Impact of Fetoscopic Surgery on the Myometrium: Experimental Study in an Ovine Model of Myelomeningocele.

Placenta accreta spectrum (PAS) is a major contributor to life-threatening obstetric hemorrhage and is increasingly encountered worldwide due to rising caesarean delivery rates. Caesarean hysterectomy remains the cornerstone of management in most cases; however, the optimal surgical techniques, subtotal versus total hysterectomy, continue to be debated. Current evidence is limited and heterogeneous, and practice often varies according to surgeon preference and intraoperative findings. By evaluating outcomes in a large cohort at a national tertiary referral center, this study aims to clarify the comparative safety and effectiveness of subtotal versus total hysterectomy in PAS management. We conducted a retrospective cohort study of women with PAS who underwent caesarean hysterectomy between 2018 and 2023. The primary outcome was intraoperative quantified blood loss (QBL). Secondary outcomes included operative time and bladder injury. Multivariable linear regression on log-transformed QBL and operative time was used to estimate adjusted geometric mean ratios, while bladder injury was analyzed using multivariable logistic regression. All models adjusted for surgical urgency, antenatal PAS severity, suspected cervical involvement, number of prior caesarean deliveries, gestational age at delivery, and surgeon identifier. Among the included patients, subtotal hysterectomy was associated with significantly lower intraoperative blood loss compared with total hysterectomy (adjusted geometric mean ratio 0.36, 95% CI 0.32-0.41; p-value < 0.001). Operative time was also significantly shorter in the subtotal hysterectomy group (adjusted geometric mean ratio 0.54, 95% CI 0.50-0.59; p-value < 0.001). In addition, subtotal hysterectomy was associated with a significantly lower odds of bladder injury (adjusted odds ratio 0.19, 95% CI 0.05-0.68; p-value = 0.013). Subtotal hysterectomy was associated with significantly lower intraoperative blood loss, shorter operative time, and fewer bladder injuries compared to total hysterectomy for placenta accreta spectrum. These findings support subtotal hysterectomy as a feasible and potentially safer surgical option in selected cases. While these findings support subtotal hysterectomy as a viable option, the retrospective design and potential selection bias highlight the need for individualized decision-making. Further multicenter prospective research with standardized surgical criteria is needed to confirm these results, minimize confounding from PAS severity, and determine the most effective surgical approach.

Postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. We evaluated maternal and perinatal outcome of primary massive postpartum hemorrhage. In a restrospective case analysis of 33 women with intractable postpartum hemorrhage initially managed either by hysterectomy or a conservative approach in a tertiary referral center between January 1, 1991 to December 30, 1998, we reviewed the procedures used as a primary or secondary attempt to arrest the hemorrhage. Medical and surgical measures were successful in controlling hemorrhage in 21 (63.6%) of the 33 women. Hemorrhage was successfully arrested by conservative surgery in 13 cases, and by medical management in 8 cases. Emergency hysterectomy was performed in 12 cases (0.7 per 1000 deliveries) No maternal deaths occurred, but there were 2 early neonatal deaths (6.1 %). Atony of the uterus was the main cause of hemorrhage (n=15). Genital tract laceration was associated with a worse prognosis, but the time lapse between delivery and surgery appears to be the main prognostic factor. Uterine atony and morbid adherent placenta are major causes of massive obstetric hemorrhage. In our series, morbidity was high, but there was no mortality. Obstetricians should identify women at risk which is especially associated with a prior cesarean delivery, a current placenta previa and high parity. Early intervention and proper procedure could minimize the complications.

Maternal and neonatal outcomes after uterine rupture in labor

First-trimester prediction of uterine rupture in cesarean scar pregnancy

Previous preterm cesarean delivery and risk of uterine rupture in subsequent trial of labor—a national cohort study

Background: The integrity of the lower uterine segment scar following cesarean section (CS) is a critical determinant of safety in subsequent pregnancies. Sonographic measurement of the uterine scar niche and residual myometrial thickness provides a non-invasive means of stratifying risk for uterine rupture, scar dehiscence, and adverse perinatal outcomes. Despite a nationally elevated CS rate in Iraq, data from local populations remain scarce. Objective: To evaluate the relationship between lower uterine segment (LUS) scar thickness measured by transabdominal ultrasonography at 36–38 weeks of gestation and subsequent obstetric outcomes in women with a previous cesarean section attending Babylon Educational Hospital for Gynecology and Pediatrics, Iraq. Methods: A prospective cohort study was conducted between January 2023 and December 2024. A total of 215 pregnant women with one or more prior CS were enrolled and classified by LUS thickness: Group I (thin scar, &lt;2.5 mm), Group II (adequate scar, 2.5–3.5 mm), and Group III (thick scar, &gt;3.5 mm). Maternal and neonatal outcomes including mode of delivery, intraoperative uterine rupture or dehiscence, blood transfusion, neonatal Apgar scores, NICU admission, and birth weight were recorded and analyzed. Results: Of the 215 participants, 67 (31.2%) had a thin scar, 89 (41.4%) an adequate scar, and 59 (27.4%) a thick scar. Complete uterine rupture occurred exclusively in Group I (7.5%), and scar dehiscence was significantly more frequent in Group I (20.9%) compared with Groups II (2.2%) and III (0%) (p&lt;0.001). Emergency CS, blood transfusion, and neonatal NICU admission were all significantly higher in Group I. Logistic regression identified LUS thickness as an independent predictor of uterine dehiscence (OR 0.34 per mm increase; 95% CI 0.18–0.63; p=0.001). Conclusion: Lower uterine segment scar thickness measured at 36–38 weeks of gestation is a reliable sonographic predictor of uterine scar complications and adverse perinatal outcomes in Iraqi women. Routine third-trimester LUS assessment should be incorporated into antenatal care protocols for women with previous cesarean delivery.

Hemostatic agents use during cesarean delivery and the risk for uterine rupture during subsequent TOLAC

Current information on the risk of uterine rupture after cesarean delivery has generally compared the risk after trial of labor to that occurring with an elective cesarean delivery without labor. Because antepartum counseling cannot account for whether a woman will develop an indication requiring a repeat cesarean delivery or whether labor will occur before scheduled cesarean delivery, the purpose of this analysis was to provide clinically useful information regarding the risks of uterine rupture and adverse perinatal outcome for women at term with a history of prior cesarean delivery. Women with a term singleton gestation and prior cesarean delivery were studied over 4 years at 19 centers. For this analysis, outcomes from five groups were studied: trial of labor, elective repeat with no labor, elective repeat with labor (women presenting in early labor who subsequently underwent cesarean delivery), indicated repeat with labor, and indicated repeat without labor. All cases of uterine rupture were reviewed centrally to assure accuracy of diagnosis. A total of 39,117 women were studied. In term pregnant women with a prior cesarean delivery, the overall risk for uterine rupture was 0.32% (125 of 39,117), and the overall risk for serious adverse perinatal outcome (stillbirth, hypoxic ischemic encephalopathy, neonatal death) was 106 of 39,049 (0.27%). The uterine rupture risk for indicated repeat cesarean delivery (labor or without labor) was 7 of 6,080 (0.12%); the risk for elective (no indication) repeat cesarean delivery (labor or without labor) was 4 of 17,714 (0.02%). Indicated repeat cesarean delivery increased the risk of uterine rupture by a factor of 5 (odds ratio 5.1, 95% confidence interval 1.49-17.44). In the absence of an indication, the presence of labor also increased the risk of uterine rupture (4 of 2,721 [0.15%] compared with 0 of 14,993, P<.01). The highest rate of uterine rupture occurred in women undergoing trial of labor (0.74%, 114 of 15,323). At term, the risk of uterine rupture and adverse perinatal outcome for women with a singleton and prior cesarean delivery is low regardless of mode of delivery, occurring in 3 per 1,000 women. Maternal complications occurred in 3-8% of women within the five delivery groups.

Introduction: Uterine scar dehiscence is a common complication of caesarean delivery, which increases the risk of uterine rupture. Uterine rupture is a complete division of all three layers of the uterus: the perimetrium, myometrium, and endometrium; while uterine dehiscence is considered an incomplete division of the three layers, allowing visibility of the foetus through the perimetrium. Objective: To determine the risk factors for uterine scar dehiscence among women undergoing repeat cesarean delivery. Methodology: This is a prospective observational study conducted at Dept. of Obst & Gynae, Shaheed Tazuddin Ahmad Medical College & Hospital, Gazipur, Bangladesh from July to December 2022. Total 120 women who underwent repeat LSCS and uterine scar dehiscence recorded by the operating surgeon were eligible. Data was collected regarding maternal age, obstetrical history, associated risk factors and outcome. Results: Total 120 women with Uterine Scar Dehiscence were studied and risk factors determined. In the age groups, maximum uterine scar dehiscence were noted in age group of 20-25 years (38.3%) and 26-30 years (34.1%) and the number of pregnancies are also seen more in these age groups. however significant number of uterine scar dehiscence were noted in age group 31-35 years (24.1%). The rate of uterine scar dehiscence was found to be associated with increased pre-term delivery, around 30.8% in our study. This leaded to increased neonatal pre-term delivery, low birth weight (19.1%) and NICU admissions. Inter-delivery interval

The consequences of previous uterine scar dehiscence and cesarean delivery on subsequent births

BackgroundPrior to 1996, most women who had undergone two previous cesarean deliveries were offered only cesarean delivery at Al-Hasa Health Centre. A policy of trial of labor was instituted in 1996. We compared the outcome of trial of labor versus cesarean delivery in women with a history of two previous cesarean deliveries who delivered between 1997 and 2002.Patients and MethodsAll patients with a history of two previous lower segment cesarean deliveries were included in the study. Those considered suitable were permitted a trial of labor that was neither induced nor augmented at any stage.ResultsOf the 205 patients in the study, 66 delivered vaginally (32.2%), 68 had an emergency cesarean delivery (33.2%), and 71 an elective cesarean delivery (34.6%). No scar dehiscence was observed, nor was hysterectomy performed in either group. The rate of complications was lower in the vaginal delivery group (4.5%) than in the cesarean delivery group (19.4%).ConclusionTrial of labor in women with a history of two cesarean deliveries is a reasonable consideration, and when carried out without the use of oxytocics or prostaglandins, is associated with reduced maternal morbidity with no difference in perinatal morbidity.

Background: Rates of cesarean delivery vary internationally, but generally, it has shown a worldwide increase. Repeated cesarean deliveries was found to be associated with increased maternal morbidity, including placenta previa, placenta accreta, hysterectomy, adhesions, bladder injury, postoperative hemoglobin deficit and need for blood transfusion. Objective: In our study, we evaluated the outcome of emergency cesarean deliveries conducted at Bani Suef General Hospital and the impact of repeated cesarean deliveries on that outcome. Patients and methods: We recruited 300 patients admitted at the Casualty Department. The patients were divided equally into 3 groups (100 patients in each group) as follows: group 1: Patients with previous one cesarean delivery, group 2: Patients with previous two cesarean delivery and group 3: Patients with previous three or more cesarean deliveries. Results: The operative duration was statistically significantly longer in patients with previous three or more cesarean deliveries (group 3) than patients with previous one cesarean delivery (group 1) or previous two cesarean delivery (group 2) [74.4, 44.4, 56.4 min respectively, p < 0.001]. The estimated blood loss was found to be higher in group three than one and two attributed to higher incidence of placenta previa and placenta accrete in group three. The incidence of adhesions (omental and bladder) was significantly higher in group three, but the incidence of bowel adhesion was the same in group three and two (which was statistically not significant). Conclusion: The rate of complications was higher in group three (bladder and bowel injuries, scar dehiscence, placenta previa, placenta accreta, hysterectomy and post-operative ICU admission).

Background: Rates of cesarean delivery vary internationally, but generally, it has shown a worldwide increase. Repeated cesarean deliveries was found to be associated with increased maternal morbidity, including placenta previa, placenta accreta, hysterectomy, adhesions, bladder injury, postoperative hemoglobin deficit and need for blood transfusion. Objective: In our study, we evaluated the outcome of emergency cesarean deliveries conducted at Bani Suef General Hospital and the impact of repeated cesarean deliveries on that outcome. Patients and methods: We recruited 300 patients admitted at the Casualty Department. The patients were divided equally into 3 groups (100 patients in each group) as follows: group 1: Patients with previous one cesarean delivery, group 2: Patients with previous two cesarean delivery and group 3: Patients with previous three or more cesarean deliveries. Results: The operative duration was statistically significantly longer in patients with previous three or more cesarean deliveries (group 3) than patients with previous one cesarean delivery (group 1) or previous two cesarean delivery (group 2) [74.4, 44.4, 56.4 min respectively, p < 0.001]. The estimated blood loss was found to be higher in group three than one and two attributed to higher incidence of placenta previa and placenta accrete in group three. The incidence of adhesions (omental and bladder) was significantly higher in group three, but the incidence of bowel adhesion was the same in group three and two (which was statistically not significant). Conclusion: The rate of complications was higher in group three (bladder and bowel injuries, scar dehiscence, placenta previa, placenta accreta, hysterectomy and post-operative ICU admission).

To determine if women with a history of a previous preterm cesarean delivery experienced an increased risk of subsequent uterine rupture compared with women who had a previous nonclassic term cesarean delivery. A prospective observational study was performed in singleton gestations that had a previous nonclassic cesarean delivery from 1999 to 2002. Women with a history of a previous preterm cesarean delivery were compared with women who had a previous term cesarean delivery. Women who had both a preterm and term cesarean delivery were included in the preterm group. A prior preterm cesarean delivery was significantly associated with an increased risk of subsequent uterine rupture (0.58% compared with 0.28%, P<.001). When women who had a subsequent elective cesarean delivery were removed (remaining n=26,454) women with a previous preterm cesarean delivery were still significantly more likely to sustain a uterine rupture (0.79% compared with 0.46%, P=.001). However, when only women who had a subsequent trial of labor were included, there was still an absolute increased risk of uterine rupture, but it was not statistically significant (1.00% compared with 0.68%, P=.081). In a multivariable analysis controlling for confounding variables (oxytocin use, two or more previous cesarean deliveries, a cesarean delivery within the past 2 years, and preterm delivery in the current pregnancy), patients with a previous preterm cesarean delivery remained at an increased risk of subsequent uterine rupture (P=.043, odds ratio 1.6, 95% confidence interval 1.01-2.50) compared with women with previous term cesarean delivery. Women who have had a previous preterm cesarean delivery are at a minimally increased risk for uterine rupture in a subsequent pregnancy when compared with women who have had previous term cesarean deliveries.

We sought to study the effects of prior vaginal delivery or prior vaginal birth after cesarean delivery (VBAC) on the success of a trial of labor after a cesarean delivery. An observational study of patients who underwent a trial of labor after a single low-transverse cesarean delivery. Patients with a previous cesarean delivery and no vaginal birth were compared with patients with a single vaginal delivery before or after the previous cesarean delivery. The rates of successful VBAC, uterine rupture, and scar dehiscence were analyzed. Multivariable regression was performed to adjust for confounding variables. Of 2,204 patients, 1,685 (76.4%) had a previous cesarean delivery and no vaginal delivery, 198 (9.0%) had a vaginal delivery before the cesarean delivery, and 321 (14.6%) had a prior VBAC. The rate of successful trial of labor was 70.1%, 81.8%, and 93.1%, respectively (P <.001). A prior VBAC was associated with fewer third- and fourth-degree lacerations (8.5% versus 2.5% versus 3.7%, P <.001) and fewer operative vaginal deliveries (14.7% versus 5.6% versus 1.9%, P <.001) but not with uterine rupture (1.5% versus 0.5% versus 0.3%, P =.12). Patients with a prior VBAC had, in addition, a higher rate of uterine scar dehiscence (21.8%) compared with patients with a previous cesarean delivery and no vaginal delivery (5.3%; P =.001). A prior vaginal delivery and, particularly, a prior VBAC are associated with a higher rate of successful trial of labor compared with patients with no prior vaginal delivery. In addition, prior VBAC is associated with an increased rate of uterine scar dehiscence.