1. Inadvertent hysterotomy extension at cesarean delivery and risk of uterine rupture
in the next pregnancy
Olivia Dumont Authentic Science Research Program Manchester-Essex Regional High School, Manchester-by-the-Sea, MA 01944
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Abstract
Inadvertent Hysterotomy Extension at Cesarean Delivery and Risk of Uterine Rupture in the Next Pregnancy Olivia Dumont Manchester-Essex High School, Manchester-by-the-Sea, MA
Teacher, Dr. Maria Burgess, Manchester-Essex High School
Mentor, Dr. Henry Barth, Mass General Hosp, Boston, MA
The risk of uterine rupture was looking to be determined for a woman who’s prior incision from a cesarean had an extension. This was examined via a retrospective cohort study of 2385 women who had two cesarean sections in a row or a cesarean and subsequent vaginal birth (VBAC). Among the study group, 271 had an extension of the initial hysterotomy. The risk of uterine rupture for this group was 1.8%, whereas the risk for a woman with a prior cesarean sans an extension is 48%. It was concluded that extension of the incision of a prior cesarean is a significant risk factor by cesarean.
Acknowledgments
I would like to thank my three mentors, Dr. Ilona Goldfarb, Dr. William Barth (Chief of Maternal Fetal Medicine), and Dr. Dana Henry from Mass General and Brigham and Women’s Hospitals. They went out of their way to provide me with an incredible, unique, informative and irreplaceable experience. I couldn’t thank them enough! Also supported by a grant from the Spaulding Educational Fund.
Future Research
Using the database we have we could ask a series of other research questions.
What is the effect of the extension on pre-term birth?
-Pre-term birth can be detrimental.
-Surfactants and lung development.
Is the suture type a predictor of uterine rupture?
-Monocryl, Vicryl, or Chromic
Is blunt vs. sharp extension a risk factor for uterine rupture?
Works cited
Chibber R, El-Saleh E, Fadhli RA, Jassar WA, Harmi JA (March 2010). "Uterine rupture and subsequent pregnancy outcome - how safe is it? A 25-year study". J Matern Fetal Neonatal Med 23 (5): 421–4.
Creinin MD, Simhan HN (March 2009). "Can we communicate gravidity and parity better?". Obstet Gynecol 113 (3): 709–11.
Opara EI, Zaidi J (October 2007). "The interpretation and clinical application of the word 'parity': a survey". BJOG 114 (10): 1295–7.
Guise, et al. Vaginal Birth after Cesarean. Obstetrics and Gynecology Vol. 115.
Scott. Solving the Vaginal Birth After Cesarean. Obstetrics and Gynecology Vol. 115.
Cunningham, et al. National Institutes of Health Consensus Development Conference Statement Vol. 115.
Repke. Does vaginal birth after cesarean have a future?. OBG Management Vol. 22. p. 4-8.
Landon, et al. Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. N Engl J Med
Lee-Parritz. When is VBAC appropriate? OBG Management Vol p
Extension of the Hysterotomy
Figure 1. Surgically-repaired vertical hysterotomy of uterus, post-birth.
Introduction
Vaginal Birth after Cesarean rates are decreasing rapidly due to risk of uterine rupture
Few risk factors for uterine rupture are known
Difficult to predict the risk of uterine rupture for each individual patient
Our research works to determine whether the unintentional extension of the uterine incision with and without a trial of labor is a risk factor for uterine rupture
Results
Analysis of data showed that 271 of 2385, or 11.4%, of women had an extension.
Methods
Subjects: 2385 women with 2 subsequent births (first cesarean and second either vaginal or cesarean) at Mass General Hospital
First Cesarean
Using the MRN I searched for the op report (c-section 1 ) using OB LMR
Hysterotomy extended either bluntly, sharply, or unknown.
Noted extension of the hysterotomy. (Yes or no)
If yes, into the uterus, into the cervix, into the vagina, unilateral, bilateral, closed with a separate suture, into the bladder, into the broad ligament, into the uterine artery, intentional, or other
Sutured with a single, double (imbricating), or unknown number of layers
Record suture type. Monocryl, vicryl, chromic, or other.
Note abnormally adherent placenta, a cystotomy, an enterotomy, hemorrhage, an extension of the hysterotomy, vascular injury, ureteral injury, uterine rupture, uterine dehiscence, neonatal laceration, or other. These are rare complications
Second Cesarean or Vaginal Birth
1. On the same patient record, I noted the second date. Is it a vaginal birth or c-section?
2. If Vaginal, it was noted and moved on to the next patient.
3. If Cesarean, Noted extension of the hysterotomy. (Yes or no)
4. If yes, into the uterus, into the cervix, into the vagina, unilateral, bilateral, closed with a separate suture, into the bladder, into the broad ligament, into the uterine artery, intentional, or other.
5. Sutured with a single, double (imbricating), or unknown number of layers
6. Record suture type. Monocryl, vicryl, chromic, or other.
7. Note abnormally adherent placenta, a cystotomy, an enterotomy, hemorrhage, an extension of the hysterotomy, vascular injury, ureteral injury, uterine rupture, uterine dehiscence, neonatal laceration, or other. These are rare complications.
8. Note maternal death, infant ICU admission.
With extension
Without extension
Without trial of labor
1.8%
0.48%
With trial of labor 6%
1.5%
Part 1- extension of the uterine incision is a risk factor for uterine rupture during the subsequent pregnancy
Overall, 271 of the 2385 women had an extension with any of the qualities noted in the methods. There were a total of 5 ruptures in that 271 (1.8%) whereas, there were 10 ruptures in the remaining 2114 women whose incisions were not extended (0.48%).
Part 2 - A trial of labor with a hysterotomy extension is a significant risk factor for uterine rupture
The rate of uterine rupture without a hysterotomy extension, but with a trial of labor was 1.5%, whereas the rate of uterine rupture with a hysterotomy extension and with a trial of labor was 6%.
Background & Definitions
Hysterotomy- the cesarean incision into the uterus
Extension- the accidental uterine incision tear that occurs when a baby is being removed from the uterus
Uterine rupture- when the myometrial wall and the peritoneum of the uterus break