Anterior Uterine Wall Research Articles

Radiating for Two: Quantifying Radiation Exposure to Pregnant Urologists During Percutaneous Nephrolithotomy.

Current occupational recommendations limit fetal radiation dose to 1 mSv. With increased gender diversity in urology, understanding radiation exposure during pregnancy is crucial. The purpose of this study was to determine surgeon uterine radiation dose during percutaneous nephrolithotomy (PCNL) and compare effectiveness of several radiation reduction strategies in a cadaver model. Two cadavers were used to simulate the surgeon and the patient in a PCNL model. An ion chamber was placed behind the surgeon's anterior uterine wall to measure the radiation dose. Three radiation reduction methods were compared: pulsed fluoroscopy (1, 4, 8, 15, 30 pps), low-dose (LD) fluoroscopy, and surgeon shielding (none, 0.35-, 0.50-, 0.70-mm lead equivalents). The average radiation dose per second was recorded for 20 trials per combination. Assuming 5 minutes of fluoroscopy per PCNL, the number of cases required to exceed the fetal occupational limit was determined. Decreasing pulse frequency from 30 to 1 pps reduced the dose by 96% (P < .001). The LD setting decreased the dose by 56% (P < .001). A 0.35-mm lead apron resulted in a 94% dose reduction (P < .001), and the 0.50- and 0.70-mm lead aprons further reduced the dose by 12% and 47%, respectively. In conventional fluoroscopy settings of automatic exposure control and at 30 pps, a surgeon could perform 12 PCNLs using no lead or 189 PCNLs using a 0.35-mm lead apron before reaching the 1 mSv limit. In addition to shielding, using 1 pps with LD fluoroscopy further decreased radiation exposure, allowing over 6000 cases to be performed with < 1 mSv uterine radiation exposure. Within the limitations of this cadaver study, these data support that high-volume pregnant surgeons using active radiation reduction techniques such as pulsed fluoroscopy, LD fluoroscopy, and appropriate shielding can maintain surgical volume with relatively low risk. Fetal dosimeter use with monthly monitoring is still encouraged to confirm safety throughout pregnancy.

The predictive role of uterocervical angle in labor outcomes: a narrative review.

Uterocervical angle (UCA) is the angle between the anterior or posterior uterine wall and the cervical canal, and it has become an unique ultrasonographic marker in the recent years. The predictive role of the UCA in spontaneous preterm births (sPTB) has been examined by numerous authors, however few data are available on UCA as predictor of labor outcome at term of pregnancy. Therefore, the purpose of this review is to evaluate the effectiveness of transvaginal ultrasound measurement of UCA at term, and its clinical implications in obstetrics' practice. A literature search was conducted including all studies regarding the predictive role of ultrasonographic evaluation of the UCA on labor outcomes from 1990 to 2023. A narrative synthesis was subsequently performed dividing studies that considered posterior and anterior UCA. Five studies were included for the anterior UCA, and ten for the posterior UCA. UCA was then evaluated as predictor of prolonged latent phase and predictor of the onset and mode of delivery. It is likely that the combination of multiple cervical parameters, rather than UCA assessment alone, together with clinical information, can achieve higher levels of accuracy in predicting delivery outcomes. Future prospective studies are needed to define with greater certainty the role of UCA as a useful screening tool before laboring, but, until then, the use of UCA as a screening test to predict labor outcome should remain investigational.

A Case Report of Rupture of Anterior Uterine Wall due to Cesarean Scar Ectopic Pregnancy

A Case Report of Rupture of Anterior Uterine Wall due to Cesarean Scar Ectopic Pregnancy

EP118 - Chronic Vesicouterine Fistula (Youssef's syndrome) Complete Opening of Anterior Uterine Wall in the Urinary Bladder: A- very rare case

Abstract Background Vesicouterine fistula is an uncommon urogenital condition typically following Caesarean sections (C/S). Youssef syndrome, characterized by haematuria, amenorrhea, and urinary incontinence, poses a diagnostic challenge and demands comprehensive assessment. Case report We present a case of a 40-year-old woman with persistent urine incontinence and haematuria for three years post her fourth C/S. Clinical evaluation revealed periodic lower abdominal pain, haematuria, amenorrhea, and urine incontinence. sonography was normally reported, while cystoscopy revealed a complete 5x2 cm opening between the anterior uterine wall and the posterior bladder wall, confirming Youssef syndrome. After a course of antibiotic therapy, surgical intervention was planned. Transabdominal total hysterectomy, partial cystectomy, and repair were performed following meticulous anatomical delineation using cystoscopy. The procedure involved dissecting the vesicouterine attachment, performing partial cystectomy, and eventually total hysterectomy. Closure of the urinary bladder defect with absorbable sutures and a negative leak test concluded the surgery. The patient showed no postoperative complications, with follow-ups at 6 and 12 months indicating complete recovery without complaints.

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

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

Imaging and video of late preterm delivery by midline laparotomy due to incarcerated uterus: A case report and literature review of a rare but morbid condition.

Incarcerated gravid uterus (IGU) is a rare and serious obstetric complication. IGU is defined as the entrapment of the gravid uterus between the pubic symphysis and the sacral promontory. The incidence of IGU is 1 in 3000-10 000 cases. IGU is associated with significant obstetric complications, including preterm labor, intrauterine fetal death, growth restriction, renal failure, uterine ischemia/rupture and thrombosis. Here, we present the case of a primigravida with urinary retention at 14 weeks. On transabdominal ultrasound at 19+5/7 weeks the cervix was difficult to visualize, and the anterior uterine wall appeared thickened. The bladder was elongated superior to the uterus and the placenta was low-lying. Initially the patient was managed with intermittent self-catheterization, and subsequently indwelling catheterization was required from 22 weeks. At 30 weeks, the patient was transferred to a tertiary center and magnetic resonance imaging (MRI) was preformed due to challenging visualization of the cervix on ultrasound and the patient's continued symptoms of constipation and recurrent urinary infections. The MRI found a retroflexed gravid uterus, with vagina and endocervix displaced anteriorly and compressed by the gravid uterus. The findings were consistent with an incarcerated uterus. The patient subsequently had positive urinary cultures for Pseudomonas and rising creatinine. Given the obstructive uropathy and associated morbidity and mortality, a plan for elective pre-term delivery at 33+6/7 weeks was made. Delivery was by midline laparotomy, normal anatomy was restored after manual evacuation of the fundus from below the sacral promontory, and an uncomplicated lower segment transverse uterine cesarean section was performed.

Low transverse caesarean section through the posterior uterine wall in a pregnant patient with asymptomatic uterine torsion of 180°: A case report

IntroductionExcessive torsion of a pregnant uterus is a rare and potentially extremely dangerous pathology for both the mother and fetus. The diagnosis is most often made intraoperatively.AimThe main aim was to show that when it is impossible to detort the uterus, a low transverse caesarean section through the posterior uterine wall can be safely performed.Case studyWe report a case of a 41-year-old multiparous woman at G II P II 39/40 weeks' gestation, who presented to the Gynecology and Obstetrics Department for an elective caesarean section due to a breech presentation of the fetus. During the caesarean section, a uterine torsion of 180° was found. As the uterus could not be detorted to its normal position, a low transverse caesarean section was performed through the posterior uterine wall. At follow-up visits after 8 weeks and 12 months, normal healing of the uterine muscle was confirmed.Results and discussionThe treatment of torsion of the pregnant uterus depends on gestational age and symptoms, in particular the presence of significant hemodynamic and ischemic lesions.ConclusionsThe procedure of choice in a full-term pregnancy should be an attempt to detort the uterus to its normal position and then perform a cesarean section through the anterior uterine wall. If detorsion of the uterus is not possible, a caesarean section through the posterior uterine wall should be performed. Based on the literature review and the case presented, it appears that this procedure is safe.

Pouch of sorrow: Undiagnosed isthmocele – presenting as secondary infertility of 11 years in a middle age female

In the past decade, the rate of cesarean sections has doubled leading to the more frequent occurrence of cesarean-related complications. Cesarean scar site diverticulum or isthmocele is one such complication that is defined as an outpouching of the anterior uterine wall at the cesarean scar site in continuity with the endometrial cavity, creating a wedge-shaped defect of variable depth. We report a case of a middle-aged female with secondary infertility for the last 11 years with one live issue 12 years back through a cesarean section at term. She had undergone an array of investigations for infertility for the past 5 years. She was diagnosed as having an isthmocele and managed with surgical repair of the defect at our hospital with subsequent assisted conception 8-month post-surgical repair. The importance of diagnosing a cesarean scar diverticulum cannot be understated not only because it is a surgically treatable cause of infertility but also because if such patients conceive, they may land in uterine rupture, placenta accreta, or scar ectopic pregnancy which can complicate into life-threatening situations.

Оценка влияния анатомического расположения плаценты на осложнения третьего периода родов: поперечное проспективное исследование

Objective. To investigate the influence of anatomical placental location (PL) on the duration and complications of the third stage of labor (TSL). Patients and methods. In this cross-sectional prospective study, 208 pregnant women were prospectively followed and determined at the delivery time at Tertiary Health Care Hospital Jamshoro from March 2021 to March 2022. The position of the placenta within the uterus was determined during obstetric examination by ultrasonography. The largest mass was identified by placing an ultrasonography probe at the center of the uterus and examining it through a sagittal view. Based on the placental location mass, participants were categorized into three groups: group A – anterior, group P – posterior, and group F – fundal. Results. The study found that among the 208 cases, the placenta was located in the anterior uterine wall in 54.81% (n = 114), in the posterior in 36.54% (n = 76), and in the fundal in 8.65% (n = 18). The duration of TSL was recorded in minutes in the anterior (6.31 ± 2.98), posterior (6.50 ± 3.49), and fundal (7.39 ± 3.27) placental groups, with a p-value of 0.06, indicating the non-significant difference. The placenta was separated peripherally in 25% (n = 52) of the subjects in each group and centrally in 75% (n = 176). Additionally, the delta-hematocrit value was determined in the anterior group (3.01 ± 4.28), the posterior group (3.23 ± 5.23), and the fundal group (2.81 ± 3.15); p = 0.96, indicating no significant difference. Conclusion. This research exhibited that PL did not affect the dynamics of TSL. Key words: anatomical placental location, complications, third stage of labor

A first trimester scan may reveal the presence of placentaaccreta. Absence of the anterior uterine wall duringcaesarean section: An unexpected placenta accreta that wastreated conservatively

Objective: Placenta accreta spectrum (PAS) is a rare condition, but it is a potential life threating obstetric event. Case report: A second-time mother, 32◦years old, has had a caesarean section before. At 11◦weeks, a doubt about scar pregnancy was posed but not confirmed at subsequent serial ultrasound evaluations. A caesarean section was performed at 38.4◦weeks for breech presentation. A placenta accreta, diagnosed during surgery and confirmed by histological evaluations, was visible at uterine examination with a lacuna in the anterior uterine wall. After fetal extraction, the surgeons opted for conservative management. Subsequent clinical and ultrasound follow-up described a patient in a good state of health with a progressively reduced intrauterine placenta residual. Conclusion:(1) Even in the absence of typical second- or third-trimester ultrasound signs, first trimester ultrasound played a role in posing the suspect of PAS. (2) Conservative management could be a safe option in cases of undiagnosed PAS, even if reported in the literature as a correlation with possible subsequent complications, which must be explained to the patient with adequate counselling.

Postcesarean disasters – Isthmocele, ventrofixed uterus, and cesarean scar pregnancy: A case series

Abstract Isthmocele is a niche defect in the area of previous cesarean scar. It is any indention representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity at the site of the previous cesarean section (CS) scar. Ventrofixed uterus is an adhesion between anterior surface of uterus and anterior abdominal wall secondary to Caesarean section. Cesarean scar pregnancy (CSP) pregnancy at a scar site is trouble either causing scar rupture or placenta accreta syndrome. Here are the seven cases of having a problem of isthmocele or ventrofixed uterus or both. All these cases had previous CS done at peripheral hospitals. The intension of this case series is to study preoperative symptoms, clinical and investigation findings, intraoperative presentation, and challenges with postoperative recovery in cases of previous CS-related problems. All these cases presented with us post-CS either lower abdominal pain, intermenstrual spotting, menorrhagia, or secondary infertility, and one had emergency abdominal pain with pregnancy. On hysteroscopy, a large niche at CS scar with trenches was detected in five cases, and on laparoscopy, ventrofixed uterus in five cases, and four cases have both. One has multiple fibroids, one has associated ventrofixed ovarian endometrioma. One case has ruptured CSP. After corrective hysterolaparoscopy surgery, all patients recovered well. Hysterolaparoscopic corrective surgery is a real need and challenge in cases of symptomatic ventrofixed uterus and isthmocele. The incidence and prevalence of isthmocele are greater than most gynecologists realize. It is imperative to understand the etiology and adopt preventive measures during CS to reduce its incidence and also to reduce the incidence of CSP.

Spontaneous Rupture of the Gravid Uterus in a Multigravida Women with a Previous History of Caesarean Section: A Case Report

Spontaneous uterine rupture is a rare obstetric complication that has catastrophic effects on both the mother and foetus, resulting in significant morbidity and 80 to 90% foetal mortality. Rupture of the uterus through a previous lower uterine segment scar is the most common cause in developing nations. However, factors such as lack of antenatal care, inappropriate obstetric interventions, obstructed labour, grand multiparity, unbooked status, limited access to emergency obstetric care, and low socioeconomic status play a crucial role in uterine rupture in developing countries like India. Hereby, the authors present a case report of a 31-year-old pregnant patient at 19 weeks of gestation with sudden severe lower abdominal pain. An ultrasound revealed the absence of foetal cardiac activity, placenta located outside the uterus, an empty endometrial cavity, and minimal free fluid in the pelvis. Further, an Magnetic Resonance Imaging (MRI) of the pelvis showed a rupture of the anterior and right lateral uterine wall, through which the foetus and most of the placental tissue had passed into the peritoneal cavity. After confirming the diagnosis, the patient underwent emergency laparotomy, during which the uterine wall defect was closed with appropriate haemostasis. The patient recovered without any untoward complications.

Evaluation of the anatomical locations and sizes of uterine fibroids from ultrasound examination in Ghana.

Uterine fibroids locations and sizes, have significant influences on the quality of life of women especially pregnant women and on live birth rate. To determine the anatomical locations and sizes of uterine fibroids and assess any possible associations with age groups. This retrospective study reviewed the locations and sizes of a total of 3,542 patients who were ultrasonographically diagnosed with uterine fibroids from January 2019 to December 2021. The obtained data were analysed using GNU PSPP, and Python on Jupyter Notebook with statistical significance level set at p≤0.05. The overall average diameter of uterine myoma was 5.50±2.60cm (95%CI=5.41-5.58, range=1.00cm-19.10cm) and the respective mean diameter of intramural, subserosal and submucosal fibroids were 5.53±2.60cm (95%CI=5.44-5.62), 5.50±2.27cm (95%CI=5.27-5.74) and 5.82±2.77cm (95%CI=5.49-6.14). Most of the fibroid nodules were small (48.36%, n=1713) and only 5.84% (n=207) were large (>10cm). Posterofundal fibroids and lower anterior myomas were mostly seen in the 35-44 years age class. The majority of the uterine fibroids were intramural and were mostly at the anterior uterine wall. The submucosal fibroids, even though the rarest, were averagely larger than the other types of uterine myomas. The diameter of uterine fibroids increased with age.

Investigating the risk factors for isthmocele development after cesarean delivery

ObjectiveCesarean section (CS) rates are increasing globally, raising concerns about associated complications like isthmocele. Isthmoceles are pouch-like defects in the anterior uterine wall at the site of a prior CS scar. This study aimed to determine isthmocele prevalence, associated symptoms, and risk factors among women with a CS history. MethodsThis cross-sectional study evaluated 297 women with prior CS using transvaginal ultrasound to screen for isthmocele. Data on demographics, pregnancy details, comorbidities, and indications for CS were collected. Isthmocele was defined sonographically as any niche or defect at the hysterotomy site. Descriptive and comparative analyses identified factors associated with isthmocele. ResultsIsthmocele prevalence was 65.3% (n=194). Abnormal vaginal bleeding was reported by 21.1%, pelvic pain by 4.1%, and both by 4.1%. Compared to women without isthmocele, those with isthmocele were older (35.9 vs. 31.6 years), had higher BMI (26.8 vs. 25.5 kg/m2), gravidity (1.8 vs. 1.3), and parity (1.7 vs. 1.2). Repeat CS was more common (30.4% vs. 12.6%) and elective CS less common (33.5% vs. 67.9%) among those with isthmocele. ConclusionOver half of the women with CS history had an isthmocele. Abnormal bleeding was common. Advanced maternal age, obesity, repeat procedures, and certain comorbidities appear to increase risk. Further research on prevention and treatment is warranted given the high prevalence.

Accuracy of Ultrasound in the Prediction of the FIGO Classification of Placenta Accreta Spectrum

ObjectivesTo evaluate the accuracy of greyscale ultrasound (US) and colour Doppler detecting placenta accreta spectrum (PAS) based on the newly recommended International Federation of Obstetrics and Gynaecology (FIGO) grading system. MethodsThis prospective study was conducted on women diagnosed with placenta previa or low-lying placenta involving the anterior uterine wall and associated with PAS as identified by the US. Transabdominal and transvaginal greyscale US was performed on admission between 34 and 36 weeks of gestation and compared to clinical grading and histopathological examination after cesarean hysterectomy. ResultsIn total, 36 pregnant females who underwent a cesarean hysterectomy due to placenta previa complicated by PAS were included in this study. All patients had a history of previous cesarean deliveries, ranging from 1 to 5 deliveries. The US has an overall sensitivity of 33%, 55%, and 84.62%, and specificity of 100%, 75%, and 60% in detecting the 3 degrees of PAS, respectively. US cannot differentiate between the different subtypes of PAS grade 3 (a, b, and c). ConclusionThe overall US evaluation was highly significant in predicting the FIGO diagnosis of PAS; however, all ultrasonographic signs were equally relevant in diagnosing grade 1 and/or 2 PAS and were inaccurate in differing the subtypes of PAS grade 3.

Effiacy of nausicaa compression sutures in terms of PPH management

ABSTRACT;&#x0D; BACKGROUND:Postpartum haemorrhage(PPH) is the most importantr cause of maternal death in Pakistan.Over 125,000 maternal deaths have been reported each year due to PPH. Major causes of PPH include uterine atony and haemorrhage from the placental bed. There is a recent increase in the rate of cesarean section which has increased the incidence of Placenta previa as well as placenta accreta spectrum. Apart from medical management, there are various conservative surgical interventions before imparting to hysterectomy such as uterine compression sutures which effectively secure hemostasis. The Nausicaa compression suture has been a new technique which effectively controls PPH in patients with uterine atony, placenta previa and accrete spectrum.&#x0D; OBJECTIVE: The objective of this study is to determine the efficacy of Nausicaa compression sutures in patientswith PPH undergoing cesarean section.&#x0D; PATIENTS AND METHOD: This study was conducted in the Obstetrics and Gynaecology department of Sir Ganga Ram Hospital,Lahore from 1st September2020 to 30th June,2022. Total of 80 patients who had PPH during cesarean section due to uterine atony or placenta previa spectrum were enrolled after informed consent. Nausicaa compression suture was applied to the anterior, posterior and both uterine walls where required.Successful procedure was those where only Nausicaa compression suture was sufficient to control PPH.&#x0D; RESULTS:The average age of patients was 30.3±4.2 years. There were 24(30%) primigravidas, 28(35%) were G2P1+0 and 28(35%) were multigravidas. The mean gestational age of patients was 37.58 weeks. 46 patients were operated on for indication of placenta previa. 6 patients had placenta accrete. 28 patients had other indications of LSCS. In 9 patients Nausicaa sutures were applied to the anterior uterine wall while in 71 patients to anterior and posterior uterine walls. In 62 patients Nausicaa suture was sufficient to control PPH. 10 patients required other interventions, while 8 patients required emergency hysterectomy due to intractable hemorrhage.&#x0D; CONCLUSION: The Nausicaa compression suture is an effective suture to control postpartum hemorrhage in patients with placenta previa and atonic uterus. It is most effective when applied to anterior and posterior both uterine walls separately.&#x0D; KEY WORDS: Post partum hemorrhage(PPH), Nausicaa Compression suture, Cesarean section.&#x0D;

Cervical ectopic pregnancy – the first case of live birth and uterus-conserving management

A 37-old III gravida II para with two previous cesarean sections (CS) presented in 7 + 3 weeks of pregnancy with cervical ectopic pregnancy (CEP). At 12th week of pregnancy, a cerclage was performed to avoid cervical distention by the expanding placenta. Due to missing experience in CEP management and to avoid emergency operation, we recommended CS in 30th week of pregnancy due to unspecific pain of the patient. Vaginal bleeding never occured.After transverse laparotomy, the urinary bladder was sharply dissected from the anterior uterine and cervical wall. The baby was delivered by transverse cervicotomy caudally of the placenta. The placenta was left in situ. The patient then got prophylactic embolization of the uterine arteries to prevent further severe hemorrhage. 48 h later, ultrasound showed a floating, avascular placenta within a poor echogenic fluid-filled cervical space as well as macrohematuria. After re-laparotomy and cervicotomy at the same day, the placenta was completely and easily evacuated. A bladder injury was recognized and closed. We performed a cervical internal os plasty by inverting the cervical lips and suturing their distal ends on the proximal cervical tissue, resulting in complete bleeding cessation. Although, the patient got 8 erythrocyte concentrates at all, she was always in a stable condition without hemorrhagic shock.This case demonstrates for the first time a live-birth with uterus-conserving management in CEP.

Ведення вагітності та розродження жінок з оперованою маткою і локалізацією плаценти на передній стінці матки (огляд літератури)

Purpose – to bring to the attention of obstetrician-gynecologists the relevance of influence of the placental location on the anterior uterine wall in women with an operated uterus after cesarean section (CS) on the course of pregnancy and childbirth with the prevention and minimization of possible complications. The placental location on the anterior wall of the uterus in pregnant women with a uterine scar after CS is the object of research in modern obstetrics. This factor of placental location can affect the course of pregnancy and childbirth, as well as creation increased risk of complications related to the health of the mother and fetus. An operated uterus with placental location on the anterior uterine wall can become a potential etiological factor of perinatal morbidity, which can be accompanied by intrauterine growth restriction, an increase in miscarriage and preterm birth, placenta previa and placenta accreta spectrum frequency, as well as an increased risk of uterine rupture in attempting vaginal birth after cesarean. As commonly stated, optimal conditions for fetal development are created by the placental location at uterus fundus, though labor dystocia is often observed during childbirth in this case. An increase in the percentage of CS and pregnancy in women with a uterine scar is often the cause of the decidual membrane defect and increases the frequency of placenta accretion (placenta accreta/increta/percreta) cases up to 30% in the cohort. One of the possible factors contributing to the attachment of the placenta to the anterior uterine wall is the presence of uterine scar after previous CS. Numerous studies indicate a significant increase in the frequency of placenta accreta cases over the past 20 years due to increase in CS cases and wide implementation of assisted reproductive technologies. Studies according to established criteria are still insufficient in modern obstetrics due to the limited number of pregnant women with localization of the placenta along the anterior wall after CS. More attention in studies is paid to the course of pregnancy and the method of delivery of pregnant women with a scar on the uterus. That states the focus of this article on the importance of clarification the pathogenesis, prevention of complications and delivery of pregnant women with uterine scar after CS and the placental anterior uterine wall localization. These findings confirm the need for further scientific research on this obstetric problem. Understanding the mechanisms behind this etiological connections can contribute to the development of better strategies for monitoring, diagnosis and various options for the delivery with the minimization of possible perinatal complications. No conflict of interests was declared by the authors.

Retrospective analysis of associated factors and adverse pregnancy outcomes of postpartum hemorrhage in the caesarean section of different types of placenta previa

Objective: To analyze associated factors and adverse pregnancy outcomes of postpartum hemorrhage in the caesarean section of puerperae with different types of placenta previa. Methods: This retrospective research was a case-control study. Puerperae with cesarean section of placenta previa from January 2019 to December 2020 in Women's Hospital, School of Medicine, Zhejiang University were collected and divided into the<1 000 ml control group or ≥1 000 ml postpartum hemorrhage group according to the amount of blood loss during cesarean section. Differences in continuous variables were analyzed by t-test and categorical variables were analyzed by χ2 test. The risk factors of postpartum hemorrhage were analyzed by logistic multivariate regression. Results: A total of 962 puerperae were enrolled with 773 cases in the control group and 189 cases in the postpartum hemorrhage group. The incidence of gestational weeks, gravidity, parity, induced abortion, placental accreta and preoperative hemoglobin<110 g/L was significantly different between two groups in different types of placenta previa (P<0.001). Logistic multivariate regression model analysis showed that the independent risk factors of postpartum hemorrhage in the caesarean section of low-lying placenta included placental accreta (OR=12.713, 95%CI: 4.296-37.625), preoperative hemoglobin<110 g/L (OR=2.377, 95%CI: 1.062-5.321), and prenatal vaginal bleeding (OR=4.244, 95%CI: 1.865-9.656). The independent risk factors of postpartum hemorrhage in the caesarean section of placenta previa included once induced abortion (OR=2.789, 95%CI:1.189-6.544), induced abortion≥2 (OR=2.843, 95%CI:1.101-7.339), placental accreta (OR=6.079, 95%CI:3.697-9.996), HBsAg positive (OR=3.891, 95%CI:1.385-10.929), and placental attachment to the anterior uterine wall (OR=2.307, 95%CI:1.285-4.142). The rate of postpartum hemorrhage and premature delivery in puerperae with placenta previa was higher than that in puerperae with low-lying placenta (P<0.001). Conclusions: The associated factors of postpartum hemorrhage in puerperae with different types of placenta previa are different. Placenta accreta is the common risk factor of postpartum hemorrhage in puerperae with low-lying placenta and placenta previa.

A first trimester scan may reveal the presence of placenta accreta. Absence of the anterior uterine wall during caesarean section: An unexpected placenta accreta that was treated conservatively

Objective: Placenta accreta spectrum (PAS) is a rare condition, but it is a potential life threating obstetric event. Case report: A second-time mother, 32◦years old, has had a caesarean section before. At 11◦weeks, a doubt about scar pregnancy was posed but not confirmed at subsequent serial ultrasound evaluations. A caesarean section was performed at 38.4◦weeks for breech presentation. A placenta accreta, diagnosed during surgery and confirmed by histological evaluations, was visible at uterine examination with a lacuna in the anterior uterine wall. After fetal extraction, the surgeons opted for conservative management. Subsequent clinical and ultrasound followup described a patient in a good state of health with a progressively reduced intrauterine placenta residual. Conclusion: (1) Even in the absence of typical second- or third-trimester ultrasound signs, first trimester ultrasound played a role in posing the suspect of PAS. (2) Conservative management could be a safe option in cases of undiagnosed PAS, even if reported in the literature as a correlation with possible subsequent complications, which must be explained to the patient with adequate counseling