Number Of Prior Cesarean Deliveries Research Articles

Factors Limiting Magnetic Resonance Imaging Diagnosis of Placenta Accreta Spectrum.

Placenta accreta spectrum (PAS) disorders are characterized by an abnormal adherence of the placenta to the uterine myometrium. Magnetic resonance imaging (MRI) is an important adjunct in antenatal diagnosis. We sought to determine if there are patient and MRI characteristics that limit the accuracy of PAS diagnosis and degree of invasion. We conducted a retrospective cohort analysis of patients who were evaluated for PAS by MRI from January 2007 to December 2020. Patient characteristics evaluated included number of prior cesarean deliveries, history of dilation and curettage (D&C) or dilation and evacuation (D&E), short interval pregnancy less than 18 months, and delivery body mass index (BMI). All patients were followed until delivery and MRI diagnosis was compared with final histopathology. Of the 353 patients with suspected PAS, 152 (43%) underwent MRI evaluation and were included in the final analysis. In patients who underwent MRI evaluation, 105 (69%) had confirmed PAS on pathology. Patient characteristics were similar between groups and not associated with accuracy of MRI diagnosis. MRI was accurate in diagnosing PAS and the associated degree of invasion in 83 (55%) patients. Accuracy was associated with lacunae (8 vs. 0%, p = 0.02), abnormal bladder interface (25 vs. 6%, p = 0.002), and T1 hyperintensity (13 vs. 1%, p = 0.002). Of the 69 (45%) patients in whom MRI was inaccurate, overdiagnosis was seen in 44 (64%) patients and underdiagnosis in 25 (36%) patients. Overdiagnosis was significantly associated with dark T2 bands (45 vs. 22%, p = 0.005). Underdiagnosis was associated with earlier gestational age at MRI (28 vs. 30 weeks, p = 0.049) and lateral placentation (16 vs. 2.4%, p = 0.025). Patient factors did not change MRI accuracy of PAS diagnosis. MRI is associated with a significant overdiagnosis of PAS when dark T2 bands are present, and underdiagnose PAS when performed earlier in gestation or when lateral placentation is present. · Patient factors are not associated with MRI accuracy of PAS diagnosis.. · MRI overdiagnoses PAS invasion when there are dark T2 bands.. · MRI underdiagnoses PAS invasion when performed earlier in gestation.. · Underdiagnosis of PAS is associated with lateral placentation..

Recent trends in term trial of labor after cesarean by number of prior cesarean deliveries

Cesarean delivery is a major source of maternal morbidity, and repeat cesarean delivery accounts for 40% of cesarean delivery, but recent data on the trial of labor after cesarean and vaginal birth after cesarean are limited. This study aimed to report the national rates of trial of labor after cesarean and vaginal birth after cesarean by number of previous cesarean deliveries and examine the effect of demographic and clinical characteristics on these rates. This was a population-based cohort study using the US natality data files. The study sample was restricted to 4,135,247 nonanomalous singleton, cephalic deliveries between 37 and 42 weeks of gestation, with a history of previous cesarean delivery and delivered in a hospital between 2010 and 2019. Deliveries were grouped by number of previous cesarean deliveries (1, 2, or ≥3). The trial of labor after cesarean (deliveries with labor among deliveries with previous cesarean delivery) and vaginal birth after cesarean (vaginal deliveries among trial of labor after cesarean) rates were computed for each year. The rates were further subgrouped by history of previous vaginal delivery. Year of delivery, number of previous cesarean deliveries, history of previous cesarean delivery, age, race and ethnicity, maternal education, obesity, diabetes mellitus, hypertension, inadequate prenatal care, Medicaid payer, and gestational age were examined concerning the trial of labor after cesarean and vaginal birth after cesarean using multiple logistic regression. SAS software (version 9.4) was used for all analyses. The trial of labor after cesarean rates increased from 14.4% in 2010 to 19.6% in 2019 (P<.001). This trend was seen in all categories of number of previous cesarean deliveries. Moreover, vaginal birth after cesarean rates increased from 68.5% in 2010 to 74.3% in 2019. The trial of labor after cesarean and vaginal birth after cesarean rates were the highest for deliveries with a history of both 1 previous cesarean delivery and a vaginal delivery (28.9% and 79.7%, respectively) and the lowest for those with a history of ≥3 previous cesarean deliveries and no history of vaginal delivery (4.5% and 46.9%, respectively). Factors associated with the trial of labor after cesarean and vaginal birth after cesarean rates are similar, but several factors have different directions of effect, such as non-White race and ethnicity, which is associated with a higher likelihood of trial of labor after cesarean but a lower likelihood of successful vaginal birth after cesarean. More than 80% of patients with a history of previous cesarean delivery deliver by repeat scheduled cesarean delivery. With vaginal birth after cesarean rates increasing among those who attempt a trial of labor after cesarean, emphasis should be put on safely increasing the trial of labor after cesarean rates.

Validation of a sonographic checklist for the detection of histologic placenta accreta spectrum

To standardize research terminology and reduce unanticipated placenta accreta spectrum (PAS), the European Working Group for Abnormally Invasive Placenta (EW-AIP) developed a consensus checklist for reporting PAS suspected on antenatal ultrasound. The diagnostic accuracy of the EW-AIP checklist has not been assessed. To test the performance of the EW-AIP sonographic checklist in predicting histologic PAS. This is a multi-site, blinded, retrospective review of transabdominal ultrasound studies performed between 26-32 weeks gestation for subjects with histologic PAS between 2016-2020. We matched a 1:1 control cohort of subjects without histologic PAS. To reduce reader bias, we matched the control cohort for known risk factors including previa, number of prior cesarean deliveries, prior dilation and curettage (D&C), in vitro fertilization (IVF), and clinical factors affecting image quality including multiple gestation, body mass index (BMI) and gestational age at the ultrasound. Nine sonologists from 5 referral centers, blinded to the histologic outcomes, interpreted the randomized ultrasound studies using the EW-AIP checklist. The primary outcome was the sensitivity and specificity of the checklist to predict PAS. Two separate sensitivity analyses were performed: 1) we excluded subjects with mild disease (i.e. only assessed subjects with histologic increta and percreta); 2) we excluded interpretations from the 2 most junior sonologists. 78 subjects were included (39 PAS, 39 matched control). Clinical risk factors and image quality markers were statistically similar between cohorts. The checklist sensitivity (95% Confidence Interval, CI) was 76.6% (63.4%-90.6%) and specificity (95% CI) was 92.0% (63.4%-99.9%), with a positive and negative likelihood ratio of 9.6 and 0.3, respectively. When we excluded subjects with mild PAS disease, the sensitivity (95% CI) increased to 84.7% (73.6%-96.4%) and specificity was unchanged at 92.0% (83.2%-99.9%). Sensitivity and specificity were unchanged when the interpretations from the 2 most junior sonologists were excluded. The 2016 EW-AIP checklist for interpreting PAS has a reasonable performance in detecting and excluding histologic placenta accreta spectrum.

Single-Layer Versus Double-Layer Uterine Closure at the Time of Cesarean and Subsequent Risks in Those With Placenta Accreta Spectrum [ID: 1381003

INTRODUCTION: Benefits of single- versus double-layer uterine closure at the time of cesarean delivery are unclear. We sought to evaluate the effect of single- versus double-layer closure in prior cesarean delivery at the time of cesarean hysterectomy for placenta accreta spectrum (PAS). METHODS: Retrospective study of patients with PAS and available prior cesarean delivery operative report were included in this IRB-approved cohort study. Those with history of single-layer closure were compared to those with history of double-layer closure, and the effect on maternal outcomes at the time of cesarean hysterectomy for PAS was evaluated. The primary outcome was surgical pathology diagnosis of percreta or increta versus accreta. Secondary outcomes included blood loss, intensive care unit admission, length of stay, and surgical time. Groups were compared via chi-square, Fisher’s exact, and t tests with logistic regression to evaluate for confounders. RESULTS: There were 36 participants available for review, 20 of whom (55.6%) had prior single-layer closure. Those with single-layer closure had a higher number of prior cesarean deliveries (2.5±1.1 versus 1.4±0.8, P=.003); otherwise, baseline characteristics were similar between groups. Diagnosis of percreta or increta at the time of cesarean delivery was more likely among those with single-layer closure (79.9% versus 41.7%, P=.056), although not statistically significant. Blood loss, operative time, and length of stay were higher as well, but these did not reach statistical significance (approximately 3,200 versus 1,900 mL, P=.138; 167 versus 140 minutes, P=.151; 4.8 versus 3.4 days, P=.059). In the regression analysis, after controlling for the number of prior cesarean deliveries and other potential confounders, the apparent increase in diagnosis of percreta or increta did not persist (adjusted odds ratio 0.55, 95% CI 0.20–1.53). CONCLUSION: No statistically significant benefit to prior single- versus double-layer closure was noted at the time of cesarean hysterectomy in those with PAS.

Association of maternal serum Netrin-1 and Netrin-4 levels with placenta accreta spectrum.

This study aimed to evaluate maternal serum Netrin-1 and Netrin-4 levels in pregnancies complicated with placenta accreta spectrum. This cross-sectional study enrolled 49 pregnant women with the diagnosis of placenta accreta spectrum as the study group. Gestational age-matched 30 uncomplicated pregnant women with prior cesarean delivery and normal placentation were randomly selected as the control group. Maternal serum Netrin-1 and Netrin-4 levels were measured between weeks 34 and 36 of gestation. There was no significant difference between the groups in terms of demographic characteristics. Maternal serum Netrin-1 levels were significantly lower in placenta accreta spectrum cases compared with those in the control group (p=0.038). There was no significant difference between the groups in terms of maternal serum Netrin-4 levels (p>0.05). There was a significant negative correlation between maternal serum Netrin-1 levels and the number of prior cesarean deliveries (r=-0.313, p=0.005). The observed decrease in maternal serum Netrin-1 levels in placenta accreta spectrum cases associated with increased angiogenesis might be one of the factors involved in the pathophysiology of this disease.

Linear cutting stapler for hysterotomy during cesarean hysterectomy for patients with placenta accreta spectrum disorder

To evaluate the impact of performing hysterotomy utilizing a linear cutting stapler on minimizing blood loss during cesarean hysterectomy compared to the classical hysterotomy technique in patients with suspected placenta accreta spectrum disorders. This is a single-center retrospective cohort study including a total of 95 patients undergoing cesarean hysterectomies between January 2014 and January 2022. The intervention of interest is utilizing a linear cutting stapler to perform the hysterotomy, a method that was introduced at our institution in 2019. The control group underwent the traditional classical hysterotomy method. Exclusion criteria included undiagnosed accreta at the time of surgery and emergent surgeries. The primary outcomes are quantitative total blood loss, units of packed red blood cell transfusion, length of postoperative stay, and intensive care unit admission. Logistic regression analyses were performed and adjusted for the effects of resuscitative endovascular balloon occlusion of the aorta, severity of disease, and number of prior cesarean deliveries. There were 64 patients undergoing the classical hysterotomy method and 31 patients undergoing the linear stapler hysterotomy technique. Compared to the classical hysterotomy group, the median blood loss in the stapler hysterotomy group was 1000 vs 2553mL (p<0.001), the median units of pRBC transfused was 1 vs 3 units (p<0.001), and postoperative length of stay was 3 vs 4 days (p<0.001). The rates of surgical blood loss of >2000ml in the stapler hysterotomy group was 22.6% vs 48.4% (p< 0.02, (aOR) 0.23[0.06-0.79]). The rate of transfusion of >4unit of pRBC in the stapler hysterotomy group was 16.1% vs 48.4% (p< 0.002, aOR 0.26[0.07-0.97]). The rate of cases not requiring blood transfusion in the stapler hysterotomy group was 45.2% vs 20.3% (p< 0.02, aOR 3.02[1.05-8.73]). The rate of ICU admission was not different between both groups. Performing hysterotomy utilizing a linear cutting stapler was associated with a significant reduction in blood loss in patients undergoing cesarean hysterectomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Analysis of risk factors for massive intraoperative bleeding in patients with placenta accreta spectrum

BackgroundTo analyze relevant factors for massive postpartum hemorrhage in women with placenta accreta spectrum in order to improve the ability to identify those at risk for intraoperative bleeding and improve outcome.MethodsThis study is a retrospective study and based on data from Hospital electronic medical record. Placenta accreta patients who delivered by cesarean section at Peking University Third Hospital from September 2017 to December 2019 were selected and included. According to the amount of intraoperative bleeding, they were categoried into the massive bleeding group (bleeding volume ≥ 2000 mL, 68 cases) and non-massive bleeding group (bleeding volume < 2000 mL, 99 cases). Univariate analysis and multivariate logistic regression were used to analyze the correlations between related risk factors or ultrasound imaging characteristics and the severity of bleeding during operation.Results(1) There were statistically significant differences in gravidity, parity, number of prior cesarean deliveries and placenta accreta ultrasound scores (P < 0.05) between the two groups of patients.(2) Among the ultrasonographic indicators, the disappearance of the post-placental clear space, the emergence of cross-border blood vessels in the region of subplacental vascularity, interruption or disappearance of the bladder line, and the presence of the cervical blood sinus had the most significant correlation with hemorrhage during PAS (P < 0.05).ConclusionThe presence of cervical blood sinus, interruption or disappearance of bladder line, the disappearance of the post-placental clear space and abnormal subplacental vascularity are independent risk factors for massive hemorrhage during PAS. We should pay more attention to these indicators in prenatal ultrasound examination in order to reduce the intraoperative bleeding and improve maternal outcomes.

Recent Trends in Term Trial of Labor After Cesarean by Number of Prior Cesarean Deliveries

Cesarean delivery (CD) is a major source of maternal morbidity and repeat CD accounts for 40% of CD, but data on trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC) are limited. The objective of this study was to report national rates of TOLAC and VBAC by number of prior cesareans.

Maternal Morbidity with Repeated Cesarean Deliveries.

This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice. Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used. A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001). Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population. · Maternal morbidity increase with each CD.. · Absolute adverse outcomes remains low in highest order CDs.. · In women without placenta previa, there is no added morbidity with additional CDs..

A regional survey evaluating patient experience seeking trial of labor after cesarean

Objective To evaluate access to trial of labor after cesarean (TOLAC) in a large metropolitan city. Study design In 2012, a public tertiary care hospital in Houston, TX promoted its TOLAC services on social media, resulting in a surge of self-referrals. In 2018, an electronic survey was distributed by email to 200 women who had previously contacted the hospital regarding TOLAC and posted on 2 local social media TOLAC sites. Women were asked to participate if they ever sought TOLAC in the Houston area. Data were analyzed for trends in patient experience seeking TOLAC and comparisons were made based on number of prior cesarean deliveries (CD) and race/ethnicity. Results The survey was open for responses for 1 month, with 128 completed surveys by the end of the study time period. Of the respondents, most (64%) had 1 prior CD and identified as White (63%). Most (60%) of all women reported contacting ≥3 providers before finding one that offered TOLAC, with no difference reported for women with 1 vs 2 prior CD (p = .2). Over half (52%) reported their experience seeking TOLAC to be difficult with more difficulty noted by those with 2 vs 1 prior CD, (61.8% vs 42.7%,) but not statistically significant (p = .06). White women were more likely to report an easier experience seeking TOLAC compared to Black women (55.6% vs 30%, p = .04). Overall, 37% attempted TOLAC at the reference hospital. Black (50%) and Hispanic (68.2%) women were significantly more likely to have delivered at the reference hospital than White women (24%) (p < .05) Conclusion Our results suggest that women seeking TOLAC have difficulty finding providers who offer the service. This may be especially true for Black and Hispanic women and women with >1 prior CD. Women may utilize social media forums for resources and recommendations and such platforms may represent an underutilized opportunity to identify regional TOLAC services.

42 Increased narcotic requirements after laparoscopic hysterectomy in patients with history of multiple cesarean deliveries

Complicated laparoscopic hysterectomies may result in increased manipulation of tissue, and potentially lead to suboptimal postoperative pain control. Given that pain in the post-anesthesia care unit (PACU) has been found to be directly associated with overall patient satisfaction, being able to identify what patients are at higher risk for increased pain would allow for preemptive targeted multimodal interventions to reduce postoperative discomfort. One of the most common factors that increases surgical complexity during hysterectomy is history of cesarean deliveries. The objective of this study was to determine if an increased number of prior cesarean deliveries in patients undergoing a laparoscopic hysterectomy resulted in higher narcotic use in the PACU. A retrospective chart review was performed using cases from 4 fellowship trained MIS surgeons with similar operative techniques. Cases from 2018-2020 were reviewed. We included all patients between the ages of 18 and 60 who underwent laparoscopic hysterectomy and received a preoperative para-cervical block. Patients who had concomitant procedures such as pelvic floor repair, interventions for urinary incontinence, or excision of endometriosis were excluded. Data collected included age, body mass index, uterine weight, estimated blood loss, operative time, and total narcotics received in the PACU. Units of narcotics administered were converted to intravenous morphine milligram equivalents (MMEs) based on the American Pain Society guidelines and critical review papers. T-student was used to compare means between groups. There were 77 patients were selected for analysis. Patients were separated into groups depending on whether they had less than 3 (n = 60) or 3 or more (n = 17) cesarean deliveries. There was no difference regarding age (44.16 vs 44.65, P =.78), BMI (33.68 vs. 34.78, P=.53), EBL (65.17 mL vs. 85.88 mL, P=.14), or uterine weight (212.13 g vs. 202.88 g, P=.78). As expected, operating time was higher in the patients with 3 or more cesareans (140.08 min vs. 180.56 min, P<.01). Total narcotic use in the PACU was also significantly higher this group (5.42 MME vs. 10.24 MME, P<.01). These findings suggest that patients undergoing a laparoscopic hysterectomy with history of 3 or more cesarean deliveries are at a risk for higher narcotic requirements in the PACU and are potential targets for further postoperative pain reduction strategies.

212 Decreased procedure-related infection rates after implementation of ERAS protocol for cesarean section

The objective of this study was to determine if the implementation of an Enhanced Recovery After Surgery (ERAS) protocol for Cesarean section was associated with procedure-related infection rates in the post-partum period. This project was designed as part of a prospective cohort study which compared surgical outcomes for cesarean section patients prior to and following implementation of an ERAS protocol. Primary interventions aimed at reducing surgical site infections included standardization of vaginal preparation and the addition of azithromycin antibiotic prophylaxis for laboring patients. Inclusion criteria were patients over the age of 18 who had a singleton or twin cesarean delivery at a tertiary care center between February 2019 and January 2020. We included patients of all gestational ages and all acuity levels (scheduled, urgent and emergent). Exclusion criteria were pregnancies of higher-level multiples, prolonged intensive care unit (ICU) stay following delivery. Final number of patients after exclusion criteria applied N= 339 with n=170 pre-intervention and n=169 post-intervention. On analysis of descriptive variables there were no significant differences between groups for age, BMI, parity, number of prior cesarean deliveries and acuity of procedure. Among laboring patients, there was no significant difference between groups in the percentage of patients who received azithromycin with (87.95% pre-intervention and 87.65% post-intervention, p=1.00). Only 12.35% of patients received a vaginal preparation in the pre-intervention group versus 78.7% in the post-intervention group (p<.0001). The resulting cesarean procedure-related infection rate was significantly lower in the post-intervention group with rates of 5.3% versus 11.7% in the pre-intervention group (p=0.038). An ERAS protocol including vaginal preparation for all patients regardless of gestational age or acuity of procedure is associated with decreased procedure-related infection rates.

Uterine Dehiscence and Subsequent Pregnancy Management: A Review of the Literature.

Uterine dehiscence is a separation of the uterine musculature with intact uterine serosa. Uterine dehiscence can be encountered at the time of cesarean delivery, be suspected on obstetric ultrasound, or be diagnosed in between pregnancies. Management is a conundrum for obstetricians, regardless of timing of onset. A literature search was undertaken by our research librarian using the search engines PubMed, CINAHL, and Web of Science. The search term used was "uterine dehiscence." The search was limited to the English language, and there was no limit on the years searched. The search identified 152 articles, 32 of which are the basis for this review. Risk factors, treatment, and management in subsequent pregnancies are discussed. The number of prior cesarean deliveries is the greatest risk factor for uterine dehiscence. Unrepaired uterine dehiscence can cause symptoms outside of pregnancies and may require repair for alleviation of these symptoms. Dehiscence should also be repaired prior to subsequent pregnancies. Planned delivery prior to the onset of labor with careful monitoring of maternal symptoms is the preferred management strategy of women with prior uterine dehiscence. Careful attention should be paid to the lower uterine segment thickness when ultrasonography is performed in women with prior cesarean delivery. An evidence-based review of uterine dehiscence in pregnancy and how to manage subsequent pregnancies following uterine dehiscence.

Association between Number of Prior Cesareans and Early Preterm Delivery in Women with Abnormal Placentation.

Delivery timing at 34 to 36 weeks is nationally recommended for pregnancies complicated by placenta accreta spectrum (PAS). However, it has recently been suggested that those with ≥2 prior cesarean deliveries (CD) and PAS should be delivered earlier than 34 weeks because of a higher risk of unscheduled delivery and complications. We sought to evaluate whether the number of prior CD in women with PAS is associated with early preterm delivery (PTD) (<34 weeks). We also evaluated the same relationship in women with placenta previa alone (without PAS). This is a secondary analysis of a multicenter and observational study that included women with prior CD (maternal-fetal medicine unit cesarean registry). Women with a diagnosis of PAS (regardless of placenta previa) were included for our primary analysis, and women with known placenta previa (without a component of PAS) were independently analyzed in a second analysis. Two groups of patients from the registry were studied: patients with PAS (regardless of placenta previa) and patients with placenta previa without PAS. The exposure of interest was the number of prior CD: ≥2 CD compared with <2 CD. The primary outcome was PTD <34 weeks. Secondary outcomes included preterm labor requiring hospitalization or tocolysis, transfusion of blood products, composites of maternal and neonatal morbidities, and NICU admission. Outcomes by prior CD number groups were compared in both cohorts. Backward selection was used to identify parsimonious logistic regression models. There were 194 women with PAS, 97 (50%) of whom had <2 prior CD and 97 (50%) of whom had ≥2 prior CD. The rate of PTD <34 weeks in women with ≥2 prior CD compared with <2 in the setting of PAS was 23.7 versus 29.9%, p = 0.27; preterm labor requiring hospitalization was 24.7 versus 13.5%; p = 0.05. The rates of plasma transfusion were increased with ≥2 prior CD (29.9 vs. 17.5%, p = 0.04), but there were no differences in transfusion of other products or in composite maternal or neonatal morbidities. After multivariable adjustments, having ≥2 CDs was not associated with PTD <34 weeks in women with PAS (adjusted odds ratio (aOR): 0.73, 95% confidence interval [CI]: 0.39-13.8) despite an association with preterm labor requiring hospitalization (aOR: 2.69; 95% CI: 1.15-6.32). In our second analysis, there were 687 women with placenta previa, 633 (92%) with <2 prior CD, and 54 (8%) with ≥2 prior CD. The rate of PTD <34 weeks with ≥2 CD in the setting of placenta previa was not significantly increased (27.8 vs. 22.1%, aOR: 1.49; 95% CI: 0.77-2.90, p = 0.08); the maternal composite outcome (aOR: 4.85; 95% CI: 2.43-9.67) and transfusion of blood products (aOR: 6.41; 95% CI: 2.30-17.82) were noted to be higher in the group with ≥2 prior CD. Women with PAS who have had ≥2 prior CD as compared with women with <2 prior CD did not appear to have a higher risk of complications leading to delivery prior to 34 weeks. As such, considering the associated morbidity with early preterm birth, we would not recommend scheduled delivery prior to 34 weeks in this population. · We do not recommend delivery prior to 34 weeks of gestational age in PAS.. · PTD was not significantly increased in PAS with ≥2 CDs.. · PTD < 34 weeks of gestational age was not increased in placenta previa with ≥2 prior CDs..

How safe is high-order repeat cesarean delivery? An 8-year single-center experience in Lebanon.

To quantify the impact of the number of prior cesarean deliveries (CD) on operative complications and preterm birth. Then to investigate the presence of a threshold, beyond which complications tend to be disproportionately dangerous. This was a retrospective cohort observational study, where data corresponding to all CD done at our service, during an 8-year period, were collected and analyzed. In total, 1840 CD were performed. Patients were divided into five categories that corresponded to the number of CD. Primary outcome was the composite adverse maternal outcome, while preterm birth and individual complications were secondary outcomes. The composite adverse maternal outcome, preterm birth, as well as all individual complications related to CD, except for placental abruption, showed a significant rise in frequency that paralleled the increase in the number of CD. Furthermore, this increase tended to be continuous as the number of CD increased, with an evident surge after the fourth. In our population, increasing number of prior CD was a risk factor for a parallel increase in the rate of composite adverse maternal outcome, preterm birth and almost all intraoperative complications attributable to CD. Decreasing exposure to such surgeries by limiting family size to four offspring should be considered seriously in patient counseling.

Association of Prior Cesarean Delivery With Early Term Delivery and Neonatal Morbidity

To assess whether a history of prior cesarean delivery is associated with an increased risk of earlier delivery timing and resultant neonatal morbidity. We performed a population-based retrospective cohort study using U.S. birth certificate data, 2012-2016. The study population included women with one or more prior cesarean deliveries compared with a referent group of parous women without prior cesarean delivery. To enrich for a population with minimized risk factors for early delivery, we excluded women with history of preterm birth, pregnancies complicated by multifetal gestation, pregnancy-induced hypertension, anomaly, small for gestational age, or malpresentation. Analyses were limited to births from 35 to 42 weeks of gestation. Women with a vaginal birth after cesarean delivery were excluded. The primary outcome was the risk of birth at each week of gestational age. Secondary outcomes included adverse neonatal and maternal outcomes. Patients were stratified by number of prior cesarean deliveries (one, two, three, or four or more) compared with parous patients without prior cesarean delivery. The adjusted relative risk (aRR) of delivery at 35 weeks of gestation was highest in women with four or more prior cesarean deliveries (aRR 2.79, 95% CI 2.74-2.82). Prior cesarean delivery also had a significant influence on neonatal morbidity. As the number of prior cesarean deliveries increased, the risk of composite neonatal morbidity increased, from 8.0% (aRR 1.5, 95% CI 1.48-1.51) with one prior cesarean delivery up to 21.0% (aRR 4.9, 95% CI 4.76-5.04) with four or more prior cesarean deliveries compared with a baseline risk of 5.5% in parous women without prior cesarean delivery. Prior cesarean delivery is correlated with earlier delivery and increased neonatal morbidity. Advocating trial of labor after cesarean delivery may provide maternal and neonatal benefit.

Prior Cesarean Section Surgical Characteristics and Subsequent Uterine Rupture [30P

INTRODUCTION: To determine if prior Cesarean surgical characteristics that may compromise healing are associated with an increased risk of subsequent uterine rupture. METHODS: Retrospective case-control study matching women with uterine rupture to randomly selected controls (1:3) based on number of prior Cesarean deliveries (CD) and labor at the time of current CD. A multivariable logistic regression was performed focusing on hemorrhage and surgical procedures at prior CD, including all factors that differentiated the groups plus maternal age. RESULTS: 60 women with uterine rupture were matched to 180 controls. Case patients were more often white (P=.005) and had a higher rate of prior pelvic surgeries (P=.002). With regards to the prior CD, case patients had increased rates of classical incisions (P=.0006), labor (P=.001), and endometritis (P=.01). Case subjects had higher rates of prior postpartum hemorrhage (PPH) (9% vs. 3%, P=.04), and more prior hysterotomy extension (23% vs 6%, P=.0009), but did not differ in the rates of prior compression suture, arterial ligation, or uterine artery embolization (5% composite rate for each group). In multivariable regression analysis, prior uterine extension remained significantly associated with rupture (aOR 2.05, 95% CI 1.48–5.69), while PPH (aOR 1.31, 95% CI 0.15–4.20) was not. CONCLUSION: A prior history of hysterotomy extension is associated with an increased risk of subsequent uterine rupture. This may reflect vascular disruption or diminished integrity of the lower uterine segment. Prior surgical details should be reviewed in counseling patients in future pregnancies.

Placenta Accreta Spectrum: The Effect of Establishing a Systematic Program for Diagnosis and Management [27M

INTRODUCTION: Improvements in management of placenta accreta spectrum (PAS) can reduce maternal morbidity and mortality. Our objective was to determine the effect on outcomes following the introduction of a systematic program for diagnosis and management of PAS at our institution. METHODS: This was a retrospective cohort study of deliveries complicated by PAS at New York Presbyterian Queens (NYPQ) from November 2011 to July 2019. NYPQ implemented a systematic program for diagnosis and management of PAS in January 2015. The program included an emphasis on antenatal diagnosis, required scans for all repeat cesarean deliveries and multidisciplinary team management. Group 1 is designated as before and Group 2 is after establishment of the program. A composite outcome which included unplanned hysterectomy, ICU admission, return to the operating room or transfusion of ≥4 units of blood) was also examined. Chi square and Mann Whitney U tests were used in statistical analysis. IRB approval was obtained. RESULTS: Of 124 cases eligible cases, 35 (28%) had confirmed PAS (6 cases in Group 1, 29 cases in Group 2). The two groups were similar in terms of maternal age, parity, BMI and number of prior cesarean deliveries. There was no difference in composite morbidity between Groups 1 and 2 (66.7% vs 48.3%, P=.42). There was a trend toward improvement in unplanned hysterectomy and blood transfusion in Group 2. CONCLUSION: The establishment of our accreta program allowed us to demonstrate improvement in several outcome measures that did not achieve statistical significance due to small numbers.

Blood Transfusion Following Intended Vaginal Birth After Cesarean Versus Elective Repeat Cesarean Section in Women With a Prior Primary Cesarean: A Population‐based Record Linkage Study

(Acta Obstet Gynecol Scand. 2019;98:382–389) For parturients with a previous cesarean delivery, counseling and decision-making needs to be made regarding whether to attempt a vaginal birth after cesarean (VBAC) or undergo elective repeat cesarean section (ERCS). Many factors should be considered during the decision-making process including the likelihood of requiring blood transfusion due to postpartum hemorrhage (PPH). This is an important factor because blood transfusions after PPH have been associated with longer hospital stay, and increased risk of infection, morbidity, and mortality. This study was undertaken to ascertain blood transfusion and PPH rates related to chosen delivery method (VBAC or ERCS) for women with a prior cesarean delivery, as well as to determine the effect of the number of prior cesarean deliveries on transfusion rates.

1222 Conservative Management of Cesarean Scar Pregnancies with Systemic Multidose Methotrexate: Predictors of Treatment Failure and Reproductive Outcomes

Study Objective The role of conservative management of CSP has been previously reported with conflicting results reported. In this retrospective study, we aimed to further evaluate its role and better delineate the subsequent reproductive outcomes Design A retrospective cohort study. Setting A large university hospital (Hadassah Medical Center Hospitals, Israel, Jerusalem) between November 2014 to April 2017 Patients or Participants All patients diagnosed with a CSP and treated by intention of conservative management with systemic methotrexate (MTX). Interventions A comparison of maternal and gestation characteristics was performed between treatment success and failure groups Measurements and Main Results Thirty seven cases of CSP were encountered. Overall, 29/37 (78.3%) were treated by systemic injection of MTX while the other 21.7% had combined systemic and local (i.e. intra-sac) MTX treatment. Invasive intervention was needed in 5 (13.5%) cases (failure group). Cases who were converted to surgical treatment had higher number of previous cesarean deliveries (median 4 vs. 2, p=0.002). In logistic regression modeling, the number of prior cesarean deliveries in the past was the only factor found independently associated with conversion to surgical management Odds Ratio 2.02, 95 % Confidence Interval 1.03,3.94. Majority of future pregnancies had term pregnancy with one preterm delivery due to severe intrauterine growth restriction Conclusion Systemic MTX therapy is a safe and effective strategy for the treatment of CSP with favorable subsequent reproductive results and a low conversion rate for surgical management. Patients with high order of previous cesarean deliveries should be considered for early surgical treatment rather than a medical one.