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.