375: Trial of labor versus elective repeat caesarean section in twin pregnancies after a previous caesarean

Abstract

A growing number of women with multiple gestations and a previous cesarean section (CS) are candidates for a trial of labor after cesarean (TOLAC). Evidence to guide decisions regarding optimal mode of delivery in this population is lacking. Our objective was to perform a systematic review and meta-analysis of success rates and maternal and neonatal outcomes in women with twin pregnancy attempting TOLAC versus elective repeat cesarean section (ERCS). We searched MEDLINE, Embase, and Web of Science from data inception to May 2018 with no language or regional restrictions, to identify all studies that compared TOLAC and ERCS in twin gestations for maternal and/or neonatal outcomes. Our primary outcome was adverse maternal and neonatal outcomes in either delivery mode. Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. We assessed the pooled relative risk and mean difference using a random-effects model of maternal and neonatal outcomes by comparing twin pregnancies with a previous CS that underwent TOLAC to ERCS. The pooled event rate for successful VBAC and uterine rupture in women who underwent TOLAC was determined using a random-effects model. Of the 841 citations identified, 10 were eligible for analysis (8,099 pregnancies, with 2,336 TOLAC cases and 5,763 ERCS cases, reporting the outcome of 3,188 neonates). The pooled event rate for a successful VBAC was 72.2% (95% CI 59.7-83.2%). The pooled event rate for uterine rupture during TOLAC was 0.87% (95% CI 0.51%-1.31%). TOLAC was associated with a significantly higher risk of neonatal death (RR 3.02: 95% CI, 1.07-8.54) compared to ERCS, with no significant differences in mean gestational age at delivery, NICU admission rates or 5’ Apgar<7 between the groups. While infection rate was significantly lower in women undergoing TOLAC (RR 0.48: 95% CI, 0.25-0.90) the rate of, uterine rupture, hysterectomy and dehiscence was comparable. TOLAC in twins is associated with successful vaginal delivery of both twins in a majority of the cases with rupture rates of less than 1%. While maternal infectious morbidity decreases in TOLAC, the finding of increased rate of neonatal death raises concerns and requires further investigation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)