Attempted vaginal birth after cesarean: assessment of morbidity and predictors of success / Parto tras cesárea anterior: análisis de la morbimortalidad materno-fetal

Objective: Determining the appropriate approach for delivery after previous cesarean is a very controversial issue. Our objective was to establish whether pregnant women with a previous cesarean have an increased maternal and fetal morbidity and mortality after attempting vaginal delivery as well as to determine which factors may influence the achievement of a vaginal birth after cesarean. Materials and methods: A retrospective observational cohort study including 390 patients (196 cesarean group and 194 nulliparous group) was carried out. We compared neonatal and maternal outcomes between groups. Afterward, a multivariate logistic regression was applied for our second objective. Results: There were higher rates of uterine rupture (2% vs. 0%, p: 0.045) and puerperal hemorrhage (9.7% vs. 3.1%, p: 0.008) in the cesarean group and lower vaginal delivery rate (58.2% vs. 77.8%, p < 0.0005). We found that the induced onset of labor (OR = 2.9) and new born weight (OR = 1.0001) were associated with an increased risk of cesarean section. Conclusions: Our findings stress the need for further investigations in this field, which might provide a basis for a better management of patients with a previous cesarean.

Objetivo: Determinar el abordaje adecuado del tipo de parto tras una cesárea previa es un tema muy controvertido. Nuestro objetivo fue establecer si las gestantes con cesárea previa presentan mayor morbimortalidad materna y fetal tras intentar parto vaginal, así como determinar qué factores pueden influir en conseguir un parto vaginal posterior a la cesárea. Material y métodos: Estudio observacional de cohortes retrospectivo incluyendo 390 pacientes (196 con cesárea previa, 194 nulíparas). Comparamos los datos sobre los resultados neonatales y maternos. Posteriormente se aplicó un modelo de regresión logística multivariante. Resultados: Hubo mayores tasas de ruptura uterina (2% vs. 0%; p = 0.045) y hemorragia puerperal (9.7% vs. 3.1%, p: 0.008) en el grupo de cesárea anterior, así como una tasa de parto vaginal mas baja (58.2% vs. 77.8%, p < 0.0005). La inducción del parto (OR = 2,9) y el peso del recién nacido (OR = 1.0001) se asociaron a un mayor riesgo de cesárea. Conclusión: La probabilidad de parto vaginal en estas pacientes disminuye cuanto mayor sea el peso del recién nacido y con partos inducidos.

Risk Factors Associated with Uterine Rupture and Dehiscence: A Cross-Sectional Canadian Study / Fatores de risco associados à ruptura uterina e deiscência: Um estudo transversal canadense

Abstract Objective To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence. Methods Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada. Results There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p=0.02), elevated maternal body mass index (BMI; OR: 3.4; p=0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p=0.05) and 5-minute low Apgar score (OR: 5.9; p<0.001). Uterine rupture was associated with preterm deliveries (36.5 ± 4.9 versus 38.2 ± 2.9; p=0.006), postpartum hemorrhage (OR: 13.9; p<0.001), hysterectomy (OR: 23.0; p=0.002), and stillbirth (OR: 8.2; p<0.001). There were no associations between uterine rupture and maternal age, gestational age, onset of labor, spontaneous or artificial rupture of membranes, use of oxytocin, type of uterine incision, and birthweight. Conclusion This large cohort demonstrated that there are different risk factors associated with either uterine rupture or dehiscence. Uterine rupture still represents a great threat to fetal-maternal health and, differently from the common belief, uterine dehiscence can also compromise perinatal outcomes.

Resumo Objetivo Comparar os fatores de risco maternos e perinatais associados à ruptura uterina completa e deiscência uterina. Métodos Estudo transversal de pacientes com ruptura/deiscência uterina no período de janeiro de 1998 a dezembro de 2017 (30 anos) internadas na Unidade de Parto de um hospital universitário terciário no Canadá. Resultados Ocorreram 174 (0,1%) casos de transtorno uterino (29 rupturas e 145 deiscências) em 169.356 partos. Houve associações entre deiscência e multiparidade (razão de chances [RC]: 3,2; p=0,02), índice demassa corporal (IMC)materno elevado (RC: 3,4; p=0,02), tentativa de parto vaginal após cesariana (RC: 2,9; p=0,05) e baixa pontuação Apgar em 5minutos (RC: 5,9; p<0,001). A ruptura uterina foi associada a partos prematuros (36,5 ± 4,9 versus 38,2 ± 2,9; p=0,006), hemorragia pós-parto (RC: 13,9; p<0,001), histerectomia (RC: 23,0; p=0,002) e natimorto (RC: 8,2; p<0,001). Não houve associação entre ruptura uterina e idade materna, idade gestacional, início do trabalho de parto, ruptura espontânea ou artificial de membranas, uso de ocitocina, tipo de incisão uterina e peso ao nascer. Conclusão Esta grande coorte demonstrou que existem diferentes fatores de risco associados à ruptura ou à deiscência uterina. A ruptura uterina ainda representa uma grande ameaça à saúde materno-fetal e, diferentemente da crença comum, a deiscência uterina também pode comprometer os desfechos perinatais.

Rotura e deiscência de cicatriz uterina: estudo de casos em uma maternidade de baixo risco do sudeste brasileiro / Rupture and dehiscence of uterine scar: cases study at a low-risk maternity in the Brazilian Southeast

OBJETIVO: Analisar os casos de rotura uterina e deiscência de cicatriz uterina ocorridos em uma maternidade de baixo risco e apontar possibilidades de aprimoramento na abordagem dessas complicações. MÉTODOS: Foi realizado um estudo descritivo em uma maternidade de baixo risco com 30 leitos, que presta assistência às usuárias do sistema público de saúde. A investigação foi realizada por meio de busca dos casos em livros de registros de sala de parto e posterior leitura dos prontuários para coleta dos dados. As informações foram inseridas em formulário previamente elaborado para este estudo. Foram incluídos os casos de rotura uterina e deiscência de cicatriz uterina diagnosticados no período de 1998 a 2012, avaliados incidência, aspectos relacionados aos fatores de risco e diagnóstico, associação com o uso de misoprostol e ocitocina e desfechos observados. RESULTADOS: No período mencionado foram registrados 39.206 partos nessa instituição. A cesárea foi a conduta adotada em 10 mil partos, o que equivale a uma taxa de 25,5%. Foram identificados 12 casos de rotura uterina e 16 de deiscência de cicatriz uterina. Os resultados mais relevantes foram a alta mortalidade perinatal associada à rotura uterina e o insucesso no diagnóstico da complicação. Não foi possível demonstrar associações com o uso de misoprostol ou ocitocina. CONCLUSÃO: Os desfechos adversos da rotura uterina podem ser minimizados se esforços forem direcionados para melhorar o desempenho diagnóstico das equipes assistentes. .

PURPOSE: To evaluate the cases of uterine rupture and dehiscence of the uterine scar at a low-risk maternity and to point out possibilities for an improved approach to these complications. METHODS: A descriptive study was conducted at a 30-bed low-risk maternity hospital that provides care to users of the public health system. The investigation was carried out by searching for cases in the delivery room registry book and later reading the medical records in order to obtain the data. The information was inserted on a form previously elaborated for this study. Cases of uterine rupure and dehiscence of the uterine scar diagnosed from 1998 to 2012 were included, with the determination of incidence, aspects related to risk factors and diagnosis, association with the use of misoprostol and oxytocin, and the outcomes observed. RESULTS: A total of 39,206 deliveries were performed in this maternity during the study period, with 12 cases of uterine rupture and 16 cases of dehiscence of uterine scar being observed. The most relevant results were a high perinatal mortality associated with uterine rupture and the unsuccessful diagnosis of this complications. It was not possible to demonstrate an association with the use of misoprostol or oxytocin. CONCLUSION: The adverse outcomes of uterine rupture could be minimized if efforts were directed at improving the diagnostic performance of the assisting teams. .

Trends in frequency and causes of uterine rupture in a tertiary care center between year 2001 and 2011

To analyze the trends in frequency and causes of uterine rupture between year 2001 and 2011. An observational study was done at Lady Reading Hospital Peshawar in year 2011 from 1[st] January 2011 to 31[st] December 2011 to analyze the trends in the frequency and causes of ruptured uterus and data was entered in a structured proforma. Same proforma was used to collect data of ruptured uterus in year 2001 from delivery registers, operation room record and patient charts. In year 2011 there were total 5313 deliveries including 1229 caesarean sections. Mean age was 35.0+2.0 years. Total 56 cases of ruptured uterus were noted. Frequency of ruptured uterus was 1.05%. Sixty% patients had previous caesarean section. While in year 2001 there ware total 3885 deliveries including 716 caesarean sections. Mean age was 33.0 +/- 2.0 years. Total 25 [0.64%] cases of ruptured uterus were noted. Obstructed labour in grand multigravidas was the commonest cause of ruptured uterus. A 3 fold increase in ruptured uterus was seen in association with scarred uterus i.e. in year 2001, 12% patient with ruptured uterus had scarred uterus while in year 2011, 35.7% cases had scarred uterus. Increase trend in frequency of uterine rupture was noted between year 2001 and year 2011. Moreover uterine rupture was more common in scarred uterus following trial of vaginal delivery compared with unscarred uterus in year 2011

Uterine rupture revisited: predisposing factors, clinical features, management and outcomes from a tertiary care center in Turkey

To determine the predisposing factors, modes of clinical presentation, management modalities and fetomaternal outcomes of uterine rupture cases at a tertiary care center in Turkey. A 14-year retrospective analysis of 61 gravid [> 20 weeks of gestation] uterine rupture cases between January 1998 to March 2012 was carried out. The incidence of ruptured uteri was calculated to be 0.116%. Persistence for vaginal delivery after cesarean was the most common cause of uterine rupture [31.1%]. Ablatio placenta was the most common co-existent obstetric pathology [4.9%]. Bleeding was the main symptom at presentation [44.3%] and complete type of uterine rupture [93.4%] was more likely to occur. Isthmus was the most vulnerable part of uterus [39.3%] for rupture. The longer the interval between rupture and surgical intervention, the longer the duration of hospitalization was. Older patients with increased number of previous pregnancies were likely to have longer hospitalization periods. Rupture of gravid uterus brings about potentially hazardous risks. Regular antenatal care, hospital deliveries and vigilance during labor with quick referral to a well-equipped center may reduce the incidence of this condition

Ruptura uterina / Uterine rupture

A ruptura uterina ocorre de forma relativamente rara na obstetrícia, com incidência deum em 585 até um em 6673 partos e apresenta alta morbimortalidade materna e fetal.O principal fator de risco é a presença de cicatriz no útero causada, na maioria doscasos, por cesariana, e raramente por outras cirurgias uterinas. Há também causas nãoobstétricas, como violência e acidentes. Sua ocorrência é maior no terceiro trimestre,no pré-parto, intraparto ou pós-parto. A ruptura uterina apresenta-se com dor abdominalintensa, de início súbito, com dificuldade de ausculta de sons cardíacos fetais, ecessação das contrações uterinas, com sangramento vaginal e choque. O risco para apaciente e o feto é maior quanto mais demorado é o diagnóstico. O tratamento é cirúrgicoe as prioridades são a retirada rápida do feto da cavidade peritoneal e a correçãoda hemorragia, quando o feto e a placenta já foram retirados. A ruptura uterina emgravidez após cesariana prévia representa preocupação especial. Entretanto, há grandeprobabilidade de sucesso no parto vaginal quando há seleção adequada das pacientes,uso cauteloso de ocitócicos e monitoramento vigilante.

Uterine rupture is a relatively rare occurrence in obstetrician which incidence was describedbetween one for 585 labors to one for 6673 labors and have high maternal andfetus morbidity and mortality. The main risk factor is a uterine scar, most of then causedby a cesarean section and seldom by others uterine surgeries and non-obstetrics causes,like accidents and violence. It usually occur in the third trimester, during the prodromallabor, the labor or at the time of delivery. The signs and symptoms are acute abdominalpain without contraction, noiseless fetus beating, vaginal bleeding and shock. The riskincrease how later the diagnosis is made. It has a surgical treatment and the priorities arethe remotion of the fetus and placenta from the abdominal cavity and to stop the bleedingafter it has been done. The main concern between the obstetricians is the uterine rupturein pregnant women who has already had a cesarean section, but if the patients werecarefully chosen and assisted, and the oxytocin were appropriated used, there is a hugechance to have a successful vaginal labor.

Clinical analysis of 40 cases of uterine rupture at Durgapur Subdivisional Hospital: an observational study.

Forty cases of uterine rupture that occurred at Durgapur Subdivisional Hospital during 5 years period from January, 1995 to December, 1999 were analysed for clinical observations. The incidence was 1:273; 77.5% were spontaneous, 15% were traumatic, and 7.5% had scar rupture. It was complete in 92.5% cases. Disproportion was responsible in 40% cases and malpresentation in 27.5% cases. Total hysterectomy was done in 30% cases, subtotal in 27.5% cases and rent repair in 42.5% of cases. Overall maternal mortality was 30% of which highest (41.2%) found in rent repair and lowest (16.6%) in total hysterectomy.

Fetomaternal outcome of cases referred to Nishtar Hospital, Multan

To determine feto-maternal outcome and to identify factors associated with adverse obstetric outcome. This descriptive case series study was conducted in the Department of Obstetrics and Gynecology Unit lit. Nishtar Hospital, Multan. During the period from 18[th] July 2007 to 17[th] January 2008. One hundred patients who were admitted through emergency after a trial of labour by traditional birth attendants [TBAs], lady health visitors [LHVs] or doctors at home or private clinics were managed and followed in the department of gynecology and obstetrics Unit-II. Mean age of the patients was 27.28 +/- 5.13 years. Fever was the most common complication found in 69[69%] patients. Antepartum hemorrhage occurred in 22 [22%] cases. Postpartum hemorrhage complicated 46 [46%] pregnancies leading, to shock in 51 [51%] patients. Oligohydramnios was observed in 35 [35%] patients and uterine rupture in 5[5%] cases. There were 3 [3%] maternal deaths. Low Apgar score was observed in 36 [36%] patients. Meconium staining was common in 34 [34%] cases and 34 [34%] patients needed for hospitalization. Fetal growth restriction was found in 23 [23%] patients. There were 23 [23%] fetal deaths. Postpartum hemorrhage led to maternal and fetal complications in majority of the patients which was not handled

Ruptured uterus: an ongoing tragedy of motherhood.

This study aimed to determine the frequency of ruptured uterus, possible aetiologic factors, foetomaternal out come and changes in obstetric care proposed to reduce this catastrophy. From September 1994 to September 1999 in Dhaka Medical College Hospital 39,782 deliveries occurred. All delivery records were reviewed and rupture uterus cases were identified. The result was compared with studies carried out in home and abroad. During the five years period among 39,782 deliveries 424 cases were of rupture uterus with a frequency of 1/93 deliveries. Eighty three percent rupture occurred in intact uterus and 17% occurred in uteri scarred by caesarian section. Common contributing factors were -prolonged/obstructed labour, grand multiparity, injudicious use of uterine stimulants, mismanaged labour by traditional birth attendant, delayed referral to well equipped centre, poor communication, poverty and ignorance.

Management of ruptured uterus

A total of 22 cases of ruptured uterus were admitted and managed in the Department of Gynaecology and Obstetrics in Bolan Medical College Quetta during the period between 1 st October 1992 - 30th September 1993. The aim of this study was to determine the occurence of this condition, the risk factors, the appropriate mode of management and to determine the maternal and foetal outcomes. During this period the occurence of uterine ruptures was 0.36% of total obstetric admissions and 0.44% of total deliveries. All the patients were nonbooked with no previous antenatal care. Most were illiterate and came from far flung areas of Baluchistan. The predisposing factors in our series included the injudicious use of oxytocin, cephalopelvic disproportion, dehiscence of previous scar and placenta acretta. 86.9% of the patients were treated by repair of the uterus with tubal ligation, 9.1% were treated by repair of the uterus without tuba] ligation and 4.5% by Caesarean hysterectomy. The maternal mortality rate was 2.1% and perinatal mortality was 100%

Rotura uterina espontánea / Spontaneous uterine rupture

Antecedentes: La rotura uterina espontánea es un accidente infrecuente pero grave. Materiales y Métodos: Estudiamos la incidencia de esa complicación del parto en un período de 5 años (1-I-90-31-XII-94) en la Maternidad Nuestra Señora de la Altagracia, Santo Domingo, República Dominicana. Resultados: Durante el período de estudio se produjeron un total de 117,070 partos y hubo 25 casos de rotura uterina espontánea para una incidencia de 1/4683 partos o 0.2//. De los 25 casos solo pudimos estudiar 18. De estos 18 casos fallecieron 4 madres para una mortalidad de 22.2//. De los 18 recién nacidos fallecieron 9, para una mortalidad de 50//. La multiparidad (5 embarazos o >) estuvo asociada a un 50// de los casos y fue el actor mas frecuentemente asociado. Conclusión: La rotura uterina espontánea es un accidente raro en nuestro medio con una alta mortalidad para el producto y su madre

Obstetrical injuries a study at Jinnah postgraduate medical center, Karachi

Seventy one cases of obstetrical injuries, seen during a period of 1 1/2 years, were analysed. Twenty three [32.4%] cases had rupture of uterus, 16 [2.5%] developed vesico-vaginal fistulae following prolonged and obstructed labour. In 13 [18.4%] cases, vulvo-vaginal haematoma was seen. Four [5.6%] patients had recto-vaginal fistulae and 7 [9.9%] suffered from 3rd degree perineal tear. 1.4% i.e. one case came with inversion of uterus

Ruptura del utero gravido en el Hospital General de Medellin: un estudio de 10 anos 1978-1987 / Gravid uterus rupture in Hospital General de Medellin: study of 10 years 1978-1987

Se realizo un estudio descriptivo, retrospectivo para evaluar la incidencia de ruptura uterina en el Hospital General de Medellin, en un periodo de 10 anos. Se presentaron 42 casos para una proporción acumulada de 1:4466 partos y una tasa de incidencia de 26.59 casos por 100.000 partos. Los 2 principales factores de riesgo fueron el antecedente de cicatriz uterina en el 50% de las pacientes y el uso de oxitocina exogena en el 30.9%. El 73.8% de las pacientes presento algunos de los factores de riesgo estudiados y entre las posibles causas, el trabajo de parto prolongado y la distocia mecanica, fueron las dos mas importantes en su orden. El tratamiento consistio en histerectomia total en le 47.6% e histerorrafia en una proporción igual de las pacientes. Dos pacientes (4.7%) fueron solamente observadas. Como tratamiento complementario se realizo hemotransfusion en el 73.8% de los casos. entre otros. No hubo muertes maternas; sin embargo, la mortalidad fetal fue de 64.2% y la perinatal del 69%. Solo el 27.5% de las muertes perinatales ocurrieron en el grupo de bajo peso (2.500 gr.) El 95% de los casos ocurrieron despues del inicio del trabajo de parto y el 4.7% ( dos casos) antes; ambos causados por acretismo placentario con perforación del peritoneo visceral

Ruptura Uterina: revisión de 5 años 1981-1985 en el Hospital de la Mujer / Uterine rupture: 5 year review at the Hospital de la Mujer

Se revisaron 20 casos de ruptura uterina atendidos en el Hospital de la Mujer de la S. S., en el periodo del 10. de enero de 1981 al 31 de diciembre de 1985. Se encontró un caso por cada 2,717 partos atendidos. La edad promedio en que ocurrió el accidente fue de 30 años, y la multiparidad fue factor predisponente. La cesárea previa se encontró en 50% de los casos y en 100% de éstos se tuvo ruptura uterina. Se clasificaron las causas en espontáneas, traumáticas e iatrogénicas; se analizó la profundidad, localización y cronología. La duración promedio del trabajo de parto en el momento de la ruptura fue de 10.38 horas. La presentación cefálica fue la más frecuente, seguida por el sufrimiento fetal el signo principal. el procedimiento anestseico predominante fue el bloqueo peridural. Se resolvieron cinco caoss por vía vaginal (25%), detectándose la ruptura al efectuarse revisión de cavidad. La mortalidad materna fue de 10% (2 casos) de los cuales solamente 1 (5%) fue atribuido directamente a la ruptura, la mortalidad fetal corregida fue de 15%

Ruptura uterina en gestantes en el Hospital de Apoyo Cayetano Heredia entre los años 1970-1985 / Uterine rupture in pregnants in the Hospital de Apoyo Cayetano Heredia during 1970-1985

Se estudiaron 61 casos de ruptura uterina, ocurridas en el Hospital de Apoyo Cayetano Heredia, desde enero de 1970 hasta diciembre de 1985, siendo la incidencia de 1 ruptura por cada 677 partos. Se estudiaron las siguientes variables: procedencia, grado de instrucción, edad, pariedad, control prenatal, antecedentes obstétricos, tiempo gestacional, trabajo de parto, vía y tipo de parto, tipo y sitio anatómico de ruptura, cuadro clínico y tratamiento, así como la morbimortalidad materna y fetal. Se hizo su clasificación de acuerdo a su etiología los resultados obtenidos fueron comparados con trabajos realizados a nivel nacional y mundial. De las variables enunciadas, antenido relevancia el elevado número de casos de ruptura uterina a edades y paridades bajas pero en úteros con cicatriz previa, así como la elevada frecuencia en pacientes sin asistencia prenatal. Sin embargo, el diagnóstico precoz y el tratamiento adecuado permitieron una sobrevivencia fetal del 67 por ciento, con una mortalidad materna del 0.0 por ciento

Rotura uterina: evaluación y estado actual del problema / Uterine rupture: evaluation and actual status of the problem

Se estudian 63 casos de rotura uterina (R.U.) ocurridos en el Hospital San Juan de Dios entre 1961 y 1985, analizándose una serie de parámetros. Resalta que este accidente sobrevino en un número significativo de primíparas. Uno de los factores predisponentes más importantes resultó ser el antecedente de cicatriz uterina, especialmente de operación cesárea, y la manifestación clínica más relevante, la hemorragia. Hubo una mortalidad materna de 12,7%, y perinatal de 24,0%. Se observó una tendencia al aumento de la incidencia de este accidente en los últimos años, al parecer en relación con la tendencia actual al incremento de la operación cesárea

Incidencia de la rotura del útero durante el trabajo de parto en algunas comunidades africanas: Angola, Benin y Etiopía / Incidence of the rupture of the uterus during labor in some African communities: Angola, Benin and Ethiopy

Se realiza un estudio en varios hospitales de países de Africa (Angola, Benin y Etiopía), sobre la incidencia de la rotura uterina en estas comunidades en el período de 1973-1980. Se analizan factores como la edad, paridad, causa, tratamiento utilizado, así como la mortalidad materna y fetal. Se comparan estos datos estadísticos con los de la literatura médica mundial y se exponen algunos factores socioculturales comunes en estos países