Previous Cesarean Section Scar Research Articles

Role of Doppler ultrasound and Creatine Kinase as a Biochemical Marker in Diagnosis of Placenta Accreta

Placenta accreta is a life-threatening obstetric condition requiring cesarean hysterectomy for management. Placenta accreta was diagnosed by gray-scale ultrasonography, color Doppler imaging, and magnetic resonance imaging. Creatine kinase (CK) is an enzyme expressed by various tissues and cell types. This study compared between creatine kinase as biological marker and ultrasound and Doppler findings for prenatal detection of morbid placentation in anterior placenta on scar of previous cesarean section. The current study is a prospective cohort observational study, Led In Benha educating support doctor's facility on 50 pregnant ladies Hosting placenta accreta coating scar about past uterine surgery. Every one incorporated ladies were conveyed Eventually Tom's perusing caesarian segments for intend gestational agdistis during conveyance might have been 34. 5 ± 2 weeks. Done ladies with low parity, youthful age, or the individuals who wanted to preserve their fertility, preservationist methodology might have been trailed. Cs hysterectomy might have been performed over 28 (90. 32%) ladies. There might have been a noteworthy Acquaintanceship between 2D-GS ultrasonography discoveries Also troublesome placental separation, need for included intraoperative steps, necessity to cs hysterectomy What's more bladder damage with affectability 90% and specificity 60%. CK distinguished 10 patients crazy about 31 with placenta accreta Also 18 patients crazy about 19 without placental invasion, its affectability 30% and specificity. Joining 2DGS with CK test demonstrated huge change to auc worth about CK. 2D grayscale U/S required a great screening ability for those prediction of sequele from claiming dismal placentation in ladies for placenta previa. CK it is questionable test alone for antenatal finding from claiming morbidly follower placenta.

Cesarean Ectopic Scar Revision

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

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

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

Isthmocele: an overview of diagnosis and treatment.

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

Uterine rupture following misoprostol improper use

Introduction: Misoprostol, a synthetic prostaglandin E1 analogue, is considered safe and is being used worldwide for second trimester pregnancy terminations, with successful results. However, complications of uterine rupture and hysterectomy have been reported, and the incidence is higher among women with prior cesarean scar. Maternal morbidity and mortality following induced abortions are directly proportional to the gestational age at termination. We report a case of a 32-year-old multipara, G3P2, with two prior low transverse cesarean sections, who experienced uterine rupture after vaginal misoprostol administration, following an illegal second trimester abortion of an undesired pregnancy of about 20 weeks’ gestation. She presented at emergency room complaining of acute lower abdominal pain and sparse vaginal hemorrhage. Fetal demise and uterine rupture were diagnosed by manual vaginal exam and ultrasound. She underwent emergency exploratory laparotomy that revealed massive hemorrhage arising from a complete and extended uterine rupture from the previous cesarean section scar. A total hysterectomy and intra-operative blood transfusion had to be performed. Her post-operative was uneventful.

Un caso de embarazo ectópico en cicatriz de cesárea anterior

El embarazo ectópico en la cicatriz de una cesárea previa se refiere a la implantación del blastocito afuera del endometrio en el sitio donde se realizó la histerotomía previa. Se reporta el caso de una paciente de 32 años de edad que ingresó por el servicio de Emergencia del Hospital de Vitarte en Lima-Perú con 7,5 semanas de gestación por fecha de la última menstruación y ecografía, cesareada previamente hace 7 años. Se realiza laparotomía exploratoria con incisión sobre el istmo uterino sobre de cicatriz de cesarea previa extrayendo el saco gestacional y realizando curetaje sobre el lugar de implantación. Se describe el caso por su rareza y consecuencias potencialmente catastróficas que ponen en peligro la vida de la madre.

Hysteroscopic and laparoscopic management of caesarean scar (niche) defects in symptomatic patients

Introduction: Worldwide, rates of caesarean section are rising. The term ‘niche’ describes the presence of an hypoechoic area within the myometrium of the lower uterine segment, reflecting a discontinuation of the myometrium at the site of a previous caesarean section. A defect in caesarean section scar is associated with symptoms like abnormal uterine bleeding, infertility and complications in subsequent pregnancy including: risk of rupture and morbidly adherent placenta. It can also increase rates of complications during gynaecological procedures: IUCD insertion, evacuation of retained products of conception, hysteroscopy and risk of ectopic pregnancy at scar site.Aims: To assess the use of surgical techniques to repair niche defects in symptomatic patients, with regards to operative complications, symptomatic relief, postop lower segment thickness and fertility.Methods: Patients were identified between August 2015–March 2017. Inclusion criteria: Patients who had one previous caesarean section, symptomatic i.e. abnormal uterine bleeding, dysmenorrhoea, dyspareunia, infertility. Exclusion criteria: Asymptomatic patients. No previous caesarean section.Results: Between August 2015 and March 2017, six patients underwent surgical management of niche defect. Four patients reported post menstrual bleeding, one patient had infertility and one had intermenstrual bleeding and dyspareunia. All patients had one caesarean section previously. Mean lower segment measurement preoperatively was 2.5 mm ± 1.6 mm. EBL intraoperatively was 130 ml (10–180 ml). Mean operating time was 90 mins (70–150 min). One patient was pregnant after niche repair and delivered by CS at 38 w. In all six cases, TVS in 3–5 months after surgery revealed restored lower segment to normal thickness 9.2 mm ± 1.8 mm. Symptom resolution was noted in all patients. There were no operative complications.Conclusions: Anterior uterine wall should be explored in the case of symptomatic patients with previous caesarean section scar. Hysteroscopic resection should not be proposed when RMT is <3 mm. Laparoscopic/vaginal repair allows restoration of the anatomy of the lower uterine segment when residual myometrium is <3 mm. Laparoscopic repair allows antefixation in cases of retroverted uterus. Consideration of a surgical approach should be determined by the patient's plans for fertility and by niche thickness. For women who do not desire pregnancy and whose niche thickness is >3 mm, a hysteroscopic approach should be considered. Women with symptomatic caesarean scar defects who do not desire fertility may also be candidates for hysterectomy. Patients who desire future fertility, especially those with <3 mm of myometrium at the niche site, should undergo laparoscopic resection.

Dehiscence of a Low Transverse Cesarean Scar by a Submucous Myoma in a Nongravid Uterus

This is a case of a 32-year-old woman (G1P1001) with a history of uterine myomas who previously underwent surgeries for her myomas as well as a low transverse cesarean section for her delivery. The patient presented to our institution with vaginal bleeding and pelvic pressure symptoms. Magnetic resonance imaging found a 6-cm type 1 submucosal myoma that extended anteriorly through the myometrium and dehisced through the previous cesarean section scar, separating the scar by 2.5 cm (Figs. 1 and 2).

Laparoscopic Resection of Post–Cesarean Section Scar Uterine Cyst

Study ObjectiveTo demonstrate a technique of performing laparoscopic resection of a post–cesarean section scar uterine cyst. DesignTechnical video (Canadian Task Force classification III). SettingUniversity Hospital. PatientA 38-year old woman. InterventionLaparoscopic excision of a uterine cyst within a cesarean section scar. Measurements and Main ResultsA 38-year-old woman presented with secondary subfertility requesting removal of a cesarean section scar defect to prepare the uterine cavity for in vitro fertilization. Preoperative ultrasound demonstrated a 17.7 × 12.2 mm scar defect. At rigid hysteroscopy the anterior uterine wall cyst was observed and noted to be narrowing the uterine cavity. A laparoscopic approach was used to excise the uterine cyst. We carefully mobilized the bladder from its adhesions at the site of the previous cesarean section scar. The uterine cyst was located and margins of the defect identified. An ultrasonic-energy device was used to enucleate and excise the cyst. A uterine manipulator helped to identify the cervical canal and protect the posterior wall from inadvertent suture placement. The defect was closed with 1 vicryl interrupted sutures, being careful to incorporate the full thickness of the uterine wall to an able maximal opposition. An adhesion barrier was applied to the area. Transvaginal ultrasound scanning performed 6 weeks postoperatively demonstrated full healing with no residual defect. ConclusionNiches are recognized complications of cesarean sections resulting from incomplete healing of the scar and more likely in single-layer closures [1]. They can be associated with postmenstrual spotting, dysmenorrhea, chronic pain, subfertility, and poorer reproductive and obstetric outcomes [1–5]. Laparoscopic resection of niches is well established, showing symptomatic relief and an increase in residual myometrium [6]. Although cesarean section scar defects have been described as niches, we presented a further variety of defect that has not been previously described, a uterine cyst.

Caesarean Scar Ectopic Pregnancy Complicated by Uterine Rupture at 10 Weeks Gestation

Abstract Background: Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy that becomes implanted at the site of a previous cesarean section scar. It may lead to horrible consequences, ...

EP24.23: Caesarean scar pregnancy: a case report

Caesarean scar pregnancy (CSP) is an ectopic pregnancy (not in definition) implanted in the myometrium at the site of a previous Caesarean section scar. This rare ectopic pregnancy can lead to severe complications such as uterine rupture or severe hemorrhage, so that's the importance of an early diagnosis. The true incidence of a CSP has not been determined because few cases have been reported in the medical literature, however, estimates are that it follows 1 in 1800 to 1 in 2500 of all Caesarean deliveries performed. We are present a case of a CSP detected in an asymptomatic woman who had come for routine prenatal ultrasound. A 39 year-old woman Gravida: 5 Para: 3, comes to our unit at 6 weeks of pregnancy, she had 3 previous Caesarean sections and a history of a previous molar pregnancy and multiple fibroids. We performed a transvaginal ultrasound that shows an uterus with a gestational sac, yolk sac and embryo without cardiac activity. Patient was informed for a next ultrasound exam in the following days, and was performed at 6.6 weeks of pregnancy where we found and embryo with cardiac activity. The patient discussed her options with her private physician and she express her wishes to prevent future pregnancies, so in order to prevent complications and given her uterus condition with multiple fibroids a supracervical hysterectomy was performed 2 weeks later without complications. CSP is the rarest ectopic pregnancy location that could lead to severe complications like uterine rupture or severe hemorrhage, so and early diagnosis with transvaginal ultrasound and Doppler is of significant importance. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Authors' response to the comment on "Antepartum hemorrhage from previous-cesarean-sectioned uterus as a potential sign of uterine artery pseudoaneurysm".

Thanks for the good comment by Matsubara et al. (2017) on our case of "Antepartum hemorrhage from previous-cesarean-sectioned uterus as a potential sign of uterine artery pseudoaneurysm" (Zhang et al., 2017), published in the Journal of Zhejiang University-SCIENCE B (Biomedicine & Biotechnology). In the comment, the authors clarified two possibilities of our scenario: the uterine artery pseudoaneurysm (UAP) could be newly formed in the present delivery as a result of vulnerability of uterine artery and/or its branches at the site of previous cesarean section (CS) scar to exogeneous stimuli during labor contractions; the other possibility is that previous CS caused UAP formation but remained unruptured, and UAP continued to be intrauterine, a hyper-dynamic state during labor causing UAP-sac rupture and resultant antepartum hemorrhage, as well as postpartum hemorrhage.

Uterine rupture: A catastrophic obstetric emergency

Background: Uterine rupture can be a catastrophic obstetrical emergency with high incidence of fetal and maternal morbidity and mortality, varying from 1 in 2000 to1 in 200 deliveries. Aims and objective: To investigate the incidence, etiology, diagnosis, treatment and outcome of uterine rupture. Material and Methods: Thirteen cases of major rupture of the pregnant uterus in which life of the mother and fetus were endangered are presented. This study examined all cases of ruptured uterus managed in the Department of Obstetrics and Gynaecology at Mamata General Hospital, Khammam over a 3 year period. Details were obtained from medical records retrospectively and analyzed manually. Results: All 13 cases had varied etiologies and presentations such as poor antenatal care, previous cesarean section scar was present in 8, uterine anomalies were noted in 3, history of trauma was present in 1 case, and 1 case was grand multipara who set into spontaneous labour. Sonography findings in all cases showed an empty uterus surrounded by echogenic intra-abdominal fluid (haemoperitoneum) with dead fetus and placenta in maternal abdomen. Most patients were in shock and required basic life support, IV fluids, blood transfusion and emergency laparotomy. Few required intensive care and ventilator support. There were no maternal deaths and 100% perinatal deaths were seen. Conclusion: This study confirms previous cesarean section scar as the predominant cause of uterine rupture which can be prevented by regular antenatal care and mandatory institutional delivery.

Placental implantation and migration following a previous caesarean section scar.

This prospective cohort study was conducted in Arash Women's Hospital between August 2014 and August 2015 to define the relationship between caesarean section scar and placental implantation and migration. Seven hundred and thirty women with one previous birth (caesarean section or vaginal delivery) and a singleton pregnancy underwent three ultrasound examinations for placental evaluation at 11-14, 20 and 34 weeks gestation. Previous caesarean section was related to the increased odds of anterior placental implantation but no relation was seen between low-lying placenta or placenta praevia and previous caesarean. The placental migration from low-lying to non-low-lying position was similar between women with and without previous caesarean.

Pregnancy, Delivery, and Neonatal Outcomes of In Vitro Fertilization-Embryo Transfer in Patient with Previous Cesarean Scar.

BackgroundWhat role should previous cesarean section play in affecting clinical pregnancy outcomes and avoiding the complications of in vitro fertilization? In this article, we focus on elective single-embryo transfer (eSET) versus double-embryo transfer (DET) and assess the clinical efficacy and safety of eSET in patients who have a previous cesarean scar.Material/MethodsThe pregnancy, delivery, and neonatal outcomes of 130 patients who had a previous cesarean scar and received in vitro fertilization-embryo transfer (IVF-ET) were retrospectively analyzed. The number of transferred embryos was chosen depending on patients’ desire after acknowledging all benefits and risks, including eSET (eSET group, n=56) and DET (DET group, n=74). A total of 101 patients with previous vaginal delivery receiving IVF-ET in the same period were included as a control group.ResultsThe pregnancy rates, multiple birth rates, abortion rates, ectopic pregnancy rates, gestational age at delivery, preterm birth rates, neonatal birth weight, and take-home baby rates were similar between the previous cesarean section group and the previous vaginal delivery group. A previous cesarean section scar did not affect embryo implantation and pregnancy outcomes in IVF. In the eSET and DET groups of previous cesarean section patients, the embryo implantation rates, pregnancy rates, abortion rates, and take-home baby rates were similar. However, the rate of multiple pregnancies reached 50% in the DET group, which led to more preterm births and lower birth weight.ConclusionsElective single-embryo transfer is a well-accepted strategy to avoid multiple pregnancies and improve the obstetric and neonatal outcomes of singleton pregnancy in IVF patients with a previous cesarean section.

Robotic-Assisted Laparoscopic Treatment of Residual Ectopic Pregnancy in a Previous Cesarean Section Scar: A Case Report

Study ObjectiveTo describe a technique of robotic-assisted laparoscopy of residual cesarean scar pregnancy (CSP) and uterine defect repair. DesignVideo case report, with step-by-step explanation of the procedure (Canadian Task Force classification III) SettingCSP may be treated by different approaches including surgery and methotrexate. Successful methotrexate treatments avoid an emergency surgical treatment. In these cases a residual CSP often remains and should be removed in women who desire to conceive. CSP is often associated with a cesarean section scar defect called an isthmocele. In case of isthmocele with important defect and desire for pregnancy, laparoscopic repair may be proposed. Diagnosis and treatment of isthmocele is usually performed in a second time after a successful treatment of CSP. In this case, a surgical treatment including the removal of the residual CSP and treatment of the isthmocele may be proposed. InterventionIn this video we describe a technique for the surgical removal of residual CSP and isthmocele treatment by robotic-assisted laparoscopy. A 32-year-old patient developed a CSP treated by 2 in situ injections of methotrexate. A magnetic resonance imaging study performed 1 month after the last methotrexate injection revealed a persistent 4-cm residual CSP, associated with an isthmocele. Preoperative uterine artery embolization was performed to reduce intraoperative bleeding. After localization of the residual CSP on the left side, a temporary left uterine occlusion was performed. Residual CSP was totally removed. The residual defect and isthmocele were closed using delayed absorbable suture. ConclusionRobotic-assisted laparoscopic removal of residual CSP and isthmocele treatment is a feasible and safe procedure. This procedure may be proposed in patients presenting with this condition after a methotrexate treatment of CSP.

Embryo Implantation in the Region of a Previous Caesarean Section Scar and Scar Dehiscence in Second Trimester: A Rare Case Report.

The first case of a Caesarean scar site ectopic pregnancy was reported in 1978 [1]. Implantation of a pregnancy within a caesarean fibrous tissue scar is considered to be the rarest form of ectopic pregnancy and a life-threatening condition. This is because of the very high risk of uterine rupture and the maternal complications related to it. The most probable mechanism that can explain scar implantation is that there is invasion of the myometrium through a microtubular tract between the caesarean section scar and the endometrial canal. A recent case series estimates an incidence of 1:2226 of all pregnancies, with a rate of 0.15 % in women with a previous caesarean section and a rate of 6.1 % of all ectopic pregnancies in women who had at least one caesarean delivery [2].Although expectant and medical management have been reported in early pregnancy, termination of a caesarean scar pregnancy by laparotomy and hysterotomy, with repair of the accompanying uterine scar dehiscence, may be the best treatment option in later weeks of pregnancy.

Successful Live Birth after Medical and Surgical Treatment of Cesarean Scar Pregnancy: A Case Report

Cesarean Scar Pregnancy (CSP) is a rare type of ectopic pregnancy needing a high index of suspicion to make an early diagnosis. Recent literature describes treatment of CSP using methotrexate (MTX). Surgical options include hysteroscopic coagulation of vessels at implantation site, laparoscopic removal of gestational sac, laparotomy with wedge resection of pregnancy; ultrasound guided suction curettage and uterine artery embolization with injection of MTX locally. However, to date no universal guidelines exist regarding its management. A case of successful management of a pregnancy in a previous Cesarean section scar, with the use of systemic methotrexate followed by ultrasound guided evacuation of the uterus is presented, followed by an uncomplicated live birth in the successive pregnancy.

Cesarean Scar Pregnancy: A Case Report

A caesarean scar pregnancy (CSP), which is considered a type of ectopic pregnancy, occurs when the embryo is implanted in the myometrium at the site of a previous caesarean section (CS) scar.

Rising incidence of morbidly adherent placenta and its association with previous caesarean section: a 15-year analysis in a tertiary hospital in Hong Kong.

To identify the incidence of morbidly adherent placenta in the context of a rising caesarean delivery rate within a single institution in the past 15 years, and to determine the contribution of morbidly adherent placenta to the incidence of massive postpartum haemorrhage requiring hysterectomy. A regional obstetric unit in Hong Kong. Patients with a morbidly adherent placenta with or without previous caesarean section scar from 1999 to 2013. A total of 39 patients with morbidly adherent placenta were identified during 1999 to 2013. The overall rate of morbidly adherent placenta was 0.48/1000 births, which increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013. The rate of morbidly adherent placenta with previous caesarean section scar and unscarred uterus also increased significantly. Previous caesarean section (odds ratio=24) and co-existing placenta praevia (odds ratio=585) remained the major risk factors for morbidly adherent placenta. With an increasing rate of morbidly adherent placenta, more patients had haemorrhage with a consequent increased need for peripartum hysterectomy. No significant difference in the hysterectomy rate of morbidly adherent placenta in caesarean scarred uterus (19/25) compared with unscarred uterus (8/14) was noted. This may have been due to increased detection of placenta praevia by ultrasound and awareness of possible adherent placenta in the scarred uterus, as well as more invasive interventions applied to conserve the uterus. Presence of a caesarean section scar remained the main risk factor for morbidly adherent placenta. Application of caesarean section should be minimised, especially in those who wish to pursue another future pregnancy, to prevent the subsequent morbidity consequent to a morbidly adherent placenta, in particular, massive postpartum haemorrhage and hysterectomy.