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Maternal morbidity associated with multiple cesarean deliveries
SMFM Abstracts S127 431 SUBSEQUENT PREGNANCY OUTCOME WITH PRIOR UTERINE RUPTURE MICHAEL MAHONEY1, JULIE MOLDENHAUER2, MARJORIE TREADWELL1, 1Wayne State University, Obstetrics and Gynecology, Detroit, Michigan, 2University of Chicago, Obstetrics and Gynecology, Chicago, Illinois OBJECTIVE: Very little information is available regarding subsequent pregnancy outcomes after a woman has had a uterine rupture in a prior pregnancy. The aim of this study was to review subsequent pregnancy outcomes after uterine rupture. STUDY DESIGN: Patients with a uterine rupture at the time of delivery were identified by ICD-9 codes. Retrospective chart review was performed to confirm the diagnosis of uterine rupture, characterize the rupture, and to abstract the data of subsequent pregnancy outcomes. Pregnancies that had reached a viable gestational age at the time of initial uterine rupture were included. RESULTS: From 1995-2005, 56 cases of uterine rupture were identified. Of those cases, 6 patients were found to have 8 subsequent pregnancies. The uterine rupture in each case was documented as ranging in size from 4 mm to 5 cm. Uterine surgeries prior to rupture were documented as low transverse cesarean section in 2 cases and undocumented in 4 of the cases. The median interval from rupture to subsequent pregnancy was 20 months (range 14-79 months). Of the 8 subsequent pregnancies, 1 resulted in first trimester intrauterine demise and 7 resulted in delivery of a viable neonate, including 6 singletons and 1 twin delivery. Each delivery occurred at a gestational age of 35 weeks or more and the median birthweight was 2760 grams (range 22403300 grams). All viable pregnancies were delivered by cesarean section, with an intraoperative median estimated blood loss of 800 mL (range 500-1200 mL). The patient presented in spontaneous labor in four of seven deliveries. There were no subsequent uterine ruptures diagnosed, nor were any cesarean hysterectomies performed. CONCLUSION: Women with a prior uterine rupture should be adequately counseled regarding maternal/fetal risks in subsequent pregnancies. Although the results of this small series are reassuring for patients desiring to carry another pregnancy after uterine rupture, further studies are necessary.
433 MATERNAL MORBIDITY ASSOCIATED WITH MULTIPLE CESAREAN DELIVERIES VICTORIA NISENBLAT1, SHLOMI BARAK2, GONEN OHEL1, RON GONEN1, 1TechnionIsrael Institute of Technology, Obstetrics and Gynecology, Haifa, Israel, 2 Bnai-zion Medical Center, Obstetrics and gynecology, Haifa, Israel OBJECTIVE: It has been recently claimed that an elective repeat cesarean delivery (CD) may be safer than a trial of labor after cesarean. However, these data may not be applicable to women who desire larger families, and may require multiple CD. The aim of this study was to assess maternal morbidity associated with multiple elective repeated cesarean deliveries. STUDY DESIGN: The medical records of all women who had undergone two or more elective cesarean deliveries in our institution, between 1.1.2000 and 31.5.2005 were reviewed. We compared, intra-operative and post-operative complications and morbidity, between women who had undergone 3 or more CD (multiple CD group) and women who had undergone a single elective repeat CD (2nd CD group). RESULTS: The multiple CD group included 277 women, of whom 213 had undergone three CD, 56 had four, 7 had five, and 1 had seven elective CD. The 2nd CD group comprised of 492 women. The two groups were similar with respect to chronic maternal medical disorders, pregnancy complications and type of anesthesia. Dense adhesions, 46.1% versus 25.6% (p!0.001), difficult delivery of the neonate, 7.9% versus 3.3% (!0.001) and blood loss over 1000 ml, 5.1% versus 0.2% (p!0.05) were significantly more common among subjects in the multiple CD group. Three women (1.1%) in the multiple CD group required hysterectomy (2 placenta accreta, 1 uterine atony) compared with only 1 woman (0.2%) in the 2nd CD group (placenta accrete). Bladder (2 cases) and bowel injury (1 case) occurred only in the 2nd CD group, however, these differences, in major morbidity between the groups, were not statistically significant. Minor and major post-operative morbidity was similar in the two groups. CONCLUSION: Multiple repeat CD are associated with more difficult surgery and increased blood loss, however, the incidence of major morbidity is relatively low.
432 ACTIVE MANAGEMENT OF LABOUR (AML) AND THE RISE IN CAESAREAN SECTION (CS) RATE 1984-2004 CLIONA MURPHY1, NANDINI RAVIKUMAR1, RATH ANN1, MICHAEL ROBSON1, 1National Maternity Hospital, Dublin, Ireland OBJECTIVE: We used the Robson classification to analyse which groups of women have contributed to the increase in the CS rate in a hospital which has practised AML for 40 years. STUDY DESIGN: The following 10 groups were studied. 1. Nulliparous (N), single cephalic (SC), O36 weeks, spontaneous labour 2. N, SC, O36 weeks, induced or CS before labour 3. Multiparous (M), (excluding previous scar) SC, O36 weeks, spontaneous labour 4. M, (excluding previous scar) SC, O36 weeks, induced or CS before labour 5. Previous CS, SC, O36 weeks 6. All N breeches 7. All M breeches including previous scars (IPS) 8. All multiple pregnancies IPS 9. All abnormal lies IPS 10. All SC, !37 weeks IPS. These groups are mutually exclusive, totally inclusive, clinically relevant and prospectively identifiable. RESULTS: The biggest contributors to the increase and to the overall CS rate are groups 5 and 2. CONCLUSION: AML continues to maintain a low CS rate in spontaneously labouring N women with a SC pregnancy O36 weeks gestation. This group embodies the principles of AML. A standard CS classification helps compare different CS rates.
434 THE MFMU CESAREAN REGISTRY: IMPACT OF INFANT BIRTH WEIGHT ON SUBSEQUENT TRIAL OF LABOR FOR PATIENTS WITH PRIOR CESAREAN FOR DYSTOCIA ALAN PEACEMAN1, 1NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: To determine the influence of change in infant birth weight (BW) between pregnancies on the outcome of a trial of labor (TOL) for women whose first cesarean delivery (CD) was performed for dystocia. STUDY DESIGN: Secondary analysis of 7078 patients with one prior CD and no other deliveries after 20 weeks’ gestation, undergoing a TOL with a singleton gestation. Data were collected as part of a 19 center prospective observation study (1999-2002). Cases were classified as dystocia if the listed indication for CD in the first pregnancy was failed induction, cephalo-pelvic disproportion, failure to progress, or failed forceps or vacuum. RESULTS: For the cohort being studied, mean birth weight for the first delivery (BW1) was 3249 G 705 gm, with 89% occurring at term. Dystocia was the indication for the first CD for 3181 (44.9%) of the women undergoing TOL. TOL resulted in vaginal delivery for 54% of patients whose first CD was performed for dystocia, compared to 67% with other indications (p!.0001). For those whose first CD was for dystocia, TOL success was correlated with birth weight (p!.0001, table). Using logistic regression and adjusting for other potential confounding factors, for each increase of 100 gm of BW2 relative to BW1 the odds of a successful TOL decreased by 3.4% in this group. For all patients, the difference in BW did not correlate with risk of uterine rupture (p=.2). CONCLUSION: For patients with prior CD for dystocia, increasing BW in the subsequent TOL relative to the first BW diminishes the chances of success.
Classification of caesarean sections - contribution of each group Overall C/S rate
4.3% (1984)
8.8% (1994)
17.0% (2004)
Gp Gp Gp Gp Gp Gp Gp Gp Gp Gp
0.9% 0.5% 0.2% 0.2% 1.0% 0.3% 0.2% 0.2% 0.3% 0.5%
1.3% 1.8% 0.4% 0.6% 1.7% 1.0% 0.6% 0.4% 0.2% 0.8%
1.7% 4.2% 0.3% 1.4% 4.3% 1.8% 1.0% 0.7% 0.4% 1.2%
1 2 3 4 5 6 7 8 9 10
TOL success rates Indication for 1st CD
Dystocia (n = 3181)
Other (n = 3897)
BW2-BW1 O 500 gm BW2, BW1 within 500 gm BW1-BW2 O 500 gm
38% 53% 65%
64% 68% 68%
433 MATERNAL MORBIDITY ASSOCIATED WITH MULTIPLE CESAREAN DELIVERIES VICTORIA NISENBLAT1, SHLOMI BARAK2, GONEN OHEL1, RON GONEN1, 1TechnionIsrael Institute of Technology, Obstetrics and Gynecology, Haifa, Israel, 2 Bnai-zion Medical Center, Obstetrics and gynecology, Haifa, Israel OBJECTIVE: It has been recently claimed that an elective repeat cesarean delivery (CD) may be safer than a trial of labor after cesarean. However, these data may not be applicable to women who desire larger families, and may require multiple CD. The aim of this study was to assess maternal morbidity associated with multiple elective repeated cesarean deliveries. STUDY DESIGN: The medical records of all women who had undergone two or more elective cesarean deliveries in our institution, between 1.1.2000 and 31.5.2005 were reviewed. We compared, intra-operative and post-operative complications and morbidity, between women who had undergone 3 or more CD (multiple CD group) and women who had undergone a single elective repeat CD (2nd CD group). RESULTS: The multiple CD group included 277 women, of whom 213 had undergone three CD, 56 had four, 7 had five, and 1 had seven elective CD. The 2nd CD group comprised of 492 women. The two groups were similar with respect to chronic maternal medical disorders, pregnancy complications and type of anesthesia. Dense adhesions, 46.1% versus 25.6% (p!0.001), difficult delivery of the neonate, 7.9% versus 3.3% (!0.001) and blood loss over 1000 ml, 5.1% versus 0.2% (p!0.05) were significantly more common among subjects in the multiple CD group. Three women (1.1%) in the multiple CD group required hysterectomy (2 placenta accreta, 1 uterine atony) compared with only 1 woman (0.2%) in the 2nd CD group (placenta accrete). Bladder (2 cases) and bowel injury (1 case) occurred only in the 2nd CD group, however, these differences, in major morbidity between the groups, were not statistically significant. Minor and major post-operative morbidity was similar in the two groups. CONCLUSION: Multiple repeat CD are associated with more difficult surgery and increased blood loss, however, the incidence of major morbidity is relatively low.
432 ACTIVE MANAGEMENT OF LABOUR (AML) AND THE RISE IN CAESAREAN SECTION (CS) RATE 1984-2004 CLIONA MURPHY1, NANDINI RAVIKUMAR1, RATH ANN1, MICHAEL ROBSON1, 1National Maternity Hospital, Dublin, Ireland OBJECTIVE: We used the Robson classification to analyse which groups of women have contributed to the increase in the CS rate in a hospital which has practised AML for 40 years. STUDY DESIGN: The following 10 groups were studied. 1. Nulliparous (N), single cephalic (SC), O36 weeks, spontaneous labour 2. N, SC, O36 weeks, induced or CS before labour 3. Multiparous (M), (excluding previous scar) SC, O36 weeks, spontaneous labour 4. M, (excluding previous scar) SC, O36 weeks, induced or CS before labour 5. Previous CS, SC, O36 weeks 6. All N breeches 7. All M breeches including previous scars (IPS) 8. All multiple pregnancies IPS 9. All abnormal lies IPS 10. All SC, !37 weeks IPS. These groups are mutually exclusive, totally inclusive, clinically relevant and prospectively identifiable. RESULTS: The biggest contributors to the increase and to the overall CS rate are groups 5 and 2. CONCLUSION: AML continues to maintain a low CS rate in spontaneously labouring N women with a SC pregnancy O36 weeks gestation. This group embodies the principles of AML. A standard CS classification helps compare different CS rates.
434 THE MFMU CESAREAN REGISTRY: IMPACT OF INFANT BIRTH WEIGHT ON SUBSEQUENT TRIAL OF LABOR FOR PATIENTS WITH PRIOR CESAREAN FOR DYSTOCIA ALAN PEACEMAN1, 1NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: To determine the influence of change in infant birth weight (BW) between pregnancies on the outcome of a trial of labor (TOL) for women whose first cesarean delivery (CD) was performed for dystocia. STUDY DESIGN: Secondary analysis of 7078 patients with one prior CD and no other deliveries after 20 weeks’ gestation, undergoing a TOL with a singleton gestation. Data were collected as part of a 19 center prospective observation study (1999-2002). Cases were classified as dystocia if the listed indication for CD in the first pregnancy was failed induction, cephalo-pelvic disproportion, failure to progress, or failed forceps or vacuum. RESULTS: For the cohort being studied, mean birth weight for the first delivery (BW1) was 3249 G 705 gm, with 89% occurring at term. Dystocia was the indication for the first CD for 3181 (44.9%) of the women undergoing TOL. TOL resulted in vaginal delivery for 54% of patients whose first CD was performed for dystocia, compared to 67% with other indications (p!.0001). For those whose first CD was for dystocia, TOL success was correlated with birth weight (p!.0001, table). Using logistic regression and adjusting for other potential confounding factors, for each increase of 100 gm of BW2 relative to BW1 the odds of a successful TOL decreased by 3.4% in this group. For all patients, the difference in BW did not correlate with risk of uterine rupture (p=.2). CONCLUSION: For patients with prior CD for dystocia, increasing BW in the subsequent TOL relative to the first BW diminishes the chances of success.
Classification of caesarean sections - contribution of each group Overall C/S rate
4.3% (1984)
8.8% (1994)
17.0% (2004)
Gp Gp Gp Gp Gp Gp Gp Gp Gp Gp
0.9% 0.5% 0.2% 0.2% 1.0% 0.3% 0.2% 0.2% 0.3% 0.5%
1.3% 1.8% 0.4% 0.6% 1.7% 1.0% 0.6% 0.4% 0.2% 0.8%
1.7% 4.2% 0.3% 1.4% 4.3% 1.8% 1.0% 0.7% 0.4% 1.2%
1 2 3 4 5 6 7 8 9 10
TOL success rates Indication for 1st CD
Dystocia (n = 3181)
Other (n = 3897)
BW2-BW1 O 500 gm BW2, BW1 within 500 gm BW1-BW2 O 500 gm
38% 53% 65%
64% 68% 68%