Trial of Labor and Vaginal Birth after Three Previous Cesarean Sections: Report of Two Special Cases

Background Natural childbirth could represent a deeply rooted need for many women, even in exceptional situations such as after 3 previous caesarean sections. Case presentation The first patient, a 28-year-old 6th gravida and 3rd para, first presented in the 40+3 week of pregnancy desiring a vaginal birth, after all the other hospitals in the area had refused her request. A detailed explanation of potential risks was given and, when 2 days later contractions started, she gave birth to a newborn of 4450 g spontaneously, without complications. A month later, a second woman, 42 years old, 5th gravida, 3rd para, read about the above-mentioned case on social media and decided to attempt a natural delivery after 3 caesarean sections at our hospital as well. She presented herself for the first time in the 41+1 week of pregnancy in our delivery room with an onset of labor after rupture of the membranes and gave birth on the same day, spontaneously without complications, to a 4150 g heavy healthy newborn. Conclusions The wish to attempt a spontaneous birth after 3 previous caesarean sections can be deeply anchored and should be professionally approached by obstetricians, even if counseling and management can be challenging.

Outcomes and Risk Factors for Failed Trial of Labor After Cesarean Delivery (TOLAC) in Women with One Previous Cesarean Section: A Chinese Population-Based Study

Background To evaluate the outcomes and risk factors for trial of labor after cesarean delivery (TOLAC) failure in patients in China. Methods Consecutive patients who had a previous cesarean delivery (CD) and were scheduled for TOLAC were included from 2014 to 2020. Patients who successfully delivered were classified into the TOLAC success group. Patients who were scheduled for TOLAC and had a repeat CD due to medical issues were classified into the TOLAC failure group. Multiple logistic regression analyses were performed to examine the risk factors for TOLAC failure. Results In total, 720 women who had a previous CD and were scheduled for TOLAC were identified and included. The success rate of TOLAC was 84.17% (606/720). Seven patients were diagnosed with uterine rupture, none of whom underwent hysterectomy. Multiple logistic regression analysis showed that the gestational weeks at pregnancy termination (odds ratio [OR] = 3.046, 95% confidence interval [CI]: 0.962-9.642, P = 0.005) and induction of labor (OR = 2.843, 95% CI: 1.571-5.145, P = 0.001) were positively associated with TOLAC failure. In contrast, the thickness of the lower uterine segment (LUS) (OR = 0.215, 95% CI: 0.103-0.448, P = 0.001) was negatively related to TOLAC failure. Conclusions This study suggests that TOLAC is effective in decreasing CD rates in the Chinese population. The gestational weeks at pregnancy termination and induction of labor were positively associated with TOLAC failure. Our findings need to be confirmed in larger samples with patients of different ethnicities.

UTERUS DIDELPHYS IN NULLIPAROUS AND MULTIPAROUS WOMEN – A RARE ENTITY

Uterus didelphys is a rare congenital uterine abnormality in which the embryogenetic fusion of the Mullerian ducts fails to occur. It will lead to the formation of a double uterus with two separate cervices and most often a double vagina with a longitudinal septum as well. Here, we present two different cases of uterus didelphys with varied presentations. The first case is a nulliparous woman presented with post-coital bleeding. On examination, two cervical openings with a longitudinal complete vaginal septum were found, conservative management was done. Findings of didelphys uterus were confirmed on USG. The patient was counseled and discharged. The second case is a multiparous woman with previous cesarean delivery, rupture of membranes, and meconium in this pregnancy with term pregnancy taken up for emergency cesarean section. Dense adhesions and a mass on the right side of uterus were found intraoperatively, which on further inspection confirmed to be patent right horn of uterus. Diagnosis of uterus didelphys was made after doing per speculum and per vaginal examination post-cesarean.

Treatment of Cervical Pregnancy with Ultrasound-Guided Intragestational Injection of Methotrexate: A Case Report

This study is aimed at describing a noninvasive conservative strategy to the treatment of cervical pregnancy and highlighting the success of ultrasound-guided therapeutic techniques. A 43-year-old woman with a history of one previous cesarean section presented in our unit with vaginal spotting and a positive urine pregnancy test. She was diagnosed with a cervical pregnancy, and she was successfully treated conservatively with the administration of intragestational sac methotrexate under ultrasound guidance. Cervical pregnancy is a rare form of ectopic pregnancy that results from conceptus implantation in the cervical canal. The main concern is the associated life-threatening hemorrhage and subsequent need for urgent hysterectomy. The evolution of ultrasound over the past decades has enabled early diagnosis and has shifted the management from a radical surgical approach towards a stepwise conservative therapeutic approach, when possible.

Induction of Labor with Vaginal Dinoprostone (PGE2) in Patients with a Previous Cesarean Section: Obstetric and Neonatal Outcomes

Background: Vaginal dinoprostone (PGE2) is currently used as the prostaglandin of choice in many obstetric units. However, few studies have evaluated its safety, especially in women who previously had a cesarean section. Objective: To evaluate the efficacy and safety of PGE2 in pregnant women who are undergoing induction of labor (IOL), and who have had a previous cesarean section. Materials and Methods: A prospective observational study was conducted in La Mancha Centro Hospital in Alcázar de San Juan, Spain, from 1 February 2019 to 30 August 2020. Obstetric and neonatal outcomes, following IOL with PGE2, in 47 pregnant women who wanted a trial of labor after cesarean (TOLAC), and 377 pregnant women without a history of cesarean section, were analyzed. The outcomes were analyzed by bivariate and multivariate analyses using binary and multiple linear regression. Results: A total of 424 women were included in this study. The percentage of cesarean sections in the TOLAC group was 44.7% (21), compared with 31.6% (119) in the group without a history of cesarean section (adjusted odds ratio: 1.4; 95% CI: 0.68–2.86). In the multivariate analysis, no statistically significant differences were observed between both groups for obstetric and neonatal outcomes (p > 0.05). However, two uterine ruptures (4.3%) occurred in the group of patients with a history of cesarean section who underwent IOL with PGE2. Conclusions: The induction of labor with vaginal dinoprostone (PGE2), in patients with a previous history of cesarean section, was not associated with worse obstetric or neonatal outcomes compared with the group of patients without a history of cesarean section in our study sample. However, further research is needed regarding this IOL method, and it should be used with caution in this population group.