Multiple Cesarean Deliveries Research Articles

What is the best mode of delivery in nulliparous, singleton, term, vertex pregnancies

With approximately 145 million births occurring worldwide each year—over 30 million by cesarean delivery (CD), the need for evaluation of maternal and perinatal outcomes in different delivery scenarios is more pressing than ever. Recently, in a meta-analysis of the available randomized controlled trials, planned CD was associated with significantly decreased rates of low umbilical artery pH, and neonatal complications such as birth trauma, tube feeding, and hypotonia when compared to planned vaginal delivery (VD). Among singleton pregnancies, planned CD was associated with a significantly lower rate of perinatal death. For mothers, planned CD was associated with significantly less chorioamnionitis, more wound infection, and less urinary incontinence at 1 to 2 years. Conversely, planned VD has been associated with benefits such as a lower incidence of wound infection and quicker postpartum recovery compared to planned CD. Nonetheless, several risk factors for CD are increasing—such as older maternal age, obesity, diabetes, excessive gestational weight gain, and birth weight—while maternal pelvises are getting smaller. Concerns about the potential long-term risks of multiple cesarean deliveries, such as placenta accreta spectrum disorders, highlight the need for a balanced evaluation of both delivery modes. However, the total fertility rate is decreasing in the US and around the world, with many people wanting two or fewer babies, which decreases future risk of placenta accreta incurred by multiple cesarean deliveries in these individuals. Furthermore, one in four obstetricians-gynecologists has undergone a CD on maternal request for their nulliparous, singleton, term, vertex (NSTV) pregnancy, and CD rates less than about 19% have been associated with higher perinatal and maternal mortality. Thus, we propose that it is imperative that we prioritize conducting randomized trials to compare planned cesarean to planned VD for NSTV pregnancies. Such trials would need to include 8000 or more individuals; they would ideally follow each participant to the end of their reproductive life and study perinatal and maternal outcomes, including nonbiologic outcomes such as patient satisfaction, postpartum depression, breastfeeding rates, mother-infant bonding, post-traumatic stress, and cost-effectiveness. The time for such a trial is now, as it holds the potential to inform and improve obstetrical care practices globally.El resumen está disponible en Español al final del artículo.

Frequency of Placenta Previa among Women with Previous Cesarean-Section

Placenta Previa was defined as when the placenta was attached to the lower uterine segment, poses significant risks, including antepartum hemorrhage and maternal mortality. The incidence was rising, attributed partly to increased cesarean sections and advanced maternal age. Objective: To determine the frequency of placenta Previa among women with previous cesarean-sections. Methods: This cross sectional study was carried out at a Teaching Hospital of Sialkot, from June to December 2021. The sample size was 147 pregnant females. These pregnant females have a history of cesarean section. The non-probability Consecutive sampling technique was used, and data were analyzed by using SPSS version 25.0. Results: Among those, 16.3% had placenta Previa, which increased significantly in women with >2 previous cesarean sections to 26.4% (p = 0.003). Regarding parity, the increase in the risk of placenta Previa was not significant: 12.8% for parity < 3 and 20.3% for parity ≥ 3 (p = 0.087). However, in the stratified analysis by BMI, this became significant: 11.0% for normal-weight, 18.6% for overweight, and 66.7% for obese women (p = 0.001). There was no significant difference concerning age groups, p = 0.177. Such findings of the significant associations of placenta Previa with such factors as BMI and number of cesarean sections indicate that great attention to monitoring should be paid. Conclusion: Hence concluded that previous cesarean sections strongly correlate with placenta previa in subsequent pregnancies. Such findings underscore the need for rigorous monitoring and proactive measures, especially in cases of multiple cesarean deliveries, in the management of associated complications.

Maternal and Fetal Outcomes after Multiple Cesarean Deliveries.

Background/Objectives: Cesarean delivery (CD) is a common procedure, but it can be associated with some increasing risks as the number of previous CD increases. Although women undergoing multiple CDs is very unusual in Spain, our center serves pregnant women with a history of three or more previous CDs with some frequency. We aimed to assess whether women who undergo multiple CDs (≥4) have more risks than those who undergo a third CD. Material and Methods: A retrospective cohort study was conducted with 161 pregnant women who had undergone ≥ 2 previous CDs and were monitored during their next pregnancy. The primary endpoint was to evaluate the obstetric hemorrhage rate in the multiple CD group and compare it with that in the third CD group. Secondary outcomes regarding maternal and neonatal complications were also analyzed. Results: Hemorrhage (7% and 10%; p = 0.522) and transfusion (3% and 8%; p = 0.141) rates were similar in both groups. The risk of dehiscence of the uterine segment (6% and 24%; p < 0.006), as well as hysterectomy (0 and 6.6%, p = 0.019), difficult abdominal opening (49% and 82%; p = 0.001), peritoneal adhesions (3% and 22%; p < 0.001), and difficult bladder separation (36% and 73%; p < 0.001), was higher in the multiple CD group. No uterine rupture or maternal-neonatal mortality was observed in either of the groups. Conclusions: Since undergoing multiple CD is uncommon, our study may be the largest sample in our environment. Our findings suggest that despite the potential risks of undergoing multiple CDs, maternal and neonatal outcomes are overall favorable.

A prospective study on risk factors associated with the development of isthmocele after caesarean section.

The primary objective was to detect the number of women developing isthmocele following lower segment caesarean section. The secondary objectives included analysing the risk factors associated with developing isthmocele and measuring the agreement between Transvaginal Ultrasonography (TVS) and Saline infusion Sonohysterography (SIS) in diagnosing Isthmocele. This study was conducted in the Department of Obstetrics and Gynecology and focused on women who had undergone Lower Segment cesarean Section (LSCS). The study aimed to detect any indentation of at least 2mm in the scar site, known as isthmocele, using Transvaginal Ultrasound (TVS) and Saline Infusion Sonography (SIS) between 6weeks and 6months after delivery. Along with the primary objective, the study also evaluated several secondary outcomes such as maternal comorbidities, closure techniques, and labor details. The evaluation of isthmocele followed the 2019 modified Delphi consensus approach. In our study, we found that 30% of our study population had isthmocele. We also observed that the number of previous caesarean deliveries, maternal BMI, duration of surgery, and characteristics of the previous CD scar were significantly associated with the development of isthmocele. When we compared the diagnostic methods, we found that TVS and SIS had similar limits of agreement for clinically important isthmocele parameters. However, we noticed a difference in the length and distance of isthmocele from the internal os, which we observed through Bland Altman plots. Our research has shown that women who have undergone multiple caesarean deliveries, have a higher maternal body mass index (BMI), and experienced longer surgery duration are at a significantly higher risk of developing isthmocele. To prevent its development, it is recommended to promote vaginal birth after caesarean delivery whenever feasible, manage maternal obesity early on, and provide adequate surgical training to medical professionals. Additionally, transvaginal ultrasound (TVS) is an effective method for detecting isthmocele and can be used interchangeably with saline-infused sonography (SIS).

The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries.

To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.

Early diagnosis of placenta accreta in case of mid trimester postabortal haemorrhage with previous 3 cesarean sections

: To know the risk and management of postabortal haemorrhage in patients with previous caesarean delivery to prevent maternal mortality. : Placenta accreta is an emergency life threatening obstetric situation may also complicate first trimester and midtrimester abortion and encountered as profuse vaginal bleeding and difficulty in placenta removal at delivery. The incidence of placenta accreta increased from 1 in 30,000 pregnancies in 1960 to 1 in 533 pregnancies in 2000. Placenta accreta developed in 55 of 590 women with placenta previa and 7 of 156080 without placenta previa. Increased incidence of caesarean increases the incidence of placenta accreta. Multiple caesarean deliveries are largest risk factor for placenta accreta. On the basis of a high risk factor, suspected case of placenta accreta spectrum, must be diagnose and be in charge of a multidisciplinary team with better maternal and fetal outcome. A 36 years old patient, P3L3A1 had prior 3 LSCS with retained placenta with profuse bleeding per vaginum with history of expulsion of fetus (18 week) on the way to hospital, presented to labor room. Patient was unbooked and uninvestigated. Initial resuscitation done along with oxytocic given but no sign of placental separation was there and bleeding was continued. On the basis of torrential bleeding and history of previous three caesarean deliveries, patient is immediately shifted to the operation theatre for exploratory laparotomy in view or provisional diagnosis of a morbidly adherent placenta with torrential haemorrhage. On laparotomy, the anterior surface of lower uterine segment of uterus accompanied by numbers of engorged blood vessels. Bladder was spared. Decision of exploratory laparotomy taken into consideration of morbidly adherent placenta, and procedure was ended with Subtotal hysterectomy, haemostasis achieved. 2 units PCV transfused intraoperatively and patient was shifted to intensive care unit for observation postoperatively. Her postoperative duration was uneventful; she got discharged on postoperative day6 under satisfactory condition. The specimen was sent for histopathological examination. Vigilant monitoring and timely intervention in obstetric emergencies can avoid maternal mortality. We wish to highlight the vigilant monitoring and timely decision, active collaboration by multidisciplinary team improve outcomes in patient of postabortal haemorrhage in midtrimester with previous caesarean delivery with placenta accreta spectrum.

Perinatal assessment of complex cesarean delivery: beyond placenta accreta spectrum

Multiple cesarean deliveries are known to be associated with long-term postoperative consequences because of a permanent defect of the lower uterine segment wall and the development of thick pelvic adhesions. Patients with a history of multiple cesarean deliveries often present with large cesarean scar defects and are at heightened risk in subsequent pregnancies of cesarean scar ectopic pregnancy, uterine rupture, low-lying placenta or placenta previa, and placenta previa accreta. Moreover, large cesarean scar defects will lead to progressive dehiscence of the lower uterine segment with the inability to effectively reapproximate hysterotomy edge and repair at birth. Major remodeling of the lower uterine segment associated with true placenta accreta spectrum at birth, whereby the placenta becomes inseparable from the uterine wall, increases the rates of perinatal morbidity and mortality, especially when undiagnosed before delivery. Ultrasound imaging is currently not routinely used to evaluate the surgical risks of patients with a history of multiple cesarean deliveries, beyond the risk assessment of placenta accreta spectrum. Independent of accreta placentation, a placenta previa under a scarred, thinned partially disrupted lower uterine segment, covered by thick adhesions with the posterior wall of the bladder, poses a surgical risk and requires fine dissection and surgical expertise; however, data on the use of ultrasound to evaluate uterine remodeling and adhesions between the uterus and other pelvic organs are scarce. In particular, transvaginal sonography has been underused, including in patients with a high probability of placenta accreta spectrum at birth. Based on the best available knowledge, we discuss the role of ultrasound imaging in identifying the signs suggestive of major remodeling of the lower uterine segment and in mapping the changes in the uterine wall and pelvis, to enable the surgical team to prepare for all different types of complex cesarean deliveries. The need for postnatal confirmation of the prenatal ultrasound findings for all patients with a history of multiple cesarean deliveries, regardless of the diagnosis of placenta previa and placenta accreta spectrum, is discussed. We propose an ultrasound imaging protocol and a classification of the level of surgical difficulty at elective cesarean delivery to stimulate further research toward the validation of ultrasound signs by which these signs may be applied to improve surgical outcomes.

A near miss case of placenta percreta at primary care: A case report

We present a case of severe placenta percreta in a 33-year-old woman, gravida 9 para5+3, who presented to the health clinic with gross hematuria for three days at 16 weeks gestation. She had a history of multiple cesarean deliveries and uterine curettage. The diagnosis was suspected, and an urgent referral was made. Ultrasonography findings done by an obstetrician in a tertiary hospital confirmed the diagnosis. Unfortunately, the pregnancy had to be terminated as her condition deteriorated. Primary care practitioners should have high clinical suspicion to recognize this rare and life-threatening condition.

Quality Initiative to Reduce Failed Trial of Labor after Cesarean Using Calculated VBAC Success Likelihood.

Vaginal birth after cesarean can reduce morbidity associated with multiple cesarean deliveries. Failed vaginal birth after cesarean is associated with increased maternal and neonatal morbidity. The Maternal-Fetal Medicine Units Vaginal Birth After Cesarean calculator is a validated tool to predict the likelihood of successful trial of labor after cesarean. Predicted likelihood < 60% has been associated with increased maternal and neonatal morbidity. We sought to determine if formal incorporation of calculated vaginal birth after cesarean likelihood into patient-centered counseling would reduce failed vaginal birth after cesarean. This is a quality improvement intervention at a single tertiary-care academic medical center, in which standardized patient counseling was implemented, facilitated by an electronic medical record template featuring patient-specific likelihood of vaginal birth after cesarean success. Term singleton pregnancies with history of one to two cesareans were included; those with contraindication to labor were excluded. Historical controls (January 2016-December 2018, n = 693) were compared with a postimplementation cohort (January 2019-April 2020, n = 328). Primary outcome was failed vaginal birth after cesarean. Fewer patients in the postintervention cohort had a history of an arrest disorder (PRE: 48%, 330/693 vs. POST: 40%, 130/326, p = 0.03); demographics were otherwise similar, including the proportion of patients with <60% likelihood of success (PRE: 39%, 267/693, vs. POST: 38%, 125/326). Following implementation, induction of labor in patients with a <60% likelihood of successful vaginal birth after cesarean decreased from 17% (45/267) to 5% (6/125, p < 0.01). The proportion of failed vaginal birth after cesarean decreased from 33% (107/329) to 22% (32/143, p = 0.04). Overall vaginal birth after cesarean rate did not change (PRE: 32%, 222/693, vs. POST: 34%, 111/326, p = 0.52). An intervention targeting provider counseling that included a validated vaginal birth after cesarean success likelihood was associated with decreased risk of failed trial of labor after cesarean without affecting overall vaginal birth after cesarean rate. · Labored cesarean increases maternal morbidity.. · Application of the Maternal-Fetal Medicine Units (MFMU) calculator to antenatal counseling decreased labored cesarean.. · Application of the MFMU calculator to antenatal counseling did not decrease overall vaginal birth after cesarean rate..

Robotic Assisted Laparoscopic Excision of a Placenta Percreta

<h3>Study Objective</h3> To illustrate the steps of a robotic-assisted laparoscopic excision of a placenta percreta. <h3>Design</h3> Placenta accreta spectrum (PAS) is a group of disorders characterized by various degrees of placental invasion through the myometrium and uterine serosa. Incidence has increased in recent years following the increase in cesarean deliveries. Risk factors include previous uterine surgeries, multiple cesarean deliveries and the presence of placenta previa. Ultrasound is the primary diagnostic modality. Most PAS cases are diagnosed in the second trimester, and guidelines for early recognition are sparse. A cesarean hysterectomy is the mainstay of management. This video shows an alternative, fertility-sparing treatment for PAS when diagnosed early. <h3>Setting</h3> The video displays a patient in the operating room in the supine position, with Trendelenburg positioning and a bedside assist for robotic-assisted laparoscopy. <h3>Patients or Participants</h3> We present a case of a 32-year-old G5P1121 with a history of one prior cesarean section and a dilation and curettage who was had early imaging concerning for CS scar ectopic and placenta accreta spectrum. <h3>Interventions</h3> The patient was counseled on termination of pregnancy and given her desire for fertility, counseled on attempted resection of invading pregnancy with uterine repair. <h3>Measurements and Main Results</h3> Key surgical steps illustrated include the following: 1. Lysis of adhesions and separation of bladder 2. Identification of the borders of the pregnancy 3. Injection of vasopressin 4. Laparoscopic guided suction dilation and curettage 5. Dissection invading pregnancy 6. Circumferential resection of the invading pregnancy 7. Full thickness myometrial closure in multiple layers <h3>Conclusion</h3> Early diagnosis of placenta accreta spectrum provides options for alternative fertility-sparing treatment.

Prevalence and risk factor of postoperative adhesions following repeated cesarean section: A prospective cohort study.

To evaluate the prevalence of intraperitoneal adhesions after repeated cesarean delivery and its associated personal and surgical risk factors. This prospective cohort study was conducted at the delivery ward at Fayoum University Hospital from October 2020 to December 2021. Women were recruited according to predetermined inclusion and exclusion criteria. Eligible women were interviewed, and data were obtained for personal history, past surgical and obstetrical history, and data about the current delivery. Nair's scoring system was used to evaluate intraperitoneal adhesions. Postoperative data and complications were reported. Three hundred women were recruited. Moderate to severe adhesions occurred in 186 patients (62%). These patients had a significantly prolonged hospital stay and were delivered by expert surgeons (P< 0.001 and P= 0.008, respectively). The adhesion score correlated positively with patients' age (P< 0.001), parity (P< 0.001), interpregnancy interval (P= 0.033), duration of hospital admission either previously or in the current delivery (P= 0.001 and P< 0.001), time to ambulation (P< 0.001), time to intestinal movement (P< 0.001), operative time (P< 0.001), and surgeons' age and experience (both P= 0.015). Adhesions led to increased maternal morbidity. Multiple contributing factors were significantly related to adhesions with multiple cesarean deliveries.

Factors Associated with Women with Multiple Caesarean Deliveries Presenting in Labour and their Fetomaternal Outcomes in Mwanza Region, Tanzania.

Background: Emergency caesarean section(C-section) for women with two or more uterine scars is documented to be associated with poor fetomaternal outcomes. The World Health Organization recommends elective C-section for women with two or more previous scars. However, in Tanzania there is a paucity of data for women with two or more prior C-sections and how it contributes to increased maternal and perinatal morbidity and mortality when they come in active labour without a planned delivery. The purpose of the study was to determine factors associated with pregnant women with multiple C-section deliveries presenting in labour and their fetomaternal outcomes.&#x0D; Methods: This was a cross-sectional, hospital-based study, involving 275 pregnant women who underwent C-section due to multiple uterine scars in the Mwanza region. Socio-demographic and clinical characteristics were collected serially until the sample size was reached using a structured questionnaire and patients’ files. Data were analyzed using STATA version 13.0 software.&#x0D; Results: All pregnant women with two or more previous uterine scars attended antenatal care (ANC) and the majority, 62.2%, had four or more visits. However, 61.9% were not told of the need for elective C-section. In addition, 26% were not counselled about the obstetric danger signs. Among the study participants, 66.6% presented with labour pain requiring emergency C-section, 13.1% had postpartum hemorrhage and 3.3% had ruptured uterus. There were 3.3% peri-natal deaths and 10.9% required newborn resuscitation. The associated factors for women with two or more C-section scars presenting in active labour were: having the last ANC visit at primary healthcare (PHC) facility (p=0.046), unemployment (p&lt;0.001), visiting ANC &lt;4 visits (p=0.002) or being attended by a non-physician health provider in her last ANC visit(p&lt;0.001).&#x0D; Conclusion: Parturient women with uterine scars, when attending primary health care facilities for their ANC visits, ought to be counselled and referred to high facilities with clinicians who can plan an elective c-section delivery.

Prospective evaluation of impact of post‐Cesarean section uterine scarring in perinatal diagnosis of placenta accreta spectrum disorder

ABSTRACTObjectiveStandardized ultrasound imaging and pathology protocols have recently been developed for the perinatal diagnosis of placenta accreta spectrum (PAS) disorders. The aim of this study was to evaluate prospectively the effectiveness of these standardized protocols in the prenatal diagnosis and postnatal examination of women presenting with a low‐lying placenta or placenta previa and a history of multiple Cesarean deliveries (CDs).MethodsThis was a prospective cohort study of 84 consecutive women with a history of two or more prior CDs presenting with a singleton pregnancy and low‐lying placenta/placenta previa at 32–37 weeks' gestation, who were referred for perinatal care and management between 15 January 2019 and 15 December 2020. All women were investigated using the standardized description of ultrasound signs of PAS proposed by the European Working Group on abnormally invasive placenta. In all cases, the ultrasound features were compared with intraoperative and histopathological findings. Areas of abnormal placental attachment were identified during the immediate postoperative gross examination and sampled for histological examination. The data of a subgroup of 32 women diagnosed antenatally as non‐PAS who had complete placental separation at birth were compared with those of 39 cases diagnosed antenatally as having PAS disorder that was confirmed by histopathology at delivery.ResultsOf the 84 women included in the study, 42 (50.0%) were diagnosed prenatally as PAS and the remaining 42 (50.0%) as non‐PAS on ultrasound examination. Intraoperatively, 66 (78.6%) women presented with a large or extended area of dehiscence and 52 (61.9%) with a dense tangled bed of vessels or multiple vessels running laterally and craniocaudally in the uterine serosa. A loss of clear zone was recorded on grayscale ultrasound imaging in all 84 cases, while there was no case with bladder‐wall interruption or with a focal exophytic mass. Myometrial thinning (< 1 mm) in at least one area of the anterior uterine wall was found in 41 (97.6%) of the 42 cases diagnosed as non‐PAS on ultrasound and 37 (88.1%) of the 42 diagnosed antenatally as PAS. Histological samples were available for all 48 hysterectomy specimens with abnormal placental attachment and for the three cases managed conservatively with focal myometrial resection and uterine reconstruction. Villous tissue was found directly attached to the superficial myometrium (placenta creta) in six of these cases and both creta villous tissue and deeply implanted villous tissue within the uterine wall (placenta increta) were found in the remaining 45 cases. There was no evidence of percreta placentation on histology in any of the PAS cases. Comparison of the main antenatal ultrasound signs and perioperative macroscopic findings between the two subgroups correctly diagnosed antenatally (32 non‐PAS and 39 PAS) showed no significant difference with respect to the distribution of myometrial thinning and the presence of a placental bulge on ultrasound and of anterior uterine wall dehiscence intraoperatively. Compared with the non‐PAS subgroup, the PAS subgroup showed significantly higher placental lacunae grade (P < 0.001) and more often hypervascularity of the uterovesical/subplacental area (P < 0.001), presence of bridging vessels (P = 0.027) and presence of lacunae feeder vessels (P < 0.001) on ultrasound examination, and increased vascularization of the anterior uterine wall intraoperatively (P < 0.001).ConclusionsRemodeling of the lower uterine segment following CD scarring leads to structural abnormalities of the uterine contour on both ultrasound examination and intraoperatively, independently of the presence of accreta villous tissue on microscopic examination. These anatomical changes are often reported as diagnostic of placenta percreta, including cases with no histological evidence of PAS. Guided histological examination could improve the overall diagnosis of PAS and is essential to obtain evidence‐based epidemiologic data. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Levonorgestrel intrauterine device as a non-invasive approach of abnormal uterine bleeding caused by cesarean scar defect

Cesarean scar defect, niche or isthmocele represents a poor healing in the anterior uterine wall after performing a cesarean section. The cesarean scar defect can be asymptomatic, or the patient could present abnormal uterine bleeding, chronic pelvic pain, dysmenorrhea, dyspareunia, cesarean scar pregnancy or abnormal placenta. Abnormal uterine bleeding caused by cesarean scar defect presents as a postmenstrual spotting and has become more and more common among women with a history of minimum one cesarean section delivery. The most studied risk factors are: multiple cesarean section deliveries, single layer suture, locked suture, retroflexed uterus and cesarean section delivery performed during active labor with a cervical dilatation of 5 cm. There have been described several surgical approaches: hysteroscopic, laparoscopic or vaginal. From our experience, we have treated successfully symptomatic patients with cesarean scar defect with the levonorgestrel-releasing intrauterine system. Although the therapeutic indications do not include this specific use, we have obtained significant improvement of abnormal uterine bleeding due to cesarean scar defect in our patients. Our results sustain the necessity of extensive interventional studies.

42 Increased narcotic requirements after laparoscopic hysterectomy in patients with history of multiple cesarean deliveries

Complicated laparoscopic hysterectomies may result in increased manipulation of tissue, and potentially lead to suboptimal postoperative pain control. Given that pain in the post-anesthesia care unit (PACU) has been found to be directly associated with overall patient satisfaction, being able to identify what patients are at higher risk for increased pain would allow for preemptive targeted multimodal interventions to reduce postoperative discomfort. One of the most common factors that increases surgical complexity during hysterectomy is history of cesarean deliveries. The objective of this study was to determine if an increased number of prior cesarean deliveries in patients undergoing a laparoscopic hysterectomy resulted in higher narcotic use in the PACU. A retrospective chart review was performed using cases from 4 fellowship trained MIS surgeons with similar operative techniques. Cases from 2018-2020 were reviewed. We included all patients between the ages of 18 and 60 who underwent laparoscopic hysterectomy and received a preoperative para-cervical block. Patients who had concomitant procedures such as pelvic floor repair, interventions for urinary incontinence, or excision of endometriosis were excluded. Data collected included age, body mass index, uterine weight, estimated blood loss, operative time, and total narcotics received in the PACU. Units of narcotics administered were converted to intravenous morphine milligram equivalents (MMEs) based on the American Pain Society guidelines and critical review papers. T-student was used to compare means between groups. There were 77 patients were selected for analysis. Patients were separated into groups depending on whether they had less than 3 (n = 60) or 3 or more (n = 17) cesarean deliveries. There was no difference regarding age (44.16 vs 44.65, P =.78), BMI (33.68 vs. 34.78, P=.53), EBL (65.17 mL vs. 85.88 mL, P=.14), or uterine weight (212.13 g vs. 202.88 g, P=.78). As expected, operating time was higher in the patients with 3 or more cesareans (140.08 min vs. 180.56 min, P<.01). Total narcotic use in the PACU was also significantly higher this group (5.42 MME vs. 10.24 MME, P<.01). These findings suggest that patients undergoing a laparoscopic hysterectomy with history of 3 or more cesarean deliveries are at a risk for higher narcotic requirements in the PACU and are potential targets for further postoperative pain reduction strategies.

Confirming the Diagnosis and Classifying Placenta Accreta Spectrum (PAS) Disorders: Minutes of 2020 Online International Workshop on PAS in Beijing

Confirming the Diagnosis and Classifying Placenta Accreta Spectrum (PAS) Disorders: Minutes of 2020 Online International Workshop on PAS in Beijing

Analysis of risk factors for cesarean scar diverticulum: A STROBE-compliant case-control study.

The purpose of this study was to explore the relevant factors that affect the risk of cesarean scar diverticulum (CSD).A retrospective, case-control study was designed among women with a history of cesarean section (CS) who were admitted in Zhejiang Tongde Hospital from January 2017 to December 2019. Women with missing information were excluded. The basic clinical characteristics and the risk factors for CSD were assessed using univariate analysis and multivariate logistic regression analysis.A total of 216 women were analyzed, including 87 patients with CSD and 129 cases without CSD as control. Significant differences in number of CS, trial of labor (elective or urgent CS), CS interval, uterine position, intraoperative hemorrhage, and dysmenorrhea between CSD group and control group (P < .05). Multivariate logistic regression analysis showed that number of CS, trial of labor, interval of CS, and uterine position were independent risk factors of CSD.In women with a history of CS, multiple cesarean deliveries, elective CS, cesarean interval of less than 5 years, and retroflexed position of the uterus may be associated with an elevated risk of CSD.

Induction of labor in women with a scarred uterus: does grand multiparity affect the risk of uterine rupture?

Previous cesarean delivery is the most important risk factor for subsequent uterine rupture. Data are inconsistent regarding grand multiparity (≥6th delivery) and a risk for uterine rupture. Specifically, no data exist regarding the risk that is associated with labor induction or augmentation in grand multiparous women after cesarean delivery. This study aimed to examine whether grand multiparity elevates the risk for uterine rupture in trials of labor after 1 previous cesarean that involved induction or augmentation of labor. A retrospective multicenter study was conducted that included all trials of labor after cesarean delivery at 24-42 gestational weeks with vertex presentation between the years 2003-2015. The study groups were defined in the following manner: (1) grand multiparous parturients (current delivery ≥6) who underwent labor induction or augmentation; (2) multiparous parturients (delivery 2-5) who underwent induction or augmentation; (3) grand multiparous parturients with no induction or augmentation of labor. The primary outcome was uterine rupture rate, which was defined as complete separation of all uterine layers. Secondary outcomes were obstetric and neonatal complications. A total of 12,679 labors were included in the study. The study group included 1304 labors of grand multiparous parturients after 1 previous cesarean delivery, of which 800 parturients underwent induction of labor and 504 parturients received labor augmentation. The multiparous group included 3681 parturients with either labor induction or augmentation. The third group included 7694 grand multiparous parturients without induction or augmentation. Incidence of uterine rupture was similar among the 3 study groups (0.3%, 0.3%, and 0.2%, respectively; P=.847). In the multivariable model that was adjusted for maternal age, ethnicity, diabetes mellitus, birthweight, and prolonged second stage of labor, no association was found between grand multiparity and uterine rupture in women with a scarred uterus who underwent labor induction or augmentation. Labor induction/augmentation during trial of labor after cesarean delivery in grand multiparous parturients appears to be a reasonable option that has a similar uterine rupture risk as in multiparous parturients. Avoiding a mandatory cesarean delivery enables reduction of the risk for future multiple cesarean deliveries.

Endometrium-free uterine closure technique and abnormal placental implantation in subsequent pregnancies

Background Abnormal placentation can result in massive hemorrhage, which is the leading cause of severe maternal morbidities and mortality in its management. Over the past 50 years, the incidence of placenta previa (PP), abnormal implantation of the placenta, and cesarean scar pregnancy have continued to rise. This coincides with the well-documented parallel rise in the rate of cesarean deliveries, the performance of multiple repeat cesarean deliveries and the adoption of newer uterine closure techniques. However, no studies have examined the role of uterine closure techniques in abnormal placentation in women with a history of a prior cesarean delivery. Objective To assess the practicality of one specific uterine closure technique at cesarean delivery and to evaluate the relationship between previous cesarean delivery and subsequent development of abnormal implantation of the placenta, as well as neonatal and other perioperative outcomes after receiving an endometrium-free uterine closure technique. Methods This retrospective observational study considered cesarean deliveries (n = 727) and subsequent vaginal births after cesarean delivery (n = 109) among total deliveries (n = 4496) performed in private practice at NYU Langone Health from 1985 to 2015. All cesarean deliveries were performed using the endometrium-free uterine closure technique. The primary outcome was the incidence of abnormal implantation of the placenta in subsequent pregnancies. The secondary outcomes were neonatal and maternal complications, specifically postoperative hemoglobin and hematocrit concentration losses. The association between independent variables and outcomes were evaluated using mixed-effect regression models. Results In contrast to published data, independent of the number of repeat cesarean deliveries, the presence of 26 (3.1%) PPs and of 366 (43.8%) anterior placentas, there were no patients with abnormal implantation of the placenta in a cesarean scar, neither prenatally nor at delivery. Maternal hemorrhage, postoperative and neonatal complications did not reach clinical significance. The statistical analysis revealed that, when compared with women who had fewer repeat cesarean deliveries using endometrium-free uterine closure technique, those with the most had a lesser risk of forming PP and less blood loss, as measured by both hematocrit and hemoglobin evaluation. Conclusion In this retrospective cohort study, the exclusion of the endometrium during the endometrium-free uterine closure technique was associated with fewer placental abnormalities in subsequent pregnancies and reduced life-threatening maternal morbidity for future cesarean deliveries.

Vaginal Birth After Cesarean: Contemporary Update and Ongoing Controversies for the Clinician in the Trenches

Mounting evidence underscoring serious maternal complications such as hemorrhage, emergent hysterectomy, thromboembolic disease and even death from multiple cesarean deliveries has refocused attention upon trial of labor after cesarean birth. Research over the last thirty years has provided insight into some of the clinical and demographic factors associated with uterine rupture and successful trial of labor after cesarean delivery. Clinical application of these strategies has the potential to mitigate the dilemma for physicians in the trenches caused by fear of uterine rupture during a trial of labor after cesarean. Individual risk stratification of candidates that optimizes success and minimizes uterine rupture during a trial of labor after cesarean shows promise for implementation of best practices leading to favorable maternal and neonatal outcomes. This review contains 4 figures, 6 tables, and 97 references. Key Words: Vaginal birth after cesarean (VBAC), Trial of labor after cesarean (TOLAC), uterine rupture, uterine scar, lower uterine segment, repeat cesarean, placenta accreta, uterine dehiscence