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Tandukar A, Aryal R, Khaniya B, Maskey S, Ojha N, Chataut D. Pregnancy in an isthmocele: A rare case from Nepal. Clin Case Rep 2023; 11:e6875. [PMID: 36694651 PMCID: PMC9842908 DOI: 10.1002/ccr3.6875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/09/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
An infrequent form of ectopic pregnancy, pregnancy in an isthmocele can be hazardous due to hemorrhage or uterine rupture. With no clear guidelines for the management of this condition, surgery is the preferred option.
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Affiliation(s)
- Alina Tandukar
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Roshan Aryal
- Maharajgunj Medical CampusInstitute of MedicineKathmanduNepal
| | - Bishal Khaniya
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Suvana Maskey
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Neebha Ojha
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Dinesh Chataut
- Department of Radiology and ImagingTribhuvan University Teaching HospitalKathmanduNepal
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Qayum K, Kar I, Sofi J, Panneerselvam H. Single- Versus Double-Layer Uterine Closure After Cesarean Section Delivery: A Systematic Review and Meta-Analysis. Cureus 2021; 13:e18405. [PMID: 34729282 PMCID: PMC8555931 DOI: 10.7759/cureus.18405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 11/05/2022] Open
Abstract
Cesarean section (CS) delivery is a common procedure, and its incidence is increasing globally. To compare single-layer (SL) with double-layer (DL) uterine closure techniques after cesarean section in terms of ultrasonographic findings and rate of CS complications. PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant randomized clinical trials (RCTs). Retrieved articles were screened, and relevant studies were included in a meta-analysis. Continuous data were pooled as mean difference (MD) with 95% confidence interval (CI), and dichotomous data were pooled as relative risk (RR) and 95% CI. Analysis was conducted using RevMan software (Version 5.4). Eighteen RCTs were included in our study. Pooled results favored DL uterine closure in terms of residual myometrial thickness (MD = -1.15; 95% CI -1.69, -0.60; P < 0.0001) and dysmenorrhea (RR = 1.36; 95% CI 1.02, 1.81; P = 0.04), while SL closure had shorter operation time than DL closure (MD = -2.25; 95% CI -3.29, -1.21; P < 0.00001). Both techniques had similar results in terms of uterine dehiscence or rupture (RR = 1.88; 95% CI 0.63, 5.62; P = 0.26), healing ratio (MD = -5.00; 95% CI -12.40, 2.39; P = 0.18), maternal infectious morbidity (RR = 0.94; 95% CI 0.66, 1.34; P = 0.72), hospital stay (MD = -0.12; 95% CI -0.30, 0.06; P = 0.18), and readmission rate (RR = 0.95; 95% CI 0.64, 1.40; P = 0.78). Double-layer uterine closure shows more residual myometrial thickness and lower incidence of dysmenorrhea than single-layer uterine closure of cesarean section scar. But single-layer closure has the advantage of the shorter operation time. Both methods have comparable blood loss amount, healing ratio, hospital stay duration, maternal infection risk, readmission rate, and uterine dehiscence or rupture risk.
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Affiliation(s)
- Kaif Qayum
- General Surgery, Wye Valley NHS Foundation Trust, Hereford, GBR
| | - Irfan Kar
- General Surgery, Wye Valley NHS Foundation Trust, Hereford, GBR
| | - Junaid Sofi
- General Surgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, IND
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Dosedla E, Gál P, Calda P. Association between deficient cesarean delivery scar and cesarean scar syndrome. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:538-543. [PMID: 32856326 DOI: 10.1002/jcu.22911] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/11/2019] [Accepted: 07/29/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION The aim of our study was to compare long-term morbidity after elective and emergency cesarean delivery (CD). METHODS A prospective cohort study was conducted in 200 women delivered by CD. Ultrasound examinations were performed transvaginally at 6 weeks and 18 months after CD. Clinical data were collected at the time of CD and after 18 months. RESULTS In the group of 200 women, 29% underwent emergency and 71% elective CD. Then, 6 weeks and 18 months after CD, a severe scar defect was present in 7% and 5%, respectively (P = .4). After 18 months of CD, 17% (34/200) of women had evidence of adhesions of the vesicouterine pouch. Severe CD scar defects were significant predictors for adhesion formation in vesicouterine pouch (OR 3.14, 95% CI, 1.54-4.74), pelvic pain (OR 1.68, 95% CI, 0.22-3.14), dysmenorrhea (OR 2.12, 95% CI, 0.74-3.50), and dyspareunia (OR 1.38, 95% CI, 0.09-2.67). Uterine scar defects detected at 6 weeks after elective CD were detectable at 18 months in only 40% of cases, whereas uterine scar defects after emergency CD were still detectable in 87% of cases. CONCLUSION Uterine scar defects are more frequent at 18 weeks after emergency CD, than after elective CD (40% vs 87%). Women with severe scar defects have higher risk of adhesion formation, dysmenorrhea, dyspareunia, and chronic pelvic pain.
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Affiliation(s)
- Erik Dosedla
- Department of Obstetrics and Gynecology, University of Pavol Jozef Safarik in Kosice, Hospital AGEL Košice-Šaca, Inc., Košice-Šaca, 04015, Slovak Republic
| | - Peter Gál
- Center of Clinical and Preclinical Research MEDIPARK, Faculty of Medicine, University of Pavol Jozef Safarik in Kosice, Košice, 04001, Slovak Republic
| | - Pavel Calda
- Department of Gynecology and Obstetrics, Charles University, Prague, First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic
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Dawood AS, Elgergawy A, Elhalwagy A, Ataallah WM, Elbohoty SB, Elshwaikh SL, Elsokary AA, Elkhyat AM, Elbadry AT, Abbas AM. The impact of mechanical cervical dilatation during elective cesarean section on postpartum scar integrity: a randomized double-blind clinical trial. Int J Womens Health 2019; 11:23-29. [PMID: 30666165 PMCID: PMC6330971 DOI: 10.2147/ijwh.s188628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective The current study aimed to evaluate the impact of mechanical cervical dilatation during elective cesarean section (CS) on postpartum scar integrity at 6 months post operation. Methods A randomized double-blind clinical trial (UMIN000027946) was conducted at a tertiary university hospital in the period between July 1, 2017 and April 30, 2018. The study included pregnant women with a singleton fetus at term ≥37 weeks of gestation scheduled for elective CS. Eligible participants were allocated either to the study group (women with intraoperative cervical dilatation) or the control group (women with no intraoperative cervical dilatation). The patients were followed up at 6 months after CS by 3D ultrasonography to check for the scar integrity and quality. The primary outcome was the difference in sonographic parameters of the scar integrity between the two groups. Results Four hundred twenty two women were approached to participate in the study. There was no statistically significant difference regarding the baseline characteristics of both the groups. Scar width and depth were significantly higher in the cervical dilatation group (P=0.002 and 0.001, respectively). Fewer cases with scar defects (niche) were found in the cervical dilatation group than in the control group (5.03% vs 11.04%, respectively, P=0.048). There was no significant difference regarding the rate of wound infection or endometritis in both the groups (P=0.717 and 0.227, respectively). The incidence of febrile morbidity was higher in the no cervical dilatation group (10.5%) compared to (5.0%) the cervical dilatation group (P=0.045). Conclusion Cervical dilatation during elective CS is associated with thick scars with low incidence of scar defects.
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Affiliation(s)
- Ayman Shehata Dawood
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Adel Elgergawy
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed Elhalwagy
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Walid M Ataallah
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Shereen B Elbohoty
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Shereef L Elshwaikh
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amal A Elsokary
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed M Elkhyat
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amr T Elbadry
- Department of Radiology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics & Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt,
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Spens K, Bird L, Bright P. Transabdominal ultrasound: Can it be used to detect and quantify adhesions/reported pain, following Caesarean section? J Bodyw Mov Ther 2018; 22:733-740. [PMID: 30100305 DOI: 10.1016/j.jbmt.2017.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 07/30/2017] [Accepted: 09/06/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Caesarean section is common in the UK with post-procedural adhesions causing life-long clinical symptoms and impacting future pregnancies. This study's aim was to explore associations between these surgical adhesions, via transabdominal ultrasound findings, and perceived symptoms. METHOD Females demonstrating 1-3 transverse, lower-segment Caesareans were included. Visceral slide transabdominal ultrasound elicited positive adhesions (<1 cm movement) and negative adhesions (>1 cm movement). Scar tissue quality was assessed by the Patient and Observer Scar Assessment Scale (POSAS) and Numerical rating scales (NRS) described pain symptoms. The relationship between adhesions was explored using Fisher's exact test and multiple regression analysis. RESULTS Twenty-two subjects (mean-age 35) were recruited; twenty participants (91%) had undergone 1 Caesarean, one each of the remainder had undergone 2 and 3 Caesareans respectively. Increased Visceral slide (>1 cm) was seen as predictive of increased scar pain (R2 = 0.76 (95% CI 0.12-0.28), P < 0.001). CONCLUSION Caesarean adhesion scans showed significant associations with pain symptomology. Comprehensive adhesion assessment needs to be developed to improve long term outcomes of adhesions. Transabdominal Ultrasound can be considered a useful, quick and non-deleterious alternative diagnostic tool to Laparoscopy, therefore preventing further adhesion formation.
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Affiliation(s)
- Katharine Spens
- European School of Osteopathy, Boxley House, The Street, Boxley, Maidstone, Kent, ME14 3DZ, UK(1).
| | - Lance Bird
- European School of Osteopathy, Boxley House, The Street, Boxley, Maidstone, Kent, ME14 3DZ, UK(1)
| | - Philip Bright
- European School of Osteopathy, Boxley House, The Street, Boxley, Maidstone, Kent, ME14 3DZ, UK(1)
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Stegwee SI, Jordans I, van der Voet LF, van de Ven PM, Ket J, Lambalk CB, de Groot C, Hehenkamp W, Huirne J. Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta-analysis. BJOG 2018; 125:1097-1108. [PMID: 29215795 DOI: 10.1111/1471-0528.15048] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Caesarean section (CS) rates are rising globally. Long-term adverse outcomes after CS might be reduced when the optimal uterine closure technique becomes evident. OBJECTIVE To determine the effect of uterine closure techniques after CS on maternal and ultrasound outcomes. SEARCH STRATEGY Literature search in electronic databases. SELECTION CRITERIA Randomised controlled trials (RCTs) or prospective cohort studies that evaluated uterine closure techniques and reported on ultrasound findings, perioperative or long-term outcomes. DATA COLLECTION AND ANALYSIS Twenty studies (15 053 women) were included in our meta-analyses for various outcomes. We calculated pooled risk ratios (RR) and weighted mean differences (WMD) with 95% CI through random-effect analysis. MAIN RESULTS Residual myometrium thickness (RMT), reported in eight studies (508 women), decreased by 1.26 mm after single- compared with double-layer closure (95% CI -1.93 to -0.58), particularly when locked sutures were used. Healing ratio [RMT/adjacent myometrium thickness (AMT)] decreased after single-layer closure (WMD -7.74%, 95% CI -13.31 to -2.17), particularly in the case of locked sutures. Niche prevalence increased (RR 1.71, 95% CI 1.11-2.62) when the decidua was excluded. Dysmenorrhea occurred more often in the single-layer group (RR 1.23, 95% CI 1.01-1.48), whereas incidence of uterine rupture was similar (RR 1.91, 95% CI 0.63-5.74). CONCLUSION Double-layer unlocked sutures are preferable to single-layer locked sutures regarding RMT, healing ratio and dysmenorrhoea. Excluding the decidua seems to result in higher niche prevalence. As thin residual myometrium or niches may serve as intermediates for gynaecological and reproductive outcomes, future studies should focus on these outcomes. TWEETABLE ABSTRACT: #Uterineclosuretechniques after #caesarean affect #longtermoutcomes.
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Affiliation(s)
- S I Stegwee
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Ipm Jordans
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - L F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, the Netherlands
| | - P M van de Ven
- Department of Epidemiology and Biostatistics, VU University, Amsterdam, the Netherlands
| | - Jcf Ket
- Medical Library, VU University, Amsterdam, the Netherlands
| | - C B Lambalk
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Cjm de Groot
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Wjk Hehenkamp
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Jaf Huirne
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
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Woźniak A, Pyra K, Tinto HR, Woźniak S. Ultrasonographic criteria of cesarean scar defect evaluation. J Ultrason 2018; 18:162-165. [PMID: 30451411 PMCID: PMC6440514 DOI: 10.15557/jou.2018.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 04/16/2018] [Indexed: 11/22/2022] Open
Abstract
Cesarean sections account for approximately 20% of all deliveries worldwide. In Poland, the percentage of women delivering by cesarean section amounts to over 43%. According to studies, the prevalence of cesarean scar defects ranges from 24-70%. Due to the overall cesarean section rate, this is a medical problem affecting a large population of women. In such cases, ultrasonographic evaluation of a cesarean scar reveals a hypoechoic space filled with postmenstrual blood, representing a myometrial tear at the wound site. Such an ultrasound appearance is referred to as a niche, and it forms after a cesarean section at the site of the hysterotomy of the anterior uterine wall, most commonly within the uterine isthmus. Currently, the exact cause of niche formation remains unexplained, yet the risk factors for its development are universally acknowledged. They include the site of hysterotomy, multiple previous cesarean section deliveries, suturing technique and maternal diabetes or smoking. Ultrasound evaluation of the cesarean section scar is an important element of obstetric and gynecologic practice, especially in the case of further pregnancies. It facilitates an early diagnosis of a cesarean scar ectopic pregnancy, and the prediction of the risk for perinatal dehiscence in the case of a vaginal birth after a cesarean section.
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Affiliation(s)
- Andrzej Woźniak
- 3 Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - Krzysztof Pyra
- Surgical Radiology and Neuroradiology Unit, Medical University of Lublin, Lublin, Poland
| | - Hugo Rio Tinto
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Sławomir Woźniak
- 3 Department of Gynecology, Medical University of Lublin, Lublin, Poland
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Huirne JAF, Stegwee SI, van der Voet LF, de Groot CJM, Hehenkamp WJK, Brölmann HAM. Re: Risk of Cesarean scar defect following single- vs double-layer uterine closure. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:664-666. [PMID: 29105218 DOI: 10.1002/uog.18901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- J A F Huirne
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
| | - S I Stegwee
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
| | - L F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, Nico Bolkesteinlaan, 75, Deventer, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology and Research Institute Amsterdam Reproduction & Development, VU University Medical Center, Amsterdam, The Netherlands
| | - W J K Hehenkamp
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | - H A M Brölmann
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
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Bø K, Artal R, Barakat R, Brown WJ, Davies GAL, Dooley M, Evenson KR, Haakstad LAH, Kayser B, Kinnunen TI, Larsén K, Mottola MF, Nygaard I, van Poppel M, Stuge B, Khan KM. Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part 3-exercise in the postpartum period. Br J Sports Med 2017. [PMID: 28642221 DOI: 10.1136/bjsports-2017-097964] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Kari Bø
- Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Raul Artal
- Department of Obstetrics, Gynecology and Women's Health, Saint Louis University, St Louis, Missouri, USA
| | - Ruben Barakat
- Facultad de Ciencias de la Actividad Física y del Deporte - INEF, Universidad Politécnica de Madrid, Madrid, Spain
| | - Wendy J Brown
- Centre for Research on Exercise Physical Activity and Health, School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Australia
| | - Gregory A L Davies
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Queen's University, Kingston, Canada
| | - Michael Dooley
- Department of Sport Gynaecology, Poundbury Clinic, Dorchester, UK.,Poundbury Clinic, King Edward VII Hospital, London, UK
| | - Kelly R Evenson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lene A H Haakstad
- Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Bengt Kayser
- Faculty of Biology and Medicine, Institute of Sport Science, University of Lausanne, Lausanne, Switzerland
| | - Tarja I Kinnunen
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Karin Larsén
- The Swedish School of Sport and Health Sciences, Stockholm, Sweden
| | - Michelle F Mottola
- R Samuel McLaughlin Foundation-Exercise and Pregnancy Lab, The University of Western Ontario, London, Canada
| | - Ingrid Nygaard
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | | | - Britt Stuge
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Karim M Khan
- Department of Family Practice and School of Kinesiology, Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
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Bennich G, Rudnicki M, Wilken-Jensen C, Lousen T, Lassen PD, Wøjdemann K. Impact of adding a second layer to a single unlocked closure of a Cesarean uterine incision: randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:417-422. [PMID: 26489989 DOI: 10.1002/uog.15792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 10/06/2015] [Accepted: 10/11/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To investigate short- and long-term effects on residual myometrial thickness (RMT) of adding a second layer to a single unlocked closure of a Cesarean uterine incision. METHODS This was a randomized double-blind controlled trial. Healthy nulliparous women scheduled for first-time elective Cesarean delivery were operated on using a modified version of the Misgav Ladach surgical technique. The women were examined by transabdominal ultrasound before discharge from the maternity ward and by transvaginal saline contrast sonohysterography at a minimum of 5 months postpartum. RESULTS Seventy-six nulliparae met the criteria and agreed to participate in the study. Thirty-five women were assigned to the single-layer technique and 38 to the double-layer unlocked closure technique. Groups were comparable regarding gestational age at delivery, duration of surgery and perioperative blood loss. There was no difference in RMT between the two groups, both at time of discharge (mean ± SD, 20.2 ± 8.0 mm vs 21.0 ± 9.7 mm) and after 5 months postpartum (mean, 5.7 ± 2.9 mm vs 5.7 ± 2.2 mm). RMT was approximately half that of the normal myometrium at both examinations. CONCLUSION The results of this study suggest that double-layer closure of a Cesarean uterine incision does not increase RMT compared with single-layer closure when an unlocked technique is used.
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Affiliation(s)
- G Bennich
- Department of Obstetrics and Gynecology, Roskilde University Hospital, Roskilde, Denmark
| | - M Rudnicki
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - C Wilken-Jensen
- Department of Obstetrics and Gynecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - T Lousen
- Department of Obstetrics and Gynecology, Roskilde University Hospital, Roskilde, Denmark
| | - P D Lassen
- Department of Obstetrics and Gynecology, Roskilde University Hospital, Roskilde, Denmark
| | - K Wøjdemann
- Department of Surgery, Bornholms Hospital, Roenne, Denmark
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Masuda H, Uchida H, Maruyama T, Sato K, Sato S, Tanaka M. Successful treatment of atypical cesarean scar defect using endoscopic surgery. BMC Pregnancy Childbirth 2015; 15:342. [PMID: 26696492 PMCID: PMC4687144 DOI: 10.1186/s12884-015-0730-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/04/2015] [Indexed: 11/23/2022] Open
Abstract
Background Cesarean scar syndrome results from a postoperative defect of the uterine isthmus, also known as an isthmocele. Patients present with gynecological symptoms, such as abnormal genital bleeding or infertility, after cesarean delivery. Although the cesarean rate is increasing worldwide, this syndrome is not widely known. Case presentation A 43-year-old G2P1 Japanese woman with atypical cesarean scar syndrome had a 3-year history of secondary infertility and postmenstrual brown discharge. Laparoscopic and hysteroscopic exploration revealed a cesarean scar defect connected to a small cavity in the myometrium: this was not an endometrial cavity or a uterine diverticulum. After endoscopic excision of the cavity, the brown discharge resolved, and the patient achieved ongoing pregnancy on her third attempt at intrauterine insemination. Conclusion Consensus is still lacking regarding the diagnosis and treatment of cesarean scar defect. However, the gynecologists should be aware that cesarean scar syndrome can have scar defects forming cavities of unusual shapes and features. Surgical correction of these defects will often improve postmenstrual bleeding and subfertility in these cases.
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Affiliation(s)
- Hirotaka Masuda
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Hiroshi Uchida
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Tetsuo Maruyama
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Kenji Sato
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Suguru Sato
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Mamoru Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
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Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women. Arch Gynecol Obstet 2014; 291:1417-23. [PMID: 25516174 DOI: 10.1007/s00404-014-3582-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Caesarean delivery (c-section) scar dehiscences may cause bleeding abnormalities, e.g. postmenstrual spotting, dysmenorrhea and abdominal pain, secondary sterility and at worst peripartum uterine rupture. The purpose of this study was firstly to identify the correlation of women's complaints after c-section with scar-related clinical symptoms. Secondly, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic. METHODS We present data of a retrospective study of 13 premenopausal, non-pregnant women with symptomatic c-section scars. In 9 out of 13 patients, a microsurgical uterus reconstruction was performed by mini-laparotomy. The postoperative changes of scar-associated symptoms were assessed by a questionnaire as earliest as 4 months after surgery (N = 5). RESULTS The c-section scar was visualised by transvaginal sonography in 12 out of 13 women by a typical U- or V-shaped hypoechoic or anechoic fluid accumulation in the region of former uterotomy and in all 13 patients by hysteroscopy. Bleeding disorders were often accompanied by dysmenorrhea/abdominal pain (38.5%, N = 5) and secondary sterility (46.2%, N = 6). Blood residues in the scar pouch and bleeding disorders/postmenstrual spotting were found in 30.8% of patients (N = 4) and combined with secondary sterility in 38.5% of patients (N = 5). Reconstructive surgeries resulted in discontinuation of bleeding disorders in all women and a pregnancy in three out of five patients (60%) with secondary sterility. CONCLUSION Clinical symptoms, e.g. "bleeding disorders" like postmenstrual spotting, "pain/dysmenorrhea" and "secondary sterility" could be specific indicators for the diagnosis of uterine dehiscence after c-section. Scar dehiscences can be diagnosed by obtaining the patients medical history and asking for typical symptoms followed by vaginal sonography and diagnostic hysteroscopy. If a c-section scar defect is confirmed, microsurgical uterus reconstruction can stop postmenstrual spotting, reduce abdominal pain/dysmenorrhea and improve fertility.
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Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis. Am J Obstet Gynecol 2014; 211:453-60. [PMID: 24912096 DOI: 10.1016/j.ajog.2014.06.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/28/2014] [Accepted: 06/05/2014] [Indexed: 02/07/2023]
Abstract
A systematic review and metaanalysis were performed through electronic database searches to estimate the effect of uterine closure at cesarean on the risk of adverse maternal outcome and on uterine scar evaluated by ultrasound. Randomized controlled trials, which compared single vs double layers and locking vs unlocking sutures for uterine closure of low transverse cesarean, were included. Outcomes were short-term complications (endometritis, wound infection, maternal infectious morbidity, blood transfusion, duration of surgical procedure, length of hospital stay, mean blood loss), uterine rupture or dehiscence at next pregnancy, and uterine scar evaluation by ultrasound. Twenty of 1278 citations were included in the analysis. We found that all types of closure were comparable for short-term maternal outcomes, except for single-layer closure, which had shorter operative time (-6.1 minutes; 95% confidence interval [CI], -8.7 to -3.4; P < .001) than double-layer closure. Single layer (-2.6 mm; 95% CI, -3.1 to -2.1; P < .001) and locked first layer (mean difference, -2.5 mm; 95% CI, -3.2 to -1.8; P < .001) were associated with lower residual myometrial thickness. Two studies reported no significant difference between single- vs double-layer closure for uterine dehiscence (relative risk, 1.86; 95% CI, 0.44-7.90; P = .40) or uterine rupture (no case). In conclusion, current evidence based on randomized trials does not support a specific type of uterine closure for optimal maternal outcomes and is insufficient to conclude about the risk of uterine rupture. Single-layer closure and locked first layer are possibly coupled with thinner residual myometrium thickness.
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Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev 2014; 2014:CD004732. [PMID: 25048608 PMCID: PMC11182567 DOI: 10.1002/14651858.cd004732.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator. OBJECTIVES To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and healthcare resource use. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 September 2013) and reference lists of all identified papers. SELECTION CRITERIA All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section. DATA COLLECTION AND ANALYSIS Two review authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently. MAIN RESULTS Our search strategy identified 60 studies for consideration, of which 27 randomised trials involving 17,808 women undergoing caesarean section were included in the review. Overall, the methodological quality of the trials was variable, with 12 of the 27 included trials adequately describing the randomisation sequence, with less than half describing adequately methods of allocation concealment, and only six trials indicating blinding of outcome assessors.Two trials compared auto-suture devices with traditional hysterotomy involving 300 women. No statistically significant difference in febrile morbidity between the stapler and conventional incision groups was apparent (risk ratio (RR) 0.92; 95% confidence interval (CI) 0.38 to 2.20).Five studies were included in the review that compared blunt versus sharp dissection when performing the uterine incision involving 2141 women. There were no statistically significant differences identified for the primary outcome febrile morbidity following blunt or sharp extension of the uterine incision (four studies; 1941 women; RR 0.86; 95% CI 0.70 to 1.05). Mean blood loss (two studies; 1145 women; average mean difference (MD) -55.00 mL; 95% CI -79.48 to -30.52), and the need for blood transfusion (two studies; 1345 women; RR 0.24; 95% CI 0.09 to 0.62) were significantly lower following blunt extension.A single trial compared transverse with cephalad-caudad blunt extension of the uterine incision, involving 811 women, and while mean blood loss was reported to be lower following transverse extension (one study; 811 women; MD 42.00 mL; 95% CI 1.31 to 82.69), the clinical significance of such a small volume difference is of uncertain clinical relevance. There were no other statistically significant differences identified for the limited outcomes reported.A single trial comparing chromic catgut with polygactin-910, involving 9544 women reported that catgut closure versus closure with polygactin was associated with a significant reduction in the need for blood transfusion (one study, 9544 women, RR 0.49, 95% CI 0.32 to 0.76) and a significant reduction in complications requiring re-laparotomy (one study, 9544 women, RR 0.58, 95% CI 0.37 to 0.89).Nineteen studies were identified comparing single layer with double layer closure of the uterus, with data contributed to the meta-analyses from 14 studies. There were no statistically significant differences identified for the primary outcome, febrile morbidity (nine studies; 13,890 women; RR 0.98; 95% CI 0.85 to 1.12). Although the meta-analysis suggested single layer closure was associated with a reduction in mean blood loss, heterogeneity is high and this limits the clinical applicability of the result. There were no differences identified in risk of blood transfusion (four studies; 13,571 women; average RR 0.86; 95% CI 0.63 to 1.17; Heterogeneity: Tau² = 0.15; I² = 49%), or other reported clinical outcomes. AUTHORS' CONCLUSIONS Caesarean section is a common procedure performed on women worldwide. There is increasing evidence that for many techniques, short-term maternal outcomes are equivalent. Until long-term health effects are known, surgeons should continue to use the techniques they prefer and currently use.
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Affiliation(s)
- Jodie M Dodd
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Elizabeth R Anderson
- Royal Liverpool University HospitalDepartment of Genito‐urinary MedicinePrescot StreetLiverpoolUKL7 8XP
| | - Simon Gates
- Division of Health Sciences, Warwick Medical School, The University of WarwickWarwick Clinical Trials UnitGibbet Hill RoadCoventryUKCV4 7AL
| | - Rosalie M Grivell
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
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Sevket O, Ates S, Molla T, Ozkal F, Uysal O, Dansuk R. Hydrosonographic assessment of the effects of 2 different suturing techniques on healing of the uterine scar after cesarean delivery. Int J Gynaecol Obstet 2014; 125:219-22. [DOI: 10.1016/j.ijgo.2013.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/15/2013] [Accepted: 02/25/2014] [Indexed: 11/26/2022]
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Lapointe-Milot K, Rizcallah E, Takser L, Abdelouahab N, Duvareille C, Pasquier JC. Closure of the uterine incision with one or two layers after caesarean section: a randomized controlled study in sheep. J Matern Fetal Neonatal Med 2014; 27:671-6. [PMID: 23952580 DOI: 10.3109/14767058.2013.834323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare the quality of the uterine scar with one or two layer closure after caesarean section by studying biomechanical and pathological properties of the scar. METHODS A randomized controlled trial performed on eight term pregnant ewes assigned into two groups during caesarean according to type of uterine closure: single-layer or double-layer. Hysterectomy was performed 8 months after caesarean delivery. Tensile strength of all scars and of unscarred myometrium was measured. Pathological properties of the scars were analyzed histologically. RESULTS The force required to reach the yield point was similar between scarred and unscarred myometrium (p=0.96), and between the scars in single-layer and double-layer closure groups (p=0.65). There was a significant increase in fibrosis width on the superficial part of the uterus in the double-layer closure group compared to the single-layer group (p=0.02). CONCLUSIONS Double-layer uterine closure modified wound healing without significant change in biomechanical properties.
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Glavind J, Madsen LD, Uldbjerg N, Dueholm M. Ultrasound evaluation of Cesarean scar after single- and double-layer uterotomy closure: a cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:207-212. [PMID: 23288683 DOI: 10.1002/uog.12376] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To compare residual myometrial thickness (RMT) and size of the Cesarean scar defect after single- and double-layer uterotomy closure following first elective Cesarean section. METHODS A retrospective cohort study was conducted in 149 women at least 6 months after an uncomplicated, elective Cesarean delivery. Two-dimensional transvaginal ultrasonographic measures of RMT, scar defect depth, width and length and myometrial thickness adjacent to the scar were compared in 68 women with single-layer and 81 women with double-layer closure delivered before and after, respectively, a change in the surgical procedure. Outcomes between the two groups were compared. RESULTS Median RMT was 5.8 (interquartile range (IQR), 4.1-7.8) mm in women with double-layer closure vs 4.6 (IQR, 3.4-6.5) mm in those with single-layer closure (P = 0.04). Scar defect length was greater in women with single-layer closure (median, 6.8 (IQR, 4.4-8.5) mm) than in those with double-layer closure (median, 5.6 (IQR, 3.9-6.8) mm) (P = 0.01). Measurements of defect depth and width, and the proportion of scars with RMT < 2.3 mm were similar in the two groups. CONCLUSIONS RMT was greater and defect length, but not defect depth and width, was smaller following double-layer compared with single-layer closure, which may indicate some limited benefit of double-layer closure following first elective Cesarean section.
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Affiliation(s)
- J Glavind
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus N, Denmark.
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Demers S, Roberge S, Afiuni YA, Chaillet N, Girard I, Bujold E. Survey on uterine closure and other techniques for Caesarean section among Quebec's obstetrician-gynaecologists. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013; 35:329-333. [PMID: 23660040 DOI: 10.1016/s1701-2163(15)30960-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the preferred types of uterine closure at Caesarean section among Quebec's obstetrician-gynaecologists. METHODS An anonymous survey with multiple-choice and open questions was sent by email to all members of the Association des Obstétriciens-Gynécologues du Québec in clinical practice. The primary response of interest was the type of uterine closure that would be favoured for a primigravida undergoing an elective CS at term for a breech fetus. Secondary responses of interest included type of uterine closure for CS performed for other indications, and methods of closure for the bladder flap, parietal peritoneum, rectus abdominis muscle, subcutaneous tissue, and skin. Results were stratified according to the number of years in practice. RESULTS Of 454 persons targeted, 176 (39%) responded. Responders were more likely to have fewer years in practice than the targeted population in general. The closures for a primigravida undergoing an elective CS at term for a breech presentation were, in order of preference: (1) a double-layer closure combining a first locked layer and an imbricating second layer (61%), (2) a double-layer closure combining a first unlocked layer and an imbricating second layer (28%), (3) a locked single layer (5%), (4) an unlocked single layer (5%), and (5) other techniques (1%). A locked single-layer closure was more frequently used for repeat CS (29%), and it was the favoured technique (40%) when tubal ligation was performed at the time of CS (P < 0.05). CONCLUSION Double-layer closure is the type of uterine closure most preferred by obstetricians in Quebec. However, the first layer is locked by two thirds of obstetricians and unlocked by the remainder.
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Affiliation(s)
- Suzanne Demers
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec City QC
| | - Stéphanie Roberge
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City QC
| | - Yamal A Afiuni
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec City QC
| | - Nils Chaillet
- Department of Obstetrics and Gynecology, University of Montreal, Montreal QC
| | - Isabelle Girard
- Department of Obstetrics and Gynecology, St-Mary's Hospital, McGill University, Montreal QC
| | - Emmanuel Bujold
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec City QC
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Management of cesarean heterotopic pregnancy with transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, and review of the literature. J Minim Invasive Gynecol 2013; 19:671-3. [PMID: 22935313 DOI: 10.1016/j.jmig.2012.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 05/03/2012] [Accepted: 05/22/2012] [Indexed: 02/06/2023]
Abstract
Cesarean scar pregnancy is one of the rarest forms of ectopic pregnancy, located in the scar from a previous cesarean section. There are few reports of such pregnancies, and there is no consensus about the best management. Herein is reported a case of cesarean heterotopic pregnancy, diagnosed at 6 weeks' gestation and successfully treated via transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, with preservation of the intrauterine pregnancy.
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Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy. Am J Obstet Gynecol 2012; 207:386.e1-6. [PMID: 23107082 DOI: 10.1016/j.ajog.2012.09.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/14/2012] [Accepted: 09/12/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of the study was to assess the efficacy of uterine arteries embolization (UAE) for the treatment of cesarean scar pregnancies (CSP). STUDY DESIGN Forty-six women with CSP were identified between March 2008 and March 2010. All of the patients underwent UAE combined with local methotrexate. RESULTS Forty-five patients were successfully treated. One patient had an emergency hysterectomy after 20 days because of massive vaginal hemorrhage. The mean time until normalization of serum β-human chorionic gonadotrophin was 37.7 days, and the mean time until CSP mass disappearance was 33.3 days. The mean hospitalization time was 10.5 days. The complications were mainly fever and pain, which were alleviated with symptomatic treatment. All 45 patients had recovered their normal menstruation at follow-up. CONCLUSION Bilateral uterine artery chemoembolization with methotrexate appears to be a safe and effective treatment for CSP and causes less morbidity than current approaches.
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Babu KM, Magon N. Uterine closure in cesarean delivery: a new technique. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2012; 4:358-61. [PMID: 22912945 PMCID: PMC3421915 DOI: 10.4103/1947-2714.99519] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Fear of scar rupture is one of risks involved in a post caesarean pregnancy. This had led to an increased rate of repeat cesarean delivery in today's times. Closure of the uterine incision is a key step in cesarean section, and it is imperative that an optimal surgical technique be employed for closing a uterine scar. This technique should be able to withstand the stress of subsequent labor. In the existing techniques of uterine closure, single or double layer, correct approximation of the cut margins, that is, decidua-to-decidua, myometrium to myometrium, serosa to serosa is not guaranteed. Also, there are high chances of inter surgeon variability. It was felt that if a suturing technique which ensures correct approximation of all the layers mentioned above with nil or minimal possibility of inter operator variability existed, there will not be any thinning of lower segment caesarean section (LSCS). Further, a scarred uterus repaired in this manner will be able to withstand the stress of labor in future. We hereby report a new technique for uterine closure devised by us, which incorporates a continuous modified mattress suture technique as a modification of the existing surgical technique of uterine closure.
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Affiliation(s)
- KM Babu
- Department of Obstetrics and Gynecology, Air Force Hospital, Gorakhpur, India
| | - Navneet Magon
- Department of Obstetrics and Gynecology, Air Force Hospital, Kanpur, Uttar Pradesh, India
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Ceci O, Cantatore C, Scioscia M, Nardelli C, Ravi M, Vimercati A, Bettocchi S. Ultrasonographic and hysteroscopic outcomes of uterine scar healing after cesarean section: Comparison of two types of single-layer suture. J Obstet Gynaecol Res 2012; 38:1302-7. [DOI: 10.1111/j.1447-0756.2012.01872.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Naji O, Abdallah Y, Bij De Vaate AJ, Smith A, Pexsters A, Stalder C, McIndoe A, Ghaem-Maghami S, Lees C, Brölmann HAM, Huirne JAF, Timmerman D, Bourne T. Standardized approach for imaging and measuring Cesarean section scars using ultrasonography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:252-259. [PMID: 21858885 DOI: 10.1002/uog.10077] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Incomplete healing of the scar is a recognized sequel of Cesarean section (CS) and may be associated with complications in later pregnancies. These complications can include scar pregnancy, a morbidly adherent placenta, scar dehiscence or rupture. To date there is uncertainty relating to the factors that lead to poor scar healing and how to recognize it. In recent years, there has been an increase in studies using ultrasound that describe scars as deficient, or poorly, incompletely or inadequately healed with few data to associate the morphology of the scar with the functional integrity of the lower segment of the uterus. There have been multiple attempts to describe CS scars using ultrasonography. Different terminology, methods and results have been reported, yet there is still no consensus regarding the prevalence, clinical significance or most appropriate method to describe the appearances of these scars. Developing a test that can predict the likelihood of women having problems associated with a CS scar is becoming increasingly important. On the other hand, understanding whether the ultrasound appearances of the scar can tell us anything about its integrity is not well supported by the research evidence. In this article we present an overview of ultrasound-based definitions and methods used to describe CS scars. We also present information relating to the performance of alternative techniques used to evaluate CS scars. Having examined the current evidence we suggest a standardized approach to describe CS scars using ultrasound so that future studies can be meaningfully compared.
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Affiliation(s)
- O Naji
- Obstetrics and Gynaecology Unit, Queen Charlottes and Chelsea Hospital, Imperial College London, London, UK.
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Yazicioglu HF, Sevket O, Ekin M, Ozyurt O, Aygun M. Incomplete Healing of the Uterine Incision after Cesarean Section: Is It Preventable by Intraoperative Digital Dilatation of the Internal Cervical Ostium? Gynecol Obstet Invest 2012; 74:131-5. [DOI: 10.1159/000339936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 06/03/2012] [Indexed: 11/19/2022]
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Abstract
Uterine rupture, which involves complete separation of the uterine wall, occurs in about 1% of those attempting vaginal birth after cesarean. Because uterine rupture is one of the most significant complications of a trial of labor (TOL) after previous cesarean, identifying those at increased risk of uterine rupture is paramount to the safety of a TOL after previous cesarean birth. It seems that both antepartum demographic characteristics and intrapartum factors modify the risk of uterine rupture. The ability to reliably predict an individual's a priori risk for intrapartum uterine rupture remains a major area of investigation.
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Affiliation(s)
- Carolyn M Zelop
- Beth Israel Deaconess Medical Center, Division of Maternal Fetal Medicine, Harvard University School of Medicine, Boston, MA 02215, USA.
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Abstract
PURPOSE OF REVIEW Cesarean section is the most common surgical procedure performed on US women, and rates of cesarean delivery continue to increase. RECENT FINDINGS Recent studies on operative technique in cesarean section have contributed significantly to our knowledge of antibiotic prophylaxis, bladder flap formation, management of the uterine repair and closure of the peritoneum and skin. There is compelling evidence that antibiotics should be given prior to skin incision rather than the traditional administration after cord clamping. Additionally, evidence suggesting benefit to multiagent, extended-coverage regimens is mounting. Recent studies challenge the accepted practice of creating a bladder flap in cesarean section. Uterine repair can be safely accomplished either intra or extraabdominally but the debate over single versus double-layer closure continues. Nonclosure of the visceral peritoneum confers significant benefit, but recent evidence suggests that closure of the parietal layer may be advantageous with respect to future adhesions. SUMMARY It is imperative that all technical aspects in cesarean section continue to be challenged. Widely accepted aspects, including antibiotics administration at cord clamping and creation of a bladder flap, may not be best practice.
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Vikhareva Osser O, Valentin L. Risk factors for incomplete healing of the uterine incision after caesarean section. BJOG 2010; 117:1119-26. [DOI: 10.1111/j.1471-0528.2010.02631.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Buhimschi CS, Zhao G, Sora N, Madri JA, Buhimschi IA. Myometrial wound healing post-Cesarean delivery in the MRL/MpJ mouse model of uterine scarring. THE AMERICAN JOURNAL OF PATHOLOGY 2010; 177:197-207. [PMID: 20489145 PMCID: PMC2893663 DOI: 10.2353/ajpath.2010.091209] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/15/2010] [Indexed: 11/20/2022]
Abstract
There is little known about healing of the uterus after Cesarean delivery (CD). Uterine wound repair was studied by using two strains of mice with different wound healing characteristics: MRL/MpJ(+/+) (MRL: "high-healer" phenotype) and C57Bl/6 ("low-healer" phenotype). First, we examined the morphology and histology of the uterine wall repair. We identified wound granulation tissue 3 days post-CD in both strains, albeit less in the MRL strain. Macroscopically, no scar could be identified either in MRL or C57Bl/6 mice on day 60 post-CD. However, histologically, we found significant differences in wound integration, inflammation, and collagen birefringence between the two strains of mice. Using a histological index, we provided evidence for significant differences in mitotic activity in the initial phases of uterine healing among strains. Functional behavior of the uterine scar also was analyzed by using biomechanical parameters such as slope (measure of stiffness), yield point (measure of elasticity), and break point (measure of strength). There were significant differences in stiffness of the scarred myometrium between the two phenotypes. MRL mice displayed a significantly lower yield point compared with C57Bl/6. The break point was reached faster on days 15 and 60 in both C57Bl/6 and MRL strains compared with day 3 post-CD. Our findings indicate that differences in regenerative ability translate in histological, mitotic, and functional differences in biomechanical properties of the scarred myometrium after CD.
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Affiliation(s)
- Catalin S Buhimschi
- Director Perinatal Research, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, 333 Cedar St, LLCI 804, New Haven, CT 06520, USA.
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Yazicioglu HF. Assessment of Cesarean section scars with transvaginal sonography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:250-252. [PMID: 20069682 DOI: 10.1002/uog.7539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Malvasi A, Tinelli A, Guido M, Zizza A, Farine D, Stark M. Should the visceral peritoneum at the bladder flap closed at cesarean sections? A post-partum sonographic and clinical assessment. J Matern Fetal Neonatal Med 2009; 23:662-9. [DOI: 10.3109/14767050903358363] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dodd JM, Anderson ER, Gates S. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev 2008:CD004732. [PMID: 18646108 DOI: 10.1002/14651858.cd004732.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator. OBJECTIVES To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and health care resource use. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2007). SELECTION CRITERIA All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section. DATA COLLECTION AND ANALYSIS Two authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently. MAIN RESULTS We identified 30 studies, of which 15 (3972 women) were included. Ten trials compared single layer uterine closure with double layer uterine closure (2531 women), two trials compared blunt with sharp dissection at the time of the uterine incision (1241 women), and two trials compared auto-suture devices with traditional hysterotomy (300 women). Blunt dissection was associated with a reduction in mean blood loss at the time of the procedure when compared with sharp dissection of the uterine incision (one study, 945 women, mean difference (MD) -43.00, 95% confidence interval (CI) -66.12 to -19.88). There was no statistically significant difference related to need for blood transfusion (one study, 945 women, risk ratio (RR) 0.22, 95% CI 0.05 to 1.01). The use of an auto-suture instrument when compared with traditional methods of hysterotomy was associated with no difference in the amount of blood loss during the procedure (one study, 200 women, MD -87.00, 95% CI -175.09 to 1.09), but a statistically significant increase in the duration of the procedure (one study, 197 women, MD 3.30, 95% CI 0.02 to 6.62). Single layer closure compared with double layer closure was associated with a statistically significant reduction in mean blood loss (three studies, 527 women, MD -70.11, 95% CI -101.61 to -38.60); duration of the operative procedure (four studies, 645 women, MD -7.43, 95% CI -8.41 to -6.46); and presence of postoperative pain (one study, 158 women, RR 0.69, 95% CI 0.52 to 0.91). AUTHORS' CONCLUSIONS While caesarean section is a common procedure performed on women worldwide, there is little information available to inform the most appropriate surgical technique to adopt.
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Affiliation(s)
- Jodie M Dodd
- School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, Australia, 5006.
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Ultrasound Evaluation of the Uterine Scar After Cesarean Delivery: A Randomized Controlled Trial of One- and Two-Layer Closure. Obstet Gynecol 2008; 111:452; author reply 452. [DOI: 10.1097/aog.0b013e318163c90b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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