Cesarean Section Scar Research Articles

Prevalence of Caesarean Section Scar Endometriosis: 10-years Experience of a Tertiary Center and Retrospective Evaluation of 40 cases

Prevalence of Caesarean Section Scar Endometriosis: 10-years Experience of a Tertiary Center and Retrospective Evaluation of 40 cases

Association of Menstrual Extension and Surgery Effectiveness with Ultrasound Parameters of Cesarean Section Scar Diverticulum in Patients Undergoing Transvaginal Uterine Diverticulum Repair.

The association of residual myometrium thickness (RMT) and scar defect depth (D) with menstrual abnormalities and the effectiveness of vaginal repair remain to be determined in patients with cesarean section scar diverticulum (CSD). To assess the value of ultrasound to predict vaginal repair effectiveness. This was a retrospective study of patients with CSD treated with vaginal repair between 01/2014 and 02/2016 at Shanghai First Maternity and Infant Hospital (Tongji University). Transvaginal ultrasound was performed before and 3 months after surgical repair. RMT, D, scar defect length (L), and scar defect width (W) were measured. Width (W), D, and L increased along the duration of menstrual period (P < 0.05). When the menstrual extension time was ≥15 days, RMT/D and RMT/(RMT + D) were smaller than in patients with period <15 days (P < 0.05). L was the most positively correlated ultrasonic parameter with menstrual prolongation (r = 0.492). RMT/D and RMT/(RMT + D) were negatively correlated with prolonged menstruation (r = ‐0.304 and -0.305, respectively). RMT/D and RMT/(RMT + D) were associated with the disappearance of CSD after vaginal repair (P < 0.05). The cutoff value of RMT/(RMT + D) was 0.496, with sensitivity of 53.0% and specificity of 61.4%. L of CSD is closely correlated with menstrual extension but has no relationship with the effectiveness of surgery. RMT/(RMT + D) is correlated with menstrual extension time ≥15 days and the effectiveness of vaginal repair.

Cesarean scar pregnancy: a report of three cases and a critical review on the management

One of the rarest forms of ectopic pregnancy is represented by the implantation of pregnancy on the scar of cesarean section. The implant in the uterine scar tissue exposes the patient to a risk of massive bleeding, uterine rupture, and penetration by the syncytiotrophoblast into the bladder wall. Currently, there is no consensus on the optimal management of this condition. The medical, surgical, and radio-interventional approaches are all contemplated. Here the authors report and discuss the diagnosis and treatment of three cases of caesarean scar pregnancies.

Infrared thermography: usefulness in treatment with percutaneous needle electrolysis in cesarean section treatment. A case study

Abstract Background and Aim In Spain, one out of every four births is a cesarean delivery and in most cases complications occur such as adhesions. Adhesions may cause functional problems, as well as psychological and esthetic problems, such as pain and itchiness.A correct scarring restores connections and replaces the lost tissue, preserving esthetics and functionality. The final change in tissue tone will be responsible for the correct reestablishment of the vascular network. If this does not occur correctly, we may encounter situations with a high level of hypervascularization (hypothermic areas) and the probability of generating fibrosis. Infrared thermography (IT) is a complementary imaging test which is able to capture the infrared radiation emitted by the human body and transform this information into a thermal image. There is proportionality between skin temperature and skin blood flow, therefore, the thermal images provide us with information on skin blood flow. These data are then used to identify the areas of hypervascularization or local inflammation. Aims The aim of this study was to evaluate whether scar tissue has a different temperature to the surrounding tissue, also to detect areas of hyperthermia (hipervascularization) and apply percutaneous needle electrolysis (PNE) using thermography as a tool for assessment and monitoring. Material and Methods A case study of a woman aged 34 years with two cesarean section scars, the last of which took place 6 months before.Four sessions of PNE were performed using IT as a method to identify treatment points, with a time interval of 21 days between each application. Via infrared thermography, the scar area was assessed and the points where a greater temperature was registered were marked. Subsequently, the PNE technique was applied, performing 3 impacts with a duration of 3 seconds and with an intensity of 4 mA in each point marked. The intervention procedure was performed under ultrasound guidance, based on a transverse section of the scar and positioning the needle on the long axis, at a 45° tilt from the skin. The Visual Analog Scale (VAS) was registered in the first and last session. Results After the performance of PNE on the hyperthermic points of the scar, the VAS decreased from 5 points to 0 and both the mean scar temperature in relation to the surrounding tissue improved, also, there was a reduction of the hyperthermic points. Conclusion Infrared thermography may be a complementary imaging tool for finding alterations in the mean temperature of a scar tissue and identifying hyperthermic points which are a therapeutic target in the treatment with PNE. Besides, it could become a follow-up tool to monitor the evolution of the temperature of the scar, and therefore the effectiveness of the treatment applied. Despite the results obtained in this case, further studies are required.

Diagnosis of Placental Position by Early First-Trimester Ultrasound: A Pilot Study.

Conventional wisdom is that placental location cannot be identified before 8 weeks' gestation when the placenta first becomes hyperechogenic on ultrasound. We sought to evaluate whether placental location could be reliably diagnosed between 5 and 6 weeks' gestation. This was a retrospective analysis of prospectively acquired data. Early placental location was diagnosed by evaluation of the embryonal and yolk sac position inside the gestational sac on transvaginal ultrasound. Placental position was described as anterior, posterior, fundal, or lateral. Early and mid-pregnancy placental locations were compared and coded as being the same, having migrated to an adjacent surface, or being on an opposite surface. A total of 111 patients met study criteria, providing 141 placental locations, comprising 85 singleton and reduced pregnancies and 28 dichorionic twin pregnancies. The most common placental location was anterior in both singleton and twin/triplet pregnancies. Placental location at the mid-pregnancy ultrasound was consistent with early pregnancy location in 100% of cases, with 79.5% (112/141) being on the same surface and 20.5% (29/141) having expanded onto an adjacent surface. Placental location was not associated with pregnancy outcome, although our study may have been underpowered to detect a significant difference. Placental location diagnosed at 5 to 6 weeks' gestation is consistent with the location on mid-pregnancy ultrasound. Excluding the presence of an ectopic, cornual, or cesarean section scar and uterine subseptation pregnancy in early first trimester would allow a more effective tailoring of pregnancy follow-up.

Anterior Abdominal Wall Endometriosis Following Caesarean Section: Two Rare Cases

Parietal endometriosis is a rare clinical entity, whose pathophysiology remains unclear. It occurs most often after gynecological or obstetrical surgery. The clinical picture is relatively unspecific. Medical imaging is not very contributive. Only histological examination of the operative specimen can confirm the diagnosis. Surgical treatment must be wide enough to prevent recurrence. We report two cases of abdominal wall endometriosis occurring on caesarean section scar. Through these two cases, we will highlight the characteristics of this pathology including prognosis, which will help the practitioners in understanding the role of diagnosis and early management of this entity and its prevention during gynecological or obstetrical surgery.

1253 A Descriptive Analysis of Anomalous Ectopic Pregnancies

Study Objective The majority of ectopic pregnancies implant in the fallopian tube; however, 10% implant in non-tubal locations including the abdominal cavity, cervix, ovary, interstitium of the fallopian tube, broad ligament, uterine cornua, and cesarean section scar. The objective of this study is to describe the characteristics and history of patients presenting with anomalous ectopics encountered at North Shore University Hospital/Long Island Jewish (NSUH/LIJ) from 2016 to 2018. Design A descriptive analysis of the anomalous ectopics encountered at NSUH/LIJ from 2016 to 2018. Setting Patients presented to the emergency room and were treated medically or in an operating room setting at NSUH/LIJ. Patients or Participants 55 women of reproductive age presented to NSUH/LIJ with pelvic pain and a positive bHCG and were determined to have an ectopic pregnancy in a non-tubal location. Interventions Patients with heterotopic, ovarian, cervical, cesarean section scar and interstitial ectopics were primarily treated via minimally invasive laparoscopic excision. Those with cesarean section scar and cervical ectopics were managed with methotrexate and intracervical balloons. Measurements and Main Results The incidence of patients with anomalous ectopics was 13.6%. The average age at diagnosis was 35. 74.5% in this cohort reported to be never smokers. 74.5% reported having previous abdomino-pelvic surgery. 74.5% did not use ART prior to their presenting diagnosis. The breakdown of ectopics was- Cesarean scar (27.3%), Cornual (23.6%), Interstitial (20.0%), Cervical (16.4%), Heterotopic (5.5%), Abdominal (3.6%), and Ovarian (3.6%). Conclusion Anomalous ectopic pregnancies in the NSUH/LIJ population of patients are 3.6% more prevalent than that reported by current data. Although these patients did not report use of ART in association with the anomalous pregnancy, many of these patients reported having previous abdominopelvic surgeries. C-section scar ectopics were the most prevalent, which may be secondary to the higher rate of c-sections in the last decade.

Cesarean Ectopic Scar Revision

Video Objective To present a laparoscopic approach to secondary surgical management of cesarean scar pregnancy through removal of retained products of conception and scar revision. Setting We present the case of a 29-year-old G4P3 at 6w5d by LMP referred to a tertiary care facility for cesarean scar ectopic pregnancy. Ultrasound revealed a fetal pole with cardiac motion located at the site of patient's previous cesarean section scar, with bHCG 112,000. Interventions The patient underwent primary medical management with intra-sac and intra-placental administration of methotrexate, followed by intra-embryonic potassium chloride injection to achieve cessation of fetal cardiac motion. bHCG down-trended precipitously, but was persistently positive three months following treatment. Repeat imaging was obtained, which demonstrated retained products of conception (POCs) at the cesarean scar measuring 4.7cm. Given patient's desire for future fertility, she underwent laparoscopic removal of POCs and scar revision. We emphasize the following features of secondary surgical management: temporary bilateral uterine artery ligation, lysis of adhesions between the bladder and lower uterine segment, injection of dilute vasopressin adjacent to defect, enucleation of POCs, and two-layer closure of the myometrial defect. Conclusion There is limited large-scale data or clinical consensus surrounding optimal management for cesarean scar pregnancies. For patients who desire future fertility, little is known about recurrence and subsequent pregnancy outcomes. We present a safe and effective option for secondary surgical management of retained products of conception, which allows for repair of the defect and restoration of normal uterine anatomy.

Robotic Assisted Laparoscopic Resection of Uterine Isthmocele

Video Objective Uterine isthmoceles are pouchlike defects in the anterior uterine wall, at the site of a prior cesarean section scar. Its prevalence has increased in direct relation to the increase in cesarean rates worldwide. Isthmoceles cause abnormal uterine bleeding, secondary infertility, and pain. There is no standard treatment for isthmoceles. This video demonstrates a robotic assisted laparoscopic approach to the resection of a uterine isthmocele. Setting The patient is a 36 year old with a history of one cesarean section with abnormal uterine bleeding. She was diagnosed with an isthmocele by transvaginal ultrasound performed in preparation for embryo transfer. The patient was treated at a tertiary care centre in Brooklyn, New York. Interventions The risks, benefits, and alternatives of a robotic assisted laparoscopic resection of a uterine isthmocele were discussed with the patient and consent was obtained. The robot was docked and simultaneous hysteroscopy was performed. The fenestrated bipolar and monopolar scissors were used to perform lysis of adhesions and dissection of the bladder off the uterine isthmus and cervix. Robotic fluorescence imaging was used to identify the isthmocele defect via the “lantern sign” where the hysteroscopic light shines through the tissue similar to a lantern. The isthmocele was excised and the defect was reapproximated with an absorbable monofilament suture. A barbed suture was then used for a second imbricating layer, with excellent hemostasis. Fluorescence imaging was used again and the hysteroscopic light could no longer be identified, as the isthmocele had been resected and repaired. Conclusion Uterine isthmoceles are increasing in relation to the increased rate of cesarean sections. Symptomatic and asymptomatic women who desire future pregnancy should be offered surgical treatment. Robotic assisted laparoscopic management of uterine isthmoceles can be associated with increased patient satisfaction with faster recovery times, and decreased length of hospitalization, and should be considered when possible.

EP29.07: Hysteroscopic management of Caesarean section scar and interstitial (cornual) pregnancy

There is no consensus about surgical approach in cases of Caesarean section scar (CSSP) and interstitial (cornual) pregnancy (ISP). The optimal management is yet to be defined because it represents a rare form of ectopic pregnancy. With the raising number of Caesarean section deliveries the rate of this type of ectopic pregnancy increases. The raising trend in minimally invasive surgery offers new treatment modalities. We present two cases of ectopic pregnancies successfully managed by minimally invasive surgical technique: hysteroscopic resectoscope removal of retained products of conception (RPOC). Case 1: a 42-year-old Caucasian woman, gravida 2, Caesarean section 2, at 7 weeks gestation was diagnosed with pregnancy in the scar of previous Caesarean section - niche, with 2 hybrid myomas on the anterior wall of uterus measured in diameter 90x76 mm and 41x39 mm. Transvaginal ultrasound (TVUS) examination revealed endogenic type I CSSP. The initial beta human chorionic gonadotropin (b-hCG) was 93.745 IU/L. After one 50 mg dose methotrexate, she underwent hysteroscopic-guided removal (HGR) of embryo, leaving chorionic sac in situ. After 3 months, b-hCG fell to 158 IU/L, and vacuum aspiration of chorionic sac was performed. The intervention was successful, without complication. Case 2: a 29-year-old Caucasian woman, gravida 0, at 9 weeks gestation, with ectopic interstitial pregnancy in left cornu. Initial b-hCG on admission valued 1.666 IU/L. After laparoscopic confirmation of the interstitial pregnancy, the patient underwent HGR of the ISP. We used hysteroscopic resectoscope (HR) as a tool. Successful minimally invasive treatment using HR in both ectopic CSSP and ISP may be applied. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

EP27.44: Assessing the thickness of extremely thin Caesarean section scars in third trimester pregnancy

EP27.44: Assessing the thickness of extremely thin Caesarean section scars in third trimester pregnancy

EP31.22: Endometriosis of the uterine Caesarean section scar: a case report

EP31.22: Endometriosis of the uterine Caesarean section scar: a case report

The Success of Surgical and Medical Approach in the Treatment of Cesarean Scar Pregnancy

Objectives: The ectopic pregnancy in the cesarean section (CS) scar (CSP) is one of the potentially dangerous and late complications of CS. The current study aimed to evaluate the therapeutic approaches in managing CS scar ectopic pregnancy. Materials and Methods: This cross-sectional study was carried out on 63 CSP patients. The treatment approach was considered based on the shape and nature of the gestational sac (GS) during ultrasound evolutions. Patients’ demographic data, clinical manifestations, and systemic drug treatment (methotrexate, MTX), as well as the type of surgery, hospitalization times, and treatment-related complications were evaluated, followed by comparing the treatment efficacy in different approaches based on the human chorionic gonadotropin (hCG) resolution time. Results: The mean age of the subjects was 34.2±5.1 years (within the range of 22-44 years) and the median of B-hCG serum levels at diagnosis was 2319 IU. The vaginal bleeding and abdominal pain (27 [42.9%]) were the most common complaints, followed by a delayed menstrual cycle (8 [12.7%]). The majority of patients were subjected to surgical treatment and 29 cases (46%) were treated by medical approaches. The median time to B-hCG resolution was 42 days. The Cox proportional hazards model showed the significant effect of the treatment approach on time to B-hCG resolution (χ2 =37.78, df=4, P&lt;0.0001). Finally, the MTX plus surgery was the most effective treatment approach (OR=10.56, P&lt;0.0001) in managing CSP patients. Conclusions: Our findings in line with previous studies showed the superiority of the surgical approach alone or in combination with medical treatments compared to medical approaches alone.

Cesarean Section Scar Increta Following First Trimester Surgical Abortion: A Rare Phenomenon Requiring Hysterectomy

Cesarean Section Scar Increta Following First Trimester Surgical Abortion: A Rare Phenomenon Requiring Hysterectomy

The Long-term Effect of Perinatal Tissue Mesenchyme Stem Cells in the Treatment for Caesarean Section Scars

The Long-term Effect of Perinatal Tissue Mesenchyme Stem Cells in the Treatment for Caesarean Section Scars

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

Efficacy of Diathermy on Healing Power of Cesarean Section Scar

Efficacy of Diathermy on Healing Power of Cesarean Section Scar

The Role of an Oral Nutrition Supplement to Improve Cesarean Section Scar Appearance (A Case Report) (P12-049-19)

ObjectivesIntroduction: Scar assessment scales are used for a number of scars related to surgical procedures, burns and trauma. These objective and subjective scales help to assess the physical characteristics, pathological wound healing and overall esthetics related to scarring. Select nutrients play a vital role in tissue repair and wound healing. MethodsCase Description: A 28-year old female underwent a cesarean section delivery due to a frank breech positioning of the baby. The patient was considered to be within a healthy BMI range pre-pregnancy (BMI = 23.5) and consumed an overall healthy diet, as determined by the Dietary Guidelines for Americans. After surgery, she consumed two packets of Juven© daily mixed with 500–1000 mL water, for two weeks, to aid in wound healing. This oral nutrition supplement is composed of L-arginine, L-glutamine, collagen protein, β-hydroxy-β -methylbutyrate and vitamins and minerals; each nutrient with evidence-based support to boost wound healing. An obstetrician performed scar evaluations at two-weeks postpartum to identify short-term wound outcomes. The Stony Brook Scar Evaluation Scale (score 5 of 5) and the Manchester Scar Scale (score 8 of 18) revealed positive measures. ResultsDiscussion: Pathological scarring can be associated with substantial physical and psychological complications. Women who undergo cesarean sections are seeking ways to minimize the physical scar appearance and pathological wound healing. A twice daily supplementation of Juven© can assist in improvement in the visual cosmetic appearance and overall physical characteristics of scarring due to cesarean section. According to the results from scar scales utilized in this case, this surgical incision indicates “best possible scar”. ConclusionsAn oral nutrition supplement, used as an intervention post-cesarean section, can optimize scar appearance and overall wound healing. This case report gives insight as to how nutrition can play a role in revitalizing standard treatment after surgery. While this is just one case, there is an opportunity to enhance the physiological and psychological recovery from surgical scars, such as from a cesarean section. Funding SourcesNo funding to report.

CD10, CD34 and Ki67 Immunohistochemical Markers Expression in Endometriosis and Adenomyosis

Endometriosis is a benign disease represented by existence of endometrial tissue outside the uterine cavity. Considered in the past a type of endometriosis, adenomyosis is, presently, described as a possible different entity, comparative to endometriosis. That is the reason why we decided to study two groups of patients - one with endometriosis and one with adenomyosis - in order to determine if they are one and the same disease. We included all successive patients admitted and surgically treated in the Emergency Clinical Hospital Constanta between 2015-2017, and, after applying the selection criteria, we assessed 61 patients (group 1) diagnosed with endometriosis - ovarian, cervical, caesarian section scar - and 39 patients (group 2) with adenomyosis. We studied all patients in terms of age, parity, lesions� size, admissions� symptoms, chronic symptoms and immunohistochemical markers CD10, CD34, Ki67. We chose there three markers because of their possible relation to endometriosis and because we were unable to find data regarding the comparison of CD34 or Ki67 expression in endometriosis and adenomyosis and because we did not find articles that reported the expression of these three immunohistochemical markers, combined, for either endometriosis or adenomyosis. According to our study, it seems that endometriosis and adenomyosis are different clinically with regard of age and dysmenorrhea, but there was no statistical difference between the studied immunohistochemical biomarkers� expression in samples of patients with endometriosis or adenomyosis.

Isthmocele: an overview of diagnosis and treatment.

An isthmocele, a cesarean scar defect or uterine niche, is any indentation 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 a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.