Influencing factors of uterine rupture during vaginal delivery in patients with scarred uterus after cesarean section

doi:10.3877/cma.j.issn.1673-5250.2023.05.011

Objective

To investigate the influencing factors of uterine rupture during vaginal delivery in patients with cesarean scar uterus (SUAC).

Methods

A total of 105 patients with SUAC who underwent vaginal delivery in the Department of Obstetrics and Gynecology of Suzhou Municipal Hospital from January 2015 to December 2022 were selected as research subjects. According to whether SUAC patients experienced uterine rupture during vaginal delivery, they were divided into uterine rupture group (n=26) and non-uterine rupture group (n=79). Independent-samples t test or chi-square test was used to compare the age, gestational age, gravidity, interval between current pregnancy and previous cesarean section, prenatal body mass index (BMI), uterine scar thickness, proportion of suture method of previous cesarean section incision, incidence of pregnancy complications, and incidence of adverse pregnancy outcomes of mother and infant between two groups. Combined with previous research results and clinical experience, multivariate unconditional logistic regression analysis was further performed to analyze the independent influencing factors of uterine rupture in SUAC patients undergoing vaginal delivery. The procedures followed in this study were in accordance with the regulations of the Ethics Committee of Suzhou Municipal Hospital and were reviewed and approved by this Ethics Committee (Approval No. 2022326).

Results

①Among 105 SUAC patients who underwent vaginal delivery, the incidence of uterine rupture was 24.8% (26/105). The age, gravidity, proportion of prenatal BMI ≥30 kg/m^2, proportion of uterine scar thickness < 3 mm, and proportion of single layer suture of previous cesarean section incision in uterine rupture group were significantly higher than those in non-uterine rupture group, and interval between current pregnancy and previous cesarean section was significantly shorter than that in non-uterine rupture group, and all the differences were statistically significant (t=4.19, P<0.001; t=3.16, P=0.002; χ²=7.07, P=0.008; χ²=13.56, P<0.001; χ²=12.69, P<0.001; t=7.60, P<0.001). ②Results of multivariate unconditional logistic regression analysis showed that uterine scar thickness < 3 mm, and single layer suture of previous cesarean section incision were independent risk factors for uterine rupture during vaginal delivery in SUAC patients (OR=2.343, 95%CI: 1.361-4.032, P=0.002; OR=1.857, 95%CI: 1.124-3.067, P=0.015), and long interval between current pregnancy and previous cesarean section was its independent protective factor (OR=0.243, 95%CI: 0.097-0.607, P=0.002). ③The total incidence of adverse maternal and infant outcomes in uterine rupture group was 34.6% (9/26), which was significantly higher than 5.1% (4/79) in non-uterine rupture group, and the difference was statistically significant (χ²=15.75, P<0.001).

Conclusions

Thin uterine scar thickness and single layer suture of previous cesarean section incision are independent risk factors for uterine rupture during vaginal delivery in patients with SUAC, while long interval between current pregnancy and previous cesarean section is its independent protective factor. Clinical attention should be paid to such SUAC patients with thin uterine scar thickness, single layer suture of previous cesarean section incision, and short interval between current pregnancy and previous cesarean section, in order to reduce the risk of uterine rupture.

Key words: Cesarean section, Vaginal birth after cesarean, Uterine rupture, Scarred uterus, Birth intervals, Pregnancy outcome, Risk factors, Pregnant women

表1 SUAC患者再次妊娠选择阴道分娩发生子宫破裂影响因素的单因素分析

组别	例数	分娩年龄(岁，±s)	分娩孕龄(周，±s)	孕次(次，±s)	产前BMI[例数(%)]		是否临产入院[例数(%)]
组别	例数	分娩年龄(岁，±s)	分娩孕龄(周，±s)	孕次(次，±s)	<30 kg/m²	≥30 kg/m²	是	否
子宫破裂组	26	33.4±4.2	39.2±1.3	3.6±1.2	8(30.8)	18(69.2)	15(57.7)	11(42.3)
非子宫破裂组	79	29.8±3.7	39.6±1.3	2.8±0.9	48(60.8)	31(39.2)	32(40.5)	47(59.5)
统计量		t＝4.19	t＝1.14	t＝3.16	χ²＝7.07		χ²＝2.34
P值		<0.001	0.256	0.002	0.008		0.126
组别	例数	子宫瘢痕厚度[例数(%)]		定期产检[例数(%)]		本次妊娠距离前次剖宫产术分娩间隔时间(年，±s)	妊娠期并发症[例数(%)]
组别	例数	<3 mm	≥3 mm	是	否	本次妊娠距离前次剖宫产术分娩间隔时间(年，±s)	是	否
子宫破裂组	26	20(76.9)	6(23.1)	12(46.2)	14(53.8)	2.1±0.4	9(34.6)	17(65.4)
非子宫破裂组	79	28(35.4)	51(64.6)	46(58.2)	33(41.8)	3.1±0.6	40(50.6)	39(49.4)
统计量		χ²＝13.56		χ²＝1.15		t＝7.60	χ²＝2.02
P值		<0.001		0.283		<0.001	0.156
组别	例数	前次剖宫产术切口缝合方式[例数(%)]		新生儿出生体重(kg，±s)	前次剖宫产术分娩指征[例数(%)]
组别	例数	单层	双层	新生儿出生体重(kg，±s)	胎位不正	阴道试产失败中转剖宫产术分娩	无剖宫产术分娩指征
子宫破裂组	26	21(80.8)	5(19.2)	3.5±0.4	11(42.3)	9(34.6)	6(23.1)
非子宫破裂组	79	32(40.5)	47(59.5)	3.4±0.4	29(36.7)	32(40.5)	18(22.8)
统计量		χ²＝12.69		t＝1.50	χ²＝0.34
P值		<0.001		0.136	0.846

表1 SUAC患者再次妊娠选择阴道分娩发生子宫破裂影响因素的单因素分析

组别	例数	分娩年龄(岁，±s)	分娩孕龄(周，±s)	孕次(次，±s)	产前BMI[例数(%)]		是否临产入院[例数(%)]
组别	例数	分娩年龄(岁，±s)	分娩孕龄(周，±s)	孕次(次，±s)	<30 kg/m²	≥30 kg/m²	是	否
子宫破裂组	26	33.4±4.2	39.2±1.3	3.6±1.2	8(30.8)	18(69.2)	15(57.7)	11(42.3)
非子宫破裂组	79	29.8±3.7	39.6±1.3	2.8±0.9	48(60.8)	31(39.2)	32(40.5)	47(59.5)
统计量		t＝4.19	t＝1.14	t＝3.16	χ²＝7.07		χ²＝2.34
P值		<0.001	0.256	0.002	0.008		0.126
组别	例数	子宫瘢痕厚度[例数(%)]		定期产检[例数(%)]		本次妊娠距离前次剖宫产术分娩间隔时间(年，±s)	妊娠期并发症[例数(%)]
组别	例数	<3 mm	≥3 mm	是	否	本次妊娠距离前次剖宫产术分娩间隔时间(年，±s)	是	否
子宫破裂组	26	20(76.9)	6(23.1)	12(46.2)	14(53.8)	2.1±0.4	9(34.6)	17(65.4)
非子宫破裂组	79	28(35.4)	51(64.6)	46(58.2)	33(41.8)	3.1±0.6	40(50.6)	39(49.4)
统计量		χ²＝13.56		χ²＝1.15		t＝7.60	χ²＝2.02
P值		<0.001		0.283		<0.001	0.156
组别	例数	前次剖宫产术切口缝合方式[例数(%)]		新生儿出生体重(kg，±s)	前次剖宫产术分娩指征[例数(%)]
组别	例数	单层	双层	新生儿出生体重(kg，±s)	胎位不正	阴道试产失败中转剖宫产术分娩	无剖宫产术分娩指征
子宫破裂组	26	21(80.8)	5(19.2)	3.5±0.4	11(42.3)	9(34.6)	6(23.1)
非子宫破裂组	79	32(40.5)	47(59.5)	3.4±0.4	29(36.7)	32(40.5)	18(22.8)
统计量		χ²＝12.69		t＝1.50	χ²＝0.34
P值		<0.001		0.136	0.846

表2 SUAC患者再次妊娠选择阴道分娩发生子宫破裂影响因素的多因素非条件logistic回归分析结果

影响因素	B	SE	Wald值	P值	OR值	OR值95%CI
子宫瘢痕厚度<3 mm(以子宫瘢痕厚度≥3 mm为对照)	0.851	0.277	9.448	0.002	2.343	1.361～4.032
本次妊娠距离前次剖宫产术分娩间隔时间(连续变量)	1.414	0.467	9.176	0.002	0.243	0.097～0.607
前次剖宫产术切口缝合方式为单层(以前次剖宫产术切口缝合方式为双层为对照)	0.618	0.256	5.845	0.015	1.857	1.124～3.067
分娩孕龄(连续变量)	0.522	0.415	1.587	0.207	1.687	0.748～3.805
产前BMI≥30 kg/m²(以产前BMI<30 kg/m²为对照)	0.757	0.548	1.908	0.167	2.132	0.728～6.241
孕次(连续变量)	1.157	0.645	3.221	0.727	3.182	0.898～11.265

表2 SUAC患者再次妊娠选择阴道分娩发生子宫破裂影响因素的多因素非条件logistic回归分析结果

影响因素	B	SE	Wald值	P值	OR值	OR值95%CI
子宫瘢痕厚度<3 mm(以子宫瘢痕厚度≥3 mm为对照)	0.851	0.277	9.448	0.002	2.343	1.361～4.032
本次妊娠距离前次剖宫产术分娩间隔时间(连续变量)	1.414	0.467	9.176	0.002	0.243	0.097～0.607
前次剖宫产术切口缝合方式为单层(以前次剖宫产术切口缝合方式为双层为对照)	0.618	0.256	5.845	0.015	1.857	1.124～3.067
分娩孕龄(连续变量)	0.522	0.415	1.587	0.207	1.687	0.748～3.805
产前BMI≥30 kg/m²(以产前BMI<30 kg/m²为对照)	0.757	0.548	1.908	0.167	2.132	0.728～6.241
孕次(连续变量)	1.157	0.645	3.221	0.727	3.182	0.898～11.265

表3 2组SUAC患者母婴不良妊娠结局发生情况比较[例数(%)]

组别	例数	产后出血	新生儿窒息	前置胎盘	胎儿窘迫	合计
子宫破裂组	26	4(15.4)	1(3.8)	2(7.7)	2(7.7)	9(34.6)
非子宫破裂组	79	2(2.5)	1(1.3)	0(0)	1(1.3)	4(5.1)
χ²值		—	—	—	—	15.75
P值		—	—	—	—	<0.001

表3 2组SUAC患者母婴不良妊娠结局发生情况比较[例数(%)]

组别	例数	产后出血	新生儿窒息	前置胎盘	胎儿窘迫	合计
子宫破裂组	26	4(15.4)	1(3.8)	2(7.7)	2(7.7)	9(34.6)
非子宫破裂组	79	2(2.5)	1(1.3)	0(0)	1(1.3)	4(5.1)
χ²值		—	—	—	—	15.75
P值		—	—	—	—	<0.001

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