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Margueritte F, Adam C, Fauconnier A, Gauthier T. Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review. Reprod Biomed Online 2021; 43:543-552. [PMID: 34353724 DOI: 10.1016/j.rbmo.2021.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.
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Affiliation(s)
- François Margueritte
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, 10 Rue du Champ Gaillard, Poissy 78300, France.
| | - Camille Adam
- Limoges University Hospital, Mother and Child Hospital, Department of Gynecology and Obstetrics and Reproductive Medicine, 8 Rue Dominique Larrey, Limoges 87000, France
| | - Arnaud Fauconnier
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, 10 Rue du Champ Gaillard, Poissy 78300, France
| | - Tristan Gauthier
- Limoges University Hospital, Mother and Child Hospital, Department of Gynecology and Obstetrics and Reproductive Medicine, 8 Rue Dominique Larrey, Limoges 87000, France
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2
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Maymon R, Mor M, Betser M, Kugler N, Vaknin Z, Pekar-Zlotin M, Melcer Y. Second-trimester and early third-trimester spontaneous uterine rupture: A 32-year single-center survey. Birth 2021; 48:61-65. [PMID: 33174227 DOI: 10.1111/birt.12510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Second-trimester and early third-trimester uterine rupture in a nonlaboring woman is a very rare and life-threatening condition for both mothers and newborns. We aimed to present clinical characteristics, prenatal findings, and maternal and neonatal outcomes following second-trimester and early third-trimester spontaneous antepartum uterine rupture in our institute. METHOD The medical records of all women with full-thickness second-trimester and early third-trimester uterine rupture treated in our department from 1988 to 2019 were retrieved from the institutional database and reviewed. Small uterine defects, incomplete ruptures, and silent uterine incision dehiscence were excluded. RESULTS From 1988 to 2019, 213 665 deliveries were recorded in our institute. Of these, 12 patients experienced second-trimester or early third-trimester spontaneous uterine rupture. Obstetric history revealed that 50% of the women in each period had undergone previous classical uterine incisions and 50% had a short interpregnancy (IP) interval. The mean age at diagnosis of uterine rupture was 26.3 ± 5.1 weeks. The ruptures were associated with abnormal placentation in 10 cases (83.3%): placenta previa (n = 7); and placenta previa and percreta (n = 3). No maternal mortality occurred. Seven of the 10 (70%) viable newborns survived. CONCLUSIONS The increasing rates of cesarean births (CB) may lead to iatrogenic complications including midgestational prelabor spontaneous uterine rupture, an obstetric emergency, which is hard to diagnose. Maternal and neonatal outcomes can be optimized by a greater awareness of the risk factors, recognition of clinical signs and symptoms, and the availability of ultrasound to assist in establishing a diagnosis to enable prompt surgical intervention.
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Affiliation(s)
- Ron Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Matan Mor
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Betser
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Kugler
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Vaknin
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marina Pekar-Zlotin
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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3
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Uterine Dehiscence and Subsequent Pregnancy Management: A Review of the Literature. Obstet Gynecol Surv 2021; 76:48-54. [PMID: 33506878 DOI: 10.1097/ogx.0000000000000856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Belfort MA, Shamshirsaz AA, Cassady CI, Donepudi R, Espinoza J, Sanz Cortes M, King A, Nassr AA. Repair of a large uterine dehiscence during the second trimester leading to successful prolongation of the pregnancy. Am J Obstet Gynecol 2020; 223:929-932. [PMID: 32712004 DOI: 10.1016/j.ajog.2020.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/14/2020] [Accepted: 07/22/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Michael A Belfort
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Neurosurgery, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Surgery, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Anesthesiology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX.
| | - Alireza A Shamshirsaz
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Surgery, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Christopher I Cassady
- Radiology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Roopali Donepudi
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Jimmy Espinoza
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Magdalena Sanz Cortes
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Alice King
- Surgery, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
| | - Ahmed A Nassr
- Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
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Hawkins L, Robertson D, Frecker H, Berger H, Satkunaratnam A. Spontaneous uterine rupture and surgical repair at 21 weeks gestation with progression to live birth: a case report. BMC Pregnancy Childbirth 2018; 18:132. [PMID: 29728141 PMCID: PMC5935985 DOI: 10.1186/s12884-018-1761-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 04/23/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Uterine rupture in the non-laboring uterus is a rare occurrence, which can lead to significant morbidity and mortality for the mother and fetus. Management of this presentation is complex at pre-viable gestations. CASE PRESENTATION A 35 year old primigravid woman with multiple previous myomectomies presented with spontaneous complete thickness uterine rupture at 21 weeks gestation. A 10 cm myometrial defect and iatrogenic amniotomy were surgically corrected with fetal preservation. This led to pregnancy continuation to 32 weeks gestation when elective cesarean delivery resulted in excellent neonatal outcome. CONCLUSIONS Early surgical diagnosis, multidisciplinary team approach, iatrogenic amniotomy and continuous two-layer myometrial closure were factors that contributed to pregnancy prolongation in this large myometrial rupture.
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Affiliation(s)
- Lesley Hawkins
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, 12th Floor, Toronto, ON, M5G1E2, Canada
| | - Deborah Robertson
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, 12th Floor, Toronto, ON, M5G1E2, Canada.,Department of Obstetrics and Gynaecology, St Michael's Hospital, 308-55 Queen St East, Toronto, ON, M5C1R6, Canada
| | - Helena Frecker
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, 12th Floor, Toronto, ON, M5G1E2, Canada.,Department of Obstetrics and Gynaecology, Michael Garron Hospital, Suite 311, 658 Danforth Avenue, M4J5B9, Toronto, Ontario, Canada
| | - Howard Berger
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, 12th Floor, Toronto, ON, M5G1E2, Canada.,Department of Obstetrics and Gynaecology, St Michael's Hospital, 308-55 Queen St East, Toronto, ON, M5C1R6, Canada
| | - Abheha Satkunaratnam
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, 12th Floor, Toronto, ON, M5G1E2, Canada. .,Department of Obstetrics and Gynaecology, St Michael's Hospital, 308-55 Queen St East, Toronto, ON, M5C1R6, Canada.
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6
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López Ramón y Cajal C, Rodríguez Fernández V. Diagnosis of a defect in the uterine wall using 3D ultrasound in the 16th week of gestation. Clin Case Rep 2017; 5:1230-1233. [PMID: 28781830 PMCID: PMC5538205 DOI: 10.1002/ccr3.1043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 03/26/2017] [Accepted: 04/14/2017] [Indexed: 11/29/2022] Open
Abstract
The 3D volumetric transabdominal study with rendering mode is a very useful tool to perform a detailed study of the uterine wall, and it allows us to create a safe and early strategy during pregnancy in uterine dehiscences, as we show in this case in the 16th week of gestation.
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7
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Abstract
Uterine fibroids (leiomyomas) are common in reproductive age women. Most women with fibroids have uneventful pregnancies. The most common complication is painful degeneration. Are fibroids associated with adverse pregnancy outcomes? If so, can we predict which fibroids are most likely to cause complications? And is there anything that can be done to prevent these complications, such as performing a myomectomy before pregnancy? Here we review the published literature looking at the impact of uterine fibroids on adverse pregnancy events, such as miscarriage, preterm labor, placental abruption, fetal growth restriction, and fetal malpresentation. A series of clinical recommendations for the management of pregnancy in women with uterine fibroids are included.
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8
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Weibel HS, Jarcevic R, Gagnon R, Tulandi T. Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:128-32. [PMID: 24518911 DOI: 10.1016/s1701-2163(15)30658-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy. METHODS We conducted a survey of 49 practising obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy. RESULTS Overall, the inter-respondent agreement was fair (kappa 0.3; P < 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour. There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins. CONCLUSION Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach.
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Affiliation(s)
- Hélène S Weibel
- Department of Obstetrics and Gynecology, McGill University, Montreal QC
| | - Radomir Jarcevic
- Department of Obstetrics and Gynecology, Université de Montréal, Montreal QC
| | - Robert Gagnon
- Department of Obstetrics and Gynecology, McGill University, Montreal QC
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University, Montreal QC
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9
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Obstetric outcomes after uterine myomectomy: Laparoscopic versus laparotomic approach. Obstet Gynecol Sci 2013; 56:375-81. [PMID: 24396816 PMCID: PMC3859018 DOI: 10.5468/ogs.2013.56.6.375] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/03/2013] [Accepted: 06/10/2013] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To compare the pregnancy-related complications after laparoscopic and laparotomic uterine myomectomy. METHODS A retrospective study of 415 women who received laparoscopic (n = 340) or laparotomic (n = 75) resection of uterine leiomyomas in one center. The mean follow-up period was 26.5 months in laparoscopic group and 23.9 months in laparotomic group. RESULTS Fifty-four and 12 pregnancies occurred in laparoscopic and laparotomic myomectomy group, respectively. The major obstetric outcomes were similar between two groups. There was no ectopic pregnancy or preterm birth. There were two cases of obstetric complication in laparoscopic group only; one experienced neonatal death and postpartum hemorrhage due to placental abruption and the other underwent subtotal hysterectomy due to uterine dehiscence identified during Cesarean section. CONCLUSION Uterine rupture or dehiscence after laparoscopic myomectomy occurred in 3.7% (2/54) which lead to unfavorable outcome. Appropriate selection of patients and secure suture techniques appears to be important for laparotomic myomectomy in reproductive-aged women.
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11
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Management of asymptomatic mid-trimester lower segment scar dehiscence. Eur J Obstet Gynecol Reprod Biol 2009; 147:241-2. [PMID: 19762141 DOI: 10.1016/j.ejogrb.2009.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Revised: 07/29/2009] [Accepted: 08/19/2009] [Indexed: 11/20/2022]
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12
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Palacios-Jaraquemada JM, Fiorillo A, von Petery F, Colaci D, Leguizamón G. Uterine repair and successful pregnancy after myometrial and placental rupture with massive haemoperitoneum. BJOG 2009; 116:456-60. [PMID: 19187380 DOI: 10.1111/j.1471-0528.2008.01980.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J M Palacios-Jaraquemada
- Department of Obstetrics and Gynecology, Center for Medical Education and Clinical Research, CEMIC University, Buenos Aires, Argentina.
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13
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Tzafettas J, Dovas D, Tolikas A, Fragkedakis N, Dinas K, Papathanasiou K. A Case of a Successful Pregnancy in a Woman with a Previous History of Spontaneous Uterine Rupture Following Laparoscopic Myomectomy. J Gynecol Surg 2008. [DOI: 10.1089/gyn.2007.b-02290-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John Tzafettas
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
| | - Dimitrios Dovas
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
| | - Athanasios Tolikas
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
| | - Nikolaos Fragkedakis
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
| | - Konstantinos Dinas
- 2nd University Department of Obstetrics and Gynaecology, Hippokration Hospital, Thessaloniki, Greece
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Shirata I, Fujiwaki R, Takubo K, Shibukawa T, Sawada K. Successful continuation of pregnancy after repair of a midgestational uterine rupture with the use of a fibrin-coated collagen fleece (TachoComb) in a primigravid woman with no known risk factors. Am J Obstet Gynecol 2007; 197:e7-9. [PMID: 17904953 DOI: 10.1016/j.ajog.2007.07.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2007] [Revised: 06/29/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
Abstract
We report the first case of successful continuation of pregnancy after repair of a midgestational uterine rupture with the use of a fibrin-coated collagen fleece (TachoComb, Nycomed, Linz, Austria). For midgestational uterine rupture, adequate uterine repair and close surveillance of preterm labor could improve perinatal outcome by permitting continuation of the pregnancy.
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Affiliation(s)
- Izumi Shirata
- Department of Obstetrics and Gynecology, Matsue Red Cross Hospital, Matsue, Japan
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Rabinowitz R, Samueloff A, Sapirstein E, Shen O. Expectant management of fetal arm extruding through a large uterine dehiscence following sonographic diagnosis at 27 weeks of gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 28:235-7. [PMID: 16933283 DOI: 10.1002/uog.2847] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- R Rabinowitz
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem and Faculty of Health Science, Ben-Gurion University of the Negev, Be'er Sheva, Israel.
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Sentilhes L, Sergent F, Marpeau L. Repair of uterine dehiscence with continuation of pregnancy. Obstet Gynecol 2005; 105:1487-8; author reply 1488. [PMID: 15932854 DOI: 10.1097/01.aog.0000167707.91658.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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