Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section

Induction of labor after one previous Cesarean section in women with an unfavorable cervix: A retrospective cohort study

Objective

Uterine rupture is a well-known but unusual complication in vaginal deliveries with a Cesarean section in the history. The risk of uterine rupture is at least two-fold when labor is induced. In Sweden, women are allowed to deliver vaginally after one previous Cesarean section, regardless if labor starts spontaneously or is induced. The aim of the study is to compare the proportion of uterine ruptures between the three methods (balloon catheter, Minprostin® and Cytotec®) for induction of labor in women with an unfavorable cervix and one previous Cesarean section.

Material and methods

Retrospective cohort study of all women with one previous Cesarean section and induction of labor with an unfavorable cervix at the four largest clinics in Stockholm during 2012–2015. Inclusion criteria: Women with a previous Cesarean section and induction of labor with a viable fetus, cephalic presentation, singleton, at ≥34 w, (n = 910).

Results

3.0% (27/910) of the women with induction of labor had a uterine rupture, 91% of them had no previous vaginal delivery. The proportion of uterine ruptures was 2.0% (6/295) with orally administrated Cytotec®, 2.1% (7/335) with balloon catheter and 5.0% (14/ 281) when Minprostin® was used.

Conclusions

No difference in the proportion of uterine ruptures was shown when orally administrated Cytotec® and balloon catheter were compared (p = 0.64). Orally administrated Cytotec® and balloon catheter give a high success rate of vaginal deliveries (almost 70%) despite an unfavorable cervix.

Association between first caesarean delivery and adverse outcomes in subsequent pregnancy: a retrospective cohort study

Background

Few studies have explored the association between a previous caesarean section (CS) and adverse perinatal outcomes in a subsequent pregnancy, especially in women who underwent a non-indicated CS in their first delivery. We designed this study to compare the perinatal outcomes of a subsequent pregnancy in women who underwent spontaneous vaginal delivery (SVD) or CS in their first delivery.

Methods

This retrospective cohort study included women who underwent singleton deliveries at the International Peace Maternity and Child Health Hospital from January 2013 to December 2016. Data on the perinatal outcomes of all the women were extracted from the medical records. Multivariate logistic regression was conducted to assessed the association between CS in the first delivery and adverse perinatal outcomes in the subsequent pregnancy.

Results

CS delivery in the subsequent pregnancy was more likely for women who underwent CS in their first birth than for women with previous SVD (97.3% versus 13.2%). CS in the first birth was also associated with a significantly increased risk of adverse outcomes in the subsequent pregnancy, especially in women who underwent a non-indicated CS. Adverse perinatal outcomes included pregnancy-induced hypertension [adjusted odds ratio (OR), 95% confidence interval (CI): 2.20, 1.59–3.05], gestational diabetes mellitus (1.82, 1.57–2.11), gestational anaemia (1.27, 1.05–1.55), placenta previa (3.18, 2.15–4.71), placenta accreta (2.75, 1.75–4.31), and polyhydramnios (2.60, 1.57–4.31) in the mother and preterm delivery (1.37, 1.06–1.78), low birth weight (3.78, 2.07–6.90), macrosomia (5.04, 3.95–6.44), and neonatal jaundice (1.72, 1.39–2.14) in the baby.

Conclusions

CS in the first delivery markedly increases the risk of repeated CS and maternal-fetal complications in the subsequent pregnancy, especially in women with a non-indicated CS.

The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi-country population-based study

OBJECTIVE

International comparison of complete uterine rupture.

DESIGN

Descriptive multi-country population-based study.

SETTING

International.

POPULATION

International Network of Obstetric Survey Systems (INOSS).

METHODS

We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes.

MAIN OUTCOME MEASURES

Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality.

RESULTS

We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived.

CONCLUSIONS

Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.

Treatment options and reproductive outcome for adenomyosis-associated infertility

PURPOSE

Adenomyosis is a benign gynecological disease mostly diagnosed in the forth and fifth decades. The recent improvement of the diagnostic tools and a better understanding of the pathology allowed clinicians to postulate a possible relationship between adenomyosis and infertility and to diagnose it in younger asymptomatic women during infertility work-up. Purpose of this article is to review the different theories regarding the possible correlation between adenomyosis and infertility and to discuss the treatment options and the final reproductive outcome after the treatment.

MATERIALS AND METHODS

We search Pubmed for articles published in the English language with the use of the following MeSH search terms: "adenomyosis" combined with "treatment" and "fertility outcome" with the restriction to the human species. A manual search of review articles and cross-references completed the search. All selected articles were assessed for study design, patients characteristic, diagnosis of adenomyosis, type of treatment, post-treatment rates of conception, full-term pregnancy and completeness of information of the data sets.

RESULTS

Limited data are available concerning the efficacy of the different treatment options of adenomyosis on fertility outcome and the only ones published are retrospective evaluations or small case series.

CONCLUSIONS

Adenomyosis represents a common gynecological disorder with a negative impact on fertility. However, it remains challenging to establish if adenomyosis is the only cause of the infertility or not, because patients, in both case and control groups, may be affected by concomitant endometriosis. Further studies are required to determine the reason of implantation failure in women with adenomyosis and the impact of adenomyosis on infertile women with or without endometriosis.

Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour.

OBJECTIVE

To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups.

METHODS

We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves.

RESULTS

We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective.

LIMITATIONS

There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses.

CONCLUSIONS

Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention.

FUTURE WORK

Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005116.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial

Background

Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean.

Methods/design

The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis.

Discussion

The intervention is designed to facilitate: (1) women’s decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine rupture risk during TOL using ultrasound evaluation of low-uterine segment thickness, (3) an estimate of chance of TOL success, using a validated prediction tool, and (4) the implementation of best practices for intrapartum management.

Trial registration

Current Controlled Trials, ID: ISRCTN15346559. Registered on 20 August 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2150-x) contains supplementary material, which is available to authorized users.

Uterine Rupture at 21 Weeks in Twin Pregnancy with TTTS and Previous C-Section

Uterine rupture is a health problem in every country. The diagnosis is not always obvious and fetal and maternal morbidity and mortality can be high.

Placental location, postpartum hemorrhage and retained placenta in women with a previous cesarean section delivery: a prospective cohort study

OBJECTIVE

Women previously giving birth with cesarean section have an increased risk of postpartum hemorrhage (PPH) and retained placenta. The objective of this study was to determine if anterior placental location increased the risk of PPH and retained placenta in such women.

MATERIALS AND METHODS

We performed a prospective cohort study on 400 women with cesarean section delivery in a previous pregnancy. Ultrasound examinations were performed at gestational week 28-30, and placental location, myometrial thickness, and three-dimensional vascularization index (VI) were recorded. Data on maternal age, parity, BMI, smoking, gestational week at delivery, induction, delivery mode, oxytocin, preeclampsia, PPH, retained placenta, and birth weight were obtained for all women. Outcome measures were PPH (≥1,000 mL) and retained placenta.

RESULTS

The overall incidence of PPH was 11.0% and of retained placenta 3.5%. Twenty-three women (11.8%) with anterior placenta had PPH compared to 12 (6.9%) with posterior or fundal locations. The odds ratio was 1.94, but it did not reach statistical significance. There was no significant risk increase for retained placenta in women with anterior placentae. Seven of eight women with placenta previa had PPH, and four had retained placenta.

CONCLUSIONS

The overall risk of PPH and retained placenta was high for women with previous cesarean section. Anterior location of the placenta in such women tended to impose an increased risk for PPH but no risk increase of retained placenta. Placenta previa in women with previous cesarean section is associated with a high risk for PPH and retained placenta.

Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy

BACKGROUND

Uterine rupture is a potential life-threatening complication during a trial of labor after cesarean delivery. Single-layer closure of the uterus at cesarean delivery has been associated with an increased risk of uterine rupture compared with double-layer closure. Lower uterine segment thickness measurement by ultrasound has been used to evaluate the quality of the uterine scar after cesarean delivery and is associated with the risk of uterine rupture.

OBJECTIVE

To estimate the impact of previous uterine closure on lower uterine segment thickness.

STUDY DESIGN

Women with a previous single low-transverse cesarean delivery were recruited at 34-38 weeks' gestation. Transabdominal and transvaginal ultrasound evaluation of the lower uterine segment thickness was performed by a sonographer blinded to clinical data. Previous operative reports were reviewed to obtain the type of previous uterine closure. Third-trimester lower uterine segment thickness at the next pregnancy was compared according to the number of layers sutured and according to the type of thread for uterine closure, using weighted mean differences and multivariate logistic regression analyses.

RESULTS

Of 1613 women recruited, with operative reports available, 495 (31%) had a single-layer and 1118 (69%) had a double-layer closure. The mean third-trimester lower uterine segment thickness was 3.3 ± 1.3 mm and the proportion with lower uterine segment thickness <2.0 mm was 10.5%. Double-layer closure of the uterus was associated with a thicker lower uterine segment than single-layer closure (weighted mean difference: 0.11 mm; 95% confidence interval [CI], 0.02 to 0.21 mm). In multivariate logistic regression analyses, a double-layer closure also was associated with a reduced risk of lower uterine segment thickness <2.0 mm (odd ratio [OR], 0.68; 95% CI, 0.51 to 0.90). Compared with synthetic thread, the use of catgut for uterine closure had no significant impact on third-trimester lower uterine segment thickness (WMD: -0.10 mm; 95% CI, -0.22 to 0.02 mm) or on the risk of lower uterine segment thickness <2.0 mm (OR, 0.95; 95% CI, 0.67 to 1.33). Finally, double-layer closure was associated with a reduced risk of uterine scar defect (RR, 0.32; 95% CI, 0.17 to 0.61) at birth.

CONCLUSION

Compared with single-layer closure, a double-layer closure of the uterus at previous cesarean delivery is associated with a thicker third-trimester lower uterine segment and a reduced risk of lower uterine segment thickness <2.0 mm in the next pregnancy. The type of thread for uterine closure has no significant impact on lower uterine segment thickness.

Laparoscopic isthmocele treatment - single center experience

INTRODUCTION

A cesarean section is the most frequently performed surgery in modern obstetrics. In case of an incorrect wound healing process there is a risk of a persistent uterine wall defect. Nowadays, due to the high frequency of cesarean sections, obstetricians have to deal with the threat of uterine rupture due to pathological wound healing. It has been proven that isthmocele can cause abnormal uterine bleeding (AUB), pelvic pain (PP), and secondary infertility (SI), and can be a place of improper pregnancy placement.

AIM

This article presents our experience with isthmocele treatment. We describe our diagnostic process scheme, method of corrective surgery and main therapeutic outcomes.

MATERIAL AND METHODS

In this manuscript we present a single center's experience in isthmocele therapy. We have operated on 16 patients who suffered from abnormal uterine bleeding, pain disorders or secondary infertility possibly due to a cesarean scar defect.

RESULTS

The results obtained in our center are promising. In 9 of 11 (81.8%) women with abnormal bleeding we obtained complete resolution of symptoms. We had slightly worse results in the case of pelvic pain. In 4 (66.6%) of 6 patients the pain resolved completely. We have obtained 7 pregnancies in 11 (63.6%) patients operated on due to secondary infertility.

CONCLUSIONS

In our opinion, laparoscopic treatment seems to be currently one of the most effective methods in isthmocele therapy. Further investigation is necessary to determine the indications for surgery, suitable treatment strategies and appropriate care.

Maternal and fetal outcomes of uterine rupture and factors associated with maternal death secondary to uterine rupture

Background

Maternal mortality and morbidity are the priority agenda for sub-Saharan Africa including Ethiopia. Uterine rupture is the leading cause of maternal and fetal death in developing countries. Limited evidence is available on the magnitude of uterine rupture; maternal and fetal outcomes of uterine rupture and factors associated with maternal death secondary to uterine rupture in Ethiopia. This study aimed to assess the magnitude of uterine rupture; maternal and fetal outcome of uterine rupture and factors associated with maternal death secondary to uterine rupture in Debremarkos Referral Hospital, Northwest Ethiopia.

Methods

An institutional-based cross-sectional study was conducted in December 2015 in Debremarkos referral hospital, Northwest Ethiopia. A total of 242 records of mothers with uterine rupture at Debremarkos referral Hospital during the year 2011–2014 were included in the study. Secondary data was collected from the records of mothers admitted for the management of uterine rupture. Descriptive statistics were performed to characterize the study population. Bivariate and multivariable logistic regression model was fitted to identify factors associated with maternal death secondary to uterine rupture. Odds ratio with 95% confidence interval was computed to determine the level of significance.

Results

A total of 10,379 deliveries were attended A total of 242 uterine rupture cases were included in this study. The magnitude of uterine rupture was 2.44% (1 in 41 deliveries). Sixteen (6.6%) mothers died from uterine rupture. Fourteen (5.8%) had experienced Vesico Vaginal Fistula. The majority of the mothers, 72% (176), admitted for uterine rupture stayed in hospital for 6–10 days. Fetal outcome was grave, 98.3% (238) were stillborn. Place of labor [Adjusted odds ratio (AOR): 6.92, 95% confidence interval (CI): (1.16, 33.74)], occurrence of hypo volume shock [AOR: 3.48, 95% CI: (1.01, 11.96)] and postoperative severe anemia [AOR: 0.092, 95% CI: (0.01, 0.956)] were significantly associated with maternal death secondary to uterine rupture.

Conclusion

The magnitude of uterine rupture was high in the study area. Initiation of labor at health institutions, early treatment of hypo-volumia and prevention of postoperative anemia is recommended to decrease maternal death secondary to uterine rupture.

Risk factors of uterine rupture with a special interest to uterine fundal pressure

PURPOSE

Uterine rupture is a rare but serious event with a median incidence of 0.09%. Previous uterine surgery is the most common risk factor. The aim of our study was to analyze retrospectively women with uterine rupture during labor and to evaluate postulated risk factors such as uterine fundal pressure (UFP).

METHODS

Twenty thousand one hundred and fifty-two deliveries were analyzed retrospectively. Inclusion criteria were 22 weeks and 0 days-42 weeks and 0 days of gestation, singleton pregnancy and cephalic presentation. Women with primary cesarean section were excluded. A logistic regression analysis adjusting for possible risk factors was conducted and a subgroup analysis of women with unscarred uterus was performed.

RESULTS

Twenty-eight cases of uterine rupture were identified (incidence: 0.14%). Uterine rupture was noticed in multipara patients only. In the multivariate analysis among all study patients, only previous cesarean section remained a statistically significant risk factor [adjusted odds ration (adj. OR) 12.52 confidence interval (CI) 95% 5.21-30.09]. In the subgroup analysis among women with unscarred uterus (n=19,415) three risk factors were associated with uterine rupture: UFP (adj. OR 5.22 CI 95% 1.07-25.55), abnormal placentation (adj. OR 20.82 CI 95% 2.48-175.16) and age at delivery >40 years (adj. OR 4.77 CI 95% 1.44-15.85).

CONCLUSIONS

The main risk factor for uterine rupture in the whole study population is previous uterine surgery. Risk factors in women with unscarred uterus were UFP, abnormal placentation, and age at delivery >40 years. The only factor which can be modified is UFP. We suggest that UFP should be used with caution at least in presence of other supposed risk factors.

Contemporary analysis of maternal and neonatal morbidity after uterine rupture: A nationwide population-based study

AIM

Uterine rupture is a rare but feared perinatal event. Despite abundant research and changes to guidelines implemented to reduce this complication, evaluation of whether uterine rupture still engenders significant maternal/neonatal morbidity has not been conducted. We analyzed recent cases of maternal/neonatal morbidity after uterine rupture.

METHODS

Deliveries complicated by uterine rupture from 2011 to 2012 in the United States were selected. Comparison cases without uterine rupture were used as controls. Measures of maternal/neonatal complications were compared with χ² test, and relative risks were calculated. Logistic regression was used to identify the most significant complications. P < 0.05 indicated statistical significance.

RESULTS

From 7 922 016 births, 1925 cases of uterine rupture and 3765 controls were identified. Regression models retained four maternal outcomes; blood transfusion was the most common (~15%) and unplanned hysterectomy had the highest odds (~97-fold). For newborns, the model retained three measures of morbidity; neonatal intensive care unit admission was the most common (~35%) and seizures had the highest odds (~20-fold).

CONCLUSIONS

Despite efforts to reduce complications, mothers remain at significant risk of unplanned hysterectomy and intensive care unit admission. Neonates are at sizeable risk for neonatal intensive care unit admission and seizures, recognized markers of long-term neurobehavioral abnormality. Uterine rupture remains a major risk for mothers and babies.

Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study

BACKGROUND

Choice of delivery route after previous cesarean delivery can be difficult because both trial of labor after cesarean delivery and elective repeat cesarean delivery are associated with risks. The major risk that is associated with trial of labor after cesarean delivery is uterine rupture that requires emergency laparotomy.

OBJECTIVE

This study aimed to estimate the occurrence of uterine rupture during trial of labor after cesarean delivery when lower uterine segment thickness measurement is included in the decision-making process about the route of delivery.

STUDY DESIGN

In 4 tertiary-care centers, we prospectively recruited women between 34 and 38 weeks of gestation who were contemplating a vaginal birth after a previous single low-transverse cesarean delivery. Lower uterine segment thickness was measured by ultrasound imaging and integrated in the decision of delivery route. According to lower uterine segment thickness, women were classified in 3 risk categories for uterine rupture: high risk (<2.0 mm), intermediate risk (2.0-2.4 mm), and low risk (≥2.5 mm). Our primary outcome was symptomatic uterine rupture, which was defined as requiring urgent laparotomy. We calculated that 942 women who were undergoing a trial of labor after cesarean delivery should be included to be able to show a risk of uterine rupture <0.8%.

RESULTS

We recruited 1856 women, of whom 1849 (99%) had a complete follow-up data. Lower uterine segment thickness was <2.0 mm in 194 women (11%), 2.0-2.4 mm in 217 women (12%), and ≥2.5 mm in 1438 women (78%). Rate of trial of labor was 9%, 42%, and 61% in the 3 categories, respectively (P<.0001). Of 984 trials of labor, there were no symptomatic uterine ruptures, which is a rate that was lower than the 0.8% expected rate (P=.0001).

CONCLUSION

The inclusion of lower uterine segment thickness measurement in the decision of the route of delivery allows a low risk of uterine rupture during trial of labor after cesarean delivery.

Tocogram characteristics of uterine rupture: a systematic review

PURPOSE

Timely diagnosing a uterine rupture is challenging. Based on the pathophysiology of complete uterine wall separation, changes in uterine activity are expected. The primary objective is to identify tocogram characteristics associated with uterine rupture during trial of labor after cesarean section. The secondary objective is to compare the external tocodynamometer with intrauterine pressure catheters.

METHODS

MEDLINE, EMBASE, and the Cochrane library were systematically searched for eligible records. Moreover, clinical guidelines were screened. Studies analyzing tocogram characteristics of uterine rupture during trial of labor after cesarean section were appraised and included by two independent reviewers. Due to heterogeneity, a meta-analysis was only feasible for uterine hyperstimulation.

RESULTS

Thirteen studies were included. Three tocogram characteristics were associated with uterine rupture. (1) Hyperstimulation was more frequently observed compared with controls during the delivery (38 versus 21 % and 58 versus 53 %), and in the last 2 h prior to birth (19 versus 4 %). Results of meta-analysis: OR 1.68 (95 % CI 0.97-2.89), p = 0.06. (2) Decrease of uterine activity was observed in 14-40 % and (3) an increasing baseline in 10-20 %. Five studies documented no changes in uterine activity or Montevideo units. A direct comparison between external tocodynamometer and intrauterine pressure catheters was not feasible.

CONCLUSIONS

Uterine rupture can be preceded or accompanied by several types of changes in uterine contractility, including hyperstimulation, reduced number of contractions, and increased or reduced baseline of the uterine tonus. While no typical pattern has been repeatedly reported, close follow-up of uterine contractility is advised and hyperstimulation should be prevented.

Caesarean sections in rural Burundi: how well are mothers doing two years on?

SETTING

A caesarean section (C-section) is a life-saving emergency intervention. Avoiding pregnancies for at least 24 months after a C-section is important to prevent uterine rupture and maternal death.

OBJECTIVES

Two years following an emergency C-section, in rural Burundi, we assessed complications and maternal death during the post-natal period, uptake and compliance with family planning, subsequent pregnancies and their maternal and neonatal outcomes.

METHODS

A household survey among women who underwent C-sections.

RESULTS

Of 156 women who underwent a C-section, 116 (74%) were traced; 1 had died of cholera, 8 had migrated and 31 were untraceable. Of the 116 traced, there were no post-operative complications and no deaths. At hospital discharge, 83 (72%) women accepted family planning. At 24 months after hospital discharge (n = 116), 23 (20%) had delivered and 17 (15%) were pregnant. Of the remaining 76 women, 48 (63%) were not on family planning. The main reasons for this were religion or husband's non-agreement. Of the 23 women who delivered, there was one uterine rupture, no maternal deaths and three stillbirths.

CONCLUSIONS

Despite encouraging maternal outcomes, this study raises concerns around the effectiveness of current approaches to promote and sustain family planning for a minimum of 24 months following a C-section. Innovative ways of promoting family planning in this vulnerable group are urgently needed.

STAT3 accelerates uterine epithelial regeneration in a mouse model of decellularized uterine matrix transplantation

Although a close connection between uterine regeneration and successful pregnancy in both humans and mice has been consistently observed, its molecular basis remains unclear. We here established a mouse model of decellularized uterine matrix (DUM) transplantation. Resected mouse uteri were processed with SDS to make DUMs without any intact cells. DUMs were transplanted into the mouse uteri with artificially induced defects, and all the uterine layers were recovered at the DUM transplantation sites within a month. In the regenerated uteri, normal hormone responsiveness in early pregnancy was observed, suggesting the regeneration of functional uteri. Uterine epithelial cells rapidly migrated and formed a normal uterine epithelial layer within a week, indicating a robust epithelial-regenerating capacity. Stromal and myometrial regeneration occurred following epithelial regeneration. In ovariectomized mice, uterine regeneration of the DUM transplantation was similarly observed, suggesting that ovarian hormones are not essential for this regeneration process. Importantly, the regenerating epithelium around the DUM demonstrated heightened STAT3 phosphorylation and cell proliferation, which was suppressed in uteri of Stat3 conditional knockout mice. These data suggest a key role of STAT3 in the initial step of the uterine regeneration process. The DUM transplantation model is a powerful tool for uterine regeneration research.

Impact of adding a second layer to a single unlocked closure of a Cesarean uterine incision: randomized controlled trial

OBJECTIVE

To investigate short- and long-term effects on residual myometrial thickness (RMT) of adding a second layer to a single unlocked closure of a Cesarean uterine incision.

METHODS

This was a randomized double-blind controlled trial. Healthy nulliparous women scheduled for first-time elective Cesarean delivery were operated on using a modified version of the Misgav Ladach surgical technique. The women were examined by transabdominal ultrasound before discharge from the maternity ward and by transvaginal saline contrast sonohysterography at a minimum of 5 months postpartum.

RESULTS

Seventy-six nulliparae met the criteria and agreed to participate in the study. Thirty-five women were assigned to the single-layer technique and 38 to the double-layer unlocked closure technique. Groups were comparable regarding gestational age at delivery, duration of surgery and perioperative blood loss. There was no difference in RMT between the two groups, both at time of discharge (mean ± SD, 20.2 ± 8.0 mm vs 21.0 ± 9.7 mm) and after 5 months postpartum (mean, 5.7 ± 2.9 mm vs 5.7 ± 2.2 mm). RMT was approximately half that of the normal myometrium at both examinations.

CONCLUSION

The results of this study suggest that double-layer closure of a Cesarean uterine incision does not increase RMT compared with single-layer closure when an unlocked technique is used.

Age-related changes in thickness of anterior lower uterine segment in normal singleton pregnancy during 20-35 weeks' gestation

PURPOSE

To observe age-related changes in the anterior lower uterine segment (LUS) thickness in normal pregnancy from 20 to 35 weeks' gestation.

METHODS

Subjects were 235 uncomplicated singleton cases that underwent single ultrasound examination at 4-week intervals during 20-35 weeks' gestation. Sagittal LUS sections were evaluated with transvaginal ultrasonography. Anterior LUS thickness (Th) was measured every centimeter from the lowest bladder point (Th0cm) to 4 cm from that point (Th4cm). Th values were standardized by dividing by the Th0cm value. Intragroup comparisons of standardized Th values and intergroup comparisons of actual Th values were made according to gestational age. Statistical analyses were performed with the Kruskal-Wallis and Tukey honest standard deviation tests; significance was set at p < 0.05.

RESULTS

In the 20-23-, 24-27- and 32-35-week groups, standardized Th decreased from Th0cm to Th2cm; in the 28-31-week group standardized Th decreased from Th0cm to Th3cm. Median Th3cm values decreased from 5.0 mm at 20-23 weeks to 3.0 mm at 28-31 weeks, but remained unchanged thereafter.

CONCLUSIONS

The anterior LUS gradually thinned from Th0cm to Th3cm at 20-35 weeks' gestation. Th3cm became increasingly thin between 20-23 and 28-31 weeks' gestation.

Back to "once a caesarean: always a caesarean"? A trend analysis in Switzerland

PURPOSE

Caesarean sections (CS) have significantly increased worldwide and a previous CS is nowadays an important and increasingly reported indication to perform a repeat CS. There is a paucity of information in Switzerland on the incidence of repeat CS after previous CS and relationship between the rates of vaginal birth after CS (VBAC). The aim of this study was to analyse the actual trend in VBAC in Switzerland.

METHODS

We performed a retrospective cohort study to analyse the proportion of VBAC among all pregnant women with previous sections which give birth during two time periods (group 1:1998/1999 vs. group 2:2004/2005) in our tertiary care referral hospital and in the annual statistics of Swiss Women's Hospitals (ASF-Statistics). In addition, the proportion of induction of labour after a previous caesarean and its success was analysed.

RESULTS

In both cohorts studied, we found a significant decrease of vaginal births (p < 0.05) and a significant increase of primary elective repeat caesarean section (p < 0.05) from the first to the second time period, while there was a decrease of secondary repeat caesarean sections. The prevalence of labour induction did not decrease.

CONCLUSION

Our study shows that vaginal birth after a prior caesarean section has decreased over time in Switzerland. There was no significant change in labour induction during the study period. While this trend might reflect an increasing demand for safety in pregnancy and childbirth, it concomitantly increases maternal risks of further pregnancies, and women need to be appropriately informed about long-term risks.

Spontaneous uterine rupture in the 35th week of gestation after laparoscopic adenomyomectomy

Uterine rupture rarely occurs during pregnancy, but it is a critical situation if so. It is already known that a history of uterine surgeries, such as cesarean section or myomectomy, is a risk factor for uterine rupture. Currently, the laparoscopic adenomyomectomy is a widely performed procedure, but associated risks have not been defined. We observed a case of spontaneous uterine rupture in a patient during the 35th week of gestation, after a laparoscopic adenomyomectomy. A 42-year-old, gravida 2, para 0 woman became pregnant after a laparoscopic adenomyomectomy and her pregnancy was conventional. At a scheduled date in the 35th week of gestation, after combined spinal epidural anesthesia and frequent uterine contractions, a weak pain suddenly ensued. After 13 minutes of uterine contractions, vaginal bleeding was evident. A cesarean section was performed, and the uterine rupture was found in the scar. After a laparoscopic adenomyomectomy, a pregnant uterus can easily rupture by rather weak and short uterine contractions, and is characterized by vaginal bleeding. When uterine bleeding is observed in pregnant women that have a history of adenomyomectomy, one should consider uterine rupture.

Transverse occiput position: Using manual Rotation to aid Normal birth and improve delivery OUTcomes (TURN-OUT): A study protocol for a randomised controlled trial

BACKGROUND

Fetal occiput transverse position in the form of deep transverse arrest has long been associated with caesarean section and instrumental vaginal delivery. Occiput transverse position incidentally found in the second stage of labour is also associated with operative delivery in high risk cohorts. There is evidence from cohort studies that prophylactic manual rotation reduces the caesarean section rate. This is a protocol for a double blind, multicentre, randomised, controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate.

METHODS/DESIGN

Eligible participants will be ≥37 weeks pregnant, with a singleton pregnancy, and a cephalic presentation in the occiput transverse position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 49%, for a reduction to 35%, an alpha value of 0.05 and a beta value of 0.2, 416 participants will need to be enrolled. Participants will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery. Secondary outcomes will be caesarean section, significant maternal mortality and morbidity, and significant perinatal mortality and morbidity. Analysis will be on an intention-to-treat basis. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, (protocol number: X110410).

DISCUSSION

This trial addresses an important clinical question concerning a commonly used procedure which has the potential to reduce operative delivery and its associated complications. Some issues discussed in the protocol include methods of assessing risk of bias due to inadequate masking of a procedural interventions, variations in intervention efficacy due to operator experience and the recruitment difficulties associated with intrapartum studies.

TRIAL REGISTRATION

This trial was registered with the Australian New Zealand Clinical Trials Registry (identifier: ACTRN12613000005752 ) on 4 January 2013.

Selected maternal morbidities in women with a prior caesarean delivery planning vaginal birth or elective repeat caesarean section: a retrospective cohort analysis using data from the UK Obstetric Surveillance System

OBJECTIVE

To conduct a secondary analysis of data from the UK Obstetric Surveillance System (UKOSS) to estimate the rates of specific maternal risks associated with planned vaginal birth after caesarean (VBAC) and elective repeat caesarean section (ERCS).

DESIGN

A retrospective cohort analysis using UKOSS data from 4 studies conducted between 2005 and 2012.

SETTING

All hospitals with consultant-led maternity units in the UK.

POPULATION

Pregnant women who had a previous caesarean section.

METHOD

Women who had undergone a previous caesarean section were divided into 2 exposure groups: planned VBAC and ERCS. We calculated the incidence of each of the 4 outcomes of interest with 95% CIs for the 2 exposure groups using proxy denominators (total estimated VBAC and ERCS maternities in a given year). Incidences were compared between groups using χ(2) test or Fisher's exact test and risk ratios with 95% CI.

MAIN OUTCOME MEASURES

Severe maternal morbidities: peripartum hysterectomy, severe sepsis, peripartum haemorrhage and failed tracheal intubation.

RESULTS

The risks of all complications examined in both groups were low. The rates of peripartum hysterectomy, severe sepsis, peripartum haemorrhage and failed tracheal intubation were not significantly different between the 2 groups in absolute or relative terms.

CONCLUSIONS

While the risk of uterine rupture in the VBAC and ERCS groups is well understood, this national study did not demonstrate any other clear differences in the outcomes we examined. The absolute and relative risks of maternal complications were small in both groups. Large epidemiological studies could further help to assess whether the incidence of these rare outcomes would significantly differ between the VBAC and ERCS groups if a larger number of cases were to be examined. In the interim, this study provides important information to help pregnant women in their decision-making process.

Uterine rupture: trends over 40 years

OBJECTIVE

To follow trends of uterine rupture over a period of 40 years in Norway.

DESIGN

Population-based study using data from the Medical Birth Registry, the Patient Administration System, and medical records.

SETTING

Norway.

SAMPLE

Women giving birth in 21 maternity units in Norway during the period 1967-2008 (n = 1 441 712 maternities).

METHODS

The incidence and outcomes of uterine rupture were compared across four decades: 1967-1977; 1978-1988; 1989-1999; and 2000-2008. Multivariable logistic regression was used to determine the odds ratio (OR) for uterine rupture in each decade compared with the second decade.

MAIN OUTCOME MEASURE

Trends in uterine rupture.

RESULTS

We identified 359 uterine ruptures. The incidence rates per 10 000 maternities in the first, second, third, and fourth decade were 1.2, 0.9, 1.7, and 6.1, respectively. The ORs for complete and partial ruptures in the fourth versus the second decade were 6.4 (95% confidence interval, 95% CI 3.8-10.8) and 7.2 (95% CI 4.2-12.3), respectively. Significant contributing factors to this increase were the higher rates of labour augmentation with oxytocin, scarred uteri from a previous caesarean section, and labour induction with prostaglandins or prostaglandins combined with oxytocin. After adjusting for risk factors, the ORs for complete and partial ruptures were 2.2 (95% CI 1.3-3.8) and 2.8 (95% CI 1.6-4.8), respectively. Severe postpartum haemorrhage, hysterectomy, intrapartum death and infant death after complete uterine ruptures decreased significantly over time.

CONCLUSIONS

A sharply increasing trend of uterine rupture was found. Obstetric interventions contributed to this increase, but could not explain it entirely.

TWEETABLE ABSTRACT

A sharply increasing trend of uterine ruptures has been found in Norway in recent years.

Persistent Occiput Posterior position - OUTcomes following manual rotation (POP-OUT): study protocol for a randomised controlled trial

BACKGROUND

Occiput posterior position is the most common malpresentation in labour, contributes to about 18% of emergency caesarean sections and is associated with a high risk of assisted delivery. Caesarean section is now a major contributing factor to maternal mortality and morbidity following childbirth in developed countries. Obstetric intervention by forceps and ventouse delivery is associated with complications to the maternal genital tract and to the neonate, respectively. There is level 2 evidence that prophylactic manual rotation reduces the caesarean section rate and assisted vaginal delivery. But there has been no adequately powered randomised controlled trial. This is a protocol for a double-blinded, multicentre, randomised controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate.

METHODS/DESIGN

Eligible participants will be (greater than or equal to) 37 weeks' with a singleton pregnancy and a cephalic presentation in the occiput posterior position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 68%, then for a reduction to 50%, an alpha value of 0.05 and a beta value of 0.2, 254 participants will need to be enrolled. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, and protocol number X110410. Participants with written consent will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery (defined as vacuum, forceps and/or caesarean section deliveries). Secondary outcomes will be caesarean section, significant maternal mortality/morbidity and significant perinatal mortality/morbidity. Analysis will be by intention-to-treat. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. The results of the trial will be presented at one or more medical conferences. The trial will be submitted to peer review journals for consideration for publication. There will be potential to incorporate the results into professional guidelines for obstetricians and midwives.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registry ACTRN12612001312831 . Trial registered 12 December 2012.

Variables influencing the integrity of lower uterine segment in post-cesarean pregnancy

BACKGROUND

There is significant increase in proportion of cases with previous cesarean delivery requiring obstetric care. The available literature fails to provide uniform opinion on each woman's characteristics to identify risk of uterine rupture while planning trial of labor after cesarean.

OBJECTIVE

To study the association of abnormal lower uterine segment with some of the present and previous obstetric variables including patient characteristics and surgical techniques at previous cesarean operation.

MATERIALS AND METHODS

Consenting consecutive 96 post-cesarean singleton pregnancies admitting after 36 weeks gestation at the same facility from July 2011 to December 2012 for repeat cesarean, were studied. Only the cases with cephalic presentation and vertex as presenting part, having no placenta previa, polyhydramnios, uterine anomaly or fibroid and those who had previous one lower segment cesarean were recruited. Based on the intra-operative finding the lower uterine segment (LUS) was categorized into those having a normal and abnormal (grades 2-4) LUS. Sonographic assessment of LUS thickness and any abnormalities if any were noted. The findings of abnormal LUS (direct observation at surgery and sonographic impression within a week before surgery) were looked for association with some of the present and previous obstetric variables including patient characteristics and surgical techniques at previous cesarean operation using Student t, Chi square or Fisher's exact test for analysis as appropriate. Receiver operating curve analysis was used to determine the optimal cut off value for prediction of LUS integrity by ultrasound.

RESULTS

Of the women recruited for the study, 36 were admitted in early labor and ultrasound evaluation of LUS was performed in 48 of the remaining 60 women admitted antenatal for elective cesarean delivery. There were 38 abnormal LUS (39.6%) with 22 of them (57.9%) graded as 'thinned out LUS'. The incidence of scar dehiscence (grade 3, cases 5) was 5.2% of 96 cases and there were no cases of scar rupture. Proportion of cases with abnormal LUS was significantly high when primary cesarean was done in preterm (p = 0.02); it was a single layer uterine closure (p = 0.02), and inter-cesarean interval was 54 months (p = 0.01). Abnormal LUS was also seen to be associated with maternal age beyond 35 years (p = 0.2), when cesarean was performed in labor (p = 0.5), following 18 h of rupture of membranes (p = 0.75), for a baby weight more than 3 kg (p = 0.4), and different suture materials (polyglactin 910 and chromic catgut) were used to close uterus at primary cesarean delivery (p = 0.1), and also if they had post-partum fever (p = 0.3). Ultrasound measurement of LUS by abdominal scan correlated with the intra-operative LUS grading and a thickness of more than 3.2 mm within a week before delivery and was seen to be the safe cut off above which most of the women had a normal LUS (sensitivity 92.3%, specificity 81.1%).

CONCLUSION

Factors at primary cesarean operation significantly influence the state of LUS at term in subsequent pregnancy .

Transvaginal ultrasound assessment of uterine scar after previous caesarean section: comparison with 3T-magnetic resonance diffusion tensor imaging

PURPOSE

This study aimed to evaluate 3-T magnetic resonance imaging in the analysis of caesarean scars in women with prior caesarean section (pCS) and investigate the potential added value of diffusion tensor imaging (3T-MR-DTI) with fibre tracking reconstruction, compared with transvaginal ultrasound (TVUS).

METHODS

Thirty women who had previously undergone elective CS in a singleton pregnancy at term were examined (19 women with one pCS formed group 1 and 11 women with two pCS formed group 2). Patients underwent TVUS and 3T-MR-DTI within 2 days. Twelve women with prior vaginal delivery served as controls and underwent only 3T-MR. Uterine fibre architecture was depicted by MR-DTI with 3D tractography reconstruction providing quali-quantitative analysis of fibre, described as the reduction of number of longitudinal fibres that run through the uterine scar.

RESULTS

Six subjects were excluded. According to 3T-MR morphology, scars were described as linear (n = 12) and retracting (n = 12); disagreement with TVUS was 54 %. The thickness of myometrium at the scar level was found to be significantly greater with 3T-MR compared to TVUS in linear scars (p = 0.01). No difference was found among retracting scars. In controls, according to 3T-MR-DTI, longitudinal myometrial fibres running in the anterior wall were similar to those in the posterior wall at same level -2 %; -27 % + 22 %). In groups 1 and 2 there was significant reduction in anterior fibres compared to posterior ones (-53 %; -77 % - 34 %; p = 0.0001). Among retracting scars, fibre reduction was significantly higher compared to linear scars, p < 0.016.

CONCLUSIONS

The added value of 3T-MR with DTI lies in the prompt evaluation of muscle fibre remaining at scar level.

The risk of uterine rupture is not increased with single- compared with double-layer closure: a Swedish cohort study

OBJECTIVE

To compare single- with double-layer closure of the uterus for the risk of uterine rupture in women attempting vaginal birth after one prior caesarean delivery.

DESIGN

Cohort study.

SETTING

Sweden.

POPULATION

From a total of 19 604 nulliparous women delivered by caesarean section in the years 2001-2007, 7683 women attempting vaginal birth in their second delivery were analysed.

METHODS

Data from population-based registers were linked to hospital-based registers that held data from maternity and delivery records. Logistic regression was used to estimate the risk of uterine rupture after single- or double-layer closure of the uterus. Results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).

MAIN OUTCOME MEASURE

Uterine rupture.

RESULTS

Uterine rupture during labour occurred in 103 (1.3%) women. There was no increased risk of uterine rupture when single- was compared with double-layer closure of the uterus (OR 1.17; 95% CI 0.78-1.76). Maternal factors associated with uterine rupture were: age ≥35 years and height ≤160 cm. Factors from the first delivery associated with uterine rupture in a subsequent delivery were: infection and giving birth to an infant large for gestational age. Risk factors from the second delivery were induction of labour, use of epidural analgesia, and a birthweight of ≥4500 g.

CONCLUSIONS

There was no significant difference in the rate of uterine rupture when single-layer closure was compared with double -layer closure of the uterus.

An unusual cause for epigastric pain in pregnancy. Spontaneous uterine rupture with herniation of the amniotic sac in a 33-week primigravida

A 29-year-old in vitro fertilisation patient presented at 33 weeks of gestation with abdominal pain. An abdominal ultrasound revealed a cystic lesion adjacent to the fundus. During caesarean section, a defect at the fundus was identified with herniation of the amniotic sac through this defect. There were no complications postoperatively and the patient made an unremarkable recovery. With at least one maternal death reported in the most recent confidential enquiry into maternal death, uterine rupture is an obstetric emergency and can have catastrophic outcomes. The incidence of uterine rupture as a result of previous perforation is unclear with little published data and few case reports. Cases of uterine rupture after perforation following hysteroscopic resection of fibroids, uterine septum are well published but the authors found no known previous cases related to laparoscopy. Counselling patients post perforation should include discussion regarding the management of future pregnancies and the risk of uterine rupture.

Laparoscopic correction of the uterine muscle loss in the scar after a Caesarean section delivery

Caesarean section is the most frequently conducted surgery in modern obstetrics. It involves a significant risk of complications; also disorders in the area of the scar after hysterotomy may lead to menstrual disorders, pain and secondary infertility. In light of the presented facts the significance of a good uterus muscle correction method is high. We present a case of a 28-year-old patient after Caesarean section with further reproductive plans. In the ultrasonographic examination the residual thickness of the uterine wall was approx. 2.5–3 mm. The patient was operated on using laparoscopy and the fibrotic scar tissue was removed. During the follow-up examination in transvaginal ultrasonography the uterine muscularis was continuous on the whole surface. Laparoscopic treatment ensures the appropriate visibility which makes the risk of damage to the adjacent organs lower, and the time of convalescence is short. It provides repetitive good results from the anatomical and functional points of view.

Closure of the uterine incision with one or two layers after caesarean section: a randomized controlled study in sheep

OBJECTIVE

To compare the quality of the uterine scar with one or two layer closure after caesarean section by studying biomechanical and pathological properties of the scar.

METHODS

A randomized controlled trial performed on eight term pregnant ewes assigned into two groups during caesarean according to type of uterine closure: single-layer or double-layer. Hysterectomy was performed 8 months after caesarean delivery. Tensile strength of all scars and of unscarred myometrium was measured. Pathological properties of the scars were analyzed histologically.

RESULTS

The force required to reach the yield point was similar between scarred and unscarred myometrium (p=0.96), and between the scars in single-layer and double-layer closure groups (p=0.65). There was a significant increase in fibrosis width on the superficial part of the uterus in the double-layer closure group compared to the single-layer group (p=0.02).

CONCLUSIONS

Double-layer uterine closure modified wound healing without significant change in biomechanical properties.

Overweight and severe acute maternal morbidity in a low-risk pregnant population in the Netherlands

Objective

To investigate the association between overweight and severe acute maternal morbidity (SAMM) in a low-risk pregnant population.

Design

Nationwide case-control study.

Setting

The Netherlands, august 2004 to august 2006.

Population

1567 cases from initially primary care and 2994 women from primary care practices as controls, out of 371 012 women delivering in the Netherlands during the study period

Methods

Cases were women with SAMM obtained from a nationwide prospective study. All women in this cohort who initially had low-risk pregnancies were compared with low-risk women without SAMM to calculate odd ratios (ORs) to develop SAMM by body mass index (BMI) category. We divided body mass index in three overweight categories and calculated the ORs (95% CI) of total SAMM and per specific endpoint by logistic regression, with normal weight as reference. We adjusted for age, parity and socio-economic status.

Main Outcome Measures

SAMM, defined as Intensive Care Unit (ICU)-admission, Uterine Rupture, Eclampsia or Major Obstetric Haemorrhage (MOH)

Results

SAMM was reported in 1567 cases which started as low-risk pregnancies. BMI was available in 1097 (70.0%) cases and 2994 control subjects were included. Analysis showed a dose response relation for overweight (aOR, 1.3; 95% CI, 1.0-1.5), obese (aOR, 1.4; 95% CI, 1.1-1.9) and morbidly obese (aOR, 2.1; 95% CI, 1.3-3.2) women to develop SAMM compared to normal weight. Sub analysis showed the same dose response relation for ICU-admission, Uterine Rupture and Eclampsia. We found no association for MOH.

Conclusion

Overweight without pre-existent co-morbidity is an important risk-indicator for developing SAMM. This risk increases with an increasing body mass index.

Ultrasound evaluation of Cesarean scar after single- and double-layer uterotomy closure: a cohort study

OBJECTIVES

To compare residual myometrial thickness (RMT) and size of the Cesarean scar defect after single- and double-layer uterotomy closure following first elective Cesarean section.

METHODS

A retrospective cohort study was conducted in 149 women at least 6 months after an uncomplicated, elective Cesarean delivery. Two-dimensional transvaginal ultrasonographic measures of RMT, scar defect depth, width and length and myometrial thickness adjacent to the scar were compared in 68 women with single-layer and 81 women with double-layer closure delivered before and after, respectively, a change in the surgical procedure. Outcomes between the two groups were compared.

RESULTS

Median RMT was 5.8 (interquartile range (IQR), 4.1-7.8) mm in women with double-layer closure vs 4.6 (IQR, 3.4-6.5) mm in those with single-layer closure (P = 0.04). Scar defect length was greater in women with single-layer closure (median, 6.8 (IQR, 4.4-8.5) mm) than in those with double-layer closure (median, 5.6 (IQR, 3.9-6.8) mm) (P = 0.01). Measurements of defect depth and width, and the proportion of scars with RMT < 2.3 mm were similar in the two groups.

CONCLUSIONS

RMT was greater and defect length, but not defect depth and width, was smaller following double-layer compared with single-layer closure, which may indicate some limited benefit of double-layer closure following first elective Cesarean section.

Uterine rupture associated with VBAC

Uterine rupture during attempted vaginal birth after cesarean is a rare, but serious complication and can result in death or long-term disability. Several factors can increase the risk of uterine rupture during vaginal birth after cesarean and adequate counseling is necessary. Current literature suggests that timely diagnosis and delivery of the fetus is necessary for optimal outcome.

Prediction of scar integrity and vaginal birth after caesarean delivery

A statistically significant association with uterine rupture during a trial of labour after caesarean delivery was found in at least two studies for the following variables: inter-delivery interval (higher risk with short interval), birth weight (higher risk if 4000 g or over), induction of labour (higher risk), oxytocin dose (higher risk with higher doses), and previous vaginal delivery (lower risk). However, no clinically useful risk estimation model that includes clinical variables has been published. A thin lower uterine segment at 35-40 weeks, as measured by ultrasound in women with a caesarean hysterotomy scar, increases the risk of uterine rupture or dehiscence. No cut-off for lower uterine segment thickness, however, can be suggested because of study heterogeneity, and because prospective validation is lacking. Large caesarean hysterotomy scar defects in non-pregnant women seen at ultrasound examination increase the risk of uterine rupture or dehiscence in subsequent pregnancy, but the strength of the association is unknown. To sum up, we currently lack a method that can provide a reliable estimate of the risk of uterine rupture or dehiscence during a trial of labour in women with caesarean hysterotomy scar(s).

Factors associated with lower uterine segment thickness near term in women with previous caesarean section

OBJECTIVE

To estimate the association between potential influencing factors and lower uterine segment (LUS) thickness at term in women with previous Caesarean section.

METHODS

We conducted a cohort study of women with previous low-transverse Caesarean section undergoing ultrasonographic measurement of LUS thickness between 35 and 38 weeks' gestation in a tertiary care centre between 2006 and 2009. Measurements of the full LUS thickness and the myometrial LUS thickness were performed both transabdominally and transvaginally. The thinnest measurements for both full and myometrial LUS thicknesses were considered dependent variables. Non-parametric analyses, multivariate linear regression analyses, and multivariate regression analyses were used to evaluate the relationships between LUS thickness and the potential influencing factors of maternal age, interdelivery interval, prior vaginal delivery, and several characteristics of the previous Caesarean section.

RESULTS

In 377 women who underwent measurement of LUS thickness, labour before previous Caesarean section was the only characteristic associated with a greater full LUS thickness (an additional 0.9 mm; 95% CI 0.5 to 1.2 mm) in multivariate linear regression analysis. Labour before previous Caesarean section (0.5 mm; 95% CI 0.2 to 0.7 mm) and the use of synthetic sutures (as opposed to catgut sutures) for the closure of the previous hysterotomy incision (0.3 mm; 95% CI 0.02 to 0.5 mm) were the only two variables significantly associated with a thicker myometrial LUS. In multivariate regression analysis, three factors were predictive of a full LUS thickness of > 2.3 mm: the presence of labour, a recurrent indication for Caesarean section, and the use of synthetic sutures for hysterotomy closure at previous Caesarean section (P < 0.05).

CONCLUSION

Labour at the time of previous Caesarean section is associated with a thicker LUS near term in the subsequent pregnancy. The use of synthetic sutures for hysterotomy closure is another factor potentially associated with a thicker LUS.

Spontaneous Rupture of the Anterior Vaginal Wall during the First Stage of Labour

The risk of uterine rupture during attempted trial of labor after caesarean delivery (TOLAC) is well documented. However, vaginal rupture (in the absence of obstructed labour) is exceptionally uncommon. Below is described the rare case of a 37-year-old multiparous woman attempting TOLAC, who suffered a vaginal—rather than uterine—rupture, during the first stage of spontaneous labour. This case is an important reminder to obstetricians that concealed ruptures of both the vagina and uterus do occur and must be considered in clinical situations where another explanation is not apparent.

Reliability of 3-dimensional transvaginal sonographic measurement of lower uterine segment thickness

OBJECTIVES

The purpose of this study was to report the intraobserver and interobserver reliability of transvaginal 3-dimensional (3D) sonographic measurement of lower uterine segment thickness.

METHODS

A prospective study of 60 pregnant women with previous low transverse cesarean deliveries was performed between 35 and 39 weeks' gestation. Two observers, blinded to the clinical data, independently measured the full lower uterine segment thickness by 2-dimensional (2D) transvaginal sonography. Three-dimensional volume data sets of the lower uterine segment were captured and analyzed more than 2 months later by both observers independently. Intraobserver, interobserver, and intermethod reliability was evaluated by median absolute differences, nonparametric limits of agreement, intraclass correlation coefficients (ICCs), and κ coefficients.

RESULTS

The median full lower uterine segment thickness was 3.6 mm (range, 0.9-8.0 mm). Intraobserver reliability (median difference, 0.3 mm [interquartile range (IQR), 0.1-0.6 mm]; ICC, 0.88 [95% confidence interval (CI), 0.81-0.93]; κ, 0.87 [95% CI, 0.69-1.00]) and interobserver reliability (median difference, 0.3 mm [IQR, 0.1-0.5 mm]; ICC, 0.88 [95% CI, 0.81-0.93]; κ, 0.86 [95% CI, 0.66-1.00]) were excellent. Reliability between 3D and 2D sonography was moderate (median difference, 0.6 mm [IQR, 0.2-0.9 mm]; ICC, 0.78 [95% CI, 0.66-0.86]; κ, 0.56 [95% CI, 0.28-0.85]). However, intermethod reproducibility was improved when the full lower uterine segment thickness was less than 3.0 mm (median difference, 0.4 mm [IQR, 0.2-0.9 mm]).

CONCLUSIONS

Full lower uterine segment thickness measured with 3D transvaginal sonographic data sets has excellent intraobserver and interobserver reliability. It also has good reproducibility with 2D sonography when the full lower uterine segment thickness is less than 3.0 mm.

[Living birth after partial hysterectomy for chemorefractory gestational choriocarcinoma]

Chemotherapy is the reference treatment for gestational trophoblastic neoplasia. In case of chemoresistance, hysterectomy has to be considered even in women wishing to conceive. A 31-year-old nulliparous patient presented a recurrent invasive mole, despite two regimens of chemotherapy. She underwent a partial uterine resection of an intramyometrial choriocarcinoma followed by a third-line regimen. Two years later she gave birth by cesarean section at 32 weeks of amenorrhea to a healthy child after a spontaneous pregnancy. In order to preserve patient's fertility, conservative uterine surgery is an alternative to hysterectomy for selected chemoresistant gestational trophoblastic neoplasia.

Remote prognosis after primary cesarean delivery: the association of VBACs and recurrent cesarean deliveries with maternal morbidity

PURPOSE

To determine the effects of vaginal birth after cesarean (VBAC) versus repeated cesarean sections (RCS) after a primary cesarean section (CS), on the rate of intraoperative and postpartum maternal morbidity.

PATIENTS AND METHODS

This is a retrospective population-based cohort study. During the study period (1988-2005) there were 200,012 deliveries by 76,985 women at our medical center; 16,365 of them had a primary CS, of which 7429 women delivered a singleton infant after the primary CS, met the inclusion criteria, were included in our study, and were followed for four consecutive deliveries. Patients were divided into three study groups according to the outcome of their consecutive delivery after the primary CS: VBAC (n = 3622), elective CS (n = 1910), or an urgent CS (n = 1897). Survival analysis models were used to investigate the effect of the urgency of CS and the numbers of pregnancy predating the primary CS on peripartum complications.

RESULTS

Women who failed a trial of labor had a higher rate of uterine rupture than those who had a VBAC. Patients who delivered by CS had a higher rate of endometritis than those giving birth vaginally. The rate of cesarean hysterectomy and transfer to other departments increased significantly at the fourth consecutive surgery (P = 0.02 and P = 0.003, respectively). VBAC was associated with a 55% reduction in the risk of intrapartum complications in comparison to a planned CS (hazard ratio [HR] 0.45; 95% confidence interval [CI]: 0.22-0.89. A greater maternal parity at the time of primary CS was associated with lower intrapartum and postpartum morbidities (HR 0.44; 95% CI: 0.24-0.79; HR 0.54; 95% CI: 0.47-0.62, respectively).

CONCLUSIONS

(1) A successful VBAC is associated with a reduction in the intrapartum complications; and (2) maternal morbidity increases substantially from the fourth consecutive cesarean delivery.