Maternal and Perinatal Outcomes.
Forty-seven studies presented data on maternal outcomes including uterine rupture (n=39), uterine dehiscence (n=16), maternal mortality (n=44), blood transfusion (n=10), and hysterectomy (n=17) (Table 2). Forty-five studies presented data on perinatal outcomes including stillbirth (n=20), neonatal mortality (n=18), perinatal mortality (stillbirth and neonatal mortality combined) (n=18), low Apgar score (n=22), and neonatal ICU admission (n=11) (Table 2).
Although 43 studies reported on uterine rupture or dehiscence, very few provided a definition (n= 4, 9%) distinguishing between rupture and dehiscence, and definitions varied across studies. Given difficulty separating the two conditions and inconsistencies, we combined uterine rupture and dehiscence to obtain a single summary estimate. Over the 29,823 deliveries amongst studies reporting uterine ruptures or dehiscence, there were 386 cases of uterine rupture or dehiscence for an overall weighted mean of 1.3% (± SD 1.6). There was regional variation in uterine rupture/dehiscence rates, with the lowest reported rate of 1.3% in West Africa and the highest rate of 8.8% in Central Africa. (Table 3)
Seventeen studies provided data on maternal and/or perinatal outcomes with a TOLAC and ERCS comparison group, representing 22,599 births in 8 countries (Figure 2). Pooled uterine rupture/dehiscence rate in this group (n=11 studies) was 1.4% in the TOLAC group and 0.2% in the ERCS group. However, the risk for uterine rupture did not differ from TOLAC vs ERCS (OR 1.54 (0.63-3.75 95% CI)). This did not differ when restricted to the nine studies which reported only on women with one prior CS [OR 1.70 (0.63-4.6 95%CI)] or with a MINORS score ≥ 16 [OR 1.77 (0.56-5.56 95% CI)].
Maternal mortality rates did not differ by TOLAC vs ERCS (n=13 studies) (0.3% vs <0.1%, OR 0.77 (0.30-1.98) with similar findings in studies restricted to women with only one prior CS or with a MINORs score > 16. Only six studies reported on perinatal mortality by comparison group. No studies with TOLAC and ERCS comparison groups separated stillbirth and neonatal mortality. Pooled rates demonstrated that perinatal mortality was higher in women undergoing TOLAC (5%) compared to ERCS (1%), OR 3.3 (1.5-6.9 95%CI).