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Muraca GM, Peled T, Kirubarajan A, Weiss A, Sela HY, Grisaru-Granovsky S, Rottenstreich M. The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth. Am J Obstet Gynecol MFM 2024; 6:101326. [PMID: 38447679 DOI: 10.1016/j.ajogmf.2024.101326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/18/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND An increased risk for preterm birth has been observed among individuals with a previous second stage cesarean delivery when compared with those with a previous vaginal delivery. One mechanism that may contribute to the increased risk for preterm birth following a second stage cesarean delivery is the increased risk for cervical injury because of extension of the uterine incision (hysterotomy) into the cervix. The contribution of hysterotomy extension to the rate of preterm birth in a subsequent pregnancy has not been investigated and may shed light on the mechanism underlying the observed relationship between the mode of delivery and subsequent preterm birth. OBJECTIVE We aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery. STUDY DESIGN We performed a retrospective cohort study using electronic perinatal data collected from 2 university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks' gestation; secondary outcomes included subsequent preterm birth at <34, <32, and <28 weeks' gestation. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios and 95% confidence intervals. Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labor, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity. RESULTS A total 4797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labor, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses that controlled for several confounders showed that a history of hysterotomy extension was not associated with a higher risk for preterm birth <37 weeks' gestation (adjusted rate ratio, 1.55; 95% confidence interval, 0.98-2.47), but it was associated with preterm birth <34 weeks' gestation (adjusted rate ratio, 2.49; 95% confidence interval, 1.06-5.42). CONCLUSION Patients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks' gestation when compared with patients who did not have this injury. This association was not observed for preterm birth <37 weeks' gestation. Future research should aim to replicate our analyses with incorporation of additional data to minimize the potential for residual confounding.
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Affiliation(s)
- Giulia M Muraca
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University (Dr Muraca), Hamilton, Canada; Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet (Dr Muraca), Stockholm, Sweden.
| | - Tzuria Peled
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Abirami Kirubarajan
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada
| | - Ari Weiss
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University (Drs Muraca, Kirubarajan, and Rottenstreich), Hamilton, Canada; Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University School of Medicine (Drs Peled, Weiss, Sela, Grisaru-Granovsky, and Rottenstreich), Jerusalem, Israel
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Hickland MM, Story L, Glazewska-Hallin A, Suff N, Cauldwell M, Watson HA, Carter J, Duhig KE, Shennan AH. Efficacy of transvaginal cervical cerclage in women at risk of preterm birth following previous emergency cesarean section. Acta Obstet Gynecol Scand 2020; 99:1486-1491. [PMID: 32777082 DOI: 10.1111/aogs.13972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/04/2020] [Accepted: 08/05/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Emergency cesarean sections (EMCS) are associated with subsequent preterm birth, particularly at full dilation (FDCS), which is a cause of both second trimester miscarriages and early, recurrent spontaneous preterm birth (sPTB). The optimal management for these women in subsequent pregnancies is currently unknown. This study aims to assess efficacy of transvaginal cervical cerclage (TVC) in prevention of preterm birth among women who have had an EMCS followed by a subsequent late miscarriage or sPTB. MATERIAL AND METHODS A historical cohort study was performed assessing outcomes of women attending the Preterm Surveillance Clinic at St Thomas' Hospital, London, who received TVC, with a history of EMCS (pregnancy A) followed by a sPTB/late miscarriage (pregnancy B) and a subsequent pregnancy (pregnancy C). A historical reference group managed in the same clinic was identified comprising women with any risk factor for sPTB, who required TVC. Incidence of delivery >24 to <30 weeks' gestation was compared with relative risk and 95% confidence intervals (CI). Subgroup analysis was carried out assessing women who had a previous FDCS. RESULTS 209 women with a previous EMCS during labor (50 with FDCS), followed by sPTB/late miscarriage were identified. 178 progressed beyond 24 weeks; of these, 56 received TVC and formed the study group. 905 high-risk women were identified; of these, 154 received TVC and formed the reference group. Despite TVC treatment, 17/56 (30%) of the study group delivered <30 weeks' gestation compared with 5/154 (3%) of the reference group (RR 9.4, 95% CI 3.6-24.2, P < .001). In the subset of 17 women in the study group with a previous FDCS, followed by sPTB/late miscarriage, 6/17 (35%) delivered <30 weeks' gestation, significantly higher than the reference group (P < .001) but similar to EMCS at less than full dilation (35% vs 28%, P = .596). Overall, 33/72 (46%) women receiving cerclage with prior EMCS had either a mid-trimester loss or delivery <30 weeks. CONCLUSIONS Transvaginal cervical cerclage appears less effective in preventing preterm birth among pregnant women who have had an EMCS followed by a sPTB/late miscarriage compared with other high-risk women. The lack of efficacy in the subgroup with an FDCS was similar.
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Affiliation(s)
| | - Lisa Story
- Department of Women and Children's Health, King's College London, London, UK
| | | | - Natalie Suff
- Department of Women and Children's Health, King's College London, London, UK
| | | | - Helena A Watson
- Department of Women and Children's Health, King's College London, London, UK
| | - Jenny Carter
- Department of Women and Children's Health, King's College London, London, UK
| | - Kate E Duhig
- Department of Women and Children's Health, King's College London, London, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, King's College London, London, UK
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Glazewska‐Hallin A, Story L, Suff N, Shennan A. Late-stage Cesarean section causes recurrent early preterm birth: how to tackle this problem? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:293-296. [PMID: 30937984 PMCID: PMC6771870 DOI: 10.1002/uog.20276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 06/09/2023]
Affiliation(s)
- A. Glazewska‐Hallin
- Department of Women and Children's HealthKing's College London, St Thomas' HospitalLondonUK
| | - L. Story
- Department of Women and Children's HealthKing's College London, St Thomas' HospitalLondonUK
| | - N. Suff
- Department of Women and Children's HealthKing's College London, St Thomas' HospitalLondonUK
| | - A. Shennan
- Department of Women and Children's HealthKing's College London, St Thomas' HospitalLondonUK
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