Uterine dehiscence in term pregnant patients with one previous cesarean delivery: growth factor immunoexpression and collagen content in the scarred lower uterine segment

Uterine wound healing after caesarean section: A systematic review

The rate of caesarean section (CS) is increasing worldwide. Defects in uterine healing have a major gynaecological and obstetric impact (uterine rupture, caesarean scar defect, caesarean scar pregnancy, placenta accreta spectrum). The complex process of cellular uterine healing after surgery, and specifically after CS, remains poorly understood in contrast to skin wound healing. This literature review on uterine wound healing was mainly based on histological observations, particularly after CS. The primary objective of the review was to examine the effects of CS on uterine tissue at the cellular level, based on histological observations. The secondary objectives were to describe the biomechanical characteristics and the therapies used to improve scar tissue after CS. This review was performed using PRISMA criteria, and PubMed was the data source. The study included all clinical and animal model studies with CS and histological analysis of the uterine scar area (macroscopic, microscopic, immunohistochemical and biomechanical). Twenty studies were included: 10 human and 10 animal models. In total, 533 female humans and 511 female animals were included. Review articles, meeting abstracts, case series, case reports, and abstracts without access to full-text were excluded. The search was limited to studies published in English. No correlation was found between cutaneous and uterine healing. The histology of uterine scars is characterized by disorganized smooth muscle, fibrosis with collagen fibres and fewer endometrial glands. As for skin healing, the initial inflammation phase and mediation of some growth factors (particularly connective tissue growth factor, vascular endothelial growth factor, platelet-derived growth factor, tumour necrosis factor α and tumour necrosis factor β) seem to be essential. This initial phase has an impact on the subsequent phases of proliferation and maturation. Collagen appears to play a key role in the initial granulation tissue to replace the loss of substance. Subsequent maturation of the scar tissue is essential, with a decrease in collagen and smooth muscle restoration. Unlike skin, the glandular structure of uterine tissue could be responsible for the relatively high incidence of healing defects. Uterine scar defects after CS are characterized by an atrophic disorganized endometrium with atypia and a fibroblastic highly collagenic stromal reaction. Concerning immunohistochemistry, one study found a decrease in tumour necrosis factor β in uterine scar defects. No correlation was found between biomechanical characteristics (particularly uterine strength) and the presence of a collagenous scar after CS. Based on the findings of this review, an illustration of current understanding about uterine healing is provided. There is currently no validated prevention of caesarean scar defects. Various treatments to improve uterine healing after CS have been tested, and appeared to have good efficacy in animal studies: alpha lipoic acid, growth factors, collagen scaffolds and mesenchymal stem cells. Further prospective studies are needed.

Uterine Cesarean Scar Tissue-An Immunohistochemical Study

Background and Objectives: Wound healing encompasses a multitude of factors and entails the establishment of interactions among components of the basement membrane. The quantification of particle concentrations can serve as valuable biomarkers for assessing biomechanical muscle properties. The objective of this study was to examine the immunoexpression and immunoconcentration of myometrial collagen type VI, elastin, alpha-smooth muscle actin, and smooth muscle myosin heavy chain, as well as the expression of platelets and clusters of differentiation 31 in the uterine scar following a cesarean section (CS). Materials and Methods: A total of 177 biopsies were procured from a cohort of pregnant women who were healthy, specifically during the surgical procedure of CS. The participants were categorized into seven distinct groups. Group 1 consisted of primiparas, with a total of 52 individuals. The subsequent groups were organized based on the duration of time that had elapsed since their previous CS. The analysis focused on the immunoexpression and immunoconcentration of the particles listed. Results: No significant variations were observed in the myometrial immunoconcentration of collagen type VI, elastin, smooth muscle myosin, and endothelial cell cluster of differentiation 31 among the analyzed groups. The concentration of alpha-smooth muscle actin in the myometrium was found to be significantly higher in patients who underwent CS within a period of less than 2 years since their previous CS, compared to those with a longer interval between procedures. Conclusions: Our findings indicate that the immunoconcentration of uterine myometrial scar collagen type VI, elastin, smooth muscle myosin heavy chain, alpha-smooth muscle actin, and endothelial cell marker cluster of differentiation 31 remains consistent regardless of the duration elapsed since the previous CS. The findings indicate that there are no significant alterations in the biomechanical properties of the uterine muscle beyond a period of 13 months following a CS.

Molecular mechanisms of uterine incision healing and scar formation

Wound healing is a tandem process involving inflammation, proliferation, and remodeling, through which damage is repaired and ultimately scar tissue is formed. This process mainly relies on the complex and extensive interaction of growth factors and cytokines, which coordinate the synthesis of various cell types. The loss of normal regulation in any part of this process can lead to excessive scarring or unhealed wounds. Recent studies have shown that it is possible to improve wound healing and even achieve scar-free wound healing through proper regulation of cytokines and molecules in this process. In recent years, many studies have focused on accelerating wound healing and reducing scar size by regulating the molecular mechanisms related to wound healing and scar formation. We summarized the role of these factors in wound healing and scar formation, to provide a new idea for clinical scar-free healing treatment of uterine incisions.

Uterine scars after caesarean delivery: From histology to the molecular and ultrastructural level

Uterine rupture during a trial of labor after caesarean delivery (CD) is a serious complication for mother and fetus. The lack of knowledge on histological features and molecular pathways of uterine wound healing has hindered research in this area from evolving over time. We analysed collagen content and turnover in uterine scars on a histological, molecular and ultrastructural level. Therefore, tissue samples from the lower uterine segment were obtained during CD from 16 pregnant women with at least one previous CD, from 16 pregnant women without previous CD, and from 16 non-pregnant premenopausal women after hysterectomy for a benign disease. Histomorphometrical collagen quantification showed, that the collagen content of the scar area in uterine wall specimens after previous CD was significantly higher than in the unscarred myometrium of the same women and the control groups. Quantitative real-time PCR of uterine scar tissue from FFPE samples delineated by laser microdissection yielded a significantly higher COL3A1 expression and a significantly lower COL1A2/COL3A1 ratio in scarred uteri than in samples from unscarred uteri. Histological collagen content and the expression of COL1A2 and COL3A1 were positively correlated, while COL1A2/COL3A1 ratio was negatively correlated with the histological collagen content. Transmission electron microscopy revealed a destroyed myometrial ultrastructure in uterine scars with increased collagen density. We conclude that the high collagen content in uterine scars results from an ongoing overexpression of collagen I and III. This is a proof of concept to enable further analyses of specific factors that mediate uterine wound healing.

Intraoperative ultrasound during repeat cesarean delivery facilitates sampling of uterine scar tissue

OBJECTIVES

Histological examination of uterine scars provides insight into uterine wound healing and helps to develop prevention methods of uterine wall rupture after previous uterine surgery. Therefore, exact intraoperative scar identification is needed for specimen collection from the actual scar tissue. The aim of this study was to correlate pre- and intraoperative ultrasound measurements of the lower uterine segment (LUS) with histological findings of scar tissue and to evaluate the relevance of intraoperative ultrasound.

METHODS

In a prospective observational study, preoperative and intraoperative sonographic measurements of the LUS thickness were performed in 33 women with a history of at least one cesarean delivery. Intraoperative ultrasound with a linear transducer placed directly on the uterus identified the scar area and uterotomy was performed 2 cm cranially. Tissue samples were taken after extraction of the fetus, embedded in paraffin wax, and stained according to Gomori Trichrome to identify scar tissue. Collagen content was evaluated with imaging software Fiji (NIH, Bethesda, USA). Preoperative and intraoperative sonographic measurements were correlated with histologic evidence of scar tissue.

RESULTS

Histological evidence of scar tissue was found in 11 out of 33 samples with significantly lower ultrasonographic thickness of the lower uterine segment compared to the other 22 samples, both antepartum (1.4 mm [1.3-1.9] vs. 2.0 mm [1.6-2.6], p=0.03) and intrapartum (1.6 mm [1.3-1.9] vs. 3.7 mm [2.0-4.7], p<0.01). Intraoperative ultrasound had a significantly higher predictive power (AUC difference 0.18 [0.03-0.33], p=0.01).

CONCLUSIONS

Intraoperative sonography identifies the uterine wall area with histologically confirmable scar tissue far better than preoperative sonography.

Scar Tissue after a Cesarean Section-The Management of Different Complications in Pregnant Women

The definition of a cesarean scar pregnancy (CSP) is the localization of the gestational sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous cesarean section (CS). The worldwide prevalence of CSP has been growing rapidly. However, there are no general recommendations regarding prophylaxis and treatment of the abnormalities of the anterior wall of the uterus discovered in a non-pregnant myometrium, or how to deal with existing cases of CSP. We present the latest knowledge, a holistic approach to the biology, histology, imaging, and management concerning post-CS scars based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy in the Medical University of Lublin, Poland. In our study, we present images of tissue samples of areas with a cicatrix in the uterus, and ultrasound and MRI images of CSP. We discuss the advances in the biology of the post-CS scar tissue, the prevention techniques used to repair the scar defect (niche) before the pregnancy, and the treatment of different complications of CSP, such as the rupture of the gravid uterus or the dehiscence of the myometrium.

Pregnancy outcomes of patients undergoing single-layer sutured laparoscopic myomectomy

AIM

In this study, we aimed to investigate the pregnancy outcomes of 102 patients who underwent laparoscopic myomectomy (LM) with single-layer suturing.

METHODS

This retrospective study included 102 women who underwent single-layer sutured LM in the obstetrics and gynaecology clinic of our hospital between September 2017 and April 2019.

RESULTS

A total of 102 patients underwent LM and colpotomy. Sixty-two patients were planning conception. Thirty-three (53.2%) of the sixty-two patients became pregnant until the study date. The mean age of the pregnant patients was 34 ± 8.2 years. In the pregnant patients, myoma localisation was anterior in 12 (50%), posterior in 7 (29%) and other in 5 (21%) patients. The mean duration between the operation and the first pregnancy was 10.2 months (2-24 months). Of the first pregnancies, 12 (50%) were between 0 and 6 months, and 12 (50%) were between 6 and 24 months to the operation. Twenty-four pregnant patients were delivered with caesarean section, six patients had a miscarriage and two patients resulted in intra-uterine pregnancy in the second trimester. Of these patients, eight were pregnant again, and eight were delivered by caesarean section. Curettage and dilatation were performed in six patients with miscarriage. None of the patients developed uterine rupture.

CONCLUSION

Single-layer closure of the uterine defect in LM is safe for subsequent pregnancies, and the risk of uterine rupture is low.

Pregnancy outcome in women with prior placenta accreta spectrum disorders treated with conservative-reconstructive surgery: analysis of 202 cases

AIM

To report the outcome of pregnant women with a prior pregnancy complicated by placenta accreta spectrum (PAS) disorders treated with resective-conservative surgery at the time of cesarean section.

MATERIALS AND METHODS

Retrospective analysis of pregnant women treated with conservative surgery in the prior pregnancy complicated by PAS disorders. The primary outcome was spontaneous preterm birth with intact membranes or following a preterm labor rupture of the membranes before 37 weeks of gestation. Secondary outcomes were uterine rupture, need for hysterectomy due to severe ante or intrapartum maternal hemorrhage, myometrial thinning at the time of cesarean section, 5 min Apgar score, birth weight centile, and the occurrence of small for gestational age newborns. All these outcomes were observed in women with prior PAS treated with conservative resective surgery divided according to the topographical surgical classification.

RESULT

Pregnancies included: 89.6% (181/202) related to PAS type 1; 7.9% (16/202) related to PAS type 2, and 2.5% (5/202) related to PAS type 3. 90% of cases (162/179) (95 CI: 90.3-90.6) completed the pregnancy at term (greater than 37 weeks). The average intergenesic period was 15 months for PAS type 1 and 2 (SD 4,76) (Q1:12; Q3:19), and 18 months for PAS 3 (SD 6,56) (Q1:14; Q3:19). A few mothers presented some complications PPROM 1; premature labor 4; hypertension 2; atony 1; overweight 1; and gestational diabetes 2. The mean age was 30 years (T1), 31 years (T2), and 36 years (T3·). The uterine segment was thicker than usual except for one case of partial uterine dehiscence (twins). There were no placenta previa or PAS, a uterine atony case, and there was one case of hysterectomy by patient request.

CONCLUSIONS

Subsequent pregnancies after use of resective-reconstructive for PAS has demonstrated to have similar maternal and neonatal outcomes to typical gestation and cesarean delivery.

Uterine Scarring Leads to Adverse Pregnant Consequences by Impairing the Endometrium Response to Steroids

Uterine surgical scarring is an increasing risk factor for adverse pregnant consequences that threaten fetal-maternal health. The detailed molecular features of scar implantation remain largely unknown. We aim to study the pathologic features of uterine surgical scarring and the mechanisms of compromised pregnancy outcomes of scar implantation. We generated a mouse model of uterine surgical scarring with a uterine incision penetrating the myometrium to endometrium to examine the pathologic changes and transcriptome profiles of uterine scarring at various postsurgery (PS) time points, as well as features of the feto-maternal interface during scar implantation. We found that uterine surgical scar recovery was consistently poor at PS3 until PS90, as shown by a reduced number of endometrial glands, inhibition of myometrial smooth muscle cell growth but excessive collagen fiber deposition, and massive leukocyte infiltration. Transcriptome annotation indicated significant chronic inflammation at the scarring site. At the peri-implantation and postimplantation stages, abnormal expression of various steroid-responsive genes at the scarring site was in parallel with lumen epithelial cell hyperplasia, inappropriate luminal closure, and disorientation of the implanted embryo, restricted stromal cell proliferation, and defective decidualization. High embryonic lethality (around 70%) before E10.5 was observed, and the small amount of survival embryos at E10.5 exhibited restricted growth and aberrant placenta defects including overinvasion of trophoblast cells into the decidua and insufficient fetal blood vessel branching in the labyrinth. The findings indicate that chronic inflammation and compromised responses to steroids in uterine scar tissues are the pivotal molecular basis for adverse pregnancy consequences of scar implantation.

Ultrasonic assessment has high sensitivity for pregnant women with previous cesarean section occurring uterine dehiscence and rupture: A STARD-compliant article

To investigate the diagnostic performance of ultrasound (US) for pregnant women with previous caesarean section (CS) occurring lower uterine segment (LUS) dehiscence and rupture.107 pregnant women with previous CS and LUS thickness of 1.0 mm or less were recruited, the LUS and myometrium was measured, and US findings suggestive of uterine rupture were compared with findings at laparotomy. The included pregnant women were assigned into 2 groups, including 64 pregnant women had vaginal delivery at full-term and 43 pregnant women underwent repeat CS at preterm.US findings suggestive of uterine rupture and dehiscence occurred in 18 women and 89 women, respectively; ten of them developed uterine rupture, and the incidence of uterine rupture was 9.34% (10/107). The sensitivity, specificity, accuracy, positive, and negative predictive values of US for the evaluation of LUS dehiscence and rupture were 100.0%, 91.8%, 92.5%, 55.6%, and 100.0%, respectively. There was no severe maternal obstetric complication, 1 fetus died, and the other fetuses were born with a 5-minute Apgar score of 7 to 10.US has high sensitivity and specificity for pregnant women with previous CS occurring LUS dehiscence and rupture.

Evaluation of the uterine scar stiffness in women with previous Cesarean section by ultrasound elastography: A cohort study

PURPOSE

To evaluate by means of elastography if the quantitative assessment of the cesarean scar elasticity is feasible using as reference the surrounding intact myometrium and to investigate if the cesarean scar stiffness is influenced by the clinical characteristics of the previous cesarean delivery.

METHODS

Prospective study including women with a previous Cesarean Section (CS) ≥ 37 weeks' gestation performed 12-15 months before. By transvaginal ultrasound two regions of interest (ROI) were selected: uterine scar (Region 1) and surrounding myometrium (Region 2). Strain index (SI) for each ROI was calculated and the Strain Ratio (SR) was defined as Region 1 SI/Region 2 SI. The primary outcome was to compare SR among women who were grouped in accordance to presence of previous vaginal delivery, CS during labor, type of suture or pyrexia during post-partum. The secondary outcome of this study was to evaluate the correlation between SR and maternal, neonatal and labor characteristics.

RESULTS

68 women were included. The mean SR was 1.8 ± 0.7 thus indicating an increased stiffness of the uterine scar compared to the surrounding myometrium. No significant differences were found in terms of SR according to presence of previous VD, CS during labor, type of suture or pyrexia during post-partum period. Strain Ratio was not correlated to maternal characteristics nor to labor and neonatal outcome.

CONCLUSIONS

Evaluation of uterine scar stiffness is feasible by using elastography. The stiffness of the uterine scar is higher than that of the surrounding myometrium and is not correlated to maternal and labor characteristics.

Long-term effect of pregnancy-related factors on the development of endometrial neoplasia: A nationwide retrospective cohort study

Objective

By identifying pregnancy-related risk factors for endometrial neoplasia, women’s risk of developing this disease after childbirth can be predicted and high-risk women can be screened for early detection.

Methods

Study data from women who gave birth in Korea in 2007 were collected from the Korea National Health Insurance (KNHI) claims database between 2007 and 2015. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the development of endometrial neoplasia were estimated by multivariate Cox proportional hazards models.

Results

Data from 386,614 women were collected for this study. By 2015, 3,370 women from the initial cohort had been diagnosed with endometrial neoplasia secondary to delivery. Multivariate Cox proportional hazards regression revealed that preeclampsia (HR 1.55, 95% CI 1.29, 1.86), advanced maternal age (≥ 35; HR 1.52, 95% CI 1.39, 1.66), multifetal pregnancy (HR 1.81, 95% CI 1.46, 2.23), multiparity (HR 1.16, 95% CI 1.08, 1.24), cesarean section (HR 1.15, 95% CI 1.07, 1.23) and delivery of a large-for-gestational-age infant (HR 1.19, 95% CI 1.02, 1.39) were independent risk factors for future endometrial neoplasia. The risk for endometrial neoplasia increased as the number of risk factors increased (risk factors ≥3: HR 2.11, 95% CI 1.86–2.40).

Conclusion

This study showed that six pregnancy-related factors—advanced maternal age, multiparity, multifetal pregnancy, cesarean section, delivery of a large-for-gestational-age infant, and preeclampsia—are positively correlated with future development of endometrial neoplasia, including endometrial hyperplasia or cancer. Close observation and surveillance are warranted to enable early diagnosis of endometrial diseases, including endometrial cancer after pregnancy in high-risk women. However, due to unavailability of clinical information, many clinical/epidemiological factors can become confounders. Further research is needed on factors associated with the risk of endometrial neoplasia.

Uterine rupture at 28 weeks of gestation after laparoscopic myomectomy - a case report

There are many reasons for sterility, and uterine malformations are of the greatest concern. Among uterine disorders, myomas play a significant role and are present in 27% of infertile women. The occurrence of myomas is frequent - 20-40% in women of reproductive age. Thus, for those infertile patients surgical treatment may be needed to preserve an opportunity to conceive. This case report refers to an uterine rupture at 28 weeks of gestation after laparoscopic myomectomy (3 months before conceiving). The myomectomy was conducted correctly and two layers of sutures on the myometrium were performed. The purpose of the myomectomy in a young woman should be well considered. In cases of infertility, removal of the lesions is usually necessary to give the patient a chance of pregnancy. At the same time, the risk of uterine rupture is increased. There are some suggestions referring to myomectomy to reduce the risk of uterine rupture in a subsequent pregnancy. It seems that the method of sewing the uterine closure is crucial. For example, multilayer uterine stitches, preservation of the endometrial cavity, and avoidance of using electrosurgery to prevent devascularization (to avoid haematoma formation) should be taken into consideration to prevent weakness of the wall of the uterus. Uterine scars differ histologically and biochemically.

A preliminary study of uterine scar tissue following cesarean section

AIM

To compare smooth muscle cells, type I collagen, and apoptosis of the lower uterine segment of women who had/without a prior cesarean delivery.

METHODS

Alpha smooth muscle actin (α-SMA), type I collagen, and nuclear apoptosis were compared between the groups from lower uterine segment. Twenty-eight controls and 82 with one prior cesarean delivery were included. The women with a prior cesarean section were classified by time since the surgery: ≤3 years, >3 and ≤5 years, >5 and ≤7 years, >7 and ≤9 years, and >9 years.

RESULTS

Smooth muscle volume density (VD) % was significantly lower in women who had cesarean sections in first three groups than in the controls (all, P<0.01). Type I collagen VD% was similar among all groups and the controls. The number of apoptotic nuclei in the lower uterine segment of the scarred group was greater up to 3 years after surgery and less than in the control at 7-9 years. The number of non-apoptotic nuclei in the scarred group was greater than controls up to 7 years after surgery.

CONCLUSION

The lower uterine segment scar becomes stable at 3 years after cesarean delivery, and by 9 years, the scar is mature.

Ultrasound elastography of the lower uterine segment in women with a previous cesarean section: Comparison of in-/ex-vivo elastography versus tensile-stress-strain-rupture analysis

OBJECTIVES

The purpose of this study was to assess, if the biomechanical properties of the lower uterine segment (LUS) in women with a previous cesarean section (CS) can be determined by ultrasound (US) elastography. The first aim was to establish an ex-vivo LUS tensile-stress-strain-rupture(break point) analysis with the possibility of simultaneously using US elastography. The second aim was to investigate the relationship between measurement results of LUS stiffness using US elastography in-/ex-vivo with results of tensile-stress-strain-rupture analysis, and to compare different US elastography LUS-stiffness-measurement methods ex-vivo.

STUDY DESIGN

An explorative experimental, in-/ex-vivo US study of women with previous CS was conducted. LUS elasticity was measured by point Shear Wave Elastography (pSWE) and bidimensional Shear-Wave-Elastography (2D-SWE) first in-vivo during preoperative examination within 24 h before repeat CS (including resection of the thinnest part of the LUS = uterine scar area during CS), second within 1 h after operation during the ex-vivo experiment, followed by tensile-stress-strain-rupture analysis. Pearson's correlation coefficient and scatter plots, Bland-Altman plots and paired T-tests, were used.

RESULTS

Thirty three women were included in the study; elastography measurements n = 1412. The feasibility of ex-vivo assessment of LUS by quantitative US elastography using pSWE and 2D-SWE to detect stiffness of LUS was demonstrated. The strongest correlation with tensile-stress-strain analysis was found in the US elastography examination carried out with 2D-SWE (0.78, p < 0.001, 95%CI [0.48, 0.92]). The laboratory experiment illustrated that, the break point - as a surrogate marker for the risk of rupture of the LUS after CS - is linearly dependent on the thickness of the LUS in the scar area (Coefficient of correlation: 0.79, p < 0.001, 95%CI [0.55, 0.91]). Two extremely stiff LUS-specimens (outlier or extreme values) rupture even at less stroke/strain than would be expected by their thickness.

CONCLUSION

This study confirms that US elastography can help in determining viscoelastic properties of the LUS in women with a previous CS. The data from our small series are promising. However whether individual extreme values of high stiffness and consecutive restricted biomechanical resilience can explain the phenomenon of rupture during TOLAC in cases of LUS with adequate thickness remains a question which prospective trials have to analyze before US elastography can be introduced into clinical practice.

Prior cesarean section is associated with increased preeclampsia risk in a subsequent pregnancy

Background

To evaluate the impact of a prior cesarean section on preeclampsia risk in a subsequent pregnancy.

Methods

Study data were collected from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service for 2006–2010. Patients who had their first delivery in 2006 and subsequent delivery between 2007 and 2010 in Korea were enrolled. The overall incidence of preeclampsia during the second pregnancy was estimated and to evaluate the risk of preeclampsia in the second pregnancy, a model of multivariate logistic regression analysis was performed with preeclampsia as the final outcome

Results

The risk of preeclampsia in any pregnancy was 2.17%; the risk in the first pregnancy was 2.76%, and that in the second pregnancy was 1.15%. During the second pregnancy, the risk of preeclampsia was 13.30% for women who had developed preeclampsia in their first pregnancy and 0.85% for those who had not. In the entire population, prior cesarean section was associated with preeclampsia risk in their subsequent pregnancy (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.13–1.41). Among women with and without preeclampsia in their first pregnancy, a prior cesarean section was associated with preeclampsia risk in their second pregnancy (OR, 1.35; 95% CI, 1.09–1.67; OR, 1.23; 95% CI, 1.08–1.40, respectively).

Conclusions

Our study showed that cesarean section in a first pregnancy was associated with increased preeclampsia risk in the second pregnancy. These results provide physicians with a preeclampsia risk evaluation method for a second pregnancy that they may aid counseling in patients.

Combined laparoscopy and hysteroscopy vs. uterine curettage in the uterine artery embolization-based management of cesarean scar pregnancy: a retrospective cohort study

Background

The number of cesarean scar pregnancy (CSP) has significantly increased in the recent decade. Although uterine artery embolization (UAE) has been adopted to minimize the blood loss during uterine curettage removing of CSP, massive bleeding and uterine rupture can still be frequently encountered. The aim of this study was to compare the efficacy and safety of a novel combined laparoscopy and hysteroscopy technique with the traditional curettage in removing the conceptus and repairing the incision defect following the UAE management of CSP.

Methods

The CSP patients (n = 58) diagnosed between March 1, 2005 and March 1, 2010 were enrolled in three medical centers in Shanghai, China. All of these patients have undergone intra-arterial methotrexate, UAE and one of the following treatments: combined laparoscopy and hysteroscopy (study group, n = 25) and uterine curettage (control group, n = 33). Their medical records and 2-year outcomes were reviewed. The CSP removal rate, amount of blood loss during the treatment, incision repair rate (note: the post-curettage healing process of the incision defect was seen as a form of natural incision repairing, i.e., the self-repair mode), hospital stay, β-hCG regression time and postoperative sequelae were compared between two groups.

Results

The CSP removal rate in the study group (100%) was significantly higher than that (79%) in the control group (p = 0.024). The average blood loss was 78.0 mL in the study group, which was much less than the 258.5 mL (p = 0.004) in the control group. A satisfactory incision repair rate (96%) was achieved in the study group, while it was 25% (p < 0.001) in the control group. Moreover, the study group had significantly shorter hospital stays (p = 0.043) and β-hCG regression times (p = 0.033), lower rates of postoperative abdominal pain (p = 0.035) and menstruation abnormalities (p = 0.043).

Conclusions

Combined laparoscopy and hysteroscopy is much safer and more effective than uterine curettage as a supplementary measure to remove the conceptus and repair the cesarean incision following the UAE management of CSP.

Cesarean scar pregnancy and early placenta accreta share common histology

OBJECTIVE

To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

METHODS

The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined.

RESULTS

Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93).

CONCLUSIONS

EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

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.

[Uterine ishtmique transmural hernia: results of its repair on symptoms and fertility]

OBJECTIVE

To study the effect of the surgical repair (isthmorraphy) of the large scar dehiscence after cesarean on symptoms and fertility for women who desire pregnancy.

PATIENTS AND METHODS

In this retrospective study, 14 symptomatic patients, who desire a new pregnancy underwent a surgical repair by laparotomy, laparoscopic or vaginal technique. Five women experienced failure of Assistance Reproductive Technique (IVF or ICSI) for idiopathic secondary infertility. The dehiscent scars were evaluated by ultrasound, hysterography, hysteroscopy and magnetic resonance imaging.

OUTCOME

Symptoms improvement was found in 92% of case. Ten pregnancy (71%) was obtained after surgical repair, 6 spontaneous and 4 after Assistance Reproductive Technique. Among the 5 women initially followed in the reproductive unit, 4 became pregnant, 3 after IVF or ICSI and 1 spontaneous. No operative complication occurred. The subsequent pregnancy was unremarkable with no uterine rupture.

DISCUSSION

Large scar defect after cesarean can take shape of a complete absent of the anterior wall of the uterus. No incident has been proved in this condition. There is a lack of data concerning these isthmocele. The experience of hysteroscopic repair cannot be applied to these real large diverticule of the scar cesarean. The results of this study suggest a link between the isthmocele and reversible symptoms after surgery. The first results concerning the subsequent fertility after surgical repair seem interesting

CONCLUSION

When a large scare defect (isthmocele) is found in symptomatic woman (pelvic pain, bleeding uterine, infertility), a surgical repair can be proposed, especially for woman who desire a new pregnancy.

Robotic repair of uterine dehiscence

A pediatric robot and 5-mm trocars were used to effect a repair of a cesarean scar dehiscence, also known as a cesarean scar defect.

Background and Objectives:

During the past few decades, there has been a significant increase in the number of cesarean deliveries, and thus an increase in the number of complications. A common complication of multiple cesarean deliveries is symptomatic uterine scar dehiscence, for which there are no treatment guidelines available. We report a case of uterine scar dehiscence—the repair of it by robotic surgery—and review the literature on this defect.

Case:

The patient was a 39-year-old woman, gravida 4 para 2022, complaining of persistent vaginal spotting for the prior 5 months with a history of a cesarean delivery 3 months before the onset of the symptoms.

Discussion:

We report a case of a successful robotic repair of a symptomatic cesarean scar defect.

Conclusion:

We propose further studies that include more patients so this technique may become the standard for cesarean scar defect.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.

Endometrial cancer implanted within a cesarean section scar

Several reports have documented adenocarcinoma arising from endometriotic implants within cesarean section (C-S) scars on the serosal surface of the uterus; however, endometrial cancer invading the C-S scar from the uterine cavity has not been described. We report a case of a grade 1 endometrioid adenocarcinoma 'drop' lesion invading a previous C-S scar with resultant cervical stromal invasion. Using both MR images and a thorough review of the pathology, the tumor at the C-S scar was determined to be an implant derived from a primary lesion at the uterine fundus. With increases in the incidence of both endometrial cancer and births by C-S, it is likely we will encounter more cases of iatrogenic implants of endometrial cancers in C-S scars.

Whey peptides improve wound healing following caesarean section in rats

We sought to determine whether postcaesarean treatment with whey peptides (WP) affects the healing of skin and uterine incision in rats during puerperium. Forty-eight rats were randomly divided into two groups. After a caesarean section, twenty-four rats were intragastrically administered WP, while others were administered a control vehicle. On days 7, 14 and 21 after delivery, the serum total protein/albumin concentration, skin tensile strength, uterine bursting pressure, skin/uterine hydroxyproline (Hyp) concentration and histological characteristics of the scar were measured in eight rats in each group. In the WP group, the albumin concentration, skin tensile strength, uterine bursting pressure and Hyp concentration in the skin increased significantly on days 21, 7, 14 and 21, respectively. Low neutrophil count and smaller scar width in the skin incision were found in the WP group on day 7. Postcaesarean treatment with WP promoted significant wound healing in the skin incision, and had a significant wound healing potential in the uterus.

High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination

OBJECTIVES

To determine the ability to correctly identify Cesarean section scars, to estimate the prevalence of defective scars, and to determine the size and location of scar defects by transvaginal ultrasound imaging.

METHODS

Two hundred and eighty-seven women underwent transvaginal ultrasound examination 6-9 months after delivery: 108 had undergone one Cesarean section, 43 had had two Cesarean sections, 11 had undergone at least three Cesarean sections, and 125 were primiparae who had delivered vaginally. The ultrasound examiner was blinded to the obstetric history until all scans had been evaluated.

RESULTS

None of the 125 vaginally delivered women had a visible scar in the uterus, whereas all women who had undergone Cesarean section had at least one visible scar. Median myometrial thickness at the level of the isthmus was 11.6 mm in women who had only been delivered vaginally, and 8.3 mm, 6.7 mm and 4.7 mm in women who had undergone one, two and at least three Cesarean sections, respectively (P < 0.001). Scar defects were seen in 61% (66/108), 81% (35/43) and 100% (11/11) of the women who had undergone one, two and at least three Cesarean sections (P = 0.002); at least one defect was classified as large by the ultrasound examiner in 14% (15/108), 23% (10/43) and 45% (5/11) (P = 0.027), and at least one total defect was seen in 6% (7/108), 7% (3/43) and 18% (2/11) (P = 0.336). In women who had undergone one Cesarean section, the median distance between an intact scar and the internal cervical os was 4.6 (range, 0-19) mm, and that between a deficient scar and the internal cervical os was 0 (range, 0-26) mm (P < 0.001).

CONCLUSIONS

Cesarean section scars can be detected reliably by ultrasound imaging. Myometrial thickness at the level of the isthmus uteri decreases with the number of Cesarean sections and the frequency of large scar defects increases. Scars with defects are located lower in the uterus than intact scars.

Severe secondary postpartum hemorrhage 3 weeks after cesarean section: alternative etiologies of uterine scar non-union

A case of secondary postpartum hemorrhage that occurred 3 weeks after cesarean section requiring total abdominal hysterectomy is reported. The patient's history and pathologic features of the removed uterus did not allow the authors to clearly recognize a previous reported cause of this potentially life-threatening complication. Alternative causes of the non-union of the uterine incision are suggested.