http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, Early Online: 1–5 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.918096

ORIGINAL ARTICLE

Induction of labor in grand multiparous women with previous cesarean delivery: how safe is this? J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Minnesota on 10/14/14 For personal use only.

Rachana Chibber1, Jehad Al-Harmi1, Mohamed Foda2, Zeinab Mohammed K2, Eyad Al-Saleh1, and Asiya Tasneem Mohammed1 1

Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, Kuwait and 2Department of Obstetrics and Gynecology, Al-Adan Tertiary Hospital, Kuwait Abstract

Keywords

Objective: To compare the outcome of induced and spontaneous labor in grand multiparous women with one previous lower segment cesarean section (CS), so that the safety of labor induction could be assessed. Methods: In 102 women (study group), labor was induced and the outcome was compared with 280 women (control group) who went into spontaneous labor. All 382 women were grand multiparous and had one previous CS. Results: There were no significant difference in oxytocin augmentation, CS, scar dehiscence, fetal birth weight or apgar scores between groups. There was one neonatal death, two still births, one early neonatal death and one congenital malformation in the study group and this was not significant. There was no significant difference in vaginal birth in the study (80.9%) and the control group (83.8%). Conclusion: In this moderate-sized study, induction of labor may be a safe option in grand multiparous women, if there is no absolute induction for repeating CS.

Adverse maternal or neonatal outcome, placenta previa and accrete, prostaglandin E2, risk factors, spontaneous labor

Introduction Induction of labor in grand multiparous women (para 5 or more) with one previous cesarean section (CS) is deemed to be a contraindication. This is because of the risk factors for uterine rupture namely: (1) Grand multiparity; (2) Uterine scar; (3) Use of prostaglandin preparations. However, there is no real data in literature to support this rigid recommendation. In fact, some studies [1,2] have shown no increase in adverse maternal or neonatal outcome when labor was induced in women with one previous CS. In Europe, most women today have only one or two children. However, this issue is of major importance in developing countries and especially Middle Eastern countries, such as Saudi Arabia and Kuwait where family size is relatively large (5 to 10 children) [3] and the risks of several repeated CS need to be considered. Several repeated CS has significantly increased the rising rate of placenta previa and accreta in subsequent pregnancies, leading to increased maternal and fetal morbidity and mortality [4–6]. Therefore, vaginal deliveries after one CS is the preferred option in these regions of the Middle East. Address for correspondence: Rachana Chibber, Associate Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait. Tel: +965 – 25319601. Fax: +965 – 25338906. E-mail: rachana_chibber@ yahoo.co.uk

History Received 11 December 2013 Accepted 22 April 2014 Published online 27 May 2014

The aim of the current study is to compare the outcome of labor and the safe use of vaginal prostaglandin E2 tablets in grand multiparous women for induction of labor with one previous cesarean delivery with grand multiparous women who enter into spontaneous labor also with one previous cesarean birth during the same study period.

Materials and methods During the study period from 1 January 2002 to December 2012, there were 392 grand multiparous women (para 45) with one previous CS who delivered at a single tertiary hospital in Kuwait. Ten women underwent elective CS and the remaining 382 women, who were the subjects of this study, had a trial of labor. Ethical committee approval was taken for this study. A total of 102 out of 382 grand multiparous women with one previous CS were induced with vaginal prostaglandin E2 and formed the study group. Analysis of hospital records showed that these women: (1) had medical or obstetrical indication for labor induction; (2) requested vaginal birth after cesarean section (VBAC) after counseling regarding the potential risks; (3) completed 37 weeks of gestation or more; (4) had cephalic presentation with uterine cervix (Bishop score 54) at the time of induction. These 102 women had induction of labor with prostaglandin E2 (1.5 mg Dinoprostone, Upjohn, Kalamazoo, MI). Prostaglandin E2

R. Chibber et al.

J Matern Fetal Neonatal Med, Early Online: 1–5

1 and 5 min apgar score, lethal fetal malformation, early neonatal deaths, still births and indication for induction of labor. The variables studied were compared with grand multiparous women with previous CS in whom labor started spontaneously (n ¼ 282 control group). The women in both groups were under the direct care of senior experienced obstetricians and their teams. Stringent intrapartum continuous fetal heart rate monitoring and maternal monitoring was carried out for all women. Statistical analysis was performed using 2 test and Fisher’s exact test. Values were considered significant when p  0.05. Biometric tables for statisticians have been used to calculate confidence limits and relative risks for binomial proportions.

was inserted in the posterior fornix during vaginal examination and this was repeated every 4–6 h if the cervix remained unfavorable, for a maximum of three doses in 24 h. If there was no response this was repeated the next day. In the study group, 75 (73%) women had one or more successful VBAC before the index pregnancy, and 27 (27%) did not have VBAC (the last delivery was by CS). The outcome was compared with 282 women with one previous CS who went into spontaneous labor at the same time period. This formed the control group. In both study and control groups if oxytocin was used for labor augmentation, fetal membrane rupture (artificially or spontaneously) was followed by very close monitoring of both mother and fetus with continuous electronic fetal monitoring. Oxytocin administration was ceased if more than 200 monte videos were recorded. The variables studied were: maternal age, parity, gestational age in weeks, oxytocin augmentation, fetal birth weight, scar dehiscence, uterine rupture, CS rate, vaginal birth rate,

Results A total of 382 women took part in this study. Figure 1(a and b) shows that there are no significant differences in maternal

(a) 50 P > 0.05 P > 0.05

45

39.1

40 34.1

35

39.4

33.6

30 Mean

Figure 1. (a) Maternal characteristics and birth weight of study and control group; (b) maternal and perinatal characteristics of study and control group.

Study group (n=102)

25

Control group (n=280)

20 P > 0.05 15

P > 0.05

10

7.04

6.6 3.391 3.287

5 0 Maternal age (years)

Parity

Gestational age (wks)

Birth weight (kg)

Maternal and Perinatal Characteristics

(b) 100 90

83.8 80.9

80 Study group (n=102)

70 Percentage (%)

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Minnesota on 10/14/14 For personal use only.

2

Control group (n=280) 60

P > 0.05 for all the groups

50 40 30 20 10

20.518.8 19.8 16.2 11.710.7 1.960.71

4.9 4.2 0 0.35

1.960

0.98 0

0

Maternal Characteriscs

Perinatal Characteriscs

0.98 0

Induction of labor in grand multipara with previous CS

DOI: 10.3109/14767058.2014.918096

3

70

Figure 2. Indications for cesarean section.

P > 0.05 60 Study group (n=20)

Percentage (%)

50

50%

Control group (n=45) 46.6%

40 P > 0.05

P > 0.05

P > 0.05

30

P > 0.05

20% 20% 17.7%

20

15% 10% 11.1%

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Minnesota on 10/14/14 For personal use only.

10

5% 4.4%

0 Failure to progress

Malpresentaon

Fetal distress

Cord Prolapse

Tender scar

Indication for cesarean section

age, parity, gestational ages, oxytocin augmentation, CS rates, birth weights, vaginal birth rates and 1 and 5 min apgar score in the two groups. Regarding perinatal deaths: out of the 102 babies delivered in the study group, one died in the early neonatal period due to multiple congenital anomalies in a poorly controlled diabetic mother diagnosed antenatally with poor antenatal attendance. There were two still births. These women came with the history of absent fetal movements for a few days and were diagnosed as intrauterine fetal death before induction. The two mothers had irregular antenatal care with poorly controlled type 1 diabetes mellitus. The CS rate was higher in the study group 19.8%, and vaginal birth rate was higher in the control group (23.8%); however, the difference was not statistically significant (p40.05). There were two cases each of scar dehiscence in both groups, and one case of uterine rupture in the control group. Scar dehiscence was discovered in all these four patients during CS for failure to progress. When uterine rupture was suspected, in a gravida 12 para 11, immediate laparotomy and delivery was performed, and the uterus was sutured and conserved. The upper 95% binomial confidence limit for the induced group was 1/102 and for the spontaneous group was 2/280. Figure 2 shows the indication for CS among the groups. Although not significant, fetal distress was more prevalent in the spontaneous group (17.7%) compared to the induced group (15%). The main indications for the study and control groups were: failure to progress (50% versus 46.6%); malpresentations (20% each) and fetal distress (15% versus 17.7%). Although labor was induced in 102 of the 382 cases (26.8%), augmentation of labor with oxytocin infusion was used very cautiously in 21 (20.5%) of women and there were no significant materno-fetal complications or uterine rupture in these women. The main indications for induction of labor in the study group were post-date (49%); gestational diabetes mellitus

(26%) and hypertensive disorders (22%). Congenital malformations (0.98%) and stillbirths (1.96%) contributed to a small fraction. The majority of the women in the study group (73%) had one or more successful VBAC prior to this delivery.

Discussion Awaiting spontaneous labor is the best option for successful vaginal delivery in grand multipara with a previous CS [7,8]. However, sometimes, induction of labor for obstetric or medical reasons may be necessary. Induction of labor with vaginal prostaglandin E2 in grand multiparous women with one previous CS is controversial. A recent review of the existing literature revealed that there were no good analytic studies concerning the safety of vaginal prostaglandins with one previous CS [7–10]. Eleven retrospective studies included 713 women with one previous CS who were induced with vaginal prostaglandin E2 [11,12] and only two women had dehiscence of the uterine scar and the success rate of VBAC was 72.6%. Thus, this led to the conclusion that there was ‘‘insufficient evidence’’ of any increased risk of rupture or dehiscence with an induction in this group. In the study group of 102 grand multiparous women, VBAC was the mode of delivery in 80.9% of women with scar dehiscence occurring in 2 (1.96%). There was no case of uterine rupture. Thus these 102 women had a good materno-fetal outcome. Grand multiparity has been traditionally considered as a high-risk situation [13,14]. However, some current studies including one from Saudi Arabia do not support this statement [9,15]. In addition, a recent study from Israel [16] involving great-grand multipara women 10 births, concluded that their maternal and neonatal outcome was good and comparable to women of similar age, but lesser parity. The authors concluded that grand multiparity or even extreme grand multiparity no longer needs to be considered as a highrisk category. Goldman et al. [17] noted this as early as 1995. This improvement is due to appropriate antenatal care, contemporary obstetrics and improved neonatal care.

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Minnesota on 10/14/14 For personal use only.

4

R. Chibber et al.

We reporting from Kuwait, Zamzami [15] and Bahar et al. [18] from neighboring Saudi Arabia, and Kugler et al. [12] from Israel have demonstrated that induction of labor in grand multiparous women with previous CS is relatively safe. Thus, various authors recently [19–22] suggested that induction of labor in such women is not a contraindication provided that it is performed by a senior experienced obstetrician with close materno-fetal follow-up with continuous electronic fetal monitoring and emergency cesarean is resorted to if labor does not progress smoothly. These guidelines were strictly adhered to in this study, under the keen guidance of the senior obstetrician. We did not have any maternal mortality but in the study group scar dehiscence was noted in two patients and in as many patients in the control group, during emergency cesarean. These four patients did not receive oxytocin and the uterus was conserved in all four cases with good fetomaternal outcome. We were surprised as such complications are expected with oxytocin augmentation. The parity of these four women ranged between para 10 and 13. Perhaps great grand multiparity contributed to the scar dehiscence. The spontaneous rupture of uterus occurred in the control group, and was not augmented with syntocinon. She was a para 11 with previous successful VBAC. In this patient also the uterus was conserved. The success rate of our VBAC in the study group was 80.9% comparing favorably with a success VBAC rate of 76.9% by Zamzami from Saudi Arabia [15]. It is noteworthy that of the 80.9% women with a successful VBAC, in the study group 73% had one or more successful VBAC before the index pregnancy. Some authors [18,19], used prostaglandin E1 to induce labor in grand multiparous women without previous CS with only 6% CS rate and no significant adverse maternal or neonatal outcome. In our study group, the CS rate was an acceptable 19.8%, as this group consisted of previous CS scar. Also there were no significant adverse maternal or neonatal outcomes. In this study, the rate of CS was not significantly different between the study and control groups; however, it was higher in the study group (19.8% versus 16.2%). Another Saudi study [15], quoted a significantly high cesarean rate in the study group (6.9% versus 3%) among 202 patients in both groups, these patients were of high parity 48. The indication for cesarean was similar in both groups in our study. Other authors have reported indications similar to ours for CS [15,21]. In grand multiparous women with previous CS scar, the alternative to induction is repeat CS. In Kuwait as in Saudi Arabia and most of the Middle East, families are usually large [3] and it is very difficult to convince women to have tubal ligation for both religious and social reasons. Therefore, the aim is to deliver women vaginally so that future pregnancies and deliveries are made less risky. In the last 15 years, there has been no maternal death associated with repeat scheduled CS at this hospital; however, the specter of morbid adherent placenta is ever present and the incidence is sharply increasing [15]. Regarding the perinatal status, in the study group, there were two stillbirths diagnosed antenatally in diabetic mothers.

J Matern Fetal Neonatal Med, Early Online: 1–5

This was neither related to the induction regime nor was the single early neonatal death that occurred due to major congenital malformation in a type 1 diabetic patient. It was reassuring to note that the fetal apgar scores in both the groups were comparable and only 4.9% of neonates in the study and 4.2% in the control group had apgar scores of 57 at 5 min. Thus, not only the maternal but also the fetal outcome is encouraging. The strengths of this study are that: (a) The present study was based on the experience of a single tertiary center, over a 10-year period, with the same team of senior specialists and consultants using the same strict protocol. Thus, potentially confounding factors, characteristic of different management protocols applied in different medical centers was minimized. (b) This study is moderate to large size, thus the results can be interpreted with reasonable confidence. (c) This is the first study from Kuwait, involving 382 patients. Constraints include that Western studies of a similar nature for comparison are rare, as Western society favors small families.

Conclusion We conclude that in this study of grand multiparous patients with previous CS, that induction of labor with prostaglandin E2 and (if indicated) very cautious labor augmentation with oxytocin infusion along with continuous electronic maternofetal monitoring, under the care of senior obstetrician, was relatively safe for mother and baby. Also the incidence of uterine rupture and scar dehiscence was low, and was not associated with any adverse materno-fetal outcome. Although not ideal, induction of labor with vaginal prostaglandin E2 in selected grand multiparous women with one previous cesarean may be a reasonable option with relative safety. Further moderate to large studies in this region, to document its safety would be beneficial.

Declaration of interest The manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work. I certify that no actual or potential conflict of interest in relation to this article exists, and the submitting/corresponding author signs for and accepts responsibility for realizing this material on behalf of any and all co-authors.

References 1. Kayani SI, Alfirevic Z. Induction of labour with previous caesarean delivery: where do we stand? Curr Opin Obstet Gynecol 2006;18:636–41. 2. McDonagh MS, Osterweil P, Guise JM. The benefits and risks of inducing labour in patients with prior caesarean delivery: a systematic review. BJOG 2005;112:1007–15. 3. Ahman E, Zupan J. Neonatal and perinatal mortality: country, regional and global estimates. Geneva: WHO World Health Organization. Department of Making Pregnancy Safer; 2007. 4. Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006;107:771–8.

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Minnesota on 10/14/14 For personal use only.

DOI: 10.3109/14767058.2014.918096

5. Halimi S. Association of placenta previa with multiparity and previous cesarean section. JPMI 2011;25:139–42. 6. Placenta accreta. Committee Opinion No. 529. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120: 207–11. 7. Ben-Haroush A, Yogev Y, Bar J, et al. Indicated labor induction with vaginal prostaglandin E2 increases the risk of cesarean section even in multiparous women with no previous cesarean section. J Perinat Med 2004;32:31–6. 8. Puliyath G. Induction of labor with prostaglandin E2 vaginal gel in women with one previous cesarean section. Middle East Fertil Soc J 2012;17:170–5. 9. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115: vaginal birth after previous cesarean delivery. Obstet Gynecol 2010;116:450–63. 10. Haas J, Barzilay E, Chayen B, et al. Safety of labor induction with prostaglandin E2 in grandmultiparous women. J Matern Fetal Neonatal Med 2013;26:49–51. 11. Yamani TY, Rouzi AA. Induction of labor with vaginal prostaglandin-E2 in grand multiparous women with one previous cesarean section. Int J Gynaecol Obstet 1999;65: 251–3. 12. Kugler E, Shoham-Vardi I, Burstien E, et al. The safety of a trial of labor after cesarean section in a grandmultiparous population. Arch Gynecol Obstet 2008;277:339–44. 13. Al JF. Grandmultiparity: a potential risk factor for adverse pregnancy outcomes. J Reprod Med 2012;57:53–8.

Induction of labor in grand multipara with previous CS

5

14. Shechter Y, Levy A, Wiznitzer A, et al. Obstetric complications in grand and great grand multiparous women. J Matern Fetal Neonatal Med 2010;23:1211–17. 15. Zamzami TY. A comparison of induction with vaginal prostaglandin E2 versus spontaneous of labor in grand multiparous women. Arch Gynecol Obstet 2005;273:176–9. 16. Fadeev A, Ioscovitch A, Rivlis A, et al. Prospective study of maternal and neonatal outcome in great-grand multiparous women (10 births) and in aged-matched women with lesser parity. Arch Gynecol Obstet 2011;284:799–805. 17. Goldman GA, Kaplan B, Neri A, et al. The grand multipara. Eur J Obstet Gynecol 1995;61:105–9. 18. Bahar AM, Archibong EI, Zaki ZMS, Mahfouz AA. Induction of labour using low and high dose regimens of prostaglandin E2 vaginal tablets. East Afr Med J 2003;80:51–5. 19. Geidam AD, Audu BM, Oummate Z. Pregnancy outcome among grand multiparous women at the University of Maiduguri Teaching Hospital: a case control study. J Obstet Gynaecol 2011;31:404–8. 20. Nassar AH, Fayyumy R, Saab W, et al. Grandmultiparas in modern obstetrics. Am J Perinatol 2006;23:345–50. 21. Alsayegh AK, Toshdy S, Hany Akef A, Maha Yousef S. Induction of labor with prostaglandin E2 in women with previous cesarean section and unfavorable cervix. Int J Health Sci (Qassim) 2007;1: 211–16. 22. Paliwal V, Dikhit SS, Singh S. Safety of induction of labor with vaginal prostaglandins (E2) in grandmultipara. Oman Med J 2009; 24:184–7.

Induction of labor in grand multiparous women with previous cesarean delivery: how safe is this?

To compare the outcome of induced and spontaneous labor in grand multiparous women with one previous lower segment cesarean section (CS), so that the ...
380KB Sizes 1 Downloads 3 Views