Uterine Dehiscence Research Articles

427: Risk factors for preterm delivery and uterine dehiscence following prenatal surgery for myelomeningocele

427: Risk factors for preterm delivery and uterine dehiscence following prenatal surgery for myelomeningocele

Operative complications and fetal morbidity encountered in 300 prophylactic transabdominal cervical cerclage procedures by one obstetric surgeon

This retrospective cohort study identifies complications associated with transabdominal cerclage (TAC). In 300 procedures performed over a 24 year time span, 11 (3.7%) surgical complications were encountered. Fetal loss (prior to 20 weeks) occurred in 4.1% of pregnancies. The median estimated blood loss among patients was 100 ml, with blood loss sufficient to require transfusion only once. Considering patients with classical indications, the gestational age at delivery was greater (37 weeks) after TAC than in the latest pre-TAC pregnancy (24 weeks) (p < 0.001). Lower uterine dehiscence in four patients and uterine rupture in one, underscore the advisability of early term delivery after fetal lung maturity is assured. A survival rate of 98.0% was calculated among infants that were delivered at >24 weeks’ gestation. Our results demonstrate that complications encountered in placing a TAC were unusual and generally manageable. This communication may assist the surgeon to balance risks in individual clinical circumstances more adequately.

Spontaneous prelabor uterine rupture in a primigravida: a case report and review of the literature

A rare case of prelabor uterine rupture in a primigravida was reported. A woman with a history of uterine perforation during hysteroscopy became pregnant after donor oocyte in vitro fertilization. To provide more insight into the possible risk factors for prelabor uterine rupture in primigravidae, a literature review was performed.

Uterine Dehiscence in Early Second Trimester

The diagnosis of uterine dehiscence in the early second trimester by ultrasonography is rare and its effect on pregnancy outcome is unclear. An asymptomatic woman presented for anatomy survey in the 19th week of pregnancy. Uterine dehiscence at the site of previous hysterotomy was diagnosed by ultrasound scan. She was admitted to the hospital for expectant management and eventually opted for termination of pregnancy in the 22nd week of pregnancy. Termination was performed by classical hysterotomy without any complications. Given the increasing cesarean delivery rate and improvements in ultrasound technology, obstetricians should expect to face the management dilemma of antenatally diagnosed uterine dehiscence. The risks of expectant management compared with termination remain theoretical, and timing of delivery and methods of termination are important questions to consider.

Concurrent Postpartum Uterine and Abdominal Wall Dehiscence and Streptococcus anginosus Infection

Postpartum uterine scar dehiscence is a rare but potentially lethal complication of cesarean deliveries. Concurrent abdominal and uterine dehiscences after cesarean delivery for arrest of descent with chorioamnionitis occurred in a 16-year-old patient after her first delivery. The uterine and fascia incisions were reclosed during exploratory laparotomy. Streptococcus anginosus was isolated from the peritoneal fluid. The patient remained afebrile and was discharged 6 days after relaparotomy and took levofloxacin and metronidazole orally for 5 more days. Uterine scar separation needs to be considered in patients with a fascial dehiscence after cesarean delivery for arrest of labor. Selected cases can be managed conservatively (uterine reclosure), but patients should be counseled about the possible need for hysterectomy at the time of relaparotomy.

Outcome of vaginal birth after caesarean section in women with one previous section and spontaneous onset of labour

The data about the safety of vaginal birth after caesarean section are conflicting. This study in a referral hospital in Sana'a, Yemen investigated the outcome of vaginal birth after caesarean section in 357 women who had one prior caesarean section and were admitted to hospital at term with spontaneous onset of labour. A control group (n = 155) was matched from women without previous caesarean section. The success rate of vaginal birth after caesarean section was 311/357 (87.1%). The mean duration of the first and second stages of labour were not significantly different in the study group (146.2 and 30.7 min respectively) compared with the control group (146.7 and 29.8 min). There were infrequent complications; only 1 woman (0.3%) had ruptured uterus and 3 women (1.0%) suffered uterine dehiscence. There was 1 stillbirth after the uterine rupture but no maternal deaths.

Anesthesia Literature Review

Anesthesia Literature Review

Metroplasty in a Large Population of Women with Septate Uterus

Study Objective To determine the reproductive outcome after hysteroscopic metroplasty in women with septate uterus. Design Retrospective comparative single-center study (Canadian Task Force classification II-3). Setting University-affiliated hospital. Patients Two hundred forty-six patients with septate uterus undergoing hysteroscopic metroplasty between January 1998 and December 2007. The diagnosis was based on hysteroscopy and 3-dimensional ultrasonography. In the most cases laparoscopy was also available. The subjects were divided into 2 age-matched groups. Group 1 consisted of 108 women with unexplained infertility, and group 2 consisted of 138 women suffering from recurrent abortion. Interventions Patients underwent hysteroscopic metroplasty by use of resectoscopy with an equatorial semicircular loop cutting at 0 degree with monopolar energy. All septa were completely removed without complications of bleeding, infection, risk of perforation, visceral injury, or uterine dehiscence during pregnancy. Measurement and Main Results The 2 groups were compared in terms of reproductive performance in mean ± SD follow-up of 37 ± 18 months. In group 1, 61 (56.5%) patients achieved pregnancy. Seventy-one pregnancies ensued, including 1 twin gestation. Fourteen of the 71 pregnancies (19.7%) ended in miscarriage. In group 2, 90 (65.3%) patients achieved pregnancy. One hundred twenty-nine pregnancies ensued, including 2 twin gestations. Forty-four of the 129 pregnancies (34.1%) ended in miscarriage. The 2 groups have no significant differences in terms of reproductive outcome after surgery, except for the number of abortions, which was higher in group 2 (p <.05). Conclusion This study confirms that hysteroscopic metroplasty is a simple, safe, and rapid surgical procedure with no complications for achieving normal uterine architecture, which is peculiar to a good reproductive outcome. The use of an equatorial semicircular loop may give satisfactory and similar results to those obtained with Collin’s loop.

Clinical Importance of Appearance of Cesarean Hysterotomy Scar at Transvaginal Ultrasonography in Nonpregnant Women

To estimate the association between the appearance of cesarean hysterotomy scars at transvaginal ultrasound examination of nonpregnant women and the outcome of subsequent pregnancies and deliveries. A total of 162 women who had ever given birth by cesarean underwent transvaginal ultrasound examination of the hysterotomy scar 6 to 9 months after the latest cesarean delivery. Published ultrasound definitions of large scar defects were used. The appearance of the hysterotomy scar at ultrasound examination was compared with the outcome of subsequent pregnancies and deliveries. Clinical information on subsequent pregnancies was obtained from medical records. Six women were lost to follow-up, leaving 156 for analysis. Of these 156 women, 69 became pregnant after the ultrasound examination (99 pregnancies, 65 deliveries). There were no placental complications or scar pregnancies. At the first repeat cesarean delivery after the ultrasound examination, 5.3% (1/19) of the women with an intact scar or a small scar defect had uterine dehiscence or rupture compared with 42.9% (3/7) of those with a large defect (P=.047), odds ratio 11.8 (95% confidence interval 0.7-746). Our results point toward a likely association between large defects in the hysterotomy scar after cesarean delivery detected by transvaginal ultrasonography in nonpregnant women and uterine rupture or dehiscence in subsequent pregnancy.

Uterine Artery Pseudoaneurysm in the Setting of Delayed Postpartum Hemorrhage: Successful Treatment with Emergency Arterial Embolization

Postpartum hemorrhage is a major cause of maternal mortality. Though uncommon, uterine artery pseudoaneurysm can follow uterine dilatation and curettage (D + C) and needs to be considered in the differential diagnosis. This 30-year-old G1P1 woman presented with right upper quadrant pain and vaginal bleeding. She was afebrile but her white blood count was significantly increased (22.2 × 109 /L). One week prior, she had undergone a Cesarean delivery which was complicated by hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP), fetal dystocia, and chorioamnionitis. Uterine dilatation and curettage (D & C) and placement of a Bakri intrauterine balloon, performed for suspected retained products of conception, failed to control her postpartum bleeding. The patient wished to have a hysterectomy only as a last resort in order to preserve fertility. Emergency uterine artery angiography revealed a left uterine artery pseudoaneurysm and contrast extravasation. The patient was successfully treated with selective embolization. Computed tomography (CT) later revealed dehiscence of her uterine Cesarean section incision with an intra-abdominal fluid collection. This collection was drained. She also developed disseminated intravascular coagulopathy (DIC) syndrome as well as multiple pulmonary emboli which were both successfully treated. We discuss this unique case of uterine artery pseudoaneurysm with associated uterine dehiscence.

Unsuccessful trial of labor in women with and without previous cesarean delivery

Objective. To compare maternal and neonatal outcomes after unsuccessful labor in women with and those without prior cesarean delivery.Methods. This was a retrospective cohort study of all women in labor delivered by cesarean section (CS) from November 2004 through December 2006. The study population was dichotomized by previous CS and compared for various maternal and neonatal outcomes. Student t-test, χ2 and Fisher exact tests were used for analysis.Results. There was a significantly higher rate of symptomatic uterine rupture [3/100 (3%) vs. 0/449 (0%), p = 0.006], asymptomatic uterine scar dehiscence [6/100 (6%) vs. 0/449 (0%), p = 0.0001], and bladder injury [2/100 (2%) vs. 0/100 (0%), p = 0.001], among women with prior cesarean delivery compared to those without. The rate of respiratory distress syndrome [(6/100) (6%) vs. 10/449 (2.2%), p = 0.05] and meconium aspiration [4/100 (4%) vs. 2/449 (0.4%), p = 0.01] was also significantly higher among neonates of women with prior cesarean delivery. However, the rate of endomyometritis [3/100 (3%) vs. 50/449 (11.1%), p = 0.009] and febrile morbidity [17/100 (17%) vs. 144/449 (32.1%), p = 0.003] was significantly lower among women with prior cesarean delivery compared to those without prior cesarean birth.Conclusions. Compared to laboring women without previous cesarean delivery, women with previous cesarean delivery have increased maternal and neonatal morbidity. Febrile morbidity was, however, lower among women with previous cesarean delivery. These differential findings should further inform our perinatal counseling of women contemplating trial of labor after a previous cesarean delivery.

A Simple Checklist for Preventing Major Complications Associated With Cesarean Delivery

I propose a simple, evidence-based, eight-item checklist that, if followed, should reduce the frequency of many of the most serious complications associated with cesarean delivery: endometritis, wound infection, wound disruption, thrombophlebitis, and uterine scar dehiscence in a subsequent pregnancy. The frequency of abdominal wound infections can be reduced significantly by using electric clippers, rather than a razor, to remove the hair at the site of the surgical incision, washing the skin with a chlorhexidine solution, and administering broad-spectrum antibiotic prophylaxis before the start of surgery rather than after the neonate's umbilical cord has been clamped. Administration of broad-spectrum antibiotic prophylaxis and removal of the placenta by traction on the umbilical cord, rather than by manual extraction, will reduce the frequency of postcesarean endometritis. Closure of the uterine incision in two layers rather than one will significantly reduce the frequency of scar dehiscence in a subsequent pregnancy. Closure of the deep subcutaneous layer in patients whose subcutaneous tissue is greater than 2 cm in thickness will significantly reduce the risk of seroma, hematoma, and subsequent wound disruption. Institution of appropriate prophylaxis for deep vein thrombosis in intermediate and high-risk patients will reduce the risk of subsequent thromboembolic events.

Acute abdominal and pelvic pain in pregnancy: MR imaging as a valuable adjunct to ultrasound?

To investigate the usefulness of magnetic resonance imaging (MRI) in the evaluation of pregnant women with acute abdominal and pelvic pain after sonographically (US) indeterminate findings. Forty pregnant patients with acute abdominal and/or pelvic pain, in whom ultrasound was indeterminate, were included in this study. Multiplanar MR images of the abdomen and pelvis were obtained and independently reviewed by two radiologists with discrepancies were resolved by consensus. Correlation of prospective clinical MR interpretations with surgical and obstetric records and clinical follow-up showed correct identification of disease entities in all 40/40 patients. The following disease processes were correctly identified using MRI in 21/40 patients: appendicitis (n = 5), ileal volvulus (n = 1), common bile duct lithiasis (n = 2), pubic chondrosarcoma (n = 1), uterine dehiscence (n = 1), placental hematoma (n = 3), iliac venous thrombosis (n = 2), ulcerative colitis (n = 1), acute pancreatitis (n = 1), hydronephrosis (n = 1), ovarian dermoid (n = 1), and ovarian torsion (n = 2). 19 of the 40 patients had normal findings on MR examinations and unremarkable follow-up. Interobserver agreement for lesion detection was excellent (0.95 k). Magnetic resonance imaging (MRI) is an accurate investigation in detecting the cause of acute abdominal and pelvic pain during pregnancy and should be considered after US indeterminate findings.

OP31.02: Follow up in patients treated with conservative surgery for ovarian borderline tumors: role of transvaginal ultrasound

birth twice. There were no placental complications and no scar pregnancies. Of the women who had intact scars or small defects in their uterine scar detected by transvaginal ultrasound 2.3% (1/43) suffered uterine dehiscence or uterine rupture in their first delivery after the scan versus 23.1% (3/13) of the women with large defects (P = 0.035). Conclusions: Large defects in the hysterotomy scar after Caesarean detected by transvaginal ultrasound in non-pregnant women increase the risk of uterine rupture or dehiscence in subsequent pregnancy.

Ultrasonographic evaluation of lower uterine segment thickness in pregnant women with previous cesarean section

To evaluate the accuracy of prenatal sonography (U/S) in determining the lower uterine segment (LUS) thickness in women with previous cesarean section (CS) and to assess its usefulness in predicting the risk of uterine rupture during a trial of vaginal birth. Prospective controlled study. Suzan Mubarak University Hospital. One hundred and fifty pregnant women with singleton pregnancies, with the gestational age between 37 and 40weeks were recruited for the study during the period from October 2007 to June 2008. The recruited patients were allocated into three equal groups. Group I included those with previous one low transverse CS and with the history of successful VBAC. Group II included those without the history of successful VBAC. Group III included those without the previous history of CS (control group). The recruited patients were subjected to clinical and U/S evaluations. The LUS thickness was evaluated by both transabdominal (TA) and transvaginal (TV) U/S. Women were categorized for the mode of delivery into either trial of VBAC or elective repeated CS (ERCS). All the intraoperative findings were correlated with U/S findings. Accuracy of US in predicting uterine dehiscence. Mean LUS thickness was lower among the study groups than in the control group. The present study reported 14 (28%) cases of dehiscent scar. Mean LUS thickness was significantly lower among the dehiscence groups (1.7±0.7mm) than in the non-dehiscence groups (2.6±0.8mm) ( P ⩽0.01). At a cutoff value of 2.5mm, the sensitivity, specificity, and positive and negative predictive values were 90.9%, 84%, 71.4%, and 95.5%, respectively, using (TA) U/S and 81.8%, 84%, 69.2%, and 91.3%, respectively, using (TV) U/S. At LUS thickness ⩽2.5mm, there was a higher risk for dehiscence than those with a thickness of more than 2.5mm. If the thickness of the LUS is more than 2.5mm, the possibility of dehiscence during the subsequent trials of labor is very small and a safe vaginal delivery can be achieved. Further large studies are recommended.

Reproductive outcomes in subsequent pregnancies after a pregnancy complicated by open maternal-fetal surgery (1996–2007)

The reproductive and gynecologic outcomes for women after the pregnancy complicated by open maternal-fetal surgery (OMFS) were evaluated. The retrospective review identified 93 women with OMFS from a single institution (1996-2007). Consent and questionnaires were sent to women. Institutional review board approval was obtained from the Committee for Protection of Human Subjects. The total return rate was 57.3%. Total pregnancies reported were 47, with 36 delivering after 20 weeks' gestation. The uterine dehiscence and rupture rates were 14% and 14%, respectively. Fetal anomalies occurred in 4 subsequent pregnancies. Normal conception occurred in 98% of subsequent pregnancies. Gynecologic issues were reported by 8 women, with infertility, abdominal pain, and ovarian and uterine factors. The reproductive outcomes of uterine dehiscence (14%) and rupture (14%) in a subsequent pregnancy continue to be a major counseling issue for OMFS. Fertility and gynecologic factors do not appear to be increased for women undergoing OMFS.

Maternal and Neonatal Outcomes of Repeat Cesarean Delivery in Women with a Prior Classical versus Low Transverse Uterine Incision

We compared maternal and neonatal outcomes following repeat cesarean delivery (CD) of women with a prior classical CD with those with a prior low transverse CD. The Maternal Fetal Medicine Units Network Cesarean Delivery Registry was used to identify women with one previous CD who underwent an elective repeat CD prior to the onset of labor at ≥36 weeks. Outcomes were compared between women with a previous classical CD and those with a prior low transverse CD. Of the 7936 women who met study criteria, 122 had a prior classical CD. Women with a prior classical CD had a higher rate of classical uterine incision at repeat CD (12.73% versus 0.59%; P < 0.001), had longer total operative time and hospital stay, and had higher intensive care unit admission. Uterine dehiscence was more frequent in women with a prior classical CD (2.46% versus 0.27%, odds ratio 9.35, 95% confidence interval 1.76 to 31.93). After adjusting for confounding factors, there were no statistical differences in major maternal or neonatal morbidities between groups. Uterine dehiscence was present at repeat CD in 2.46% of women with a prior classical CD. However, major maternal morbidities were similar to those with a prior low transverse CD.

685: Single versus double layer closure and risk of uterine rupture : systematic review and meta-analysis

Uterine rupture is one of the worst obstetrical emergencies. While studies have shown that the type of uterine closure (single layer vs double layer) could impact the risk of uterine rupture, this association remains controversial. We aimed to evaluate the role of uterine closure on the risk of uterine scar defect (uterine rupture & dehiscence) according to the best available evidence.

Imaging and Diagnosis of Postpartum Complications

Postpartum complications can be broadly divided into 4 categories: postpartum hemorrhage, obstetrical trauma, thromboembolic complications, and puerperal infections. Postpartum hemorrhage is most commonly caused by uterine atony, abnormal placentation, or genital tract trauma. Secondary causes of hemorrhage include retained products of conception and, rarely, subinvolution of the placental implantation site. Uterine dehiscence or rupture may be occult on ultrasound examination and may be better visualized on sagittal computed tomography or magnetic resonance imaging. Obstetric trauma during prolonged vaginal or cesarean delivery may lead to fistula formation, ureteral injury, or bowel injury. Later potential complications of cesarean delivery include cesarean delivery scar ectopic, endometrial implants in the cesarean scar, and placenta accreta. Thromboembolic complications can include pulmonary embolism and deep vein thrombosis as well as ovarian vein thrombosis, the latter of which can be difficult to clinically differentiate from appendicitis in the postpartum female.

OP15.06: Ultrasound prediction of uterine scar dehiscence during pregnancy in patients with a previous C-section

(UtR), and estimate the fraction of CO distributed to the uteroplacental circulation during the second half of pregnancy. Methods: Fifty-three low risk-pregnancies were evaluated longitudinally at approximately 4-weekly intervals from 22 weeks until term (a total of 253 observations). Mean arterial blood pressure (MAP), CO and SVR were measured using impedance cardiography, and the uterine artery blood flow velocities and diameter using Doppler and B-mode ultrasonography, respectively. Quta of both uterine arteries was estimated as the product of time-averaged intensity weighted mean velocity and cross-sectional area of the uterine artery. UtR was calculated as: MAP/sum of right and left Quta. Results: CO increased from 5.5 to 5.8 L/min (p = 0.006) despite a significant increase in SVR from 1046 to 1135 dyne s cm-5 (p = 0.0077) during 22–40 weeks. The UtR decreased from 0.26 to 0.13 mmHg/mL/min (p < 0.00001) and the total utero-placental blood flow more than doubled during the same period increasing from 299 ml/min to 673 ml/min which represented 5.6% to 11.7% of the maternal CO. Conclusion: We have established longitudinal reference intervals for the fraction of maternal CO distributed to the utero-placental circulation at 22–40 weeks of gestation. Increments in uteroplacental blood flow are relatively higher than that of the CO in the second half of pregnancy suggesting redistribution of maternal circulation due to continuous reduction in UtR.