Hysterotomy Incision Research Articles

Cesarean section prior to 28 weeks’ gestation: which type of uterine incision is optimal?

Objective The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin pregnancy undergoing cesarean section under 28 weeks, and to assess factors that result in delivery complications, defined as either intraoperative dystocia or hysterotomy extension. We hypothesized that compared to those with non-cephalic presentations, gravidas with a presenting fetus in cephalic presentation would have higher rates of low-transverse cesarean section, and reduced rates of delivery complications with low-transverse hysterotomy. Methods This was a retrospective cohort chart analysis of 128 gravidas between 23 0/7 and 27 6/7 weeks undergoing cesarean section at a single academic institution between August 2010 and December 2022. Data was abstracted for factors that might influence the decision for hysterotomy incision type, as well as for documentation of difficulty with delivery of the fetus or need for hysterotomy extension to affect delivery. Results There was a total of 128 subjects, 113 with a singleton gestation and 15 with twins. The presenting fetus was in cephalic presentation in 43 (33.6%), breech presentation in 71 (55.5%), transverse/oblique lie in 13 (10.2%), and not documented in 1 (0.8%). Sixty-eight (53.1%) had a low-transverse cesarean section (LTCS), 53 (41.4%) had a Classical, 5 (3.9%) had a low-vertical hysterotomy and 2 (1.6%) had a mid-transverse incision. There was a significantly higher rate of LTCS among gravidas with the presenting fetus in cephalic presentation (30/43, 69.8%) compared to those with breech (31/71, 43.7%) or transverse/oblique presentations (7/13, 53.8%), p = .03. No other significant associations were related to hysterotomy incision, including nulliparity, racially or ethnically minoritized status, plurality, indication for cesarean delivery, or pre-cesarean labor. Twenty (15.6%) subjects experienced either an intraoperative dystocia or hysterotomy extension. For the entire cohort, there was a greater median cervical dilatation in those with delivery complications (4.0 cm, IQR .5 - 10 cm) compared to those without complications (1.5, IQR 0 – 4.0), p = .03, but no significant association between delivery complications and fetal presentation, hysterotomy type, plurality, or other demographic/obstetrical factors. However, among gravidas undergoing low-transverse cesarean section, only 2/30 (6.7%) with cephalic presentations had a delivery complication, compared to 9/31 (29.0%) with breech presentations and 3/7 (42.9%) with a transverse/oblique lie, p = .03. Conclusion In pregnancies under 28 weeks, the performance of a low-transverse cesarean section was significantly associated only with presentation of the presenting fetus. Among those with cephalic presentations, the rate of intrapartum dystocia or hysterotomy extension was low after a low-transverse hysterotomy, suggesting that in this subgroup, a low-transverse cesarean section should be considered.

Tek kat ve çift kat onarımın rezidüel miyometriyal kalınlık, istmosel oluşumu ve jinekolojik bozukluklar üzerine etkisi: Prospektif Randomize Kontrollü Bir Çalışma.

Abstract:
 Physicians are making great efforts to decrease the long-term complications of the cesarean section such as placental adherent syndromes, uterine scar pregnancies, uterine rupture, abnormal menstrual bleeding, or isthmocele. There is a controversy about the closure technique of the cesarean incision. The purpose of that study was to compare the impact of single layer versus double-layer closure of the hysterotomy incision on the residual myometrial thickness, isthmocele, menstrual disorders, dysmenorrhea, and dyspareunia.
 Material and Method
 A prospective randomized cohort study has been performed in a tertiary center named Bursa Yuksek İhtisas Training Research Hospital between July – October 2021. Patients were randomly assigned to each procedure (1:1) to the Single Layer Locked Continuous group and Double-layer Continuous un-locked group as uterine closure technique. Patients were examined via transvaginal ultrasound to evaluate the isthmocele occurrence, residual myometrium thickness, and inquired about menstrual properties, dysmenorrhea, and dyspareunia. Patients were also divided into groups via underwent first cesarean and more than one cesarean. 
 Results:
 The numbers of the women whose hysterotomy incision was closed by single-layer locked continuous( SLLC) technique and double-layer un-locked continuous(DLUC) technique 68 and 71 respectively. There was no statistically significant difference in terms of demographic variables, obstetric history, post-operative complications, neonatal outcomes. The comparison of these groups revealed that there was no significant difference in terms of post-menstrual bleeding, heavy menstrual bleeding, post-coital bleeding, dysmenorrhea, dyspareunia. The incisional residual myometrial thickness was higher in the DLUC group with a p-value of 0,007. Six patients in SLLC and 5 patients in the DLUC group have detected isthmocele (p: 0,941). 
 Patients have also been categorized as women who undergone their first cesarean section (SLLC n: 33 versus DLUC, n:33) and more than one cesarean section (SLLC n: 35 versus DLUC, n:38). Comparing the patients in these subgroups also did not differ significantly in terms of isthmocele occurrence, menstrual disorders, or residual myometrial thickness. 
 Conclusion:
 No significant difference had occurred in terms of isthmocele incidence, or menstrual disorders comparing the single layer versus double-layer closure. However, women whose hysterotomy insicions were closed with double-layer un-locked continuous technique have a thicker resudial myometrium than single layer closure group especially women who underwent repeated cesarean.

Isthmocele: The “Hot Air Balloon Sign,” a Gynecologic Consequence of an Obstetric Procedure

Cesarean section is the most common surgical procedure performed on women of reproductive age [1]. Occasionally, the hysterotomy incision's healing leaves areas of myometrial loss of continuity creating pouchlike defects known as isthmocele. Such defects function as reservoir collecting menstrual blood generating postmenstrual spotting, pelvic pain, dyspareunia, and secondary infertility among other symptoms [2]. Saline infusion sonogram is an effective imaging modality [3]. Both surgical and nonsurgical options have been recommended for the treatment of patients with symptomatic isthmocele [4].

Resection of five centimeter cesarean scar ectopic pregnancy and isthmocele repair using vascular clamps

The objective of this video is to present a surgical case of resection and repair of a five centimeter cesarean scar ectopic pregnancy. We will highlight the use of laparoscopic vascular bulldog clamps to aid in hemostatic control during the resection. We will also demonstrate the use of laparoscopic suturing and intracorporeal knot tying techniques to repair the hysterotomy incision and help prevent formation of a postoperative isthmocele. We will present the case of a 33 you G4P1021 that presented with a five centimeter cesarean scar ectopic pregnancy. She failed medical management and had a strong desire for future fertility. We will present a surgical approach to the resection and repair of a cesarean scar ectopic pregnancy. We will highlight the use of laparoscopic vascular bulldog clamps to aid in the isolation and temporary occlusion of the vascular supply to aid in the hemostatic resection of the ectopic pregnancy. We will also demonstrate laparoscopic suturing and knot tying techniques to approximate the hysterotomy incision and prevent formation of a post operative isthmocele. Resection of a cesarean scar ectopic pregnancy with repair is a viable treatment option for patients that have failed medical therapy and desire future fertility. Laparoscopic vascular bulldog clamps can aid in a hemostatic excision and repair. Sound surgical principles and laparoscopic suturing techniques can be employed to prevent the formation of a postoperative isthomcele.

''A STUDY OF INDICATIONS OF PRIMARY CESAREAN SECTION AND FETOMATERNAL OUTCOME IN MULTIPAROUS WOMEN ON A TERTIARY CARE CENTRE''

Laparotomy and hysterotomy incision through surgery to deliver the fetus is called Cesarean section. In modern days, higher complications in normal vaginal delivery is the major reason for choice of c section in India whereas this was already followed by US since decades. Healthy survival was possible for women in ancient days post normal delivery as they performed heavy physical work. However, modern women have less physical ability for normal vaginal delivery because of the low strength and fear of issues after a normal vaginal delivery. Today's women being literate and aware of the difculties like Postpartum infections which includes uterine, bladder, or kidney infections, excessive bleeding after delivery, pain in the perineal area (between the vagina and the rectum), Vaginal discharge, swollen breasts, clogged ducts, Stretch marks and also the vital reasons are Hemorrhoids and constipation along with Urinary or fecal (stool) incontinence, Hair loss, Postpartum depression, Discomfort during sex and difculty regaining the pre-pregnancy shape becomes crucial factor to decide for C section over normal vaginal delivery.

MON-003 Uterine Contractility in Pregnancies Complicated by Obesity: The Effects of Adipokines on the in Vitro Functional Contractility of Isolated Uterine Samples

Objectives: The onset of parturition in pregnant women with obesity is frequently delayed. Without induction, these women are nearly twice as likely as normal-weight to have prolonged pregnancy (≥41 weeks gestation) which is concerning because of associated two-fold increased risk of third-trimester stillbirth. Data from vascular studies have shown that different adipokines have different effects on smooth muscle contractility; either as relaxants or constrictors. However, only few studies have investigated their role in uterine contractility, a relationship that we sought to investigate. Materials and Methods: Total of 22 pregnant women scheduled for term cesarean delivery (CD) were recruited. Strips from the first two participants were used to identify dose response effects for each adipokine, and 20 participants’ data were included in the final analysis. Study groups consisted of normal-weight (N=10) and women with obesity (N=10). Myometrial strips were obtained from the hysterotomy incision at the time of the CD. Muscle strips were mounted within experimental recording baths. Both spontaneous and oxytocin induced contractions were recorded by a custom-build data acquisition software. Adipokines of interest included adiponectin, TNFα, resistin, and omentin. Adipokines were added to the muscle baths after muscle equilibration was achieved. Contractions outcomes of interest included forces, durations, and frequencies. Data comparisons were conducted using Wilcoxon Rank-Sum tests; medians and ranges are presented. Results: Forces of contractions in normal-weight participants were double those studied from participants with obesity (13.9 [9.3-34.3] vs. 8.9 [4.8-23.6], p=0.05). There were no statistically significant differences between contractility outcomes of interest after adding adiponectin, TNFα, and resistin to the muscle baths within and between the study groups. In participants with obesity, compared to baseline, omentin significantly reduced the force of spontaneous induced contractions (p=0.002) and prolonged the period between contractions (p=0.01). Importantly, that effect was not seen in normal-weight participants or in oxytocin induced contractions. Omentin also significantly reduced the forces of spontaneous induced contractions (2.9 [2.2-4.6] vs. 14.4 [4.8-33.6]; p=0.01) and prolonged the period (790.6 [753.0-832.0] vs. 611.4 [128.3-702.7]; p=0.04) in participants with obesity compared to normal-weight participants. Differences were no longer observed after adding oxytocin. Conclusion: In vitro, uterine contractions were reduced in muscle samples prepared from pregnant women with obesity compared to normal-weight counterparts. Omentin may have a role in reduced uterine contractility in pregnant women with obesity and that effect may be corrected by oxytocin administration.

1078: Barbed versus conventional suture for uterine closure during cesarean section: An integrated retrospective study

Although a variety of options exist for uterine incision repair during cesarean section (CS) in regards to suture type and repair technique, there is limited evidence on the best approach. The objective of this study was to compare knotless barbed and conventional synthetic suture use for uterine closure in different settings of CS. A retrospective cohort study was conducted using 217 CS cases at a community teaching hospital between January 2016 and May 2019, in which the hysterotomy incision was closed with knotless barbed (n=99, 45.6%) or conventional synthetic suture (n=118, 54.4%). Aggregate cases were further categorized into one or two-layer hysterotomy closure and primary or repeat CS. Parameters of operating room (OR) time, estimated blood loss (EBL), and complication rate were designated for comparison. Patient body mass index (BMI) and assistant post-graduate year (PGY) were correlated with OR time. Statistical analysis was performed to assess whether differences between groups were significant using a p-value of ≤0.05. Mean OR times, mean EBL, and complication rates were lower for knotless barbed compared to conventional synthetic suture across all uterine closure scenarios (Figure 1 and 2). Statistically significant differences were observed for EBL in aggregate (752.9 vs. 820.9 mL; p=0.03), two-layer closure (643.6 vs. 850.4 mL; p=0.002), and repeat CS (712.2 vs. 824 mL; p=0.03) groups. BMI positively correlated with OR time (r=0.205; p=0.002). There was no significant correlation between assistant PGY and OR time (r=-0.067; p=0.325). Using knotless barbed suture compared with conventional synthetic suture for uterine closure during CS is associated with significantly lower EBL, particularly for two-layer closure and repeat CS groups. Consideration of other factors is imperative during such comparison. When selecting suture material for uterine closure, knotless barbed suture may be a favorable option to conventional synthetic suture from a patient care and healthcare cost perspective.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Risk Factors for Inverted T Hysterotomy Incision at the Time of Cesarean Delivery [35R

INTRODUCTION: We sought to examine those for an inverted T hysterotomy. METHODS: This was a retrospective study of all women undergoing cesarean delivery at 23 weeks' gestation or greater between 2012 and 2017. We only included cases in which the hysterotomy incision was either low transverse or inverted T hysterotomy. Risk factors included age, race, repeat cesarean, gestational age, fetal presentation, large fibroid >10 cm, emergency cesarean, second stage cesarean, previa or accreta, general anesthesia, and multiple gestations. Outcomes were compared between cases with low transverse and inverted T hysterotomy. Multivariable logistic regression to obtain adjusted odds ratios (aOR) and 95% confidence interval (95% CI). MedStar Institutional Review Board approved this analysis. RESULTS: Of 6,608 women undergoing cesarean delivery, inverted T hysterotomy incisions occurred in 68 (1.0%). In multivariable logistic regression, risk factors for inverted T hysterotomy included non-Hispanic black (aOR 4.85; 95%CI 1.14-20.60), repeat cesarean (aOR 1.81; 95%CI 1.04-3.16), preterm delivery (23 0/7-31 6/7 weeks' gestation [aOR 7.58; 95%CI 3.59-16.00]; 32 0/7-36 6/7 weeks' gestation [aOR 2.08; 95%CI 1.06-4.07]), malpresentation (transverse [aOR 22.29; 95%CI 9.77-50.82]; breech [aOR 2.91; 95%CI 1.49-5.67]), fibroid >10 cm (aOR 7.77; 95%CI 1.95-30.88), emergency cesarean (aOR 3.17; 95%CI 1.53-6.58), and second stage cesarean delivery (aOR 2.98; 95%CI 1.32-6.74). CONCLUSION: We identified independent risk factors for an inverted T hysterotomy. These findings will help clinicians identify and counsel high-risk women regarding potential implications of having a cesarean delivery.

Pelvic pedicled omental flaps and autologous free omental grafts in a rabbit model.

BackgroundThere is a need to identify an inexpensive, effective method to prevent postoperative adhesion formation. The objective of this study was to create a novel model for studying omentum as a pelvic adhesion barrier.Randomized, prospective, controlled surgical intervention with serial follow-up in 16 female rabbits at a University-based Center for Comparative Medicine. Interventions included bilateral hysterotomy incision and repair. The left hysterotomy was randomized into coverage with an omental flap or graft; the right hysterotomy remained uncovered. Adhesions were scored via laparoscopy on postoperative days 2, 4, 8, and 12; postmortem evaluation and scoring took place on postoperative day 16. Statistical tests consisted of Kappa tests of agreement between adhesion scorers and Kruskal-Wallis nonparametric tests for the comparison of adhesion scores by intervention arm and by uterine horn.ResultsAll omental flaps and grafts survived. The only significant difference in mean adhesion scores was seen in non-hysterotomy-associated adhesions, where grafts had a lower score than flaps (p = 0.03).ConclusionsSurvival of all omental flaps and grafts demonstrates that this is a practical model for studying omentum as a pelvic adhesion barrier. Determining the efficacy of omentum as a pelvic adhesion barrier will require further investigation.

Comment on "Alternate Sequential Suture Tightening: A Novel Technique for Uncontrolled Postpartum Hemorrhage".

We read with interest the recent article “Alternate Sequential Suture Tightening: A Novel Technique for Uncontrolled Postpartum Hemorrhage” by Ghosh and Mala [1]. They developed a novel technique of uterine compression suture (UCS) for atonic bleeding where a Hayman suture [2] is performed, but importantly they sequentially tighten the knot, yielding “very tight” compression. In 92% (11/12) of their patients, the UCS alone stopped the bleeding. No patients had untoward sequelae. Their data is promising; however, we have two concerns. First, we wonder if such a tight knot is needed. In the Ghosh technique, the final knot was eventually tightened compared to the initial knot by as much as 3–5 cm, meaning tighter by 3–5 cm compared with an ordinary Hayman suture [2]. In our opinion, the Ghosh suture may be too tight and we wish to describe two supporting pieces of evidence. First, we usually use the Matsubara-Yano (MY) UCS in patients with atonic bleeding (Figure 1(a)) [3] and sometimes even cut the sutures because the knot looks “too tight.” We then reperform the MY UCS, making a looser knot. A knot that is too tight may lead to tissue damage caudal to the suture, that is, the lower uterine segment. This portion would become thin and weak, and a knot that is too tight would forcefully pull this portion in the cephalad direction, easily damaging this area (Figure 1(b)). We sometimes loosen the knot also for fear of possible subsequent uterine ischemia. After placing the UCS and closing the hysterotomy incision, it is our experience that the uterus becomes, more or less, contracted even in patients with an atonic uterus. Uterine contraction may make the knot even tighter. Second, we are concerned about Figure 1(d) in Ghosh and Mala's article [1]. The uterus looks ischemic in the area between two sutures even 1.5 years after the Ghosh UCS, possibly indicating that the suture significantly deprived blood flow to the uterus. Mowat et al. [4] reported a case of uterine necrosis after B-Lynch suture, describing, “there was central necrosis of the anterior body and fundus of the uterus between the two limbs of the B-Lynch suture”: this feature was similar to Ghosh and Mala's figure (Figure 1(d)) [1]. Figure 1 Schematic presentation of the Matsubara-Yano (MY) uterine compression suture (a) and possible drawbacks of the Ghosh suture (b, c). (a) The MY suture consists of two (or three) longitudinal transfixation sutures and two transverse sutures. Upper insets ... As described previously, generally speaking, compression force is related to the ability to induce hemostasis but is also related to adverse events associated with UCS [3]. A tight knot or tight suture, exerting excessive compression, naturally may lead to effective hemostasis at the time but may lead to uterine ischemia afterward, meaning that the hemostatic ability and occurrence of ischemia may have a “trade-off” relationship. Since the incidence rate of uterine ischemia is low [3, 4], the fact that it is not reported by Ghosh and Mala does not entirely rule out its occurrence. We proposed the concept of a removable UCS [5] that has been used clinically [6], removing the compression suture within two days postpartum. Strong compression of the uterus for up to two days postpartum and then removing the suture may be reasonable [5, 6]. Second, since the Ghosh technique is a modified Hayman suture [2], a drawback of Hayman suture [2] and B-Lynch suture [7] persists, that is, “the suture sliding out” (Figure 1(c)). We have previously pointed this out [3] and Hayman wrote, “the suture threatened to slide off the uterine fundus, like braces off a round shouldered man” [2]. This may occur more readily with a tight knot. When the uterus temporarily contracts and the knot becomes tighter, the possibility of “sliding out (off)” becomes higher; there may be no room for the suture other than “sliding out.” Sliding out of the suture makes compression insufficient. Figures 1(b) and 1(c) in Ghosh and Mala's article [1] lead us to consider this possibility. Obstetric practice has surely changed before and after the introduction of the UCS. We have now obtained a powerful tool, the UCS, against postpartum hemorrhage. Every effort should be made to make the UCS better and, thus, we applaud and respect Drs. Ghosh and Mala. The development of a number of UCS techniques shows that there may be no one best UCS. Further study of the UCS and wide discussion are needed.

The Influence of Maternal Body Mass Index on Myometrial Oxytocin Receptor Expression in Pregnancy

Obese pregnant women have higher rates of dysfunctional labor patterns, need for oxytocin augmentation, labor induction, postdates pregnancy, and cesarean delivery compared to normal weight pregnant women. We tested the hypothesis that myometrial oxytocin receptor (OXTR) gene and protein expression are affected by obesity in pregnancy. Myometrial samples were obtained at the time of cesarean delivery from the upper aspect of the uterine hysterotomy incision and processed for real-time quantitative polymerase chain reaction and Western blot. There were 63 myometrial samples available for analysis. The median body mass index (BMI) at delivery was 31.0 kg/m(2) (interquartile range, 26.0, 40.0 kg/m(2)), and the median gestational age at delivery was 38.0 weeks (interquartile range, 33.0, 39.1 weeks). The OXTR gene expression did not correlate with maternal BMI at delivery by linear regression, and the median OXTR gene expression did not differ between women with a BMI ≤ 30 kg/m(2) and those with a BMI ≥ 40 kg/m(2). The OXTR protein expression was also not affected by maternal BMI. Myometrial OXTR gene expression appears to be independent of BMI at the time of delivery. Dysfunctional labor patterns and increased oxytocin utilization seen in obese women may not be due to differences in OXTR expression, though functional studies are required.

Bladder Injury During Cesarean Delivery.

Cesarean section is the most common surgery performed in the United States with over 30% of deliveries occurring via this route. This number is likely to increase given decreasing rates of vaginal birth after cesarean section (VBAC) and primary cesarean delivery on maternal request, which carries the inherent risk for intraoperative complications. Urologic injury is the most common injury at the time of either obstetric or gynecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during cesarean section include previous cesarean delivery, adhesions, emergent cesarean delivery, and cesarean section performed at the time of the second stage of labor. Fortunately, most bladder injuries are recognized at the time of surgery, which is important, as quick recognition and repair are associated with a significant reduction in patient mortality. Although cesarean delivery is a cornerstone of obstetrics, there is a paucity of data in the literature either supporting or refuting specific techniques that are performed today. There is evidence to support double-layer closure of the hysterotomy, the routine use of adhesive barriers, and performing a Pfannenstiel skin incision versus a vertical midline subumbilical incision to decrease the risk for bladder injury during cesarean section. There is also no evidence that supports the creation of a bladder flap, although routinely performed during cesarean section, as a method to reduce the risk of bladder injury. Finally, more research is needed to determine if indwelling catheterization, exteriorization of the uterus, and methods to extend hysterotomy incision lead to bladder injury.

Single- Versus Double-Layer Closure of the Hysterotomy Incision During Cesarean Delivery and Risk of Uterine Rupture

Abstract Objective To evaluate the best available evidence regarding the association between single-layer closure and uterine rupture. Methods The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant observational and experimental studies that included women with a previous single, low, transverse cesarean delivery who had attempted a trial of labor (TOL). The risks of uterine rupture and uterine dehiscence were assessed by pooled odds ratios (OR) calculated with a random effects model. Results Nine studies including 5810 women were reviewed. Overall, the risk of uterine rupture during TOL after a single-layer closure was not significantly different from that after a double-layer closure (OR 1.71; 95% confidence interval [CI] 0.66–4.44). However, a sensitivity analysis indicated that the risk of uterine rupture was increased after a locked single-layer closure (OR 4.96; 95% CI 2.58–9.52, P Conclusion Locked but not unlocked single-layer closures were associated with a higher uterine rupture risk than double-layer closure in women attempting a TOL.

Case Scenario: Anesthesia for Maternal-Fetal Surgery

Case Scenario: Anesthesia for Maternal-Fetal Surgery

Factors Associated With Lower Uterine Segment Thickness Near Term in Women With Previous Caesarean Section

ObjectiveTo estimate the association between potential influencing factors and lower uterine segment (LUS) thickness at term in women with previous Caesarean section. MethodsWe conducted a cohort study of women with previous low-transverse Caesarean section undergoing ultrasonographic measurement of LUS thickness between 35 and 38 weeks’ gestation in a tertiary care centre between 2006 and 2009. Measurements of the full LUS thickness and the myometrial LUS thickness were performed both transabdominally and transvaginally. The thinnest measurements for both full and myometrial LUS thicknesses were considered dependent variables. Non-parametric analyses, multivariate linear regression analyses, and multivariate regression analyses were used to evaluate the relationships between LUS thickness and the potential influencing factors of maternal age, interdelivery interval, prior vaginal delivery, and several characteristics of the previous Caesarean section. ResultsIn 377 women who underwent measurement of LUS thickness, labour before previous Caesarean section was the only characteristic associated with a greater full LUS thickness (an additional 0.9mm; 95% CI 0.5 to 1.2 mm) in multivariate linear regression analysis. Labour before previous Caesarean section (0.5 mm; 95% CI 0.2 to 0.7 mm) and the use of synthetic sutures (as opposed to catgut sutures) for the closure of the previous hysterotomy incision (0.3mm; 95% CI 0.02 to 0.5 mm) were the only two variables significantly associated with a thicker myometrial LUS. In multivariate regression analysis, three factors were predictive of a full LUS thickness of > 2.3mm: the presence of labour, a recurrent indication for Caesarean section, and the use of synthetic sutures for hysterotomy closure at previous Caesarean section (P < 0.05). ConclusionLabour at the time of previous Caesarean section is associated with a thicker LUS near term in the subsequent pregnancy. The use of synthetic sutures for hysterotomy closure is another factor potentially associated with a thicker LUS.

Sonographically detected caesarean section scar defects and menstrual irregularity

SummaryThe purpose of this study was to estimate the frequency of post-caesarean section scar defects (PCSD) on transvaginal ultrasound and to correlate these with the presence of abnormal menstrual bleeding. We reviewed the pelvic ultrasound images of 318 women referred for a gynaecological scan in a private women’s ultrasound clinic. The incidence of defects at the expected location of a caesarean scar was evaluated and then correlated with patient responses to a questionnaire on abnormal menstrual bleeding. Of the 318 patients, 71 had a history of caesarean section and technically adequate pelvic ultrasound images. Fluid-filled defects in the hysterotomy incision were noted in 29 (40%). The presence of a PCSD was significantly associated with patients reporting prolonged periods or post-menstrual spotting. The larger the defect, the higher was the incidence of abnormal vaginal bleeding.

Ultrasonographic diagnosis of the retained semen straw in the uterus of a repeat breeder cow

Summary A 6-year-old lactating Holstein cow with a history of repeat breeding syndrome (failed to conceive after three artificial inseminations (AI) with fertile semen) was referred to the Veterinary Teaching Hospital of the School of Veterinary Medicine, Shiraz University. According to the history, neither abnormal clinical signs, nor uterine discharge had been observed subsequent to AI. The cow had shown signs of oestrus on a cyclic and regular basis. On rectal examination, no palpable object was detected inside the uterine horns, however, transrectal ultrasonographic examination revealed a hyperechoic straw-shape object in the left uterine horn. Left-flank laparotomy was performed and after exposure of left uterine horn, the palpated straw was removed through a small hysterotomy incision. Postoperative follow-up did not show any complication. No attempt was made to inseminate the cow after operation as it was not the farmer's plan to get the cow in calf.

Confirmation of Biologic Ingrowth into a Polyester Matrix in the Endometrial Cavity in an Animal Model

Study Objective: To determine the ability to achieve biologic ingrowth into a polyester matrix in the endometrial cavity in an animal model. The purpose of this is to allow further investigation into the use of polyester to promote biologic ingrowth into the endomyometrium near the uterotubal junction for sterilization purposes. Design: Devices were inserted into four Nubian goats on the same day. Because of anatomic differences from the human model, the devices could not be placed transcervically. A device was placed in each horn via a small hysterotomy incision and secured with non-reactive suture material. The animals were recovered. The uterus was removed from a goat on each of the successive four weeks. The uteri were sent to a pathology lab with expertise in staining for biologic ingrowth. Serial sections were obtained and stained to determine the degree of biologic ingrowth into the polyester matrix. Setting: The devices were inserted into the animal models in a qualified veterinary surgical facility. Measurements and Main Results: Pathologic determination of progressive biologic ingrowth into the polyester matrix was confirmed. By Week 1, early ingrowth was readily identified. By Week 4, ingrowth of tissue into the polyester matrix was confirmed, with the endometrium essentially replaced by ingrowth. The ingrowth provided contact of the polyester to an depth close to the myometrium. Conclusion: Biologic ingrowth into a polyester matrix can be acheived in the endometrial cavity. With the local destruction of the endometrial layer and ingrowth to a depth approaching the myometrium by Week 4, there should be no concern about the device being expelled during menses. Further investigation into the usefulness of this finding is necessary to determine if the concept can be applied to a transcervical sterilization device.

Intraoperative placement of the Copper T-380 intrauterine devices in women undergoing elective cesarean delivery: a pilot study

Background The purpose of this pilot project was to test the feasibility of a technique designed to place a copper intrauterine device (IUD) through the hysterotomy incision of an elective cesarean delivery to minimize possible contamination and to guarantee that tailstrings were visible in the vagina for easy removal should complications occur. Study Design Women were monitored in the hospital for signs of infection or excessive blood loss. At the time of hospital discharge and at 2 and 6 weeks postpartum, they were examined to determine the status of the tailstrings. The position of the IUD was assessed by ultrasound at week 6. Results All seven of the subjects had successful placement. The sutures tied to the IUD strings were visible on vaginal examination in each case. The original tailstrings were visible in the vagina at 6 weeks and each IUD was fundally positioned. Conclusion Successful intraoperative placement of Copper T-380A IUDs through incision at the time of cesarean birth is possible.

Cesarean Section Scar Diverticulum: Appearance on Hysterosalpingography

The purpose of this study was to characterize the frequency and appearance of hysterotomy defects on hysterosalpingography in patients with a history of cesarean section. We reviewed the hysterosalpingograms of 150 women with a history of cesarean section. The incidence, location, and appearance of defects at the expected location of a hysterotomy scar were evaluated. Of the 148 patients with history of cesarean section and technically adequate hysterosalpingograms, 89 (60%) had defects that were in the expected location of a hysterotomy incision. Fifty-eight (65%) of the diverticula were focal outpouchings, and 31 (35%) were thin linear defects. Forty-eight (54%) of the diverticula were located at the lower uterine cavity, 32 (36%) at the uterine isthmus, and nine (10%) at the upper endocervical canal. A diverticulum at the lower uterine cavity, uterine isthmus, or upper endocervical canal is a common finding on hysterosalpingography in patients with a history of cesarean section.