Uterine 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.

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.

Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk

Background The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri. Objective Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy Methods From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group. Results The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors. Conclusion In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.

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.

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.

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)

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.

A new fertility-preserving surgery for interstitial pregnancy involving hysteroscopic removal under laparoscopic guidance

Interstitial pregnancy is a rare form of tubal ectopic pregnancy, accounting for 2%–4% of all such pregnancies [1]. Although medical treatment can successfully resolve the pregnancy when detected early enough, the standard treatment is cornual resection [2]. However, surgical treatmentmay result in aweakened uterinewall, leading to reduced fertility and a risk of uterine rupture in subsequent pregnancies. Successful transcervical evacuation of interstitial pregnancy under laparoscopic guidance has been reported [2]. However, owing to the characteristics of interstitial pregnancy and potential difficulties encountered during surgery, the placenta may be left behind—necessitating further treatment [3]. Hysteroscopic removal, when possible, reduces the incidence rate of this complication. In 2013, a 26-year-old nulliparous woman presented with an interstitial pregnancy. She wanted to preserve an intact uterus, so hysteroscopic removal was carried out using a technique similar to that performed for intrauterine evacuation. Hegar dilators were used for dilation of the cervical canal and the ostium of the fallopian tube; the dilators were used to reach the uterine cornu and to carefully establish a passage to the gestational site under laparoscopic guidance. A 6-mm suction catheter was then inserted into the uterus and introduced into the gestational site. The products of conception were evacuated at a negative pressure of 180 mm Hg. The hysteroscope was then introduced into the interstitial cavity because a more dilated pathologic tubal ostium was observed. Graspers were used to remove residual tissue from the interstitial cavity, leaving it empty (Fig. 1). Had uterine perforation occurred, cornual resection and salpingectomy would have been performed via laparoscopy. Thewomanwas discharged 2 days later; her serum β-human chorionic gonadotropin levels were undetectable by the second postoperative week. Ultrasound examination 4 weeks postoperatively showed that the cornual region had a normal appearance. When there is a possibility of interstitial pregnancy that is a relatively short distance from the cornual end and is associated with an unruptured mass and hemodynamic stability, hysteroscopic removal under laparoscopic guidance—rather than cornual resection—is a feasible treatment option. Furthermore, this new treatment can prevent a large amount of blood loss; however, when there is a high risk of tubal scarring, recurrent interstitial pregnancy may occur.

688: Risk of uterine rupture in subsequent pregnancy after first birth emergency cesarean section compared to planned cesarean section, a nationwide comparative cohort study

688: Risk of uterine rupture in subsequent pregnancy after first birth emergency cesarean section compared to planned cesarean section, a nationwide comparative cohort study

Single layer uterine closure in laparoscopic myomectomy

ObjectiveOur goal was to assess uterine rupture in subsequent pregnancy following single layer closure during laparoscopic myomectomy (LM).DesignData was collected from Reproductive Associates of Delaware/RAD for those patients who underwent LM from December 2003 to August 2009. At this practice, single layer myometrial closure is uniformly performed by an experienced laparoscopist. Women were included if they had undergone LM requiring the use of suture and had a subsequent viable pregnancy (greater than 24 weeks).Materials and MethodsBilling records were searched for the diagnostic code for LM. Operative reports were reviewed to confirm the use of suture, and pregnancy outcome data was collected.ResultsOf 164 women who had myomectomies which met inclusion criteria, outcome data on 76 pregnancies was collected. Ten women had undergone previous myomectomy. The mean size of myoma removed was 40.4mm. The mean number of myoma removed was 3.83; 46 patients underwent removal of multiple myoma. Of 76 pregnancies, 19 were delivered vaginally and 57 were delivered by cesarean section. No uterine ruptures were reported.ConclusionBased on our case series and other data in the literature, we believe that appropriate and complete myometrial closure can be safely achieved through a single layer, when done by an experienced laparoscopist.Reproductive Associates of Delaware/RAD ObjectiveOur goal was to assess uterine rupture in subsequent pregnancy following single layer closure during laparoscopic myomectomy (LM). Our goal was to assess uterine rupture in subsequent pregnancy following single layer closure during laparoscopic myomectomy (LM). DesignData was collected from Reproductive Associates of Delaware/RAD for those patients who underwent LM from December 2003 to August 2009. At this practice, single layer myometrial closure is uniformly performed by an experienced laparoscopist. Women were included if they had undergone LM requiring the use of suture and had a subsequent viable pregnancy (greater than 24 weeks). Data was collected from Reproductive Associates of Delaware/RAD for those patients who underwent LM from December 2003 to August 2009. At this practice, single layer myometrial closure is uniformly performed by an experienced laparoscopist. Women were included if they had undergone LM requiring the use of suture and had a subsequent viable pregnancy (greater than 24 weeks). Materials and MethodsBilling records were searched for the diagnostic code for LM. Operative reports were reviewed to confirm the use of suture, and pregnancy outcome data was collected. Billing records were searched for the diagnostic code for LM. Operative reports were reviewed to confirm the use of suture, and pregnancy outcome data was collected. ResultsOf 164 women who had myomectomies which met inclusion criteria, outcome data on 76 pregnancies was collected. Ten women had undergone previous myomectomy. The mean size of myoma removed was 40.4mm. The mean number of myoma removed was 3.83; 46 patients underwent removal of multiple myoma. Of 76 pregnancies, 19 were delivered vaginally and 57 were delivered by cesarean section. No uterine ruptures were reported. Of 164 women who had myomectomies which met inclusion criteria, outcome data on 76 pregnancies was collected. Ten women had undergone previous myomectomy. The mean size of myoma removed was 40.4mm. The mean number of myoma removed was 3.83; 46 patients underwent removal of multiple myoma. Of 76 pregnancies, 19 were delivered vaginally and 57 were delivered by cesarean section. No uterine ruptures were reported. ConclusionBased on our case series and other data in the literature, we believe that appropriate and complete myometrial closure can be safely achieved through a single layer, when done by an experienced laparoscopist.Reproductive Associates of Delaware/RAD Based on our case series and other data in the literature, we believe that appropriate and complete myometrial closure can be safely achieved through a single layer, when done by an experienced laparoscopist.

Pitfall in Ultrasound Evaluation of Uterine Scar from Prior Preterm Cesarean Section

We report two cases of women with a previous cesarean performed before active labor at 29 weeks of gestation who underwent sonographic measurement of the lower uterine segment (LUS) at 36 weeks' gestation in their subsequent pregnancy. In both cases, uterine scar defect was detected on the upper part of the LUS, at ∼9 to 11 cm from the cervical os, and was only visualized by the transabdominal approach. We suggest that early gestational age and the absence of labor at previous cesarean can lead to a higher uterine scar location on the LUS and, therefore, increase the risk of uterine rupture in subsequent pregnancy. The heterogeneity of uterine scar location could explain discrepancies observed in studies using the transabdominal versus the transvaginal approach or both regarding the predictive value of LUS measurements for uterine rupture.

Surgical procedure to conserve the uterus for future pregnancy in patients suffering from massive adenomyosis

The treatment for severe adenomyosis has usually been hysterectomy, because there is no line of demarcation between diseased and normal tissue. Yet many such women wish to retain their uterus and some even wish to bear children. This report evaluates the efficacy of a new method of adenomyomectomy, where adenomyotic tissues are radically excised and the uterine wall is reconstructed by a triple-flap method, without overlapping suture lines, to prevent uterine rupture in subsequent pregnancies. This is a prospective case series followed for 10 years from June 1998 to August 2008 of 104 women with severe adenomyosis verified histologically and with magnetic resonance imaging. There was a dramatic reduction in both dysmenorrhoea and hypermenorrhoea and all patients returned to having normal menstrual cycles. Of 26 women who wished to conceive, 16 became pregnant, 14 (53.8%)went to term and delivered a healthy baby and there were no cases of uterine rupture. Adenomyosis symptoms recurred in only four out of 104 cases. The procedure thus resulted in a dramatic reduction in symptoms and allowed over half of women who wished to conceive to go to term without uterine rupture.