Sliding sign in third-trimester sonographic evaluation of intra-abdominal adhesions in women undergoing repeat Cesarean section: a novel technique

Timing of planned cesarean delivery among patients with two previous cesarean sections

OBJECTIVES

The timing of planned repeat cesarean delivery (CD) is debateful in clinical practice. Planned repeat CD is typically scheduled before the spontaneous onset of labor to minimize the risk of uterine rupture during labor and the associated risk for fetal compromise. This timing should be balanced with the potential risk of delivering an infant who could benefit from additional maturation in utero. We aim to study the influence of gestational age at the time of repeat CD on maternal and fetal complications.

STUDY DESIGN

A population-based retrospective cohort study including all term singleton third CDs (≥ 37 weeks of gestation), between February-2020 and January-2022 at a tertiary medical center was conducted. Maternal and neonatal adverse outcomes were compared by gestational age at the time of the CD. A logistic regression models were constructed to adjust for confounders.

RESULTS

The study population included624 third CDs. Among them, two study groups were defined: 199 were at 37 + 0 to 37 + 6 weeks of gestation, and 44 were at ≥ 39 weeks of gestation at the time of delivery. 381 were at 38 + 0 to 38 + 6 weeks. Since our routine practice is to schedule elective CD at 38 + 0 to 38 + 6 weeks of gestation, we defined this group as the comparison group. In a multivariate analysis, both study groups were associated with significantly higher rates of emergent CDs after adjusting for maternal age, parity, ethnicity, premature rapture of membranes, spontaneous onset of labor and birthweight. After adjusting also for emergent CDs, CDs at 37 + 0 to 37 + 6 weeks of gestation were significantly associated with maternal and neonatal length of stay exceeding 4 days. Additionally, CDs at 37 + 0 to 37 + 6 weeks of gestation were also associated with composite of adverse neonatal and maternal outcomes.

CONCLUSIONS

Our study demonstrated that scheduling third CD at 38 + 0 to 38 + 6 weeks is associated with reduced risk of emergent CD, as well as beneficial maternal and neonatal outcomes.

Surgical repair of post-cesarean vesicouterine fistula: A systematic review and a plea for prevention

BACKGROUND

Vesicouterine fistula (VUF) is a iatrogenic injury in the vast majority of cases. The worldwide increase of cesarean delivery rates is expected to lead to increased complications.

OBJECTIVES

To assess current evidence on VUF pathogenesis and surgical management.

SEARCH STRATEGY

Pubmed and Embase databases were searched from January 2000 to January 2023 using relevant key words.

SELECTION CRITERIA

Only original articles including either transabdominal or transvaginal surgical routes for post-cesarean VUF repair, in English language, were included.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the references for eligibility, data extraction, and assessment of methodologic quality. All available surgical outcomes were recorded.

MAIN RESULTS

Of the 1160 studies retrieved, 67 were selected for analysis. Most of these were case reports, case series, or observational cohort studies including a total of 284 patients. The majority (78.6%) of patients had more than one cesarean section, and approximately 10% of them experienced an overt bladder injury and/or uterine rupture at the time of cesarean delivery. The supratrigonal part of the bladder was most commonly involved (92.5%). The majority of patients (88.8%) underwent delayed VUF repair through laparotomy. Length of stay and blood loss were significantly less in patients treated via a minimally invasive approach (P < 0.001 and P = 0.02, respectively). Most patients had double-layer bladder repair and single-layer uterine repair. The overall success rate was 100% on first attempt for each independent combination of different surgical approaches and techniques. Live birth following VUF repair was reported in 23 patients.

CONCLUSIONS

Paying close attention to surgical details is crucial to reduce the incidence of this complication and recurrence rates. Double-layer bladder closure and delayed timing of repair of VUF are recommended.

The use of ultrasound sliding sign for prediction of adhesions in women undergoing repeated caesarean section

We carried out this study to validate the use of ultrasound sliding sign to predict intraperitoneal adhesions in women undergoing repeated caesarean section (CS). A cross-section study was performed in women with at least one CS scheduled for an elective CS. We used the sliding sign of the uterus against the anterior abdominal wall to assess intraperitoneal adhesions, positive sliding sign if uterus moved freely and a negative sliding sign if limited mobility. The obstetrician was blind to the ultrasound results, asked to report if adhesions were absent or present during CS to validate accuracy of the sliding sign. We examined 120 women, negative sliding was reported in 54 patients, positive sliding in 66 women. The presence of intra-abdominal adhesions was confirmed in 44/54 cases assigned to the high-risk group, while the prediction of low risk for adhesions confirmed in 66/66 patients with a sensitivity of 100%, specificity of 86.84%. Sliding sign is an effective method to detect intra-abdominal adhesions in women with a history of repeated caesarean delivery.Impact statementWhat is already known on this subject? There has been a dramatic increase in the caesarean section (CS) rate worldwide; repeated CSs may be associated with intraperitoneal adhesions that result in difficulty during the procedure and may be related to bowel or bladder injuries and neonatal morbidities.What do the results of this study add? The sliding sign by ultrasound has a sensitivity of 100%, specificity of 86.84%, a positive predictive value of 81.5, a negative predictive value of 100, and accuracy of 91.67, considering it rapid, easy and reliable method for prediction of intraperitoneal adhesions.What are the implications of these findings for clinical practice and/or future research? The use of sliding sign by ultrasound in cases with repeated CSs offers a good predictor tool for presence of intraperitoneal adhesions and subsequently avoid severe sequels during surgery and good preparation.

A new technique for uterine-preserving pelvic organ prolapse surgery: Laparoscopic rectus abdominis hysteropexy for uterine prolapse by comparing with traditional techniques

Contemporary understanding of the dynamic anatomy of pelvic floor support has led us to new conservative surgery for uterine prolapse (UP). In this study, we comprehensively evaluate the safety and feasibility of a new technique for uterine-preserving pelvic organ prolapse surgery: laparoscopic rectus abdominis hysteropexy for uterine prolapse (LRAHUP). A retrospective study was conducted between 2006 and 2016. Sixty-five women diagnosed with advanced prolapsed uterus were eligible and grouped into traditional vaginal surgery (TVS, n = 30) group and new laparoscopic surgery (NLS, n = 35) group. Evaluated items of 65 cases included surgery-related parameters and postoperative outcomes. Surgical safety evaluating indicators, including operation time, blood loss, postoperative hospitalized day, and operation complications, also showed great significant difference between two groups (P < 0.05). The subjective index of post-operative Pelvic Floor Distress Inventory-short form 20 scores and some objective anatomic outcomes all showed great difference between pre- and post-operation (P < 0.05). Although the TVL showed no difference between pre- and post-operation in the same group, the TVL displayed a remarkable elongation. And a remarkable tendency was a higher cumulative recurrence ratio in the TVS group and a shorter follow-up period in the NLS group. LRAHUP may be a good procedure to manage women with advanced prolapsed uterus.

Prediction of intraperitoneal adhesions in repeated cesarean sections: A Systematic review and Meta-analysis

OBJECTIVE

With the rate of repeated cesarean sections on the rise, intraperitoneal adhesions caused by repeated cesareans could give rise to maternal morbidity during delivery. As a result, it's critical to have the ability to predict adhesions. The current meta-analysis aims to determine if intraperitoneal adhesions are likely to be present based on the characteristics of the cesarean scar, striae gravidarum, and sliding sign.

MATERIALS AND METHODS

We systematically searched electronicdatabases beforeretrieving articles up until October 13th, 2022 for analysis. After data extraction and literature screening, we first performed a quality assessment using the QUADAS-2 score system. Following that, a bivariate random-effect meta-analysis model was used to obtain the combined diagnostic and predictive values. To pinpoint the origins of heterogeneity, we conducted a subgroup analysis. Fagan's Nomogram was used to validate the clinical utility. Sensitivity analysis was used to gauge the reliability of each included study, and Egger's test and funnel plot asymmetry was used to investigate publication bias.

RESULTS

25 studies totaling 1840 patients with intra-abdominal adhesions and 2501 controls without adhesions were included in the systematic review. Diagnostic values from 8 studies regarding skin characteristics were combined, and the results for depressed scar showed: sensitivity[95 %CI] = 0.38[0.34-0.42]; Specificity[95 %CI] = 0.88[0.85-0.90]; DOR[95 %CI] = 4.78[2.50-9.13]; AUC = 0.65. Negative sliding sign from 7 studies, although not showing a diagnostic difference between cases and controls, had excellent predictive values: sensitivity[95 %CI] = 0.71[0.65-0.77]; Specificity[95 %CI] = 0.87[0.85-0.89]; DOR[95 %CI] = 6.88[0.6-78.9]; AUC = 0.77. Subgroup analysis illustrated non-Turkish studies to reveal more significant associations than Turkish studies.

CONCLUSION

Our meta-analysis found that the occurrence of adhesions can be predicted by the characteristics of abdominal wounds, particularly depressed scar, and scar width,as well as a negative sliding sign following a previous cesarean section.

Preoperative sonographic sliding sign for prediction of intra-abdominal adhesions before repeat cesarean delivery

OBJECTIVE

To evaluate the usefulness of the uterine sliding sign for predicting intra-abdominal adhesions in women undergoing repeat cesarean section (CS) and the association of the sliding sign with other operative and neonatal outcomes.

METHODS

A prospective cohort study was conducted among pregnant women with at least one previous CS. Transabdominal ultrasonography was performed and classified as a positive or negative sliding sign. Surgeons blinded to the sonographic results assessed intra-abdominal adhesions. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Operative and neonatal outcomes of the positive and negative sliding sign groups were compared. Factors associated with intraoperative adhesions were also analyzed.

RESULTS

A total of 380 women were recruited. The sensitivity and specificity of the uterine sliding sign to detect moderate-to-thick adhesions were 60.6% and 91.9%, respectively. A negative sliding sign was significantly associated with a higher incidence of adhesions, longer skin-to-delivery time, longer total operative time, and lower 5-min APGAR score in newborns. A negative sliding sign and history of two or more previous CS were significant predictors of moderate-to-thick adhesions.

CONCLUSION

The uterine sliding sign is an independent predictor of intraoperative adhesions, with acceptable sensitivity and high specificity and negative predictive value.

Ultrasonography of the Explanted Uterus in Placenta Accreta Spectrum: Correlation With Intraoperative Findings and Gross Pathology

OBJECTIVE

To better understand placenta accreta spectrum (PAS) by correlating postoperative ultrasonographic findings of the explanted uteroplacental interface with intraoperative findings and gross pathology.

METHODS

We enrolled consecutive pregnant patients aged 18 years and older with a prior cesarean delivery and antenatal diagnosis of lower uterine segment PAS who planned to undergo hysterectomy into this prospective, descriptive study. All underwent cesarean hysterectomy with standardized intraoperative photography. Ultrasonography of explanted postsurgical uteruses was performed by expert radiologists to obtain standard detailed images of the myometrial-placental interface and other areas of interest. Sagittal views of the gross pathologic specimen were photographed. We correlated the intraoperative, ultrasonographic, and gross pathologic findings as a study team and report four consistent patterns that emerged from this systematic evaluation.

RESULTS

Thirty-four consecutive eligible patients were enrolled. The following consistent observations emerged: 1) The uteroplacental interface in the explanted specimen was smooth and distinct. At the point of maximal placental protrusion, the myometrium was imperceptible, but the placenta was confined by a smooth thin echogenic line of uterine serosa (the scar shell) unless surgically disrupted. 2) Every specimen of PAS grade 2-3 showed placenta bulging through the lower uterine segment in the region of prior hysterotomy. 3) Placentas extended to, but not through, the uterovesical interface or scar shell. Dense adhesive disease was found between the placenta and bladder. There were no cases of true bladder invasion. 4) Placental extension beyond the serosa (invasion) has a distinct appearance on postoperative ultrasonography with irregular frond-like protrusion of placental tissue. This appearance was always the result of surgical manipulation and was not present before delivery of the neonate.

CONCLUSION

These findings suggest that PAS severity is likely mediated by progressive scar dehiscence and uterine remodeling, not placental invasion. This challenges the existence of in situ invasive percreta as it is currently described.

The effectiveness of preoperative diagnostic methods in predicting intra-abdominal adhesions before repeat cesarean section delivery

OBJECTIVE

This study aimed to evaluate the effectiveness of skin appearance, striae gravidarum severity, and ultrasonographic "sliding sign" in predicting preoperative adhesions before repeat cesarean section delivery on the same patient and find the most useful one.

METHODS

This was a prospective cohort study conducted on pregnant women with a history of cesarean section delivery. Davey's scoring system was used for stria evaluation. The scar was assessed using their visual appearance, and transabdominal ultrasonography was applied to detect sliding sign existence. Surgeons blinded to preoperative assessment graded the severity of intra-abdominal adhesions intraoperatively using Nair's scoring system.

RESULTS

Of the 164 pregnant women with at least one previous cesarean section delivery, 73 (44.5%) had filmy or dense intra-abdominal adhesions. Statistically significant association was found between three groups regarding parity, previous cesarean number, scar appearance, total stria score, and sliding sign existence. Negative sliding sign had a likelihood ratio of 4.198 (95%CI 1.178-14.964) for the detection of intra-abdominal adhesions. Stria score and scar appearance were also valuable for detection adhesions with likelihood ratios of 1.518 (95%CI 1.045-2.205) and 2.405 (95%CI 0.851-6.796), respectively. After receiver operator characteristics curve analysis, striae score cutoff value in adhesion prediction was determined as 3.5.

CONCLUSION

Stria score, scar appearance, and sliding sign are all significant predictors for intraperitoneal adhesions, and sliding sign, as an easy-to-apply, inexpensive, useful sonographic marker, is the most effective adhesion predictor before repeat cesarean section delivery compared to other known adhesion markers.

Difficulty in predicting intra-abdominal adhesion before cesarean section: A case report

Severe adhesions between the bladder and uterus necessitated an atypical incision in the cesarean section of a woman with endometriosis. This could not be predicted with pre-surgery MRI. No methods in the literature are able to predict adhesions with true certainty; it is therefore still difficult to diagnose intra-abdominal adhesions.

Preoperative sonographic prediction of intra-abdominal adhesions using sliding sign at repeat caesarean section at the University of Maiduguri Teaching Hospital, Nigeria: a prospective observational study

OBJECTIVE

To determine if the presence or absence of sonographic sliding sign preoperatively is a good predictor of the presence and type of intra-abdominal adhesions; and to determine the time taken to demonstrate this sign.

DESIGN

A prospective, observational, triple-blind study using tests of diagnostic accuracy.

SETTING

Single-centre tertiary health institution in north-east Nigeria.

PARTICIPANTS

67 women in the third trimester scheduled for repeat elective caesarean sections (CS) had transabdominal sonography to determine the absence or presence and degree of sliding sign. The time taken to make these decisions were noted. Surgeons blinded to the ultrasound findings graded adhesions intraoperatively and comparison between sonographic and intraoperative findings made. Women who were scheduled for emergency CS were excluded.

MAIN OUTCOME MEASURES

Accuracy of preoperative ultrasound to determine no/mild, moderate and severe adhesions. Secondary outcomes were interobserver correlations and time taken to determine sliding.

RESULTS

When classified as adhesion and no adhesion, the sliding sign demonstrated a sensitivity of 100.00% (CI₉₅ 85.18% to 100.00%), specificity of 100.00% (CI₉₅ 92.13% to 100.00%). In predicting presence of moderate intra-abdominal adhesions, a sensitivity of 65.0% (CI₉₅ 40.78% to 84.61%) and specificity of 82.98% (CI₉₅ 69.19% to 92.35%) was found. For predicting severe intra-abdominal adhesions, it had a sensitivity of 25.00% (CI₉₅ 0.63% to 80.59%) and specificity of 98.41 (CI₉₅ 91.47 to 99.96). Disease prevalence for mild, moderate and severe adhesions was 33.82% (CI₉₅ 22.79% to 46.32%), 29.85% (CI₉₅ 19.28% to 42.27%) and 5.97% (CI₉₅ 1.65% to 14.59%), respectively. Interobserver Cohen's kappa coefficient and PPA were 0.58 (CI₉₅ 0.39 to 0.76) and 58.82 (CI₉₅ 52.82 to 64.82), respectively. The mean duration to determine sliding sign was 7.56±2.86 s.

CONCLUSION

This study supports the role of transabdominal sliding sign in preoperative prediction of intra-abdominal adhesions in women with previous CS without significant increase in sonography duration. This information can encourage planning for CS by ensuring that surgeons of appropriate seniority are deployed to undertake anticipated complex operations.

Predicting Intra-abdominal Adhesions for Repeat Cesarean Delivery with the Ultrasound Sliding Sign

OBJECTIVE

To evaluate the diagnostic value of the "sliding sign", a sonographic test, in predicting intra-abdominal adhesions for women undergoing repeat cesarean delivery.

METHODS

This was a prospective observational study of women undergoing a scheduled repeat cesarean delivery at a regional hospital. The sliding sign is a sonographic observation of sliding movement between the uterus and the abdominal wall during deep breathing. The absence of the sliding sign was considered indicative of a high risk for dense uterine-abdominal adhesions, and this finding was compared with the operative findings. The primary outcome was the accuracy of the sliding sign in predicting adhesions. Secondary outcomes included incision-to-delivery time, operative time, and blood loss.

RESULTS

We examined 112 pregnant women. Dense uterine-abdominal adhesions were found in 15 women, 8 of whom had no sliding sign identified on ultrasound. Therefore, the presence of the sliding sign detected 78 out of 97 women without uterine-abdominal adhesions. The sensitivity, specificity, and positive and negative predictive values of the sliding sign were 53.3%, 80.4%, 29.6%, and 91.8%, respectively. The intra- and inter-observer reliability using the kappa coefficient showed moderate consistency at 0.43 and 0.45, respectively.

CONCLUSION

The sliding sign was less predictive than desired for clinical use, and it only detected half of the women with dense uterine-abdominal adhesions. Furthermore, a moderately low kappa coefficient indicates a lack of reproducibility, further emphasizing the sign's limited clinical value.

Prevalence of negative sliding sign representing pouch of Douglas obliteration during pelvic transvaginal ultrasound for any indication

OBJECTIVES

Pouch of Douglas (POD) obliteration can be predicted with a high degree of certainty and reproducibility using the dynamic transvaginal ultrasound (TVS) sliding-sign technique. So far, studies on POD obliteration prediction have focused on tertiary-care populations with high prevalence of endometriosis; however, POD obliteration may exist in individuals with asymptomatic endometriosis or other conditions. Our primary aim was to determine the prevalence of a negative sliding sign, representing POD obliteration, in a cohort of patients undergoing TVS for any gynecological indication.

METHODS

This was a prospective observational study of consecutive women with an indication for gynecological TVS, conducted at a high-volume ultrasound practice between July and August 2018. Clinical and surgical history, indication for TVS and TVS findings were documented. The prevalence of TVS-confirmed POD obliteration, determined by interpretation of the sliding sign, was calculated for the entire cohort and for the subgroups of women with and without risk factors for endometriosis. High risk for endometriosis was defined as having (1) a TVS referral for endometriosis-like pelvic pain or endometriosis specifically and/or (2) clinical symptoms or signs suggestive of endometriosis. Low risk was defined as the absence of these characteristics.

RESULTS

During the study period, 1043 consecutive women underwent TVS. After excluding those who underwent transabdominal ultrasound, had a history of hysterectomy or with missing data, 909 women were analyzed. The prevalence of a negative sliding sign in the entire cohort was 47/909 (5.2%). A negative sliding sign was observed in 22/639 (3.4%) women with a low risk for endometriosis and 25/243 (10.3%) of those with a high risk for endometriosis (difference in proportions, 6.9% (95% CI 2.8-10.9%); P < 0.001).

CONCLUSIONS

We have demonstrated an overall prevalence of a negative sliding sign, suggesting POD obliteration, of 5.2% (or 1/20) in women seeking TVS for a gynecological indication. The prevalence of negative sliding sign in low-risk women is not negligible (3.4% or 1/29 women). These women are most likely to have asymptomatic endometriosis or another important etiology of POD obliteration. The prevalence of a negative sliding sign is approximately three-times higher in women with signs and/or symptoms of endometriosis (10.3% vs 3.4%). Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Cesarean bladder injury - obstetrician's nightmare

Urinary bladder is an adjacent viscus susceptible for intraoperative injury during cesarean section (CS). Prolonged labor, scarred uterus, intraabdominal adhesion, emergency CS, advanced labor, cesarean hysterectomy etc., are the predisposing factors for bladder injury during CS. While operating on such conditions, one should be meticulous to explore the possibility of bladder injury. Family physician practicing community obstetrics should be aware of this and know how to tackle this. Usually the dome of the bladder is injured and the trigonal area remains away from the injury field by 6-10 cm. Bladder rent is repaired in two layers either by continuous simple or interrupted suture with 3-0 & 2-0 polyglycolic acid suture. Suprapubic cystostomy and transurethral catheter are kept for 10-14 days. While postoperative adhesion, CS during full dilatation of cervix, abnormal anatomy etc., may not proceed for negligence, bladder injury in normal patients and unrecognized intraoperative bladder injury may attract penalty from the consumer court.

Subcutaneous tissue stiffness of cesarean incision scar by elastography as a predictor of intra-abdominal adhesions

AIM

This study aimed to investigate whether subcutaneous tissue stiffness of the previous cesarean section (CS) skin incision could predict the severity of the intra-abdominal adhesions at a repeat CS.

METHODS

In this prospective cross-sectional study, pregnant women with at least one prior cesarean delivery were included. The subcutaneous tissue stiffness of the previous CS skin scar was measured by shear wave elastography (SWE) on the day of the repeat CS and the intra-abdominal adhesions were recorded by an adhesion classification scheme specific for CS. Total adhesion score was classified as mild adhesion between 1 and 4, moderate adhesion between 5 and 12, and severe adhesion if ≥13.

RESULTS

Of the 102 women, 41 (40.2%) had no adhesions, 18 (17.6%) had mild adhesions, 26 (25.5%) had moderate adhesions and 17 (16.7%) had severe adhesions. The mean SWE measurements were significantly higher in the moderate and severe adhesion group than the non-adhesion and mild adhesion group (51.5 ± 25.3 vs 36.8 ± 22.6, P = 0.003). There was a statistically significant correlation between the preoperative SWE measurements and total adhesion scores (correlation coefficient [r] = 0.397, P < 0.001). In receiver-operator characteristics curve analysis, the cut-off value for moderate or severe adhesions was found to be 36.5 (area under curve = 0.710, %95 confidence interval 0.606-0.815; P < 0.001). With the cut-off point of ≥36.5, the sensitivity and specificity for the prediction of mild and severe adhesions were 74.4% and 40.5%, respectively.

CONCLUSION

Elastographic evaluation of the subcutaneous tissue stiffness of the cesarean incision scar might show the degree of intra-abdominal adhesions at a repeat CS.