735 TOLAC versus repeat cesarean section amongst women with a twin gestation: a retrospective cohort study

Abstract

Greater than 90% of women with a previous cesarean section in the USA deliver by repeat cesarean section and one third of hospitals in the USA no longer offer a trial of labor after cesarean section (TOLAC). TOLAC amongst women with a singleton gestation is widely accepted but there is a paucity of data on TOLAC in twin gestations. We sought to assess maternal and neonatal outcomes amongst women with a current twin gestation and a prior cesarean section who opted to undergo TOLAC versus repeat cesarean section. This retrospective cohort study was undertaken at a community medical center from January 1st 2010 to December 31st 2019. Inclusion criteria were women with a current twin pregnancy at > 32 weeks gestation, presenting twin in vertex presentation and a history of one prior cesarean section. Exclusion criteria included a prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, non-vertex presenting twin, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. A total of 83 patients fulfilled study criteria. 81% of women who underwent TOLAC (N=21) had a successful vaginal delivery. There was no difference in mean gestational age between the two groups (37+2 vs 36+6 weeks, P=0.24). There were no differences in neonatal intensive care unit admissions for twin A (29% vs 28.6%, P=0.96) or twin B (27.4% vs 28.6%, P=0.94) and 5 minute APGAR scores for twin A (P=0.24) or twin B (P=0.63) amongst women who opted for TOLAC versus repeat cesarean section. Moreover, no difference in maternal morbidity was noted with regards to blood transfusion rates (4.8% vs 4.8%, P=1.0), bowel injury (0% vs 1.6 %, P=1.0) and immediate postpartum infection (0% vs 1.6 %, P=1.0). No hysterectomy, bladder injury, maternal or neonatal deaths occurred in either group. TOLAC following one prior cesarean section for women with a twin gestation has comparable maternal and neonatal morbidity with repeat cesarean section.