Cesarean Section Scar Research Articles

Caesarean Section Scar Ectopic Pregnancy Presenting with Uterine Rupture: A Rare Case Report

Caesarean scar ectopic pregnancy is a rare form of pregnancy implanting on a caesarean scar and is considered a gynaecological emergency associated with scar rupture and increased incidence of maternal morbidity when complicated with haemorrhage. Scar pregnancy incidence being more common as there are increased caesarean deliveries nowadays. Here the authors present a case of 28-year-old female with caesarean section scar ectopic pregnancy with ruptured uterine scar and haemorrhage associated with haemodynamic collapse which has poor prognosis. Imaging plays a crucial role in early detection and helps the clinician in further management to reduce maternal morbidity and mortality.

Endovaginal Ultrasound versus Hysterosalpingography in Evaluation of Cesarean Scar

Background: Cesarean section (CS) is one of the most common surgical procedures in women. A recent study documented that Egypt ranked 3rd among world countries with an estimated rate of CS of 51.8%. Objective: We aimed to evaluate uterine scar after cesarean section (CS) by transvaginal ultrasound (TVS) versus hysterosalpingogram (HSG). Patient and methods: This cross-sectional studywas conducted on 38 patients after obtaining their approval to evaluate CS scar 3 months after delivery using TVS compared to HSG. The study was conducted in Obstetrics and Gynecology Department, Menoufia University in the period between January 2019 and January 2020. Results: Uterine scar defect was identified in 21 cases by HSG (55.3%), while TVS was able to identify it in only 13 cases (34.2%). Compared to HSG, transvaginal ultrasound had sensitivity and specificity of 61.9 and 100% respectively in detecting scar defects, with an accuracy of 78.94%, Conclusion: Along with increased radiological expertise expected with time, TVS will be more comparable to HSG and appears to be a promising tool in evaluation cesarean scar defect as it has significant agreement with HSG.

What are Polish women afraid of in vaginal birth? – A Cross-Sectional Study

Introduction. Fear of childbirth is a specific feeling related to approaching birth that ranges from negligible to very intense. Women’s choices and doubts regarding the way of birth may be related to a lack of knowledge about the benefits and advantages of VB or a fear of this method of childbearing. Aim. The aim of the study was to assess knowledge regarding labour, its possible complications and ways to prepare for vaginal delivery among Polish women Material and Methods. A cross-sectional study was performed among 4721 women who were pregnant or who had had at least one delivery. A self-composed questionnaire was distributed via the internet in 2018. Results. It seems that 13.9% of the respondents were pregnant, 49.2% women gave birth vaginally and 30.8% had a caesarean delivery. Most of the respondents were afraid of the pain associated with the labour (75% pregnant women, 63.4% women after vaginal birth, 59.1% women after caesarean section), and 57.8% of respondents would like to avoid episiotomy, but only 27,5% of them used any methods of perineal protection for vaginal delivery. Also, 43.4 % of respondents believe that vaginal delivery may have a negative impact on satisfaction in their sexual life, 26% of respondents think that a caesarean section scar has no impact on subsequent pregnancies, and 41% claim that women who had a caesarean delivery feel discriminated against as a cesarean section is considered to be a labour failure in society. Conclusions. Women’s knowledge on the advantages and risks related to the methods of labour is insufficient, which may affect their preferences regarding vaginal or cesarean birth.

Lower Uterine Section Transverse Incision Defect and Ectopic in the Cesarean Section Scar: A Case Presentation and Review of The Literature

Lower Uterine Section Transverse Incision Defect and Ectopic in the Cesarean Section Scar: A Case Presentation and Review of The Literature

Caesarean scar pregnancy: A rare form of ectopic pregnancy

Pregnancy in a caesarean scar is a rare entity where the pregnancy is implanted into a prior caesarean delivery uterine scar and located outside the normal uterine cavity. We report a case of caesarean scar ectopic pregnancy occurring in the scar of a previous caesarean section, diagnosed by ultrasonography and Doppler and the surgical management of such a case following failure of medical therapy. We present history, clinical findings and imaging of our case followed by discussion about, diagnosing and management of such a case and the options available. Keywords: CSP – Caesarean scar pregnancy, LSCS- Lower segment caesarean section, POG – Period of gestation.

Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk

Background The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri. Objective Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy Methods From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group. Results The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors. Conclusion In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.

Practical application of kinesiotaping in the case of a cesarean section scar

A scar is a skin change resulting from the healing process following, among others, a mechanical injury. Its reconstruction is an important stage that determines the final appearance of the scar and the functionality of the adjacent tissues. The aim of the study is to present the possibility of kinesiotaping in reducing the undesirable effects of a postoperative scar after a C-section on tissue mobility and disturbance of muscle tone. Kinesiotaping supports the spontaneous healing of the scar by reducing pain sensations, activating the lymphatic system, microcirculation, improving the functioning of the surrounding muscles and joints and normalizing muscle tension. Taping the scars is carried out using various techniques, where the direction of sticking or the extent to which the tape is stretched is important. The following techniques are useful in the treatment of caesarean scars: the Z technique, the step technique or the isolated fascial technique.

Robotic CSP Resection and Hysterotomy Repair

To demonstrate a technique for the robot-assisted laparoscopic surgical management of cesarean section scar ectopic pregnancy (CSP) and hysterotomy repair. Step-by-step presentation of the procedure using video. CSP is a rare form of ectopic pregnancy. The incidence of CSP has been increasing with rising cesarean deliveries and is estimated to range from 1 of 1800 to 1 of 2500 of all pregnancies. Various management of CSP have been used such as systemic or local methotrexate, surgical resection, and uterine artery chemoembolization. Exogenic or deep CSP occurs when the gestational sac is deeply embedded in the scar and the surrounding myometrium and grows toward the bladder. Surgical resection of this type of CSP seemed reasonable, which could shorten hospitalization and follow-up time and reduce the failure rate of treatment. For its magnification of the 3-dimensional laparoscope, flexibility endo-wrist, and stabilization of instruments within the surgical field, robot-assisted laparoscopic resection can be performed to manage this type of complex procedure. In this video, we describe our technique for robot-assisted laparoscopic management of a CSP and a hysterotomy repair. We present the case of a 34-year-old gravida 2 para 1 woman with the finding of a 7-week pregnancy embedded in the cesarean section scar. The patient had undergone 1 previous uncomplicated cesarean section at term. On presentation, her β-human chorionic gonadotropin level was 9212 IU/L. In this case, the gestational sac was deeply embedded in the scar and the surrounding myometrium and was growing toward the bladder. A decision was made to proceed with surgical treatment in the form of a robot-assisted laparoscopic resection of the ectopic pregnancy and the hysterotomy repair. The surgery was uneventful, and the patient was discharged home within 48 hours of her procedure. No residual scar defect was visible on follow-up ultrasonography 1 month after surgery. Forty days after surgery, the patient had resumed normal menstruation and was followed up for 3 years with regular menstruation and no abnormal uterine bleeding. Robot-assisted laparoscopic excision of CSP and hysterotomy repair is an effective procedure for the management of this increasingly more common condition. The use of a cervix dilator and robot-assisted laparoscopic suturing can prevent hemorrhage and peripheral tissue damage and allow for the safe removal of the ectopic pregnancy with multilayer repair of the uterine defect.

Differential Diagnosis of Cesarean Scar Pregnancies and Other Pregnancies Implanted in the Lower Uterus by Ultrasound Parameters.

Purpose Cesarean scar pregnancy is an extremely rare type of ectopic pregnancy implanted in the myometrium at the site of a previous cesarean section scar. On the other hand, pregnancies are considered low implantations if they are identified in the lower third of the uterus without the sac implanted into the scar and have a better prognosis. Early diagnosis of both types of pregnancies can help avoid serious complications. This study is aimed at investigating the significance of transvaginal ultrasound in the differential diagnosis of cesarean scar pregnancies and pregnancies implanted in the lower uterus. Methods Ninety-three patients with an average age of 32.7 years (range, 24–43 years) were enrolled in this study, including 66 cesarean scar pregnancies and 27 other pregnancies implanted in the lower uterus, and they were examined by transvaginal ultrasound. Results We observed significant differences in the relationship between the cesarean sac and the scar, the source of the trophoblastic blood flow, and the thickness of the residual muscle between the cesarean scar pregnancy group and the lower uterus pregnancy group. We established the logistic model to improve the differential diagnosis of cesarean scar pregnancies and pregnancies implanted in the lower uterus. Conclusions Transvaginal ultrasound is recommended in early pregnancy, especially for patients who have undergone a previous cesarean section delivery.

Experience With Medical Treatment of Cesarean Scar Ectopic Pregnancy (CSEP) With Local Ultrasound-Guided Injection of Methotrexate.

Objective: Ectopic pregnancy within Cesarean section scars is a rare condition. Late diagnosis carries significant risk of bleeding with poor prognosis for survival. There is no consensus on the management of this type of pregnancy. Historically, our facility offered an intra-muscular injection of methotrexate that resulted in a significant failure rate and later need for surgery. We hypothesized that injecting methotrexate directly into the gestational sac would improve the success rate of the treatment.Patients and Methods: This retrospective, uni-centric study examined nine patients aged between 33 and 42 years (mean age = 36.5 years) with Cesarean scar ectopic pregnancy (CSEP) between 2010 and 2018. CSEP was diagnosed by transvaginal ultrasound at a mean gestational age of 8w0/7. CSEP was treated under general anesthetic by ultrasound-guided methotrexate injection directly into the gestational sac. HCG levels and subsequent childbearing were monitored post-treatment.Results: Half of the patients were asymptomatic at the time of diagnosis. All patients tolerated treatment well and all ectopic pregnancies were successfully removed. HCG levels returned to negative within 3 months without additional medical or surgical intervention. The post-treatment pregnancy rate was 50%.Discussions/Conclusions: Our findings indicate that local ultrasound-guided injection of methotrexate into the gestational sac is a safe and effective therapeutic approach when performed by a trained team on a hemodynamically stable patient in the early stages of CSEP.

The B-mode sonographic evaluation of the post-caesarean uterine wall and its methodology: A study protocol.

The aim of this study is to utilize the niche measurement guidelines outlined by Jordans et al. in order to establish normal values and accurate description of caesarean section scars in a normal population. After defining the normal distribution, abnormal pregestational scar characteristics will be identified for predicting adverse pregnancy outcomes. This is a prospective observational multicenter clinical study where women with a history of only one caesarean section and yet open family planning are enrolled. The uterine length, cervical length, niche length, niche depth, niche width, residual myometrial thickness, endometrial thickness, scar to internal os distance, anterior myometrial thickness superior and inferior to the scar and the posterior myometrial thickness opposite the scar, superior and inferior to it are measured in a pregestational uterus. The lower uterine segment is measured over a length of 3 cm during subsequent pregnancy and followed up until delivery. Data from 500 patients will yield normal distribution curves for all predefined measurements. Establishing a correlation between deviations from the normal measures and adverse events would be instrumental for counseling women regarding subsequent pregnancy and mode of delivery. This study will demonstrate the changes of the post-caesarean scar from a non-pregnant uterus until delivery and can confirm the importance of the scar characteristics in predicting pregnancy outcome.

Intra- and inter-evaluator reliability of the MyotonPRO for the assessment of the viscoelastic properties of caesarean section scar and unscarred skin.

The clinical evaluation of viscoelastic properties of the Caesarean section (C-section) scar, such as stiffness and elasticity, is usually carried out using subjective scales and palpation techniques. There is currently no reliable and valid tool that objectively quantifies these properties. The MyotonPRO could fill this gap. Nineteen healthy women aged between 21 and 40years with C-section scars participated in this reliability study. Two points, one on the scar and one on unscarred skin, were measured four times successively with the MyotonPRO by three independent evaluators on the same day. The intra-class correlation (ICC) coefficients were estimated using a two-factor ANOVA to determine the inter- and intra-rater reliability. The capacity of the MyotonPRO to discriminate the viscoelastic properties of the C-Section scar against unscarred skin was assessed using the Wilcoxon signed rank test. The intra- and inter-rater reliability of the viscoelastic property measurements was good to excellent (ICC 0.99-1.00 and 0.87-0.98, respectively). There was no significant difference between C-section scar and unscarred skin in terms of elasticity (P=.737). Significant differences between C-section scars and unscarred skin tissue were observed for tone (P<.001), stiffness (P<.001), creep (P<.001), and mechanical stress relaxation time (P<.001). The MyotonPRO is a reliable tool for an objective measurement of the viscoelastic properties of the C-section scar and unscarred skin. The MyotonPRO can discriminate the viscoelastic properties of the C-section scar against the unscarred skin, for tone, stiffness, creep and relaxation times, but not for elasticity.

A Strategic Approach to a Total Laparoscopic Hysterectomy for an Advanced Cesarean Section Scar Ectopic Pregnancy with Cystotomy Repair.

Study Objective Present an interesting case of an advanced cesarean scar ectopic pregnancy that failed medical management and underwent treatment with a total laparoscopic hysterectomy. Design Video Case Report. Setting Tertiary Referral Hospital at a community-based OB/GYN residency program. Patients or Participants 37-year-old G3P3013 at 9 weeks gestation with a cesarean scar ectopic pregnancy. Interventions This video will present an interesting case of a 37yo G5P3013 that presented with a 9-week cesarean scar ectopic pregnancy. Initial treatment was with injection of KCL into the fetal heart and methotrexate into the gestational sac at 10 weeks gestation. The patient presented 5 weeks after initial treatment with persistent pain and vaginal bleeding. The patient was the thoroughly counseled on her treatment options. She had no desire for future pregnancy and the plan was made for total laparoscopic hysterectomy with bilateral salpingectomy. This video presentation shows how as strategic anatomic approach using isolation of the blood supply and utilizing avascular spaces can allow this case to be completed in a minimally invasive fashion. This case will also present the steps to repairing an incidental cystotomy that was encountered in the dissection Measurements and Main Results N/A Conclusion Advanced cesarean scar ectopic pregnancy can be treated in a minimally invasive fashion with total laparoscopic hysterectomy when future fertility is not desired.

Cesarean Section Scar Ectopic: Laparoscopic and Hysteroscopic Surgical Management

Study Objective To present a case of resection of cesarean section scar ectopic pregnancy with isthmocele repair using both laparoscopic and hysteroscopic techniques. Design N/A Setting Patient was positioned in the standard dorsal lithotomy position. Throughout the entirety of the video the patient is in Trendelenburg position. Patients or Participants A 25 yo G7P3124 who was diagnosed with a c-section scar ectopic pregnancy via 5w4d ultrasound after presenting with vaginal bleeding and abdominal pain. After being counseled on options for medical versus surgical management, she was initially treated with a dose of methotrexate. Upon further discussion the patient was transferred and opted for surgical management. Interventions In anticipation of potential significant blood loss, a laparoscopic tourniquet was placed at the lower uterine segment and the uterine arteries were skeletonized for easy ligation. A bladder flap was made at the level the vesicouterine peritoneum. The ectopic products of conception were removed hysteroscopically. The isthmocele was then resected and repaired laparoscopically. Finally, hysteroscopic inspection was used to confirm normal contour of the uterus and isthmocele repair. Measurements and Main Results Our patient underwent uncomplicated laparoscopic and hysteroscopic resection of cesarean section scar ectopic with isthmocele repair with minimal blood loss. She was discharged from PACU and was doing well at one week follow up. Conclusion There is currently no standard of care for management of cesarean section scar ectopic. When opting for surgical management it is important to anticipate possible complications, including dense adhesions and hemorrhage. In this video we provide a detailed combined hysteroscopic and laparoscopic approach to removal of cesarean scar ectopic. Techniques to minimize blood loss and reduce injury to surrounding organs are highlighted; including bladder distension, laparoscopic tourniquet, and uterine artery skeletonization. Anticipating and mitigating potential complications with these techniques leads to an optimal outcome.

A Case Report of Cesarean Scar Site Endometriosis: Diagnosis and Management

Endometriosis is a frequent clinical problem in women of reproductive age, which means the presence and proliferation of endometrial glands and stroma outside the uterus, the most common site of endometriosis is in the pelvic cavity, extra pelvic endometriosis as on the surgical scar (as caesarean section, laparoscopic incision, episiotomy, and hysterectomy scars) which is relatively rare, it is clinically presented by chronic pelvic pain, dysmenorrhea, dyspareunia, subfertility, infertility, and poor both maternal & fetal outcomes and even stillbirth. Caesarean section endometriosis is presented with cyclic pain and bleeding from the scar site. Our 33- year case presented with a scar site endometriosis after the third Cesarean section. MRI was done to exclude uterine fistula and a definite diagnosis has been made by histopathology. Management involved different modalities of treatment including medical management, Mirena coil insertion. However, the definite treatment was surgical excision of the endometriotic lesion and reclosure of the skin incision.

OC15.05: Evaluation of subendometrial wave patterns in women with a niche in the Caesarean section scar compared to controls without a Caesarean scar

OC15.05: Evaluation of subendometrial wave patterns in women with a niche in the Caesarean section scar compared to controls without a Caesarean scar

Dehiscence of cesarean section scar during pregnancy and delivery — risk factors

We wanted to identify risk factors for dehiscence of cesarean section (CS) scars in patients undergoing repeated cesarean section. This was a retrospective case-control study over a 3-year period in our medical center (2011-2014), comparing women who had repeated CS without complications and women diagnosed with dehiscence. Data were collected from medical records and the groups were compared for demographic and obstetrical data. Dehiscence was identified in 27 women, while 54 women without dehiscence were the control group. Statistically significant differences were found in the need for augmentation, the number of previous cesarean sections, cesarean section in the active phase of labor and length of hospitalization. The need for augmentation of labor, CS in the nonactive stage and more than one cesarean section, all increased the risk of dehiscence. There was no association between dehiscence and scar pain, time elapsed since the previous cesarean section, the method of wound closure or fever.

The ultrasound of subcutaneous extrapelvic endometriosis.

Background: The presence of ectopic functional endometrial glands and struma anywhere except in the lining of the uterine cavity is considered as endometriosis. Extrapelvic endometriosis involving the abdominal wall cesarean section scar is uncommonly seen, and it rarely involves the perineum, umbilicus, pleura, kidneys, lungs and liver. Objectives: The purpose of the present study is to highlight rare ectopic sites, explain the pathogenesis of extrapelvic endometriosis, and evaluate the diagnostic significance of clinical findings, serum CA 125 level, and ultrasonography. Materials and methods: 24 female patients with extrapelvic endometriomas in whom the final diagnosis was based on the surgical results and histopathological reports of the excised specimens. The patients underwent a clinical examination, an ultrasound scan, and evaluation of the serum CA 125 level. They were also examined by transvaginal ultrasound to rule out ovarian endometriosis or uterine adenomyosis. They were further subjected to abdominal wall ultrasound in cases of cesarean section scar or umbilical region swellings, and transperineal ultrasound for perianal lesions. Transvaginal ultrasound was performed in patients with perineal endometrioma to assess the relation between the lesion and the external anal sphincter. Results: In 19 patients, abdominal wall cesarean section scar endometrioma was detected. Three patients had perianal endometriomas, and two patients – umbilical endometriomas. Conclusion: Ultrasound scanning was a useful diagnostic tool to evaluate extrapelvic endometriosis and its extension, especially in cases without typical clinical features that can be suggestive of endometrioma, low diagnostic sensitivity of serum CA 125, and low incidence of concomitant intrapelvic disease.

Effectiveness and Tolerability of a Patch Containing Onion Extract and Allantoin for Cesarean Section Scars.

BackgroundThe prevention or early treatment of pathological scars is the most appropriate therapeutic approach. Gels and patches containing onion extract and allantoin are safe and effective in patients with scars of various origins and severity. However, no controlled studies have evaluated the effects of the patch formulation in women after Cesarean delivery. This study aimed to investigate the effects of a patch containing Allium cepa and allantoin on Cesarean section (C-section) scars.MethodsThis is an observational study. Women were consecutively recruited at the University Hospital of Salerno and subdivided into two groups considering the number of C-section. Group A included subjects without and group B with a history of C-section. Scars assessment was made using digital photographs and the Patient and Observer Scar Assessment Scale (POSAS). After 4 weeks, the C-section of the women who had applied a patch containing Allium cepa and allantoin and those of women who had not used any products (controls) were re-evaluated as at baseline. The Observers independently performed the scars assessment at baseline and after 4 weeks. Data are expressed as the difference of the POSAS scores after 4 weeks minus the POSAS scores at baseline. The statistical significance was established at a p value <0.05.ResultsNinety-three subjects completed the study (47 in group A and 46 in group B). Women who had used a patch showed an improvement in total score by observer scale when compared with controls (p = 0.013). By the patient scale, no significant changes from baseline were found in group A and group B. Group B with patch showed changes in scars’ pigmentation (p = 0.015), relief (p = 0.039), and pliability (p = 0.046) in comparison of controls. Digital photographs confirmed such improvements in women who had already undergone previous C-section, while no significant changes from baseline were found in women without a history of C-section.ConclusionsIntense treatment of just 4 weeks with a patch containing Alium Cepa extract and allantoin was able to improve pigmentation, relief, and pliability of C-section scars in women with a history of C-section.Clinical trial registrationClinicalTrials.gov, identifier NCT04046783.

Incidence and outcomes of cases of caesarean scar ectopic pregnancy in a tertiary referral centre

Background. Caesarean scar ectopic pregnancy (CSEP) is a rare condition in which the implantation of the gestational sac takes place within the uterine scar of a previous caesarean section (CS). If the pregnancy continues within the uterus, the risk of placenta accrete or uterine rupture is increased. Objective. To investigate four treatment methods, based on each patient’s clinical presentation, gestational age of the pregnancy and haemodynamic stability, for the management of CSEP. Methods. CSEP cases ( N =30) were diagnosed by ultrasound at the Shatby Maternity University Hospital, Egypt. Various treatment modalities, based on gestational age, were employed to treat the patients. Treatments included suction curettage ( n =12), embryo reduction with local methotrexate injection ( n =12), laparoscopic excision ( n =3) and excision through laparotomy ( n =3). Serum levels of beta-human chorionic gonadotrophin (β-hCG) were measured at diagnosis and weekly following treatment until the levels returned to non-pregnant values. Results. There was a significant positive correlation between gestational age in weeks and the CSEP management strategy employed. β-hCG levels decreased from before treatment to the end of the follow-up period 3 weeks later. No cases required a hysterectomy, and no maternal complications were reported in this study. Conclusion. The appropriate CSEP management strategy varies according to gestational age. Suction and embryo reduction with local methotrexate injection offers an effective, safe and minimally invasive surgical treatment to remove ectopic pregnancy tissue. Closely monitored follow-up of patients, including serial measurement of β-hCG levels and ultrasonographic examinations, is recommended after CSEP management.