Uterine Incision Research Articles

Geçirilmiş sezaryeni olan hastalarda uterus insizyonunun transvers veya sefalokaudal genişletilmesinin sonuçları: Prospektif randomize kontrollü çalışma

Geçirilmiş sezaryeni olan hastalarda uterus insizyonunun transvers veya sefalokaudal genişletilmesinin sonuçları: Prospektif randomize kontrollü çalışma

Management of Breech Presentation: Green-top Guideline No. 20b.

Management of Breech Presentation: Green-top Guideline No. 20b.

A pregnant woman with a surgical site infection after mesh repair of an abdominal wall incisional hernia: a case report

BackgroundSurgical meshes are widely used in incisional hernia repair. However, there are no reports of pregnancies complicated by infection of surgical meshes used for hernia repair. This is the first case report of a pregnant woman who experienced surgical site infection associated with surgical mesh used for repair of an abdominal wall incisional hernia.Case presentationWe report a case of a 41-year-old pregnant Japanese woman with surgical site infection after mesh repair of an abdominal wall incisional hernia. She was diagnosed with an abdominal wall incisional hernia at 3 months after her third cesarean section, and she underwent an operation of hernia repair with use of monofilament polypropylene mesh 7 months after the third cesarean section. However, a surgical site infection associated with surgical mesh occurred. During antibiotic treatment, she was found to be pregnant. She was referred to our hospital at 13 weeks and 2 days of gestation. The surgeons removed the infected mesh at 16 weeks and 3 days of gestation. Neither the hernia nor infection at the surgical site recurred throughout pregnancy. We planned a cesarean section using a transverse uterine fundal incision method with an upper abdominal incision. The patient delivered a 2478-g healthy female infant.ConclusionsThe present report shows that removal of mesh can safely control surgical site infection during pregnancy.

Vacuum-assisted cesarean section.

There has been a dramatic rise in the frequency of cesarean sections, surpassing 30% of all deliveries in the US. This upsurge, coupled with a decreasing willingness to allow vaginal birth after cesarean section, has resulted in an expansion of the use of vacuum assistance to safely extract the fetal head. By avoiding the use of a delivering hand or forceps blade, the volume being delivered through the uterine incision can be decreased when the vacuum is used properly. Reducing uterine extensions with their associated complications (eg, excessive blood loss) in difficult cases is also a theoretical advantage of vacuum delivery. Maternal discomfort related to excessive fundal pressure may also be lessened. To minimize the risk of neonatal morbidity, proper cup placement over the “flexion point” remains essential to maintain vacuum integrity and reduce the chance of inadvertent detachment and uterine extensions. Based on the published literature and pragmatic clinical experience, utilization of the vacuum device is a safe and effective technique to assist delivery during cesarean section.

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.

Reproductive Outcome of Transcervical Uterine Incision in Unicornuate Uterus.

Background:The pregnancy outcome of the unicornuate uterus is associated with an increased risk of miscarriage, cervical incompetence, and a number of obstetric complications. However, at present, there is no accepted treatment method for women with unicornuate uterus, other than expectant measures. The aim of this study was to evaluate the reproductive outcome of transcervical uterine incision (TCUI) in patients with unicornuate uterus.Methods:Thirty-three patients with unicornuate uterus presented to our tertiary center for infertility or miscarriage. All 33 patients underwent TCUI and were followed up for 10–52 months. The pregnancy outcomes (first-trimester miscarriage, second-trimester miscarriage, preterm, term, intrauterine death, ongoing pregnancy, and live birth) before and after TCUI were compared by t-test.Results:Among 31 patients who attempted to conceive after TCUI, twenty conceived including one termination of pregnancy, one second-trimester miscarriage, one ectopic pregnancy, five preterm deliveries, 11 term delivery, and one ongoing pregnancy. There were 16 live births in total. There was significant reduction in the first-trimester miscarriage rate (t = 4.890; P < 0.001), increase in term delivery (t = −3.288; P = 0.002), and live birth rates (t = −4.073; P < 0.001) after TCUI.Conclusion:TCUI appeared to improve the pregnancy outcome in women with unicornuate uterus presenting with infertility or miscarriage.

External Pop-out Cesarean Section: A Novel Technique for Supporting the Lower Uterine Segment During Fetal Head Extraction

Objectives: To assess the safety and feasibility of a novel technique, External Pop-out (EPO), for supporting the loweruterine segment during fetal head extraction in cesarean section (CS).Study design: Prospective cohort study.Patients and Methods: The current research is a registered (NCT02755168) study compassing the new technique, EPO,for head extraction during CS. The technique was performed on single, living, cephalic, elective cesarean deliveries atWomen's Health Hospital, Assiut University, Egypt. The primary study outcomes were; the feasibility and the rate ofincision extensions with the External Pop-out technique. The secondary outcomes included the easiness score and thelearning curve of this technique on five senior obstetricians’ trainee.Results: The EPO technique was successful in 845/877 cases (96.3%) but impossible in the remaining 32 case because ofextensive pelvic adhesions. The rate of occurrence of minor extensions associated with EPO was 8/845 (0.95%) with nomajor extensions in succeeded cases. There was a statistically significant difference between the mean of easiness score in the early 5 cases and the next 5 cases in 4 out of 5 trainees. The remaining trainee reported a higher easiness score earlier from his 4th case. The mean of total scores in the late cases was also significantly higher than the early cases (p=0.0001).Conclusions: External Pop-out technique is feasible with low rates of uterine incisions extensions. Moreover; thistechnique is easily learned and performed by obstetricians

Reverse breech extraction versus the standard approach of pushing the impacted fetal head up through the vagina in caesarean section for obstructed labour: A randomised controlled trial

The objective of this study was to assess effectiveness and safety of the reverse breech extraction approach in Caesarean section for obstructed labour, and compare it with the standard approach of pushing the fetal head up through the vagina. This randomised controlled trial included 192 women. In 96, the baby was delivered by the ‘reverse breech extraction approach’, and in the remaining 96, by the ‘standard approach’. Extension of uterine incision occurred in 18 participants (18.8%) in the reverse breech extraction approach group, and 46 (47.9%) in the standard approach group (p = .0003). Two women (2.1%) in the reverse breech extraction approach group needed blood transfusion and 11 (11.5%) in the standard approach group (p = .012). Pyrexia developed in 3 participants (3.1%) in the reverse breech extraction approach group, and 19 (19.8%) in the standard approach group (p = .0006). Wound infection occurred in 2 women (2.1%) in the reverse breech extraction approach group, and 12 (12.5%) in the standard approach group (p = .007). Apgar score <7 at 5 minutes was noted in 8 babies (8.3%) in the reverse breech extraction approach group, and 21 (21.9%) in the standard approach group (p = .015). In conclusion, reverse breech extraction in Caesarean section for obstructed labour is an effective and safe alternative to the standard approach of pushing the fetal head up through the vagina.

A large amniocele through a fundal uterine defect diagnosed on 2D ultrasound imaging

Introduction: Amniocele is herniation of amniotic sac through a uterine myometrial defect. It commonly results from intrauterine procedures such as suction evacuation, dilatation and curettage, manual removal of placenta and other products of conception, etc. Early diagnosis is imperative as that will go a long way to reduce morbidity and mortality. Case Report: A 35-year-old G4P3+0 women was presented to our health facility at 21st week gestation with a week history of lower abdominal pain. Obstetric ultrasound scan done at presentation revealed a fundal myometrial defect with a large amniocele through it, resulting in apparent oligohydramnios. Her first two deliveries were uneventful, but the third was complicated by post-partum hemorrhage due to retained placenta. This necessitated instrumentation and manual removal in the theatre at a secondary Health institution, four years prior to the index pregnancy. No immediate complication was noticed after the procedure. Two weeks after this diagnosis, precisely at 23rd week gestation, she had laparotomy, aimed at reducing the herniated amniotic sac and repairing the defect. This was not possible due to the narrow neck of the defect. She was then closed back and kept on exclusive bed rest and weekly sonographic evaluation of the pregnancy. A scan done at 31st week gestation revealed ruptured herniated amniotic sac into the peritoneal cavity with fetal distress. Estimated ultrasound fetal weight at this time was 1.76 kg. She had emergency cesarean section with delivery of a live very low birth weight baby whose APGAR score was 7 and 8 at 1 and 5 minutes respectively. The baby was admitted into special care baby unit (SCBU) but died 10 hours thereafter. The myometrial defect and uterine incision were repaired in layers. She did well, hemodynamically stable and was discharged on postoperative day-7. Follow-up visits were satisfactory. Conclusion: This case is presented to emphasize the need for training and retraining of physicians and midwives on active management of third stage of labor to forestall the observed pitfalls. It also brings to the fore the utility of gray scale and color Doppler ultrasound in antenatal diagnosis of uterine defect and placenta accreta.

Discussion on the Timing of Balloon Occlusion of the Abdominal Aorta during a Caesarean Section in Patients with Pernicious Placenta Previa Complicated with Placenta Accreta.

Objective This paper is aimed at investigating the role and value of the timing of balloon occlusion of the abdominal aorta during caesarean section in patients with pernicious placenta previa complicated with placenta accreta. Methods 79 cases admitted to the Second Affiliated Hospital of Zhengzhou University from September 2015 to December 2016 were treated with ultrasound mediated abdominal aortic balloon occlusion. Among them, 42 cases, whose balloon occlusion time was selected before the delivery and transverse incision was taken, were group A. The other 37 cases were group B, whose timing of balloon occlusion was selected after the delivery and the uterine incision made trying to avoid the placenta or double incisions. The intraoperative blood loss, utilization of blood, and other indicators were compared between the two groups. Results The intraoperative blood loss in groups A and B was 413.8 ± 105.9 ml and 810.3 ± 180.3 ml, and the utilization of blood products in groups A and B was 30.23% and 89.2%. The total hysterectomy rate was 2.53% (2/79), with no hysterectomies in groups A and 2 cases in group B. Conclusion The balloon occlusion of the abdominal aorta before the delivery combined with a transverse incision is more effective.

The Effect of Single-Layer or Double-Layer Closure of the Uterine Incision at Cesarean Section on Uterine Scar Formation

The Effect of Single-Layer or Double-Layer Closure of the Uterine Incision at Cesarean Section on Uterine Scar Formation

Two novel classification systems for uterine fibroids and subsequent uterine reconstruction after myomectomy

Laparoscopic approaches are the gold standard surgical treatment for intramural and subserous fibroids, whereas submucosal myomas can be treated via hysteroscopy. Removal of intramural myomas often requires a subsequent reconstruction of the uterine wall that ranges from single- to multiple-layer sutures to complex reconstructions. Several classification systems are currently used to characterize uterine fibroids, all of which focus on the assessment of submucosal fibroids during hysteroscopic myomectomy. There are no classification systems for the comprehensive localization of fibroids or for uterine reconstruction after myomectomy. Therefore, the aim of this study was to validate a new scoring system developed by our group to classify uterine leiomyoma as well as a standardized assessment scoring system for uterine reconstruction after surgical myomectomy. To validate the uterine fibroid and uterine reconstruction classification systems, a retrospective review of 136 patients undergoing surgical myomectomy and uterine reconstruction at a single tertiary institution was performed. The age of the patient, duration of surgery, number, size, and location of excised fibroids, number of uterine incisions, level of uterine reconstruction, desire for future pregnancies, pre- and postoperative hemoglobin concentrations, duration of postoperative hospitalization, and operating surgeon were obtained by medical chart review. For each patient, a specific fibroid score and the level of uterine reconstruction were determined according to the classification systems. Correlations between the uterine fibroid and reconstruction scores, as well as between the classification scores and perioperative parameters, were analyzed. The newly developed classification system for uterine fibroids incorporates the number, location, and size of myomas, as well as the number of uterine incisions required for myomectomy. The uterine reconstruction scoring system comprises four levels of reconstruction, ranging from no reconstruction to advanced reconstruction. Outcomes from 136 patients showed a correlation between uterine fibroid and uterine reconstructive scores. High fibroid scores were correlated with higher levels of reconstruction. Both scoring systems showed associations with the duration of surgery, intraoperative blood loss, and days of hospitalization. This study presents the first scoring system for uterine fibroids that incorporates all possible fibroid locations and a standardized assessment of uterine reconstruction. Scoring systems were validated in a large cohort, and a correlation was identified between uterine fibroid and uterine reconstruction scores. In daily clinical practice, this scoring system allows a better planning of surgery, specifically of the estimated duration of surgery, blood loss, and time of hospitalization.

Possibility of reducing blood loss during and after multiple birth

Multiple pregnancy and multiple birth are pathologic obstetric situations. Recently occurrence of multiple pregnancy has increased due to increase of the age at planned pregnancy and widespread use of assisted reproductive technologies including in vitro fertilization. As a result clinicians practicing in obstetrics face more frequent multiple pregnancies, mostly twins. Risk of bleeding during multiple pregnancy, delivery and the postpartum period is estimated as high and is two times higher than in single pregnancy. The main causes of postpartum hemorrhage in multiple pregnancy are uterine hypotony or atony. Hemostatic changes occurring during pregnancy, unspecific and specific complications of multiple pregnancy are important as well. Correct management of the second period of a multiple vaginal delivery allows reducing the volume of blood loss. Method of fetal extraction in the intact amniotic sac allows reducing the influence of external factors on neonate’s head and the volume of blood loss during Cesarean section. Blood loss reducing is caused by amniotic sac compressing the vessels and therefore decreasing bleeding from the uterine incision for the time enough to extract the fetuses. Active management of the third period of vaginal delivery and afterbirth extraction with traction of umbilical cord during Cesarean section are crucial. Suggested regimens of uterotonics (oxytocin, carbetocin, misoprostol) and antifibrinolytics (tranexamic acid) reduce the risk of postpartum hemorrhage.

Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21.

Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21.

Retained Suture Material Post Cesarean Section: A Case Report

Introduction: There are different causes of abnormal uterus bleeding. Foreign body is a less common etiology due to the increasing rate of cesarean delivery. We are confronting some uncommon complications of cesarean section. Uterine incision closure is a substantial step in cesarean section. Since suture material hydrolysis is affected by patient different features, impaired suture material degradation in uterus scar may cause some complications like abnormal uterine bleeding. Case Presentation: We reported a 49-year-old woman who had abnormal uterine bleeding with prior history of multiple cesarean section. During hysteroscopy, abnormal mass was seen in anterior surface of uterine cavity compatible with the level of internal os. Polypectomy and removal of foreign body followed by endometrial curettage were performed. After hormonal assay and sonography evaluation, the patient underwent hysteroscopy and foreign body was observed in anterior surface of uterus. She was followed and visited 6 month after operation and she had no abnormal bleeding. Perhaps this foreign body led to abnormal uterine bleeding. Conclusions: Patient characteristics has important role in suture material degradation. Impaired suture hydrolysis in uterus incision may cause abnormal uterine bleeding. It is interesting to demonstrate whethersuture degradation in previous cesarean section has a role in formation of placenta accrete or not .This issue needs more investigation. Because there is no similar case in literature, we cannot compare our article with others.

Management strategy of umbilical artery aneurysm complicated by cardiac anomaly: case study and literature review

Objective: Key considerations for managing an umbilical artery aneurysm (UAA) are a timely termination and the prevention of rupture of the UAA during delivery. Herein, we propose a treatment strategy based on our experience of UAA complicated by a fetal cardiac anomaly.Case: A case of UAA was referred to our hospital at 23 weeks of gestation. The UAA increased its size to 6 cm. The blood reservoir within the UAA was presumed to be equivalent to the circulating blood volume of the fetus. At 28 weeks, small echogenic components suspected to be hematomas appeared in the umbilical vein, and the umbilical interstitial substance became edematous. An improvement in the fetus’ condition could not be expected unless the UAA size was smaller. Thus, a cesarean delivery was performed at 30 weeks during which the UAA ruptured. The baby was anemic, disseminated intravascular coagulation (DIC) and later died.Conclusion: We present an assessment of a large blood reservoir within an UAA that may indicate the likelihood of high-output cardiac failure of the fetus. Either a classical cesarean section or a transverse uterine fundal incision should be performed when the UAA size is greater than 5 cm to prevent rupture of the UAA.

Abstract PR188

Background & Objectives: Uric acid (UA) is a marker of oxidative stress. Labor may generate reactive oxygen species by repetitive ischemia and reperfusion1. Recent retrospective report has associated hyperuricemia with decrease in vascular relaxation and uterine contractility2. Given these associations, we hypothesized that serum UA levels may increase beyond physiological levels in low risk parturients during labor with a decrease in incidence of post-spinal hypotension and impaired uterine contractility during non-elective cesarean deliveries. Materials & Methods: We included 100 normotensive parturients with singleton pregnancy coming for emergency cesarean delivery under subarachnoid block (SAB). UA samples were obtained on admission to labor room and before shifting for cesarean delivery. Following SAB, episodes of hypotension and total vasopressor dose given to keep SBP>100mmHg or prevent a fall of >20% in MAP upto time of uterine incision was recorded. Following placental expulsion, uterine tone and contractility were assessed every 2 minutes for 10 minutes and graded as satisfactory or unsatisfactory. Total dose of oxytocin infused was recorded. In cases of unsatisfactory uterine tone use of other uterotonics and other measures taken to manage uterine atony were recorded. Intraoperative blood loss was estimated using modified Gross formula. Results: There was no significant correlation between UA change and duration of labor. Incidence of post-spinal hypotension was significantly lower in women with hyperuricemia than in those with normal UA levels (45.5% vs 67.2%).Mean UA levels were significantly higher (4.94±1.39 vs 3.95±1.38mg/dl) in patients not needing vasopressors to maintain their blood pressure within normal limits. Supplemental uterotonics were used in 31% patients to maintain satisfactory uterine score. Though greater percentage of these patients were those with hyperuricemia, the results were not statistically significant (p=0.203). The mean blood loss was higher in patients with hyperuricemia (631ml vs 577ml), though not statistically significant (p=0.208). Conclusion: In normotensive, healthy parturients undergoing cesarean delivery under SAB, elevated serum UA levels are associated with lower incidence of post-spinal hypotension and reduced need of vasopressors to maintain maternal blood pressure within a normal range.

Standardized ultrasonographic approach for the assessment of risk factors of incomplete healing of the cesarean section scar in the uterus

ObjectiveTo identify factors related to the healing of a Cesarean uterine incision using the standardized ultrasonographic approach of scar assessment in the non-pregnant uterus. Study designMeasurements of the uterine scar were taken from 409 women with a history of at least one low transverse cesarean section (CS) with a single layer uterine closure. Residual myometrial thickness (RMT), width (W) and depth (D) of the triangular hypoechoic scar niche, D/RMT ratio and clinical characteristics were analyzed. For statistical analysis, the Mann–Whitney U test, chi-square test, Spearman's rank correlation coefficient, ANOVA test, and logistic regression were used. Results268 women presented with a scar defect. RMT values were significantly correlated with the number of CSs (R=−0.17) and uterus retroflection (R=−0.15). The presence of a scar defect was significantly associated with lower RMT values (R=−0.33), greater gestational age (R=0.10), and younger maternal age (R=−0.11). The mean RMT value was significantly smaller in women with CSs performed in the second stage of labor (0.62) when compared to women with CSs in the first stage of labor (0.97) or without cervical dilatation (0.91). ConclusionA standardized approach of CS scar assessment in the non-pregnant uterus helps to identify women at risk of long-term complications of CS.

Complications of blunt versus sharp expansion of the uterine incision in lower segment caesarean section. A randomized controlled trial

Introduction: Caesarean section has now become the most frequently performed major surgical procedure in women in the field of Obstetrics and Gynaecology. There is however a wide variation in the surgical technique of caesarean section. Our objective was to compare incidence of complications associated with blunt versus sharp expansion of the uterine incision at the time of caesarean section. Methods: 274 women who underwent a lower segment caesarean section at North Colombo Teaching Hospital, Ragama was assigned randomly to have the expansion of the primary uterine incision either bluntly using the index fingers of both hands of the surgeon or sharply using a curved scissors. Rest of the surgery was performed alike in all participants. Results: The blunt expansion group (n=141) and the sharp expansion group (n=133) were similar with regard to age distribution, BMI, parity, history of previous LSCS and proportion of elective or emergency procedures and the cervical dilatation at the time of LSCS. The incidence of inadvertent extensions (42.1% vs 28.4%; p=0.02) and the mean time taken to repair the uterine incision (14.9min vs 13.7min; p=0.03) was significantly higher in the blunt expansion group compared to the sharp expansion group. The percentage drop in haematocrit more than 10% (30.8% vs 28.4%; p=0.48) and the drop in haemoglobin more than 2g/dl (22.6% vs 20.6%; p=0.47) was not significantly different in the blunt expansion group compared to the sharp expansion group. Incidence of inadvertent extensions was significantly different (38.5 vs 24.1; p=0.03) during elective LSCS but not during emergency LSCS (50% vs 44.8%; p=0.67) between the blunt expansion group and sharp expansion group. The incidence of inadvertent extensions was significantly higher (36.5% vs 24%; p=0.03) when the cervical dilatation was less than 4cm at the time of LSCS in the blunt expansion group compared to the sharp expansion group. Blunt expansion group required more blood pint transfusions when compared to the sharp expansion group (6 vs 2). Conclusion: The sharp expansion of the uterine incision at the time LSCS is associated with a lower risk of inadvertent extensions as well as extensions into broad ligament and uterine vessels compared to the blunt expansion method. The sharp expansion of the uterine incision is preferable to blunt expansion during LSCS and its advantage is more evident during elective LSCS than during emergency LSCS and when the cervical dilatation was less than 4cm at the time of LSCS.

Negative pressure wound treatment for uterine incision necrosis following a cesarean section

Abstract Extended-spectrum β-lactamase sepsis with concurrent uterine incision dehiscence after cesarean section with T-shaped incision for chorioamnionitis occurred in a 29-year-old patient after her first delivery. Following an exploratory laparotomy with a diagnosis of necrosis of the anterior uterine wall, a uterine negative-pressure wound treatment (NPWT) was performed, successfully avoiding hysterectomy and enabling secondary suture of the uterine wall.