Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
Am J Obstet Gynecol. 2019 Apr;220(4):336-347. doi: 10.1016/j.ajog.2018.11.125. Epub 2018 Nov 19.
Trial of labor after cesarean is offered as a routine option for singleton gestations with previous cesarean delivery. However, adequate data are not available to determine whether the approach is equally valid in women with twin gestation.
This systematic review and meta-analysis aimed to assess maternal morbidities associated with trial of labor after cesarean delivery in twin gestations.
Electronic databases were searched for cohort studies and randomized controlled trials evaluating the association between trial of labor after cesarean delivery in twin gestations and pregnancy outcomes. Maternal mortality and severe morbidities, such as uterine rupture and hysterectomy, were compared between women who had trial of labor and women who had a planned repeat cesarean delivery. Pooled odds ratios were calculated using a random-effects model. Additional analyses were performed to compare trial of labor after cesarean outcomes in singleton and twin gestations.
Eleven cohort studies including a total of 8209 twin gestations with previous cesarean delivery were included in the present study. Of these gestations, 2484 were intended for planned vaginal birth and 5725 were intended for planned repeat cesarean delivery. The rate of uterine rupture in twin gestations was higher in the trial of labor after cesarean group than the elective cesarean group (odds ratio, 10.09, 95% confidence interval, 4.30-23.69, I = 68%). However, no statistically significant difference was found in the rate of uterine rupture between twin and single gestations attempting trial of labor after cesarean delivery (odds ratio, 1.34, 95% confidence interval, 0.54-3.31, I = 0%). Women who attempted a trial of labor after cesarean delivery with twins did not have an increased risk of uterine scar dehiscence, hemorrhage, blood transfusion, or neonatal morbidity and mortality compared with elective repeat cesarean delivery. Patients with twins had similar rates of successful vaginal delivery as patients with singletons (odds ratio, 0.85, 95% confidence interval, 0.61-1.18, I = 36%).
This meta-analysis demonstrates that, although trial of labor with twins after previous cesarean delivery is associated with higher rates of uterine rupture compared with elective cesarean delivery, pregnancy outcomes and success rates are similar to a trial of labor after previous cesarean delivery in singleton gestations. Planned vaginal birth for women with twin gestation and previous cesarean delivery may be a safe alternative to a planned repeat cesarean.
对于有剖宫产史的单胎妊娠，试产是一种常规选择。然而，尚无足够的数据来确定这种方法在双胎妊娠中的有效性是否相同。
本系统评价和荟萃分析旨在评估双胎妊娠剖宫产术后试产与妊娠结局相关的产妇发病率。
检索了评估双胎妊娠剖宫产术后试产与妊娠结局之间关联的队列研究和随机对照试验的电子数据库。比较了试产和计划再次剖宫产的产妇死亡率和严重并发症（如子宫破裂和子宫切除术）。使用随机效应模型计算汇总优势比。还进行了额外的分析，以比较单胎和双胎妊娠剖宫产术后试产的结局。
本研究共纳入 11 项队列研究，共计 8209 例有剖宫产史的双胎妊娠。其中，2484 例计划阴道分娩，5725 例计划再次剖宫产。与择期剖宫产相比，剖宫产术后试产的双胎妊娠子宫破裂发生率更高（优势比，10.09，95%置信区间，4.30-23.69，I²=68%）。然而，在尝试剖宫产术后试产的双胎和单胎妊娠中，子宫破裂的发生率没有统计学差异（优势比，1.34，95%置信区间，0.54-3.31，I²=0%）。与择期再次剖宫产相比，尝试剖宫产术后试产的双胎妊娠产妇子宫瘢痕破裂、出血、输血或新生儿发病率和死亡率无增加风险。与单胎妊娠相比，双胎妊娠患者阴道分娩成功率相似（优势比，0.85，95%置信区间，0.61-1.18，I²=36%）。
本荟萃分析表明，尽管与选择性剖宫产相比，双胎妊娠剖宫产术后试产与子宫破裂发生率较高相关，但妊娠结局和成功率与单胎妊娠剖宫产术后试产相似。对于有剖宫产史的双胎妊娠妇女，计划阴道分娩可能是一种安全的替代计划再次剖宫产的方法。
