Optimal timing and mode of delivery after cesarean with previous classical incision or myomectomy: a review of the data

Cesarean section prior to 28 weeks' gestation: which type of uterine incision is optimal?

OBJECTIVE

The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin pregnancy undergoing cesarean section under 28 weeks, and to assess factors that result in delivery complications, defined as either intraoperative dystocia or hysterotomy extension. We hypothesized that compared to those with non-cephalic presentations, gravidas with a presenting fetus in cephalic presentation would have higher rates of low-transverse cesarean section, and reduced rates of delivery complications with low-transverse hysterotomy.

METHODS

This was a retrospective cohort chart analysis of 128 gravidas between 23 0/7 and 27 6/7 weeks undergoing cesarean section at a single academic institution between August 2010 and December 2022. Data was abstracted for factors that might influence the decision for hysterotomy incision type, as well as for documentation of difficulty with delivery of the fetus or need for hysterotomy extension to affect delivery.

RESULTS

There was a total of 128 subjects, 113 with a singleton gestation and 15 with twins. The presenting fetus was in cephalic presentation in 43 (33.6%), breech presentation in 71 (55.5%), transverse/oblique lie in 13 (10.2%), and not documented in 1 (0.8%). Sixty-eight (53.1%) had a low-transverse cesarean section (LTCS), 53 (41.4%) had a Classical, 5 (3.9%) had a low-vertical hysterotomy and 2 (1.6%) had a mid-transverse incision. There was a significantly higher rate of LTCS among gravidas with the presenting fetus in cephalic presentation (30/43, 69.8%) compared to those with breech (31/71, 43.7%) or transverse/oblique presentations (7/13, 53.8%), p = .03. No other significant associations were related to hysterotomy incision, including nulliparity, racially or ethnically minoritized status, plurality, indication for cesarean delivery, or pre-cesarean labor. Twenty (15.6%) subjects experienced either an intraoperative dystocia or hysterotomy extension. For the entire cohort, there was a greater median cervical dilatation in those with delivery complications (4.0 cm, IQR .5 - 10 cm) compared to those without complications (1.5, IQR 0 - 4.0), p = .03, but no significant association between delivery complications and fetal presentation, hysterotomy type, plurality, or other demographic/obstetrical factors. However, among gravidas undergoing low-transverse cesarean section, only 2/30 (6.7%) with cephalic presentations had a delivery complication, compared to 9/31 (29.0%) with breech presentations and 3/7 (42.9%) with a transverse/oblique lie, p = .03.

CONCLUSION

In pregnancies under 28 weeks, the performance of a low-transverse cesarean section was significantly associated only with presentation of the presenting fetus. Among those with cephalic presentations, the rate of intrapartum dystocia or hysterotomy extension was low after a low-transverse hysterotomy, suggesting that in this subgroup, a low-transverse cesarean section should be considered.

Adenomyosis and fertility-sparing surgery: A literature appraisal

Adenomyosis is an intricate pathological condition that negatively impacts the uterus. It is closely related to the more well-known endometriosis, with which it shares parallels in terms of diagnosis, therapy, and both microscopic and macroscopic features. The purpose of this narrative review is to give a clear univocal definition and outlook on the different, patient-adapted, surgical treatments. MEDLINE and PubMed searches on these topics were conducted from 1990 to 2022 using a mix of selected keywords. Papers and articles were identified and included in this narrative review after authors' revision and evaluation. From the literature analysis, authors reported the following surgical techniques: laparoscopic double/triple-flap method, laparotomic wedge resection of the uterine wall, laparotomic transverse H-incision of the uterine wall, laparotomic wedge-shaped excision, and laparotomic complete debulking excision by asymmetric dissection technique. Each of these techniques has strengths and weaknesses, but the literature data on the pregnancy rate are somewhat limited. The only certain information is the risk of uterine rupture up to 6.0% after surgical treatment for uterine adenomyosis. Over the years, the surgical approach continued to reach a positive result by minimally invasive treatment, with less hospitalization, less postoperative pain, and less blood loss. Over the years, the gynecological surgeon has gained the skills, training and increasingly sophisticated surgical techniques to target effective therapy. That's why a hysterectomy is no longer the only surgical resource to treat adenomyosis, but in patients who wish to preserve the fertility, there is a wide variety of surgical alternatives.

Updated criteria for the approval of subsequent pregnancy after cesarean section with a transverse uterine fundal incision based on 17 years of experience

In the case of placenta previa-accreta when the placenta covers the entire anterior uterine wall, it is difficult to avoid transecting the placenta by traditional low-transverse cesarean section (CS), resulting in catastrophic hemorrhage and fetal anemia. To prevent this critical risk, we developed the CS with transverse uterine fundal incision (TUFI) and this technique has been widely used as a beneficial surgical method in clinical practice owing to its safety advantages for the mother and neonate since our first report. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. Based on our 17 years of experience, patients who require TUFI do not need to avoid this beneficial operative method simply because of their desire to conceive again, as long as certain conditions can be met. To approve a post-TUFI pregnancy, an appropriate suture method, delay in conception for at least 12 months with evaluation of the TUFI scar, and cautious postoperative management are at a minimum essential. In this article, we showed our recommendation for operative procedure and discuss the current status of the management of post-TUFI pregnancies based on the evaluation of the TUFI wound scar and experience with postoperative pregnancies.

A cesarean section scar dehiscence during the first trimester of an intrauterine pregnancy: a rare case report and literature review

Uterine rupture is specified as a complete laceration of the uterine wall, including its serosa, leading to a connection between the endometrial and peritoneal chambers. It can occur in any stage of pregnancy and is considered a severe and perhaps fatal complication. A 35-year-old woman at 9 weeks of gestation with a medical history of five prior cesarean sections presented with lower abdominal pain that had lasted for 5 hr. We detected small amounts of free fluid in the Douglas pouch using ultrasound. Subsequently, a laparotomy revealed a cesarean scar dehiscence from a non-cesarean scar pregnancy. Patients who experience a uterine rupture may have vague symptoms, severe abdominal discomfort, abnormal uterine bleeding, and severe hemorrhagic shock, depending on their gestational age. Ultrasound imaging can be used to diagnose this fatal condition in addition to laparoscopy to immediately identify and treat the issue in urgent cases.

Evaluation of incision healing status after transverse uterine fundal incision for cesarean delivery and postoperative pregnancy: a ten-year single-center retrospective study

BACKGROUND

Transverse uterine fundal incision (TUFI) is a beneficial procedure for mothers and babies at risk due to placenta previa-accreta, and has been implemented worldwide. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. We therefore evaluated the TUFI wound scar to determine the approval criteria for pregnancy after this surgery.

METHODS

Between April 2012 and August 2022, we performed TUFI on 150 women. Among 132 of the 150 women whose uteruses were preserved after TUFI, 84 women wished to conceive again. The wound healing status, scar thickness, and resumption of blood flow were evaluated in these women by magnetic resonance imaging (MRI) and sonohysterogram at 12 months postoperatively. Furthermore, TUFI scars were directly observed during the Cesarean sections in women who subsequently conceived.

RESULTS

Twelve women were lost to follow-up and one conceived before the evaluation, therefore 71 cases were analyzed. MRI scans revealed that the "scar thickness", the thinnest part of the scar compared with the normal surrounding area, was ≥ 50% in all cases. The TUFI scars were enhanced in dynamic contrast-enhanced MRI except for four women. However, the scar thickness in these four patients was greater than 80%. Twenty-three of the 71 women conceived after TUFI and delivered live babies without notable problems until August 2022. Their MRI scans before pregnancy revealed scar thicknesses of 50-69% in two cases and ≥ 70% in the remaining 21 cases. And resumption of blood flow was confirmed in all patients except two cases whose scar thickness ≥ 90%. No evidence of scar healing failure was detected at subsequent Cesarean sections, but partial thinning was found in two patients whose scar thicknesses were 50-69%. In one woman who conceived seven months after TUFI and before the evaluation, uterine rupture occurred at 26 weeks of gestation.

CONCLUSIONS

Certain criteria, including an appropriate suture method, delayed conception for at least 12 months, evaluation of the TUFI scar at 12 months postoperatively, and cautious postoperative management, must all be met in order to approve a post-TUFI pregnancy. Possible scar condition criteria for permitting a subsequent pregnancy could include the scar thickness being ≥ 70% of the surrounding area on MRI scans, at least partially resumed blood flow, and no abnormalities on the sonohysterogram.

TRIAL REGISTRATION

Retrospectively registered.

Current opinion on large-scale prospective myomectomy databases toward evidence-based preconception and antenatal counselling utilising a standardised myomectomy operation note

Background

No large-scale databases exist of pregnancy outcomes and rate of uterine rupture for women after myomectomy, resulting in inconsistent antenatal counselling and decision-making regarding mode and timing of delivery. Standardising information collected at myomectomy may facilitate data collection, informing prenatal/ antenatal counselling.

Objectives

To determine clinician opinions regarding standardisation of myomectomy operation notes to allow comprehensive data input into a prospective database of pregnancy outcomes, toward an evidence-based approach to decision making regarding timing and mode of delivery in subsequent pregnancies.

Materials and Methods

A google forms survey was emailed to all consultant (attending-level) obstetricians and gynaecologists across 25 hospitals in London, Kent, Surrey, and Sussex (UK) between March and May 2022. To enhance response rates, two further email reminders were sent alongside in-person reminders from selected local unit representatives.

Main outcome measures

Senior clinician opinion for characteristics necessary to collect at time of surgery to develop a widescale database of post myomectomy pregnancy outcomes.

Results

209/475 (44%) responses received; 95% (198/209) agreed with standardising operation notes. Criteria selected for inclusion included cavity breach (98%, 194/198), location (98%, 194/198), number of fibroids removed (93%, 185/198) and number of uterine incisions (96%, 190/198).

Conclusions

Gynaecologists support standardising myomectomy operation notes to inform the development of prospective large-scale databases of pregnancy outcomes after myomectomy.

What is new?

Acquisition of clinician opinions on the development and content of a standardised myomectomy operation note to aid the development of a pregnancy-outcome database for women after myomectomy.

Subsequent fertility, pregnancy, and gynaecological and psychological outcomes after maternal-fetal surgery for open spina bifida: A prospective cohort study

OBJECTIVE

To determine the medium-term maternal impact of open fetal spina bifida repair.

DESIGN

Prospective cohort study.

SETTING

University Hospitals Leuven, Belgium.

POPULATION

Mothers who had open maternal-fetal spina bifida repair between March 2012 and December 2021.

METHODS

A patient-reported survey on subsequent fertility, pregnancy, and gynaecological and psychological outcomes.

MAIN OUTCOME MEASURES

Complications during subsequent pregnancies, and gynaecological and psychological problems.

RESULTS

Seventy-two out of 100 invited women completed the questionnaire (72%). Despite being advised not to, seven of 13 women attempting to conceive became pregnant within 2 years after fetal surgery and one woman delivered vaginally. Two of the 16 subsequent pregnancies were complicated by an open neural tube defect. One pregnancy was complicated by a placenta accreta and one pregnancy was complicated by a uterine rupture, both with good neonatal outcomes. Nearly half of respondents who did not attempt to conceive reported that this was because of their experience of the index pregnancy and caring for the index child. Three out of four respondents reported medium-term psychological problems, mostly anxiety for the health of the index child, fear for recurrence in subsequent pregnancies and feelings of guilt.

CONCLUSIONS

Open maternal-fetal surgery for spina bifida did not appear to affect fertility in our cohort. Half of the attempts to conceive took place within 2 years. One uterine rupture and one placenta accreta occurred in 16 subsequent pregnancies. Most respondents reported psychological problems linked to the index pregnancy, which reinforces the need for long-term psychological support.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, September 2022) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and on the Management of Preterm Premature Rupture of Membranes

Aim The revision of this guideline was coordinated by the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (OEGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of the guideline is to improve the prediction, prevention and management of preterm birth based on evidence from the current literature, the experience of members of the guidelines commission, and the viewpoint of self-help organizations. Methods The members of the contributing professional societies and organizations developed recommendations and statements based on international literature. The recommendations and statements were presented and adopted using a formal process (structured consensus conferences with neutral moderation, written Delphi vote). Recommendations Part 2 of this short version of the guideline presents statements and recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

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.

Prior vertical uterine incision: Effect on subsequent pregnancy characteristics and outcomes

OBJECTIVE

To examine characteristics and outcomes of cesarean delivery (CD) in women with a history of vertical hysterotomy.

METHOD

This is a comparative study that retrospectively queried the National Inpatient Sample from October 2016 to December 2018. Pregnancy characteristics and surgical outcomes of CD among 18 575 women with prior vertical uterine incision were compared to 1 072 949 women with prior low-transverse incision, assessed by multivariable generalized estimating equation model and propensity score weighting.

RESULTS

In a multivariable analysis, women who had prior vertical uterine incision were more likely to have placenta percreta (odds ratio [OR] 3.41, 95% confidence interval [CI] 1.87-6.20), pre-labor uterine rupture (OR 2.70, 95% CI 1.52-4.80), in-labor uterine rupture (OR 2.33, 95% CI 1.55-3.51), and extreme preterm delivery <28 weeks (OR 17.8, 95% CI 15.2-20.7) in the current pregnancy, compared to those who had prior low-transverse uterine incision. In a weighted model, prior vertical hysterotomy was associated with increased surgical morbidity in current CD compared to prior low-transverse hysterotomy (10.6% vs. 4.8%, OR 2.02, 95% CI 1.81-2.26), including hemorrhage (OR 1.99, 95% CI 1.74-2.27) and hysterectomy (OR 3.67, 95% CI 2.97-4.53).

CONCLUSION

Prior vertical uterine incision at CD was associated with increased risk of placenta percreta, uterine rupture, particularly before labor, and adverse outcomes in the subsequent pregnancy.

Maternal Outcomes in Subsequent Pregnancies After Classical Cesarean Delivery

OBJECTIVE

To compare maternal outcomes in subsequent pregnancies of patients who had a prior classical cesarean delivery with those with a prior low transverse cesarean delivery.

METHODS

We conducted a cross-sectional analysis of patients with live singleton births at or after 24 weeks of gestation who had a prior classical cesarean delivery or a low transverse cesarean delivery in the 2016-2019 National Inpatient Sample database. Outcome measures included mode of delivery, uterine rupture, and severe maternal morbidity (SMM), as defined by the Centers for Disease Control and Prevention. Maternal outcomes were compared using the χ2 test and the propensity score method, accounting for differences in patients' clinical risk factors. Multivariable regressions further assessed how patients' sociodemographic and hospital characteristics might influence the differences in maternal outcomes between the two groups.

RESULTS

The sample included 1,671,249 patients: 25,540 with prior classical cesarean delivery and 1,645,709 with prior low transverse cesarean delivery. Cesarean delivery occurred in 95.5% of patients with prior classical cesarean compared with 91.3% of those with prior low transverse delivery (P<.001; propensity score method: odds ratio [OR] 0.99, 95% CI 0.85-1.16) and uterine rupture occurred in 1.1% and 0.3%, respectively (P<.001; propensity score method: OR 2.17, 95% CI 1.40-3.36). Among patients with prior classical cesarean delivery, uterine rupture occurred in 10.6% of those who underwent labor compared with 0.3% of those who did not (P<.001). Rates of SMM were 5.9% and 2.0% in the two groups, respectively (P<.001; propensity score method: OR 1.87, 95% CI 1.53-2.29). After adjustment of maternal sociodemographic and hospital characteristics, differences in the risk of uterine rupture and SMM between the two groups were attenuated but remained significant.

CONCLUSION

Prior classical cesarean delivery was associated with a higher risk of uterine rupture and SMM in subsequent pregnancies, compared with prior low transverse cesarean delivery, even after accounting for patients' clinical, sociodemographic, and hospital characteristics.

Intrapartum ultrasound measurement of the lower uterine segment thickness in parturients with previous scar in labor: a cross-sectional study

Background

There is a lack of reliable methods to estimate the risk of uterine rupture or dehiscence during a trial of labor in women with previous cesarean sections. This study aimed to assess the lower uterine segment and myometrial thickness by ultrasonography in women with previous cesarean sections during labor and assess their association with the uterine defect.

Methods

A cross-sectional study was conducted on 161 women in the active phase of labor having one previous cesarean section. The study was conducted et al.-Azhar University Hospital, Assiut City, Egypt, from March 2018 to March 2019. Ultrasound measurements of lower uterine segment thickness and myometrial thickness were conducted by vaginal and abdominal ultrasound by two observers. The correlation of both thicknesses with the uterine defect was analyzed.

Results

Uterine defects were reported in 42 women (25.9%), uterine rupture in four women (2.5%), and dehiscence in 38 women (23.5%). The uterine defects were not associated with maternal factors (maternal age, gestational age at labor, body mass index, birth weight, interpregnancy, and inter-delivery interval). Receiver operating curve analysis demonstrated that lower uterine segment thickness was linked with uterine defect, with an area under the curve of 60% (95% CI, 51–70%, P = 0.044). Myometrial thickness was also linked to the uterine defect, with an area under the curve of 61% (95% CI, 52–71%, P = 0.025). Full lower uterine segment thickness of 2.3 mm and myometrial thickness of 1.9 mm were the cutoff value with the best combination of sensitivity and specificity for the uterine defect. Lower uterine segment thickness (OR = 0.49, 95%CI 0.24–0.96) and myometrial thickness (OR = 0.44, 95%CI 0.20–0.94) were significantly associated with the uterine defect. Lower uterine segment thickness (OR = 0.41, 95%CI 0.22–0.76) and myometrial thickness (OR = 0.33, 95%CI 0.16–0.66) were also significantly associated with cesarean section delivery.

Conclusion

A lower uterine segment thickness of 2.3 mm and myometrial thickness of 1.9 mm during the first stage of labor are associated with a high risk of uterine defects during a labor trial. These measurements during labor can have a practical application in deciding the mode of delivery in women with previous cesarean sections and might reduce uterine rupture.

Complete Uterine Rupture: A Case Report

Background: Uterine rupture during pregnancy is a considerable obstetric complication. The presence of a previous uterine scar is the most significant risk factor. Early clinical diagnosis is paramount to maternal and fetal survival. Case Report: A 36- year-old woman, gravida 2 para 2, presented with sudden acute abdominal pain at 38 weeks of gestation. The patient had a history of cesarean delivery one year ago. Ultrasound scans showed an empty endometrial cavity and fetus outside the uterus. Emergency laparotomy was performed, a live baby boy weighing 3.420 kg was delivered, and the uterine disruption was repaired. Conclusion: Increasing trends in the cesarean section may lead to a higher number of uterine ruptures. The survival of patients after uterine rupture depends on the time interval between rupture and intervention, and the availability of appropriate medical team and equipment. Health professionals caring for pregnant women should be alert for the symptoms and risk factors of uterine rupture.

Recurrent uterine rupture in third trimester of pregnancy

We report a case of recurrent upper segment uterine rupture in a 31-year-old woman at 32+5/40 weeks of gestation. She had fundal uterine rupture 3 years ago in her first pregnancy at 40 weeks of gestation. There was no history of uterine malformation or prior uterine surgery. However, we noted that she had had three laparoscopic procedures for endometriosis treatment. She was scheduled to have an elective repeat caesarean section at 34+6/40 weeks of gestation in the index pregnancy. Unfortunately, she presented at 32+5/40 weeks with features of acute abdomen and signs of fetal distress. She had a category 1 caesarean section and was found to have fundal uterine rupture at the same site. She had a smooth uneventful recovery following a timely intervention and discharged home on day 5 postoperatively in a good condition with her baby girl.

Factors associated with the outcome of TOLAC after one previous caesarean section: a retrospective cohort study

The factors associated with the outcome of trial of labour after one previous Caesarean Section; a retrospective cohort study. A retrospective observational study was performed on all eligible consecutive singleton pregnancies planned for trial of labour after one previous Caesarean Section (TOLAC) over a period of 18 months to study the success rate of vaginal birth after Caesarean Section (VBAC) and to find out the factors associated with successful and failed TOLAC. All of the data were entered in electronic format and the data was analysed in detail. Of the 1324 women studied, the VBAC rate was 65.3% and the incidence of scar rupture was 0.5%. The composite adverse maternal (postpartum haemorrhage and intensive care admission) and foetal outcome (still birth, 5-minute APGAR <7 and NICU admission) was more in the failed TOLAC group. Various demographic, clinical and obstetric factors were studied in detail between the successful and failed TOLAC groups. The favourable Bishop Score (>4) was independently associated with successful TOLAC (OR 4.3; 95% CI 3.3-5.6 p < .001). Maternal age of >30 years, (OR 0.57; 95% CI 0.41-0.79; p = .001), labour induction (OR 0.43; 95% CI 0.33-0.56; p < .001) and estimated foetal weight of >3500 g (0.31; 95% CI 0.14-0.6; p = .002) were the factors independently associated with failed TOLAC. Previous indication for a Caesarean Section and previous vaginal delivery were not found to be independently associated with the outcome of TOLAC. The predictive models for TOLAC need to be used cautiously and the risk assessment should be done on an individual basis.IMPACT STATEMENTWhat is already known on this subject? TOLAC is a reasonable strategy in Obstetrics especially after one Caesarean Section to minimise the morbidity associated with rising Caesarean Section. However, the maternal and foetal morbidity are more following unsuccessful TOLAC. The factors which predict the outcome of TOLAC are multifactorial which include maternal demographic factors, previous obstetric factors like indication for Caesarean Section, intraoperative complications, inter-pregnancy interval, current obstetric factors such as gestational age, Bishop Score before delivery, labour factors and foetal factors, e.g. sex and foetal size.What do the results of this study add? We tried to include all the possible factors which probably influence TOLAC and found only Bishop Score, maternal age, foetal size and labour induction were the factors independently associated with the outcome of TOLAC. A Bishop Score of >4 admission was the greatest predictor of successful TOLAC (OR 4.3). Similarly, labour induction and foetal size of >3.5 kg were associated with 60% and 70% less chance of VBAC, respectively.What are the implications of these findings for clinical practice and/or further research? The factors found to be associated with successful and failed TOLAC may be utilised to develop a predictive model. More so, prospective studies are needed to test such predictive models.

Stinging abdominal pain at 32 gestational weeks with prior classical uterine incision: Careful assessment or emergency cesarean delivery?

The risk of uterine rupture in subsequent pregnancy is 1%-12% in patients with prior classical uterine incision. Management of mild/moderate abdominal pain without an obvious abnormal finding before 36 weeks is challenging owing to fetal immaturity.

Maternal morbidity by attempted route of delivery in periviable birth

OBJECTIVE

Much of the literature on clinical decision-making regarding the optimal route of delivery for periviable birth, 23 0/7-25 6/7 weeks gestation, has focused on neonatal risks. In fact, routine cesarean delivery at these early gestational ages has not been shown to improve neonatal mortality or neurological outcomes. Neonatal risks associated with the route of delivery are well known. Conversely, there is a paucity of data on maternal morbidity associated with the route of delivery. We examined maternal morbidity according to the attempted route of delivery in women undergoing periviable birth.

STUDY DESIGN

In a secondary analysis of the Consortium on Safe Labor, a retrospective cohort study, maternal outcomes were compared between attempted vaginal delivery and planned cesarean delivery in women undergoing periviable birth. Analyses were repeated to compare maternal outcomes among actual mode of delivery (vaginal delivery versus cesarean delivery). Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) with 95% confidence intervals (95% CI), controlling for predefined covariates.

RESULTS

Of 678 women who underwent periviable birth, 558 (82.3%) and 120 (17.7%) attempted vaginal delivery and planned cesarean delivery, respectively. Of 558 women who attempted a vaginal delivery, 411 (73.7%) achieved a vaginal delivery. Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery were less likely to have endometritis (3.1 versus 15.0%; aRR 0.18, 95% CI 0.09-0.35). Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery had 7-day shorter total length of hospital stay (p < .001). Comparison of actual mode of delivery showed that women with vaginal had decreased risks of fever (2.9 versus 7.9%; aRR 0.42, 95% CI 0.20-0.90), endometritis (0.5 versus 12.4%; aRR 0.03, 95% CI 0.01-0.13), and maternal thrombosis (0.2 versus 3.0%; aRR 0.08, 95% CI 0.01-0.93) compared to cesarean delivery. Women with vaginal delivery had 3-day shorter total length of hospital stay (p < .001) compared to cesarean delivery.

CONCLUSION

The majority of women (73.7%) who attempted a vaginal delivery achieved a vaginal delivery. Attempting a vaginal delivery between 23 0/7 and 25 6/7 weeks gestation compared to a planned cesarean delivery was associated with decreased risks of maternal infectious morbidity. Deciding the route of delivery is challenging in women undergoing periviable delivery. Our analysis provides important information on short-term maternal risks when considering the risks and benefits during these discussions.

Uterine Dehiscence and Subsequent Pregnancy Management: A Review of the Literature

Importance

Uterine dehiscence is a separation of the uterine musculature with intact uterine serosa. Uterine dehiscence can be encountered at the time of cesarean delivery, be suspected on obstetric ultrasound, or be diagnosed in between pregnancies. Management is a conundrum for obstetricians, regardless of timing of onset.

Evidence Acquisition

A literature search was undertaken by our research librarian using the search engines PubMed, CINAHL, and Web of Science. The search term used was "uterine dehiscence." The search was limited to the English language, and there was no limit on the years searched.

Results

The search identified 152 articles, 32 of which are the basis for this review. Risk factors, treatment, and management in subsequent pregnancies are discussed. The number of prior cesarean deliveries is the greatest risk factor for uterine dehiscence. Unrepaired uterine dehiscence can cause symptoms outside of pregnancies and may require repair for alleviation of these symptoms. Dehiscence should also be repaired prior to subsequent pregnancies.

Conclusion and Relevance

Planned delivery prior to the onset of labor with careful monitoring of maternal symptoms is the preferred management strategy of women with prior uterine dehiscence. Careful attention should be paid to the lower uterine segment thickness when ultrasonography is performed in women with prior cesarean delivery.

Relevance Statement

An evidence-based review of uterine dehiscence in pregnancy and how to manage subsequent pregnancies following uterine dehiscence.

Systematic classification of maternal and fetal intervention-related complications following open fetal myelomeningocele repair - results from a large prospective cohort

OBJECTIVE

To systematically categorise all maternal and fetal intervention-related complications after open fetal myelomeningocele (fMMC) repair of the first 124 cases operated at the Zurich Centre for Fetal Diagnosis and Therapy.

DESIGN

A prospective cohort study.

SETTING

Single centre.

POPULATION

Mothers and fetuses after fMMC repair.

METHODS

Between 2010 and 2019, we collected and entered all maternal complications following fMMC repair into the Clavien-Dindo classification. For fetal complications, a classification system based on the Medical Dictionary for Regulatory Activities terminology of Adverse Events was used including the preterm definitions of the World Health Organization.

MAIN OUTCOME MEASURES

Systematic classification of maternal and fetal complications following fMMC repair.

RESULTS

Gestational ages at surgery and birth were 25.0 ± 0.8 and 35.4 ± 2.0 weeks, respectively. In 17% of all cases, no maternal complications occurred. Maternal intervention-related complications were observed as follows: 69% grade 1, 36% grade 2, 25% grade 3, 6% grade 4 and 0% grade 5. In 34%, no fetal complications were noted; however, 43% of the fetuses developed a grade 1, 14% a grade 2, 8% a grade 3, 2% a grade 4 and 2% a grade 5 complication.

CONCLUSION

This study raises awareness of complications following open fMMC repair; 6% of mothers and 2% of fetuses experienced a severe complication (grade 4) and perinatal death rate of 2% was observed (grade 5). These data are useful for prenatal counselling, they help to improve the system of fetal surgical care, and they allow benchmarking with other centres as well as comparison with fetoscopic approaches.

TWEETABLE ABSTRACT

Systematic classification of all maternal and fetal intervention-related complications following open fMMC repair.

Number of prior vaginal deliveries and trial of labor after cesarean success

OBJECTIVE

Prior vaginal delivery (VD), including vaginal birth after cesarean (VBAC), is one of the greatest predictors of successful trial of labor after cesarean (TOLAC) and uterine rupture. We aimed to evaluate VBAC and uterine rupture rates associated with TOLAC in women with VD prior to cesarean delivery (CD) or with prior VBAC, and the cumulative effect of the number of prior VD's.

STUDY DESIGN

This retrospective study included women having TOLAC between 2005-2019. The study compared the caesarean and uterine rupture rates of TOLAC in women with only prior VD as compared to women with only prior VBAC. Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. Receiver operating characteristic (ROC) and decision tree analyses (chi-square automatic interaction detection algorithm) was conducted to evaluate the influence of the number of prior VD's on the likelihood of successful TOLAC.

RESULTS

Overall, 9,038 women met the inclusion criteria. Women with prior VBAC and prior VD showed significantly higher rates of successful VBAC compared to those with no prior VD or prior VBAC (96 % and 86 % vs 76 %; p < 0.01). However, women with prior VBAC but not women with prior VD showed significantly lower rates of uterine rupture compare to women with no prior VD or VBAC (0.1 % vs 0.6 % and 0.6 %; p < 0.01). The prevented fraction of TOLAC success was significantly higher in women with prior VBAC than that of women with VD prior to CD (83 % vs. 42 %, p < 0.01). ROC curve showed that the number of prior VBACs was a better predictor of TOLAC success and uterine rupture than the number of prior VD's. However, each single variable was found to have low positive predictive value (PPV) and requires other variables to improve the prediction. Finally, decision tree analysis demonstrated significant association between TOLAC success rate and prior VBAC, prior VD, and CD indications, without any association with the number of prior deliveries.

CONCLUSION

Prior VBAC has some prediction value for TOLAC success and uterine rupture. However, it has low PPV as a single variable and requires other variables to improve the prediction. The number of prior VDs is not improving prediction.

Is Uterine Myomectomy a Real Contraindication to Vaginal Delivery? Results from a Prospective Study

OBJECTIVES

The main goal of our research was to explore correlations between a history of uterine myomectomy and maternal-fetal outcomes, throughout a comparison between vaginal deliveries in patients with or without a history of uterine myoma excision.

MATERIALS AND METHODS

A prospective study was carried out at two tertiary care hospitals between January 2019 and January 2020. Women were assigned into two groups according to the history of laparoscopic or laparotomic myomectomy (Group 1) or without myomectomy (Group 2).

RESULTS

80 women successfully delivered after myomectomy. Pregnancies with previous laparoscopic or laparotomic myomectomy were associated with a minor rate of spontaneous labor onset (RR 1.17; 95% CI 1.04 - 1.31) and with an increased rate of emergency cesarean section (RR 1.22; 95% CI 1.09 - 1.36). Moreover, myomectomy group had a significant number of indications to emergency cesarean section correlated to suspected uterine rupture (RR 1.19; 95% CI 1.02-1.39). There were no uterine ruptures or neonatal deaths recorded. First stage of labor was longer in the myomectomy group (316 vs 204 mins, p = 0.01). No differences in the rates of the prolonged first and second stage of labor, postpartum hemorrhage and vaginal laceration, and no neonatal adverse outcomes were found between groups.

CONCLUSIONS

Pregnancies after myomectomy might be associated with an elevated rate of emergency cesarean section only due to a higher percentage of suspected uterine rupture, without a real hazard of adverse obstetric or neonatal outcomes.

Prelabour uterine rupture: characteristics and outcomes

OBJECTIVE

To describe the characteristics and outcomes of prelabour uterine ruptures.

DESIGN

Descriptive study based on population data from the Medical Birth Registry of Norway, the Patient Administration System and medical records.

SAMPLE

Maternities with uterine rupture before start of labour in Norway during the period 1967-2008 (8 complete ruptures among 2 334 712 women with unscarred uteri, and 22 complete and 45 partial ruptures among 121 085 women with scarred uteri).

METHOD

We measured the rate of perinatal deaths and peripartum hysterectomy following ruptures. In addition, we studied the characteristics of ruptures.

RESULTS

The eight complete ruptures in women with unscarred uteri were associated with trauma from traffic accidents (n = 3; 37.5%), previous curettage (n = 3; 37.5%) and congenital uterine malformations (n = 2; 25%), resulting in seven perinatal deaths and two hysterectomies. The 22 complete ruptures in scarred uteri were mostly outside the lower uterine segment (n = 17; 72.7%). Abnormally invasive placenta (AIP) and previous rupture were present in four (18.2%) and three women (13.6%), respectively. They resulted in nine perinatal deaths (39.1%) and two hysterectomies (9.1%). The 45 partial ruptures involved mostly scars in the lower uterine segment (n = 39; 86.7%). None of them resulted in perinatal death or hysterectomy. Perinatal deaths have decreased dramatically in recent years, despite increasing prelabour rupture rates.

CONCLUSION

Although complete uterine ruptures before labour start were rare, they often resulted in catastrophic outcomes, such as perinatal death. Scars outside the lower segment were associated with a higher percentage of catastrophic prelabour ruptures compared with scars in the lower segment (Video S1).

TWEETABLE ABSTRACT

Complete prelabour uterine ruptures were rare, but resulted in high perinatal deaths, especially if they were in scars outside the lower segment.

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia

BACKGROUND

Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women's experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women's experiences when planning a VBAC in Australia.

METHODS

The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor.

RESULTS

In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC.

CONCLUSION

This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC.

Reproductive Outcomes following Use of Barbed Suture during Laparoscopic Myomectomy

STUDY OBJECTIVE

To review pregnancy outcomes after laparoscopic myomectomy with the use of barbed suture.

DESIGN

Retrospective cohort study and follow-up survey.

SETTING

Single, large academic medical center.

PATIENTS

Patients who underwent laparoscopic myomectomy with the use of barbed suture for myometrial closure between 2008 and 2016.

INTERVENTION

Laparoscopic myomectomy and a follow-up survey regarding pregnancy outcome.

MEASUREMENTS AND MAIN RESULTS

A total of 486 patients met inclusion criteria and underwent a laparoscopic myomectomy between 2008 and 2016. Of the 428 with viable contact information, 240 agreed to participate (56%). Of those who responded to the survey, 101 (42%) attempted to get pregnant, and there were 4 unplanned pregnancies. There were 110 pregnancies among 76 survey respondents. In total, of the women attempting a postoperative pregnancy, 71% had at least 1 pregnancy. Comparing the women who did and did not conceive postoperatively, the group who got pregnant was on average younger, 33.8 ± 4.5 years vs 37.5 ± 6.5 years (p = .001); had fewer myomas removed, median = 2 (range 1-9) vs median = 2 (range 1-16) myomas (p = .038); and had a longer follow-up period, 30 months ( vs 30 (11-93 months) ± 20 (p <.001). The mean time to first postoperative pregnancy was 18.0 months (range 2-72 months). Of the 110 reported postoperative pregnancies, there were 60 live births (55%), 90% by means of cesarean section. The mean gestational age at birth was 37.8 weeks. In the cohort, there were 8 preterm births, 3 cases of abnormal placentation, 2 cases of fetal growth restriction, 3 cases of hypertensive disorders of pregnancy, and 2 cases of myoma degeneration requiring hospitalization for pain control. There were no uterine ruptures reported.

CONCLUSION

According to our findings, pregnancy outcomes after laparoscopic myomectomy with barbed suture are comparable with available literature on pregnancy outcomes with conventional smooth suture.

Classical Cesarean Section

Cesarean section is the most common surgery in obstetrics. Several techniques are proposed according to the indication and the degree of urgency. Usually laparotomy followed by hysterotomy with a low transverse incision is preferable. However, in cases in which it is difficult to access the lower uterine segment, such as that in preterm labor, dense adhesion, placenta previa/accrete a vertical hysterotomy (classical cesarean section) may be needed. Although a smooth and gentle delivery of the fetus is possible through the vertical incision, uterine closure is technically difficult. To decrease the risks of hemorrhage and adhesion, a speedy and skillful technique is mandatory. The most serious risk of vertical incision in the contractile corpus is uterine rupture in the subsequent pregnancy. Therefore, cases of prior classical cesarean section are contraindicated for trial of labor after cesarean section.

Maternal outcomes according to cesarean uterine incision between 23 and 27 weeks' gestation

OBJECTIVE

Cesarean delivery between 23 and 27 weeks' gestation is a risk factor for performing classical and inverted T uterine incisions. When attempting cesarean delivery via a low transverse incision at a very preterm gestational age, having difficulty in delivery of the fetus may require conversion to an inverted T-incision. We sought to examine maternal short-term outcomes according to the type of attempted uterine incisions in preterm deliveries.

STUDY DESIGN

This was a multihospital retrospective cohort study of women undergoing cesarean delivery between 23 0/7 and 27 6/7 week' gestation from 2005 through 2014. Cases were classified as attempting low transverse incision if the uterine incision was a low transverse or an inverted T incision. Composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, respiratory complications, and intensive care unit admission) was compared between cases where a low transverse incision was attempted and those with a classical uterine incision. We also examined operative time and Apgar score at 5 minutes. Multivariable logistic regression or linear regression was used to obtain adjusted p-value or adjusted odds ratios (aOR) with 95% confidence interval (95%CI), controlling for maternal age, gestational age, body mass index (kg/m²), and preterm premature rupture of membranes.

RESULTS

Of 311 women undergoing cesarean delivery between 23 0/7 and 27 6/7 week' gestation, attempting low transverse incision occurred in 127 (41%). Of these, conversion to an inverted T or J uterine incision occurred in 14 (11%). There was no difference in the composite outcome between cases with attempting low transverse incision and those with classical incision (17.3 versus 23.4%, respectively; aOR 0.58 [95%CI 0.30-1.11]). Cases in which a low transverse uterine incision was attempted had shorter median operative time (46 versus 55 minutes; adjusted p-value < 0.01). No differences were seen in the Apgar score at 5 minutes (adjusted p-value = .81).

CONCLUSION

The incidence of conversion from a low transverse to an inverted T uterine incision in very preterm cesarean deliveries was low. Attempting a low transverse compared to a classical uterine incision was associated with similar odds of the primary outcome and shorter operative time.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes

Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair

OBJECTIVE

This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre.

STUDY DESIGN

Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application.

RESULTS

The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30-31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation - chorioamniotic membrane separation (6%), preterm premature rupture of membranes - preterm premature rupture of membranes (pPROM; 15%) and preterm labour - preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%).

CONCLUSION

Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children's Hospital of Philadelphia, and Vanderbilt University Medical Centre.

Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele

BACKGROUND

Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies.

OBJECTIVE

The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure.

STUDY DESIGN

An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry.

RESULTS

From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3-37.1) weeks. The uterine rupture rate was 9.6% (n = 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%).

CONCLUSION

The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.

Vaginal birth after prior myomectomy

OBJECTIVE

The aim of this retrospective cohort study was to evaluate the obstetrical and perinatal outcomes of vaginal birth in case of pregnancies achieved after prior myomectomy. We also analyzed how operative characteristics at the time of surgery might influence the choice of obstetricians about mode of delivery.

STUDY DESIGN

We analyzed retrospectively all women who underwent laparoscopic (LPS) or laparotomic (LPT) myomectomy between January 2002 and December 2014, in a network of three Institutions belonging to the University of Milano Bicocca, Italy. Women were contacted by phone interview and only cases with available follow-up data and who had a subsequent pregnancy were included. Operative characteristics and subsequent obstetrical outcomes were recorded and analyzed.

RESULTS

469 women who underwent myomectomy were contacted by phone interview, and 152 pregnancies were achieved after surgery, 96 after LPS and 56 after LPT. A total of 110 pregnancies ended in deliveries at ≥24 weeks. Seventy-three (66.4%) women had trial of labor after myomectomy (TOLAM), while 24 (21.8%) had a planned cesarean delivery (CD). Sixty-six (90.4%) of the TOLAM cases successfully accomplished vaginal delivery. No cases of uterine rupture (UR) were reported, and all deliveries ended in live births. The incidence of Neonatal Intensive Care Unit admission was 14.5% (16/110), with no cases of perinatal death. Comparing the surgical details at the time of myomectomy, the incidence of uterine cavity entered was significantly higher in planned CD group compared to TOLAM cases (p < 0.001). No other significant difference between the two groups was reported.

CONCLUSIONS

A successful vaginal delivery was accomplished by 90.4% of women who had TOLAM, without any case of UR or severe maternal and perinatal complications. TOLAM may be considered and offered as feasible and relatively safe option. Obstetricians' attitude toward mode of delivery after prior myomectomy seems to be influenced by the reported entry into the uterine cavity at the time of surgery.

Laparoscopic uterine surgery as a risk factor for uterine rupture during pregnancy

The incidence of uterine rupture through a previous cesarean scar (CS) is declining as a result of a lower parity and fewer options for vaginal birth after cesarean. However, uterine ruptures attributable to other causes that traumatize the myometrium are on the rise. To determine whether changes in the causes of uterine rupture had occurred in recent years, we retrospective retrieved the clinical records of all singletons with uterine rupture observed in the delivery room of a Taiwanese tertiary obstetric center over a 15-year period. The overall uterine rupture rate was 3.8 per 10,000 deliveries. A total of 22 cases in 20 women (with two of them experiencing two episodes). Seven uterine ruptures occurred through a previous cesarean scar (CS ruptures, 32%), 13 through a non-cesarean scar (non-CS ruptures, 59%), whereas the remaining two (9%) were in women who did not previously undergo any surgery. All of the 13 non-CS ruptures were identified in women with a history of laparoscopic procedures to the uterus. Specifically, 10 (76%) occurred after a previous laparoscopic myomectomy, one (8%) following a hysteroscopic myomectomy, and two (16%) after a laparoscopic wedge resection of cornual ectopic pregnancy. Severe bleeding (blood loss >1500 mL) requiring transfusions was more frequent in women who experienced non-CS compared with CS ruptures (10 versus 1 case, respectively, P = 0.024). Patients with a history of endoscopic uterine surgery should be aware of uterine rupture during pregnancy.

Cesarean section scar dehiscence during pregnancy: Case reports

Background:

The incidence of cesarean section increased worldwide with subsequent increase in the risk of cesarean section scar dehiscence (CSSD). The clinical significance and the management of the CSSD are still unclear.

Case Reports:

Here, we report two cases of CSSD. A 35-year-old woman, gravida 2, previous CS, due to preterm premature rupture of membranes (PPROM) and breech presentation at 30 weeks, was admitted for elective CS at 38^+3d weeks’ gestation. During the second elective CS, it was seen that the site of the previous CS scar was very thin along its whole length and the anterior uterine wall was completely deficient, leaving visible bulging fetal membranes and moving baby underneath. A 32-year-old woman, previous three CSs, was admitted as unbooked case without any antenatal records at 29^+4d weeks’ gestation, triplet pregnancy with preterm labor. She received betamethasone and magnesium sulfate (MgSO₄) for fetal lung and fetal brain protection, respectively, followed by emergency CS. During the CS, the previous CSs scars were dehiscent over more than half of its length and the anterior uterine wall was missing leaving visible fetal membranes. The uterine incision of the studied women was repaired in two layers using vicryl 0 interrupted simple stitches for the first layer, followed by interrupted mattress stitches for the second layer. The studied women had uneventful postoperative recovery and were discharged from the hospital after counseling regarding intraoperative findings, uterine incisions repair, and future pregnancies.

Conclusion:

It is useful to assess the lower uterine segment of women with previous CS using the available ultrasound facilities. If the CSSD is diagnosed before the elective CS, the surgeon should prepare himself with the safest uterine incision with least possible complications and the best way of repair of the defective or dehiscent uterine wall.

When Consent Does Not Help: Challenges to Women's Access to a Vaginal Birth After Cesarean Section and the Limitations of the Informed Consent Doctrine

Pregnant women with a prior cesarean delivery face challenges in accessing a vaginal birth due to both hospital and provider preferences and practices. Although the doctrine of informed consent secures women's reproductive rights, it is not a viable legal remedy. Instead, women should champion increased maternity-related education and transparency as well as medical malpractice reform to increase the desired access.

Association between prior vaginal birth after cesarean and subsequent labor outcome

OBJECTIVE

To estimate the effect of prior successful vaginal birth after cesarean (VBAC) on the rate of uterine rupture and delivery outcome in women undergoing labor after cesarean.

METHODS

A retrospective cohort study of all women attempting labor after cesarean delivery in a university-affiliated tertiary-hospital (2007-2014) was conducted. Study group included women attempting vaginal delivery with a history of cesarean delivery and at least one prior VBAC. Control group included women attempting first vaginal delivery following cesarean delivery. Primary outcome was defined as the rate of uterine rupture. Secondary outcomes were delivery and maternal outcomes.

RESULTS

Of 62,463 deliveries during the study period, 3256 met inclusion criteria. One thousand two hundred and eleven women had VBAC prior to the index labor and 2045 underwent their first labor after cesarean. Women in the study group had a significantly lower rate of uterine rupture 9 (0.7%) in respect to control 33 (1.6%), p = .036, and had a higher rate of successful vaginal birth (96 vs. 84.9%, p < .001). In multivariate analysis, previous VBAC was associated with decreased risk of uterine rupture (OR = 0.46, 95% CI 0.21-0.97, p = .04).

CONCLUSIONS

In women attempting labor after cesarean, prior VBAC appears to be associated with lower rate of uterine rupture and higher rate of successful vaginal birth.

Diagnosis and Management of 'Cornual' Pregnancies from 2002 to 2015 at a Tertiary Referral Centre in South India: Insights from Introspection

Purpose

Interstitial, angular and rudimentary horn pregnancies have all been referred to as cornual pregnancies despite definite diagnostic criteria. Angular pregnancies can be followed up expectantly under close surveillance while interstitial and rudimentary horn pregnancies are terminated by medical or surgical methods. This study aimed to assess accuracy of ultrasound in the diagnosis of 'cornual pregnancy' and evaluate management.

Methods

Data pertaining to clinical features, ultrasound findings and treatment modalities of the aforementioned conditions between January 2002 and December 2015 at a tertiary perinatal centre were retrieved from the medical records. The ultrasound images and surgical videos were reviewed by the authors.

Results

Of 62 cases, 35 were interstitial, 26 were angular/eccentric intrauterine, and 1 was a rudimentary horn pregnancy. The accuracy of ultrasonography in the diagnosis of interstitial and angular pregnancies was 71.0 and 46.8%, respectively. Medical management was successful in 33.3% of interstitial pregnancies. Fifteen women with interstitial pregnancy had subsequent pregnancies and nine (75.0%) were Caesarean deliveries. Rupture and recurrence rates of interstitial pregnancy were 34.2 and 2.9%, respectively. The rudimentary horn pregnancy was managed by laparoscopic excision followed by a subsequent term delivery.

Conclusion

This study identified frequent occurrences of imprecise nomenclature that resulted in mismanagement of a few potentially viable angular pregnancies. It is imperative for clinicians and sonologists to use unambiguous nomenclature and avoid the term 'cornual pregnancy' altogether.

Treatment and repair of uterine scar dehiscence during cesarean section

The incidence of cesarean section (c‐section) has increased worldwide. Because the major risk factor for uterine scar dehiscence (USD) is a previous c‐section, the rate of this complication has also increased. Its clinical significance and management strategies are unclear. Here, we discuss USD particularly pertaining to its surgical treatment.

Sonographic Findings and Diagnostic Pitfalls in Evaluation for Uterine Rupture in a Case of Fetal Demise and Prior Cesarean Delivery of Unknown Type

A 38-week pregnant patient with history of cesarean delivery was admitted to the hospital for induction of labor after diagnosis of fetal demise. When the clinical picture became concerning for uterine scar dehiscence, an ultrasound was ordered. After targeted ultrasound of the lower uterine segment, the sonographer initially reported thin but intact lower uterine segment and normal positioning of the fetus. By keeping a high level of suspicion, the radiologist analyzed the images submitted and found other clues suggesting possible dehiscence or rupture. Additional images were then obtained, ultimately demonstrating uterine rupture with fetus external to uterus.

Management of uterine rupture: a case report and review of the literature

Background

Maternal morbidity and mortality has been a major World Health Organization concern over the years, especially in sub-Saharan Africa. This paper reports uterine rupture with severe hypovolemic shock managed at the Douala General Hospital, Cameroon. Early clinical diagnosis is paramount to maternal survival.

Case presentation

Mrs. MM aged 25 years, G3P2012, of the Bamileke tribe in Cameroon was admitted to our Department in hypovolemic shock BP = 70/40 mmHg, pulse 120 beats per minute, with altered consciousness (Glasgow Coma Scale = 13). She has a history of missed abortion at 19 weeks gestation and an attempt to evacuate the uterus with misoprostol that led to uterine rupture. She underwent a total abdominal hysterectomy and blood transfusion. Her post-operative stay in hospital was uneventful.

Conclusion

Uterine rupture is a complication that can be eliminated under conditions of best obstetric practice. To attain this objective, use of misoprostol in primary health facilities should be stopped or proper management of the medication instituted. The survival of patients after uterine rupture depends on the time interval between rupture and intervention, and the availability of blood products for transfusion.

Nationwide population-based cohort study of uterine rupture in Belgium: results from the Belgian Obstetric Surveillance System

OBJECTIVES

We aimed to assess the prevalence of uterine rupture in Belgium and to evaluate risk factors, management and outcomes for mother and child.

DESIGN

Nationwide population-based prospective cohort study.

SETTING

Emergency obstetric care. Participation of 97% of maternity units covering 98.6% of the deliveries in Belgium.

PARTICIPANTS

All women with uterine rupture in Belgium between January 2012 and December 2013. 8 women were excluded because data collection forms were not returned.

RESULTS

Data on 90 cases of confirmed uterine rupture were obtained, of which 73 had a previous Caesarean section (CS), representing an estimated prevalence of 3.6 (95% CI 2.9 to 4.4) per 10 000 deliveries overall and of 27 (95% CI 21 to 33) and 0.7 (95% CI 0.4 to 1.2) per 10 000 deliveries in women with and without previous CS, respectively. Rupture occurred during trial of labour after caesarean section (TOLAC) in 57 women (81.4%, 95% CI 68% to 88%), with a high rate of augmented (38.5%) and induced (29.8%) labour. All patients who underwent induction of labour had an unfavourable cervix at start of induction (Bishop Score ≤7 in 100%). Other uterine surgery was reported in the history of 22 cases (24%, 95% CI 17% to 34%), including 1 case of myomectomy, 3 cases of salpingectomy and 2 cases of hysteroscopic resection of a uterine septum. 14 cases ruptured in the absence of labour (15.6%, 95% CI 9.5% to 24.7%). No mothers died; 8 required hysterectomy (8.9%, 95% CI 4.6% to 16.6%). There were 10 perinatal deaths (perinatal mortality rate 117/1000 births, 95% CI 60 to 203) and perinatal asphyxia was observed in 29 infants (34.5%, 95% CI 25.2% to 45.1%).

CONCLUSIONS

The prevalence of uterine rupture in Belgium is similar to that in other Western countries. There is scope for improvement through the implementation of nationally adopted guidelines on TOLAC, to prevent use of unsafe procedures, and thereby reduce avoidable morbidity and mortality.

Management of stillbirth delivery

Stillbirth is a common adverse outcome of pregnancy. Management should be individualized based on gestational age, maternal condition, prior uterine surgery, availability of skilled professionals, and maternal desires. This article discusses available data on management by gestational age and prior uterine surgery. Expectant management is a viable option for women and families who desire it and do not have any contraindications. In the second trimester, misoprostol induction and dilatation and evacuation are effective in the evacuation of the uterus. In the third trimester, induction of labor with prostaglandins, mechanical dilators, and augmentation with oxytocin is appropriate. Care should be taken with women with prior cesarean delivery; prostaglandins ideally should be avoided. Delivery by cesarean section should be performed selectively, i.e., when there is a maternal indication.