Nora, Anne E.

INTRODUCTION: After an increase in labor induction-associated uterine rupture cases, our institution implemented a restrictive trial of labor after cesarean (TOLAC) induction of labor (IOL) eligibility policy. The policy did not allow elective IOL to TOLAC patients and denied medically indicated IOL to patients who met any of the following criteria: two or more cesarean deliveries; body mass index greater or equal to 50 AND without a prior vaginal delivery; a priori predicted success rate of less than 60% AND Bishop score of less than 8. We investigated how this policy affected uterine rupture and VBAC rates. METHODS: This was a retrospective cohort of 4,356 participants with a prior cesarean delivery who delivered a subsequent neonate between 2011 and 2022. Uterine rupture rates were compared before and after implementation of the eligibility policy in 2018. The primary outcomes were uterine rupture and rates of VBAC. Multivariable logistic regression was performed. RESULTS: The uterine rupture rate decreased by 50% after implementation of eligibility criteria (0.9% pre-policy, 0.5% post-policy). The VBAC rate decreased from 30% to 25%, whereas the unsuccessful TOLAC rate decreased from 7.3% to 5%. CONCLUSIONS/IMPLICATIONS: This study supports previous studies that demonstrate IOL in TOLAC patients may increase the risk of uterine rupture. Restrictive criteria for IOL in TOLAC patients decreased the rates of uterine rupture and unsuccessful TOLAC, however decreased the overall VBAC rate. Uterine rupture is a rare, yet catastrophic event, and more studies are needed to develop policies that minimize risk to TOLAC patients and maximize VBAC rates.

INTRODUCTION: Since the early 20th century, surgical practices on prophylactic oophorectomy at the time of hysterectomy have fluctuated. This study aims to assess how current gynecologic surgeons are counseling patients on ovary-sparing benign hysterectomies and assess any gaps in provider knowledge. METHODS: Institutional review board exception was obtained. A survey was piloted and underwent several rounds of editing before being sent to members of American Association of Gynecologic Laparoscopists (AAGL) in April 2023. The questionnaire evaluated preoperative counseling on risks and benefits of ovary-sparing hysterectomy for benign indications and surgical practices for when to perform bilateral salpingectomy and oophorectomy. Descriptive statistics and regression analyses were performed. RESULTS: The survey was sent out by email to 6,622 AAGL members, 3,576 opened the email, and 520 completed surveys (14% response rate). Approximately one-half (58%) completed subspeciality training. Most counsel patients on the benefits of ovarian conservation including the prevention of osteoporosis (88%), early onset menopause (87%), cardiovascular disease (84%), and dementia (52%). Fifty percent recommend routine bilateral salpingo-oophorectomy at time of hysterectomy starting at age 61, whereas 38% recommend this be performed at age 51–55 years. CONCLUSION: Gynecologic surgeons are counseling patients on the risks and benefits of ovarian conservation. How frequently ovary-sparing hysterectomies are offered and the age at which bilateral salpingo-oophorectomy is recommended vary by provider. Additional high-quality studies are needed to further understand the optimal timing of oophorectomy at time of benign hysterectomy, and there is also a need for provider education to minimize discrepancy in practice patterns.