Thisted Dorthe L A, Mortensen Laust H, Hvidman Lone, Krebs Lone
Fetal Medicine Unit. Department of Gynaecology and Obstetrics, University of Copenhagen, Hvidovre Hospital, Kettegaard Alle 30, Hvidovre, Denmark.
Methods and Analysis, Statistics Denmark, Sejeroegade 11, Copenhagen, Denmark.
PLoS One. 2017 Nov 14;12(11):e0187850. doi: 10.1371/journal.pone.0187850. eCollection 2017.
To estimate the relation of single-layer closure at previous caesarean delivery, and other pre-labour and intra-partum risk factors for complete uterine rupture in trial of vaginal birth after a caesarean (TOLAC) at term.
Population-based case-control study. We identified all women (n = 39 742) recorded in the Danish Medical Birth Registry (DMBR) during a 12-year period (1997-2008) with a singleton pregnancy at term and TOLAC. Among these, all women with a complete uterine rupture were identified (cases). Information from the registry was validated against medical records. Controls were selected in the DMBR as the following two births with TOLAC at term and no uterine rupture. Detailed information from cases and controls was collected from manual review of medical records. Main outcome measure was complete uterine rupture during TOLAC at term.
Upon validation, 175 cases and 272 controls met the above criteria. After adjustment for possible confounding factors there was no association between single layer closure and uterine rupture (aOR 1.38, CI: 0.88-2.17). Significant risk factors were: Induction with an unfavourable cervix (aOR 2.10 CI: 1.19-3.71), epidural (aOR 2.17 CI 1.31-3.57), augmentation by oxytocin for more than one hour (aOR 2.03 CI: 1.20-3.44), and birth weight ≥ 4000g (aOR 2.65 CI 1.05-6.64). Previous vaginal delivery (aOR 0.41 CI: 0.25-0.68) and inter-delivery interval of more than 24 months (aOR 0.38 CI: 0.18-0.78) reduced the risk of uterine rupture.
Single-layer uterine closure did not remain significantly associated to uterine rupture during TOLAC at term after adjustment for confounding factors. Induction of labour with an unfavourable cervix, birth weight ≥ 4000g and indicators of prolonged labour were all major risk factors for uterine rupture.
评估足月剖宫产术后经阴道分娩（TOLAC）时，前次剖宫产单层缝合与其他产前及产时子宫完全破裂风险因素之间的关系。
基于人群的病例对照研究。我们确定了丹麦医疗出生登记处（DMBR）在12年期间（1997 - 2008年）记录的所有足月单胎妊娠且进行TOLAC的妇女（n = 39742）。其中，确定了所有发生子宫完全破裂的妇女（病例）。登记处的信息与病历进行了核对。在DMBR中选择对照为接下来两次足月进行TOLAC且未发生子宫破裂的分娩。通过人工查阅病历收集病例和对照的详细信息。主要结局指标是足月TOLAC期间子宫完全破裂。
经核对，175例病例和272例对照符合上述标准。在对可能的混杂因素进行调整后，单层缝合与子宫破裂之间无关联（校正比值比[aOR]为1.38，可信区间[CI]：0.88 - 2.17）。显著的风险因素包括：宫颈条件不佳时引产（aOR 2.10，CI：1.19 - 3.71）、硬膜外麻醉（aOR 2.17，CI 1.31 - 3.57）、缩宫素引产超过1小时（aOR 2.03，CI：1.20 - 3.44）以及出生体重≥4000g（aOR 2.65，CI 1.05 - 6.64）。既往阴道分娩（aOR 0.41，CI：0.25 - 0.68）和两次分娩间隔超过24个月（aOR 0.38，CI：0.18 - 0.78）可降低子宫破裂风险。
在对混杂因素进行调整后，足月TOLAC期间单层子宫缝合与子宫破裂之间无显著关联。宫颈条件不佳时引产、出生体重≥4000g以及产程延长的指标均是子宫破裂的主要风险因素。
