--
Richard Chudacoff, MD
As Mankind becomes more liberal, they will be more apt to allow
that all those who conduct themselves as worthy members of the
community are equally entitled to the protections of civil
government. I hope ever to see America among the foremost
nations of justice and liberality.
George Washington
If the freedom of speech is taken away then dumb
and silent we may be led, like sheep to the slaughter.
George Washington
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Valerie
Jacobsen
Sent: Monday, March 22, 2004 12:07 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: OB: 31 week IUFD
>approx 30 YO P2002, 2 prior unknown sections, now 31 weeks presents for
>a routine visit and found to have an IUFD, vertex, closed/thick cervix.
>My partner has said she is not the best and the brightest, and her
>understanding level (to him) was substandard.
I am new here so I want to make some introduction and explain why this
question interests me so. I was first licensed about 20 years ago. I
have spent the majority of my career, the earlier part, not in maternity
services but as an ACLS certified ICU nurse.
Of all the events in my career, severe placenta accreta, increta, and
percreta have been invariably memorable. Seeing blood pour out as fast
as it is put into a ventilated, unresponsive patient who has a lonely
newborn and whose doctor is available by telephone.... No, I certainly
wouldn't know what it's like to be responsible for another person's
life, would I? :-/
I think that my three most-despised letters are probably D, I, and C.
There are two options for this woman.
First, VBA2C.
She might have a great big hole in what is probably low-transverse
scarring. An ultrasound could rule this out.
Every study that has ever been done on unknown scars has failed to find
any increase in the rupture rate over the risk in low transverse scars.
These studies aren't huge, but right now we have no evidence that the
risk of two unknown incisions is greater than the risk of two low
segment transverse incision. The risk with two unknown incisions (even
sans windows) *might* be greater, but we have no evidence basis for
concluding that this is so.
There is some evidence to the effect that vertical scars can be
consistently visualized by ultrasound. No recent, controlled study (of
several completed) has ever found a greater risk with VBAC after a *low
segment* vertical scar. Again, small studies by necessity. (Shipp did
one of the largest, 350+, and had a good discussion to go with it.)
Were these previous Cesareans done for any indication that makes an
upper segment vertical scar at all likely?
If the low segment doesn't have a window and an upper segment scar is
extremely unlikely, her risk might not be greater than it would be with
any other VBA2C.
But since her risk is unknown, I will suppose that it's higher than a
typical VBA2C. Err on the side of caution. Maybe her risk is 5%.
(There wouldn't be a variety of opinions on this question if anyone
supposed that it were higher!)
What would her risk of death be if she has a 5% risk of UR?
Maternal death with ***VBAC-related*** uterine rupture in a monitored
labor is so rare that we really don't have a reliable risk number, but
I've seen estimates in the neighborhood of 1:5000. (Of course, if we
were to use numbers for unscarred uteri, numbers from UR reviews that
include ruptures in unscarred uteri, numbers including out-of-hospital
events, or numbers from Ghana, we could get higher risk numbers easily
enough. But if we hope to help *this* woman, why would we use any of
that?)
Her risk of death going into VBA2C with a speculative 5% risk of low
segment UR might be somewhere around 1:100,000. Could be somewhat more.
Could be less. Could be her that dies. We don't know how low her
mortality risk really is, exactly, but it's very low.
The low mortality risk with spontaneous VBA2C might be acceptable to her
and to you. Even if she has a UR, you will almost certainly preserve
her life--and probably her uterus too.
The other option is ERCS. She would almost certainly survive that so
I'm not very interested in discussing the possibility that she wouldn't.
It's a safe option short-term. Arguably the safest. If it's what the
mother prefers and she plans no more children, is there any question
that this is best?
But I would want to know this mother's future plans. Was this a wanted
pregnancy? Is she saying, "Tie my tubes so I never go through this
again"? Or is she asking questions like, "Does this mean that the same
thing would happen to our next baby?" Scariest of all, does she say
anything like, "I've always wanted a large family"?
She may not be highly intelligent, but she probably has an opinion on
this question. If she doesn't.... The majority of pregnancies are
unplanned, right?
If it's likely that she'll have another pregnancy, accreta is well worth
discussion, imho.
After 3 Cesareans the risk of placenta accreta in the subsequent
pregnancy is in the neighborhood of about 3%. (I didn't look this up
today--but I'm close on this. If it's not 3%, it's about 4%. The
evidence that this risk increases almost linearly with every Cesarean is
abundant. After four Cesareans, it's 7%!)
According to the current ACOG Opinion Paper on placenta accreta, the
evidence-based mortality risk for placenta accreta is 7% overall. Seven
percent! The maternal mortality risk with ***VBAC0-related*** UR is
nowhere close!
Maybe a maternal mortality risk of 2:1000 in her next pregnancy? Give or
take. Some evidences point to the ACOG opinion on mortality as too low,
others as too high.
But a future pregnancy after 3 Cesareans *is much riskier* than a future
pregnancy after 2 Cesareans + one VBAC. If she is willing to wait a
reasonable amount of time for labor and is willing to labor, she would
enter a future pregnancy more safely if she didn't have a third
Cesarean.
For her two options, it seems to me that if she plans no more children,
maternal preference should be heavily considered as the deciding factor.
If she does plan more children, however, VBAC is safer--if she accepts
it.
I referenced Mankuta, AJOG, Sept 2003 in my first response. That paper
is important reading for anyone working with populations where large
families are more common. Mankuta concluded that if a single future
pregnancy is likely, the long-term risk of Cesarean (placenta accreta)
makes a VBAC is the better, safer option, *even if* the risk of a rescue
Cesarean is high in the current pregnancy.
And his model did not include either the sharply increasing risk of
accreta with more than one subsequent pregnancy or the strong
indications that later VBACs are probably much safer than the first one.
(All of the evidences that we have point in this direction. One smaller
study found an 80% reduction in UR risk after the first VBAC.)
The currently popular approach to VBAC has a low mortality risk in
populations where women have 1 or 2 children. I don't think that a
blanket restriction of maternal choice is good in/for any population,
but strictly from the standpoint of maternal mortality, outcomes will be
close where VBAC services are withheld from average-sized families.
But for ethnic and religious groups where women have 4 or more children,
where sterilization is often considered unacceptable, the policies of
refusing VBAC and neglecting to reveal the long-term risks of placenta
accreta with serial Cesarean *are* dangerous for women.
I think that the current belief that a VBAC is legally more risky than
even *serial* Cesarean is probably very short-sighted. When a mother of
5 young children is killed by percreta after her doctor demanded that
she have repeat Cesareans against her will and without ever mentioning
"placenta acccreta" in his blood-and-death speech, we're going to see a
father getting vengeance in court, big time.
How is a jury going to feel when the pictures of 5 motherless little
children are put in their faces? This kind of thing appears to be more
effective than proving causation. The future is not bright.
Valerie Jacobsen, RN, BSN, MS
