Rupture In Subsequent Pregnancy Research Articles

Reproductive outcomes following abdominal repair for cesarean scar defect in women who desire subsequent pregnancies: A single-center retrospective study

ObjectiveTo clarify the reproductive outcomes of women who underwent abdominal repair surgery for cesarean scar defect (CSD). Study designThis is a retrospective observational study performed in a tertiary center. We retrospectively reviewed 20 women who underwent abdominal repair between 2007 and 2021. The indication for the repair was a minimal residual myometrial thickness (RMT) of ≦3.0 mm. We investigated surgical complications, changes in minimal RMT before and three-months after the repair, and reproductive outcomes. ResultsThe median age at the time of repair was 36 years (27–40), with a median body mass index of 21.0 (17.7–28.7) and a median of 1 prior cesarean section (1–5). Twelve women reported secondary infertility, while eight women were concerned about the potential risk of uterine rupture in future pregnancies due to thin RMT. Additionally, one woman had a co-existing vesicouterine fistula, two had abscess and hematoma formation at the precedent cesarean section, and three showed remarkable dehiscence of the defect. The median minimal RMT significantly increased to 5.05 mm (range; 2.5–14.2 mm) after the repair. Seven women had a total of eight live births, with a median duration from the repair to a live-birth pregnancy of 11.5 months (range; 4–20 months). No surgical complications occurred during the repair, and there were no instances of uterine rupture in subsequent pregnancies. However, one woman who became pregnant with twins following double blastocyst transfer required a cesarean section at 25 weeks of pregnancy due to bulging towards the bladder side of the repaired CSD. ConclusionAbdominal repair for CSD is feasible in women with thin RMT who experience secondary infertility. Twin pregnancies can promote thinning of the CSD repair site, potentially increasing the risk of uterine rupture.

Comparison between Intraoperative and Ultrasound Determined Cesarean Scar Thickness after Elective Cesarean Sections and Unplanned Cesarean Sections in Subsequent Term Pregnancies

Background Cesarean section (CS) rates are increasing worldwide. As a result, women presenting with pregnancy with previous CS are also rising. Previous CS is becoming the most common indication for CS, confirming the age old dictum proposed by Edward Craigin in 1914 “Once a cesarean always a cesarean. Aim of the Work Assessment of cesarean scar; as non-healthy or poor-healed scar are associated with some complications such as chronic pelvic pain, dyspareunia, and abnormal bleeding. Moreover, these poor-healed scars may predispose to preterm labour and uterine dehiscence or rupture in subsequent pregnancy. It was reported also that poor-healed scar may predispose to abnormal placental invasion. Patients and Methods This comparative cross-sectional study was conducted on 100 randomly selected pregnant women attending the outpatient clinic of Ain Shams University Maternity Hospital (ASUMH) in the third trimester at term aged >18 years old with single intrauterine pregnancy, previous one cesarean delivery and not in labor. Pregnant women with abnormal placentation, uterine abnormalities and/or previous uterine surgeries other than one CS delivery were excluded from current study. Results there was no significant difference betweenn two studied groups according to demographic data as age (27.0±3.9 vs. 27.6±3.6, p = 0.382) and BMI (28.2 ± 3.3 vs. 28.7 ± 2.2, p = 0.283). Both groups were comparable with statistically significant difference regarding scar thickness in (ml) and LUS staging. The scar was thicker in elective cases compared with emergency ones (8.4±1.1 vs. 7.7±1.3, p = 0.002), stage I (34 (68.0%) vs. 16 (32.0%)), stage II (15 (30.0%) vs. 25 (50.0%)), stage III (1 (2.0%) vs. 7 (14.0%)) and stage IV (0 (0.0%) vs. 2 (4.0%)). Conclusions From the results of current study we can conclude that, Maternal age and BMI had no effect on cesarean scar quality, integrity and complications incidence. The scar was thicker in elective cases compared with emergency ones.

Outcome of uterine functional structures protection by fertility preservative PUSH surgery in diffuse adenomyosis

This study reports the outcomes of an innovative fertility-preserving surgery for the treatment of diffuse adenomyosis that is known as a surgery for protection of uterine structure for healing (PUSH Surgery). Developed at Peking University Shenzhen Hospital, PUSH Surgery aims to achieve radical excision of adenomyotic lesions by reconstructing the uterus with overlapping muscle flaps to promote optimal healing of the uterine wall and reduce the risk of scar rupture in subsequent pregnancies. PUSH Surgery was performed on 146 patients with diffuse adenomyosis, with uteri measuring from 8 to 16 gestational weeks and an average volume of 230 ± 150cm³. Regular follow-up was conducted for up to 156 months, revealing a significant reduction in VAS pain scores from 9.4 ± 1.2 before the surgery to 0.3 ± 0.8 and 0.6 ± 1.0 at 1 and 2 years post-surgery, respectively, with a continuous alleviation rate of 96.4% after the operations. Notably, 100% of patients with severe menorrhagia reported normal menstruation volumes within 2 years. Additionally, 31 patients attempted to conceive, resulting in a 58% postoperative pregnancy rate and a 60.0% intrauterine live embryo rate. Operation-related complications occurred in 2.7% of patients, with a 3.6% recurrence rate after more than 2 years of follow-up. Importantly, no cases of uterine rupture or severe complications were observed in the pregnant patients. In conclusion, PUSH Surgery offers a promising approach for the radical excision of adenomyotic lesions, promoting improved tissue healing and significant symptom relief.

MATERNAL AND FETAL OUTCOMES IN PATIENTS WITH PREVIOUS CAESAREAN SECTION UNDERGOING TRIAL OF VAGINAL BIRTH

Background: Vaginal birth after cesarean section (VBAC) is one of the strategies developed to control the rising rate of cesarean sections (CSs). It is a trial of vaginal delivery in selected cases of a previous CS in a well-equipped hospital. In 1916, Cragin popularized the dictum, once a caesarean section, always a caesarean section. That was the era of the classical CS. In the present era of lower segment caesarean section (LSCS), cesarean-related morbidity and mortality are significantly reduced. The dictum now is once a caesarean section, always an institutional delivery in a well-equipped hospital. The reasons which led to the reversal of the old dictum are based upon the newer concepts of the assessment of scar integrity, fetal well-being, and improved facilities of emergency Cesarean Section. Successful vaginal birth after cesarean section is more comfortable than repeat emergency or elective cesarean section. Antenatal examinations are important in selection for trial of labor, while birth management can be difficult when the patients present at emergency condition. But there is an increased chance of vaginal birth with advanced cervical dilation.Nevertheless, a previous CS does cast a shadow over the outcome of future pregnancies. With present techniques and skill, the incidence of cesarean scar rupture in subsequent pregnancies is very low. The strength of the uterine scar and its capacity to withstand the stress of subsequent pregnancy and labor cannot be completely assessed or guaranteed in advance. These cases require the assessment and supervision of a senior obstetrician during labor. Hence, the present study is undertaken to assess the success and safety of VBAC in selected cases of one previous LSCS and to evaluate the maternal and fetal outcome in these cases. Methods:This prospective observational study was conducted over a period of 18 months from 1st August 2019 to 28th February 2021 at the department of obstetrics and Gynaecology, tertiary care hospital Pune, Maharashtra, India. After achieving ethic committee approval, informed consent of patients enrolled for the study taken, a thorough history and physical examination was done as per proforma. Cases were evaluated thoroughly to collect maternal age, gestational age at admission, association of success rate of VBAC and Parity, Mode of delivery, whether instrumentation was required, indication of previous LSCS, indication of caesarean section in repeat emergency caesarean section, history of prior vaginal delivery, interpregnancy interval. Maternal and fetal outcomes in both successful VBAC and emergency caesarean section were observed.Data collected in structured pro-forma, entered in Microsoft Office Excel format, and statistical analysis was performed using SPSS software. The data so collected was presented with graphical representation. Results: Out of 65 patients undergoing TOLAC, a total of 51 patients had successful vaginal birth and for 14 patients emergency caesarean section was needed. Therefore, the success rate of VBAC in this study in 78%. The most common indication of failed TOLAC was fetal distress. Factors affecting success of TOLAC seen in the study were inter-pregnancy interval, fetal weight and previous caesarean section done for non-recurrent indications. No significant fetal or maternal morbidity was observed in this study. There was no fetal and maternal mortality. Conclusion:Trial of labor after one caesarean section should be undertaken in selected patients in well-equipped hospitals where facilities to deal with emergencies are available.Despite the risks, trial of labor after caesarean remains safer option for many patients as there are fewer complications with less maternal morbidity and will lead to a successful outcome in a high percentage of cases.

A case of uterine rupture in second term delivery after septum resection

Introduction: The decision to resect a uterine septum remains individualized. Hysteroscopic approach is the gold standard for uterine septum resection. Uterine rupture in subsequent pregnancy is a known but rare complication without identified methods of prevention. Case Report: A 32-year-old woman underwent uncomplicated hysteroscopic uterine septum resection followed by uncomplicated term vaginal delivery, with uterine rupture and intrauterine fetal demise at 38 weeks gestational age in the subsequent pregnancy. Conclusion: Term uterine rupture is possible when the only history of uterine surgery is hysteroscopic septum resection, even with an intervening delivery. Providers should have a low threshold to initiate diagnostic evaluation with fetal or maternal distress in pregnancy after any uterine surgery. Modifiable risk factors for uterine rupture after septum resection may include residual septa, short interval between surgery and pregnancy, and labor induction methodology. Providers should consider these factors when counseling regarding the risks and benefits of resection.

Stinging abdominal pain at 32 gestational weeks with prior classical uterine incision: Careful assessment or emergency cesarean delivery?

The risk of uterine rupture in subsequent pregnancy is 1%‐12% in patients with prior classical uterine incision. Management of mild/moderate abdominal pain without an obvious abnormal finding before 36 weeks is challenging owing to fetal immaturity.

Outcomes following medical termination versus prolonged pregnancy in women with severe preeclampsia before 26 weeks.

ObjectiveTo compare maternal complications and describe neonatal outcomes in women with severe preeclampsia at ≤ 26+0 weeks in two countries with different management policies: expectant management (Brazil) versus termination of pregnancy (France).MethodsWe conducted a retrospective comparative study by reviewing the medical records of women with severe preeclampsia at ≤ 26+0 weeks, from January 2010 to June 2018, in two centers: Hospital das Clínicas da Faculdade de Medicina, in Sao Paulo, Brazil (where medical abortion is forbidden in this indication) and Hôpital Antoine-Béclère, Clamart, France (where medical termination is accepted). We collected information on maternal characteristics, laboratory tests, maternal complications and fetal and newborn characteristics. We used Student’s t-test and the Mann-Whitney U nonparametric test to compare quantitative variables, and Chi-square test or Fisher's exact test to evaluate the associations between the qualitative variables.ResultsThere was no between-group difference in maternal complications during hospitalization (p = 0.846). In Brazil, the rate of cesarean section was 66.7%, and 20% of patients had vertical incision. The rate of spontaneous fetal death was 35.6% and among the live-born infants 26.6% were discharged from hospital. In France, one patient had a cesarean section with vertical incision.ConclusionWhen comparing termination of pregnancy to expectant management in severe preeclampsia before 26 weeks, maternal complications were equivalent but maternal reproductive future might have been compromised in 20% of cases due to a higher risk of uterine rupture in subsequent pregnancies for patients having classic cesarean (vertical incision). 26.6% of children survived the neonatal period when pregnancy was pursued, however we lack information on their long-term follow-up.

Single layer suturing in intracapsular myomectomy of intramural myomas is sufficient for a normal wound healing

Study objectiveTo evaluate surgical outcomes of intracapsular single-layer myomectomy in terms of efficacy and safety as well as examine potential alterations based on kind of surgical approach. MethodsA prospective observational study was performed between January 2010 and December 2018. Women in reproductive age, affected by intramural or subserous myomas (FIGO type 3–6) of 4–14 cm diameter were enrolled. Primary outcomes included initial and final uterine incision length, time to wound healing and uterine rupture in subsequent pregnancies. Furthermore, a sub-analysis was also performed regarding surgical approach, namely laparoscopical or laparoscopically-assisted myomectomy, in order to confirm whether overall observations are similar for both potential surgical approaches. ResultsThere were finally 273 patients included in the present study. Overall mean uterine incision was initially 3.1 cm and was shortened to 2.2 cm at the end of operation, indicating a reduction of 29.1 %. Mean estimated blood loss was 154.2 mL and mean operative time was 82.1 min. No severe intraoperative and postoperative complications were presented. 121 of the studied women had pregnancy 3–36 months after myomectomy, without reporting any uterine rupture. When comparing LIM vs. LAIM, all outcomes were also favorable in the total of patients. ConclusionIntracapsular myomectomy either by LIM or LAIM is a safe and attractive alternative to abdominal myomectomy in setting of premenopausal patients with myomas up to 14 cm. A single-layer continuous suturing in intracapsular myomectomies is enough for a successful wound healing.

Uterine Rupture in Subsequent Pregnancy in a Patient with Previous Uterine Manipulator Associated Uterine Perforation

To report a case who experienced uterine rupture at 38th week of gestation and had a history of manipulator associated uterine rupture. A 25 years old primigravid woman at 38 weeks of gestation was referred to our hospital with the signs of active labor. Heavy lower abdominal cramps and signs of acute abdomen suggested uterine rupture and emergent cesarean section was performed. A 3 cm in size and circular in shape uterin rupture at the fundus that was imitative of enlarged previous manipulator associated rupture was observed. A manipulator associated uterine rupture should be repaired when encountered in reproductive ages in order to prevent a possible uterine perforation during subsequent pregnancy.

Adenomyosis

The usual treatment for severe adenomyosis has been hysterectomy, because its removal is complicated by infiltrative tissue destruction of normal uterine myometrium.. Yet many women wish to retain their uterus to preserve their ability to become pregnant and carry babies. Our objective was to see if it is possible to remove very large, symptomatic adenoymas with a technique that allows safe future childbearing. Complete excision of adenomyotic tissue and reconstruction of the uterine wall by a triple-flap method to prevent uterine rupture in subsequent pregnancies. From June 1998 to August 2017, 113 women with very severe adenomyosis who desired pregnancy, and all of whom had severe and debilitating symptoms were enrolled and followed for relief of symptoms and successful pregnancy and live birth. A dramatic reduction of menstrual symptoms occurred immediately and 69.5% of women delivered a healthy baby at term without any incidence of uterine rupture. Adenomyosis is a disabling disease in women that until recently had been treated by hysterectomy. However, many patients wish to preserve their uterus for childbearing, necessitating the need for a more effective conservative approach in treating this disease. The “triple-flap method” described here has not only significantly decreased the symptoms of adenomyosis but has also increased fertility in these patients with no incidence of uterine rupture. A successful live baby delivery rate of 69.5% has been achieved in these women who otherwise would have undergone hysterectomy.

Clinical and Histologic Evaluation of the Hysterotomy Site and Fetal Membranes after Open Fetal Surgery for Fetal Spina Bifida Repair

Introduction: Among the risks associated with open fetal surgery, myometrium and fetal membrane issues are vexing problems since they may lead to uterine dehiscence or preterm premature rupture of membranes resulting in uterine rupture or preterm birth or both. The aim of this study was to examine whether stapled and sutured hysterotomy scars demonstrate partial or complete healing. Methods: Hysterotomy sites after open fetal surgery were clinically evaluated in 36 women during Caesarean section, classified into the categories intact, thin, and partially or completely dehiscent, then completely excised and histologically analyzed in 25 cases. The histological examination focused on wound healing of myometrium and fetal membranes. Results: The myometrium was intact, thin, and partially or completely dehiscent in 33, 58, and 9%, respectively. The interval between myelomeningocele repair and delivery did not correlate with the healing process. The myometrium showed a reparative zone (scar) with adjacent avital myometrium tissue, fibrosis, and inflammation with foreign body reaction. The intact myometrium was below 1 mm thickness in 56%. All fetal membranes showed complete dehiscence; in 41% they were completely avital. Conclusion: Our study provides evidence that the myometrium shows scarring with substantial thinning or dehiscence. Fetal membranes do not heal spontaneously. In order to prevent uterine rupture in subsequent pregnancies, we recommend the hysterotomy site to be completely excised after birth.

Combined Results of New Surgery Approach and Hormone Therapy with Massive Diffuse Forms of Adenomyosis

The advised treatment for severe adenomyosis is hysterectomy, but the patients wishing to preserve their uterus were operated with a novel conservative surgery, called adenomyomectomy. The history of this new surgery approach dates back to 2011 when Japanese Professor Hisao Osada worked it out and applied this new method of surgery for his patients. Adenomyomectomy, in this method, suggests radically excised adenomyotic tissues and reconstructed uterine wall by a triple-flap method, without overlapping suture lines, to prevent uterine rupture in subsequent pregnancies. This is a prospective case series followed for 6 years from October 2012 to January 2018 of 26 women with massive diffuse adenomyosis verified histologically and diagnosed with ultrasound. 18 women of 26 wished to conceive; 3 patients became spontaneous pregnant and delivered healthy babies. There were no cases of uterine rupture. Adenomyosis symptoms did not recur in all 26 cases. Thus, our experience of intraoperative radical resection of adenomyotic tissues suggests that this technique may be a surgery of the patient’s choice, especially for women of reproductive age with diffuse adenomyosis, we use it for those aging ones who wish to preserve the uterus.

Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials.

There is a growing body of evidence that suggests that the surgical technique for uterine closure following Cesarean delivery influences the healing of the Cesarean scar, but there is still no consensus on the optimal technique. The aim of this systematic review and meta-analysis was to compare the effect of single- vs double-layer uterine closure on the risk of uterine scar defect. MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE and the Cochrane Central Register of Controlled Trials were searched from inception of each database until May 2016. All randomized controlled trials (RCTs) evaluating the effect of single- vs double-layer uterine closure following low transverse Cesarean section on the risk of uterine scar defect were included. The primary outcome was the incidence of uterine scar defects detected on ultrasound. Secondary outcomes were residual myometrial thickness evaluated by ultrasound and the incidence of uterine dehiscence and/or rupture in subsequent pregnancy. Summary measures were reported as relative risk (RR) or mean difference (MD), with 95%CIs. Quality of the evidence was assessed using the GRADE approach. Nine RCTs (3969 participants) were included in the meta-analysis. The overall risk of bias of the included trials was low. Statistical heterogeneity within the studies was low, with no inconsistency in the primary and secondary outcomes. Women who received single-layer uterine closure had a similar incidence of uterine scar defects as did women who received double-layer closure (25% vs 43%; RR, 0.77 (95% CI, 0.36-1.64); five trials; 350 participants; low quality of evidence). Compared with double-layer uterine closure, women who received single-layer closure had a significantly thinner residual myometrium on ultrasound (MD, -2.19 mm (95% CI, -2.80 to -1.57 mm); four trials; 374 participants; low quality of evidence). No difference was found in the incidence of uterine dehiscence (0.4% vs 0.2%; RR, 1.34 (95% CI, 0.24-4.82); three trials; 3421 participants; low quality of evidence) or uterine rupture (0.1% vs 0.1%; RR, 0.52 (95% CI, 0.05-5.53); one trial; 3234 participants; low quality of evidence) in a subsequent pregnancy. Single- and double-layer closure of the uterine incision following Cesarean delivery are associated with a similar incidence of Cesarean scar defects, as well as uterine dehiscence and rupture in a subsequent pregnancy. However, the quality level of summary estimates, as assessed by GRADE, was low, indicating that the true effect may be, or is even likely to be, substantially different from the estimate of the effect. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Incidence and outcomes of uterine rupture among women with prior caesarean section: WHO Multicountry Survey on Maternal and Newborn Health

Caesarean section (CS) is increasing globally, and women with prior CS are at higher risk of uterine rupture in subsequent pregnancies. However, little is known about the incidence, risk factors, and outcomes of uterine rupture in women with prior CS, especially in developing countries. To investigate this, we conducted a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health, which included data on delivery from 359 facilities in 29 countries. The incidence of uterine rupture among women with at least one prior CS was 0.5% (170/37,366), ranging from 0.2% in high-Human Development Index (HDI) countries to 1.0% in low-HDI countries. Factors significantly associated with uterine rupture included giving birth in medium- or low-HDI countries (adjusted odds ratio [AOR] 2.0 and 3.88, respectively), lower maternal educational level (≤6 years) (AOR 1.71), spontaneous onset of labour (AOR 1.62), and gestational age at birth <37 weeks (AOR 3.52). Women with uterine rupture had significantly higher risk of maternal death (AOR 4.45) and perinatal death (AOR 33.34). Women with prior CS, especially in resource-limited settings, are facing higher risk of uterine rupture and subsequent adverse outcomes. Further studies are needed for prevention/management strategies in these settings.

Single Layer Versus Double Layer Closure of Uterus during Caesarean Section – A Prospective Study in Index and Subsequent Pregnancy

Background: Suturing of caesarean incision leads to reduction in maternal mortality, suturing can be done in either single layer or double layer. Many studies have shown both of them to be effective, with no conclusive evidence of preference of any one of them. The objective of this study was to compare method of uterine closure by single-layer and double-layer closure keeping in mind the intraoperative and postoperative morbidity in index pregnancy and risk of uterine rupture in future pregnancy. Methods: This prospective randomized controlled study was done from March 2007 to January 2009, a total of 357 women were enrolled for lower segment caesarean section either to single layer (n=188) or double layer (n=169) closure of uterine incision. Primary outcome measures studied were operating time, intraoperative blood loss, and febrile morbidity in index pregnancy and chances of uterine rupture in subsequent pregnancy. Secondary outcome measures were cystitis, wound infection and hospital stay. Results were compared by Chi-square test. Results: Patients with single layer closure had significantly (p 0.05). Operative findings in subsequent pregnancy don’t differ much. Conclusions: Single layer closure was associated with lesser operating time, intra-operative blood loss, febrile morbidity and hospital stay in index pregnancy as compared to double-layer closure.

Rupture of a caesarean scar during a trial of vaginal birth: a dramatic consequence as old as the modern caesarean section.

Among other pioneering surgical procedures, John Hunter (1728–1793), the father of modern surgery, is credited to have performed the first caesarean section deliveries using an evidence-based anatomical approach (Moore W, The Knife Man, Bantam Press, 2005). Even if his procedures were technically successful – and Hunter managed to deliver a few live and surviving babies – the mother inevitably died, mainly because of the lack of suitable suturing material and wound infection. Thus, until the 19th century, caesarean section remained a surgical procedure of last resort performed almost exclusively to save the baby's life. It is only when surgeons started to suture the uterus after delivery that the maternal death rate started to fall. Further technical advances in surgical techniques during the early 20th century reduced the complication rates of caesarean section substantially. As a result, mothers not only survived the surgical procedure but were also able to have one or more subsequent pregnancies. With the rising numbers of caesarean sections came new complications in subsequent pregnancies and, in particular, rupture of the previous uterine scar became more commonly reported in the medical literature. In 1921, in a special issue on caesarean section published by this journal, Eardley Holland (1880–1967), consultant at the London Hospital, reported on five cases of scar rupture leading to maternal death during pregnancy or labour (Holland E, J Obstet Gynecol Br Emp 1921;28:488–522). Holland recalled having performed the primary caesarean section of one of these patients 5 years earlier, and stated that: ‘The occurrence of these treacherous accidents made a very great impression on the minds of myself and my colleagues’. His inquiry indicated that there was little information about the causes and frequency of scar rupture after caesarean section, and that ‘certain surgeons were so afraid of ruptured scar that they sterilize their patients at the first operation’. The classical caesarean section is associated with the greatest damage to the uterine wall, and not surprisingly with the highest risk of ruptured scar in subsequent pregnancies, before and during labour. Low-segment caesarean sections are rarely associated with spontaneous scar rupture during pregnancy, but are observed in one in 250 spontaneous labours, and the risk is higher when labour is induced with prostaglandins (Landon et al., NEJM 2004;351:2581–9); however, the reason why some women rupture their scar and others do not remains unclear. Variations in surgical techniques or different suture material used do not seem to explain scar rupture in subsequent pregnancies (Roberge et al., Int J Gynaecol Obstet 2011;115:5–10). The use of continuous fetal heart monitoring during labour and access to fluid infusion and blood transfusion has reduced fetal and maternal morbidity and mortality in deliveries complicated by ruptured uterine scar. The data analysis of a representative sample of the French obstetric population indicates that the incidence of elective repeat caesarean section is well above that expected from the national guidelines for women eligible for a trial of scar (Bartolo et al., BJOG, in this issue). They suggest that non-medical reasons are involved in the decision. Perhaps collective memory of the dramatic consequences of a ruptured scar still influences doctor and patient choice. None declared. Completed disclosure of interests form available to view online as supporting information. 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.

A Growing Concern: Cesarean Scar Defect and Massive Uterine Bleeding

Cesarean Scar Defect (CSD) is the formation of a diverticulum at the site of the old caesarean incision [1]. With a rising cesarean sections being performed, the complications caused by CSDs has attracted more and more attentions. These include conditions such as scar pregnancy, placenta accreta, placenta previa, and uterine rupture in subsequent pregnancies [2,3].

Efficacy of Transrectal Three-Dimensional Ultrasound-Guided Hysteroscopic Metroplasty

Background: Transabdominal ultrasound is not the standard for scanning pelvic structures, and the transvaginal route can result in repeated removals and reinsertions of the hysteroscope, with subsequent uterine refilling. Objective: The goal of this research was to evaluate the efficacy of transrectal 3-D ultrasound for intraoperative guidance during hysteroscopic metroplasty. Design: This pilot, prospective, randomized comparative study (Canadian Task Force classification I) was conducted in the Shatby Maternity University Hospital in Alexandria, Egypt. Materials and Methods: The study involved 60 patients with infertility or recurrent pregnancy-loss problems, who were diagnosed by hysterosalpingogram (HSG) and 3-D vaginal ultrasound to have uterine septa. The patients were randomized into two groups. Group A (30 patients) had hysteroscopic metroplasty with transrectal 3-D ultrasound performed intermittently during the procedure. Group B (30 patients) had hysteroscopic metroplasty without ultrasound guidance. All patients had postoperative HSG 3 months later. Results: A statistically significant longer operative time was found in group A (p=0.001). No statistically significant difference was found between both groups regarding volume of fluid deficit and intraoperative complications. No residual septa were found on HSG 3 months postoperatively in group A, while 4 cases (13.3%) of residual septa were seen in group B, with a significant statistical difference between both groups (p=0.04). Conclusions: Transrectal, 3D, ultrasound-guided hysteroscopic metroplasty seems to be a reliable, safe noninvasive tool that enables complete precise removal of a uterine septum in one session with no residual tissue remaining and no myometrium injury, thus eliminating the risk of uterine rupture in subsequent pregnancies. Moreover, there is no need for intraoperative laparoscopic monitoring or postoperative HSG. (J GYNECOL SURG 30:209)

The dilemma of vaginal breech delivery worldwide

The number of caesarean sections being done is increasing worldwide, with an increase in associated complications such as major haemorrhage, sepsis, organ injury, and re-operations at short term, and abnormal placentation with subsequent haemorrhage, obstetric hysterectomy, and uterine scar rupture in subsequent pregnancies. 1 Grivell RM Dodd JM Short- and long-term outcomes after cesarean section. Expert Rev Obstet Gynecol. 2011; 6: 205-215 Crossref Scopus (33) Google Scholar Risks for these and even more serious complications such as maternal death are disproportionally higher in resource-poor settings than in resource-rich settings, leading to huge human suffering. Many doubtful reasons for caesarean sections are reported in the scientific literature, such as reduced amniotic fluid, big babies, premature rupture of membranes, twins, obstructed labour with intact fetal membranes, and a fetus in breech presentation. 2 Maaløe N Sorensen BL Onesmo R Secher NJ Bygbjerg IC Prolonged labour as an indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG. 2012; 119: 605-613 Crossref PubMed Scopus (45) Google Scholar The dilemma of vaginal breech delivery worldwideWe wish to remark on a Comment by Jos van Roosmalen and Tarek Meguid (May 31, p 1863).1 The authors lament the decrease of vaginal breech delivery and express that despite much critique of the Term Breech Trial, caesarean breech delivery practice has been extensively used.2 The Comment presents a sorrowful picture of the unintended results of this practice change, with reported increases in maternal complications and mortality. More than a decade after the Term Breech Trial and its policy implementation, the way forward might no longer be the return of vaginal breech delivery. Full-Text PDF The dilemma of vaginal breech delivery worldwide – Authors' replyWe thank the correspondents for their remarks on our Comment.1 We agree that external cephalic version (ECV) should be done for all suitable women with breech presentation. Unfortunately, ECV is seldom done in sub-Saharan Africa and in many other parts of the world. ECV should, however, be part of obstetric training, but even when ECV is practised, vaginal breech delivery will still result from the many failed ECVs. We do not agree that a failed ECV is an indication for an elective caesarean section. Full-Text PDF The dilemma of vaginal breech delivery worldwideJos van Roosmalen and Tarek Meguid have discussed the decrease of vaginal breech delivery in contemporary obstetric practice in their Comment.1 The publication of the Term Breech Trial2 in 2000 has undoubtedly been associated with an almost complete elimination of breech presentations from delivery suites in the developed world. Our group has previously reported, however, that the practice of vaginal breech delivery was already decreasing prior to publication of the Term Breech Trial and that the trial's findings simply accelerated that trend. Full-Text PDF

Uterine Rupture After Uterine Artery Embolization for Symptomatic Leiomyomas

There are few data regarding safety of pregnancy after uterine artery embolization. However, numerous women desire future fertility after this procedure. Uterine rupture without a history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy. We report a case of uterine rupture in a primigravid woman after uterine artery embolization. Her pregnancy was also complicated by placenta previa with placenta increta, resulting in a favorable neonatal outcome in an otherwise life-threatening situation for mother and fetus. Uterine artery embolization is a risk factor for abnormal placentation and uterine rupture in subsequent pregnancies.