Prediction of complete uterine rupture by sonographic evaluation of the lower uterine segment

The role of the lower uterine segment thickness in predicting preterm birth in twin pregnancies presenting with threatened preterm labor

OBJECTIVES

To examine the relationship between the lower uterine segment (LUS) thickness and the onset of labor in dichorionic twin pregnancies experiencing threatened preterm labor.

METHODS

This prospective cohort study included dichorionic twin pregnancies between 24 and 32 weeks of gestation, presenting with symptoms of preterm labor. The LUS thickness and mid-anterior wall thickness were measured via transabdominal ultrasonography, cervical length, and posterior cervical lip thickness were measured transvaginally. The presence of the cervical sliding sign and funneling findings were recorded.

RESULTS

Among the patients with an onset of labor before the 34th week, the mean LUS thickness was 3.8 ± 0.9 mm, compared to 4.6 ± 1.1 mm in those with an onset of labor at or after 340/7 GW, indicating a statistically significant difference (p=0.012). Similarly, accepting the GW threshold as 350/7 weeks, a statistically significant difference was found in the mean LUS thickness, which was 4.0 ± 1.0 mm in those with an earlier onset of labor and 4.7 ± 1.0 mm in those with a later onset of labor (p=0.022). While univariate analysis indicated that the LUS thickness was a significant predictor (p=0.017 for <34 GW and p=0.028 for <35 GW), multivariate analysis showed a reduced effect (p=0.04 and p=0.06, respectively).

CONCLUSIONS

LUS was significantly thinner in pregnancies with an onset of labor before the 34th and 35th GW. The measurement of the LUS thickness can be considered an alternative method for predicting spontaneous preterm birth in dichorionic twin pregnancies.

Incarcerated gravid uterus: a new treatment using the transvaginal ultrasound probe and narrative literature review

BACKGROUND

'Incarcerated gravid uterus' is a morbid complication that occurs in 1 in 3000 pregnancies. It is characterized by failure of a retropositioned uterus to become an abdominal organ between 12 to 14 weeks of gestation. If maternal symptoms develop or gestational age surpasses 14 to 16 weeks, replacement of a retropositioned uterus is recommended to reduce adverse outcomes. Previously described techniques for management include passive reduction, digital replacement, or more invasive methods such as laparoscopy, laparotomy, or sigmoidoscopy. These methods are either minimally effective, painful, or risky.

OBJECTIVE

The objective of this report is to describe our clinical experience with a new minimally invasive technique that uses the transvaginal ultrasound probe for uterine replacement in cases of incarceration, to conduct a narrative literature review on 'incarcerated gravid uterus,' and to propose an algorithm for management of this condition.

STUDY DESIGN

This is a case series of 8 patients with an incarcerated gravid uterus who were managed with the transvaginal ultrasound probe technique at one academic medical institution between March 2020 and July 2023, as well as a narrative review of the literature on 'incarcerated gravid uterus.' PubMed, Google Scholar, and Ovid MEDLINE databases were searched for the terms "incarcerated gravid uterus," "uterine incarceration," "uterine sacculation," and "retroverted uterus" up to April 2024.

RESULTS

The transvaginal ultrasound probe technique resulted in successful uterine replacement, with resolution of symptoms, in all 8 patients. All pregnancies resulted in live births with good neonatal outcomes-7 out of 8 patients delivered at term, and 1 delivered in the late preterm period.

CONCLUSION

Our proposed technique for treatment of an incarcerated gravid uterus with the transvaginal ultrasound probe is simple, minimally invasive and effective. Based on our experience and the narrative literature review, an algorithm for the management of an incarcerated gravid uterus is proposed.

Short stature and vaginal dinoprostone as independent predictors of composite maternal-newborn adverse outcomes in induction of labor after one previous cesarean: a retrospective cohort study

BACKGROUND

The rates of labor induction and cesarean delivery is rising worldwide. With the confluence of these trends, the labor induction rate in trials of labor after cesarean can be as high as 27-32.7%. Induction of labor after one previous cesarean (IOLAC) is a high-risk procedure mainly due to the higher risk of uterine rupture. Nevertheless, the American College of Obstetricians and Gynecologists considers IOLAC as an option in motivated and informed women in the appropriate care setting. We sought to identify predictors of a composite of maternal and newborn adverse outcomes following IOLAC.

METHODS

The electronic medical records of women who delivered between January 2018 to September 2022 in a Malaysian university hospital were screened to identify cases of IOLAC. A case is classified as a composite adverse outcome if at least one of these 11 adverse outcomes of delivery blood loss ≥ 1000 ml, uterine scar complications, cord prolapse or presentation, placenta abruption, maternal fever (≥ 38 0C), chorioamnionitis, intensive care unit (ICU) admission, Apgar score < 7 at 5 min, umbilical artery cord artery blood pH < 7.1 or base excess ≤-12 mmol/l, and neonatal ICU admission was present. An unplanned cesarean delivery was not considered an adverse outcome as the practical management alternative for a clinically indicated IOLAC was a planned cesarean. Bivariate analysis of participants' characteristics was performed to identify predictors of their association with composite adverse outcome. Characteristics with crude p < 0.10 on bivariate analysis were incorporated into a multivariable binary logistic regression analysis model.

RESULTS

Electronic medical records of 19,064 women were screened. 819 IOLAC cases and 98 cases with composite adverse outcomes were identified. Maternal height, ethnicity, previous vaginal delivery, indication of previous cesarean, indication for IOLAC, and method of IOLAC had p < 0.10 on bivariate analysis and were incorporated into a multivariable binary logistic regression analysis. After adjustment, only maternal height and IOLAC by vaginal dinoprostone compared to Foley balloon remained significant at p < 0.05. Post hoc adjusted analysis that included all unplanned cesarean as an added qualifier for composite adverse outcome showed higher body mass index, short stature (< 157 cm), not of Chinese ethnicity, no prior vaginal delivery, prior cesarean indicated by labor dystocia, and less favorable Bishop score (< 6) were independent predictors of the expanded composite adverse outcome.

CONCLUSION

Shorter women and IOLAC by vaginal dinoprostone compared to Foley balloon were independently predictive of composite of adverse outcome.

Accuracy of sonographic lower segment thickness and prediction of vaginal birth after caesarean in a resourced-limited setting; Prospective study

OBJECTIVES

To assess the accuracy of ultrasound measurement of the lower uterine segment (LUS) thickness against findings at laparotomy, and to investigate its correlation with the success rate of vaginal birth after one previous caesarean delivery (CD) in a resource-limited setting.

DESIGN

Prospective study.

SETTING

Obstetrics and Gynaecology department in a tertiary hospital in Ghana.

POPULATION

Women with one previous CD undergoing either a trial of labour (TOLAC) or elective CD.

METHODS

Myometrial lower uterine segment thickness (mLUS) and full lower uterine segment thickness (fLUS) were measured with transvaginal ultrasound (TVUS). The women were managed according to local protocols with the clinicians blinded to the ultrasound measurements. The LUS was measured intraoperatively for comparison with ultrasound measurements.

MAIN OUTCOME MEASURES

Lower uterine segment findings at laparotomy, successful vaginal birth.

RESULTS

A total of 311 pregnant women with one previous CD were enrolled; 147 women underwent elective CD and 164 women underwent a TOLAC. Of the women that underwent TOLAC, 96 (58.5%) women had a successful vaginal birth. The mLUS was comparable to the intraoperative measurement in the elective CD group with LUS thickness <5 mm (bias of 0.01, 95% CI -0.10 to 0.12 mm) whereas fLUS overestimated LUS <5 mm (bias of 0.93, 95% CI 0.80-1.06 mm). Successful vaginal birth rate correlated with increasing mLUS values (odds ratio 1.30, 95% CI 1.03-1.64). Twelve cases of uterine defect were recorded. LUS measurement ≤2.0 mm was associated with an increased risk of uterine defects with a sensitivity of 91.7% (95% CI 61.5-99.8%) and specificity of 81.8% (95% CI 75.8-86.8%).

CONCLUSION

Accurate TVUS measurement of the LUS is technically feasible in a resource-limited setting. This approach could help in making safer decisions on mode of birth in limited-resource settings.

[Usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean: Literature review]

Identifying women with a history of cesarean delivery and at real risk for uterine rupture is an important aim in obstetric care. It is with this objective that different authors have evaluated the interest of ultrasound for predicting the risk of a cesarean scar defect by measuring the thickness of the lower uterine segment. The literature is sparse and subject to numerous biases because they are mainly prospective cohort studies with small numbers. However, the results are concordant: Ultrasound measurements of lower uterine segment thickness are strongly correlated with the operative findings observed during cesarean delivery. Moreover, the thinner the lower uterine segment on ultrasound, the higher the likelihood of a uterine defect. Two randomized trials have recently been published. The PRISMA cluster randomized controlled trial evaluated a multifaceted intervention including an ultrasound estimation of the risk of uterine rupture by ultrasound measurement of the lower uterine segment thickness and aimed at helping women in their choice of mode of delivery after a previous cesarean delivery. This multifaceted intervention resulted in a significant reduction in the rates of major perinatal and maternal morbidity, without any increase in the rate of cesarean delivery or uterine rupture. However, due to its design, it is impossible to specifically specify the benefit of lower uterine segment measurement in reducing major maternal and perinatal morbidity since the trial combined several interventions. The LUSTrial randomized controlled trial evaluated the impact on maternal-fetal morbidity and mortality of proposing a mode of delivery based on ultrasound measurement of the lower uterine segment thickness compared to usual care among women with a history of cesarean delivery. Ultrasound measurement of lower uterine segment thickness was not associated with a statistically significant reduction in maternal-fetal morbidity and mortality compared to usual care. In this literature review, we will mainly detail and analyze the results of this trial.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Biomechanical Modeling of Cesarean Section Scars and Scar Defects

Uterine rupture is an intrinsically biomechanical process associated with high maternal and fetal mortality. A previous Cesarean section (C-section) is the main risk factor for uterine rupture in a subsequent pregnancy due to tissue failure at the scar region. Finite element modeling of the uterus and scar tissue presents a promising method to further understand and predict uterine ruptures. Using patient dimensions of an at-term uterus, a C-section scar was modeled with an applied intrauterine pressure to study how scars affect uterine stress. The scar positioning and uterine thickness were varied, and a defect was incorporated into the scar region. The modeled stress distributions confirmed clinical observations as the increased regions of stress due to scar positioning, thinning of the uterine walls, and the presence of a defect are consistent with clinical observations of features that increase the risk of uterine rupture.

Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial

BACKGROUND

Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery.

METHODS

We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559.

FINDINGS

21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups.

INTERPRETATION

A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture.

FUNDING

Canadian Institutes of Health Research (CIHR, MOP-142448).

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

Transvaginal repair of isthmocele after cesarean scar pregnancy

The transvaginal approach represents a suitable choice for the management of isthmocele in women seeking to become pregnant.

Cesarean scar disorder: Management and repair

Cesarean scar disorder (CSD) is an entity recently defined as uterine niche with at least one primary or 2 secondary symptoms. CSDs can be visualized by hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging, but diagnosis should be performed by exams able to measure the residual myometrial thickness (RMT). Although there is a limited number of studies evaluating fertility and reproductive outcomes after different types of surgery, the following consideration should be kept in mind. Asymptomatic women should not be operated with the hope of improving obstetrical outcomes. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be offered according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and RMT measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique in case of RMT <3 mm. In this instance, repair is essential and can only be achieved by a laparoscopic or vaginal approach. The benefit of laparoscopic approach seems to persist after subsequent CS. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made.

Effectiveness of laparoscopic niche resection versus expectant management in patients with unexplained infertility and a large uterine caesarean scar defect (uterine niche): protocol for a randomised controlled trial (the LAPRES study)

INTRODUCTION

A uterine niche is a defect at the site of the uterine caesarean scar that is associated with gynaecological symptoms and infertility. Promising results are reported in cohort studies after a laparoscopic niche resection concerning reduction of gynaecological symptoms in relation to baseline and concerning pregnancy outcomes. However, randomised controlled trials to study the effect of a laparoscopic niche resection on reproductive outcomes in infertile women are lacking. This study will answer the question if laparoscopic niche resection in comparison to expectant management improves reproductive outcomes in infertile women with a large uterine niche.

METHODS AND ANALYSIS

The LAPRES study is a randomised, non-blinded, controlled trial, including 200 infertile women with a total follow-up of 2 years. Women with the presence of a large niche in the uterine caesarean scar and unexplained infertility of at least 1 year or failed IVF will be randomly allocated to a laparoscopic niche resection within 6 weeks or to expectant management for at least 9 months. A large niche is defined as a niche with a depth of >50% of the myometrial thickness and a residual myometrium of ≤3 mm on transvaginal ultrasound. Those receiving expectant management will be allowed to receive fertility therapies, including assisted reproductive techniques, if indicated. The primary outcome is time to ongoing pregnancy, defined as a viable intrauterine pregnancy at 12 weeks' gestation. Secondary outcome measures are time to conception leading to a live birth, other pregnancy outcomes, received fertility therapies after randomisation, menstruation characteristics, patient satisfaction, quality of life, additional interventions, and surgical and ultrasound outcomes (intervention group). Questionnaires will be filled out at baseline, 6, 12 and 24 months after randomisation. Ultrasound evaluation will be performed at baseline and at 3 months after surgery.

ETHICS AND DISSEMINATION

The study protocol was approved by the medical ethics committee of the Amsterdam University Medical Centre. (Ref. No. 2017.030). Participants will sign a written informed consent before participation. The results of this study will be submitted to a peer-reviewed journal for publication. TRIAL REGISTRATION NUMBER DUTCH TRIAL REGISTER REF NO NL6350 : http://www.trialregister.nl.

Measurement of Lower Uterine Segment Thickness to Detect Uterine Scar Defect: Comparison of Transabdominal and Transvaginal Ultrasound

OBJECTIVES

Lower uterine segment (LUS) thickness measurement using transabdominal ultrasound (TA-US), transvaginal ultrasound (TV-US), or the combination of both methods can detect scar defect in women with prior cesarean. We aimed to compare the sensitivity of three approaches.

METHODS

Women with prior cesarean underwent LUS thickness measurement at 34-38 weeks' gestation. Among those who underwent repeat cesarean before labor, we compared the accuracy of TA-US, TV-US, and the thinner of the two measurements (the "combined measurement") for uterine scar dehiscence using the area under the curve (AUC) of receiver operating curves with their 95% confidence intervals (CI). We calculated the sensitivity and specificity of the three approaches using a cut-off of 2.3 mm based on prior literature.

RESULTS

We included 747 participants. The mean LUS thickness was greater with TA-US (3.8 ± 1.6 mm) compared with TV-US (3.5 ± 1.9 mm) or the combined measurement (3.2 ± 1.5 mm; P < .001). The AUC was 78% (95% CI: 69%-87%), 85% (95% CI: 79%-91%), and 88% (95% CI: 82%-93%), respectively (all with P < .001). The AUC difference between TA-US and the combined measurement was not significant (P = .057). A LUS below 2.3 mm would have predicted 9 (45%) of the 20 cases of uterine scar dehiscence using TA-US, 17 (85%) using TV-US, and 18 (90%) using the combined measurement (P < .01).

CONCLUSION

The choice of ultrasound approach influences the measurement of the LUS thickness. The combination of the TA-US and TV-US seems to be superior for the detection of uterine dehiscence.

Predicting Uterine Rupture Risk Using Lower Uterine Segment Measurement During Pregnancy With Cesarean History: How Reliable Is It? A Review

Importance

Uterine rupture during labor is a calamitous event that can result in maternal/neonatal morbidity/mortality. Lower uterine segment (LUS) thickness measurement is a proposed method to determine the risk factor of uterine rupture in women undergoing trial of labor after cesarean. Does this measurement predict uterine rupture risk?

Objectives

This review examines current evidence to determine if a thin LUS ultrasound diagnosis during pregnancy with prior cesarean delivery(s) can reliably predict uterine rupture risk while attempting vaginal birth after cesarean (VBAC).

Evidence Acquisition

Electronic databases (PubMed and CINAHL) were searched with one limitation of abstracts in English. Search terms used were "lower uterine segment" AND "risk(s)" AND "rupture" OR "dehiscence.

Results

After reviewing 164 identified articles, 15 were used in this review. Of the studies including LUS thickness measurement, notable differences were found: gestational age at time of measurement, full thickness measurement versus myometrial thickness, number of sonographers involved, ultrasound technique (transabdominal vs transvaginal), and blinding. Other factors influencing LUS thickness include fetal weight, amniotic fluid volume, and gestational age. The most recent systematic review and meta-analysis suggests that an LUS > 3.65 mm should be safe for a VBAC, 2-3.65 mm is probably safe, and <2 mm identifies a patient at higher risk for uterine rupture/dehiscence.

Conclusions

Study heterogeneity, absence of an agreed upon thickness threshold, poor correlation between ultrasound and MRI measurements, or physical cesarean measurements currently make VBAC uterine rupture risk prediction uncertain.

Relevance

Our aim is to analyze existing literature to determine if evidence supports LUS measurement in women undergoing VBAC after cesarean to determine risk of uterine rupture.

Scope and Suction: Hysteroscopic-guided Suction Evacuation of Cesarean Scar Pregnancy - A Safe and Efficacious Treatment for Selected Patients

Objectives

This study aimed to evaluate hysteroscopic-guided suction evacuation for the treatment of cesarean scar pregnancy (CSP).

Materials and Methods

This was a retrospective analysis of CSP over 2 years. This study was conducted at KK Women's and Children's Hospital (KKH), Singapore, thirty-seven patients with a CSP. Hysteroscopic-guided suction evacuation to treat CSP used alone or in combination with laparoscopy depending on residual myometrial thickness (RMT) and future fertility requirements.

Results

The majority of women (29) were diagnosed under 9-week gestation. Just over a third (13) had an RMT of more than 3 mm. Women with an RMT <3 mm had added laparoscopy. In total, 22 women had hysteroscopic-guided suction evacuation with 9 having it performed under laparoscopic guidance because the RMT was under 3 mm. The remaining patients underwent either laparoscopic repair (5 cases) or vaginal repair (1 case) done under laparoscopic guidance.

Conclusion

Hysteroscopic-guided suction evacuation of CSP has the potential to become part of the routine management for uncomplicated cases of CSP in women with an RMT of greater than 3 mm who do not wish for future pregnancy. Its use, in combination with other minimally invasive techniques, can be extended to more complex cases where the RMT is <3 mm and future fertility is desired.

Cesarean Scar Pregnancy: Current Understanding and Treatment Including Role of Minimally Invasive Surgical Techniques

The incidence of cesarean scar pregnancy (CSP) is increasing reflecting the global increase in cesarean section (CS) rate which has almost doubled since 2000. CSP differs from other types of ectopic pregnancy in its ability to progress while still carrying a significant risk of maternal morbidity. Little is known about precise etiology or natural history although current interest in the pathology of placenta accretes spectrum disorders might be enlightening. Early detection and treatment of CSP are challenging. Once diagnosed, the recommendation is to offer early termination of pregnancy because of the potential risks of continuing the pregnancy. However, as the likelihood of future pregnancy complications for any CSP varies depending on its individual characteristics, this might not always be necessary nor might it be the patient's preferred choice if she is asymptomatic, hemodynamically stable, and wants a baby. The literature supports an interventional rather than a medical approach but the safest and most efficient clinical approach to CSP in terms of treatment modality and service delivery has yet to be determined. This review aims to provide an overview of CSP etiology, natural history, and clinical implications. Treatment options and methods of CSP repair are discussed. We describe our experience in a large tertiary center in Singapore with around 16 cases/year where most treatment modalities are available as well as an "accreta service" for continuing pregnancies. We present a simple algorithm for approach to management including a method of triaging for those CSPs suitable for minimally invasive surgery.

Prognostic model on niche development after a first caesarean section: development and internal validation

OBJECTIVE

To develop and internally validate a prognostic prediction model for development of a niche in the uterine scar after a first caesarean section (CS).

STUDY DESIGN

Secondary analyses on data of a randomized controlled trial, performed in 32 hospitals in the Netherlands among women undergoing a first caesarean section. We used multivariable backward logistic regression. Missing data were handled using multiple imputation. Model performance was assessed by calibration and discrimination. Internal validation using bootstrapping techniques took place. The outcome was 'development of a niche in the uterus', defined as an indentation of ≥ 2 mm in the myometrium.

RESULTS

We developed two models to predict niche development: in the total population and after elective CS. Patient related risk factors were: gestational age, twin pregnancy and smoking, and surgery related risk factors were double-layer closure and less surgical experience. Multiparity and Vicryl suture material were protective factors. The prediction model in women undergoing elective CS revealed similar results. After internal validation, Nagelkerke R² ranged from 0.01 to 0.05 and was considered low; median area under the curve (AUC) ranged from 0.56 to 0.62, indicating failed to poor discriminative ability.

CONCLUSIONS

The model cannot be used to accurately predict the development of a niche after a first CS. However, several factors seem to influence scar healing which indicates possibilities for future prevention such as surgical experience and suture material. The search for additional risk factors that play a role in development of a niche should be continued to improve the discriminative ability.

Ultrasound evaluation of uterine scar thickness after open fetal surgery for myelomeningocele

PURPOSE

This study aimed to analyse the evolution of uterine scar thickness after open fetal surgery for myelomeningocele (MMC) by ultrasonography, and to establish a cut-off point for uterine scar thickness associated with high-risk of uterine rupture.

METHODS

A prospective longitudinal study was conducted with 77 pregnant women who underwent open fetal surgery for MMC between 24 and 27 weeks of gestation. After fetal surgery, ultrasound follow-up was performed once a week, and the scar on the uterine wall was evaluated and its thickness was measured by transabdominal ultrasound. At least five measurements of the uterine scar thickness were performed during pregnancy. A receiver operating characteristics (ROC) curve was constructed to obtain a cut-off point for the thickness of the scar capable of detecting the absence of thinning. Kaplan-Meier curves were constructed to evaluate the probability of thinning during pregnancy follow-up.

RESULTS

The mean ± standard deviation of maternal age (years), gestational age at surgery (weeks), gestational age at delivery (weeks), and birth weight (g) were 30.6 ± 4.5, 26.1 ± 0.8, 34.3 ± 1.2 and 2287.4 ± 334.4, respectively. Thinning was observed in 23 patients (29.9%). Pregnant women with no thinning had an average of 17.1 ± 5.2 min longer surgery time than pregnant women with thinning. A decrease of 1.0 mm in the thickness of the uterine scar was associated with an increased likelihood of thinning by 1.81-fold (95% confidence interval [CI]: 1.32-2.47; p < 0.001). The area below the ROC curve was 0.899 (95% CI: 0.806-0.954; p < 0.001), and the cut-off point was ≤ 3.0 mm, which simultaneously presented greater sensitivity and specificity. After 63 days of surgery, the probability of uterine scarring was 50% (95% CI: 58-69).

CONCLUSION

A cut-off point of ≤ 3.0 mm in the thickness of the uterine scar after open fetal surgery for MMC may be used during ultrasonography monitoring for decision-making regarding the risk of uterine rupture and indication of caesarean section.

Uterine dehiscence: a laparoscopic uterine repair in early pregnancy

OBJECTIVE

To review the existing literature on uterine cesarean scar defect repair in pregnancy and describe an approach to minimally invasive surgical repair in early pregnancy to facilitate a term live birth.

DESIGN

A case study and literature review, followed by a demonstration of the procedure with surgical video and concurrent ultrasound footage.

SETTING

Academic medical center.

PATIENT(S)

This video is a case presentation of a 35-year-old, gravida 2, para 1 woman with a previous cesarean section. She presented at 10 weeks and 3 days gestational age with complete uterine dehiscence at the site of her previous cesarean section scar, which was diagnosed by ultrasound. Surgical video and medical images have been extracted from this patient's chart after consent was obtained.

INTERVENTION(S)

Ultrasound-guided laparoscopic repair of cesarean scar defect at 11 weeks and 3 days of gestation.

MAIN OUTCOME MEASURE(S)

The video showed a large 2.6-cm uterine scar defect in early pregnancy confirmed using ultrasound and magnetic resonance imaging. This diagnosis was confirmed by direct visualization at the time of surgery. This video demonstrates our surgical approach as follows: careful uterine manipulation and identification of the defect with laparoscopy and concurrent transvaginal ultrasound; reflection of the bladder using an ultrasound-guided approach to confirm the borders of the defect; and repair with a running 2-layer closure under transvaginal ultrasound guidance.

RESULT(S)

Through ultrasound-guided laparoscopic repair, we were able to demonstrate a restoration of approximately 8 mm of myometrial thickness across the cesarean scar defect on antenatal follow-up. The patient had a term live birth via cesarean section.

CONCLUSION(S)

With an increased number of cesarean sections and improved quality of ultrasound imaging, an increase in the incidental findings of cesarean scar defects has been observed. The risk of spontaneous prelabor uterine rupture remains unknown. There is a literature gap in this area regarding the appropriate standard of care. This video demonstrates that ultrasound-guided laparoscopic repair was possible, safe, and effective in our patient. However, further studies are required to establish the safety and efficacy of this approach.

Levonorgestrel-Releasing Intrauterine Device Use Can Be a Treatment Option in Symptomatic Patients with Isthmocele

Levonorgestrel-releasing intrauterine devices have been used for contraception and treatment of heavy menstrual bleeding. There is only limited data about the effect of this on isthmocele. Here, we aimed to evaluate the effect of levonorgestrel-releasing intrauterine devices in a larger study population with a longer follow-up as compared to the literature on symptomatic patients with isthmocele. A total of 29 patients with symptomatic isthmocele and inserted levonorgestrel-releasing device were included in this prospective study. All patients were included at January 2020 and followed for 18 months. Sociodemographic findings, laboratory parameters, premenstrual spotting, postmenstrual spotting, menorrhagia, dysmenorrhea, and pelvic pain related to isthmocele were recorded. In sonography, width, length, area of isthmocele, and residual myometrial thickness were determined. The frequency of symptoms during follow-up was compared between visits and also compared between groups according to residual myometrial thickness. Premenstrual spotting and pelvic pain were significantly reduced at 6th months (48.3 to 10.3%, p = 0.007 and 34.5 to 10.3%, p = 0.039, respectively) and no significant change was detected until the end of follow-up period. Postmenstrual spotting reduced at 6th months (96.6 to 34.5%, p < 0.001) and also significant change was detected between 6 and 12th months (34.5% vs 13.8%, p = 0.031). Menorrhagia and dysmenorrhea disappeared at 12th months. No association was found between residual myometrial thickness and the frequency of symptoms for each follow-up. Levonorgestrel-releasing intrauterine devices are useful and reliable therapeutic tools for symptomatic isthmocele patients who do not desire fertility, regardless of residual myometrial thickness.

Complications of Caesarean delivery part 1: Early complications

Introduction

With the rise in Caesarean deliveries, complications related to the procedure are increasingly encountered. Sonography has an indispensable role in the assessment of these complications and is often the first-line investigation of choice.Topic Description: Part 1 of this pictorial review summarises the early complications unique to and associated with Caesarean deliveries.

Discussion

Acute haemorrhagic complications include retained products of conception, subfascial and bladder flap haematomas and, rarely, postpartum uterine dehiscence or rupture and iatrogenic vascular complications. Infective complications include puerperal and wound infections. Key sonographic features of these conditions are illustrated. Pitfalls, mimics, limitations and indications for cross-sectional imaging are discussed.

Conclusion

Sound knowledge of the sonographic features of common early complications of Caesarean delivery will facilitate accurate diagnosis, timely management and improved patient outcomes.

Definition of large niche after Cesarean section based on prediction of postmenstrual spotting: Chinese cohort study in non-pregnant women

OBJECTIVE

A large niche after Cesarean section (CS) is associated with long-term complications, of which postmenstrual spotting is associated positively with the size of the niche. However, the diagnosis of a large niche in the literature is inconsistent and the definition is largely subjective. The aim of this study was to generate a definition for a large niche in non-pregnant women based on the presence of postmenstrual spotting.

METHODS

Women who had undergone CS in our hospital between January 2012 and June 2017 were selected randomly from our database, contacted by telephone and subsequently examined between January 2016 and June 2020. Eligible for inclusion were non-pregnant women who had their last CS more than 1 year earlier and agreed to undergo transvaginal sonography (TVS). All participants underwent examination of their CS scar by TVS (two-dimensional color Doppler) during the midfollicular phase. Niche depth, length, width, residual myometrial thickness (RMT), adjacent myometrial thickness (AMT) and ratio of niche depth/AMT were recorded. Women diagnosed with a niche, defined as an indentation at the site of the CS with a depth of at least 2 mm, were classified into two groups (symptomatic or asymptomatic) according to whether they experienced postmenstrual spotting. Logistic regression analysis was used to establish the best cut-off values for the niche parameters to predict postmenstrual spotting. A new definition was generated based on the niche parameters with the highest area under the receiver-operating-characteristics (ROC) curve (AUC) for the prediction of postmenstrual spotting.

RESULTS

A total of 727 women who had a CS > 1 year earlier underwent TVS examination, of whom 263 were diagnosed with a niche (prevalence of 36.2%). Of these, 160 women experienced postmenstrual spotting and 103 were asymptomatic. The three variables with the highest AUC for prediction of postmenstrual spotting were niche depth/AMT ratio (AUC, 0.798; 95% CI, 0.745-0.852), niche depth (AUC, 0.731; 95% CI, 0.668-0.795) and RMT (AUC, 0.683; 95% CI, 0.618-0.748). Based on the best cut-offs according to ROC-curve analysis, a large niche was defined as: niche depth ≥ 0.50 cm, RMT ≤ 0.21 cm or niche depth/AMT ratio ≥ 0.56. The prevalence of a large niche according to this definition was 22.4% (163/727). The new definition had a specificity of 61.17% (95% CI, 52.34-70.41%) and sensitivity of 76.87% (95% CI, 70.28-84.16%) for a large niche.

CONCLUSION

This study has provided a new definition for a large niche after CS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Cesarean Scar Thickness Decreases during Pregnancy: A Prospective Longitudinal Study

Background and Objectives: The aim of this study is to evaluate changes in uterine scar thickness after previous cesarean delivery longitudinally during pregnancy, and to correlate cesarean section (CS) scar myometrial thickness in the first trimester in two participants groups (CS scar with a niche and CS scar without a niche) with the low uterine segment (LUS) myometrial thickness changes between the second and third trimesters. Materials and Methods: In this prospective longitudinal study, pregnant women aged 18−41 years after at least one previous CS were included. Transvaginal sonography (TVS) was used to examine uterine scars after CS at 11−14 weeks. The CS scar niche (“defect”) was defined as an indentation at the site of the CS scar with a depth of at least 2 mm in the sagittal plane. Scar myometrial thickness was measured, and scars were classified subjectively as a scar with a niche (niche group) or without a niche (non-niche group). In the CS scar niche group, RMT (distance from the serosal surface of the uterus to the apex of the niche) was measured and presented as CS scar myometrial thickness in the first trimester. The myometrial thickness at the internal cervical os was measured in the non-niche group. The full LUS and myometrial LUS thickness at 18−20 and 32−35 weeks of gestation were measured in the thinnest part of the scar area using TVS. Friedman’s ANOVA test was used to analyse scar thickness during pregnancy and Mann−Whitney test to compare scar changes between CS scar niche and non-niche women groups. For a pairwise comparison in CS scar thickness measurements in the second and third trimesters, we used Wilcoxon Signed Ranks test. Results: A total of 122 eligible participants were recruited to the study during the first trimester of pregnancy. The scar niche was visible in 40.2% of cases. Uterine scar myometrial thickness decreases during pregnancy from 9.9 (IQR, 5.0−12.9) at the first trimester to 2.1 (IQR, 1.7−2.7) at the third trimester of pregnancy in the study population (p = 0.001). The myometrial CS scar thickness in the first trimester (over the niche) was thinner in the women’s group with CS scar niche compared with the non-niche group (at internal cervical os) (p < 0.001). The median difference between measurements in the CS scar niche group and non-niche group between the second and third trimester was 2.4 (IQR, 0.8−3.4) and 1.1 (IQR, 0.2−2.6) (p = 0.019), respectively. Myometrial LUS thickness as percentage decreases significantly between the second and third trimester in the CS scar niche group compared to the non-niche group (U = 1225; z = −2.438; p = 0.015). Conclusions: CS scar myometrial thickness changes throughout pregnancy and the appearance of the CS scar niche was associated with a more significant decrease in LUS myometrial thickness between the second and third trimesters.

Association between the occurrence of adenomyosis and the clinical outcomes of vaginal repair of cesarean section scar defects: an observational study

Background

To examine the correlation between the occurrence of adenomyosis and the outcome of vaginal repair of cesarean section scar defects (CSDs).

Methods

A total of 278 women with CSD were enrolled in this retrospective observational cohort study at the Shanghai First Maternity & Infant Hospital between January 2013 and August 2017. Patients were divided into two groups according to preoperative magnetic resonance imaging (MRI) findings: the adenomyosis group and the non-adenomyosis group. They all underwent vaginal excision and suturing of CSDs and were required to undergo examinations 3 and 6 months after surgery. Preoperative and postoperative clinical information was collected. Optimal healing was defined as a duration of menstruation of no more than 7 days and a thickness of the residual myometrium (TRM) of no less than 5.8 mm after vaginal repair.

Results

Before vaginal repair, for patients in the adenomyosis group, the mean duration of menstruation was longer and TRM was significantly thinner than those in patients in the non-adenomyosis group (p < 0.05). The TRM and duration of menstruation 3 and 6 months after surgery were significantly improved in both groups (p < 0.05). There were more patients with optimal healing in the non-adenomyosis group than in the adenomyosis group (44.7% vs. 30.0%; p < 0.05). Furthermore, 59.3% (32/54) of the women tried to conceive after vaginal repair. The pregnancy rates of women with and without adenomyosis were 66.7% (8/12) and 61.9% (26/42), respectively. The duration of menstruation decreased significantly from 13.4 ± 3.3 days before vaginal repair to 7.6 ± 2.3 days after vaginal repair in 25 patients (p < 0.001). The TRM increased significantly from 2.3 ± 0.8 mm before vaginal repair to 7.6 ± 2.9 mm after vaginal repair (p < 0.001).

Conclusions

Vaginal repair reduced postmenstrual spotting and may have improved fertility in patients with CSDs. Patients with adenomyosis are more likely to have suboptimal menstruation and suboptimal healing of CSDs. Adenomyosis might be an adverse factor in the repair of uterine incisions.

Endometriosis and Isthmocele: Common or Rare?

Higher cesarean section rates and better ultrasound diagnostics have led to a more frequent diagnosis of isthmocele, a cesarean scar defect. Sometimes, endometriosis is found in the isthmocele, but simultaneous extrauterine endometriosis and endometriosis in the isthmocele have not yet been reported. Additionally, the surgical technique to repair the isthmocele is the subject of ongoing controversy. The aim of this study is to analyze a possible correlation between uterine scar (isthmocele) endometriosis and extrauterine endometriosis and to investigate the outcome of laparoscopic isthmocele resection in the rendezvous technique. In this single-center retrospective study, we included 83 women of reproductive age with symptomatic isthmocele undergoing laparoscopic isthmocele repair in rendezvous technique from 2004 to 2020 at the University of Bern. We collected data on patient and surgical characteristics as well as on postoperative outcomes (symptoms, further pregnancy, and pregnancy outcomes) retrospectively. We analyzed and compared these data for patients with and without endometriosis. Endometriosis was diagnosed during surgery in 22 out of 83 operated patients (26.5%). Diagnosis of isthmocele endometriosis (n = 9, 11%) was significantly higher in patients with extrauterine endometriosis (n = 6, p = 0.004). While the duration of surgery was significantly longer for patients with endometriosis (p = 0.006), the groups did not differ with regard to blood loss or complications. In addition, both groups showed similar indications for isthmocele repair (infertility, abnormal uterine bleeding, or dysmenorrhea). Surgery significantly improved abnormal uterine bleeding (χ2 p < 0.001), dysmenorrhea (χ2, p = 0.03), and infertility (χ2, p < 0.001). Regardless of the presence of endometriosis, 25 of 40 (63%) infertile patients became pregnant after surgery. In one out of eight pregnancies, however, we observed scar complications during pregnancy such as uterine scar pregnancy (n = 3), uterine scar dehiscence (n = 3), and placenta previa (n = 1). Endometriosis is a non-negligible intraoperative finding in patients with symptomatic isthmocele. The laparoscopic approach in the rendezvous technique is safe and effective. Therefore, this method should be recommended, especially in women with secondary infertility, and preoperatively simultaneous endometriosis resection should be discussed with the patient. In follow-up, postoperative pregnancies have to be monitored with care.

Case Report: Laparoscopic Isthmocele Repair on an 8 Weeks Pregnant Uterus

An isthmocele, also known as a caesarean scar defect, is a long-term complication of caesarean sections with an increasing incidence. Although is often asymptomatic, it is a novel recognised cause of abnormal uterine bleeding, and it is a major risk factor for caesarean scar pregnancies or uterine ruptures in subsequent pregnancies. Currently there are no guidelines for the diagnosis and management of this condition. Several surgical techniques for the correction of isthmocele are proposed, including laparoscopic excision, vaginal repair, a combined laparoscopic-vaginal approach or more recently hysteroscopic resection. We present the case of a GII PI, 29 years old patient with a previous c-section who presented in our clinic with a positive pregnancy test for pregnancy confirmation. The ultrasound examination revealed an intrauterine evolutive 8 weeks pregnancy and a caesarean scar defect. After counselling the patient opted for pregnancy continuation and laparoscopic correction of the isthmocele. The surgery was performed under ultrasound guidance. The defect was resected, and the uterus was closed with a continuous two-layer suture. No intraoperative or postoperative complications were present. The pregnancy continued uneventfully A caesarean section was performed at term revealing a fully healed scar.

Evaluation of the usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean delivery: a randomized trial

BACKGROUND

The main reason to avoid trial of labor after cesarean delivery is the possibility of uterine rupture. Identifying women at risk is thus an important aim, for it would enable women at low risk to proceed with a secure planned vaginal birth.

OBJECTIVE

To evaluate the impact of proposing mode of delivery based on the ultrasound measurement of the lower uterine segment thickness on a composite outcome of maternal-fetal mortality and morbidity, compared with usual management, among pregnant women with a previous cesarean delivery.

STUDY DESIGN

This multicenter, randomized, controlled, parallel-group, unmasked trial was conducted at 8 referral university hospitals with a neonatal intensive care unit and enrolled 2948 women at 36 weeks 0 days to 38 weeks 6 days of gestation with 1 previous low transverse cesarean delivery and no contraindication to trial of labor. Women in the study group had their lower uterine segment thickness measured by ultrasound. Those with measurements >3.5 mm, were encouraged to choose a planned vaginal delivery, and those with measurements ≤3.5 mm, were encouraged to choose a planned repeat cesarean delivery. This measurement was not taken in the control group; their mode of delivery was decided according to standard management. The primary outcome was a composite criterion comprising maternal mortality, uterine rupture, uterine dehiscence, hysterectomy, thromboembolic disease, transfusion, endometritis, perinatal death, or neonatal encephalopathy. Prespecified secondary outcomes were repeat cesarean deliveries, elective or after trial of labor.

RESULTS

The study group included 1472 women, and the control group included 1476 women. These groups were similar at baseline. The primary outcome occurred in 3.4% of the study group and 4.3% of the control group (relative risk, 0.78; 95% confidence interval, 0.54-1.13: risk difference, -1.0%; 95% confidence interval, -2.4 to 0.5). The uterine rupture rate in the study group was 0.4% and in the control group 0.9% (relative risk, 0.43; 95% confidence interval, 0.15-1.19). The planned cesarean delivery rate was 16.4% in the study group and 13.7% in the control group (relative risk, 1.21; 95% confidence interval, 1.00-1.47), whereas the rates of cesarean delivery during labor were 25.1% and 25.0% (relative risk, 1.01; 95% confidence interval, 0.89-1.14) in the study and control groups, respectively.

CONCLUSION

Ultrasound measurements of lower uterine segment thickness did not result in a statistically significant lower frequency of maternal and perinatal adverse outcomes than standard management. However, because this study was underpowered, further research should be encouraged.

Can ultrasound predict the delivery time of patients with previous cesarean section in the 37th gestational week? A prospective cross-sectional study

BACKGROUND

The aim was to investigate factors that predict when patients with previous cesarean section will undergo cesarean section (CS) using ultrasonography in the 37th gestational week.

MATERIAL AND METHODS

In this prospective cross-sectional study, a total of 166 patients with previous CS who presented to the hospital for routine checks at the 37^0/7th gestational week were included in the study. Uterine-related, fetus-related, and patient-related factors that affect labor time were analyzed by the same physician at admission, and the patients were then divided into two groups as those having CS at early term (37^0/7 to 38^{6/7 weeks} of gestation) and full-term (39^0/7 to 40^{6/7 weeks} of gestation). Ninety-four patients underwent CS at full-term and 72 patients underwent CS at the early term in the study.

RESULTS

There was no significant difference for age (years), parity, weight gain, previous cesarean number, cervical length, myometrial thickness, estimated fetal weight, and full lower uterine segment thickness between the groups (p>.05). In the full-term group, 58% had a history of vaginal birth, whereas, in the early-term group, 42% had a history of vaginal birth (p < .05). Vaginal birth history was found to be independently associated with reaching full-term (respectively, OR: 2.876, 95% CI: [1.227-6.738]; p = .015) in all patients. Two different regression models were created to predict different CS times after the 37th week of pregnancy. Weight gain was found to be independently associated with CS time within the first seven days after admission (OR: 1.267, 95% CI: [1.003-1.599]; p = .047). Vaginal birth history and estimated fetal weight were found to be independently associated with CS time in the 8th day and further after admission (OR: 0.244, 95% CI: [0.089-0.675]; p = .007 and OR: 1.002, 95% CI: [1.000-1.003]; p = .047).

CONCLUSION

Vaginal birth history can be useful to predict reaching full-term in patients with previous CS. Determination of such risk factors is important in terms of reducing the frequency of emergency cesarean delivery.

Impact of third-trimester measurement of low uterine segment thickness and estimated fetal weight on perinatal morbidity in women with prior cesarean

OBJECTIVES

This study aimed to estimate the impact of third-trimester ultrasound with measurement of the lower uterine segment thickness (LUST) and estimation of fetal weight (EFW) on maternal and perinatal morbidity among women with a prior cesarean delivery.

METHODS

We performed a secondary analysis of the QUARISMA trial, including women who delivered at term after 1 prior cesarean delivery in tertiary care centres. Major and minor maternal and perinatal morbidities were compared between centres that had introduced LUST and EFW measurements into routine practice and those that had not, using generalized estimating equations and adjusted odds ratios (aOR). In a secondary analysis, we compared women who underwent a trial of labour with and without LUST and EFW measurements.

RESULTS

We observed a significant reduction in major perinatal morbidity (aOR 0.52; 95% CI 0.28-0.96, P = 0.04), minor perinatal morbidity (aOR 0.49; 95% CI 0.25-0.96, P = 0.04), and minor maternal morbidity (aOR 0.56; 95% CI 0.34- 0.94, P = 0.03) but no significant difference in major maternal morbidity (aOR 0.40; 95% CI 0.04-3.69, P = 0.42) in the 2 centres that had introduced third-trimester ultrasound with EFW and LUST measurements (1458 women), compared with the 4 centres (1247 women) that had not. Among women who underwent a trial of labour, we observed a reduction in major perinatal morbidity (aOR 0.25; 95% CI 0.11-0.54, P < 0.001) and a lower rate of uterine rupture (0% vs. 0.3%, P = 0.045) with LUST and EFW measurements.

CONCLUSION

Third-trimester ultrasound with EFW and LUST measurement is associated with a significant reduction in major perinatal morbidity in women with a prior caesarean delivery.

Changes in lower uterine segment thickness during different gestational weeks in pregnant women qualified for trial of labor after cesarean section

Objective

To investigate the correlation between lower uterine segment thickness (LUST) and gestational weeks (GW) in women who attempted trial of labor after cesarean section (TOLAC) and to estimate the reference ranges of LUST.

Methods

A prospective cohort study was conducted between January 2019 and December 2020 at a tertiary‐care center in Foshan, China. A total of 2588 women who attempted TOLAC were included. LUST was measured in different trimesters using transabdominal ultrasound. Histograms were used to review the mean and standard deviations (SD) of LUST at different GW.

Results

The mean LUST of the patients were 6.90 ± 2.86, 4.36 ± 1.87, 2.83 ± 0.65, and 2.57 ± 0.51 mm in the first (12.10 ± 1.28 weeks), second (21.79 ± 3.40 weeks), middle third (34.28 ± 2.64 weeks), and late third (38.20 ± 1.00 weeks) trimesters, respectively. An inverse correlation was noted between LUST and uterine rupture in women who underwent a planned ERCD (P < 0.001), but not in women who attempted TOLAC during the late third trimester (P = 0.629).

Conclusion

LUST is inversely correlated with GW and decreases faster in the first and second trimesters than in the middle and late third trimesters. TOLAC should be approached with caution for pregnant women with a thin myometrium in late third trimester.

Lower uterine segement thickness measured by ultrasound is inversely correlated with gestation and decreases faster in the first two trimesters than in the third trimester.

Gynecological outcomes of uterine niche after cesarean section: A descriptive study

Objectives:

Our aim was to study the prevalence of isthmocele in cases with previous cesarean section scar presented to El Shatby maternity university hospital and its association with gynecological complications.

Material and Methods:

After approval of the ethics committee of Alexandria faculty of medicine, a sample of 300 patients delivered by cesarean section since 6 months or more presented by one or more of the following symptoms: Abnormal uterine bleeding (AUB) dysmenorrhea, secondary infertility, and lower abdominal pain were selected from the gynecology clinic of El Shatby maternity university hospital. All patients were subjected to history taking, clinical, and gynecological examination. Post-menstrual 2D transvaginal ultrasonography was done. Where the niche or isthmocele was seen as triangular or dome- shaped echo-free space. Data were collected and entered to the computer using Statistical Package for the Social Science program for statistical analysis.

Results:

Niche was found in 44 cases. Most of them were symptomatic. Duration from the last (CS) was statistically significant. Symptoms were related to number of previous cesarean sections.

Conclusion:

The incidence of post-cesarean section niche in El Shatby Maternity hospital was 14.67%. Most common symptoms were AUB and dyspareunia.

Two uterine scars and a vaginal birth

Uterine scarring increases the risk of uterine rupture during labour, which can result in significant maternal and fetal morbidity and mortality. There is insufficient evidence for a clear recommendation on the safety of vaginal delivery in the context of a patient with both a uterine perforation and a previous lower uterine segment caesarean section. We present the case of a woman with a history of one previous caesarean section and uterine perforation with a uterine manipulator, who subsequently had an uncomplicated normal vaginal delivery.

Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk

BACKGROUND

The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri.

OBJECTIVE

Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy.

METHODS

From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group.

RESULTS

The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors.

CONCLUSION

In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.

Hysteroscopy in the Treatment of Myometrial Scar Defect (Diverticulum) Following Cesarean Section Delivery: A Systematic Review and Meta-Analysis

Various management approaches have been developed to treat symptoms and prevent complications of the cesarean diverticulum. This systematic review aims to report the outcomes and fertility-related effects of hysteroscopy on women with myometrial scar defects after the cesarean section. Following the formulation of the patient/population, intervention, comparison, and outcomes (PICO) criteria, a systematic search was conducted on seven databases. Finally, a total of 18 studies were included for this systematic review and meta-analysis. All of the included patients suffered from post-cesarean section scars and presented with abnormal bleeding, pain, or secondary infertility. The overall pooled symptomatic improvement rate was 78.83% (95% CI: 72.46-85.76%); however, there was significant heterogeneity among the analyzed studies (I²=87%; p-value: <0.001) and a significant risk of bias (p-value: <0.001). The overall resolution/improvement rate after adjusting for possible bias was higher, 92.82% (95% CI: 85.17-100%). The overall pregnancy rate was 69.77% (95% CI: 59.03-82.48%), while in the individual studies the rates varied, ranging from 25% to 80%. Nevertheless, there was moderate heterogeneity among the included studies (I²=56%; p-value=0.011). In contrast, there was no significant risk of bias among the included studies (p-value=0.100). Furthermore, the meta-regression analyses did not show any significant effect of different follow-up durations on the overall effect size for both outcomes. In conclusion, there is still a need for high-quality, comparative studies with larger sample sizes and long-term follow-up periods to draw firm conclusions. Moreover, future studies should consider the minimum myometrial thickness that is sufficient to complete a healthy pregnancy.

Prevalence and predictors of uterine rupture among Ethiopian women: A systematic review and meta-analysis

Background

Uterine rupture has a significant public health importance, contributing to 13% of maternal mortality and 74%-92% of perinatal mortality in Sub-Saharan Africa, and 36% of maternal mortality in Ethiopia. The prevalence and predictors of uterine rupture were highly variable and inconclusive across studies in the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence and predictor of uterine rupture in Ethiopia.

Methods

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 checklist. PubMed, Cochrane Library, Google Scholar, and African Journals Online databases were searched. The Newcastle- Ottawa quality assessment tool was used for critical appraisal. I² statistic and Egger’s tests were used to assess the heterogeneity and publication bias, respectively. The random-effects model was used to estimate the pooled prevalence and odds ratios with a 95% confidence interval.

Results

Sixteen studies were included, with a total of 91,784 women in the meta-analysis. The pooled prevalence of uterine rupture was 2% (95% CI: 1.99, 3.01). The highest prevalence was observed in the Amhara regional state (5%) and the lowest was in Tigray region (1%). Previous cesarean delivery (OR = 9.95, 95% CI: 3.09, 32.0), lack of antenatal care visit (OR = 8.40, 95% CI: 4.5, 15.7), rural residence (OR = 4.75, 95% CI: 1.17, 19.3), grand multiparity (OR = 4.49, 95% CI: 2.83, 7.11) and obstructed labor (OR = 6.75, 95%CI: 1.92, 23.8) were predictors of uterine rupture.

Conclusion

Uterine rupture is still high in Ethiopia. Therefore, proper auditing on the appropriateness of cesarean section and proper labor monitoring, improving antenatal care visit, and birth preparedness and complication readiness plan are needed. Moreover, early referral and family planning utilization are the recommended interventions to reduce the burden of uterine rupture among Ethiopia women.

Effect of single- versus double-layer uterine closure during caesarean section on postmenstrual spotting (2Close): multicentre, double-blind, randomised controlled superiority trial

OBJECTIVE

To evaluate whether double-layer uterine closure after a first caesarean section (CS) is superior compared with single-layer uterine closure in terms of postmenstrual spotting and niche development in the uterine caesarean scar.

DESIGN

Multicentre, double-blind, randomised controlled superiority trial.

SETTING

Thirty-two hospitals in the Netherlands.

POPULATION

A total of 2292 women aged ≥18 years undergoing a first CS were randomly assigned to each procedure (1:1): 1144 women were assigned to single-layer uterine closure and 1148 women were assigned to double-layer uterine closure.

METHODS

Single-layer unlocked closure and double-layer unlocked closure, with the second layer imbricating the first.

MAIN OUTCOME MEASURES

Number of days with postmenstrual spotting during one menstrual cycle 9 months after CS.

SECONDARY OUTCOMES

perioperative and menstrual characteristics; transvaginal ultrasound measurements.

RESULTS

A total of 774 (67.7%) women from the single-layer group and 770 (67.1%) women from the double-layer group were evaluable for the primary outcome, as a result of drop-out and amenorrhoea. The mean number of postmenstrual spotting days was 1.33 (bootstrapped 95% CI 1.12-1.54) after single-layer closure and 1.26 (bootstrapped 95% CI 1.07-1.45) after double-layer closure (adjusted mean difference -0.07, 95% CI -0.37 to 0.22, P = 0.810). The operative time was 3.9 minutes longer (95% CI 3.0-4.9 minutes, P < 0.001) and niche prevalence was 4.7% higher (95% CI 0.7-8.7%, P = 0.022) after double-layer closure.

CONCLUSIONS

The superiority of double-layer closure compared with single-layer closure in terms of postmenstrual spotting after a first CS was not shown. Long-term obstetric follow-up of our trial is needed to assess whether uterine caesarean closure guidelines should be adapted.

TWEETABLE ABSTRACT

Double-layer uterine closure is not superior for postmenstrual spotting after a first caesarean; single-layer closure performs slightly better on other outcomes.

Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased

Around 20% of pregnant women undergo cesarean section (CS), and in most regions of the world CS rates continue to grow. There is still no clear definition of what is considered a normal physiologic aspect of a CS scar and what is abnormal. Cesarean scar defects (CSDs) should be suspected in women presenting with spotting, dysmenorrhea, pelvic pain, or infertility and a history of CS. CSDs can be visualized with the use of hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be contemplated according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and residual myometrium thickness (RMT) measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique if the RMT is <3 mm, in which case repair is essential and can be achieved by only laparoscopic or vaginal approach. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made. Because prevention is better than cure, risk factors should be identified early to ensure appropriate management.

The use of sonographic myometrial thickness measurements for the prediction of time from induction of labor to delivery

BACKGROUND

Several attempts have been made to find tools for the prediction of successful induction of labor. Sonographic myometrial thickness has not yet been investigated regarding its use as a clinical tool for the course of labor induction.

OBJECTIVE

To evaluate the role of sonographic measurement of myometrial thickness in the prediction of the time interval to successful vaginal delivery after induction of labor.

STUDY DESIGN

A prospective study was conducted including term singleton pregnancies with a vertex presentation designated for balloon induction at 38-42 weeks gestation. Prior to induction, abdominal sonographic myometrial thickness was assessed at five locations: lower uterine segment (above and below the reflection of the urinary bladder), mid-anterior wall, fundus and posterior uterine wall. Induction of labor was then carried out with a trans-cervical Foley catheter that was substituted with intravenous oxytocin after balloon expulsion. The parameters assessed were successful induction of labor resulting in a vaginal delivery and the time interval from balloon insertion to balloon expulsion, the time interval from initiation of oxytocin administration to delivery and the total time from balloon insertion to delivery.

RESULTS

Fifty-two women were recruited to the study. Indications for labor induction were: post-date pregnancy (48.1%), gestational diabetes mellitus (19.2%), oligohydramnios (11.5%), gestational hypertensive disorders (5.8%) and other indications (15.4%). Vaginal delivery was achieved in 46 patients (88.5%). A statistically significant correlation was found between fundal and posterior uterine wall myometrial thickness and time from induction to balloon expulsion (r = 0.36, p = 0.03; r = - 0.35, p = 0.05, respectively). This correlation remained significant in a multivariate logistic regression model controlling for confounders. A correlation between myometrial thickness and the total time from induction to delivery was not statistically significant.

CONCLUSION

Myometrial fundal and posterior uterine wall thickness in women undergoing labor induction with a balloon catheter was found to be correlated with the interval from balloon insertion to expulsion. Our findings support further investigations into the use of sonographic myometrial thickness as part of the assessment prior to induction of labor.

Demonstration of Isthmocele Surgical Repair

STUDY OBJECTIVE

To describe the surgical treatment of a uterine isthmocele.

DESIGN

Demonstration of the laparoscopic technique with narrated video footage.

SETTING

Cesarean section rate has been increasing despite the World Health Organization's recommendation of a maximum 15%, with some countries reaching rates as high as 50%. The choice of delivery method is a complex topic based on physical and psychologic health, social and cultural context, and quality of maternity care. With the increasing number of cesarean sections, a new entity was recognized, the isthmocele [1]. A uterine isthmocele is a dilatation of the uterine cesarean scar and functions as a reservoir collecting blood during menstruation. Isthmocele prevalence ranges from 19% to 84%[2]. The most frequent complaint relates to intermittent postmenstrual bleeding (30%). Isthmocele can be a cause of infertility and pelvic pain [3]. Interstitial pregnancy is a known complication with a mortality rate up to 2.5%. The diagnosis can be made by transvaginal ultrasound and/or magnetic resonance imaging but also by hysteroscopy or hysterosalpingography. Treatment can be done by controlling the symptoms with oral combined contraceptive (decreasing metrorrhagia) or with surgical correction improving symptoms and/or fertility [4-7]. Isthmocele correction seems to improve secondary infertility in patients in whom a fertility workup did not find other cause [8,9]. Surgical approach can be done by vaginal route with hysteroscopy; abdominal route with laparoscopy, robotic or laparotomy; or through a combine procedure with both routes. Hysterectomy is the definitive treatment, but for those who want to preserve fertility, isthmocele correction can be offered. For laparoscopic surgery, several ways have been described to detect the isthmocele such as Foley catheter, hysteroscopy, methylene blue, and Hegar probe. When we do laparoscopy, we prefer concomitant use of hysteroscopy. There is a trending opinion that patients with a smaller isthmocele could be treated hysteroscopically (2.5 mm according to Jeremy et al [10] and 3.0 mm described by Marotta et al [11]). The goal of hysteroscopy correction is to remove the inflammatory infiltration in the endocervix, cutting the superior and inferior edges of the defect enabling normal blood evacuation of the uterus. By contrast, those with a larger isthmocele (with <2.5-3.0-mm residual myometrium) and a risk of perforation during hysteroscopy could be better treated by laparoscopy. This is especially important in patients interested in pregnancy because of the risk of uterine perforation [12]. There is still no strong evidence that hysteroscopic correction leads to an increased number of uterine ruptures compared with laparoscopy, but myometrium thickness seems to be greater after laparoscopic correction. Myometrium thickness is an independent risk factor for uterine rupture [13], and therefore, laparoscopic correction is preferred over hysteroscopic in women with a pregnancy desire. Finally, after surgical correction of an isthmocele, we recommend a 6-month interval before attempting pregnancy.

INTERVENTIONS

Laparoscopic treatment is important in women who are symptomatic, have thin endometrium, and desire a pregnancy. Key strategies are (1) dissection of the vesicouterine pouch laterally to avoid entering the bladder wall; (2) transillumination with hysteroscopy; (3) cut with cold scissors avoiding thermal damage of remaining myometrium; and (4) suture with figure 8 in multiple layers. No evidence of using a specific suture is available.

CONCLUSION

Surgical treatment of a uterine isthmocele is a good option in women who are symptomatic and infertile. Laparoscopic treatment guided by hysteroscopy is a good option if residual myometrium is <3 mm.

Prediction of Delivery Complications by First-Trimester Ultrasound Measurement of the Gestational Sac's Distance From a Previous Cesarean Section Scar

OBJECTIVES

This study was designed to investigate the clinical relationship between labor complications in the second and third trimesters and the distance from the gestational sac to a previous cesarean section (CS) scar.

METHODS

We conducted a retrospective review of the electronic medical records and included all 7- to 9-week transvaginal ultrasound examination reports from pregnancies with a history of a single cesarean delivery in our hospital between January 2015 and December 2017. Women were divided into 6 groups according to the distance of the gestational sac to the CS scar (groups A-F). A composite of pregnancy outcomes (gestational age at birth, delivery mode, placental abnormality, blood loss, uterine rupture, and hysterectomy) and other maternal and neonatal outcomes were assessed.

RESULTS

A total of 699 cases were included in our study. The median gestational age was 39.0 (range, 38.1-39.9) weeks. The median intrapartum blood loss volume was 400 (range, 300-500) mL. The results showed no statistically significant difference in blood loss (P = .297) or birth weight of the neonate (P = .318) among the distance subgroups. Overall, the fetuses were stillborn in 9 of 699 cases (1.29%). There was a statistically significant difference in a morbidly adherent placenta, placenta previa, and preterm labor, and their incidence increased with decreasing distance (P < .001; P for trend < .05). There was no statistically significant difference in uterine rupture (P = .597) or the delivery mode (P = .187) among the subgroups.

CONCLUSIONS

The relative positions of a CS scar and the gestational sac in the first trimester are associated with the incidence of placental abnormalities. As the distance decreases, the extent of a morbidly adherent placenta increases.

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.

Cesarean scar thickness in non-pregnant women as a risk factor for uterine rupture

Introduction: Whether there is an association between residual myometrial thickness (RMT) after cesarean section (CS) and the risk of uterine rupture (UR) or uterine scar dehiscence at the subsequent delivery has been sparsely investigated.Materials and methods: Our cohort included 149 women with a first CS in whom we measured RMT by transvaginal ultrasonography 6-15 months after their delivery. We did a follow-up study on delivery outcomes in the women's subsequent births. The exposure was scar measurements in the non-pregnant uterus, and the primary outcome was a diagnosis of UR or dehiscence. We calculated likelihood ratios (LRs) with 95% confidence intervals of having UR or dehiscence with a thin RMT (<3 mm).Results: Among the 149 women, 39 had a repeat CS (14 scheduled and 25 unscheduled procedures), and within these, we found one woman with UR and five women with uterine dehiscence. The proportion of women with a thin RMT was significantly higher among cases (4/6) than in controls (4/33); the LR was 5.5 (95% CI 1.9-16.2).Conclusions: The results suggest a significant association between a thin RMT as measured by transvaginal ultrasonography in the non-pregnant uterus after a first scheduled CS and the risk of UR or dehiscence at a subsequent delivery.

The INTEGRITY Trial: Preservation of Uterine-Wall Integrity 12 Months After Transcervical Fibroid Ablation with the Sonata System

Objective: The aim of this research was to evaluate uterine-wall integrity 12 months after transcervical fibroid ablation (TFA) of uterine fibroids with the Sonata^® system (Gynesonics Inc., Redwood City, CA).

Materials and Methods: INTEGRITY is a secondary analysis of the FAST-EU clinical trial, a prospective, longitudinal, multicenter single-armed trial involving women with heavy menstrual bleeding secondary to fibroids who were treated at 7 academic and community hospitals in the United Kingdom, the Netherlands, and Mexico with transcervical, intrauterine, ultrasound-guided radiofrequency ablation (the Sonata system). TFA was performed on up to 5 fibroids per subject ranging from 1–5 cm in diameter as determined by magnetic resonance imaging (MRI). All measurements and comparisons, including uterine-wall thicknesses were derived from baseline and 12-month MRI scans by an independent core MRI center. Scans were analyzed to assess preservation of uterine-wall integrity and reviewed for uterine-wall anomalies after TFA with the Sonata system.

Results: Twenty-nine patients had baseline and 12-month MRI with contrast enhancement. Minimum uterine-wall thicknesses in all visible slices were >2.5 mm in diameter. No areas on MRI indicated any loss of uterine-wall integrity, compared with baseline imaging; comparison of baseline and postablation uterine-wall thicknesses revealed no significant changes.

Conclusion: Transcervical fibroid ablation with the Sonata system was associated with preservation of uterine-wall integrity in this patient cohort.

Comparison of the lower uterine segment in pregnant women with and without previous cesarean section in 3 T MRI

BACKGROUND

Prenatal risk stratification of women with previous cesarean section (CS) by ultrasound thickness measurement of the lower uterine segment (LUS) is challenging. There is a wide range of proposed cutoff values and a valuable algorithm for selection before birth is not available. Using 3 T magnetic resonance imaging (MRI), we aimed to identify possible shortcomings of the current protocols used for birth selection after CS. Therefore, we evaluated anatomic and morphologic differences of the LUS and its thickness in patients with CS and those without. Possible impact factors on LUS thickness were studied.

METHODS

We retrospectively analyzed 3 T MRI scans of 164 pregnant women in their second or third trimester, with (patient group, n = 60) and without previous CS (control group, n = 104). Sagittal T2-weighted images were studied. Normal findings of the LUS in MRI, reliability of MRI measurements, as well as factors influencing LUS thickness were assessed. MRI findings were compared to intraoperative findings.

RESULTS

MRI provided good intra- (ICC 0.872) and fair inter-rater reliability (ICC 0.643). The relationship of the LUS and the cesarean scar to the surrounding anatomical structures and also its morphology varied strongly in patients and controls. Scar identification was possible in only 9/60 (15.0%) patients. The LUS was thinner in patients (1.9 ± 0.7 mm) than in controls (2.7 ± 1.3 mm). An LUS thinning up to 1 mm was observed in 23% of women without a previous CS and in 34% of women with normal intraoperative findings. Suspicion of a uterine dehiscence (LUS thickness < 1 mm) was only found in the patient group (5/59 (8.5%)) and was intraoperatively confirmed. In controls, LUS thickness was influenced by fetal weight, gestational age and amniotic fluid amounts.

CONCLUSION

Variability in anatomy, thickness and morphology seem to limit common prenatal LUS imaging diagnostics. Therefore, we consider that diagnostic protocols must be re-evaluated and imaging should be adjusted to the individual patient conditions. Due to its independency of ultrasound limitations, an additional MRI might be useful for altered anatomy and impaired ultrasound conditions. An LUS thinning up to 1 mm might be a normal finding and should be further investigated as reference value.

Impact of Audits and Multifaceted Intervention on Vaginal Birth After Caesarean: Secondary Analysis of the QUARISMA Trial

OBJECTIVES

This study estimated the effect that a multifaceted intervention aiming to improve the quality of obstetrical care and reduce Caesarean section (CS) had on the rate of vaginal birth after Caesarean (VBAC).

METHODS

This is a secondary analysis of the cluster randomized controlled trial Quality of Care, Obstetrics Risk Management, and Mode of Delivery involving (1) audits regarding the indications for CS, (2) provision of feedback to health professionals, and (3) implementation of best practices to reduce CS rates in Quebec. The impact of intervention on VBAC, trial of labour (TOL), and maternal and neonatal morbidity was reported using adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Out of 105 351 women who delivered during the pre- and postintervention period, 12 493 (11.9%) had a previous CS. We observed no significant impact of the multifaceted intervention on the rates of TOL (adjusted OR 1.22; 95% CI 0.96-1.56, P = 0.11) and VBAC (adjusted OR 1.20; 95% CI 0.97-1.48, P = 0.10) in women with one previous CS. However, the rate of TOL was reduced (adjusted OR 0.38; 95% CI 0.14-0.99) in women with more than one previous CS. The intervention has no influence on maternal and neonatal morbidity.

CONCLUSIONS

A multifaceted intervention including audits, feedback to health professionals, and implementation of best practices did not affect VBAC rates or maternal and neonatal morbidity. Our results pointed out the need for decision-making processand risk management tools specific to women with previous CS.

Cesarean scar defect- obstetric consequences

Scope. This review aims to achieve a parallelism between literature studies on imaging diagnosis, the characteristics of cesarean scar defect and its evolution during pregnancy, and the obstetric consequences that can lead to increased maternal morbidity. Materials and Methods. There have been many literature studies published in recent years aimed to identify the methods of diagnosis for cesarean scar defect, the characteristics and the main changes of it during pregnancy, and the risks undertaken by pregnant women undergoing labor for vaginal delivery after a previous cesarean surgery. Results and Discussions. The most commonly used method for visualizing and evaluating uterine scar is transvaginal ultrasound in the first trimester of pregnancy, and abdominal ultrasonography in the II and III trimesters. The two areas characteristic of uterine scarring: "niche" and "thickness of the residual myometrium" undergo changes during the three trimesters of pregnancy. Some studies in the literature reported a higher incidence of uterine rupture, especially when the lower uterine segment fell below 2.3 mm, and a mean thickness of 3.2 mm, higher among multiparous women. A question that still does not have a generally valid answer refers to the hysterorrhaphy technique. There are different opinions among the authors, but most of them consider that after a double layer suture the thickness of the residual myometrium is higher. However, data from the literature show that the incidence of complications such as uterine rupture, dehiscence of the uterine trance are similar, regardless of the type of suture used. Another complication that occurs due to uterine scar is the pregnancy inserted at this level, which in the case of expectancy, leads to an increase in maternal and fetal morbidity. 50% of them evolve to spontaneous abortion in the first trimester, and almost all full-term pregnancies result in hysterectomy of necessity. Conclusions. Due to the many obstetrical and gynecological complications that occur on a uterine scar, an evaluation in dynamics is essential. There are no standardized protocols yet, but the identification and measurement of the uterine scar area in the third trimester may predict the chance of success of the labor test for vaginal delivery after cesarean surgery.