous preterm labor.

Incidence of Recurrent Uterine Rupture: A Systematic Review and Meta-analysis

OBJECTIVE

We aimed to quantify the incidence of recurrent uterine rupture in pregnant women.

DATA SOURCES

A literature search of PubMed, Web of Science, Cochrane Central, and ClinicalTrials.gov for observational studies was performed from 2000 to 2023.

METHODS OF STUDY SELECTION

Of the 7,440 articles screened, 13 studies were included in the final review. We included studies of previous uterine ruptures that were complete uterine ruptures , defined as destruction of all uterine layers, including the serosa. The primary outcome was the pooled incidence of recurrent uterine rupture. Between-study heterogeneity was assessed with the I2 value. Subgroup analyses were conducted in terms of the country development status, year of publication, and study size (single center vs national study). The secondary outcomes comprised the following: 1) mean gestational age at which recurrent rupture occurred, 2) mean gestational age at which delivery occurred without recurrent rupture, and 3) perinatal complications (blood loss, transfusion, maternal mortality, and neonatal mortality).

TABULATION, INTEGRATION, AND RESULTS

A random-effects model was used to pool the incidence or mean value and the corresponding 95% CI with R software. The pooled incidence of recurrent uterine rupture was 10% (95% CI 6-17%). Developed countries had a significantly lower uterine rupture recurrence rate than less developed countries (6% vs 15%, P =.04). Year of publication and study size were not significantly associated with recurrent uterine rupture. The mean number of gestational weeks at the time of recurrent uterine rupture was 32.49 (95% CI 29.90-35.08). The mean number of gestational weeks at the time of delivery without recurrent uterine rupture was 35.77 (95% CI 34.95-36.60). The maternal mortality rate was 5% (95% CI 2-11%), and the neonatal mortality rate was 5% (95% CI 3-10%). Morbidity from hemorrhage, such as bleeding and transfusion, was not reported in any study and could not be evaluated.

CONCLUSION

This systematic review estimated a 10% incidence of recurrent uterine rupture. This finding will enable appropriate risk counseling in patients with prior uterine rupture.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42023395010.

Clinical decision analysis of elective delivery vs expectant management for pregnant individuals with COVID-19-related acute respiratory distress syndrome

BACKGROUND

Pregnant individuals are vulnerable to COVID-19-related acute respiratory distress syndrome. There is a lack of high-quality evidence on whether elective delivery or expectant management leads to better maternal and neonatal outcomes.

OBJECTIVE

This study aimed to determine whether elective delivery or expectant management are associated with higher quality-adjusted life expectancy for pregnant individuals with COVID-19-related acute respiratory distress syndrome and their neonates.

STUDY DESIGN

We performed a clinical decision analysis using a patient-level model in which we simulatedpregnant individuals and their unborn children. We used a patient-level model with parallel open-cohort structure, daily cycle length, continuous discounting, lifetime horizon, sensitivity analyses for key parameter values, and 1000 iterations for quantification of uncertainty. We simulated pregnant individuals at 32 weeks of gestation, invasively ventilated because of COVID-19-related acute respiratory distress syndrome. In the elective delivery strategy, pregnant individuals received immediate cesarean delivery. In the expectant management strategy, pregnancies continued until spontaneous labor or obstetrical decision to deliver. For both pregnant individuals and neonates, model outputs were hospital or perinatal survival, life expectancy, and quality-adjusted life expectancy denominated in years, summarized by the mean and 95% credible interval. Maternal utilities incorporated neonatal outcomes in accordance with best practices in perinatal decision analysis.

RESULTS

Model outputs for pregnant individuals were similar when comparing elective delivery at 32 weeks' gestation with expectant management, including hospital survival (87.1% vs 87.4%), life-years (difference, -0.1; 95% credible interval, -1.4 to 1.1), and quality-adjusted life expectancy denominated in years (difference, -0.1; 95% credible interval, -1.3 to 1.1). For neonates, elective delivery at 32 weeks' gestation was estimated to lead to a higher perinatal survival (98.4% vs 93.2%; difference, 5.2%; 95% credible interval, 3.5-7), similar life-years (difference, 0.9; 95% credible interval, -0.9 to 2.8), and higher quality-adjusted life expectancy denominated in years (difference, 1.3; 95% credible interval, 0.4-2.2). For pregnant individuals, elective delivery was not superior to expectant management across a range of scenarios between 28 and 34 weeks of gestation. Elective delivery in cases where intrauterine death or maternal mortality were more likely resulted in higher neonatal quality-adjusted life expectancy, as did elective delivery at 30 weeks' gestation (difference, 1.1 years; 95% credible interval, 0.1 - 2.1) despite higher long-term complications (4.3% vs 0.5%; difference, 3.7%; 95% credible interval, 2.4-5.1), and in cases where intrauterine death or maternal acute respiratory distress syndrome mortality were more likely.

CONCLUSION

The decision to pursue elective delivery vs expectant management in pregnant individuals with COVID-19-related acute respiratory distress syndrome should be guided by gestational age, risk of intrauterine death, and maternal acute respiratory distress syndrome severity. For the pregnant individual, elective delivery is comparable but not superior to expectant management for gestational ages from 28 to 34 weeks. For neonates, elective delivery was superior if gestational age was ≥30 weeks and if the rate of intrauterine death or maternal mortality risk were high. We recommend basing the decision for elective delivery vs expectant management in a pregnant individual with COVID-19-related acute respiratory distress syndrome on gestational age and likelihood of intrauterine or maternal death.

Outcome of subsequent pregnancies in women with complete uterine rupture: A population-based case-control study

INTRODUCTION

In the attempt of a trial of labor after a cesarean section approximately one in 200 women experience a complete uterine rupture. As a complete uterine rupture is associated with an adverse perinatal outcome, data regarding subsequent pregnancies are needed to provide proper care and guidance to women with a complete uterine rupture when informing them of future possibilities. The objective of this study was to investigate the fetal and maternal outcomes in subsequent pregnancies after a complete uterine rupture.

MATERIAL AND METHODS

Retrospective population-based case-control study. Denmark 1997-2017. A total of 175 women with complete uterine rupture during an attempted trial of labor after cesarean (TOLAC) at term (cases) and a corresponding group of 272 women with no uterine rupture during an attempted TOLAC at term (controls) were labeled as index deliveries. Index deliveries were included from January 1, 1997 to December 31, 2008. From the date of the index delivery to December 31, 2017 the information on subsequent pregnancies and deliveries, and on referral to hospital with any obstetric or gynecological diagnosis were retrieved from the Danish Medical Birth Registry and National Patient Registry. Main outcome measures were miscarriage, perinatal death, neonatal morbidity, preterm birth, and recurrence of uterine rupture. Outcome measures were compared between cases and controls.

RESULTS

After the index deliveries; there were 109 pregnancies and 70 deliveries after gestational age 22⁺⁰  weeks in the population of cases. In the population of controls, there were 183 pregnancies and 126 deliveries after 22⁺⁰  weeks. Cases had a significantly higher risk of miscarriage (odds ratio [OR] 3.99; 95% confidence interval [CI] 1.36-13.17). The incidence of uterine rupture was 8.6% among cases and 0.8% among controls (OR 11.7; 95% CI 1.36-543.1). Among cases, 98.6% had live-born infants, and none of these had severe neonatal morbidity. No significant association was found between previous complete uterine rupture and preterm delivery, placenta previa, hysterectomy in relation to subsequent births, diagnosis such as meno/metrorrhagia, dysmenorrhea, or procedures such as hysteroscopy or hysterectomy.

CONCLUSIONS

In pregnancies following complete uterine rupture continuing after 22⁺⁰  weeks, maternal and fetal outcomes are good when managed promptly with cesarean delivery.

Timing of antenatal corticosteroids for optimal neonatal outcomes: A Markov decision analysis model

OBJECTIVE

Antenatal corticosteroids (ACSs) are administered to pregnant individuals at high risk of preterm delivery to reduce neonatal morbidity and mortality. ACSs have a limited timeframe of effectiveness, and timing of administration can be difficult because of uncertainty surrounding the likelihood of preterm delivery. The objective of the current study was to design a decision analysis model to optimize the timing of ACS administration and identify important model variables that impact administration timing preference.

METHODS

We created a Markov decision analysis model with a base case of a patient at 24⁰ weeks gestation with antepartum hemorrhage. Decision strategies included immediate, delayed, and no ACS administration. Outcomes were based on the neonatal perspective and consisted of lifetime quality adjusted life years (QALYs). Data for model inputs were derived from current literature and clinical recommendations.

RESULTS

Our base case analysis revealed a preferred strategy of delaying ACSs for 2 weeks, which maximized QALYs (39.18 lifetime discounted), driven by reduced neonatal morbidity at the expense of 0.1% more neonatal deaths, when compared with immediate ACS administration. Sensitivity analyses identified that, if the probability of delivery within the next week was >6.19%, then immediate steroids were preferred. Other important variables included gestational age, ACS effectiveness, and ACS adverse effects.

CONCLUSION

ACS timing involves a trade-off between morbidity and mortality, and optimal timing depends on probability of delivery, gestational age, and risks and benefits of ACSs. Clinicians should carefully consider these factors prior to ACS administration.

Recurrent uterine rupture in third trimester of pregnancy

We report a case of recurrent upper segment uterine rupture in a 31-year-old woman at 32+5/40 weeks of gestation. She had fundal uterine rupture 3 years ago in her first pregnancy at 40 weeks of gestation. There was no history of uterine malformation or prior uterine surgery. However, we noted that she had had three laparoscopic procedures for endometriosis treatment. She was scheduled to have an elective repeat caesarean section at 34+6/40 weeks of gestation in the index pregnancy. Unfortunately, she presented at 32+5/40 weeks with features of acute abdomen and signs of fetal distress. She had a category 1 caesarean section and was found to have fundal uterine rupture at the same site. She had a smooth uneventful recovery following a timely intervention and discharged home on day 5 postoperatively in a good condition with her baby girl.

Optimizing Term Delivery and Mode of Delivery

Full-term deliveries are defined as occurring between 39 weeks and 40 weeks and 6 days. Because contemporary research suggests improved outcomes with delivery in the term period compared with the early term period, nonindicated delivery should be pursued no earlier than 39 weeks. There are, however, multiple medical, obstetric, and fetal indications for delivery before 39 weeks, and the obstetric provider must weigh the risks and benefits of delivery versus expectant management on both the mother and fetus. This review serves to provide a basic framework of evidentiary support toward optimizing the term delivery.

Obstetric management for stillbirth complicated by a prior cesarean delivery: a cost-effectiveness analysis

BACKGROUND

The primary concern for a trial of labor after cesarean (TOLAC) is a uterine rupture leading to neonatal injury or mortality and maternal mortality. In individuals who have a term stillbirth, the neonatal concern is absent, yet repeat cesarean delivery remains common in this setting. Given the increased maternal risks from cesarean, it is important to evaluate obstetric management options in the population of women who have a term stillbirth and prior cesarean delivery (CD).

OBJECTIVES

To examine the outcomes and costs of a TOLAC via induction of labor verses a repeat CD for cases of stillbirth occurring near term.

STUDY DESIGN

A decision-analytic model incorporating the current and a subsequent delivery using TreeAge software was designed to compare outcomes in women induced for a TOLAC to those undergoing repeat CD in the setting of stillbirth at 34-41 weeks' gestation. We used a theoretical cohort of 6000 women, the estimated annual number of women a prior cesarean who experience a stillbirth in the United States. Outcomes included quality-adjusted life years (QALY) for both modes of delivery with consideration of future pregnancy risks. Future pregnancy risks included uterine rupture, hysterectomy, placenta accreta, maternal death, neonatal death, and neonatal neurological deficits. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY.

RESULTS

In our theoretical cohort of 6000 women with a prior CD and current stillbirth, induction of labor resulted in 4836 fewer cesarean deliveries during stillbirth management, 1040 fewer cesarean deliveries in the subsequent pregnancy, and 14 fewer cases of placenta accreta in the subsequent pregnancy, despite 29 additional uterine ruptures across both pregnancies. Induction of labor was found to be the dominant strategy, resulting in decreased costs and increased QALYs. Univariate sensitivity analyses demonstrated that induction of labor was cost effective until the risk of uterine rupture in the first delivery exceeded 0.83% (baseline estimate: 0.38%). Additional univariate sensitivity analyses found that induction of labor was cost effective until the risk of IOL failure in the first delivery exceeded 64% (baseline estimate: 19%).

CONCLUSION

In our theoretical cohort, induction of labor for TOLAC in the setting of a stillbirth with a history of prior CD is cost effective compared to a repeat CD. The results of this analysis demonstrate the benefit of induction of labor among women in this scenario who desire a future pregnancy.

Eosinophilic gastroenteritis in pregnancy: A review of the literature

Eosinophilic gastroenteritis (EGE) is an uncommon and heterogeneous disease characterized by eosinophilic infiltration of the gastrointestinal tract. There are very few reports in literature describing pregnancies in EGE patients, and no review has ever been published. We found a total of 12 cases including one that occurred in our clinic. In 5 out of 12 cases, EGE was diagnosed after delivery and pregnancies are described as uneventful. Of the 5 patients who already had a diagnosis of EGE before pregnancy, only one registered an improvement of symptoms during gestation, while the rest had no significant changes, and their pregnancies needed to be monitored as high risk. Regarding pregnancy complications, only two patients had a pre-term delivery. Both patients had not only EGE, but a remarkable obstetrical history, that could slightly complicate the interpretation of the events that occurred in their pregnancies. More studies are necessary to demonstrate if EGE is connected with pre-term onset of labor. It's not easy to define the reasons of some patient's pre term labor, and we could suppose that a combination of different mechanisms leads to this condition of breakdown of maternal-fetal tolerance. Nevertheless, we know that spontaneous preterm labor is a syndrome attributable to multiple pathologic processes and most of them are yet to be understood. However, we cannot exclude that EGE is related to late preterm delivery. We hope that this review will provide some measures of guidance to those clinicians who must satisfy the questions of young female patients diagnosed with EGE and wishing for a pregnancy.