Transabdominal ultrasound sliding sign for predicting intra-abdominal adhesions in repeat cesarean delivery: a prospective observational study from Vietnam.

To estimate the incidence of gestational diabetes mellitus (GDM) according to The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria and the pregnancy complications in women fulfilling these criteria but who are not considered diabetic according to the Canadian Diabetes Association criteria. We estimated the rate of GDM according to the IADPSG criteria from November 2008 to October 2010. Then, we conducted a chart review to compare maternal and neonatal outcomes between women classified as GDM according to the IADPSG criteria but not by the Canadian Diabetes Association criteria (group 1; n=186) and nondiabetic women according to both criteria (group 2; n=372). Results were expressed as crude (odds ratio [OR]) or adjusted OR and 95% confidence interval (CI). The study has a statistical power of 80% to detect a difference between 16% and 8% in large for gestational age newborns (α level of 0.05; two-tailed). The rate of GDM using the IADPSG criteria was 27.51% (95% CI 25.92-29.11). Group 1 presented similar rates of large-for-gestational-age newborns (9.1% compared with 5.9%, adjusted OR 1.58, 95% CI 0.79-3.13; P=.19), delivery complications (37.1% compared with 30.1%, OR 1.37, 95% CI 0.95-1.98; P=.10), preeclampsia (6.5% compared with 2.7%, adjusted OR 2.40, 95% CI 0.92-6.27; P=.07), prematurity (6.5% compared with 2.7%, OR 1.10, 95% CI 0.53-2.27; P=.85), neonatal complications at delivery (13.4% compared with 9.7%, OR 1.45, 95% CI 0.84-2.49; P=.20), and metabolic complications (10.8% compared with 14.2%, OR 0.73, 95% CI 0.42-1.26; P=.29) compared with group 2. Women classified as nondiabetic by the Canadian Diabetes Association Criteria but considered GDM according to the IADPSG criteria have similar pregnancy outcomes as women without GDM. More randomized studies with cost-effectiveness analyses are needed before implementation of these criteria. II.

To examine trends in repeat cesarean delivery, the characteristics of women who have repeat cesareans, and the risk of neonatal mortality for repeat cesarean birth compared to vaginal birth after cesarean (VBAC). Trends and characteristics of repeat cesareans were examined for: the period 1998-2002 for [1] all births, [2] low-risk births (singleton, term, vertex births) and [3] "no indicated risk" (NIR) births (singleton, term, vertex presentation births with no reported medical risks or complications). For low-risk and NIR births, neonatal mortality rates for repeat cesareans and VBACs were compared. Multivariate logistic regression was used to examine the risk of neonatal mortality for repeat cesareans and VBACs, after controlling for demographic and health factors. In 2002 the repeat cesarean rate was 87.4%, and varied little by maternal risk status or by demographic and health characteristics. From 1998-2002 rates increased by 20% for low risk and by 21% for NIR births, respectively. For low-risk women for the 1998-2002 birth cohorts, the adjusted odds ratio for neonatal mortality associated with repeat cesarean delivery (compared with VBAC) was 1.36 (95% C.I. 1.20-1.55). For NIR women, the adjusted odds ratio was 1.24 (0.99-1.55). The experience of a prior cesarean has apparently become a major indication for a repeat cesarean. Regardless of maternal risk status, almost 90% of women with a prior cesarean have a subsequent (i.e., repeat) cesarean delivery. This is the case even if there was no other reported medical indication. Our findings do not support the widely-held belief that neonatal mortality risk is significantly lower for repeat cesarean compared to VBAC delivery.

This study aims to investigate the relationship between cutaneous scar morphology and severe intra-abdominal adhesions and to predict uterine scar grade in repeat cesarean sections. It could be a valuable tool to plan elective repeat cesarean sections in patients with predicted weak uterine scars and also to have an experienced surgeon for repeat cesareans in patients predicted to have dense intra-abdominal adhesions. Preoperatively, the external scar was assessed using the Manchester score in 260 women. Intraoperatively, the Knightly score was used for adhesions at 5 different sites. The total adhesion score was categorized into scores ≤5 and >5 (severe adhesions). The uterine scar was graded using the Qureshi method and grouped into intact scar and weak scar (grades 3 and 4). Fischer exact and chi-square tests were used to compare the groups. The receiver operating characteristic curve calculated a cutoff score for predicting severe adhesions and weak scars. Of the 260 patients, 63.5% had adhesions and 36.5% had no adhesions. The distortion of the skin scar had 71.3% specificity, and the texture had 84.8% sensitivity in predicting severe adhesions. Similarly, the texture had 72.2% sensitivity, and the distortion had 68.3% specificity in predicting weak uterine scar. A Manchester Scar Scale score of 9 includes the area under the curve of 0.72 for predicting severe adhesions and 0.62 for predicting weak uterine scar. A score of 9 was 66.6% sensitive and 66.5% specific, with a negative predictive value (NPV) of 93.2% for predicting severe adhesions. The same score was 55.5% sensitive and 65.1% specific, with an NPV of 90.1% for predicting weak uterine scar. A Manchester Scar Scale cutoff score of 9 has a high NPV for predicting severe adhesions and weak uterine scar. The texture had high sensitivity, and distortion had high specificity for predicting severe adhesions.

Background Cesarean delivery (CD) is one of the most common operations worldwide. Vaginal birth after cesarean (VBAC) could be a solution to decrease increased CD rates. On the other hand, risks of VBAC on maternal and neonatal outcomes drifts physicians and patients to a scheduled CD. Successive CDs, especially after the 3rd operation, increase complications for the fetus and the mother. Operation type (emergency or elective CD) could be a risk factor of increased morbidities, like placental implantation anomalies. Evaluation of these conditions related to complications and morbidities were investigated. Material and methods: Women who underwent the fourth and more repeat CD in Bursa Yuksek Ihtisas Training Research Hospital between March 2016 and December 2019 were retrospectively reviewed. Pre-operative characteristics, per-operative and post-operative complications were reviewed. Patients were separated into groups as operational type, repeat cesarean number, and major morbidities. A comparison between groups was evaluated. Results: A total of 46.048 women gave birth, of which 17,721 underwent CDs with a rate of 38%. The rate of primary CD was 18%. The number of the fourth or more CD performed was 854. The number of patients who underwent fourth and fifth or more CD and of these operational data could be accessed was 599 and 145, respectively. The overall complications were detected as severe adhesions (n: 220), preterm delivery (n: 91), stillbirth (n: 9), admission to NICU (n: 98), bladder injury (n: 10), uterine scar dehiscence (n: 6), uterine rupture (n: 6), uterine atony (n: 26), blood transfusion requirement (n: 68), preterm delivery (n: 91), placenta previa totalis (n: 24), morbidly adherent placenta (n: 14), hysterectomy (n: 12), partial uterine resection (n: 2), uterus-conserving interventions (n: 26). The number of patients with major morbidity was 105. Emergency cesarean performed in 339 of 744 patients. A comparison of the emergency cesarean group with elective repeat cesarean group revealed no significant difference in operative adverse outcomes. Comparing patients between 4th repeat CD with 5th and more CD revealed a significant difference in severe adhesion, morbidly adherent placenta and hysterectomy. Previa totalis were detected in 24 patients. All of them experienced major morbidity with 12 of them underwent hysterectomy. The rest of them performed Uterus-conserving treatments (B-Lynch Suture, Bacri Balloon, Hypogastric artery ligation ) and a total of 51 units of packed red blood cells and 32 units of Fresh Frozen Plasma were transfused to 9 (37%) of 24 patients. Conclusion: The major risk factor of the morbidity is placenta previa whose incidence has dramatically increased after 3rd cesarean. Emergency cesarean did not increase the complication rate in the present study. Fourth and more repeat CDs ought to be performed by experienced obstetricians in high-equipped tertiary hospitals.

Intra-abdominal adhesions following caesarean sections pose significant challenges during repeat surgeries, leading to increased maternal morbidity. A reliable, non-invasive preoperative diagnostic tool such as the ultrasound (USG) sliding sign may help predict adhesions and improve surgical preparedness. To evaluate the diagnostic accuracy of the ultrasound sliding sign in predicting intra-abdominal adhesions in women undergoing repeat lower segment caesarean section (LSCS), and to correlate sonographic findings with intraoperative adhesion severity. This prospective observational study was conducted on 250 pregnant women with a history of one or more previous LSCS. All participants underwent preoperative transabdominal ultrasound to assess the presence or absence of the sliding sign. Adhesion severity was classified intraoperatively using the Nair classification. Associations between adhesion severity and clinical variables such as age, BMI, number of previous LSCS, and gestational age were analysed using chi-square and ANOVA tests. A significant association was observed between the absence of the USG sliding sign and the presence of moderate to severe adhesions (p < 0.001). The sliding sign demonstrated a sensitivity of72.88%, specificity of85.86%, positive predictive value of61.43%, and negative predictive value of91.11% and an overall accuracy of 82.8%. The receiver operating characteristic (ROC) curve analysis showed an area under the curve (AUC) of 0.96, indicating excellent diagnostic accuracy. Mean intraoperative blood loss and time from skin incision to delivery significantly increased with higher adhesion grades (p < 0.001). A statistically significant correlation was also noted between the number of previous LSCS and adhesion severity (p = 0.022), whereas age, BMI, gestational age, and place of previous delivery were not significantly associated. The ultrasound sliding sign is a simple, non-invasive, and effective tool for the preoperative prediction of intra-abdominal adhesions in women undergoing repeat caesarean sections. Its use may aid in surgical planning and reduce operative complications.

ObjectiveTo determine if the presence or absence of sonographic sliding sign preoperatively is a good predictor of the presence and type of intra-abdominal adhesions; and to determine the time taken...

Objective To explore the optimal timing of termination of pregnancy,we analyzed the different gestational age in repeat cesarean delivery and maternal and neonatal outcomes.Methods This was a retrospective study.The information of cesarean sections was collected from maternal obstetric records in the electronic medical recording system of the First Affiliated Hospital of Chongqing Medical University from June 1,2011 to June 30,2013,and women with intrauterine viable singleton pregnancies delivered after 37 weeks of gestation without prenatal complications were selected.They were divided into five groups with different gestational weeks.Maternal general information,perioperative outcome and rate of neonatal adverse event were analyzed with one way ANOVA analysis and Chi-square test.Results A total of 579 cases of elective repeat cesarean at term were performed.The ratios of cesarean section prior to 39 and 39-39+6 weeks of gestation were 64.6％ (374/579) and 29.0％ (168/579),respectively.No fetal,neonatal or maternal death occurred.There were no statistically significant differences in the termination of pregnancy at 37-37+6 weeks,38 38+6 weeks,39-39+6 weeks,40 weeks and ≥ 41 weeks between the two time intervals for cesarean section (P＞0.05).There were statistically significant differences in the length of hospitalization [(4.9±3.0),(4.3 ± 1.3),(4.3 ± 1.0),(4.5± 1.2) and (4.0±0.7) d,respectively; F=2.849,P＜0.05].No significant difference was observed in the maternal BMI,placental membrane residue,maternal perioperative bleeding,premature rupture of membrane (PROM),intensive care unit (ICU) admission and uterine resection (P＞0.05).There were statistically significant differences among the five groups in neonatal weight [(3 082.9±479.2),(3 318.1 ±390.8),(3 415.7±431.1),(3 630.5±475.2) and (3 334.0±242.5) g,F=13.798] and length [(48.8± 1.5),(49.3± 1.5),(49.6± 1.5),(50.0± 1.5) and (47.8±3.9) cm,F=7.460; both P＜0.05].One min and 5 min Apgar scores also showed statistically significant differences [1 min:(9.7±0.7),(9.8±0.6),(9.8±0.4),(9.7±0.5) and (8.8±2.7) ; F=4.432; 5 min:(9.9±0.3),(10.0±0.3),(10.0±0.2),(10.0±0.2) and (9.2± 1.8),F=9.625; all P＜0.05].The overall rates of neonatal adverse events,including the admission to neonatal intensive care units (NICU),the rates of cardiopulmonary resuscitation or ventilator therapy,asphyxiation,as well as the length of stay in NICU ≥ 5 d among the five groups also showed statistically significant differences [overall:5.4％ (5/93),1.8％ (5/281),0.6％ (1/168),0.0％ (0/32) and 2/5,x2=16.812;NICU:3.2％ (3/93),1.1％ (3/281),0.0％ (0/168),0.0％ (0/32) and 1/5; x2=1 1.294; cardiopulmonary resuscitation or ventilator therapy:2.2％ (2/93),0.7％ (2/281),0.0％ (0/168),0.0％(0/32) and 1/5,x2=10.584; asphyxiation:1.1％ (1/93),0.7％ (2/281),0.0％ (0/168),0.0％ (0/32) and 1/5,x2=9.637; NICU ≥ 5 d:3.2％ (3/93),1.1％ (3/281),0.0％ (0/168),0.0％ (0/32) and 1/5,x2=1 1.294; P＜0.05].The risks of neonatal adverse outcomes in delivery at 37-38+6 weeks were:OR=1.1(95％CI:1.0-2.1) at 37 37+6 weeks,OR=1.3 (95％CI:0.9-1.9) at 38-38+6 weeks,compared with delivery at 39-39+6 weeks.Conclnsions The percentage of repeat cesarean delivery prior to 39 weeks of gestation is high in our hospital,early termination of pregnancy would not reduce the maternal perioperative adverse outcome,but may increase the risk of neonatal adverse events.Taking into account the maternal benefit,we suggest 39 39+6 weeks of gestation as the best time of elective repeat cesarean in order to reduce the risk of neonatal adverse events. Key words: Cesarean section, repeat; Pregnancy outcome

Objectives:To compare maternal and neonatal outcomes in women who had repeated cesarean section between transverse and vertical skin incision.Materials and Methods:This comparative study was conducted from April 2014 until July 2015 at Rajavithi Hospital. Patients were recruited from women who had planned and undergone repeated cesarean delivery both scheduled and in emergency conditions. Women who enrolled in this study were having single pregnancy, without classical cesarean section, previous intra-abdominal surgery from other indication, and HIV infection backgrounds. Subjects were divided into two groups, transverse and vertical skin incisions. Data was collected from antenatal care records, anesthetic notes, operative notes and the research record forms.Results:According to the inclusion and exclusion criteria, 500 subjects were selected. There were 286 and 214 subjects in the transverse and vertical skin incision groups, respectively. Incision-to-delivery interval in transverse was longer than in the vertical group by about 2 minutes (p < 0.001). The total operative time ± SD was 84.67±30.96 and 79.69±26.83 minutes in the transverse and vertical skin incision groups, respectively (p = 0.043). There was no statistical difference in internal organ injuries, estimated blood loss, post-operative outcomes, Apgar scores and fetal injuries.Conclusion:In repeated cesarean delivery, transverse skin incision illustrated more incision-to-delivery interval and total operative time than vertical skin incision, but no difference in adverse maternal and neonatal outcomes.

Vaginal Birth After Cesarean: New Insights Manuscripts from an NIH Consensus Development Conference, March 8-10, 2010

The sliding sign (the relative motion between the abdominal and uterine wall as assessed by ultrasonography) may help identify severe intra-abdominal adhesions before repeat cesarean delivery. We conducted a prospective observational study of scheduled repeat cesarean deliveries. Using transabdominal ultrasonography, while the parturient breathed deeply, the ultrasonographer recorded a video clip in a sagittal plane lateral to the umbilicus. These clips were assessed for the presence (sliding-positive) or absence (sliding-negative) of relative movement between the maternal abdominal and uterine wall. Surgeons blinded to ultrasonography results graded the severity of intraperitoneal adhesions intraoperatively. Study outcomes were the accuracy of the preoperative sliding sign for prediction of severe adhesions and its association with surgical times and bleeding. We recruited 370 women. A negative sliding sign was associated with severe adhesions (sensitivity 56%, 95% CI 35-76; specificity 95%, 95% CI 93-97). A similar accuracy (sensitivity 64%, 95% CI 43-82; specificity 94%, 95% CI 92-97) was achieved by combining the sliding sign with a history of adhesions in the previous surgery. In multivariable models, a negative sliding sign was significantly correlated with a longer interval from skin incision to delivery and increased risk for bleeding. A negative sliding sign predicts severe intra-abdominal adhesions encountered during repeat cesarean delivery, longer time to delivery, and a higher chance of bleeding.

The decreasing trend in early-term repeat cesarean deliveries in the United States: 2005 through 2014

To assess the accuracy and utility of transabdominal sonographic paraumbilical and suprapubic sliding signs in predicting intra-abdominal adhesions in women undergoing repeat Cesarean section (CS), and to investigate the association of repeat CS with short-term maternal and neonatal outcomes. This was a prospective observational study of pregnant women with a history of CS who were scheduled for third-trimester elective or emergency CS at a tertiary referral and teaching hospital between July 2021 and June 2022. In order to evaluate the role of transabdominal sonographic paraumbilical and suprapubic sliding signs in the prediction of intra-abdominal adhesions, participants underwent a high-resolution transabdominal ultrasound scan prior to repeat CS. Free cephalad and caudad gliding of the uterus under the abdominal wall during deep inhalation and exhalation in each area was considered a positive sliding sign, suggesting a low risk of intra-abdominal adhesions. The absence of such movement was considered a negative sliding sign, suggesting a high risk of intra-abdominal adhesions. The presence or absence of intra-abdominal adhesions was then confirmed during surgery by physicians who were blinded to the sonographic sliding-sign findings. The type of adhesion, structures involved, method of adhesiolysis, incision-to-delivery time, 1-min and 5-min Apgar scores, maternal and neonatal injury and other short-term complications were also reported. Of 419 women with a history of at least one previous CS who underwent repeat CS, the preoperative sonographic paraumbilical and suprapubic sliding signs were negative in 173 (41.3%) and 178 (42.5%) women, respectively. On repeat CS, 224 (53.5%) women had intra-abdominal adhesions, of which 165 (39.4%) had dense adhesions and 59 (14.1%) had only filmy adhesions. The sensitivity and specificity of a negative preoperative paraumbilical sliding sign in predicting the presence of dense intra-abdominal adhesions in women undergoing repeat CS were 94.6% (95% CI, 92.4-96.7%) and 93.3% (95% CI, 90.9-95.7%), respectively. A negative suprapubic sliding sign also showed high sensitivity (95.2% (95% CI, 93.1-97.2%)) and specificity (91.7% (95% CI, 89.1-94.4%)). Additionally, a negative sliding sign at both locations in the same patient had robust sensitivity (90.2% (95% CI, 87.3-93.0%)) and specificity (96.3% (95% CI, 94.5-98.1%)). We found that the risk of dense intra-abdominal adhesions increased with parity and the number of previous CS. Dense intra-abdominal adhesions were associated with increased incision-to-delivery time, higher risk of maternal bladder injury, intraoperative bleeding and postpartum hemorrhage. Dense intra-abdominal adhesions are common in women with a history of CS and are associated with delayed delivery of the neonate and increased risk of adverse maternal outcomes. The transabdominal sonographic paraumbilical and suprapubic sliding signs are robust methods for the accurate preoperative prediction of dense intra-abdominal adhesions in patients with a history of CS. As the techniques are easy to learn and perform, the sliding sign should be used more widely for triaging patients at high risk of dense intra-abdominal adhesions for appropriate preoperative planning. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of postpartum quality of life between patients with repeat cesarean delivery and vaginal birth after cesarean

To assess clinical utility of the urine Congo red dot test (CRDT) in predicting composite adverse maternal and neonatal outcomes in women with suspected preeclampsia (PE). CRDT result and pregnancy outcomes were prospectively documented in women with new onset or pre-existing hypertension, new or pre-existing proteinuria, PE symptoms and suspected PE-related fetal growth restriction or abnormal Doppler presenting from 20weeks' gestation between January 2020 and December 2022. Participants and clinicians were blinded to the CRDT result and managed according to internally agreed protocols. Composite maternal outcome was defined as PE, postpartum hemorrhage, intensive care unit admission, and maternal death. Composite neonatal outcome was defined as small for gestational age, preterm birth, 5-min Apgar score < 7, neonatal intensive care unit admission, and neonatal death. Two hundred and forty-four women out of two hundred and fifty-one (97.2%) had a negative CRDT. All seven women with positive CRDT had both adverse maternal and neonatal outcomes, giving positive predictive values (PPV) of 100%. Rates of composite adverse maternal and neonatal outcomes in CDRT negative women were 103/244 [42.2%, 95% confidence interval (CI) 36.2%-48.5%] and 170/244 (69.7%, 95% CI 63.6%-75.1%), respectively. CRDT negative predictive values (NPV) for adverse maternal and neonatal outcomes were, respectively, 141/244 (57.8%, 95% CI 48.6%-68.2%) and 74/244 (30.3%, 95% CI 23.8%-38.1%). CRDT had low NPV but high PPV for adverse maternal and neonatal outcomes in women with suspected PE. Its role in clinical management and triage of women with suspected PE is limited as it cannot identify those at low risk of developing adverse outcomes.

In the early 1990s, there was a rapid increase in the number of vaginal birth after cesarean (VBAC) deliveries, followed by a decline beginning in 1996; during the later period, VBACs were considered controversial, largely because of a fear of uterine rupture. By 2001, the incidence of VBACs had markedly decreased, as many obstetricians instead performed repeat cesareans in women who had had a previous cesarean. Repeat cesareans are now common in pregnant women who have no medical indications for cesarean or would be at low maternal risk with a VBAC delivery. This study compared the maternal characteristics and rates of neonatal mortality of pregnancies delivered by repeat cesarean to those of pregnancies delivered by VBAC. Between 1998 and 2002, trends and characteristics of repeat cesareans were assessed in the following 3 groups: (1)all women; (2)low-risk women with singleton, full-term fetuses in vertex presentation; and (3)women with no indicated risk (NIR); women with singleton, full-term fetuses in vertex presentation, without 16 specific medical risk factors or 15 labor/delivery complications. The rates of neonatal mortality among low-risk and NIR births after either repeat cesarean or VBAC delivery were compared. Multivariate analysis was used to examine the rates of neonatal mortality in these 2 groups and to adjust for confounding factors. Trends in the repeat cesarean rate were very similar across all 3 groups in 2002; all had almost a 90% repeat cesarean rate. Between 1998 and 2002, there was an overall 20% to 21 % increase in the repeat cesarean rate among low risk and NIR births. The risk of neonatal mortality among low-risk women was significantly higher for repeat cesareans compared with VBAC deliveries (adjusted odds ratio [aOR]: 1.36; 95% confidence interval [CI]: 1.20-1.55; P ≤ 0.001). The risk of neonatal mortality was also higher in NIR women, but did not reach statistical significance (aOR: 1.24; 95% CI: 0.99-1.55). These findings indicate that the risk of neonatal mortality is not increased in pregnancies delivered by VBAC compared with those delivered by repeat cesarean. The data provide no support for the widely accepted belief that a VBAC delivery is associated with an enhanced risk of neonatal mortality.