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Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy

Published:February 22, 2019DOI:https://doi.org/10.1016/j.ajog.2019.02.036

      Background

      Prior studies have reported an increased risk for preterm delivery following a term cesarean delivery. However, these studies did not adjust for high-risk conditions related to the first cesarean delivery and are known to recur.

      Objective

      The objective of the study was to determine whether there is an association between term cesarean delivery in the first pregnancy and subsequent spontaneous or indicated preterm delivery.

      Study Design

      This was a retrospective cohort study of women with the first 2 consecutive singleton deliveries (2007–2014) identified through a linked pregnancy database at a single institution. Women with a first pregnancy that resulted in cesarean delivery at term were compared with women whose first pregnancy resulted in a vaginal delivery at term. Exclusion criteria were known to recur medical or obstetrical complications during the first pregnancy. A propensity score analysis was performed by matching women who underwent a cesarean delivery with those who underwent a vaginal delivery in the first pregnancy. The association between cesarean delivery in the first pregnancy and preterm delivery in the second pregnancy in this matched set was examined using conditional logistic regression. The primary outcome was overall preterm delivery <37 weeks in the second pregnancy. Secondary outcomes included type of preterm delivery (spontaneous vs indicated), late preterm delivery (34–36 6/7 weeks), early preterm delivery (<34 weeks), and small-for-gestational-age birth.

      Results

      Of a total of 6456 linked pregnancies, 2284 deliveries were matched; 1142 were preceded by cesarean delivery and 1142 were preceded by vaginal delivery. The main indications for cesarean delivery in the first pregnancy were dystocia in 703 (61.5%), nonreassuring fetal status in 222 (19.4%), breech presentation in 100 (8.8%), and other in 84 (7.4%). The mean (SD) gestational ages at delivery for the second pregnancy was 38.8 (1.8) and 38.9 (1.7) weeks, respectively, for prior cesarean delivery and vaginal delivery. The risks of preterm delivery in the second pregnancy among women with a previous cesarean and vaginal delivery were 6.0% and 5.2%, respectively (adjusted odds ratio, 1.46, 95% confidence interval, [CI] 0.77–2.76). In an analysis stratified by the type of preterm delivery in the second pregnancy, no associations were seen between cesarean delivery in the first pregnancy and spontaneous preterm delivery (4.6% vs 3.9%; adjusted odds ratio, 1.40, 95% confidence interval, 0.59–3.32) or indicated preterm delivery (1.6% vs 1.4%; adjusted odds ratio, 1.21, 95% confidence interval, 0.60–2.46). Similarly, no significant differences were found in late preterm delivery (4.6% vs 4.1%; adjusted odds ratio, 1.13, 95% confidence interval, 0.55–2.29), early preterm delivery (1.6% vs 1.2%; adjusted odds ratio, 1.25, 95% confidence interval, 0.59–2.67), or neonates with birthweight less than the fifth percentile for gestational age (3.6% vs 2.2%; adjusted odds ratio, 1.26, 95% confidence interval, 0.52–3.06).

      Conclusion

      After robust adjustment for confounders through a propensity score analysis related to the indication for the first cesarean delivery at term, cesarean delivery is not associated with an increase in preterm delivery, spontaneous or indicated, in the subsequent pregnancy.

      Key words

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      References

        • American College of Obstetricians and Gynecologists
        Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1.
        Obstet Gynecol. 2014; 123: 693-711
        • Martin J.A.
        • Hamilton B.E.
        • Osterman M.J.
        • Curtin S.C.
        • Mathews T.J.
        Births: final data for 2012.
        Natl Vital Stat Rep. 2013; 62: 1-68
        • Martin J.A.
        • Hamilton B.E.
        • Osterman M.J.
        • Driscoll A.K.
        • Drake P.
        Births: final data for 2016.
        Natl Vital Stat Rep. 2018; 67: 1-55
        • Little S.E.
        • Orav E.J.
        • Robinson J.N.
        • Caughey A.B.
        • Jha A.K.
        The relationship between variations in cesarean delivery and regional health care use in the United States.
        Am J Obstet Gynecol. 2016; 214: 735.e1-735.e8
        • Kennare R.
        • Tucker G.
        • Heard A.
        • Chan A.
        Risks of adverse outcomes in the next birth after a first cesarean delivery.
        Obstet Gynecol. 2007; 109: 270-276
        • Vahanian S.A.
        • Lavery J.A.
        • Ananth C.V.
        • Vintzileos A.M.
        Placental implantation abnormalities and risk of preterm delivery: a systematic review and meta-analysis.
        Am J Obstet Gynecol. 2015; 213: S78-S90
        • Creanga A.A.
        • Bateman B.T.
        • Butwick A.J.
        • et al.
        Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasing important contributor?.
        Am J Obstet Gynecol. 2015; 213: 384.e1-384.e11
        • Spong C.Y.
        • Mercer B.M.
        • D’Alton M.
        • Kilpatrick S.
        • Blackwell S.
        • Saade G.
        Timing of indicated late-preterm and early-term birth.
        Obstet Gynecol. 2011; 118: 323-333
        • Oyelese Y.
        • Catanzarite V.
        • Prefumo F.
        • et al.
        Vasa previa: the impact of prenatal diagnosis on outcomes.
        Obstet Gynecol. 2004; 103: 937-942
        • Oyelese Y.
        • Smulian J.C.
        Placenta previa, placenta accreta, and vasa previa.
        Obstet Gynecol. 2006; 107: 927-941
        • Cahill A.G.
        • et al.
        • Society of Gynecologic Oncology, American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine
        Placenta accreta spectrum.
        Am J Obstet Gynecol. 2018; 219: B2-B16
        • Clark Sl
        • Garite T.J.
        • Hamilton E.F.
        • Belfort M.A.
        • Hankins G.D.
        “Doing something” about the cesarean delivery rate.
        Am J Obstet Gynecol. 2018; 219: 267-271
        • Marcellin L.
        • Delorme P.
        • Bonnet M.P.
        • et al.
        Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta.
        Am J Obstet Gynecol. 2018; 219: 193.e1-193.e9
        • Melcer Y.
        • Jauniaux E.
        • Maymon S.
        • et al.
        Impact of targeted scanning protocols on perinatal outcomes in pregnancies at risk of placenta accreta spectrum or vasa previa.
        Am J Obstet Gynecol. 2018; 218: 443.e1-443.e8
        • Jauniaux E.
        • Collins S.
        • Burton G.J.
        Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging.
        Am J Obstet Gynecol. 2018; 218: 75-87
        • Ananth C.V.
        • Vintzileos A.M.
        Maternal-fetal conditions necessitating a medical intervention resulting in preterm birth.
        Am J Obstet Gynecol. 2006; 195: 1557-1563
        • Quiñones J.N.
        • Gómez D.
        • Hoffman M.K.
        • et al.
        Length of the second stage of labor and preterm delivery risk in the subsequent pregnancy.
        Am J Obstet Gynecol. 2018; 219: 467.e1-467.e8
        • Wood S.
        • Tang S.
        • Crawford S.
        Cesarean delivery in the second stage of labor and the risk of subsequent premature birth.
        Am J Obstet Gynecol. 2017; 217: 63.e1-63.e10
        • Berghella V.
        • Gimovsky A.C.
        • Levine L.D.
        • Vink J.
        Cesarean in the second stage: a possible risk factor for subsequent spontaneous preterm birth.
        Am J Obstet Gynecol. 2017; 217: 1-3
        • Watson H.A.
        • Ridout A.
        • Shennan A.H.
        Second stage cesarean as risk factor for preterm birth: how to manage subsequent pregnancies?.
        Am J Obstet Gynecol. 2018; 218: 367-368
        • Levine L.D.
        • Srinivas S.K.
        Length of second stage of labor and preterm birth in a subsequent pregnancy.
        Am J Obstet Gynecol. 2016; 214: 535.e1-535.e4
        • Smid M.C.
        • Lee J.H.
        • Grant J.H.
        • et al.
        Maternal race and intergenerational preterm birth recurrence.
        Am J Obstet Gynecol. 2017; 217: 480.e1-480.e9
        • Paquette A.G.
        • Shynlova O.
        • Kibschull M.
        • Price N.D.
        • Lye S.J.
        Global Alliance to Prevent Prematurity and Stillbirth Systems Biology of Preterm Birth Team. Comparative analysis of gene expression in maternal peripheral blood and monocytes during spontaneous preterm labor.
        Am J Obstet Gynecol. 2018; 218: 345.e1-345.e30
        • Strauss 3rd, J.F.
        • Romero R.
        • Gomez-Lopez N.
        • et al.
        Spontaneous preterm birth: advances toward the discovery of genetic predisposition.
        Am J Obstet Gynecol. 2018; 218: 294-314.e2
        • Bustos M.L.
        • Caritis S.N.
        • Jablonski K.A.
        • et al.
        Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The association among cytochrome P450 3A, progesterone receptor polymorphisms, plasma 17-alpha hydroxyprogesterone caproate concentrations, and spontaneous preterm birth.
        Am J Obstet Gynecol. 2017; 217: 369.e1-369.e9
        • Stout M.J.
        • Zhou Y.
        • Wylie K.M.
        • Tarr P.I.
        • Macones G.A.
        • Tuuli M.G.
        Early pregnancy vaginal microbiome trends and preterm birth.
        Am J Obstet Gynecol. 2017; 217: 356.e1-356.e18
        • Zhang J.
        • Troendle J.
        • Reddy U.M.
        • et al.
        for the Consortium on Safe Labor. Contemporary cesarean delivery practice in the United States.
        Am J Obstet Gynecol. 2010; 203: 326.e1-326.e10
        • Parsons L.S.
        Reducing bias in a propensity score matched-pair sample using greedy matching techniques (paper 214-26).
        in: Presented at the Twenty-Sixth Annual SAS Users Group International Conference. SAS Institute Inc, Cary, NC2001
        • Oken E.
        • Kleinman K.P.
        • Rich-Edwards J.
        • Gillman M.W.
        A nearly continuous measure of birth weight for gestational age using a United States national reference.
        BMC Pediatr. 2003; 3: 6

      Linked Article

      • Term cesarean delivery in the first pregnancy and increased risk for preterm delivery in the subsequent pregnancy
        American Journal of Obstetrics & GynecologyVol. 222Issue 6
        • Preview
          We read with great interest the article by Vahanian et al1 in the July 2019 issue. They used propensity scores to ascertain whether cesarean delivery in labor at term is a risk factor for preterm delivery in a subsequent pregnancy and found no association between cesarean delivery and preterm birth. Preterm birth is responsible for a massive health care burden, costing society more than 25 billion dollars per year in the United States alone.
        • Full-Text
        • PDF
      • The role of second-stage cesarean delivery in contributing to preterm delivery
        American Journal of Obstetrics & GynecologyVol. 222Issue 6
        • Preview
          We thank Dr de Vries et al1 for their thoughtful comments regarding our recent publication “Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy.” Using propensity score analysis to evaluate for potential confounders, we found no association between previous cesarean delivery and subsequent preterm delivery. The nature of the study design did not allow for us to evaluate second-stage cesarean deliveries as a separate risk factor.
        • Full-Text
        • PDF