Long-term use of hormonal contraceptive DMPA not linked to breast cancer

A study conducted by the World Health Organization (WHO) Special Programme of Research, Development and Research Training in Human Reproduction with the collaboration with the University of Otago Medical School in Dunedin, New Zealand, and the Fred Hutchinson Cancer Research Center in Seattle, Washington, reveals that the injectable contraceptive DMPA (depot-medroxyprogesterone acetate) does not increase the overall risk of developing breast cancer, especially in women who have used DMPA for long periods in the past. Women who began using DMPA within the last 5 years may face a 2-fold increased risk of developing breast cancer, however. Enhanced detection of breast tumors or an acceleration of the growth of pre-existing tumors may explain this increased risk in recent or current users of DMPA. The researchers concluded that providers should not restrict DMPA on the grounds of breast cancer risk. The study reaffirmed the known link of increased risk of breast cancer with early menarche, being single, late age at birth of first child, nulliparity, family history of breast cancer, and history of benign breast disease. The study data originated from New Zealand, the US, Kenya, Mexico, and Thailand. Disadvantages of DMPA include: irregular bleeding, that it is provider-dependent, and slow return to fertility after DMPA use ceases. Advantages include high contraceptive effectiveness, no effect on blood clotting factors, and a protective effect against endometrial cancer.     

Family history as a risk factor for development of uterine leiomyomas. Results of a pilot study

OBJECTIVE: To determine (1) the association between maternal history of leiomyomas and those in women under the age of 50, and (2) the ability of subjects to report a family history of leiomyomas. STUDY DESIGN: We performed a hospital-based, case-control study. The cases were women with pathologically confirmed leiomyomas, and the controls were women with no leiomyomas after pathologic examination of the uterus or by transvaginal ultrasonography. All women were sent a questionnaire regarding potential risk factors for the development of leiomyomas. RESULTS: Eighty-one of 169 (47.9%) cases and 103 of 214 (48.1%) of controls completed the questionnaire. By multiple logistic regression, significant risk factors for the presence of leiomyomas were maternal history (odds ratio = 2.85, confidence intervals 1.25-6.52) and reduced parity (odds ratio = 0.75, confidence intervals .57-.98). Increasing age was nearly significant as a risk factor (odds ratio = 1.07, confidence intervals 1.00-1.15). Of the subjects, 24% did not know the maternal history of leiomyomas, while 29% and > 50% were not aware of this history in a sister or grandmother, respectively. Extended family histories of leiomyomas could not be ascertained by this questionnaire-based study. CONCLUSION: Our results suggest that a maternal history of leiomyomas might be the largest risk factor for development of leiomyomas in a largely Caucasian population of women. Further studies are needed to better understand the possible genetic contribution to the development of uterine leiomyomas. Given the ascertainment bias inherent in second-hand maternal histories, future studies should assess maternal leiomyoma presence by ultrasonographic or pathologic evaluation.     

Association study between catechol-O-methyltransferase polymorphisms and uterine leiomyomas in a Japanese population

PURPOSE: To investigate a possible association between uterine leiomyomas and catechol-O-methyltransferase (COMT) polymorphisms in a Japanese population. METHODS: We compared the allele frequencies and genotype distributions of the exon 4 NlaIII restriction site polymorphism (RSP), the P2 promoter HindIII RSP at -1217, and the exon 6 BglI RSP in the COMT gene in 250 leiomyoma cases and 182 controls using polymerase chain reaction-restriction fragment-length polymorphism analysis. RESULTS: No significant differences in allele frequencies and genotype distributions of the exon 4 NlaIII RSP, the P2 promoter HindIII RSP at -1217, and the exon 6 BglI RSP were found between uterine leiomyoma cases and controls. Moreover, no associations were noted between these three polymorphisms in COMT genes and leiomyoma size or a family history of uterine leiomyomas. CONCLUSION: COMT gene polymorphisms are unlikely to be associated with an increased risk of uterine leiomyomas in a Japanese population.     

Fertility and uterine size among Asian women undergoing hysterectomy for leiomyomas

OBJECTIVE: To ascertain whether an epidemiological relationship exists between fertility and uterine leiomyomas, and whether uterine size is associated with fertility among Asian women undergoing hysterectomy for leiomyomas. METHODS: The study was conducted in Sapporo, Japan. 91 women undergoing hysterectomy for myomas were compared with age-matched controls with respect to reproductive factors. Further comparisons were made of these factors in women with large myomas and those with small ones. RESULTS: Women with leiomyomas were more likely to be nulliparous than controls (P < .01), and the risk of leiomyoma increased as the number of births decreased (P < .01). Time since last birth was associated with increased risk in women with large myomas (P < .05). Women with fewer births undergoing hysterectomy for leiomyomas tended to have greater uterine weight. CONCLUSION: Fewer births may be a cause of larger leiomyomas.     

Familial and hormonal risk factors for papillary serous uterine cancer

OBJECTIVES: To identify genetic and non-genetic risk factors for papillary serous uterine cancer. METHODS: A case-control study was conducted. Case women with papillary serous uterine cancer were compared with two control groups: 1) women with endometrioid uterine cancer and 2) healthy women with no past history of cancer. Cases and controls were matched for age (within two years) and ethnic group. All study subjects completed a questionnaire addressing family history. The cases and healthy controls were assessed for factors associated with estrogen exposure. RESULTS: The risks of breast cancer (RR 1.84, CI 1.03-3.31) and of prostate cancer (RR 2.21, CI 0.77-6.37) were higher among the relatives of patients with papillary serous uterine cancer, than among relatives of those with endometrioid uterine cancer. Other significant risk factors included weight at 18 years (p = 0.04) and the use of estrogen replacement therapy (p = 0.04). CONCLUSION: Relatives of women with papillary serous cancer of the uterus had an increased risk of breast and prostate cancer. Hormonal exposure also increases the risk for this cancer. These findings suggest that predisposing genetic factors, possibly related to hormone metabolism, may be common to the three forms of cancer.     

A prospective study on the effects of depot medroxyprogesterone acetate on trabecular and cortical bone after attainment of peak bone mass

Objective To study the annual change of bone mass in women aged 30–45 years being treated with depot medroxyprogesterone acetate (DMPA) in order to evaluate whether the bone mass depends on the duration of DMPA use or the oestradiol level.
Design Prospective longitudinal study over an interval of 12 months.
Setting A family planning centre of a university hospital.
Patients Thirty-six current users of DMPA.
Interventions Injection of 150 mg DMPA every 12 weeks.
Measurements Bone mass was measured at the distal radius by peripheral quantitative computed tomography (reproducibility 0.3%).
Results Mean annual changes (SD) in trabecular and cortical bone mass were 0.06 (1.6%) [   P = 0.8  ] and −0.26% (0.6) [   P < 0.04  ]. The decrease in cortical bone mass was not significant because the changes were within the precision error of the method used for the measurements. Duration of DMPA use and oestradiol levels were not associated to the bone parameters.
Conclusion We did not find a negative impact of DMPA on the bone mass of premenopausal women aged 30–45 years.     

Use of oral contraceptives and uterine fibroids: results from a case-control study

Objective To analyse the association between oral contraceptive use and the risk of uterine fibroids.
Design Participants We considered data collected in a case-control study on risk factors for uterine fibroids.
Participants We studied 843 women with uterine fibroids, whose clinical diagnosis dated back no more than two years. Controls were 1557 non-hysterectomised patients younger than 55 years admitted for acute, non-gynecological, non-hormonal, non-neoplastic conditions.
Results A total of 254 cases (30.1 %) and 360 controls (23.1 %) reported ever using oral contraceptives: the odds ratio (OR) for ever vs never users was 1–1 (95% CI 0-8–1.3). The risk in current users was below unity when compared with never users (OR 0.3,95% CI 0.2–0.6), while ex-users had a risk of fibroids comparable with never users (OR 1. I, 95% CI 0.9–1.4). The risk of uterine fibroids decreased with duration of oral contraceptive use: compared with never users, the estimated OR was 0.8 (95% CI 0.5–1.2) in ever users for four to six years and 0.5 (95% CI 0.349) for seven years or more (trend = 4.6,   P = 0.03  ).
Conclusions Although the role of selection bias should be carefully evaluated, the present data suggest that uterine fibroids should not be considered a contra-indication for oral contraceptive use.     

Induced abortion in the first trimester of pregnancy and risk of miscarriage

Objective To analyse the relation between induced abortion and risk of subsequent miscarriage.
Design Case-control study conducted between February 1990 and May 1995.
Participants Case group included 782 women (median age 32 years, range 1446) admitted for spontaneous abortion (within the 12th week of gestation) to a network of obstetric departments in the greater Milan area. The control group was recruited among women who gave birth at term (> 37 weeks of gestation) to healthy infants on randomly selected days at the hospitals where cases had been identified. A total of 1543 controls (median age 30 years, range 14–45) were interviewed.
Results A total of 102 cases (13%) and 181 controls (12%) reported one or more induced abortions. No clear relation emerged between miscarriage and induced abortions. In comparison with women reporting no induced abortion the odds ratio (OR) for miscarriage were 1.1 (95% CI 0.8–1.4) in women reporting one induced abortion and 0.9 (95% CI 0.4–1.8) in women reporting two or more. Likewise, there was no association between time since last and age at first induced abortion and risk of miscarriage.
Conclusions This study did not find any strong association between induced and spontaneous abortion.     

Bone density in long term users of depot medroxyprogesterone acetate

Objective To identify any adverse effect on bone density in long term users of depot medroxyprogesterone acetate (DMPA) for contraception.
Design Cross-sectional measurement of bone density in users with amenorrhoea of more than one year or any woman using DMPA for more than five years.
Setting Community Family Planning Clinics in Portsmouth and Manchester.
Population One hundred and eighty-five women aged 17–52 years (mean 33.3 years) who had used DMPA for between 1 and 16 years and were attending the clinics for further injections, between August 1994 and August 1996.
Methods Dual energy X-ray measurement of bone density of femoral neck and lumbar spine, and venous blood sample taken just prior to the next injection of DMPA.
Main outcome measures Bone density of femoral neck and lumbar spine and serum oestradiol in relationship to years of DMPA use and duration of amenorrhoea.
Results Most women (   n = 153  ) had serum oestradiol levels < 150 pmol/l. Despite this, the mean bone density of the lumbar spine compared with the population mean for women aged 20–59 years gave a Z score (95% CI) of -0.332 (-0.510 to -0.154). There was no significant difference in the mean density of the femoral neck from the normal population mean.
Conclusion Despite amenorrhoea and low serum oestradiol, this sample of long term DMPA users had bone density only minimally below the normal population mean. We therefore found no clinically important adverse effect on bone density and therefore no reason to recommend bone conserving measures, such as add-back oestrogen.     

Swyer syndrome: presentation and outcomes

Objective  To establish the spectrum of presentation, natural history and gynaecological outcomes in women with Swyer syndrome.
Design  Retrospective notes review.
Setting  Tertiary referral centre for disorders of sex development.
Population  A total of 29 adult women with Swyer syndrome.
Methods  Information was collected on age at diagnosis, biometric characteristics, timing of gonadectomy, histology of gonad, bone mineral density, uterine size and fertility.
Main outcome measures  Age at diagnosis, risk of gonadal malignancy, bone mineral density, uterine size.
Results  With regard to presentation, 26/29 (90%) women in this series presented with delayed puberty, and the median age at diagnosis was 17.2 years (range 0–55 years). The median age at gonadectomy was 18 years (range 9–33 years). Histology of the gonad was available in 22 women and demonstrated streak gonads with no evidence of malignancy in 12, dysgerminoma in 7 and gonadoblastoma in 3. The youngest patient diagnosed with dysgerminoma was 10 years old. The median height of the women was 1.73 m (range 1.54–1.95 m). Twelve out of the 20 (60%) women had evidence of osteopenia on dual energy X-ray absorptiometry scan. The uterine size and shape was assessed in eight women after completion of induction of puberty, and the uterine cross-section was found to be significantly lower than that in normal controls. Fertility was achieved with ovum donation in three women, all of whom had live births and one subsequently had a second successful pregnancy.
Conclusion  Early diagnosis of Swyer syndrome is necessary in view of the risk of dysgerminoma that can develop at an early age. Adequate hormone replacement is required to maintain bone mineral density and may improve the uterine size and shape.     

Exposure to DMPA in pregnancy may cause low birth weight

A study sponsored by the Special Program of Research, Development and Research Training in Human Reproduction of the World Health Organization was carried out in Thailand involving groups of women with 1573 accidental pregnancies. There were 830 accidental pregnancies while using the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), while 743 women had become pregnant before use. There were also 601 accidental pregnancies in oral contraceptive (OC) users. The comparison group of a total of 2587 controls comprised women whose pregnancies were planned as opposed to the exposed group. Women using DMPA had more pregnancy risk factors compared to other groups owing to low socioeconomic status, lower maternal weight and height, smoking and alcohol use during pregnancy, and unplanned pregnancy. However, even after adjusting for these factors, DMPA users had a 50% higher than normal risk of having a low-birth-weight child. The same level of statistically not significant risk was also found among the OC users. Among those who had had accidental pregnancies during DMPA use, and in whom conception was estimated to have occurred within 4 weeks of a DMPA injection, the risk of low birth weight was 90% higher than that in the control group. The increase in risk appeared to decline to 50% when the interval between conception and DMPA injection was 5-8 weeks, and to 20% when the interval between conception and DMPA injection was 5-8 weeks, and to 20% when the interval was or= 9 weeks. This trend was highly significant. Early, high-dose exposure in utero to DMPA seemed to affect fetal growth. There was no increase in the risk of mortality in the 1st year of life for infants exposed to OCs as compared to infants not exposed. However, infants from DMPA-exposed pregnancies had an 80% higher than normal risk of dying during the 1st year of life. Therefore, some infants born out of accidental pregnancies that occur during DMPA use may be at an increased risk of infant death.     

An audit of the management of uterine malignancy within the West Midlands. West Midlands Gynaecological Oncology Group

Objective To audit the management of uterine malignancy.
Design Retrospective casenote analysis.
Setting Cancer units/centres within the West Midlands.
Sample The last 10 cases managed by each hospital in 1997.
Results Ninety-six cases of uterine malignancy from ten hospitals were analysed. Only six hospitals were able to provide a complete data set. Eighty-eight cases (92%) presented with abnormal, usually postmenopausal, vaginal bleeding. Over 90% of the cases were primary endometrial carcinomas. Of the 15 standards audited, 11 were met by at least one hospital. No hospital met all the standards, although every hospital was able to meet at least one. Standards concerned with initial referral and diagnostic intervals were universally failed. Outpatient diagnosis was made in only 30%. The availability of Rapid Access Clinics neither promoted outpatient diagnosis nor sped up diagnosis. Once the diagnosis had been made, surgery was usually performed within six weeks.
Conclusions This audit has provided valuable baseline data for future activity. Serious attention must be given to improvement in clinical cancer data collection. Referral pathways for women with suspected uterine cancer, and endometrial cancer in particular, need improvement. It is recommended that the current standards remain unaltered, and after the West Midlands Gynaecological Oncology Group had the opportunity to consider and implement the necessary changes, the audit be repeated.     

Oral contraceptive use in women with a family history of breast cancer

To evaluate the effect of oral contraceptive use on the risk of breast cancer from 20-54 years of age in women with a family history of the disease, we analyzed data from the Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. For 2 years, beginning December 1980, the study enrolled from eight geographical areas in the United States 4730 women with breast cancer and 4646 controls who were breast cancer-free. For women with a first-degree family history of breast cancer, 554 cases and 280 controls, there was no evidence that use of oral contraceptives, even long-term, contributed to their risk of the disease. Neither total duration of use nor duration of use before first term pregnancy bore any relationship with breast cancer risk. Analyses designed to reveal a potential latent effect also showed no evidence of an adverse effect. For women with a second-degree family history of breast cancer, 777 cases and 595 controls, some isolated elevations in risk were observed for selected subgroups of oral contraceptive users. Detailed analyses of oral contraceptive formulation, the characteristics of the women involved, and the patterns of risk observed by latent period and duration of use suggest that these results, most within the limits of chance variation, are not likely to be a consequence of oral contraception.     

Dyslipoproteinaemia in postmenopausal women with a history of eclampsia

Objective To test the hypothesis that postmenopausal women with a history of eclampsia manifest a more high risk lipid profile than postmenopausal women with a history of normal pregnancy.
Setting The Department of Obstetrics and Gynaecology, National University Hospital, Reykjavik, Iceland, and the Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA.
Participants Thirty Icelandic women with a history of eclampsia, aged between 50 and 67 years at the time of re-examination (cases) were individually matched for current age, and for age and parity at index pregnancy, to 30 unrelated Icelandic women with a history of normal pregnancy (controls).
Methods The participating women completed a health and family history questionnaire and underwent a physical examination. Fasting plasma low density lipoprotein diameter, serum lipids, insulin, and glucose were measured.
Results Mean low density lipoprotein size was significantly smaller and apolipoprotein B concentration was higher in women with prior eclampsia. The percentage of cases receiving blood pressure medication (33%) was significantly greater than controls (6.7%). Thirteen cases had had hypertensive complications in at least one other pregnancy (recurrent subgroup); postmenopausally, these women displayed significantly increased diastolic blood pressures, smaller-sized low density lipoprotein, increased apolipoprotein B, decreased high density lipoprotein₂ (HDL₂) cholesterol, and increased total cholesterol: HDL cholesterol ratio compared with their controls. Fourteen cases were normotensive in all other pregnancies (nonrecurrent); these showed no differences from their controls.
Conclusions Dyslipoproteinaemia is more prevalent among postmenopausal women with prior eclampsia, especially with recurrent hypertension in pregnancy, than in postmenopausal women with prior normal pregnancies.     

Diagnostic criteria for uterine smooth muscle tumors: leiomyoma variants associated with malignant behavior

OBJECTIVE: To determine the prognostic accuracy of current diagnostic criteria for uterine smooth muscle tumors. STUDY DESIGN: Cases of uterine leiomyosarcoma (LMS) treated from 1976 to 1999 were analyzed retrospectively. Uterine LMS specimens were reevaluated using current criteria by a pathologist specializing in gynecologic diseases. Kaplan-Meier survival curves were evaluated. RESULTS: Specimens were available from 67 patients diagnosed with uterine LMS. On rereview, only 47 specimens were thought to represent uterine LMS. The 20 other patients were deemed to have leiomyomas or leiomyoma variants, including 13 cellular leiomyomas, 5 atypical leiomyomas and 2 leiomyomas. Median survival for patients with uterine LMS was 2.1 years. (Ninety-seven percent of disease-specific deaths occurred within 6 years after the diagnosis.) With leiomyoma variants, median survival was > 25 years. Among these 18 women were 3 disease-specific deaths (all > 6 years after diagnosis). CONCLUSION: Diagnostic criteria for uterine smooth muscle tumors require continued refinement. A small but significant number of patients diagnosed with leiomyoma variants will die of the disease. In contrast to the aggressive behavior of uterine LMS, disease-specific deaths attributed to leiomyoma variants occurred later. With this potential for delayed recurrence, these patients warrant close clinical surveillance.     

Unexplained fetal death: Are women with a history of fetal loss at higher risk?

Aims: To identify factors, including the loss of a previous pregnancy before 20 weeks gestation, which are associated with increased risk of singleton antepartum unexplained fetal death (UFD) in Western Australia (WA) using information recorded in routine data collections.
Methods: All fetal deaths in WA from 1990 to 1999 that underwent thorough post-mortem investigations were classified using the Perinatal Society of Australia and New Zealand Perinatal Death Classification System. All UFDs were selected as cases and unmatched controls were randomly drawn from all live births in WA occurring during the study period. Demographic and clinical information on cases and controls was obtained from the WA Midwives' Notification System. Multivariable logistic regression was carried out to determine the independent effect of risk factors and calculate odds ratios.
Results: Almost one quarter (22%) of stillbirths were unexplained. Primigravid and primiparous women with a history of pregnancy loss before 20 weeks were at higher risk of UFD than multiparous women who had not experienced any loss. Women with a history of fetal death (after 20 weeks) had the highest risk of UFD.
Conclusion: The current practice of closely monitoring pregnant women with a history of fetal loss or death should continue as this study suggests they may have a higher risk of poor obstetric outcome. Larger studies are needed to confirm the association between previous pregnancy loss and UFD.     

Complications in pregnancy, labor, and delivery with uterine leiomyomas: a population-based study

OBJECTIVE: To determine the extent to which uterine leiomyomas are associated with characteristics of pregnancy, labor, and neonatal outcome recorded on birth certificates. METHODS: In a population-based series of women who delivered singleton live infants in Washington state from 1987-1993, we linked computerized birth certificates and hospital discharge records to investigate the relationship between uterine leiomyomas and complications in pregnancy and delivery. Subjects were 2065 women with uterine leiomyomas noted on computerized hospital discharge records. From the remaining records, a comparison group of women without uterine leiomyomas diagnoses were selected at random and frequency-matched by birth year to women with leiomyomas. We used unconditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of pregnancy or delivery complications in relation to uterine leiomyomas after multivariate adjustment. RESULTS: Women with leiomyomas were more likely than controls to be over age 35 at delivery, nulliparous, or black. We observed independent associations between uterine leiomyomas and abruptio placentae (OR 3. 87, 95% CI 1.63, 9.17), first trimester bleeding (OR 1.82, 95% CI 1. 05, 3.20), dysfunctional labor (OR 1.85, 95% CI 1.26, 2.72), and breech presentation (OR 3.98, 95% CI 3.07, 5.16). The risk of cesarean was also higher among women with uterine leiomyomas (OR 6. 39, 95% CI 5.46, 7.50), but a portion of the excess risk might have been due to biased detection of leiomyomas at cesarean delivery. CONCLUSION: Leiomyomas appear to increase likelihood of complications during pregnancy, labor, and delivery.     

Induced abortion and risk of small-for-gestational-age birth

Objective  To investigate the possibility of an association between previous induced abortion and subsequent birth of a small-for-gestational-age (SGA) infant.
Design  Case–control study.
Setting  General and university hospitals.
Methods  Cases were 555 women who delivered SGA babies. Controls were 1966 women who gave birth at term (>37 weeks of gestation) to healthy infants of normal weight on randomly selected days at the hospital where cases had been identified. All women in the case and control categories were interviewed on the obstetric wards by one of a team of six interviewers. During the interviews, information was obtained regarding general socio-demographic factors, personal characteristics and habits, gynaecological and obstetric history, general anamnesis, family history of obstetric and gynaecological diseases, and the age of the father of the child. Further information on current pregnancy and delivery was also collected. We used conditional multiple logistic regression (with age as the matching variable), with maximum likelihood fitting, to obtain odds ratios and their corresponding 95% CIs. Included in the regression equations were terms for education, plus terms significantly associated in this data set with the risk of SGA birth (smoking in pregnancy, history of SGA, gestational hypertension and parity).
Population  Women admitted to a general and a university hospital.
Results  No significant increase in the risk of SGA birth was observed in women with a previous induced abortion [odds ratio (OR) 1.0; 95% CI 0.6–1.7]. The OR for SGA birth was 1.2 (95% CI 0.7–2.1) for preterm and 1.0 (95% CI 0.7–1.4) for term SGA births.
Conclusion  This study found no association between risk of SGA birth and induced abortion.     

Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden

Objective  Uterine rupture is a rare but a catastrophic event. The aim of the present study was to explore the risk factors for uterine rupture and associated neonatal morbidity and mortality among a cohort of Swedish women attempting vaginal birth in their second delivery.
Design  Population-based cohort study.
Setting  Sweden.
Population  A total of 300 200 Swedish women delivering two single consecutive births between 1983 and 2001.
Methods  Swedish population-based registers were used to obtain information concerning demographics, pregnancy and birth characteristics, and neonatal outcomes. Logistic regression was used to analyse potential risk factors for uterine rupture and risk of neonatal mortality associated with uterine rupture. Odds ratios were used to estimate relative risks using 95% CI.
Main outcome measure  Uterine rupture and neonatal mortality in the second pregnancy.
Results  Compared with women who delivered vaginally in their first birth, women who underwent a caesarean delivery were, during their second delivery, at increased risk of uterine rupture (adjusted OR 41.79; 95% CI 29.73–57.00). Induction of labour, high (≥4000 g) birthweight, postterm (≥42 weeks) births, high (≥35 years) maternal age, and short (≤164 cm) maternal stature were also associated with increased risk of uterine rupture. Uterine rupture was associated with a substantially increased risk in neonatal mortality (adjusted OR 65.62; 95% CI 32.60–132.08).
Conclusion  The risk of uterine rupture in subsequent deliveries is not only markedly increased among women with a previous caesarean delivery but also influenced by induction of labour, birthweight, gestational age, and maternal characteristics.