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A study of the outcome of subsequent pregnancy following previous cesarean section.

INTRODUCTION: Caesarean delivery is defined as the birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy) (1). Wide-spread emphasis to the detection of actual & suspected non-reassuring fetal status, over diagnosis of dystocia in primi-mother, increased frequency of elderly primi-gravida with obvious co-morbidity of pregnancy induced hypertension, gestational diabetes mellitus etc. day by day actually increase the rate of primary caesarean section (1), resulting in an increased proportion of a new group of mothers, carrying reproductive performance with a scarred uterus due to previous caesarean section (CS).

Primary CS whether done due to recurrent indication or not, carries risk of abnormal placentation in subsequent pregnancy. Morbid adherence of placenta is a rarer but more severe complication, even more so when number of caesarean delivery increases (2, 3).

Though classical upper segment caesarean section is obsolete now-a-days, even with lower segment caesarean section (LSCS), in a developing country like ours, where malnutrition, frequent conceptions, post-operative infection & subsequent blood transfusion are more common, the wound-healing would not be up to the quality found in developed countries, raising the possibility of scar dehiscence & uterine rupture in next pregnancy.

Now, regarding mode of delivery in women with previous caesarean delivery, primary choice is whether to have elective repeat caesarean section (ERCS) or to attempt vaginal birth after caesarean section (VBAC). Major problem is that lately developed investigational methods like MRI; color Doppler could not assess the scar integrity properly so as to help clinician in decision-making. Therefore, on successful attempt with VBAC in suitable cases makes it "THE CHOICE" but, if failed, it adds up to the significant proportion of maternal and neonatal morbidity, even mortality, as shown by different studies (4,5). On the other hand, ERCS, if selected after 39 weeks of gestation, gives significant good feto-maternal outcome (1). Still about ERCS, major obstetric concern lays in severe adverse outcomes in future pregnancies.

Despite extensive work, clear-cut guideline for exact mode of delivery in post caesarean pregnancy is yet to be decided; and associated risks are still uncertain. Few studies (4, 6-10) in India have dealt with outcome of post-caesarean cases. The current study has been done to review the existing facts with the hope that meticulous individualization in management and modification of certain factors would improve maternal & neonatal outcome.

MATERIALS AND METHODS: The present observational analytical study was carried out over two years (2010-11) taking consecutive 100 post-caesarean cases as admitted on my admission days & delivered in BR Singh Hospital. Third trimester antenatal profile was only included & cases with multiple gestation, prior myomectomy or hysterotomy were excluded from study. Data collection was done by interview technique along with hospital records. Percentage analysis was most often done. Categorical variables were compared with chi-square test; P value was calculated with 2012 Graphpad Software. Relative risk (RR) & Odd ratio (OR) were calculated with 1993-2012 Medcalc Software bvba (Version 12.3.0). All statistical tests were evaluated at the 0.05 significance level.

RESULTS AND ANALYSIS: Amongst a total number of 1276 pregnant women, admitted & delivered in B.R. Singh Hospital, as per Railway Register in my study period (Table 1), 26.02% (4.23+13.87+7.92) cases were post-caesarean. Out of 100 cases under study, maternal morbidity was found in 37 cases & neonatal morbidity in 21 cases. No maternal mortality or stillborn occurred relating to my study cases.

Table 2 clearly tells that among 37 cases with maternal morbidity, operation related morbidity was maximum; intra-operative complications & operative interference, related to ERCS, were responsible for the majority.

Table 3 clearly shows 55% success among TOLAC cases. Morbidity association was significant with mode of delivery (For Maternal Morbidity, [X.sup.2]=13.28, P=0.0013 & for Neonatal Morbidity, [X.sup.2]=6.11, P=0.0471). Comparing with TOLAC cases, ERCS group less likely (RR=0.78) shows maternal morbidity; but in TOLAC group, failed VBAC cases result more significant maternal morbidity (RR=3.97, P=0.0037). Neonatal morbidity was also found highest in failed VBAC cases.

Among cases who had undergone caesarean delivery (table 4), post-partum morbidity was significantly associated ([x.sub.2]=7.7; P=0.0047) with scar condition; more significantly morbidity found (RR=2.47, P=0.0001) when scar integrity was lost, especially in failed VBAC cases.

Most of the cases (table 5), whether prior history of vaginal delivery was present or not, had received caesarean section. But importantly, maternal and neonatal outcomes were poor (85% & 60% respectively) for cases that had history of vaginal delivery & undergone CD, mainly due to failed trial.

Table 6 clarify that maternal and neonatal morbidity outcomes (100% & 75% respectively) were poor when non-admitted cases had undergone caesarean delivery (CD). Even when admitted cases had undergone CD, maternal outcome was not good (39.19% morbidity). Neonatal morbidity was found to be high in first group (40%) as there were cases operative deliveries.

Most of the study cases (table 7) were from 25-30 yrs. age group, where maternal & neonatal morbidity were found in certain range. Importantly, morbidity association with age was found to be highly significant (P=0.0029 & P<0.0001) in both group, specially raised in older age group (>35yrs).

In another scenario (table 8), antenatal status co-relation with outcome was found to be highly significant in both groups. Among post-caesarean cases, who were booked, were found to have less maternal (OR=0.12, RR=0.35) and neonatal outcome (OR=0.12, RR=0.24).

Table 9 shows cases, prior CS which were done due to either CPD or non-progress of labor, mostly received ERCS (86.11 % & 55.56% respectively) & rest those given trial for VBAC, found unsuccessful. With all other indications for prior CS, VBAC success rate was good, except in cases with placenta previa & PROM, where abnormal placentation & dystocia recurred & ERCS (87.5% & 77.78% respectively) performed.

DISCUSSION: National United States CS rate was 4.5% in 1965 when it was first measured. But with 2007 rate of 31.8%, about one mother in three now gives birth by caesarean section in States. CS rate is higher in Latin America, even 40% in different countries of this region (11). The estimate of CS rate in East Asia also is shown to be well above the 15% mark (12).

The estimate of caesarean section (CS) rate in India is 7.1% in the year 1998 and there is 16.7% change in the rate annually (12), which is one of the highest among the countries. Though high values of CS rate found in southern India, West Bengal is the only state from eastern side with high caesarean section rate. A five year audit from a large teaching hospital in Kolkata showed a CS rate of 49.9% (13). Studying in urban referral institution, BR Singh Railway Hospital shows high caesarean section rate of 41.77% in my study period.

Miller et al (14) reported a post caesarean pregnancy rate of 8.1% in 1983 and 14.1% in 1992. Bhat et al al (6) showed a post caesarean pregnancy rate of 8.7%. Agarwal et al (15) study gave 13.7% report whereas in my study period, rate was found to be 26.02%.

Though no maternal or neonatal mortality was found in my study, as compared with Bhat et al study (6), intra-operative complications caused major maternal morbidity.

Vardhan et al (10), Tan et al (16), Shah et al (17), and Dhall et al (18) reported 70 to 80% success in attempts at VBAC. Chhabra et al (4) & Bhat et al (6) gave a 71.2% & 64.6% success report respectively in those who had trial of labor. My study had 55% success rate on attempts of VBAC.

Aisien et al (19) reported a 48.1% incidence of vaginal delivery in previous caesarean section cases, whereas Chhabra et al (4) reported an incidence of 32.4%. Bhat et al (6) & Agarwal et al (15) study reported a 33.3% & 27.7% incidence of vaginal delivery in previous caesarean section cases. In my study, incidence was 22%.

With improved antenatal (clinical & gadgetry) care and institutional confinement, VBAC is considered safer than repeat elective CS in a carefully selected population (20). However in the event of a failed trial, there was a definite increase in neonatal (7) and maternal morbidity (5) which is also reflected in our study.

The most serious adverse outcome of VBAC occurs when uterine scar integrity is lost. In a study of more than 8000 women the rate of scar rupture was 0.5% (21). Locateli et al (22) & Guise et al (23) reported a uterine rupture rate of 0.3% in women with previous caesarean section. Out of 100, one suffered uterine rupture in my study with severe maternal & perinatal morbidity. The incidence of scar dehiscence in my study was 9 in 100 cases.

Any previous vaginal delivery, either before or following a caesarean birth, significantly improves the prognosis for a subsequent vaginal delivery with either spontaneous or induced labour (24). My study also reported that cases with prior history of vaginal delivery delivered vaginally in more occasions (41.18%).

Puja P et al (9) study gave 80.95% success rate in VBAC on admission with Bishop Score >7. My study reported 75% success upon admission in labor with favorable Bishop Score. This statistically significant success was also found in a previous study (7).

Maternal age appears to be an independent risk factor over pregnancy outcome (25), especially in post-CS older women (26). My study found both maternal & neonatal morbidity status to be raised in older age group (>35yrs).

Another statistically significant finding was that cases that were booked, regular in antenatal check-up & aware about the risk got admitted as advised & avoided morbidity in more occasions.

Peaceman and associates (27) found that those with dystocia as the original indication had a significantly lower success rate (54%). In my study, prior CS cases due to either CPD or non-progress of labor, mostly received ERCS (86.11 % & 55.56% respectively), whereas rest those given trial for VBAC, found unsuccessful.

CONCLUSION:

* All cases with post-caesarean pregnancy should have a regular antenatal check-up & mandatory institutional confinement.

* Awareness regarding symptoms of low-lying placenta (especially with previous history of placenta previa), scar tenderness etc. & timely admission would improve perinatal outcome.

* Trial of labor after caesarean (TOLAC) should only be considered in properly selected cases with meticulous labor monitoring & availability of round the clock emergency caesarean facility in the institution.

DOI: 10.14260/jemds/2014/2009

REFERENCES:

(1.) Cunningham FG, Levono KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Caesarean Delivery and Peripartum Hysterectomy. In: Editors, Williams Obstetrics. 23rd ed. New York: McGraw Hill Medical; 2010.p.544-564.

(2.) Chagotte C, Wayne R, Cohen M. Catastrophic complications of previous caesarean section. Am J Obstet Gynecol 1990; 164:738-42.

(3.) Faize AS, Ananth CV. Etiology & risk factor of placenta previa: An observational study. J Matern Fetal neonatal Med 2003; 13:175-190.

(4.) Chhabra S, Arora G. Delivery in women with one previous caesarean section. J Obstet Gynecol India 2006; 56(4):304-7.

(5.) Mcmohan MJ, Luther ER, Bowes WA, Olshan AF. Comparison of trial of labor with elective second caesarean section. N Engl J Med 1996; 335:689-95.

(6.) Bhatt BPR, Savant R, Kamath A. Outcome of a Post Caesarean Pregnancy in a Tertiary Center of a developing country. Journal of Clinical and Diagnostic Research 2010 February; 3:2005-9.

(7.) Iyer S, Handa PR, Basu SB. Delivery after one previous caesarean section-one year prospective study. J Obstet Gynecol India 2001; 51(2):51-54.

(8.) Mafatlal SJ, Narendrabhai MM. Analysis of mode of delivery in women with previous one caesarean section. J Obstet Gynecol India 2009; 59(2):136-39.

(9.) Puri P, Abraham M, Grover S. Vaginal Birth after One Previous Lower Segment Caesarean Section. JK Science 2011 Oct-December; 13(4):179-181.

(10.) Vardhan S, Behera RC, Sandhu GS, Singh A, Bandhu HC. Vaginal birth after caesarean delivery. J Obstet Gynecol India 2006; 56(4): 320-3.

(11.) Belizen J, Althabe F, Barros F, Alexander S. Rate and implications of cesarean section in Latin America: Ecological study. British Medical Journal 1999; 319(7222):1397-1400.

(12.) Stanton CK, Holtz SA. Levels and trends in caesarean birth in the developing world. Studies in Family Planning 2006; 37(1):41-48.

(13.) Pahari J, Ghosh A. Study of pregnancy outcome over a period of five years in a Postgraduate Institute of West Bengal. Journal of Indian Medical association 1997; 95(6):172-74.

(14.) Miller DA, Diaz FG, Paul RH. Vaginal birth after caesarean: A 10 year experience. Obstet Gynecol 1994; 84:255-8.

(15.) Agarwal A, Chowdhary P, Das V, Srivastava A, Pandey A, Sahu MT. Evaluation of pregnant women with scarred uterus in a low resource setting. J Obstet Gynaecol Res 2007 October; 33(5):651-4.

(16.) Tan PC, Subramaniam RN, Omar SZ. Lab our and perinatal outcome in women at term with one previous lower segment caesarean: A review of 1000 consecutive cases. Aust NZJ Obstet Gynecol 2007;47(1):31-6.

(17.) Shah JM, Mehta MN, Gokhale AV. Vaginal birth after caesarean delivery. Obs & Gynae Today 2007;12(6):280-1.

(18.) Dhall K, Mittal SC, Grover V. Child birth following primary caesarean section: Evaluation of a scoring system. Int J Gynecol Obstet 1987;25:199-201.

(19.) Aisien AO, Oronsaye AU. Vaginal birth after one previous caesarean section in a tertiary institute in Nigeria. J Obstet Gynaecol 2004;24(8):886-90.

(20.) Mukherjee SN. Rising Cesarean section rate. J Obstet Gynecol India 2006;56:298-300.

(21.) O'Sullivan MJ, Fumia F. Vaginal delivery after caesarean section. Clin Perinatol 1991;8:131.

(22.) Locatelli A, Ghidini, Ciriello E, Incerti M, Bonardi C, Regalia Al. Induction of labour: Comparison of cohort with uterine scar from previous caesarean section vs. a cohort with intact uterus. J Matern foetal Neonatal Med 2006; 19(8):471-5.

(23.) Guise JM, Denman MA, Emeis C, Marsall N, Walker M, Fu R et al. Vaginal birth after caesarean: New insights on maternal & neonatal outcomes. Obstet Gynecol 2010; 115(6):1267-78.

(24.) Rossi AC, D'Addario V. Maternal morbidity following trial of VBAC vs PRCS: A systematic review with meta-analysis. Am J Obstel Gynecol 2008; 199(3):224.

(25.) Bujold E, Hammoud AO, Hendler I. Trial of labour in patients with a previous cesarean section: does maternal age influence outcome? Am J Obstet Gynecol 2004; 190:1113-18.

(26.) Peipert JF, Bracken MB. Maternal age: an independent risk factor for cesarean delivery. Obstet Gynecol 1993 February;81(2):200-5.

(27.) Peaceman AM, Gersnoviez R, Landon MB. The MFMU cesarean registry: Impact of fetal size on trial of labour success for patient with previous caesarean section for dystocia. Am J Obstet Gynecol 2006;195:1127.

Suman Poddar [1]

PARTICULARS OF CONTRIBUTORS:

[1.] Senior Resident, Department of Obstetrics and Gynaecology, Chitta Ranjan Seva Sadan College of Obstetrics, Gynacology and Child Health, Kolkata.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Suman Poddar, Rama Apartment (2nd Floor), 19, Lal Baba Road, PO+PS: Dankuni, Dist. Hooghly, West Bengal, India, PIN--712311. E-mail: drsuman81@yahoo.in

Date of Submission: 11/01/2014.

Date of Peer Review: 12/01/2014.

Date of Acceptance: 24/01/2014.

Date of Publishing: 06/02/2014.
TABLE 1: Delivery statistics from Jan '10 to Dec '11

Type of delivery         Total delivery (n = 1276)     %

VBAC*                               54               4.23
VB* other than VBAC                 689              54.0
CS* in primi-gravida                255              19.98
CS in single prior CS               177              13.87
CS in >2 prior CS                   101              7.92

VBAC*: Vaginal Birth (VB*) After Caesarean Section (CS*)

TABLE 2: Analysis of maternal morbidity

     Causes of morbidity        Number of Cases (%)   VBAC   ERCS *

Abnormal placentation                 5(13.5)          --      5
Preterm labor                         1(2.7)           1       --
Operative interference               10(27.0)          --      6
Intra-operative complication         11(29.7)          --      9
Peripartum hysterectomy               1(2.7)           --      0
Post-partum hemorrhage                3(8.1)           2       0
Post-partum wound sepsis              2(5.4)           0       0
Post-partum thrombosis                2(5.4)           1       0
Puerperal pyrexia                     2(5.4)           0       0
Total                                 37(100)          4       20

     Causes of morbidity        Failed VBAC

Abnormal placentation               --
Preterm labor                       --
Operative interference               4
Intra-operative complication         2
Peripartum hysterectomy              1
Post-partum hemorrhage               1
Post-partum wound sepsis             2
Post-partum thrombosis               1
Puerperal pyrexia                    2
Total                               13

ERCS *: Elective Repeat Caesarean Section

TABLE 3: Mode of delivery co-relating outcome

Mode of          Number      Maternal              Neonatal
Delivery        of cases    Morbidity      %      Morbidity      %
               (n = 100)     (n = 37)              (n = 21)

ERCS               60           20       33.33        8        13.33
VBAC               22           4        18.18        6        27.27
Failed VBAC        18           13       72.22        7        38.89

TABLE 4: Scar integrity & post-operative complications

Scar integrity    Number of cases    Complication        %
                     (n = 78) *        developed

Scar dehiscence          9                 7           77.78
Scar rupture             1                 1            100
Normal scar              68               22         32.35 (#)

* Including those cases undergone caesarean delivery / (#) excluding
3 cases of abnormal placentation with antepartum morbidity

TABLE 5: Maternal & neonatal outcome in relation to
previous history of vaginal delivery & present mode of delivery

Mode of present delivery &    Number      Maternal      %
H/O vaginal delivery         of cases    morbidity

VD with (+) history             14           2        14.29
VD with (-) history              8           2         25
CS with (+) history             20           17        85
CS with (-) history             58           16       27.59

Mode of present delivery &    Neonatal      %
H/O vaginal delivery         morbidity

VD with (+) history              4        28.57
VD with (-) history              2         25
CS with (+) history              12        60
CS with (-) history              3        5.17

TABLE 6: Maternal & neonatal outcome comparing mode
of admission & subsequent delivery

Mode of admission    Number    Maternal      %     Neonatal      %
& delivery          of cases   morbidity           morbidity

Before labor & VD      10          2        20         4        40
Before labor & CS      74         29       39.19      12       16.22
In-labor & VD          12          2       16.67       2       16.67
In-labor & CS          4           4        100        3        75

TABLE 7: Age distribution co-relating outcome

               Number of cases        Maternal
Age in years      (n = 100)      morbidity (n = 37)     %

< 25                 23                  2             8.7
25-30                43                  16           37.21
31-35                27                  14           51.85
> 35                  7                  5            71.43

                    Neonatal
Age in years   morbidity (n = 21)     %

< 25                   0              0
25-30                  8            18.6
31-35                  7            25.93
> 35                   6            85.71

TABLE 8: Antenatal care co-relating morbidity status

                   Case numbers        Maternal
Antenatal status    (n = 100)     morbidity (n = 37)     %

Booked                  77                20           25.97
Un-booked               23                17           73.91

                        Neonatal
Antenatal status   morbidity (n = 21)     %

Booked                     11           14.29
Un-booked                  10           43.48

TABLE 9: Previous caesarean indication co-relating mode of present
delivery

Previous                 Number of cases    VBAC *      %      ERCS *
indication                  (n = 100)      (n = 22)           (n = 60)

CPD *                          36             0         0        31
Fetal Distress                  5             5        100       0
PROM ([double dagger])          9             0         0        7
Mal-presentation               13             9       69.23      3
Post-dated                      5             2        40        0
Placenta previa                 8             1       12.5       7
PIH ([section]                  8             1       12.5       5
IUGR ([parallel])               5             3        60        2
Accidental Hge                  2             1        50        0
Non-progress                    9             0         0        5

Previous                   %     Failed VBAC *     %
indication                         (n = 18)

CPD *                    86.11         5         13.89
Fetal Distress             0           0           0
PROM ([double dagger])   77.78         2         22.22
Mal-presentation         23.07         1          7.7
Post-dated                 0           3          60
Placenta previa          87.5          0           0
PIH ([section]           62.5          2          25
IUGR ([parallel])         40           0           0
Accidental Hge             0           1           0
Non-progress             55.56         4         44.44

CPD *: Cephalo-pelvic Disproportion, PROM ([double dagger]): Premature
Rupture of Membrane, PIH ([section]): Pregnancy Induced Hypertension,
IUGR: Intra-uterine Growth Restriction.
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Title Annotation:ORIGINAL ARTICLE
Author:Poddar, Suman
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Feb 10, 2014
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