Interdelivery interval and uterine rupture

OBJECTIVE: The purpose of this study was to measure the impact of the interdelivery interval on uterine rupture during subsequent delivery. STUDY DESIGN: An observational cohort study was performed to assess the rate of uterine rupture in women with a previous low transverse cesarean delivery and no previous vaginal delivery who undergo a trial of labor from 1988 to 2000 in a tertiary care center. The rate of uterine rupture was measured for each of the following interdelivery intervals: 36 months of gestation. Multivariate logistic regression analysis was used to adjust for selected confounding variables. RESULTS: Of the 1527 women who met the study criteria, the rate of uterine rupture was 4.8% for patients with an interdelivery interval of 36 months of gestation (P =.04). After adjustment for the confounding variables, the odds ratio for uterine rupture in women with an interdelivery interval of 24 months of gestation.     

Dystocia among women with symptomatic uterine rupture

OBJECTIVE: The purpose of this study was to analyze cervical dilatation patterns among women with uterine rupture by means of a mathematic model and to use the results to determine optimal intervention criteria. STUDY DESIGN: This was a case-control review that compared a case patient group of 19 women with uterine rupture during labor with control groups with either no previous cesarean deliveries, vaginal birth after cesarean delivery, or failure of attempted vaginal birth after cesarean delivery. The mathematic model quantified dilatation and adjusted for conditions specific to each patient. Case patients were compared with matched control subjects by means of paired t tests, analysis of variance, odds ratios, and conditional logistic regression. RESULTS: Dystocia was present in 31.6% to 47.4% of patients with uterine rupture, versus 2.6% to 13.2% of the control group with no previous cesarean deliveries (P< or =.001). The incidence of an arrest disorder among patients with uterine rupture was similar to that seen in the control group with failure of attempted vaginal birth after cesarean delivery. However, the interval from diagnosis to rupture or cesarean delivery was 5.5 +/- 3.3 hours among case patients with uterine rupture and 1.5 +/- 1.3 hours in the control group with failure of attempted vaginal birth after cesarean delivery. CONCLUSION: When cervical dilatation was lower than the 10th percentile and was arrested for > or =2 hours, cesarean delivery would have prevented 42.1% of the cases of uterine rupture and resulted in excess 2.6% and 7.9% cesarean delivery rates among women with no previous cesarean deliveries and women with vaginal birth after cesarean delivery, respectively.     

Short interpregnancy interval: risk of uterine rupture and complications of vaginal birth after cesarean delivery

OBJECTIVE: To investigate whether short or long interpregnancy interval is associated with uterine rupture and other major maternal morbidities in women who attempt vaginal birth after cesarean delivery (VBAC). METHODS: We performed a secondary analysis of a U.S. multi-center, record-based, retrospective cohort study of 13,331 pregnant women, identified by a validated International Classification of Disease, 9th Revision, code search, with at least one prior cesarean delivery, who attempted VBAC between 1995 and 2000. We performed univariable and multivariable logistic regression analyses to evaluate the association between long or short interpregnancy interval and three maternal outcomes: 1) uterine rupture, 2) composite major morbidity (including rupture, bladder or bowel injury, and uterine artery laceration), and 3) blood transfusion. We evaluated short interpregnancy interval with cutoffs at less than 6, less than 12, and less than 18 months between prior delivery and conception and defined long interval as 60 months or more. RESULTS: A total of 128 cases (0.9%) of uterine rupture occurred, and 286 (2.2%), 1,109 (8.3%), 1,741 (13.1%), and 2,631 (19.7%) women had interpregnancy intervals of less than 6, 6-11, 12-17, and 60 months or more, respectively. An interval less than 6 months was associated with increased risk of uterine rupture (adjusted odds ratio [aOR] 2.66, 95% confidence interval [CI] 1.21-5.82), major morbidity (aOR 1.95, 95% CI 1.04-3.65), and blood transfusion (aOR 3.14, 95% CI 1.42-6.95). Long interpregnancy interval was not associated with an increase in major morbidity. CONCLUSION: Short interpregnancy interval increases risk for uterine rupture and other major morbidities twofold to threefold in VBAC candidates. LEVEL OF EVIDENCE: II.     

Identifying risk factors for uterine rupture

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.     

Interdelivery interval and the success of vaginal birth after cesarean delivery.

OBJECTIVE: To determine whether a short interdelivery interval is associated with decreased rate of successful vaginal birth after cesarean (VBAC). METHODS: A retrospective cohort study from January 1, 1997, to December 31, 2000, was conducted. Patients with previous cesarean delivery who attempted VBAC were identified. The analysis was limited to patients at term with one prior cesarean. The interdelivery interval was calculated in months between the index pregnancy and prior cesarean delivery. RESULTS: A total of 1516 subjects who attempted VBAC were identified among 24,162 deliveries, with complete data available in 1185 cases. The VBAC success rate was 79.0% for patients with an interdelivery interval less than 19 months compared with 85.5% for patients with an interval delivery greater than or equal to 19 months (P =.12). For patients whose labors were induced, interdelivery intervals of less than 19 months were associated with a decreased rate of VBAC success when compared with longer intervals (P <.01). Sufficient power (beta =.95) existed to detect a 64% difference between the groups (alpha =.05). No significant difference was detected in women who underwent spontaneous labor (P =.98). There was no difference in the rate of symptomatic uterine rupture (P = 1.00). CONCLUSION: Interdelivery intervals of less than 19 months were associated with a decreased rate of VBAC success in patients who underwent induction, a difference not found in those with spontaneous labor.     

Previous preterm cesarean delivery and risk of subsequent uterine rupture

OBJECTIVE: To determine if women with a history of a previous preterm cesarean delivery experienced an increased risk of subsequent uterine rupture compared with women who had a previous nonclassic term cesarean delivery. METHODS: A prospective observational study was performed in singleton gestations that had a previous nonclassic cesarean delivery from 1999 to 2002. Women with a history of a previous preterm cesarean delivery were compared with women who had a previous term cesarean delivery. Women who had both a preterm and term cesarean delivery were included in the preterm group. RESULTS: A prior preterm cesarean delivery was significantly associated with an increased risk of subsequent uterine rupture (0.58% compared with 0.28%, P<.001). When women who had a subsequent elective cesarean delivery were removed (remaining n=26,454) women with a previous preterm cesarean delivery were still significantly more likely to sustain a uterine rupture (0.79% compared with 0.46%, P=.001). However, when only women who had a subsequent trial of labor were included, there was still an absolute increased risk of uterine rupture, but it was not statistically significant (1.00% compared with 0.68%, P=.081). In a multivariable analysis controlling for confounding variables (oxytocin use, two or more previous cesarean deliveries, a cesarean delivery within the past 2 years, and preterm delivery in the current pregnancy), patients with a previous preterm cesarean delivery remained at an increased risk of subsequent uterine rupture (P=.043, odds ratio 1.6, 95% confidence interval 1.01-2.50) compared with women with previous term cesarean delivery. CONCLUSION: Women who have had a previous preterm cesarean delivery are at a minimally increased risk for uterine rupture in a subsequent pregnancy when compared with women who have had previous term cesarean deliveries.     

Cervical ripening with transcervical foley catheter and the risk of uterine rupture

OBJECTIVE: To estimate whether the rate of uterine rupture in patients with a previous cesarean delivery is related to labor induction and/or cervical ripening using transcervical Foley catheter. METHODS: Charts of all patients who had a trial of labor after a previous cesarean delivery in our institution between 1988 and 2002 were reviewed. The rates of successful vaginal birth after cesarean delivery and uterine rupture in patients with spontaneous labor (control group) were compared with those of patients who underwent a labor induction by means of amniotomy with or without oxytocin and patients who underwent a labor induction/cervical ripening using a transcervical Foley catheter. Logistic regression analysis was performed to adjust for confounding variables. RESULTS: Of 2479 patients, 1807 had a spontaneous labor, 417 had labor induced by amniotomy with or without oxytocin, and 255 had labor induced by using transcervical Foley catheter. The rate of successful vaginal birth after cesarean delivery was significantly different among the groups (78.0% versus 77.9% versus 55.7%, P <.001), but not the rate of uterine rupture (1.1% versus 1.2% versus 1.6%, P =.81). After adjusting for confounding variables, the odds ratio (OR) for successful vaginal birth after cesarean delivery was 0.68 (95% confidence interval [CI] 0.41, 1.15), and the OR for uterine rupture was 0.47 (95% CI 0.06, 3.59) in patients who underwent an induction of labor using a transcervical Foley catheter when compared with patients with spontaneous labor. CONCLUSION: Labor induction using a transcervical Foley catheter was not associated with an increased risk of uterine rupture.     

Risk factors for symptomatic uterine rupture during a trial of labor: the 1990s

The purpose of this study is to identify pregnancy and labor factors that place women at increased risk for symptomatic uterine rupture during trial of labor following cesarean section. The study population consisted of 16 women with uterine rupture after a trial of labor who were compared with 32 women without uterine rupture after a trial of labor. Using a case-control study design with a 1:2 match, we examined risk factors that might be associated with an increased risk of uterine rupture. Cases were more likely to have an induction of labor with the use of oxytocin and/or amniotomy (56 vs. 34%) and more likely to undergo augmentation with oxytocin (25 vs. 19%) in comparison with controls. In addition, cases were more likely to be given oxytocin (for either induction or augmentation) (75 vs. 50%) and cervical ripening agents (31 vs. 9%) versus controls. Neonates born after uterine rupture had a higher rate of significant acidosis (pH < 7.0, 57 vs. 0%, p = 0.0002) and lower Apgar scores. There was a significantly higher risk of maternal infection (36 vs. 3%, p = 0.003), transfusion (13 vs. 0%, p = 0.03), and longer length of stay in patients with uterine rupture. There is a trend for increased use of augmentation and induction agents to be associated with uterine rupture. Serious maternal and fetal morbidities are increased following uterine rupture.     

Trends,risk factors and pregnancy outcome in women with uterine rupture

Objective  

This study aimed at determining trends, risk factors and pregnancy outcome in women with uterine rupture.     

Pregnancy after uterine-artery embolization for symptomatic fibroids: a case of placenta accreta with uterine rupture

The evolution of pregnancies following uterine-artery embolisation (UAE) for symptomatic fibroids remains uncertain. We report a case of pregnancy after UAE, complicated of adherent placenta with uterine rupture, in a context of uterine leiomyomata with a prior cesarean delivery. Through a recent review of the literature, we discuss the main obstetrical complications following UAE. Appropriate management of these high-risk pregnancies, notably in case of risk of adherent placenta, seems to be necessary.     

The association of maternal age and symptomatic uterine rupture during a trial of labor after prior cesarean delivery

OBJECTIVE: To estimate whether maternal age is associated with a symptomatic uterine rupture during a trial of labor after prior cesarean delivery. METHODS: We retrospectively reviewed the medical records of all patients undergoing a trial of labor after prior cesarean delivery over a 12-year period. We analyzed the labors of women with one prior cesarean and no prior vaginal deliveries. The uterine rupture rate was determined with respect to maternal age. Multiple logistic regression was used to control for potential confounding variables. RESULTS: Overall, 32 (1.1%) uterine ruptures occurred among 3015 women. For women younger than 30 years, the risk of uterine rupture was 0.5%, and for those women aged at least 30 years, the risk of uterine rupture was 1.4% (P =.02). Controlling for birth weight, induction, augmentation, and interdelivery interval, the odds ratio for symptomatic uterine rupture for women aged at least 30 years compared with those less than 30 years was 3.2 (95% confidence interval 1.2, 8.4). CONCLUSION: Women aged 30 years or older have a greater risk of uterine rupture as compared with women younger than 30 years.     

子宫破裂的诊断和治疗

子宫破裂可以发生在妊娠的各个时期,分娩期以及产后期。不同的子宫破裂,其临床表现也不尽相同。胎儿监护胎心率、超声以及核磁共振成像等是确诊子宫破裂的重要辅助手段。而治疗时需根据孕产妇及胎儿的不同情况选择个性化的治疗方案。     

Oxytocin dose and the risk of uterine rupture in trial of labor after cesarean

OBJECTIVE: To examine the association between uterine rupture and oxytocin use in trial of labor after cesarean. METHODS: A case-control study was performed. Cases were all women with uterine ruptures who received oxytocin during a trial of labor after a single cesarean delivery within a 12-year period (n = 24). Four controls undergoing trial of labor after a single cesarean delivery were matched to each case by 500 g birth weight category, year of birth, and by induction or augmentation (n = 96). The study had an 80% power to detect a 40% increase in oxytocin duration or a 65% increase in total oxytocin dose. RESULTS: No significant differences were seen in initial oxytocin dose, maximum dose, or time to maximum dose. Although women with uterine ruptures had higher exposure to oxytocin as measured by mean total oxytocin dose (544 mU higher) and oxytocin duration (54 minutes longer), these differences were not statistically significant. Women with uterine rupture who received oxytocin were more likely to have experienced an episode of uterine hyperstimulation (37.5% compared with 20.8%, P =.05). However, the positive predictive value of hyperstimulation for uterine rupture was only 2.8%. CONCLUSION: Although no significant differences in exposure to oxytocin were detected between cases of uterine rupture and controls, the rarity of uterine rupture limited our power to detect small differences in exposure. In women receiving oxytocin, uterine rupture is associated with an increase in uterine hyperstimulation, but the clinical value of hyperstimulation for predicting uterine rupture is limited.     

Short interpregnancy interval increases the risk of preterm premature rupture of membranes and early delivery

Objectives: Preterm premature rupture of membranes (PPROM) is a major contributor to overall preterm birth (PTB) rates. A short interpregnancy interval (IPI) is a well-known risk factor for PTB. It is unknown if a short IPI specifically affects the risk of developing PPROM in a subsequent pregnancy. We sought to determine the association between IPI and the risk of PPROM in a subsequent pregnancy.

Methods: A retrospective cohort study using the Missouri birth certificate database of singleton births from 2003 to 2013 was conducted. A short IPI (delivery of the prior pregnancy to conception of the index pregnancy) was defined as ≤6 months. IPI >6 months was categorized into two groups: IPI 7–23 months and IPI ≥24 months. PPROM was defined as premature rupture of membranes between 16⁰ and 36⁶ weeks. Multivariable logistic regression was conducted to determine the association between IPI and PPROM while controlling for maternal age, race, body mass index (BMI), education level, use of social services (Medicaid insurance, food stamps, or participation in the WIC [Women, Infants, and Children] program), tobacco use, and history of PTB. Secondary outcome included the gestational age at delivery, categorized into five subgroups (≤24⁰, 24¹?28⁰, 28¹?32⁰, 32¹?34⁰, and 34¹?36⁶ weeks).

Results: 474,957 subjects with singleton gestations had data available to calculate the IPI. Of these, 1.4% (n?=?6797) experienced PPROM. IPI ≤6 months was significantly associated with an increased risk of developing PPROM compared with patients with IPI ≥24 months (odds ratio (OR) 1.80, 95% CI 1.70–1.90, p?1 and 32⁰ weeks compared to the other two IPI groups (27.0 versus 15.0 and 16.4%, p?2, BMI ≥30?kg/m², use of social services, tobacco use, and a prior PTB.

Conclusion: Our data demonstrate that an IPI of ≤6 months is significantly associated with an increased risk of developing PPROM in the subsequent pregnancy. Of greater clinical relevance is that these women were more likely to deliver between 28¹ and 32⁰ weeks as compared with women with a longer IPI. Novel to this study is the establishment of a specific link between a short IPI and PPROM with subsequent early delivery. Several maternal demographic factors known to be associated with PTB risk were also found to be associated with an increased risk of PPROM. Further studies are necessary to elucidate plausible biologic mechanisms ultimately leading to the development and implementation of preventive and therapeutic strategies for this high-risk cohort.