Women with a history of uterine rupture or dehiscence had excellent outcomes in subsequent pregnancies with scheduled cesarean deliveries, according to a research letter published online today in Obstetrics and Gynecology.
The findings are contrary to common advice that women with such a history avoid future pregnancies, on the basis of a currently estimated recurrence rate of 0 to 33%.
“Women with prior uterine rupture or uterine dehiscence appear to have a low risk of adverse outcomes in subsequent pregnancies if managed in a standardized manner,” writes Nathan S. Fox, MD, of Maternal Fetal Medicine Associates, PLLC, and Icahn School of Medicine at Mount Sinai in New York City. “We encourage other centers to report their experiences from this unique population.”
The researchers retrospectively reviewed the charts of 87 patients, all of whom delivered at Fox’s practice from July 2005 to August of this year when at least 24 weeks’ gestation. Clinic procedures involve scheduling cesarean deliveries at 36 to 37 weeks’ gestation for patients with a history of uterine rupture and at 37 to 39 weeks for those with a previous uterine dehiscence.
In addition to tracking placenta previa, placenta accreta, and uterine dehiscence at delivery, Fox’s team looked for the following severe complications: “uterine rupture, hysterectomy, transfusion, cystotomy, bowel injury, mechanical ventilation, intensive care unit admission, thrombosis, reoperation, maternal death, and perinatal death.” They calculated percentages and confidence intervals using women, not total pregnancies, as a denominator.
The analysis included cases from a previous report in 2014 that described outcomes for 20 pregnancies in 14 women with a history of uterine rupture and 40 pregnancies in 30 women with a history of uterine dehiscence. In that report, 6.7% of the 60 pregnancies involved uterine dehiscence at delivery, but none involved severe morbidity.
In this current review, the total patient population of 87 women (134 pregnancies) included 37 women (59 pregnancies) with a previous uterine rupture and 50 women (75 pregnancies) with a previous uterine dehiscence. Uterine rupture occurred in one pregnancy (0.7% of pregnancies; 1.2% of women), and no deaths occurred.
Overall uterine dehiscence incidence at delivery among the women was 18.4% (11.9% of pregnancies), “suggesting that these patients should not labor and supporting our protocol for cesarean delivery before the onset of labor,” Fox writes.
The woman who had the uterine rupture entered labor 2 days before her scheduled delivery, at 36 weeks 2/7 days, and had “three prior cesarean deliveries, a prior uterine dehiscence, and a unicornuate uterus,” Fox reported. The infant had 1-minute and 5-minute Apgar scores of 9 and did not need neonatal intensive care.
The only other severe morbidity observed was in a patient who had a cesarean delivery at 34 weeks’ gestation as a result of bleeding. She had transferred to the practice at 25 weeks and had a history of four cesarean deliveries, placenta previa, and suspected placenta accreta. At delivery, she had placenta accreta and needed a hysterectomy, mechanical ventilation, and blood transfusion.
Fox has disclosed no relevant financial relationships and did not report any external funding.
Obstet Gynecol. Published online December 5, 2019. Research Letter