Scarred Uterus Research Articles

Clinical Strategy of First Cesarean Section and Second Cesarean Section with Scar Uterus

Clinical Strategy of First Cesarean Section and Second Cesarean Section with Scar Uterus

Spontaneous uterine rupture during the first trimester of a partial molar pregnancy in a scar uterus: A rare case report.

IntroductionSpontaneous uterine rupture in the first trimester is a redoubtable obstetric emergency that carries a high risk for both mother and fetus.Cases presentationWe present the case of a spontaneous uterine rupture in a patient with a scarred uterus at 9 weeks' gestation treated by laparotomy in emergency obstetrical department of Ibn Rochd University Hospital of Casablanca; whose histological examination of the removed material found a partial mole.Clinical discussionSpontaneous uterine rupture in the first trimester is rare and usually occurs in a scarred or malformed uterus. Clinicians should consider this diagnosis in the presence of an acute abdominal pain in early pregnancy with or without first trimester metrorrhagia.ConclusionSince the rate of uterine surgeries is increasing, it is necessary to highlight the risk of uterine rupture occurring early in order to improve their management. Molar pregnancy is a factor of fragility of the uterine wall and uterine rupture must be suspected in any molar pregnancy associated with a hemoperitoneum.

An Exceptional Case of Uterine Rupture on a Scarred Uterus Discovered Following a Late Abortion

Uterine rupture (UR) is a life-threatening peripartum complication with a high incidence of maternal morbidity and mortality. It is quite common in the third trimester of pregnancy ranging from 1 / 8,000 to 1 / 15,000 pregnancies. Its true incidence in the first trimester is unknown as most of the reports are case reports or small series of cases. We report an exceptional case of uterine rupture at 13 weeks of amenorrhea in a 34-year-old patient with a history of a cesarean delivery 2 years ago, discovered following a late abortion due to persistent bleeding and failure of aspiration. Through this observation we would like to draw the attention of practitioners to this diagnosis, which is often overlooked in the first trimester.

Uterine Rupture: A Rare Case and its Successful Management

Misoprostol is a commonly preferred drug for induction of labor but it should be strictly avoided in scarred uterus because of high chances of uterine rupture. Here presented a 31 year old female with intrauterine death of twin pregnancy at 20 weeks of gestation who had uterine rupture probably due to vaginal misoprostol. This report elaborates about the uterine rupture, a rare presentation and its successful management.

Rupture Uterus in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Rupture uterus is an obstetric catastrophe with poor maternal and fetal outcome. The objective of the study is to determine the prevalence of rupture uterus in pregnancy. This was a descriptive cross sectional study conducted in a tertiary care centre from January 2016 to December 2016 after taking ethical approval (Approval No. F-NMC-510/76/77) from Institutional Review Committee. Convenience sampling method was used. Data were entered in the Microsoft Excel sheet and obtained data was analysed using Statistical Package for Social Sciences version 18 software for central tendency and frequencies. Out of total 1559 deliveries, prevalence of rupture uterus was found to be 12 (0.0077%). Previous lower segment caesarean scar rupture was the most common risk factor noted in 7 (58.3%) cases. A total of seven patients (58.3%) required intensive care unit admission and blood transfusion. Other maternal complications were surgical site infection 2 (16.67%), sepsis 2 (16.67%), paralytic ileus 1 (8.3%), pelvic collection 1 (8.3%) and vesico vaginal fistula 1 (8.3%). Two maternal deaths (16.67%) and perinatal death was noted in 8 (66.66 % ) cases. Rupture uterus most commonly occurred in scarred uterus. Identification of high risk pregnancy, judicious caesarean section, proper labor monitoring, early diagnosis and prompt management are essential in reducing its occurrences.

Risk factors and outcomes of uterine rupture in Singapore: Emerging trends

Uterine rupture is uncommon but has catastrophic implications on the pregnancy. A scarred uterus and abnormal placentation are known contributory factors. The aim of our study was to review the contributing factors, clinical presentation, complications and management of uterine rupture in our population in light of the changing nature of modern obstetric practices. A retrospective observational study was conducted at KK Women's and Children's Hospital by studying proven cases of uterine rupture in the period between January 2003 and December 2014. These cases were analysed according to their past history, clinical presentation, complications, management and outcome. A total of 48 cases of proven uterine rupture were identified. The incidence of uterine rupture was 1 in 3,062 deliveries. The ratio of scarred uterus rupture to unscarred uterus rupture was approximately 3:1. The most common factor was previous lower segment caesarean section for the scarred group, followed by a history of laparoscopic myomectomy. Abdominal pain was the common clinical presentation in the antenatal period, while abnormal cardiotocography findings were the most common presentation in intrapartum rupture. There is a notable shift in the trend of uterine rupture cases given the increasing use of laparoscopic myomectomy and elective caesarean sections. While ruptures from these cases were few, their presentation in the antenatal period calls for diligent monitoring with informed patient involvement in their pregnancy care.

Posterolateral uterine rupture in scarred uterus complicated by external iliac vein injury

Uterine wall rupture is a rare yet catastrophic complication of pregnancy with a high mortality rate of both the mother and the fetus. The condition could be classified according to etiology into primary unscarred uterus, and secondary scarred uterus or according to the site of rupture. Our case presented with scarred uterine rupture through a posterolateral injury. The patient had history of 3 previous CS and a D&C procedure. The rupture was complicated by EIV injury. Uterine rupture does not always present with profound manifestations of shock especially in posterior wall rupture and timely management ensures the best possible outcome. Finally, meticulous examination of the anatomically related structures and vessels, and the repair of any associated injuries, is essential.

Misoprostol only or in combination with intra cervical Foley’s catheter for termination of the second trimester demise pregnancy in patient with previous caesarean sections

Objective: Termination of second trimester pregnancy is unique obstetric contest due to its difficulty and risky especially if the condition is associated with prior Caesarean deliveries. Aim of the work: To compare the safety and efficacy of two regimens for termination of the second trimester pregnancy in ladies with scarred uterus by prior Caesarean deliveries either by using sublingual and vaginal misoprostol or sublingual misoprostol in a combination with intra cervical Foley’s catheter. Patients and methods: 163 pregnant ladies with second trimester demise pregnancy at14-24 gestational weeks in scarred uterus (≥ one cesarean sections) participated in this prospective randomized comparative study which was performed in obstetric emergency unit in Zagazig University Hospitals, Egypt from June 2019 to May 2020. 140 patients only far-reached the trial through termination of the pregnancy via induction of abortion by sublingual and vaginal misoprostol Group 1 (GI) or Foley’s catheter with vaginal misoprostol Group 2 G (II). Whichever of those methods sustained for 48 hours else the fetus expulsed formerly .Outcomes was determined by comprehensive expulsion of fetus and placenta, Induction Abortion interval, Incidence of side effects, requirement for surgical intervention and complications" rate. Results: The demographic criteria of both groups revealed no significant difference (P-value>0.05). The mean (SD) of Induction to abortion interval (hours) in GI was significant longer than in G II (51.07±23.84, 45.20±31.28) respectively with (P- value 0.021). Total dose (μg) of misoprostol used in GI (1100.72±23.54) was higher than G II (645.35± 322) with p value 0.001. Admission-termination hospitalization (days) was significant longer in G I (4.11±1.02) than in G II (2.371±1.98) with P value 0.004. No significant difference as regard occurrence of adverse effects between both groups except the incidence of fever (17.1%) in G I and (5.7%) in G II with P value 0.01. Success rate in GI and G II were (80%, 95%) respectively with P-value 0.01. Incomplete expulsion was higher in GI (14.3%) in comparison with G II (4.2%) with P value 0.04. Incidence of haemorrhage was significant higher in G II than in GI P value 0.03. No significant differences between both groups as regard incidence of rupture uterus or occurrence of infection. Conclusion: Practice of inserting Foley’s catheter through cervix with misoprostol sublingually for termination of mid-trimester pregnancy in preceding uterine scar(s) is efficient, inexpensive and safe procedure.

Reducing neonatal morbidity by discontinuing oxytocin during the active phase of first stage of labor: a multicenter randomized controlled trial STOPOXY

BackgroundOxytocin is effective in reducing labor duration, but can be associated with fetal and maternal complications such as neonatal acidosis and post-partum hemorrhage. When comparing discontinuing oxytocin in the active phase with continuing oxytocin infusion, previous studies were underpowered to show a reduction in neonatal morbidity. Thus, we aim at evaluating the impact of discontinuing oxytocin during the active phase of the first stage of labor on the neonatal morbidity rate.MethodsSTOPOXY is a multicenter, randomized, open-label, controlled trial conducted in 20 maternity units in France. The first participant was recruited January 17th 2020. The trial includes women with a live term (≥37 weeks) singleton, in cephalic presentation, receiving oxytocin before 4 cm, after an induced or spontaneous labor. Women aged < 18 years, with a lack of social security coverage, a scarred uterus, a multiple pregnancy, a fetal congenital malformation, a growth retardation <3rd percentile or an abnormal fetal heart rate at randomization are excluded. Women are randomized before 6 cm when oxytocin is either continued or discontinued. Randomization is stratified by center and parity. The primary outcome, neonatal morbidity is assessed using a composite variable defined by an umbilical arterial pH at birth < 7.10 and/or a base excess > 10 mmol/L and/or umbilical arterial lactates> 7 mmol/L and/or a 5 min Apgar score < 7 and/or admission in neonatal intensive care unit. The primary outcome will be compared between the two groups using a chi-square test with a p-value of 0.05. Secondary outcomes include neonatal complications, duration of active phase, mode of delivery, fetal and maternal complications during labor and delivery, including cesarean delivery rate and postpartum hemorrhage, and birth experience. We aim at including 2475 women based on a reduction in neonatal morbidity from 8% in the control group to 5% in the experimental group, with a power of 80% and an alpha risk of 5%.DiscussionDiscontinuing oxytocin during the active phase of labor could improve both child health, by reducing moderate to severe neonatal morbidity, and maternal health by reducing cesarean delivery and postpartum hemorrhage rates.Trial registrationClinical trials NCT03991091, registered June 19th, 2019.

Mid Trimester Termination of Pregnancy : Role of Combined Mifepristone and Misoprostol

Background: Mid trimester abortions constitute 10%-15% of all induced abortionsworld wide. Over the last decade this increase is due to better prenatal screening. Itcan be done by surgical and medical methods. Medical methods such as Misoprostolis widely used for mid trimester abortion. Mifepristone has antiprogesteroneproperty,so addition of Mifepristone with Misoprostol can increase its effectiveness.To assess the safety, effectiveness and acceptibility of combined Mifepristone andMisoprostol for mid trimester medical termination of pregnancy (Between 13-24weeks of gestation).&#x0D; Materials and methods: This experimental study was conducted among 40 healthywomen who presented for mid trimester termination of pregnancy between 13-24weeks with missed abortion, gross congenital anomalies with or without previoushistory of one caesarian section. The study was conducted from March October2018 at Chattogram Maa-O-Shishu Hospital Medical College, Chattogram,Bangladesh. Each woman received a single dose of tablet Mifepristone 200mg. After24 hours, 200 mcg vaginal Misoprostol was administered which was repeated at 6hourly interval for maximum of 5 doses (1000 mcg) in 24 hours. Success was takenas complete expulsion of fetus and placenta within 24 hours of first dose ofMisoprostol. Primary and secondary outcomes were measured. Statistical analysiswas done using SPSS version 23.&#x0D; Results: Success rate of complete abortion was 97.5%. Mean Induction AbortionInterval was11.59 hours (SD± 3.34). Mean dose of Misoprostol was 1.85 (SD± 0.77)or 370 mcg. Over all safety of the study was satisfactory with only 1 patientexperienced fever and 1 had nausea .There was no major complication.&#x0D; Conclusion: The Mifepristone/Misoprostol regimen is a highly effective as well assafe option for mid trimester medical termination of pregnancy with a shortinduction abortion interval and it can also be used in scarred uterus with closesupervision.&#x0D; Chatt Maa Shi Hosp Med Coll J; Vol.19 (1); January 2020; Page 63-67

Clinical study on perinatal outcomes of 80 cases with unicornuate uterus pregnancy

Objective: To analyze the perinatal outcomes of unicornuate uterus pregnancy. Methods: The clinical data of patients with unicornuate uterus pregnancy who delivered between January 2009 and December 2018 in Women's Hospital, School of Medicine, Zhejiang University, were reviewed retrospectively. Live birth was defined as the delivery of a baby after at least 28 weeks gestational age. Ninety-eight patients were diagnosed as unicornuate uterus, while 4 cases of stillbirth and 4 cases of twin pregnancy and 10 cases of incomplete data were excluded, and 80 patients with unicornuate uterus were included in the observation group. By matching the age, gestational age and delivery mode, 160 patients were randomly selected as the control group. The perinatal outcomes such as delivery mode, cesarean section indication sequence, postpartum hemorrhage, vaginal delivery time, newborn birth weight and Apgar score were analyzed retrospectively. Results: In the unicornuate uterus group, there were 10 cases of vaginal delivery and 70 cases of cesarean section, among which the primary indication of premature cesarean section and full-term cesarean section was abnormal fetal position, accounting for 7/18 and 50.0% (26/52), respectively. While in the control group, there were 20 cases of vagianl delivery and 140 cases of cesarean section, among which the main indications of premature cesarean section were placenta previa, intrahepatic cholestasis during pregnancy and scar uterus, accounting for 19.4% (7/36), and the primary indication of full-term cesarean section was abnormal fetal position, accounting for 23.1% (24/104). The postpartum hemorrhage of the vaginal delivery in the unicornuate uterus group and the control group was (319±161) and (261±152) ml, respectively, and the postpartum hemorrhage of the cesarean section delivery was (257±106) and (272±123) ml, respectively. There were no significant differences between the two groups statistically (all P>0.05). The time of the first stage of labor was (502±386) and (465±296) minutes in the unicornuate uterus group and the control group, and the time of the second stage was (74±73) and (47±30) minutes, respectively. There were no significant differences between the two groups statistically (all P>0.05). The neonatal birth weight in the unicornuate uterus group and the control group was (3 018±548) and (3 080±562) g, respectively, and there was no significant difference between the two groups statistically (P=0.42). According to preterm birth and different pre-pregnancy body mass index, the neonatal birth weight of the two groups were compared, and the differences were not statistically significant (all P>0.05). One-minute Apgar score of premature in the unicornuate uterus group and the control group were 10 (9.25-10) and 10 (10-10), 5-minute Apgar score were 10 (10-10) and 10 (10-10), respectively. One-minute Apgar score of full-term in the unicornuate uterus group and the control group were 10 (10-10) and 10 (10-10), 5-minute Apgar score were 10 (10-10) and 10 (10-10), respectively. There were no statistically significant differences between the two groups, respectively (all P>0.05). Conclusions: The patients with unicornuate uterus could give birth vaginally in the absence of other operation indications. The perinatal outcome of women with unicornuate uterus is similar to that of women with non-uterine abnormalities. It is found that the abnormal fetal position with unicornuate uterus is the main reason for cesarean section.

Comparative Observation on Clinical Effect of Transverse Incision and Longitudinal Incision of Abdominal Wall on Cesarean Section of Scar Uterus

Comparative Observation on Clinical Effect of Transverse Incision and Longitudinal Incision of Abdominal Wall on Cesarean Section of Scar Uterus

A Prospective Observational Study to Know the Incidence of Placenta Previa and Comparing its Effect on Fetomaternal Outcome in Scarred and Unscarred Uterus at A Tertiary Care Centre

A Prospective Observational Study to Know the Incidence of Placenta Previa and Comparing its Effect on Fetomaternal Outcome in Scarred and Unscarred Uterus at A Tertiary Care Centre

Term spontaneous trial of labor in nulliparous women of short stature: A hospitals-based cohort study

ObjectivesTo study the mode of delivery in a well selected cohort of short nulliparous women. Study designHospitals-based cohort study between 2010-2018. The threshold (150 cm, i.e 2,3°p), for the short stature was chosen before the analysis by corresponding to – 2SD of the average population size distribution of all women who delivered over the same period: 2010–2018.Were included nulliparous women with a heigh ≤ 150 cm in term spontaneous labor with a single livung fetus in vertex presentation without malformation.Exclusion criteria were: multiparous, scarred uterus, twin pregnancy, induced labor, preterm delivery (< 37 W P), non-vertex pregnancy, medical termination of pregnancy, stillbirth, severe fetal malformations, pre-labor cesarean, and late dating ultrasound.The main outcome was the mode of delivery. Univariate and multivariate analysis adjusted on potential confounding variable were performed to investigate the risk of intrapartum CS. Results178 nulliparous women were included. The mean height was 148 cm. The rate of spontaneous vaginal delivery, operative vaginal delivery a nd intrapartum CS were :35,4 %, 35,4 % and 29,2 % respectively.Intrapartum CS was performed during the first stage labor in 15 (28, 8 %) women and during the second stage in 37 (71, 2 %) women. An arrest of labor was significantly more frequent in the active labor than the early labor stage: 62,1 % vs. 33.3 % (p = 0, 02).In univarate analysis were associated with intrapartum CS : Gestational diabetes, birthweight> 3,5 kg, individual adjusted birthweight >90°p, occiput posterior, oxytocin use, cephalic circumference.After adjustment on birthplace and overweight (BMI over 25), only a birthweight > 3,5 kg remains associated with the risk of intrapartum CS (aOR4.3 ;95 %CI 1.96–10.2). ConclusionAn attempt of vaginal birth is a reasonable option for short stature women. Maternal height could be included in the selection criteria for planned birth center or home birth.The customized gestational-related optimal weigh could be useful to identify large of gestational age fetus.

Predictive factors of Uterine Rupture

Objectives: To assess the frequency and predictive factors of uterine rupture on no-scar uterus and on scarred uterus in an intermediate level health hospital in Dakar. Method of study: This retrospective was carried out by the Philippe Maguilen Senghor Health Center in Yoff (Dakar) during the period from January 1, 2011 to December 31, 2017. It included all the women who gave birth there'' a single pregnancy after 22 weeks of amenorrhea with a longitudinal fetal presentation or admitted after childbirth. We had studied socio-demographic characteristics and risk factors for uterine rupture. The extracted data was analyzed first on Microsoft Excel 2016 and then on EPI info. Results: Over 7 years, 29,332 deliveries of single pregnancies were recorded in our structure with 54 uterine ruptures, and a frequency of 0.18%. Induction of labor was spontaneous in 47 of the patients who presented with uterine rupture; labor was artificially induced in only 7 patients, with frequencies of 0.17% and 0.36% of all uterine ruptures, respectively. Considering the risk factors of uterine rupture, 5 parameters were discriminating: multiparity (p&lt;0.0001), transfer from another health facility for admission (p&lt;0.0001), type of fetal presentation (p=0.0001), the presence of a uterine scar (p&lt;0.0001) and the age class (p&lt;0.0001). Conclusion: The rate of uterine rupture in our structure is certainly low but should call for more vigilance during labor with a focus on evacuated patients who have started their work in another structure, patients with a uterine scar and multiparous. Childbirth on a scar uterus is a reasonable option after eliminating a potential cause of obstructed labor. Keywords: Ruptured uterus; Scar uterus; Risk factors

Emergency Caesarean Section in Adolescent Girls at the Referral Health Center in Commune I

Teenage pregnancy is common in Mali due to the high rate of unwanted pregnancies and early marriages. The general objective of this study was to study emergency cesarean delivery in adolescent girls at the referral health center (RHC) in commune I of the district of Bamako. It was a descriptive study with prospective data collection from January 1 to December 31, 2018. Any adolescent girls in whom an emergency caesarean section was performed were included. The data were entered and analyzed on SPSS 20.3. Results: we have collected 616 adolescent parturients, 202 caesareans were performed in emergency, with a frequency of 32.8%. The average age was 17 with the extremes of 13 and 19. Early marriage was found out in 95.5% of our patients, 40 adolescent girls were primiparous (20%), 4 of whom had an inter-reproductive interval of less than a year. The main indications for cesarean section were fetal distress in 71 cases (35%), fetal-pelvic disproportion, scar uterus in the border pelvis (11% each), breech presentation in 15 cases (7%). Anemia (10.4%) was the main complication, followed by vascular pedicle attack (5.94%), infection of the operating site (1.5%) and a bladder wound (0.99%). Fetal mortality was 1.4% and neonatal 3.8%. Conclusion: the association between adolescence and caesarean section in emergency constitutes risk factors which increase maternal and neonatal morbidity and mortality. Fighting these factors improves the survival of the mother and the newborn.

Prevalence of Placenta Previa in Developing Countries and Its Association with Scarred and Unscarred Uterus

Placenta previa is an obstetric complication that occurs in the second and third trimester of pregnancy. It may cause severe feto-maternal morbidities and mortalities to mother and fetus. The risk of placenta previa increases with the history of cesarean section. In the presence of these two risk factors (placenta previa and previous cesarean section) incidence of placenta accrete spectrum is also increased. The value of making the diagnosis of placenta previa before delivery is important to involve for multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality so the feto-maternal outcome can be optimized. The aim of the study is to determine the prevalence of placenta previa in developing countries like Pakistan and find out its association with scarred and unscarred uterus. It is a descriptive cross sectional study. 207 cases of placenta previa were found in six month of period, among them 138 patients were having previously scared uterus, and 69 were having previously unscarred uterus. Most patients 35.74% were between 36-40 years age group, and presented with gestational age between 32-35 weeks were 53.62%. Mostly found between G5-G7 i.e. 52.65%. While frequency of placenta previa in scarred uterus was 66.66% and in unscarred uterus was 32.45%. Association of placenta previa with previous four LSCS was found 33.33%. Occurrence of major degree placenta previa was found 18.84% and minor was 81.15%. Prevalence of placenta previa was found 5.78%. Strong association was found between placenta previa and scared uterus which is highest with previous four. Our objective is to determine the frequency of placenta previa in scared and un-scared uterus. To minimize the rate of cesarean section we can reduce the feto-maternal morbidity and mortality, rising trend of cesarean section in turn increases the rate of placenta previa.

Analysis of Cesarean Section Indications According to the Robson Classification in Surgical Maternities in Dakar, Senegal: About 9185 Cases

Background: The caesarean section rate remains relatively high in the surgical maternity hospitals in Dakar and the indications for scarred uterus are still high. The management of induced prematurity for maternal pathologies still poses real problems in Dakar. The aim of our study is to compare the Caesarean section rate in the different surgical facilities in Dakar. We used the ROBSON's classification to evaluate the indications for Caesarean section in surgical maternity hospitals in Dakar. Methods: This was a descriptive and analytical prospective study which took place from January 1^st to December 31^st 2019 in 10 surgical maternity hospitals in Dakar (University hospital Aristide Le Dantec, National Hospital Center of Pikine, Municipal Hospital Center Abass NDAO, Principal Hospital of Dakar, Youssou Mbargane DIOP Hospital in Rufisque, Ouakam Military Hospital, Grand Yoff General Hospital, Gaspard Kamara Health Center, Nabil Choucair Health Center, Roi Baudoin Hospital Center) and which included all patients who delivered by caesarean section. Indications for Caesarean section were classified according to ROBSON's 10 group classification. The parameters studied were age, frequency, indications for Caesarean section in these surgical maternity hospitals and, Apgar score at five minutes and, birth weight. Data collection was done through birth records and registers, on-call diaries and integrated into a database developed with Sphinx software. Statistical analysis was done using SPSS software. Results: During the period of the study we recorded 35287 deliveries with 9185 Caesarean sections, i.e. a frequency of 26%. The average age of the patients was 29 years. Indications for Caesarean section in Dakar surgical maternity hospitals were dominated by group 5 (28.4%) according to Robson's classification. Group 10 in Robson's classification was predominant in the maternity hospitals of University hospital Aristide Le Dantec (23.3%) and Municipal Hospital Center Abass NDAO (22.5%). Group 5 was found in the maternity units of the Gaspard Kamara Health Center (32.3%), Nabil Choucair Health Center (39%), Principal Hospital of Dakar (26.4%), Youssou Mbargane Hospital Diop Hospital in Rufisque (31.4%), Roi Baudoin Hospital Center (29.8%), Grand Yoff General Hospital (32%), Ouakam Military Hospital (34.2%), and, National Hospital Center of Pikine (27.9%). 4 facilities had a caesarean section rate higher than 30% (University hospital Aristide Le Dantec 35.6%, Youssou Mbargane Diop Hospital in Rufisque 32.03%, Municipal Hospital Center Abass Ndao 32.01% and, National Hospital Center of Pikine 30.45%). The average birth weight of new-borns was 2943 grams, with an average Apgar score of 8 at the fifth minute. The post-op care was simple. Conclusion: The caesarean section rate remains relatively high in the surgical maternity hospitals in Dakar and the indications for scarred uterus are still high.

Development of a Novel Nomogram for Predicting Placenta Accreta in Patients With Scarred Uterus: A Retrospective Cohort Study.

Objective: The aim of this study was to develop a nomogram to predict the risk of placenta accreta in scarred uterus patients in China.Methods: We retrospectively analyzed 8,371 singleton pregnancies with scarred uterus at Shengjing Hospital, affiliated with China Medical University. Two thirds of the patients were randomly assigned to the training set (n = 5,581), and one third were assigned to the validation set (n = 2,790). Multivariate logistic regression was performed by using the training set, and the nomogram was developed. Discrimination and calibration were performed by using both the training and validation sets.Results: The multivariate logistic regression model identified number of previous cesarean section, number of vaginal bleeding, medication during pregnancy, and placenta previa as covariates associated with placenta accreta. A nomogram was developed to predict the risk of placenta accreta in the training set with a Harrell's C-index of 0.93 and 0.927 in the training set and validation set, respectively. Calibration of the nomogram predicted placenta accreta corresponding closely with the actual placenta accreta.Conclusion: We developed a nomogram predicting the risk of placenta accreta in scarred uterus patients in China. Validation using both the training set and the validation set demonstrated good discrimination and calibration, suggesting good clinical utility.

Indications and practices of Cesarean Sections in a French region – The Robson classification

Abstract Background Cesarian-section (CS) deliveries, although sometimes vital, are associated with increasing immediate- and long-term maternal and/or neonatal risks. The objective was to describe the indications of scheduled CS, measure the potentially avoidable CS and study the rate variations between maternities in one French region, Centre Val-de-Loire (CVL). Methods A cross-sectional study was conducted from September 2016 to February 2017. Information about all CS performed in the maternities of the region was collected: medical history, indication, schedule. Data collection was completed with the 2016 regional birth data repository (25,864 deliveries, including 19.2% of CS, among which 7.0% were scheduled). CS were classified according to the pre-existing risk high or low of CS as defined by the Robson classification. Results During the study period, 1,979 CS (18.6% of deliveries) were performed, of which 762 were scheduled (7.1% of deliveries). The main indications for planning a CS were: scarred uterus (60%, of which 56% with only one previous CS) or breech presentation (25%), considered at high risk of CS according to the Robson classification. For these two contexts, the regional birth repository showed decreasing scheduled CS rates from high to low level of maternities’ expertise. Remarkly, 22 nulliparous women with a single cephalic pregnancy in spontaneous labor before term (Robson’s low risk of CS) had a CS performed for unfavorable pelvimetry (0.2% of deliveries). Conclusions This study allowed identifying specific potential interventions: targeted CS on scarred uterus with only one previous CS or breech presentation, as recommended by national guidelines, and targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices through cautious maternity comparisons to improve quality of care. Key messages Although potentially avoidable c-sections are rare, interventions were identified: targeted CS on uterus with one previous CS or breech presentation, targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices, in order to improve healthcare quality.