Verbessert die Diagnostik des unteren Uterinsegments die Geburtsplanung bei Status nach Sectio?

Purpose To identify risk factors associated with the occurrence of complete uterine rupture (CUR) in comparison to partial uterine rupture (PUR) to further investigate to what extent a standardized definition is needed and what clinical implications can be drawn. Methods Between 2005 and 2017 cases with CUR and PUR at Charité University Berlin, Germany were retrospectively identified. Demographic, obstetric and outcome variables were analyzed regarding the type of rupture. Binary multivariate regression analysis was conducted to identify risk factors associated with CUR. In addition, the intended route of delivery (trial of labor after cesarean delivery (TOLAC) and elective repeat cesarean delivery (ERCD)), divided according to the type of rupture, was compared. Results 92 cases with uterine rupture were identified out of a total of 64.063 births (0.14%). Puerperal complications were more frequent in CUR (67.9 versus 41.1%, p = 0.021). Multiparity ≥ 3 was more frequent in CUR (31 versus 10.7%, p = 0.020). Factors increasing the risk for CUR were parity ≥ 3 (OR = 3.8, p = 0.025), previous vaginal birth (OR = 4.4, p = 0.011), TOLAC (OR = 6.5, p < 0.001) and the use of oxytocin (OR = 2.9, p = 0.036). After multivariate analysis, the only independent risk factor associated with CUR was TOLAC (OR = 7.4, p = 0.017). Conclusion TOLAC is the only independent risk factor for CUR. After optimized antenatal counselling TOLAC and ERCD had comparable short-term maternal and fetal outcomes in a high resource setting. A high number of previous vaginal births does not eliminate the risk of uterine rupture. A clear distinction between CUR and PUR is essential to ensure comparability among studies.

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Risk factors and outcomes associated with type of uterine rupture

Dimitrova

Kästner

Schwickert

et al. 2022

Arch Gynecol Obstet

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Comparison of the lower uterine segment in pregnant women with and without previous cesarean section in 3 T MRI

Hoffmann

Exner

Bremicker

et al. 2019

BMC Pregnancy Childbirth

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Background Prenatal risk stratification of women with previous cesarean section (CS) by ultrasound thickness measurement of the lower uterine segment (LUS) is challenging. There is a wide range of proposed cutoff values and a valuable algorithm for selection before birth is not available. Using 3 T magnetic resonance imaging (MRI), we aimed to identify possible shortcomings of the current protocols used for birth selection after CS. Therefore, we evaluated anatomic and morphologic differences of the LUS and its thickness in patients with CS and those without. Possible impact factors on LUS thickness were studied. Methods We retrospectively analyzed 3 T MRI scans of 164 pregnant women in their second or third trimester, with (patient group, n = 60) and without previous CS (control group, n = 104). Sagittal T2-weighted images were studied. Normal findings of the LUS in MRI, reliability of MRI measurements, as well as factors influencing LUS thickness were assessed. MRI findings were compared to intraoperative findings. Results MRI provided good intra- (ICC 0.872) and fair inter-rater reliability (ICC 0.643). The relationship of the LUS and the cesarean scar to the surrounding anatomical structures and also its morphology varied strongly in patients and controls. Scar identification was possible in only 9/60 (15.0%) patients. The LUS was thinner in patients (1.9 ± 0.7 mm) than in controls (2.7 ± 1.3 mm). An LUS thinning up to 1 mm was observed in 23% of women without a previous CS and in 34% of women with normal intraoperative findings. Suspicion of a uterine dehiscence (LUS thickness < 1 mm) was only found in the patient group (5/59 (8.5%)) and was intraoperatively confirmed. In controls, LUS thickness was influenced by fetal weight, gestational age and amniotic fluid amounts. Conclusion Variability in anatomy, thickness and morphology seem to limit common prenatal LUS imaging diagnostics. Therefore, we consider that diagnostic protocols must be re-evaluated and imaging should be adjusted to the individual patient conditions. Due to its independency of ultrasound limitations, an additional MRI might be useful for altered anatomy and impaired ultrasound conditions. An LUS thinning up to 1 mm might be a normal finding and should be further investigated as reference value.

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Outcomes and risk factors for failed trial of labor after cesarean delivery (TOLAC) in women with one previous cesarean section: a Chinese population-based study

He¹,

Dai²,

Wu³

et al. 2022

BMC Pregnancy Childbirth

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Objective To evaluate the outcomes and risk factors for trial of labor after cesarean delivery (TOLAC) failure in patients in China. Methods Consecutive patients who had a previous cesarean delivery (CD) and attempted TOLAC were included from 2014 to 2020. Patients who successfully delivered were classified into the TOLAC success group. Patients who attempted TOLAC but had a repeat CD due to medical issues were classified into the TOLAC failure group. Multiple logistic regression analyses were performed to examine the risk factors for TOLAC failure. Results In total, 720 women who had a previous CD and attempted TOLAC were identified and included. The success rate of TOLAC was 84.2%(606/720). Seven patients were diagnosed with uterine rupture, none of whom underwent hysterectomy. Multiple logistic regression analysis showed that the induction of labor (OR = 2.843, 95% CI: 1.571–5.145, P < 0.001) was positively associated with TOLAC failure, but the thickness of the lower uterine segment (LUS) (OR = 0.215, 95% CI: 0.103–0.448, P < 0.001) was negatively associated with TOLAC failure. Conclusions This study suggested that TOLAC was effective in decreasing CD rates in the Chinese population. The induction of labor was positively associated with TOLAC failure, but the thickness of the LUS was negatively associated with TOLAC failure. Our findings need to be confirmed in larger samples with patients of different ethnicities.

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Verbessert die Diagnostik des unteren Uterinsegments die Geburtsplanung bei Status nach Sectio?

Cited by 3 publications

References 31 publications

Risk factors and outcomes associated with type of uterine rupture

Risk factors and outcomes associated with type of uterine rupture

Comparison of the lower uterine segment in pregnant women with and without previous cesarean section in 3 T MRI

Outcomes and risk factors for failed trial of labor after cesarean delivery (TOLAC) in women with one previous cesarean section: a Chinese population-based study

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