Trial of labor after cesarean section in twin pregnancies: maternal and neonatal safety.
OBJECTIVE
To assess maternal and perinatal morbidity in patients undergoing a trial of labor after cesarean section (TOLAC) in twin gestations.


METHODS
A retrospective study including all twin pregnancies with a single prior cesarean section was performed. Stratified analysis using a multiple logistic regression model was performed to control for confounders. Patients who had a clear medical indication for a cesarean section (i.e. previous corporeal cesarean section, breech or transverse presentation, placenta previa, placental abruption, and herpes infection) were excluded from the analysis.


RESULTS
During the years 1988-2007, 134 patients met the inclusion criteria. Of these, 25 patients underwent a trial of labor and the remaining 109 underwent a repeat cesarean delivery. There were no cases of uterine rupture, maternal mortality, or peripartum fever in our population. Higher rates of perinatal mortality were noted in patients undergoing a trial of labor (8% vs. 1.8%, p = 0.042, OR = 4.652, 95% CI = 1.122-19.286). However, a trial of labor was not found to be an independent risk factor for perinatal mortality after controlling for confounders such as gestational age, ethnicity, and fetal malformations (adjusted OR = 1.07, 95% CI = 0.07-15.95, p = 0.95).


CONCLUSIONS
A TOLAC is not associated with an increased risk for maternal morbidity, including uterine rupture. Nevertheless, in our population TOLAC was noted as a risk factor for perinatal mortality, although residual confounding cannot be excluded. Further prospective randomized studies should evaluate the safety of TOLAC in twin gestations to establish appropriate guidelines.
Aaronson
Daniel
D
Faculty of Health Sciences, The Joyce and Irving Goldman Medical School, Ben-Gurion University of Negev, Be'er-Sheva, Israel.
Harlev
Avi
A
Sheiner
Eyal
E
Levy
Amalia
A
D017604:Cesarean Section, Repeat / Q000706:statistics & numerical data; D005260:Female; D005865:Gestational Age; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D008954:Models, Biological; D009035:Mothers / Q000706:statistics & numerical data; D007744:Obstetric Labor Complications / Q000453:epidemiology*; D011247:Pregnancy; D011256:Pregnancy Outcome; D011272:Pregnancy, Multiple / Q000502:physiology / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012449:Safety; D014219:Trial of Labor; D014427:Twins; D016064:Vaginal Birth after Cesarean / Q000009:adverse effects / Q000706:statistics & numerical data*