(255) Association between planned delivery mode and postpartum hemorrhage in twin pregnancies with previous cesarean delivery

Although it is now clear that a trial of labor after cesarean is a reasonable option and does not increase maternal morbidity in singleton pregnancies, data regarding twin pregnancies are scarce. Postpartum hemorrhage (PPH) is the main cause of maternal morbidity in twin pregnancies. Our objective was to evaluate the association between the planned mode of delivery and PPH in women with twin pregnancies and a previous cesarean delivery.

Study Design:

We conducted a secondary analysis of the JUMODA population-based national prospective cohort study of twin pregnancies in France (n=8823). We included women with one previous cesarean, with live twins beyond 24 weeks. We excluded women with a contraindication to vaginal birth (placenta previa, antepartum hemorrhage, placental abruption, first twin in transverse presentation, 2 previous cesareans, and previous other uterine surgery). The primary outcome was PPH, defined as a blood loss of 500 milliliters or more in the 24 hours following delivery. To assess the association between planned mode of delivery and PPH, we used a multivariable multilevel modified Poisson regression model. Then, analyses were rerun according to the actual mode of delivery.

Results:

Among the 735 women included, 187 (25.4 %) had planned vaginal delivery and 548 (74.6%) had planned cesarean delivery. The incidence of PPH was 8.2 % in the planned cesarean group and 9.1 % in the planned vaginal delivery group (p=0.709). After adjustment for confounders, the planned mode of delivery was not associated with the risk of PPH (adjusted relative risk 0.94, 95% CI 0.56 – 1.60) (Table 1). Analyses according to the actual mode of delivery found similar results (adjusted relative risk 1.24, 95% CI 0.64 – 2.40). Among the women with planned vaginal delivery, 125 (66.8%) had a successful vaginal delivery. Notably, there were only 2 uterine ruptures, both in the planned cesarean delivery group.

Conclusion:

In women with a twin pregnancy and a previous cesarean delivery, there is no overall association between the planned mode of delivery and the risk of PPH.