Elective Primary Cesarean Delivery Research Articles

Seeking the Truth About Primary Elective Cesarean Delivery and Pelvic Floor Disorders: A Systematic Review and Meta-Analysis.

A better understanding of the effect of elective cesarean delivery (CD) on the development of pelvic floor disorders can help obstetricians counsel pregnant women. This study aimed to perform a systematic review and meta-analysis evaluating whether primary elective CD is protective against pelvic floor disorders. Using the MOOSE criteria, electronic databases were searched for studies that compared the prevalence of pelvic floor disorders among primiparous women. Outcomes of interest were urinary incontinence (UI), fecal incontinence (FI), anal incontinence (AI), and pelvic organ prolapse (POP). Comparisons were made between CD before the onset of labor ("Elective CD"), CD after trial of labor ("Labor CD"), and vaginal delivery (VD). Risk ratios (RRs) were computed using STATA. Between-study heterogeneity was assessed via Cochrane's homogeneity test and review of the I2 statistic. Nineteen studies were included. The overall prevalence of UI for Elective CD was estimated at 7% (95% confidence interval [CI], 3%-13%), Labor CD at 14% (95% CI, 8%-21%), and VD at 26% (95% CI, 20%-32%). Meta-analysis demonstrated a decreased risk of UI after Elective CD compared with Labor CD (RR, 0.75; P = 0.011) or VD (RR, 0.43; P < 0.001). There was a decreased risk of FI or AI after Elective CD compared with VD, but not when compared with Labor CD. Only 2 studies examined POP, precluding meta-analysis. Among primiparous women, Elective CD may be protective against UI when compared with Labor CD. There was not a protective effect of Elective CD against FI and AI when compared with Labor CD. More data on the effect of elective CD on POP are needed.

Cesarean delivery on maternal request in the United States from 1999 to 2015

The rate of cesarean delivery has increased in the United States over the last several decades. However, the rate of cesarean delivery on maternal request remains undetermined, and recent data on cesarean delivery on maternal request are lacking. This study aimed to describe the prevalence and temporal trends of cesarean delivery on maternal request in the United States and characterize the population of women who elect to undergo a cesarean delivery in the absence of fetal or maternal indications. Maternal outcomes between women who delivered by cesarean delivery on maternal request and those who did not were compared. A retrospective cohort study was conducted using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1999 to 2015. An algorithm based on International Classification of Diseases, Ninth Revision codes was created to identify patients who underwent a primary elective cesarean delivery in the absence of fetal or maternal indications. Maternal characteristics and outcomes between women who delivered by cesarean delivery on maternal request and those who did not were compared using descriptive and logistic regression analyses. Of the 13,698,835 deliveries included throughout the study period, 228,586 were identified as cesarean delivery on maternal request. Rates of cesarean delivery on maternal request among all live births increased throughout the study period, from 1% in 1999 to 1.62% in 2015 (P<.0001). Women who delivered by cesarean delivery on maternal request were more likely to be >35 years of age, were in the highest income quartile, and have private insurance. Cesarean delivery on maternal request was associated with an increased risk of venous thromboembolism (odds ratio, 1.9; 95% confidence interval, 1.8-2.0), myocardial infarction (odds ratio, 6.3; 95% confidence interval, 3.8-10.4), sepsis (odds ratio, 5.6; 95% confidence interval, 4.7-6.6), disseminated intravascular coagulation (odds ratio, 2.9; 95% confidence interval, 2.3-3.7), death (odds ratio, 14.5; 95% confidence interval, 11.4-18.6), and prolonged hospital stay (odds ratio, 4.9; 95% confidence interval, 4.8-5.1) and a lower risk of postpartum hemorrhage (odds ratio, 0.7; 95% confidence interval, 0.7-0.7). Our findings indicated that cesarean delivery on maternal request accounts for a small but increasing proportion of all cesarean deliveries in the United States. Cesarean delivery on maternal request was more prevalent among women with certain demographic characteristics, indicating that the option of cesarean delivery on maternal request may be more appealing or more frequently offered to a certain population of women. Although the overall risk of adverse events is low for individual births, population effects can result in increased morbidity and mortality. Therefore, the rates of cesarean delivery on maternal request should be monitored on a national level. Study findings were limited by the absence of a specific diagnostic code for cesarean delivery on maternal request.

Sezaryen Sonrası Cerrahi Alan Enfeksiyonlarının Erken Dönem Tanısında Prokalsitonin ve C-reactive protein Ölçümlerinin Yeri

Objective: We aimed to determine whether serum procalcitonin (PCT) levels measured after cesarean section were superior to the levels of other infection markers in the early diagnosis of surgical site infection (SSI).&#x0D; Material and Methods: The present study was conducted with consecutive 249 patients who underwent elective primary cesarean delivery in our obstetrics clinic of a Private Hospital between November 2018 and April 2019. Measurements of serum PCT, C-reactive protein (CRP) and white blood cell (WBC) counts were performed at the postoperative 6th, 12thand 24th hours. The participating patients were examined for SSI on the postoperative 2nd,4h and 7th days.&#x0D; Results: Of the participants, 15 (6%) developed surgical site infections, PCT was the most sensitive and specific marker of the SSI. Area under the curve (AUC) for PCT in predicting the SSI was 0.912 (95% CI: 0.79-1) and cutoff point was 0.099 ng/ml with a sensitivity of 93.3%, and specificity of 92.3% (p

Outcome of multiple cesarean sections in a tertiary maternity hospital in the United Arab Emirates: A retrospective analysis

TitleOutcome of multiple cesarean sections in a tertiary maternity hospital in the United Arab Emirates. ObjectiveTo describe the operative outcomes, clinical findings, maternal morbidity and neonatal outcome associated with increasing numbers of cesarean deliveries. DesignRetrospective study. SettingCorniche Hospital, Abu Dhabi, United Arab Emirates. PopulationThe study cohort was 1008 women giving birth by cesarean section who had previously undergone one or more cesarean sections, who had a singleton pregnancy, and who were not in labor. MethodsA retrospective study was undertaken over the one-year period from January 2016 to December 2016. Women were divided into five groups according to number of previous cesarean sections. The first group comprised of women who had one previous cesarean section, the second group women who had two previous cesarean sections, the third group consequently three previous cesarean sections and the fourth group four previous cesarean sections, whereas in the fifth group women had previously five or more previous cesarean sections. The maternal and neonatal outcomes of the groups were retrospectively evaluated. ResultsThe risks of placenta previa, placenta accreta, uterine dehiscence or rupture, postpartum hemorrhage, blood transfusion, bladder injury, lengths of operative time and hospital stay, and number of admissions to the high dependency unit increased with increasing numbers of previous cesarean sections. Women with five or more previous cesarean sections had a 10-fold increased risk of placenta previa (odds ratio [OR], 9.8; 95 % confidence interval [CI], 3.3–28.6), a 27 - fold increased risk of placenta accreta (OR, 26.5; 95 % CI, 4.2–166.3), and an 11-fold increased risk of uterine dehiscence or rupture (OR, 11.3; 95 % CI, 1.8–70.8). DiscussionThe results of our study indicate that serious maternal morbidity increases with increasing numbers of previous cesarean sections. Women planning large families should consider the risks of repeat cesarean sections when contemplating elective primary cesarean delivery or attempted vaginal birth after one previous cesarean section.

Sudden Diastasis of Rectus Abdominis During Labor: A Case Report

We present a case of a nulliparous patient with a sudden diastasis of rectus abdominis (DRA) during labor. DRA is defined in literature as a separation of 2 muscle bellies of rectus abdominis of more than 2 fingerbreadths either 4.5 cm above or below the umbilicus.&lt;sup&gt;1&lt;/sup&gt; DRA is clinically recognized; however, there is limited knowledge on the prevalence, risk factors, and complications of DRA. Here, we present a patient who had an abrupt DRA during labor with herniation of bowel anterior to the fundus with associated abdominal pain. Due to similarity in presentation as uterine rupture, this case resulted in an elective cesarean delivery. Thus, this case report highlights the need to review DRA and uterine rupture and the associated risk factors to help health care professionals make prompt diagnoses and avoid elective primary cesarean delivery in an otherwise healthy, nulliparous patient.

The risk of abnormal placentation and hemorrhage in subsequent pregnancy following primary elective cesarean delivery

Objective: We aimed to evaluate the relationship between mode of first delivery with subsequent placenta previa, placenta accreta/increta, and significant postpartum hemorrhage (PPH).Method: This retrospective cohort study included women with two consecutive singleton deliveries between 2007 and 2017 at our institution if the women were nulliparous and delivered at term at the time of first delivery. The first pregnancy delivery mode was classified as (1) vaginal delivery, (2) antepartum cesarean delivery (CD) without labor, or (3) intrapartum CD after the onset of labor. Within these three groups, rates of placenta previa, placenta accreta/increta, and significant PPH at the time of the second delivery were compared. Significant PPH was defined as hemorrhage requiring a blood transfusion.Results: A total of 8208 women were analyzed. Most first deliveries were vaginal (n = 5210, 63.5%), followed by antepartum CD (n = 2432, 29.6%) and intrapartum CD (n = 566, 6.9%). The incidence of placenta previa in subsequent deliveries differed by previous delivery mode: vaginal, 0.9%; antepartum CD, 2.0%; intrapartum CD, 1.6% (p < .001). Similar differences were also observed with respect to placenta accreta/increta (0.5 versus 1.5 versus 0.9%, p < .001) and PPH (0.6 versus 1.2 versus 0.4%, p = .017). Compared to the previous vaginal delivery group, the antepartum CD group had increased risks of placenta previa (aORs 2.02, 95% CI 1.35–3.05), placenta accreta/increta (aOR 2.52; 95% CI 1.53–4.14) and PPH (aOR 1.78, 95% CI 1.14–2.98) in subsequent pregnancies. However, the previous intrapartum CD was not significantly associated with increased risks of these complications.Conclusion: Previous antepartum CD was associated with two-fold increased risks of placenta previa, placenta accreta/increta, and significant PPH in the second delivery compared to women with a prior vaginal delivery. The increased risks of subsequent abnormal placentation following primary antepartum CD may be important for counseling concerning nonmedically indicated elective cesarean.Condensation: Previous antepartum cesarean delivery (CD) was associated with two-fold increased risks of placenta previa, placenta accreta/increta, and significant PPH in the second delivery.

731: The risk of abnormal placentation and hemorrhage in subsequent pregnancy following primary elective caesarean delivery

China has the highest caesarean rate in the world largely driven by the overuse of elective caesarean delivery (CD). With termination of the one child policy in 2015, more women are now having a second pregnancy. We aimed to evaluate the relationship between mode of first delivery with subsequent placenta previa, placenta accreta/increta and significant postpartum hemorrhage (PPH). This retrospective cohort study included women with 2 consecutive singleton deliveries between 2007-2017 at our institution if the women were nulliparous and delivered at term at the time of first delivery. The first pregnancy delivery mode was classified as (1) vaginal delivery, (2) antepartum CD without labor, or (3) intrapartum CD after onset of labor. Within these 3 groups, rates of placenta previa, placenta accreta/increta and PPH at the time of the second delivery were compared. Significant PPH was defined as hemorrhage requiring blood transfusion. Logistic regression was used to adjust for maternal characteristics, gestational week, obstetric complications, previous pregnancy loss, history of placenta previa, and the time interval between the two pregnancies. RESULTS: A total of 8 208 women were analyzed. Most first deliveries were vaginal (n=5210, 63.5%), followed by antepartum CD (n=2432, 29.6%) and intrapartum CD (n=566, 6.9%). The incidence of placenta previa in subsequent deliveries differed by previous delivery mode: vaginal, 0.9%; antepartum CD, 2.0%; intrapartum CD,1.6% (P<0.001). Similar differences were also observed with respect to placenta accreta/increta (0.5% vs 1.5% vs 0.9%, P<0.001) and PPH (0.6% vs 1.2% vs 0.4%, P=0.017). Compared to the previous vaginal delivery group, the antepartum CD group had increased risks of placenta previa (aORs 2.02, 95% CI 1.35-3.05), placenta accreta/increta (aOR 2.52; 95% CI 1.53-4.14) and PPH ( aOR 1.78, 95%CI 1.14-2.98) in subsequent pregnancies. However, previous intrapartum CD was not significantly associated with increased risks of these complications. Previous antepartum CD was associated with 2-fold increased risks of placenta previa, placenta accreta/increta and significant PPH in the second delivery compared to women with a prior vaginal delivery. The increased risks of subsequent abnormal placentation following primary antepartum CD may be important for counseling concerning non-medically indicated elective caesarean.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Does Suture Material Affect Uterine Scar Healing After Cesarean Section? Results from a Randomized Controlled Trial

ABSTRACTBackground: Impaired healing of the uterine scar after cesarean has been associated with adverse gynecological and obstetric outcomes. Although a large number of studies have been conducted on the events leading to this, information obtained from prospective randomized studies examining the role of suture material in the formation of cesarean scar defect (CSD) is lacking. Objective: To evaluate the effects of synthetic suture materials on CSD formation. Study design: We performed a two-arm 1:1 randomized study in women with singleton pregnancies undergoing elective primary cesarean delivery after the 38th week of gestation. Uterine scar closure was performed using synthetic absorbable monofilament and multifilament sutures. The primary outcome was residual myometrial thickness (RMT) in the area of the scar, measured by transvaginal ultrasound 6–9 months after birth. Secondary outcomes included differences in mean operative time, mean estimated blood loss at the time of surgery, and the rates of postoperative gynecological sequelae. Results: Complete follow-up was obtained from 94 (88%) of 107 participants. RMT was thicker in the monofilament compared to the multifilament suture group (5.5 ± 2.24 vs. 4.18 ± 1.76, p = 0.01). Hemoglobin delta was higher in the monofilament suture group (1.59 ± 0.96 vs. 1.25 ± 0.60, p = 0.04). There was no statistically significant difference between the monofilament suture and multifilament suture groups in terms of gynecological sequelae. Conclusion: Closure of the uterine scar with monofilament suture has a positive effect on scar healing and increases RMT thickness.

Effect of Primary Elective Cesarean Delivery on Placenta Accreta: A Case-Control Study.

Background:Cesarean section (CS) is an independent risk factor for placenta accreta. Some researchers think that the timing of primary cesarean delivery is associated with placenta accreta in subsequent pregnancies. The aim of this study was to investigate the risk of placenta accreta following primary CS without labor, also called primary elective CS, in a pregnancy complicated with placenta previa.Methods:A retrospective, single-center, case-control study was conducted at Peking University Third Hospital. Relevant clinical data of singleton pregnancies between January 2010 and September 2017 were recorded. The case group included women with placenta accreta who had placenta previa and one previous CS. Control group included women with one previous CS that was complicated with placenta previa. Maternal age, body mass index, gestational age, fetal birth weight, gravity, parity, induced abortion, the rate of women received assisted reproductive technology, other uterine surgery, and primary elective CS were analyzed between the two groups.Results:The rate of primary elective CS (90.1% vs. 69.9%, P < 0.001) was higher, and maternal age was younger (32.7 ± 4.7 years vs. 34.6 ± 4.0 years, P < 0.001) in case group, compared with control group. Case group also had higher gravity and induced abortions compared with the control group (both P < 0.05). Primary CS without labor was associated with significantly increased risk of placenta accreta in a subsequent pregnancy complicated with placenta previa (odds ratio: 3.32; 95% confidential interval: 1.68–6.58).Conclusion:Women with a primary elective CS without labor have a higher chance of developing an accreta in a subsequent pregnancy that is complicated with placenta previa.

Timing of elective cesarean delivery at term and its impact on maternal and neonatal outcomes among Thai and other Southeast Asian pregnant women.

The impact of timing of elective cesarean delivery (CD) at term on maternal and neonatal outcomes among Thai and other Southeast Asian pregnancies was investigated. The rate of spontaneous labor before the scheduled CD, as well as maternal characteristics predicting spontaneous labor, was also evaluated. Data on maternal and neonatal outcomes of 1221 singleton pregnancies scheduled for either an elective repeat CD or an elective primary CD at 37-40 weeks of gestation were studied. The association between maternal characteristics and the risk of spontaneous labor was evaluated by univariate and multivariate analyses. There were no significant differences in severe maternal complications between performing an elective CD at 39 weeks and at the other gestational ages. Severe neonatal complications were significantly decreased when a CD was performed electively from 38 weeks onwards. A total of 503 women (41.2 %) went into spontaneous labor before the scheduled CD. Using 39 weeks as the reference group, scheduling a CD at 37 or 38 weeks decreased the risk of spontaneous labor (6.67-fold and 4.55-fold, respectively) while scheduling a CD at 40 weeks had a 2.54-fold increased risk. A history of previous CD and teenage pregnancy were also predictors of spontaneous labor; adjusted odds ratios were 14.27 and 3.93, respectively. The timing of elective CD at term had impacts on pregnancy outcomes among Thai and other Southeast Asian women. Gestational age at scheduled CD, a previous CD and teenage pregnancy were predictors of spontaneous labor.

Persistent Paralysis After Spinal Anesthesia for Cesarean Delivery

Anterior spinal artery syndrome has rarely been reported as a cause of permanent neurologic complications after neuraxial anesthesia in obstetric patients. A parturient developed anterior spinal artery syndrome after spinal anesthesia for cesarean delivery. A healthy 32-year-old parturient presented at 41(2/7) weeks for primary elective caesarean delivery for breech presentation. Spinal anesthesia was easily performed with clear cerebrospinal fluid, and block height was T4 at 5 minutes. Intraoperative course was uneventful except for symptomatic bradycardia (37-40 beats per minute) and hypotension (88/44 mm Hg) 4 minutes postspinal anesthesia, treated with ephedrine and atropine. Dense motor block persisted 9 hours after spinal anesthesia, and magnetic resonance imaging of the lumbosacral region was normal, finding no spinal cord compression or lesion. Physical examination revealed deficits consistent with a spinal cord lesion at T6, impacting the anterior spinal cord while sparing the posterior tracts.

Impact of uterine closure on residual myometrial thickness after cesarean: a randomized controlled trial

Incomplete healing of uterine scar after cesarean has been associated with adverse gynecological and obstetrical outcomes. Several studies reported that uterine closure at cesarean influences the healing of uterine scar and the risk of uterine rupture at subsequent pregnancies: the commonly used locked single-layer suture including the decidua being associated with a 4-fold increased risk of uterine rupture. However, data from randomized trials are lacking. We sought to evaluate the impact of 3 techniques of uterine closure after cesarean delivery on uterine scar healing. This was a 3-arm 1:1:1 randomized study in women with singleton pregnancies undergoing elective primary cesarean delivery at ≥38 weeks' gestation. Closure of the uterine scar was carried out by locked single layer including the decidua, double layer with locked first layer including the decidua, or double layer with unlocked first layer excluding the decidua. Primary outcome was residual myometrial thickness (RMT) at the site of the scar, measured by transvaginal ultrasound 6 months after delivery. Secondary outcome was the RMT as a percentage of the myometrial thickness above the scar (healing ratio). Intent-to-treat analyses using Student t test were performed to compare each double-layer technique to the single-layer closure, and P < .025 was considered significant. Complete follow-up was obtained from 73 (90%) of the 81 participants. Compared to single-layer closure, double-layer closure with unlocked first layer was associated with thicker RMT (3.8 ± 1.6 mm vs 6.1 ± 2.2 mm; P < .001) and greater healing ratio (54 ± 20% vs 73 ± 23%; P = .004). In contrast, double-layer closure with locked first layer was not significantly different than single-layer closure in either RMT (4.8 ± 1.3; P = .032) or healing ratio (60 ± 21%; P = .287). Double-layer closure with unlocked first layer is associated with better uterine scar healing than locked single layer.

Validating the British Columbia Perinatal Data Registry: a chart re-abstraction study.

BackgroundThe British Columbia Perinatal Data Registry (BCPDR) contains individual-level obstetrical and neonatal medical chart data for virtually all births occurring in British Columbia, Canada. The objective of this study was to assess the validity of information in the BCPDR by performing a provincial chart re-abstraction study.MethodsA two-stage stratified clustered sampling design was employed. Obstetrical facilities were stratified based on geographic location and obstetrical volume. Charts of mothers and newborns with a length of stay of five or more days or transfer to another facility following the delivery were oversampled. A total of 85 maternal and 32 newborn variables were assessed for completeness (percent completion) and validity (sensitivity and specificity for categorical variables, intra-class correlation coefficient [ICC] for continuous variables).Results1,084 maternal and 1,142 newborn charts were abstracted. Mandatory variables such as primary indication for induction and primary indication for cesarean delivery were 100 % complete. Some variables such as pre-pregnancy weight were relatively more complete in the re-abstraction as compared with the BCPDR (83.0 % vs 76.8 %; p < 0.001). The validity of key surveillance variables was high (e.g., HIV screening completed [sensitivity 98.0 %, 95 % confidence interval (CI) 97.0–98.8 %; specificity 72.3 %, 95 % CI 60.8–81.9 %], induction of labour [sensitivity 93.9 %, 95 % CI 90.2–96.5 %; specificity 98.7 %, 95 % CI 97.7–99.3 %], primary elective cesarean delivery [sensitivity 96.0 %, 95 % CI 83.8–99.7 %; specificity 99.8 %, 95 % CI 99.4–100.0 %], gestational age from newborn examination [ICC 0.99, 95 % CI 0.99–0.99]). Examples of variables with lower validity included total admissions prior to delivery episode, maternal smoking status, and timing of breastfeeding initiation.ConclusionMany important clinical and population health variables in the BCPDR had excellent validity. Some key variables warrant strengthening through improved definitions, system changes, and abstractor training.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0563-7) contains supplementary material, which is available to authorized users.

Comparing Clinical Outcomes

INTRODUCTION: Although the postoperative complications of cesarean delivery are well defined, studies have yet to identify if the rate of complications vary between attending and supervised resident surgeons. The purpose of this study was to determine whether the clinical outcome in elective cesarean delivery is less favorable when the operation is performed by a supervised resident surgeon. METHODS: Patients who underwent primary elective cesarean delivery at Winnie Palmer Hospital January to December 2012 were stratified into group I or II based on whether an attending or supervised resident surgeon was documented as performing the operation. Surgical length, postoperative complications, and length of hospital stay were collected. RESULTS: Of 359 cases, 286 were performed by an attending surgeon (group I) and 73 were performed by a supervised resident surgeon (group II). The rate of postoperative complications for group I and II was 3.5% and 8.2%, respectively, without statistical significance (P=.11). The median surgical length for group I and II was 39 and 54 minutes, respectively, with statistical significance (P<.001). The median length of hospital stay for group I and II was 4 and 3 days, respectively, with statistical significance (P<.001). CONCLUSION AND IMPLICATIONS: Patients undergoing elective cesarean delivery performed by a supervised resident surgeon are not more likely to experience postoperative complications than those operated on by an attending surgeon. On average, patients operated on by supervised resident surgeons have a 1-day shorter hospital stay. This finding is of most importance because longer hospital stays are associated with increased health care costs.

The Relationship Between Socioeconomic Status and the Prevalence of Elective Cesarean Section in Nulliparous Women in Niknafs Teaching Centre in Rafsanjan, Iran

Background: In the recent decades, the high rate of cesarean section is increased worldwide along with critical concerns about its primary benefits. Many researchers showed the positive relationship between socioeconomic status (SES) and the prevalence of cesarean delivery. However, it seems that the prevalence of elective cesarean section is even rising in low socioeconomic classes. Objectives: The aim of this study was to evaluate the relationship between the socioeconomic status and the prevalence of elective cesarean section in nulliparous women in Niknafs Teaching Centre, in Rafsanjan, Iran. Patients and Methods: This cross-sectional study was comprised of 459 nulliparous women and was carried out in Niknafs Teaching Center, in Rafsanjan from August 2011 to April 2012. A valid questionnaire was completed during a brief interview with the subjects. It included the demographic, economic, and educational statuses of the subjects as well as information about the delivery types. The collected data was analyzed using chi-square and Fisher exact tests in SPSS version 16. Results: Five socioeconomic groups were defined as very poor, poor, fair, good, and very good. Overall, 74% of the participants were placed in fair and lower groups. Significant relationships were observed between SES and primary elective cesarean delivery (P < 0.001) as well as the final rate of cesarean delivery (P = 0.02). However, there was no statistically significant relationship between the reason for cesarean delivery and SES of the mothers. Conclusions: The improvement of the SES has a linear relationship with demand for cesarean delivery. But elective cesarean section is notably high in Iran even in lower socioeconomic classes. This could verify that socioeconomic factors are not the only reason for the high prevalence of cesarean delivery in Iran and that other factors are in fact responsible for this level of performance.

The Risk of Placenta Accreta Following Primary Elective Caesarean Delivery

The Risk of Placenta Accreta Following Primary Elective Caesarean Delivery

The Risk of Placenta Accreta Following Primary Elective Caesarean Delivery

The rate of abnormal human placentation has risen dramatically, with an increased risk of placenta accreta in older women, women with placenta previa in the present pregnancy, and those with a previous cesarean delivery (CD). This case-control study was performed to determine the association between placenta accreta in a pregnancy complicated by placenta previa and the type of primary CD. Parturients with placenta accreta and placenta previa from 1993 to 2008 were included. Data analysis examined the effects of delivery mode for the primary CD on the development of placenta accreta or its variants in a pregnancy complicated by placenta previa. The primary outcome was the influence of the indication for the primary CD (elective without labor or emergency after some labor) on the subsequent risk of developing placenta accreta. Secondary outcomes were the risk of placenta accreta considering parity, gravidity, uterine surgery before the primary CD, and vaginal delivery before and after the primary CD. Criteria for controls included placenta previa, delivery during the study period, and a history of 1 or more CDs. Statistical analysis was performed using SPSS version 18 for Windows and Logxact 8.1. All tests were 2 sided, and P < 0.05 indicated statistical significance. From 82,667 live births, 88 cases of placenta accreta were identified. The final cohort included 65 women with placenta accreta or variants matched with 101 controls; 67% of cases and 38% of controls delivered at less than 37 weeks’ gestation. Thirty-seven cases (56.9%) had placenta accreta, 15 (23.1%) had placenta increta, and 13 (20.0%) had placenta percreta. Cases and controls differed neither in maternal age, gravidity, or parity nor in other demographic or socioeconomic factors (all P > 0.05). A primary elective CD was performed in 46.2% of the cases and 18.6% of controls (P < 0.001). For women with primary emergency CD, significant differences were noted between cases and controls neither in cervical dilatation or length of labor in the primary labor nor in gestational age or presentation when the primary CD occurred without labor. Compared with women in whom the primary CD occurred after some labor, women whose primary CD occurred without labor were significantly more likely to develop placenta accreta (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.47–6.12; P = 0.025). Gravidity (aOR, 0.79; 95% CI, 0.61–1.03, P = 0.063), parity (aOR, 1.12; 95% CI, 0.75–1.66; P = 0.588), previous vaginal delivery (aOR, 0.85; 95% CI, 0.60–1.21; P = 0.364), and previous uterine surgery (aOR, 1.06; 95% CI, 0.53–2.15; P = 0.866) were not associated with placenta accreta with coexisting placenta previa. Women who undergo a primary CD without labor are 3 times more likely to develop placenta accreta in a subsequent pregnancy complicated by placenta previa than women whose primary CD occurred after labor onset. Clinicians should be aware of this risk when counseling women for whom CD is an option. They should consider limiting the availability of elective CD as a choice to women in whom the alternatives of labor with vaginal delivery or the possibility of an emergency CD pose an unacceptable risk to her and the fetus’s well-being.

Consequences of a Primary Elective Cesarean Delivery Across the Reproductive Life

Consequences of a Primary Elective Cesarean Delivery Across the Reproductive Life

Consequences of a Primary Elective Cesarean Delivery Across the Reproductive Life

Seattle, Washington Financial Disclosure: The author did not report any potential conflicts of interest.

Consequences of a Primary Elective Cesarean Delivery Across the Reproductive Life

To estimate cumulative risks of morbidity associated with the choice of elective cesarean delivery for a first delivery. A decision analytic model was designed to compare major adverse outcomes across a woman's reproductive life associated with the choice of elective cesarean delivery compared with a trial of labor at a first delivery. Maternal outcomes assessed included maternal transfusion, hysterectomy, thromboembolism, operative injury, and death. Neonatal outcomes assessed included cerebral palsy and permanent brachial plexus palsy in the offspring. Choosing an initial cesarean delivery resulted in a 0.3% increased risk of a major adverse maternal outcome in the first pregnancy. In each subsequent pregnancy, the difference in composite maternal morbidity increased such that by the fourth pregnancy, the cumulative risk of a major adverse maternal outcome was nearly 10% in the elective primary cesarean delivery group, three times higher than women who initially underwent a trial of labor. Although the choice of an initial cesarean delivery resulted in 2.4 and 0.41 fewer cases of cerebral palsy and brachial plexus palsy, respectively, per 10,000 women in the first pregnancy, by a fourth pregnancy, the risk of a adverse neonatal outcome was higher among offspring of women who had chosen the initial elective cesarean delivery (0.368% compared with 0.363%). Maternal morbidity associated with the choice of primary elective cesarean delivery increases in each subsequent pregnancy and is greater in magnitude than that associated with the choice of a trial of labor. These increased risks are not offset by a substantive reduction in the risk of neonatal morbidity.