Trial of Labor After Cesarean for Twins and Risks for Adverse Outcomes
BACKGROUND AND PURPOSE:
Trial of labor after cesarean section (TOLAC) offered for singletons but data less clear regarding twin gestation
Kabiri et al. (AJOG, 2019) sought to assess risks of TOLAC in twins
Systematic review and meta-analysis
Cohort studies and RCTs
Maternal mortality and severe morbidities (e.g. uterine rupture and hysterectomy) were compared between
Women who underwent trial of labor
Women who had a planned repeat cesarean delivery
Random-effects model to calculate pooled odds ratios
TOLAC singleton vs twin was also assessed
11 cohort studies | 8,209 twin gestations with previous cesarean
2,484 intended planned vaginal birth
5,725 intended planned repeat cesarean delivery
Rate of uterine rupture in twin pregnancies was higher in TOLAC group
Odds ratio (OR) 10.09 (95% CI, 4.30–23.69)
No difference in risk of uterine rupture between twin and singleton TOLAC
OR 1.34 (95% CI, 0.54–3.31)
No difference between twin TOLAC and planned cesarean for the following
Uterine scar dehiscence
Neonatal morbidity and mortality
Note: Maternal mortality could not be assessed as only 2 publications reported this outcome resulting in an insufficient ‘n’
Vaginal delivery success was similar between twins and singletons
OR 0.85 (95% CI, 0.61–1.18)
There is a higher risk of uterine rupture with twin TOLAC, but not greater than that of singletons
Vaginal delivery success rate was >70% in both groups with uterine rupture rate <1%
The authors state
The latest guidelines of ACOG, the Royal College of Obstetricians and Gynaecologists, and other organizations of women’s health care physicians worldwide affirmed that twin gestation is not a contraindication to a trial of labor after cesarean delivery. The results of this meta-analysis support this conclusion and increase the quality of the evidence.
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