Prior Cesarean Section Research Articles

Impact of placenta accreta spectrum (PAS) pathology on neonatal respiratory outcomes in cesarean hysterectomies

Objective Placenta accreta spectrum (PAS) is a continuum of disorders characterized by the pathologically adherent placenta to the uterine myometrium. Delivery by cesarean hysterectomy at 34–36 weeks is recommended to mitigate the risks of maternal morbidity. Iatrogenic preterm delivery, has potential neonatal implications; late preterm infants are at risk for significant respiratory morbidity. Neonatal outcomes in PAS neonates are not well described in the literature, we aimed to investigate these outcomes. Methods A case-control study was performed with 107 cases of pathology-confirmed PAS patients with singleton, non-anomalous, viable pregnancies, compared to 76 cases of placenta previa with prior cesarean section who underwent repeat cesarean section. All patients were delivered through our institution’s Placenta Accreta Program from 2005 to 2020. Rates of neonatal respiratory morbidity and related outcomes were analyzed. Results Maternal characteristics and antenatal complications were similar between groups, as were gestational age, steroid exposure, and emergent delivery. PAS was associated with increased use of general anesthesia (20 vs. 54%, p = .001), larger estimated blood loss (1875 vs. 6077 ml, p = .008), and longer post-operative stays (4.8 vs. 7.3 days, p = .01). PAS was also associated with neonatal increased rates of high flow nasal cannula (HFNC) (41 vs. 58%, p = .02), intubation (17 vs. 37%, p = .008), and duration of respiratory support (0 vs. 2 days, p = .03). There were no differences in rates of continuous positive airway pressure (CPAP)/positive pressure ventilation (PPV) (21 vs. 22%, p = .85), anemia, hyperbilirubinemia, or NICU length of stay. Multivariate analysis adjusting for general anesthesia demonstrated this variable confounded the impact of PAS pathology in respiratory outcomes the risk of the respiratory composite (adjusted odds ratio (aOR) 0.57, 95% CI [0.11, 2.82]), use of HFNC (aOR 0.33, 95% CI [0.08–1.48]), and intubation (aOR 1.29, 95% CI [0.25–6.75]), were no longer significant. Conclusions Based on these results, we conclude that PAS neonates have higher rates of respiratory morbidity and that general anesthesia is a significant contributor to these respiratory outcomes. This is important for the antenatal counseling of cases of PAS, especially if general anesthesia is anticipated or requested. Furthermore, it supports efforts to limit general anesthesia exposure of neonates when necessary.

P048Risk of uterine rupture in second-trimester medication abortions using mifepristone and misoprostol after cesarean section birth: A systematic review and meta-analysis

<h3>Objectives</h3> To assess the risk of uterine rupture when using current mifepristone and misoprostol regimens for second-trimester abortion among those who had a prior cesarean section birth. <h3>Methods</h3> After prospectively registering on PROSPERO (CRD42022302626), we systematically searched PubMed, EMBASE, POPLINE, ClinicalTrials.gov, and Cochrane Library using search terms "second-trimester," "induction," "mifepristone," and "abortion" from inception until January 2022. We limited our sample to studies including pregnancies of 14–28 weeks' gestation, studies with a mixed cohort with and without uterine scar, and studies available in English. We excluded case reports and narrative reviews. Two authors independently reviewed studies. Absolute risk with binomial confidence intervals was calculated from pooled data. Using R software, total risk difference was estimated by the Mantel-Haenszel random effects method without continuity correction. For studies with zero events, a continuity correction of 0.5 was applied in the forest plot for individual risk differences. Statistical heterogeneity was assessed with Higgins I2 statistics. Funnel plot assessed for publication bias. <h3>Results</h3> Of 198 articles identified, 19 met inclusion criteria: seven randomized trials (n=923) and 12 observational studies (n=2,589). Uterine rupture risk with prior cesarean birth was 1.8% (7/385) (95% CI, 0.7–3.7) and without was 0.1% (2/3,127) (95% CI, 0.0–0.2). The risk difference was 0.01 (95% CI, 0.00–0.03; I2=0%). Minor funnel plot asymmetry demonstrated low evidence of publication bias. <h3>Conclusions</h3> Uterine rupture during second-trimester abortion is a rare event but risk does appear to increase among those with a prior cesarean section birth. In the context of patient-centered counseling, this may be acceptable to both patients and providers.

Laparoscopic Wedge Resection of a Cesarean Scar Ectopic Pregnancy at Nine Weeks Gestation

<h3>Study Objective</h3> To demonstrate an approach to laparoscopic wedge resection of a cesarean scar pregnancy (CSP). <h3>Design</h3> Video abstract. <h3>Setting</h3> Tertiary care Centre. <h3>Patients or Participants</h3> This case is of a 40-year-old G6P3, with 3 prior cesarean sections who was referred with a possible ectopic pregnancy at 8+3 weeks gestation after presenting with cramping and irregular bleeding. Following admission to hospital, transvaginal ultrasound revealed a CSP and a type 1 placenta percreta with no bladder involvement. The patient wished for fertility-sparing management which was planned to include pre-operative intragestational methotrexate and uterine artery embolization followed by laparoscopic wedge resection. Before pre-operative interventions could be done, the patient experienced acute vaginal bleeding and she was taken urgently for surgical management. <h3>Interventions</h3> Laparoscopic wedge resection of the CSP. <h3>Measurements and Main Results</h3> Laparoscopy revealed bladder adhesions high over the lower uterine segment and the CSP. Wedge resection of the CSP was successfully achieved with restoration of normal anatomy using a systematic approach to lysis of adhesions as well as intraoperative vascular control using dilute vasopressin and pre-emptive skeletonization of the uterine vessels. Surgical blood loss was 100mL. There were no intraoperative or postoperative complications, and the patient was discharged home post-operative day 1. The patient's beta HCG levels returned to normal within one month. <h3>Conclusion</h3> CSPs account for approximately 4% of all ectopic pregnancies. Management is individualized and often requires a multi-modal approach. This case demonstrates a safe and successful approach to fertility-sparing laparoscopic wedge resection.

Management of Cesarean Scar Pregnancy Via Laparoscopic and Transcervical Approaches

<h3>Study Objective</h3> To detail novel management of sequelae of pre-operative uterine artery embolization in the setting of a cesarean scar pregnancy in a patient undergoing laparoscopic uterine wedge resection. <h3>Design</h3> A video case report with follow up at 2- and 6-weeks post-procedure. <h3>Setting</h3> An operative suite at a tertiary care center. <h3>Patients or Participants</h3> A 30-year-old woman with cesarean scar pregnancy in the setting of one prior cesarean section who underwent uterine artery embolization. Following embolization, she developed significant clot in the uterus, consistent with placental abruption, which was unable to be evacuated with uterine wedge resection alone. <h3>Interventions</h3> Uterine artery embolization followed by laparoscopic uterine wedge resection of a cesarean scar pregnancy with hysteroscopy and dilation and aspiration under direct laparoscopic visualization. <h3>Measurements and Main Results</h3> Approximately 100cc of additional products of conception and clot was evacuated from this patient by using a secondary method of uterine evacuation (dilation and aspiration). <h3>Conclusion</h3> Use of both laparoscopic and transcervical resection of cesarean scar ectopic pregnancy resulted in increased evacuation of products of conception. Further study is warranted to determine if this results in overall decreased blood loss in patients.

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.

8506 Surgical Management of Late 1st Trimester Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> To describe the safe surgical management of late 1^st trimester cesarean scar ectopic pregnancy. <h3>Design</h3> A case report. <h3>Setting</h3> Academic tertiary care hospital. Patient placed in dorsal lithotomy in Trendelenburg position with sponge on ring forceps placed in the vagina. <h3>Patients or Participants</h3> 33-year-old G8P4044 presenting with foul smelling discharge and an LMP 10 weeks prior. Her surgical history is notable for 3 prior cesarean sections and laparoscopic right salpingectomy for ectopic pregnancy. Pelvic ultrasound notable for live intrauterine pregnancy measuring 10 weeks 6 days with complete posterior placenta previa and thin myometrium in lower uterine segment concerning for cesarean scar ectopic pregnancy. <h3>Interventions</h3> Patient was diagnosed with cesarean scar ectopic pregnancy by Maternal Fetal Medicine. She underwent preoperative bilateral uterine artery embolization by Interventional Radiology. She underwent total laparoscopic gravid hysterectomy and left salpingectomy with lysis of adhesions by Benign Gynecology. <h3>Measurements and Main Results</h3> Diagnosis and management of cesarean scar ectopic pregnancy requires multidisciplinary collaboration for safe management. Here, we present a case of a late 1^st trimester cesarean scar ectopic pregnancy managed safely with input from Maternal Fetal Medicine, Family Planning, Interventional Radiology and Benign Gynecology teams. We show the diagnosis of cesarean scar ectopic pregnancythrough transvaginal ultrasound and discuss management options in the late 1^st trimester. We show preoperative bilateral uterine artery embolization. Finally, we show technique for safe lysis of adhesions with low estimated blood loss during laparoscopic total gravid hysterectomy. Final pathology was consistent with intrauterine fetus with placenta accreta. The patient was discharged home on day of surgery without any postoperative complications. <h3>Conclusion</h3> A detailed 1^st TM ultrasound should be considered inpatients who are high risk for cesarean scar ectopic pregnancy. Embolization of bilateral uterine arteries prior to gravid hysterectomy can decrease intraoperative blood loss. A multidisciplinary approach is preferred for management of late 1^st trimester cesarean scar ectopic pregnancies.

8189 “Failed CS-BS” a Role for vNOTES in Patient with 4 Prior Cesarean Sections and Severe Adhesive Disease Desiring Sterilization

Study Objective To demonstrate the utility of vNOTES for opportunistic bilateral salpingectomy for permanent sterilization after failed attempt at bilateral tubal ligation at the time of previous Cesarean section. Design Stepwise demonstration with narrated video footage. Setting vNOTES opportunistic bilateral salpingectomy for permanent sterilization after failed bilateral tubal ligation during previous Cesarean section. Patients or Participants 31-yo G4P3013 with 4 prior Cesarean sections desiring permanent sterilization, BMI 38. Interventions During previous Cesarean section, bilateral adnexa unable to be accessed due to dense adhesions from previous surgeries. Patient to have vNOTES instead of conventional laparoscopy. Measurements and Main Results Patient underwent a successful vNOTES bilateral salpingectomy, with pathology confirming bilateral fallopian tubes. Conclusion vNOTES bilateral salpingectomy is a reasonable alternative to conventional laparoscopy in patients with severe adhesive disease. To demonstrate the utility of vNOTES for opportunistic bilateral salpingectomy for permanent sterilization after failed attempt at bilateral tubal ligation at the time of previous Cesarean section. Stepwise demonstration with narrated video footage. vNOTES opportunistic bilateral salpingectomy for permanent sterilization after failed bilateral tubal ligation during previous Cesarean section. 31-yo G4P3013 with 4 prior Cesarean sections desiring permanent sterilization, BMI 38. During previous Cesarean section, bilateral adnexa unable to be accessed due to dense adhesions from previous surgeries. Patient to have vNOTES instead of conventional laparoscopy. Patient underwent a successful vNOTES bilateral salpingectomy, with pathology confirming bilateral fallopian tubes. vNOTES bilateral salpingectomy is a reasonable alternative to conventional laparoscopy in patients with severe adhesive disease.

8519 Effects of Prior Cesarean Section on Outcomes of Laparoscopic Hysterectomies Performed by Minimally Invasive Gynecology Trained Surgeons

<h3>Study Objective</h3> To evaluate the effect of a history of cesarean section (CS) on complications and operative time of minimally invasive hysterectomies (MIH) performed by surgeons trained in minimally invasive gynecologic surgery (MIGS). <h3>Design</h3> Retrospective cross-sectional study. <h3>Setting</h3> Single institution, tertiary care center in Southeastern USA from 2016-2019 <h3>Patients or Participants</h3> Patients who underwent MIH for benign conditions, performed by a MIGS trained surgeon, and did not have a history of laparotomy other than CS. <h3>Interventions</h3> Minimally invasive hysterectomy. <h3>Measurements and Main Results</h3> A total of 484 hysterectomies met inclusion criteria. Of these, 152 patients had a history of CS and 332 did not have a history of CS. No significant demographic differences were noted between groups. In patients with a history of CS, 69 (45.4%) had one, 52 (34.2%) had two, 24 (15.8%) had three, and 7 (5.2%) had four or more prior CS. Generalized linear models controlling for body mass index (BMI) did not show a relationship between history of CS as a binary variable (CS vs no CS) and estimated blood loss (EBL) (mean 62 mL vs 57 mL, p=0.44) or operative time (mean 152 minutes vs 148 minutes, p=0.70). Similarly, there was no relationship between the number of prior CS and EBL (p=0.421) or operative time (p=0.411). The adjusted odds ratios were not significant between CS vs no CS for intraoperative complication (aOR = 0.920, CI 0.282 – 3.00) or 30-day postoperative complication (aOR = 0.946, CI 0.573 – 1.563). <h3>Conclusion</h3> While previous studies have found a relationship between history of CS and hysterectomy complications, this has not been evaluated in patients undergoing MIH with a MIGS trained surgeon. In our study, neither a history of any CS nor the number CS had an effect on EBL, operative time, or intraoperative or post-operative complications of MIH performed by MIGS trained surgeons.

7675 Tri-Topic Pregnancy: A Case of Spontaneous Triplets in Three Distinct Locations

<h3>Study Objective</h3> To present a case of spontaneous triplet pregnancy consisting of a single intra-uterine pregnancy and two distinct ectopic pregnancies and review the literature regarding interstitial pregnancy management. <h3>Design</h3> Case report. <h3>Setting</h3> Tertiary care hospital. <h3>Patients or Participants</h3> One patient. <h3>Interventions</h3> 29-y/o G3P2002 at approximately seven weeks gestational age by LMP with history significant for two prior full-term cesarean sections presented to the emergency department with severe, sudden onset abdominal pain. Beta-HCG was greater than 200,000. Bedside transabdominal ultrasound was limited by degree of pain; however, it revealed a fetal pole measuring eight weeks with cardiac activity surrounded by a sizable layer of myometrium, as well as an additional fetal pole with cardiac activity laterally with a thin surrounding layer of myometrium. Given severe pain in early pregnancy, ruptured ectopic pregnancy was presumed and the patient was consented for a diagnostic laparoscopy and removal of ectopic pregnancy. Intraoperatively, approximately 500cc of hemoperitoneum and both an interstitial pregnancy and an ampullary pregnancy were appreciated. Laparoscopic unilateral salpingectomy and cornuectomy were performed. Ultrasound postoperatively surprisingly demonstrated a third remaining viable intrauterine pregnancy. The patient denied any history of ART. <h3>Measurements and Main Results</h3> Pathology confirmed ectopic pregnancies in both specimens. Laparoscopic excision of two ectopic pregnancies was safely performed in this patient with maintenance of a viable, intrauterine pregnancy. Excision of the interstitial pregnancy posed greatest risk to both the patient and concurrent intrauterine pregnancy. Care was taken during cornuectomy to minimize entry depth into surrounding myometrium and blood loss. <h3>Conclusion</h3> The incidence of heterotopic pregnancy without ART is approximately 1 in 30,000. Furthermore, interstitial pregnancies make up only 1-4% of ectopic pregnancies. Laparoscopic management of interstitial pregnancies has been repeatedly demonstrated as a safe approach. We present a rare case of a ruptured triplet heterotopic pregnancy with minimal risk factors managed successfully with laparoscopic removal technique and maintenance of intrauterine pregnancy.

Robotic-Assisted Laparoscopic Hysterectomy for Management of Cesarean Scar Ectopic Concerning for a Molar Pregnancy

<h3>Study Objective</h3> Demonstrate the safety and feasibility of a robotic approach to management of a cesarean scar ectopic concerning for molar pregnancy. <h3>Design</h3> Case presentation. <h3>Setting</h3> Tertiary Hospital Operating Room. <h3>Patients or Participants</h3> 38-yo G3P2012 at 8w5d by LMP with history of 1 prior cesarean section presenting with vaginal bleeding and abdominal pain. Ultrasound and MRI finding cesarean scar ectopic pregnancy concerning for molar pregnancy. <h3>Interventions</h3> Robotic assisted laparoscopic hysterectomy. <h3>Measurements and Main Results</h3> Perioperative outcomes of EBL and complications. EBL 100 cc with no post operative complications or need for transfusion. <h3>Conclusion</h3> Robotic approach is safe and feasible management of a cesarean scar ectopic concerning for molar pregnancy.

Uterine Surgery and Risk of Adenomyosis: A Retrospective Study

<h3>Study Objective</h3> To determine an association between adenomyosis and history of uterine surgery, including cesarean section, dilation & curettage (D&C), and myomectomy. Also, if repeat uterine surgery increases the risk of adenomyosis development. <h3>Design</h3> Retrospective case control study. <h3>Setting</h3> Large academic center, Parkland Hospital in Dallas, TX. <h3>Patients or Participants</h3> Data was collected from electronic medical records of women who underwent hysterectomy for benign indications at Parkland Hospital between January 2014-December 2018. A total of 2911 women were included, 1184 with adenomyosis and 1727 without adenomyosis. <h3>Interventions</h3> Variables included gravidity/parity, number of vaginal deliveries, number of cesarean sections, number of D&C procedures, and number of myomectomies. Pathology of uterine specimens were noted for presence of adenomyosis, leiomyomata, and endometriosis. Non-parametric rank sum test compared medians of continuous variables, Chi-square or Fisher exact tests compared categorical variables. Logistic regression was used to generate odds ratios for adenomyosis and clinical factors. <h3>Measurements and Main Results</h3> History of any uterine surgery was associated with an increased risk of adenomyosis (OR 1.28, 95% CI 1.11-1.49). Patients with a history of D&C were significantly more likely to have adenomyosis on pathology (OR 1.57, 95% CI 1.30-1.90). Repeat D&C was also associated with increased risk of adenomyosis (OR 1.31, 95% CI 1.01-1.72). The association between history of prior cesarean section and adenomyosis was not statistically significant (OR 1.12, 95% CI 1.00-1.37). A history of myomectomy was not significantly associated with adenomyosis (OR 0.95, 95% CI 0.59-1.54). <h3>Conclusion</h3> Of the risk factors explored, history of any uterine surgery, D&C and repeat D&C were associated with an increased risk of adenomyosis. However, there was not a significant association between history of cesarean section or increasing numbers of repeat cesarean delivery with the development of adenomyosis. This is the largest known retrospective study thus far investigating this association and we concluded that cesarean sections do not individually increase the risk of adenomyosis.

Frequency of Placenta Previa in Patients with Repeated C-Section

Objective: The purpose of this study is to determine the prevalence of placenta previa and adverse outcomes in patients with repeated C-sections. Study Design: Descriptive/Observational study Place and Duration: Gynaecology and Obstetrics Department, Combined Military Hospital, Peshawar for the period from February 2021 to January 2022. Methods: There were 60 pregnant women had age 20-50 years were presented. Pregnant women with the history of c-section were included in this study. After getting informed written consent demographics of included patients i.e age, body mass index, gestational age, parity and gravidity were recorded. After delivery, association of placenta previa was recorded. Maternal and fetus outcomes were also assessed in this study. SPSS 21.0 was used to analyze all data. Results: Majority of the cases 28 (46.7%) were aged between 20-30 years, 20 (33.3%) had age 31-40 years and 12 (20%) patients were aged between 41-50 years. 34 (56.7%) cases had BMI &gt;25kg/m2 and 26 (43.3%) patients had BMI &lt;25kg/m2. Mean parity of the patients was 4.7±3.21 and mean gestational age was 36.13±14.61 weeks. Frequency of placenta previa was found in 15 (25%) cases in which majority 9 (60%) were males and 6 (40%) were females. Among 15 cases of placenta previa, low apgar score, low birth weight and ICU admission were the adverse outcomes among new borns. In mothers, frequent bleeding, pre-eclampsia and gestational diabetes were the adverse events. Conclusion: The results of this research led us to the conclusion that the prevalence of placenta previa rises with an increasing number of prior caesarean sections and the associated negative fetomaternal outcome. Keywords: C-section, Placenta Previa, Adverse Events, Parity

S1968 Pregnancy With a Twist: A Case of Sigmoid Volvulus in the Third Trimester

Introduction: Sigmoid volvulus is a rare cause of bowel obstruction in the general population and particularly in pregnancy. Here, we present a case of a young woman in her third trimester presenting with acute sigmoid volvulus. Case Description/Methods: A 27-year-old woman with no prior medical history who was 31 weeks pregnant presented with 4 days of progressive abdominal pain and distension with associated obstipation, nausea, vomiting and decreased oral intake. Her surgical history was pertinent for prior cesarean section and right laparoscopic salpingectomy. Her vital signs are normal. Her abdomen is distended and tender to light palpation with guarding and rebound tenderness. CBC and CMP are within normal limits. A computed tomography (CT) scan of the abdomen and pelvis showed large bowel distension up to 10.5 cm with air fluid levels and twisting of the mesentery at the sigmoid colon. Based on these findings, she was diagnosed with sigmoid volvulus. The patient was emergently taken to the operating room for endoscopic sigmoid volvulus reduction. A therapeutic colonoscopy revealed a sigmoid volvulus with health appearing mucosa which was successfully traversed and detorsion was performed. A nasogastric tube was placed in the rectum with the proximal tip near the hepatic flexure for decompression.The patient’s abdominal pain improved significantly after colonic decompression. Three days later, she underwent definitive open sigmoidectomy with primary anastomosis. Three days later, the patient had vaginal bleeding along with contractions and had breech vaginal delivery of a male infant ( Figure). Discussion: Sigmoid volvulus in pregnancy is rare but should be included within the differential diagnosis for abdominal pain as a delay in diagnosis or late presentation can result in significant morbidity and mortality for mother and fetus. Delays in diagnosis are associated with high rates of morbidity and mortality for the mother and fetus. Maternal complications include sepsis, peritonitis, and bowel perforation. Fetal complications include pre-term delivery, intrauterine death, and neonatal sepsis. Endoscopic decompression is successful in 75-95% of cases. Elective surgery is recommended after endoscopic detorsion. Finally, it is important to have a multi-disciplinary approach with colorectal surgeons and obstetricians in the management of sigmoid volvulus in pregnancy.Figure 1.: Sagittal view of abdomen and pelvis CT Scan.

Robotic repair of a branching vesicouterine and vesicovaginal fistula.

We present technical considerations and tips for repairing a complex branching vesicouterine and vesicovaginal fistula via a robotic approach. A 31-year-old female presented with constant urinary leakage following a vaginal birth after prior cesarean section. Evaluation with cystoscopy and cross-sectional imaging demonstrated a branching vesicouterine and vesicovaginal fistula. Repair with robotic-assisted approach was carried out. An intentional cystotomy was made with a tear-drop incision around the fistula tracts. The vesicouterine and vesicovaginal planes were dissected and mobilized. The vaginotomy and cystotomy were closed in a running two-layer fashion with absorbable suture and the uterine defect closed with interrupted absorbable suture. Retrograde bladder filling confirmed a watertight repair. A broad peritoneal flap was created, positioned, and secured with care to ensure it covered past the apex of the fistula closure. Following overnight observation she had an uneventful recovery, including catheter removal at 3 weeks after cystogram confirmed resolution of the fistula. At 6 weeks the fistula and her leakage remained resolved, with no de novo voiding or incontinence symptoms. A robotic approach to complex branching vesicouterine and vesicovaginal fistula is technically feasible. Careful attention to surgical technique and the use of tissue interposition may improve fistula resolution rates.

Factors Associated with Placenta Previa: A Retrospective, Single-Center Study in Turkey.

BackgroundThe incidence of placenta previa is gradually increasing. The major risk factor is a history of cesarean section (CS). Such patients may experience severe bleeding during pregnancy and surgery. Patients with placenta previa were classified based on risk factors in this study. This retrospective study from a single center in Turkey aimed to evaluate the factors associated with placenta previa in 151 women.Material/MethodsPatients with placenta previa were grouped by the presence/absence of prior CS. Group 1 (123 patients) had undergone at least 1 CS, and Group 2 (28 patients) had not undergone CS. The diagnosis of placenta previa was made by ultrasound. Placenta previa was defined as cases where the placenta crossed the internal os. Duration of surgery, bleeding during surgery, and the amounts of erythrocyte suspensions required were compared between groups.ResultsOf Group 1 patients, 67.5% had anterior placenta previa compared to 46.4% in Group 2. The mean duration of surgery was: 52.0±19.2 and 28.5±4.6 min (P<0.001); the number of sutures was 8.4±2.4 and 5.9±0.9 (P<0.001); the bleeding volumes were 720.3±536.2 and 344±137.0 mL (P<0.001); and the amount of erythrocyte suspension administered intraoperatively was 0.2±0.7 and 0.0±0.0 unit (P=0.032).ConclusionsMean duration of surgery, number of sutures, bleeding volume, and intraoperatively applied ES volumes were significantly different between groups. Identification of placenta previa patients who have undergone prior CS is vitally important in terms of preoperative preparation.

The safety of misoprostol alone use for second-trimester termination of pregnancy in women with previous caesarean deliveries

Purpose To investigate the safety of misoprostol use in second-trimester pregnancy termination among women with previous caesarean sections. Materials and methods This is a retrospective cohort study conducted in a tertiary centre, examining 359 patients whose pregnancy was terminated with misoprostol alone between 14 and 24 weeks with the indication of foetal anomalies. Two dose regimens were administered vaginally or sublingually: (1)400 mcg misoprostol every 3–6 h; (2) 200 mcg misoprostol every 3–6 h following a loading dose of 400 mcg. The patients were divided into three groups according to the number of previous caesarean sections (CSs) and compared in terms of demographic and clinical characteristics and complications. Termination-related complications were the primary outcomes considered. Results Of the 217 patients, 80 (36.8%) had no previous uterine scar, 79 (36.4%) had one previous CS, and 58 (26.7%) had at least two prior CSs. The overall complication rate was 0.9%. There were no differences among groups in terms of complications (p > 0.05). There was no difference in complications in women with prior CS when they were compared according to the misoprostol regimens used (p > 0.05). The total dose of misoprostol used ranged from200 to 3,600 mcg. The treatment success of misoprostol during the second trimester was 92.1%. According to regression analysis, an increase in the week of gestation increased the failure rate of misoprostol for inducing second-trimester abortion by 2.7 times (95%CI (1.38–5.39)). Conclusion Misoprostol alone is a safe and effective option for terminating second-trimester pregnancies with one or more previous CSs in settings where mifepristone is unavailable.

Diagnostic accuracy of uterine artery doppler velocimetry in patients with placenta previa

Background; The placenta previa (PP) is an obstetric problem in which the placental tissue is improperly located inside the lower uterine segment. Aim and objectives: was to see how effective uterine artery Doppler velocimetry was in detecting unusually morbidly adhering placentas in patients who had had one or more prior caesarean sections with placenta previa. Subjects and methods; Cross-sectional research of 100 patients was undertaken in the Department of Gynecology and Obstetrics, El- Sayed Galal Hospital, AL- Azhar University. Result; Our results showed highly statistically significant correlation between the presence of abnormal lacunae and histopathological confirmation (P-value &gt; 0.001). In addition, the overall Sensitivity, specificity, PPV, NPV and accuracy were 90%, 100%, 100%, 64.2%, 91.6%. This criterion showed very high sensitivity and specificity with very high positive predictive value and accuracy to become the most important criteria, Conclusion; As a result of this, we conclude that the accuracy of abnormal placental lacunae, loss of the reto-placental clear zone, myometrial thinning, and utero-vesical hypervascularity are the most critical ultrasound criteria for diagnosing placenta accreta in patients who had a previous CS with a placenta previa overlying the previous uterine scar.

Analysis of predictive variables of success of the mechanical cervical ripening with Foley catheter in patients with a prior cesarean section and a postterm pregnancy

Objectives: Analysis of success variables of cervical ripening with the Foley catheter in patients with prior cesarean section (PCD), post-term pregnancy (PP), and a Bishop score £6. Evaluation of technique’s safety. Study design: Prospective cohort trial in which 120 patients were enrolled, from April 2014 to May 2018. PCD was codified in four groups: 1) failed Induction (FI); 2) non-progressive labor (NPL) or cephalopelvic disproportion (CPD); 3) abruptio placentae (AP), risk of fetal distress (RFD) or placenta previa; or 4) other causes. Inclusion criteria: singleton pregnancy; &gt;40+6 weeks’ gestation; cephalic presentation; Bishop Score £6; PCD &gt;18 months; signed consent of vaginal delivery (VD). Exclusion criteria: myomectomy with entry into the endometrial cavity; &gt;1 PCDs or uterine rupture; other presentations; macrosomia; multiple pregnancy; placenta or vasa previa; premature rupture of membranes (PROM); inferior genital tract infection. Used material and protocol: Foley catheter insertion at 9 am, followed by 2 hours of fetal cardiotocograph register (CR). This was repeated 6 hours later. Catheter removal 12 hours after the insertion. Intravenous oxytocin was started at 8 am the following day. Statistical analysis: multivariable logistic regression to assess the similarity of populations. Assessment of the relation between VD and APL with the PCD indication and the CL through logistic regressions. The analysis were performed using R (3.5.1), clickR packages (0.3.64), and Boot Validation (0.1.6). Results: A total of 86/109 (78.9%) achieved APL. Whereas 52/86 (60.47%) finished by VD, 34/86 (39.53%) had a cesarean delivery (CD). No significant differences were found between populations. PCD indications for AP, RFD or placenta previa (OR = 7.85 IC95% [1.87, 39], p=0.007) have a higher likelihood of VD. The PCD indication for NPL or CPD; and AP, RFD and placenta previa, have a higher likelihood of achieving APL (OR 14,55 [IC 95% 2.01, 308.5], p=0.023; OR 15,81 [IC 95% 2.03, 359.78], p=0.024; respectively). As CL was higher, the likelihood of APL was lower (OR=0.92 IC95% [0.84, 0.99], p=0.034). No uterine rupture registered. Conclusions: Cervical ripening with the Foley catheter was satisfactory in 78.9% (86/109). PCD indications that are different from FI associate a higher likelihood of VD. CL has a decreasing effect on the likelihood of APL. The Foley catheter is a safe method for cervical ripening.

Potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy: A retrospective longitudinal cohort study

IntroductionPlacenta previa greatly contributes to severe antenatal and post-partum hemorrhage. Previous studies have mainly focused on the risk factors of placenta previa, with very few studies reporting which factors may affect the potential resolution of 28th-week previa. This study aimed to investigate the impact of maternal characteristics on potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy. MethodsA retrospective longitudinal sub-cohort investigation was carried out among 368 pregnant women with 28th-week previa from the Longitudinal Placenta Previa Study (LoPPS). Logistic regression analysis was used to discover the connections between maternal covariates and the placental potential resolution. Multivariable linear regression analysis was used to detect the associations between perioperative characteristics and volume of intraoperative bleeding. ResultsAmong pregnant women whose placenta completely or partially covered the internal os at the 28th-week of pregnancy, 37.5% were without placenta previa at the 36th-week and 25.8% converted into marginal placenta previa. There were significant correlation between placenta previa type and GHD (Beta: 2.808, 95% CI: 1.642, 7.138; p = 0.041), type of 28th-week previa (Beta: 6.767, 95% CI: 1.592, 18.767; p < 0.001), and number of prior cesarean sections (Beta: 3.326, 95% CI: 1.580, 9.081; p < 0.001). Discussion62.5% of the pregnant women with 28th-week placenta previa were still with previa at the 36 weeks of gestation (25.8% with marginal and 36.7% with partial/complete placenta previa). This proportion is even higher for 28th-week complete placenta previa. Trial registrationChinese Clinical Trial Registry ChiCTR2100054068, December 8, 2021.

Trial of labor after two cesarean sections: A retrospective case-control study.

The objective of this study was to compare neonatal and maternal outcomes among women with two previous cesarean deliveries who undergo trial of labor after two cesarean section (TOLA2C) versus elective repeat cesarean delivery (ERCD). Our primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included APGAR score <7 at 5 min, TOLA2C success rate, uterine rupture, postpartum hemorrhage, maternal blood transfusion, maternal bowel and bladder injury, immediate postpartum infection, and maternal mortality. This retrospective cohort study was undertaken at a community medical center from January 1, 2008 to December 31, 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a previous successful TOLA2C, prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, multiple gestation, nonvertex presentation, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. A total of 793 patients fulfilled study criteria. There were no differences in neonatal intensive care unit admissions or 5-min APGAR scores <7 between the two groups. Sixty-eight percent of women who underwent TOLAC (N=82) had a successful vaginal delivery. The uterine rupture rate was 1.16% (N=1) in the TOLA2C group with no case of uterine rupture in the ERCD group. No difference in maternal morbidity was noted between the two groups. No maternal or neonatal mortalities occurred in either group. There was no difference in maternal or neonatal morbidity among patients in our study population with two previous cesarean sections who opted for TOLA2C versus ERCD.