RESUMEN
Objective: As the cesarean delivery rate has risen future pregnancy outcomes are impacted including the decision to undergo a repeat cesarean or a vaginal birth after cesarean (VBAC) in the subsequent pregnancy. A calculator was developed by the maternal fetal medicine units (MFMUs) network in 2007 to estimate the chance of successful VBAC and is used widely. The purpose of this study was to investigate the calculator's validity on our obstetric patient population.Study design: This was a retrospective study of patients attempting a VBAC delivery at a single center from January 2012 to June 2014. Chances for success were estimated using the MFMU network VBAC calculator in 201 evaluable patients. We then compared the calculator's results with the outcomes observed. In order to determine if the MFMU VBAC calculator was accurately predicting successful vaginal deliveries, we discretized our dataset by binning into MFMU score deciles. Each decile was then tested for significant deviations from the predicted success rate using an exact binomial test. Significance was determined at 0.05 levels.Results: Two hundred and one patients were included. Our results demonstrated higher actual VBAC success than anticipated by using the MFMU network calculator for patients with scores in the 40-80% decile range. When stratified by race, we found the calculator to be a better predictor of success in African-American patients, as the calculator appears to underestimate success in white and Hispanic patients.Conclusion: Calculators are helpful to facilitate patient counseling and shared decision-making regarding the patient's choice for VBAC. When providing such counseling, the potential for reduced predicted VBAC success in the mid-decile range with the MFMU calculator should be recognized.
Asunto(s)
Parto Vaginal Después de Cesárea/estadística & datos numéricos , Adulto , Algoritmos , Femenino , Humanos , Embarazo , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: Unilateral obstruction of the proximal fallopian tube is identified in 10-24% of patients undergoing hysterosalpingography for evaluation of infertility. Upon further testing, this obstruction spontaneously resolves 16-80% of the time. We hypothesized that patient rotation during hysterosalpingography might resolve proximal tubal obstruction in some cases by altering either the location of intrauterine air bubbles or the spatial relationship of the tube to the uterine fundus. METHODS: In patients in whom unilateral proximal tubal obstruction was detected during hysterosalpingography performed for standard clinical indications, the patient was rotated on her hip approximately 45 degrees such that the obstructed tube was first superior (ventral) to the patent tube, and dye was reinjected. If obstruction did not resolve, the patient was rotated in the opposite direction so that the obstructed tube was inferior (dorsal) to the patent tube and dye reinjected. RESULTS: Unilateral tubal obstruction was found in 15% of cases (24 of 156). Rotating the patient with obstructed tube superior to the patent tube never resulted in tubal patency, whereas rotating the patient with the obstructed tube inferior resulted in resolution of tubal patency in 63% of cases (15 of 24) CONCLUSION: . Unilateral cornual obstruction during hysterosalpingography is often resolved by rotating the patient such that the obstructed tube is more inferior. Although this observation may be the result of dislodging smaller air bubbles, from a fluid dynamics perspective a more likely explanation is unkinking of the more inferior tube.