Der Gynäkologe

, Volume 38, Issue 6, pp 514–521

Entbindung nach Uterotomie oder bei Uterusanomalien

  • D. Fischer
  • R. Axt-Fliedner
  • D. Hornung
  • D. Finas
  • M. Friedrich
Zum Thema

Zusammenfassung

Die Zahl der Mehrgebärenden, bei denen eine Uterotomie vorausgeht, steigt ständig an. Das liegt v. a. an der weiterhin zunehmenden Anzahl von Sectiones, die Sectiorate liegt derzeit in Niedersachsen bei 27%. Auch der Anteil der Schwangeren, bei denen bereits eine Myomenukleation durchgeführt wurde, nimmt zu, da der Altersdurchschnitt der Schwangeren steigt. In beiden Settings stellt sich die Frage des anzustrebenden Entbindungsmodus, bei der neben der größtmöglichen Sicherheit für Mutter und Kind auch psychologische Faktoren und gesellschaftliche Trends in die Entscheidung einfließen. Risiken und Entscheidungshilfen werden dargestellt. In 0,1–1% der Schwangeren ist mit einer Uterusfehlbildung zu rechnen, die sich in der Ausprägung von einem angedeuteten Septum bis zur komplexen Fehlbildung wie beim Uterus didelphys erstrecken kann. Eine gefürchtete Komplikation stellt die Uterusruptur dar, allerdings bestehen auch noch andere Risiken für Schwangerschaft und Geburt. Dennoch kann nach Sichtung der Datenlage außer beim Vorliegen bestimmter weiterer Faktoren zum Versuch des Spontanpartus geraten werden.

Schlüsselwörter

Uterotomie Sectiorate Myomenukleation Uterusfehlbildung Spontanpartus 

Spontaneous birth and uterine anomalies

Abstract

The number of multiparous women with a uterine scar is rising constantly. This is mostly due to the increasing number of cesarean sections. At present cesarean sections account for 27% of all births in the German State of Lower Saxony. Besides cesarean sections, there is also an increased number of pregnant women in whom enucleation of fibroids has been performed, mostly due to constantly rising maternal age. In both situations, it is difficult to decide on the mode of delivery. Besides safety concerns for mother and fetus, psychological factors and trends in society may also play a role. This article evaluates the risks involved and provides guidelines for decision making. Uterine malformations occur in 0.1–1% of all pregnancies ranging from an incomplete septum up to complex malformations such as uterus didelphys. Besides other possible events, uterine rupture is the most dangerous and feared complication in these situations. However, a review of the available data and current literature shows that spontaneous delivery can be advised after exclusion of certain risk factors.

Keywords

Uterotomy Cesarean section rate Enucleation of fibroids Uterine anomaly Spontaneous delivery 

Literatur

  1. 1.
    Acien P (1993) Reproductive performance of women with uterine malformations. Hum Reprod 8: 122–126PubMedGoogle Scholar
  2. 2.
    Angell NF, Tan Domingo J (2002) Uterine rupture at term after uncomplicated hysteroscopic metroplasty. Obstet Gynecol 100: 1089–1099CrossRefPubMedGoogle Scholar
  3. 3.
    Brown JM, Malkasian GD, Symmonds RE (1967) Abdominal myomectomy. Am J Obstet Gynecol 99: 126PubMedGoogle Scholar
  4. 4.
    Bujold E, Mehta SH, Bujold C, Gauthier RJ (2002) Interdelivery interval and uterin rupture. Am J Obstet Gynecol 187: 1199–1202CrossRefPubMedGoogle Scholar
  5. 5.
    Chauhan S, Martin JN, Henrichs CHE, Morrison JC, Magann EF (2003) Maternal and perinatal complications with uterine rupture in 142.075 patients who attempted vaginal birth after cesarean delivery: a review of the literature. Am J Obstet Gynecol 189: 408–417CrossRefPubMedGoogle Scholar
  6. 6.
    Davids AM (1975) Myomektomie in the relief of infertility and sterility and in pregnancy. Surg Clin North Am 37: 563Google Scholar
  7. 7.
    Dubuisson JB, Fauconnier A, Deffarges JV et al. (2000) Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod 15: 869–873CrossRefPubMedGoogle Scholar
  8. 8.
    Düring P, Schneider H (2001) Einmal Sectio caesarea immer Sectio caesarea: Wieder zutreffend? In: Huch A, Chaoui R, Huch R (Hrsg) Sectio caesarea. Unimed, BremenGoogle Scholar
  9. 9.
    Fayez JA (1986) Comparison between abdominal and hysteroscopic metroplasty. Obstet Gynecol 68: 399–403PubMedGoogle Scholar
  10. 10.
    Feige A (1997) Myomektomie. In: Feige A, Rempen A, Würfel W, Jawny J, Caffier H (Hrsg) Frauenheilkunde. Urban & Fischer, München, S 615–616Google Scholar
  11. 11.
    Flamm BL (2001) Vaginal birth after cesarean (VBAC). Best practice & research. Clin Obstet Gynecol 15: 81–92Google Scholar
  12. 12.
    Goetzl L, Shipp TD, Cohen A, Zelop CM (2001) Oxytocin dose and the risk of uterine rupture in trial of labor after cesarean. Obstet Gynecol 97: 381–384CrossRefPubMedGoogle Scholar
  13. 13.
    Golan D, Aharoni A, Gonen R et al. (1990) Early spontaneous ruptur of the myomectomy gravid uterus. Int J Gynaecol Obstet 31: 167CrossRefPubMedGoogle Scholar
  14. 14.
    Greene FM (2001) Vaginal delivery after cesarean section. Is the risk acceptable? N Engl J Med 345: 54–55CrossRefPubMedGoogle Scholar
  15. 15.
    Heinonen P, Saarikoski S, Pystynen P (1982) Reproductive performance of women with uterine anomalies: an evaluation of 182 cases. Acta Obstet Gynecol Scand 61: 157PubMedGoogle Scholar
  16. 16.
    Hook B, Kiwi R, Amini SB, Fanaroff A, Hack M (1997) Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 100: 348–353CrossRefPubMedGoogle Scholar
  17. 17.
    Kobelin CG (2001) Intrapartum management of vaginal birth after cesarean section. Clin Obstet Gynecol 44: 588–593CrossRefPubMedGoogle Scholar
  18. 18.
    Kolben M, Vetter K, Schneider KTM, Ratzel R (1999) Empfehlung zur Geburtsleitung bei Zustand nach Kaiserschnitt (Arbeitsgemeinschaft für maternofetale Medizin). Frauenarzt 40: 1003–1004Google Scholar
  19. 19.
    Leghart J, Hansen B (1982) Uterus didelphys. Report of a case with torsion of the uterus occuring during labor. Acta Obstet Gynecol Scand 61: 517–518PubMedGoogle Scholar
  20. 20.
    Liebermann E (2001) Risk factors of uterine rupture during a trial of labor after cesarean. Clin Obstet Gynecol 44: 609–621CrossRefPubMedGoogle Scholar
  21. 21.
    Ludmir J, Samuels P, Brooks S et al. (1990) Pregnancy outcome of patients with uncorrected uterine anomalies managed in a high-risk obstetric setting. Obstet Gynecol 75: 906–910PubMedGoogle Scholar
  22. 22.
    Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP (2001) Risk of uterine rupture during labor among woman with a prior cesarean delivery. N Engl J Med 345: 3–8CrossRefPubMedGoogle Scholar
  23. 23.
    Lynch CM, Kearney R, Turner MJ (2002) Maternal morbidity after elective repeat cesarean section after two or more previous procedures. Eur J Obstet Gynecol 106: 10–13CrossRefGoogle Scholar
  24. 24.
    Maneschi I, Maneschi F, Parlato M, Fuca G, Incandela S (1989) Reproductive performance in women with uterus didelphys. Acta Eur Fertil 20: 121–124PubMedGoogle Scholar
  25. 25.
    March CM, Israel R (1987) Hysteroscopic management of recurrent abortion caused by septate uterus. Am J Obstet Gynecol 156: 834PubMedGoogle Scholar
  26. 26.
    Martel MJ, Mac Kinnon CJ (2004) Guidelines for vaginal birth after previous cesarean birth. J Obstet Gynecol 26: 660–670Google Scholar
  27. 27.
    McKenzie IZ, Bradley S, Embrey MR (1984) Vaginal PG and labour induction for patients previosly delivered by cesarean section. Br J Obstet Gynecol 91: 7Google Scholar
  28. 28.
    McMahon M, Luther ER, Bowes WA, Olshan AF (1996) Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 335: 689–695CrossRefPubMedGoogle Scholar
  29. 29.
    NN (2004) ACOG practice bulletin. Vaginal birth after previous cesarean. Obstet Gynecol 104: 203–212PubMedGoogle Scholar
  30. 30.
    Patton PE, Novy MJ (2004) The diagnosis and reproductibe outcome after surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum. Am J Obstet Gynecol 190: 1669–1675CrossRefPubMedGoogle Scholar
  31. 31.
    Pridjian G (1992) Labor after prior cesarean section. Clin Obstet Gynecol 35: 445–456PubMedGoogle Scholar
  32. 32.
    Rageth JC, Juzi C, Großenbacher H (1999) Delivery after previous cesarean: a risk evaluation. Swiss working group of Obstetric and Gynecologic Institutions. Obstet Gynecol 93: 332–337CrossRefPubMedGoogle Scholar
  33. 33.
    Rock J, Jones H Jr (1979) The clinical management of the double uterus. Fertil Steril 28: 789Google Scholar
  34. 34.
    Rosen MG, DickinsonJC, Westhoff CL (1991) Vaginal birth after cesarean: a metanalysis of morbidity and mortality. Obstet Gynecol 77: 465–470PubMedGoogle Scholar
  35. 35.
    Schneider H (2000) Geburtshilfliches Management bei Status nach Sectio. Speculum 18: 9–13Google Scholar
  36. 36.
    Shuiqing M, Xuming B, Jinghe L (2002) Pregnancy and its outcome in women with malformed uterus. Chin Med Sci J 17: 242–245PubMedGoogle Scholar
  37. 37.
    Strassmann EO (1952) Surgical unification of double uterus; technic, indications and results. South Med J 45: 818–827PubMedGoogle Scholar
  38. 38.
    The Amercan Fertility Society (1988) The American Fertility Society classification of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Müllerian anomalies and intrauterine adhesions. Fertil Steril 49: 944PubMedGoogle Scholar
  39. 39.
    Wing DA, Paul RH (1999) Vaginal birth after cesarean section: selection and management. Clin Obstet Gynecol 42: 436–448CrossRefPubMedGoogle Scholar
  40. 40.
    Zentrum für Qualitätsmanagement im Gesundheitswesen (2003) Qualitätsbericht Geburtshilfe, Jahresauswertung 2003. Zentrum für Qualitätsmanagement im Gesundheitswesen, HannoverGoogle Scholar
  41. 41.
    Zinberg S (2001) Vaginal delivery after previous cesarean delivery: a continuing controversy. Clin Obstet Gynecol 44: 561–570CrossRefPubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag 2005

Authors and Affiliations

  • D. Fischer
    • 1
    • 2
  • R. Axt-Fliedner
    • 1
  • D. Hornung
    • 1
  • D. Finas
    • 1
  • M. Friedrich
    • 1
  1. 1.UniversitätsfrauenklinikUniversität Schleswig-Holstein, Campus Lübeck
  2. 2.UniversitätsfrauenklinikUniversität Schleswig-Holstein, Campus LübeckLübeck

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