Uterine rupture: differences between a scarred and an unscarred uterus

OBJECTIVES: This study aimed to compare risk factors, site of rupture, and outcome of uterine rupture among patients with a scarred versus an unscarred uterus.Study design We conducted a comparison between all cases of uterine rupture (n=53) in women with a scarred versus an unscarred uterus, occurring between January 1988 and July 2002. RESULTS: During the study period, there were ruptures among 26 patients with a scarred uterus and 27 patients without a uterine scar. No significant differences were noted between the scarred and unscarred groups while comparing risk factors such as birth order, birth weight, hydramnios, oxytocin induction, diabetes, and malpresentation. The main site of involvement in both groups was the lower uterine segment representing 92.6% of the ruptures in the unscarred group and 92.3% of the ruptures in the scarred uterus group. Cervical involvement was significantly more common among patients without a previous uterine scar (33.3% vs 7.7%; odds ratio [OR]=6.0, 95% CI, 1.16-31.23, P=.04). Conversely, uterus corpus involvement did not differ between the groups. Perinatal mortality did not differ between the groups. In addition, no significant differences were noted regarding maternal morbidity such as the need for hysterectomy, blood transfusion, or length of hospitalization. CONCLUSION: Although cervical involvement was significantly more prevalent in the rupture of an unscarred uterus, no significant differences in maternal or perinatal morbidity were noted between rupture of a scarred versus an unscarred uterus.     

Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study

OBJECTIVE: This study was undertaken to determine whether adolescent pregnancy is associated with increased risks of adverse pregnancy outcomes. STUDY DESIGN: We studied 854,377 Latin American women who were younger than 25 years during 1985 through 2003 using information recorded in the Perinatal Information System database of the Latin American Center for Perinatology and Human Development, Montevideo, Uruguay. Adjusted odds ratios were obtained through logistic regression analysis. RESULTS: After an adjustment for 16 major confounding factors, adolescents aged 15 years or younger had higher risks for maternal death, early neonatal death, and anemia compared with women aged 20 to 24 years. Moreover, all age groups of adolescents had higher risks for postpartum hemorrhage, puerperal endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants. All adolescent mothers had lower risks for cesarean delivery, third-trimester bleeding, and gestational diabetes. CONCLUSION: In Latin America, adolescent pregnancy is independently associated with increased risks of adverse pregnancy outcomes.     

Anesthetic considerations in pregnant women at advanced maternal age

Objective: To evaluate anesthetic considerations in pregnancy for women at advanced maternal age (≥?40 years).

Methods: A retrospective cohort study of laboring women aged 40 years or above comparing women aged 40–44 years old with those aged ≥45 years, in a single, tertiary, university affiliated medical center.

Results: Overall, 39?006 women delivered in our institution during the study period, of them 376 (1%) were eligible for analysis: 278 (74%) were 40–44 years old (control group) and 98 (26%) were 45 years old and above (study group). No differences were found between the groups with regards to analgesia or anesthesia management during labor. Differences were found in obstetrical characteristics such as higher rates of primiparity, preeclampsia, need for magnesium sulphate therapy and chronic hypertension among parturients aged ≥45 years. Of note, parturients aged ≥?45 years had an approximately eight-fold risk for postpartum hemorrhage.

Conclusion: Anesthesia management of parturients aged 45 years and above is comparable to the management of women aged 40–44 years. However, parturients ≥45 are more susceptible to bleeding complications.     

Examining the role and relevance of the critical analysis and comparison of cesarean section rates in a changing world

Cesarean section (CS) is one of the most commonly performed surgical operations in the world and has resulted in improved maternal and neonatal morbidity and mortality rates internationally. However, concerns have been raised regarding the ever increasing CS rates to what has been described as ‘epidemic’ proportions. Global CS rates have increased from 6.7% in 1990 to 19.1% in 2014. However, there is a vast variation in the CS rates between countries with CS rates of 44.3% reported across Latin America & the Caribbean and CS rates as low as 4.1% in central and West Africa. There is much controversy regarding the optimal figure for CS in a population. The optimal CS rates for a population have been recommend in various studies, ranging from 10% to 19%, above which no reported improvement in maternal and neonatal mortality rates is observed. This review examines the evolution of the changing indications for CS and increasing CS rates in a world where family sizes are reducing and maternal age at first pregnancy is increasing. Efforts must be made to agree on an appropriate classification system whereby CS rates can be compared accurately between units and countries as a useful tool to audit and monitor our practice. Obstetricians should consider the indications for each CS performed, be conscious of the CS rate in our own countries and institutions and most importantly, be cognizant of how the CS rate impacts the maternal and perinatal morbidity and mortality rates and adjust our practice accordingly, to minimize harm.     

瘢痕子宫再次妊娠剖宫产手术时机及并发症

随着全面“二孩政策”实施及宫腹腔镜的广泛应用,瘢痕子宫产妇再次妊娠率逐年升高,多半患者仍选择剖宫产分娩。手术并发症、合并症随之增高。掌握适时终止妊娠的时机和分娩方式,减少并发症是产科医生面临的重要课题。文章就瘢痕子宫再次妊娠剖宫产的手术时机及并发症进行了综合分析。     

Perinatal outcome in women with severe chronic hypertension during the second half of pregnancy.

OBJECTIVES: To determine the perinatal outcome associated with severe chronic hypertension (SCH) in pregnancies of > or =20 weeks' gestation. METHODS: A retrospective analysis of data obtained prospectively of patients with SCH (> or =160/110 mmHg) who were hospitalized and delivered during a 5-year period. Each patient received intensive monitoring of the clinical status throughout the hospitalization (mother, fetus and neonates). Antihypertensive drugs were used for blood pressure > or =160/110 mmHg, glucocorticoids for pregnancies of 24-34 weeks and magnesium sulfate for women with superimposed pre-eclampsia (SPE). The main outcome measures were fetal and neonatal deaths, fetal growth restriction (FGR), major neonatal complications and length of stay in the neonatal intensive care unit (NICU). RESULTS: Of 154 women studied, 78% developed SPE and the mean week's gestation at delivery was 34.5+/-4.6. The average birth weight was 2329+/-1011 g. and the FGR was 18.5%. Four patients had a dead fetus at the time of admission, eight during the hospitalization and there were six neonatal deaths resulting in perinatal mortality of 11.4%. Thirty-eight babies were admitted to the NICU, average stay was 14.8 days. The most common contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. CONCLUSIONS: This study found that the neonatal outcomes in pregnancy with SCH are better than the historical experience, but preterm deliveries, cesarean section, SPE, abruptions and total perinatal mortality remains very high.     

Neonatal outcomes of successful VBAC among obese and super-obese mothers

Objective: We sought to evaluate neonatal morbidity and mortality among women who experienced successful vaginal births after previous cesarean delivery (VBAC) by obesity subtypes. Methods: Missouri maternally linked cohort data files were utilized. Analyses were restricted to successful singleton VBACs. Main study outcomes were neonatal death and neonatal morbidity. Risk estimates were obtained using logistic and hazards regression modeling. Results: A total of 30,017 singleton births met inclusion criteria. The prevalence of VBAC was 2.3%. The neonatal death rate (per 1000) by maternal obesity subtype was 4.1 for moderate, 3.2 for severe, 4.5 for extreme and 14.3 for super-obese. The overall risk for neonatal morbidity was 56% greater among obese women when compared with normal weight women, with risk estimates increased incrementally with ascending body mass index (BMI) (p for trend < 0.01). Conclusion: Infants of obese women undergoing successful VBAC are at elevated risk for neonatal morbidity, and the risk increases progressively with ascending BMI.     

Comparison of Fetomaternal Outcome Between Planned Vaginal Delivery and Planned Cesarean Section in Women with Eclampsia: Observational Study

ObjectiveThe route of termination of pregnancy in eclampsia is not clearly established. This study aims to compare the fetomaternal outcome between planned vaginal delivery and planned cesarean section in women with eclampsia after 34 weeks of gestation.MethodsThis prospective observational study was conducted in the department of Obstetrics and Gynecology, Midnapore Medical College, West Bengal, India. 182 women with eclampsia carrying 34 weeks or more gestation were allocated to either cesarean(CD) or vaginal delivery (VD) group. The primary measure of outcome was severe maternal outcome. Secondary measures of outcome were perinatal mortality and morbidity.ResultsOf the 62 women allocated in vaginal delivery (VD) group, 60 women (32.97%) had vaginal delivery and 122 (67.03%) had undergone cesarean delivery (CD). Severe maternal outcome was more common in VD group in comparison with CD group (72.5% vs 27.5%, P < 0.00001 RR 2.64 OR 6.98). Perinatal outcome in relation to Apgar score at 5 min, still birth was better in CD group than VD group. Perinatal death was higher in VD group when compared with CD group (25.8%; vs. 8.33%; P = 0.002, RR 3.1 OR 3.83)ConclusionThere is increasing trend of delivering the eclampsia mother at > 34 weeks of gestation by cesarean section instead of inducing labor and delivering vaginally. Cesarean section when chosen as method of delivery does not increase morbidity or mortality.     

Cesarean Section Rates and Maternal and Neonatal Mortality in Low‐, Medium‐, and High‐Income Countries: An Ecological Study

ABSTRACT: Background: Cesarean section rates show a wide variation among countries in the world, ranging from 0.4 to 40 percent, and a continuous rise in the trend has been observed in the past 30 years. Our aim was to explore the association of cesarean section rates of different countries with their maternal and neonatal mortality and to test the hypothesis that in low‐income countries, increasing cesarean section rates were associated with reductions in both outcomes, whereas in high‐income countries, such association did not exist. Methods: We performed a cross‐sectional multigroup ecological study using data from 119 countries from 1991 to 2003. These countries were classified into 3 categories: low‐income (59 countries), medium‐income (31 countries), and high‐income (29 countries) countries according to an international classification. We assessed the ecological association between national cesarean section rates and maternal and neonatal mortality by fitting multiple linear regression models. Results: Median cesarean section rates were lower in low‐income than in medium‐ and high‐income countries. Seventy‐six percent of the low‐income countries, 16 percent of the medium‐income countries, and 3 percent of high‐income countries showed cesarean section rates between 0 and 10 percent. Three percent of low‐income countries, 36 percent of medium‐income countries, and 31 percent of high‐income countries showed cesarean section rates above 20 percent. In low‐income countries, a negative and statistically significant linear correlation was observed between cesarean section rates and neonatal mortality and between cesarean section rates and maternal mortality. No association was observed in medium‐ and high‐income countries for either neonatal mortality or maternal mortality. Conclusions: No association between cesarean section rates and maternal or neonatal mortality was shown in medium‐ and high‐income countries. Thus, it becomes relevant for future good‐quality research to assess the effect of the high figures of cesarean section rates on maternal and neonatal morbidity. For low‐income countries, and on confirmation by further research, making cesarean section available for high‐risk pregnancies could contribute to improve maternal and neonatal outcomes, whereas a system of care with cesarean section rates below 10 percent would be unlikely to cover their needs. (BIRTH 33:4 December 2006)     

Prevalence of hypertensive disorders in women after preeclamptic pregnancy associated with decidual vasculopathy

Objective: A subgroup of preeclamptic women has spiral artery lesions termed decidual vasculopathy (DV) which relate to worse clinical outcome. We aimed to determine whether a history of preeclampsia (PE) with DV is associated with adverse overall and future pregnancy outcome, including increased recurrence risk of hypertensive diseases of pregnancy. Methods: Via posted survey women with PE and DV (DV positive) in the index pregnancy were compared to those without the lesions (DV negative) on overall and future pregnancy outcome. Results: DV positive cases showed a higher incidence of chronic hypertension both preconceptionally and at time of survey, adjusted odds ratio 4.8 (2.0–11.9). The DV positive group had a higher overall incidence of pregnancies with gestational hypertension (22% vs 13%, p?=?0.04), preterm birth (59% vs 45%, p?=?0.02) and a lower birth weight centile (30 vs 39, p?=?0.02). There was no difference in outcome of future pregnancies, irrespective of the use of prophylactic aspirin. Conclusion: Women with DV-associated PE have a higher overall incidence of adverse obstetric outcome and of chronic hypertension, indicating an underlying vascular pathology, putting them at risk for pregnancy and cardiovascular complications. These women constitute a target group for counseling, monitoring and possibly lifestyle or pharmacological interventions.     

Neonatal complications of term pregnancy: rates by gestational age increase in a continuous, not threshold, fashion

OBJECTIVE: The purpose of this study was to determine whether, when, and how rates of short-term neonatal complications increase beyond 37 weeks of gestation. STUDY DESIGN: A retrospective cohort study was conducted of all low-risk, term, cephalic, and singleton births that were delivered at the University of California, San Francisco, between 1976 and 2001. Primary outcomes included neonatal umbilical artery pH, umbilical artery base excess, the presence of meconium, macrosomia, 5-minute Apgar scores, and admission to the intensive care nursery. Multivariate analyses were performed that controlled for maternal ethnicity, weight, age, socioeconomic status, and obstetric history. RESULTS: Among the 32,679 women who were delivered at > or =37 completed weeks of gestation, the rates of umbilical artery pH <7.0, umbilical artery base excess less than -12 increased beyond 40 weeks of gestation, and the presence of meconium increased beyond 39 weeks of gestation (chi-squared test; P < .001). These outcomes continued to increase in each subsequent week, and these findings persisted when they were controlled for potential confounders in multivariate models. CONCLUSION: We found that the rates of immediate neonatal morbidity increase with increasing gestational age. Accurate determination of these rates is important in the determination of gestational age at which the risk of continuing the pregnancy outweighs the risk of induction of labor.     

Cesarean section — A review of two annual periods separated by a ten-year interval

In the Soroka Medical Center in Beer-Sheba during the two annual periods 1969 and 1979, 693 cesarean sections were performed, of which 633 are presented. The main reasons for the rise in cesarean section rate from 2.6% in 1969 to 8.0% in 1979 were evaluated. Cesarean sections were performed more often for fetal indications during 1979 than in 1969, reflecting the change in our approach to the management of the fetus at risk. The increase in the cesarean section rate was concomitant with a drop in the perinatal mortality from 23/1000 in 1969 to 13.1/1000 in 1979.     

Evaluation of outcomes associated with trial of labor after cesarean delivery after a change in clinical practice guidelines in an academic hospital

Objective: To evaluate maternal–neonatal morbidity for women undergoing trial of labor after cesarean (TOLAC) following clinical practice changes based upon ACOG’s 2010 VBAC guideline.

Study design: Four-year retrospective cohort analysis around implementation of a hospital guideline in women undergoing TOLAC with a live, cephalic, singleton without lethal anomaly ≥24 weeks and ≥1 prior cesarean. Maternal–neonatal outcomes pre- and post-guideline implementation were compared. Primary outcome was composite maternal morbidity (uterine rupture or dehiscence, hysterectomy, transfusion, thromboembolism, operative/delivery injury, chorioamnionitis/endometritis, shoulder dystocia, death). Secondary outcomes included neonatal morbidity.

Results: Four hundred and fifty women underwent TOLAC before and 781 after guideline implementation. Post-guideline, there was a significant increase in age, body mass index, labor length, women with >1 cesarean, comorbid condition and induced labor. Composite maternal morbidity was significantly higher after the guideline (13.78% versus 18.82%, p?=?0.02), possibly due to an increased rate of chorioamnionitis/endometritis, which was no longer significant after control for potential confounders in multivariable analysis. There were no differences in neonatal outcomes. Vaginal birth after cesarean (VBAC) success rates were unchanged (78.9% before versus 78.1% after, p?=?0.75), however hospital VBAC rates increased after the guideline (26% versus 33%, p?Conclusions: Adoption of ACOG’s TOLAC practice changes can increase VBAC rates without increasing maternal–neonatal morbidity from TOLAC.     

Subsequent pregnancy outcome after preterm breech delivery,a population based cohort study

Objective: The objective of this study is to investigate the effect of the mode of delivery in women with preterm breech presentation on neonatal and maternal outcome in the subsequent pregnancy.

Methods: Nationwide population-based cohort study in the Netherlands of women with a preterm breech delivery and a subsequent delivery in the years 1999–2007. We compared planned caesarean section versus planned vaginal delivery for perinatal outcomes in both pregnancies.

Results: We identified 1543 women in the study period, of whom 259 (17%) women had a planned caesarean section and 1284 (83%) women had a planned vaginal delivery in the first pregnancy. In the subsequent pregnancy, perinatal mortality was 1.1% (3/259) for women with a planned caesarean section in the first pregnancy and 0.5% (6/1284) for women with a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31–10.1). Composite adverse neonatal outcome was 2.3% (6/259) versus 1.5% (19/1284), (aOR 1.5; 95% CI 0.55–4.2). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49–1.9).

Conclusion: In women with a preterm breech delivery, planned caesarean section does not reduce perinatal mortality, perinatal morbidity, or maternal morbidity rate over the course of two pregnancies.     

Pregnancy complications in women with inherited thrombophilia

Objective: The purpose of this study was to examine whether women with inherited thrombophilia have an increased risk of developing pregnancy complications. Methods: All singleton pregnancies with known inherited thrombophilia were compared to those without inherited thrombophilia for deliveries during the years 2000–2002 in a tertiary medical center. Data regarding inherited thrombophilia (International Classification of Disease 9th revision, Clinical Modification code 286.3) were available from the perinatal database in our center. Women lacking prenatal care were excluded from the analysis. Stratified analysis, using a multiple logistic regression model, was performed to control for confounders. Results: Out of 32,763 singleton deliveries that occurred during the study period, 0.2% (n=57) of the women were diagnosed with inherited thrombophilia. Using a multivariate analysis, with backward elimination, the following conditions were significantly associated with inherited thrombophilia: previous fetal losses [odds ratio (OR)=5.5; 95% confidence interval (CI) 2.9–10.3; P<0.001], recurrent abortions (OR=9.5; 95% CI 5.5–16.3; P<0.001), fertility treatments (OR=3.7; 95% CI 1.3–10.6; P=0.014), and intrauterine growth restriction (OR=7.2; 95% CI 3.4–15; P<0.001). Perinatal mortality was significantly higher in women with inherited thrombophilia than in those without known thrombophilia 5.3% (3/57) versus 0.6% (477/32,763) P=0.017. However, inherited thrombophilia was not found to be an independent risk factor for perinatal mortality (OR=3.05; 95% CI 0.90–10.3; P<0.073) in a multivariate analysis with perinatal mortality as the outcome variable, controlling for recurrent abortions, IUGR, and gestational age. Conclusion: Inherited thrombophilia, associated with previous fetal losses, recurrent abortions, fertility treatments, and intrauterine growth restriction, was not an independent risk factor for perinatal mortality.