Conclusion
Since our data come from a single tertiary centre, the treatment and
surgical protocols were relatively uniform. Only 1% of the study group
and 3% of the control group were treated with pitocin for augmentation
during TOLAC (p=0.81). One patient in the control group was induced
using an Atad catheter, as compared to none in the study group. All
uterine closures of the first CD were done in two layers. The time
interval between the CD and next delivery was 38.7±24.4 months in the
study group and 28.6±10.7 months in the control group (p = 0.00).
However, there were large variations within the groups. It can be
assumed that the experience of a traumatic labour (such as one
accompanied by infection or re-hospitalization) may affect the time
interval between deliveries but many other factors can affect this
decision and this topic requires further research.
We analysed women with dehiscence or uterine rupture (n=71) and a
subgroup of women with complete uterine rupture (n=40). We did so
because we believe that uterine rupture and dehiscence are one sequence
of the same entity, with the same ethology. Thus, it is important to
include cases of dehiscence in the analysis. On the other hand, we
understand that including them may pose a confounder because some
patients in the control group may have had a subclinical dehiscence
during their VBAC, and since we do not perform a routine scar test after
successful VBAC, these cases could be underdiagnosed. Therefore, we
chose to present the groups together and separately and show that in
both, infection in the first delivery was found to be a risk-factor for
uterine rupture.
This study investigated a possible new risk-factor for a disastrous
event. Further studies are needed to establish this finding but this is
a manageable risk and its incidence can be reduced.
Knowing that infection in general and endometritis specifically may
increase the risk for uterine rupture in the next delivery, should
inform the treating staff on the following issues: when consulting with
a patient on repeat CD versus TOLAC, endometritis after the previous CD
should be included among the considerations, along with other
traditional risk-factors. In addition, our results emphasize the
importance of adhering to the guidelines for perioperative preventative
treatment of infection, and finally, diagnosed infection in general and
endometritis, in particular, should be treated quickly and accurately.