quinta-feira, 15 de abril de 2010

Estudos sobre VBAC

Estudos abaixo:

Uma cesárea prévia:
10.880 TPS / 83% de sucesso / 0.6% de ruptura/ Óbito fetal: 0.018%

Duas cesáreas prévias:
1,586 TPS / 76% de sucesso / 1.8% de ruptura/ Óbito fetal: 0.063%

Três cesáreas prévias:
241 TPS / 79% de sucesso / 1.2% de ruptura/ Óbito fetal: 0

Fonte: Miller, D. A., F. G. Diaz, and R. H. Paul.1994. Obstet Gynecol 84
(2): 255-258 (14/10/2002)

_____________________________

*RISCOS DE UM PARTO NORMAL DEPOIS DE DUAS OU MAIS CESÁREAS*

- Ruptura uterina: varia na literatura entre 0,3 e 0,9% (em torno de 0,5%).
Análise multivariada no estudo de Landon et al não evidenciou AUMENTO do
risco quando se comparou uma com DUAS OU MAIS cicatrizes anteriores de
cesárea.

- Histerectomia: 0,6% (risco aumentado de DUAS ou mais cesáreas em relação a
UM VBAC, com freqüência em torno de 0,2%.

- Transfusão: 3,2% (risco aumentado em relação a um VBAC: 1,6%)

*COMPLICAÇÕES DE TRÊS OU MAIS CESÁREAS*

- Perda sanguínea excessiva (7,9%)

- Aderências (46,1%)

- Dificuldade de extração fetal (5,1%)

- Acretismo placentário (1,4%)

- Necessidade de histerectomia (1%)
- Qualquer complicação: risco 2 vezes maior (8,7% x 4,3%) em relação a UMA
cesárea anterior.

Fonte: Compilado da comunidade GOBE - Pesquisado por Melania
_____________________________

*Risk of uterine rupture with a trial of labor in women with multiple and
single prior cesarean delivery.*

Landon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, Moawad AH,
Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M,
Peaceman AM, O'sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer
BM, Gabbe SG.

Obstet Gynecol 2006 Jul;108(1):12-20.

OBJECTIVE: To determine whether the risk for uterine rupture is increased in
women attempting vaginal birth after multiple cesarean deliveries.

METHODS: We conducted a prospective multicenter observational study of women
with prior cesarean delivery undergoing trial of labor and elective repeat
operation. Maternal and perinatal outcomes were compared among women
attempting vaginal birth after multiple cesarean deliveries and those with a
single prior cesarean delivery. We also compared outcomes for women with
multiple prior cesarean deliveries undergoing trial of labor with those
electing repeat cesarean delivery.

RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple
prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior
operation (P = .37). Multivariable analysis confirmed that multiple prior
cesarean delivery was not associated with an increased risk for uterine
rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and
transfusion (3.2% versus 1.6%, P < .001) were increased in women with
multiple prior cesarean deliveries compared with women with a single prior
cesarean delivery attempting trial of labor. Similarly, a composite of
maternal morbidity was increased in women with multiple prior cesarean
deliveries undergoing trial of labor compared with those having elective
repeat cesarean delivery (odds ratio 1.41, 95% confidence interval
1.02-1.93).

CONCLUSION: A history of multiple cesarean deliveries is not associated with
an increased rate of uterine rupture in women attempting vaginal birth
compared with those with a single prior operation. Maternal morbidity is
increased with trial of labor after multiple cesarean deliveries, compared
with elective repeat cesarean delivery, but the absolute risk for
complications is small. Vaginal birth after multiple cesarean deliveries
should remain an option for eligible women.

LEVEL OF EVIDENCE: II-2.

__________________________

*Labor before a primary cesarean delivery: reduced risk of uterine rupture
in a subsequent trial of labor for vaginal birth after cesarean.*

Obstet Gynecol. 2008 Nov;112(5):1061-6.

Algert CS, Morris JM, Simpson JM, Ford JB, Roberts CL.

OBJECTIVE: To estimate the effect of the onset of labor before a primary
cesarean delivery on the risk of uterine rupture if vaginal birth after
cesarean (VBAC) is attempted in the next pregnancy.

METHODS: Longitudinally linked birth records were used to follow women from
a primary cesarean delivery to a trial of labor at term for their next
birth. The effects of characteristics of both the trial of labor and primary
cesarean deliveries on the risk of uterine rupture were examined.

RESULTS: Of 10,160 women who had a trial of labor, 39 (0.38%) had a uterine
rupture. Women who were induced or augmented for their trial of labor had a
greater relative risk (RR) of uterine rupture (crude RR 4.24, 95% confidence
interval [CI] 2.23-8.07). Women whose primary cesarean delivery was planned
or followed induction of labor also had an increased risk of uterine rupture
(crude RR 2.61, 95% CI 1.24-5.49), and this risk remained after adjustment
for other factors. Women with a history of either spontaneous labor or
vaginal birth had one uterine rupture for every 460 deliveries; women
without this history who required induction or augmentation to proceed with
a VBAC attempt had one uterine rupture for every 95 deliveries.

CONCLUSION: Labor before the primary cesarean delivery can decrease the risk
of uterine rupture in a subsequent trial of labor. A history of primary
cesarean delivery preceded by spontaneous labor is favorable for VBAC.

LEVEL OF EVIDENCE: II.

__________________________

http://www.rcog.org.uk/news/bjog-release-do-we-need-revisit-vbac-guidelines-women-three-or-more-prior-caesareans

*BJOG release: Do we need to revisit VBAC guidelines for women with three
or more prior caesareans?*

New research to be published in *BJOG: An International Journal of
Obstetrics and Gynaecology* has found that women with three or more prior
caesareans who attempt vaginal birth have similar rates of success and risk
for maternal morbidity as those with one prior caesarean, and similar
overall morbidity (adding vaginal births and emergency caesareans together)
as those delivered by elective repeat caesarean.

Planned vaginal birth after caesarean (VBAC) refers to any woman who has
experienced a prior caesarean birth who intends to try for a vaginal birth
rather than to deliver by elective repeat caesarean. Although relatively low
complication rates, including uterine rupture, have been demonstrated among
women with two prior low-transverse caesareans who attempt vaginal birth,
there are very limited data available on outcomes among women with more than
two prior caesareans. Neither the American College of Obstetricians and
Gynaecologists (ACOG) nor the Royal College of Obstetricians and
Gynaecologists (RCOG) currently recommend planned VBAC attempt in women with
three or more prior caesarean deliveries1.
In this study, the researchers sought to estimate the rate of success and
risk of maternal morbidity in women with three or more prior caesareans who
attempt VBAC. The study reviewed multi-centre data from 17 tertiary and
community delivery centres in the Northeastern United States from 1996 to
2000. A total of 25,005 women who had a least one prior caesarean delivery
were included.

The findings indicate that women with three or more prior caesarean
deliveries did not experience a difference in morbidity based on whether
they attempted VBAC or elected for a repeat caesarean. The 89 women with
three or more prior caesareans who attempted VBAC were as likely to be
successful as women with one or two prior caesareans, 79.8% compared to
75.5% and 74.6% respectively. In addition, none of them experienced
significant maternal morbidity such as uterine rupture, uterine artery
laceration, and bladder or bowel injury.
The authors suggest that, given the findings, precluding VBAC for all women
with three or more prior caesareans may not be evidence based. Although
there is a measurable maternal morbidity associated with delivery for a
woman with a history of three or more prior caesareans, it does not differ
significantly by mode of delivery. Risks associated with multiple caesareans
are several, including surgical morbidity and abnormal placentation in
future pregnancies.

Lead author, Dr. Alison Cahill, from the Department of Obstetrics and
Gynaecology at Washington University in St. Louis School of Medicine, said
"These data suggest that women with three or more prior caesareans who
attempt VBAC have similar rates of success and risk for maternal morbidity
as those with one or two prior caesareans, and along with other
publications, suggest that perhaps it is time to revisit the current
recommendations for VBAC attempts for women with more than one prior
caesarean".
"Many have proposed a 'conservative' approach to VBAC attempts, which we
agree is prudent. But our evidence does not suggest that a conservative
approach, which we interpret as one that aims to reduce morbidity - and
specifically the risk of uterine rupture - is necessarily achieved by
allowing VBAC attempts only in women with one prior caesarean. Given
appropriate patient selection, VBAC following two or even three previous
caesareans in certain cases may be reasonably safe."

Prof. Philip Steer, *BJOG* editor-in-chief, said "Although confidence in the
findings of the study is limited by the relatively small sample size of
women who have had three previous caesareans, these findings provide
additional information for women, and contribute to the available evidence
on VBAC success and safety in women with more than one prior caesarean.

"As childbirth does not always 'follow the plan', the results may also serve
as a useful reference for clinicians when a women with three or more prior
caesareans presents in spontaneous labour."
*Ends*

*Notes*

*BJOG: An International Journal of Obstetrics and Gynaecology* is owned by
the Royal College of Obstetricians and Gynaecologists (RCOG) but is
editorially independent and published monthly by Wiley-Blackwell. The
journal features original, peer-reviewed, high-quality medical research in
all areas of obstetrics and gynaecology worldwide. Please quote '*BJOG*' or
'*BJOG: An International Journal of Obstetrics and Gynaecology' * when
referring to the journal and include the website: www.bjog.org as a hidden
link online.

To speak to Dr. Alison Cahill, please call +1 (314) 747 0739 or email
cahilla@wustl. edu. To speak to Professor Philip Steer, please call +44 (0)
20 7772 6357 or email p.steer@imperial. ac.uk.

*Reference *

Cahill A. Tuuli M, Odibo A, Stamilio D, Macones G. Vaginal birth after
caesarean for women with three or more prior caesareans: assessing safety
and success. BJOG 2010; DOI: 10.1111/j.1471- 0528.2010. 02498.x.

To view an abstract of the paper, click here (
http://dx.doi.org/10.1111/j.1471-0528.2010.02498.x.)

1 American College of Obstetricians and Gynecologists (ACOG). Practice
Bulletin #54: Vaginal birth after previous cesarean. Obstet Gynecol
2004;104:203-12; Royal College of Obstetricians and Gynaecologists (RCOG)
Green-top Guideline No.45, Birth After Previous Caesarean Birth (February
2007) available online at
http://www.rcog.rg.uk/womens-health/clinical-guidance/birth-after-previous-caesarean-birth-green-top-45
Date published: 03/02/2010
Published by: Anonymous

O artigo original:

http://www3.interscience.wiley.com/journal/123266608/abstract?SRETRY=0

Um comentário:

  1. E pensar que a mulherada se submete a cesáreas sem o emnor peso, sem questionar!

    Cath da Laura

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