Uterine Scar Research Articles

Umbilical Cord Mesenchymal Stem Cell-Derived Exosomes Inhibit the Proliferation and Invasion of Uterine Fibroblast Cells

Objective: To investigate the effects of exosomes derived from human umbilical cord mesenchymal stem cells (hUC-MSC) on the proliferation and invasion capacities of uterine fibroblast cells. Methods: Exosomes were isolated from the hUC-MSC culture medium via ultracentrifugation. The morphology, particle size, and surface markers of the hUC-MSC-derived exosomes (hUC-MSC-exo) were characterized using transmission electron microscopy (TEM), nanoparticle tracking analysis (NTA), and Western blotting. The impact of the exosomes on uterine fibroblast proliferation and invasion was assessed using the CCK-8 proliferation assay and Transwell invasion assays. Results: The exosomes exhibited a typical bilayer membrane structure with a diameter of 100–150 nm, and their average particle size was approximately 130 nm. The zeta potential was around -33 mV. Specific exosome markers, including CD9, TSG101, and CD63, were prominently expressed. Functionally, hUC-MSC-exo significantly inhibited the proliferation and invasion of uterine fibroblast cells. Conclusion: This study reveals the inhibitory effects of hUC-MSC-derived exosomes on uterine fibroblast proliferation and invasion, highlighting their potential therapeutic value. These findings provide new insights into the mechanisms underlying uterine scarring and suggest novel approaches for pharmacological treatment.

Prospects for increasing the chances of successful vaginal delivery in women with a scar on the uterus after cesarean section

The review is devoted to one of the pressing problems of modern obstetrics — the delivery of women with a uterine scar after cesarean section. A scar on the uterus can cause various complications during pregnancy and childbirth. One of the main problems is scar failure. Pregnant women with a uterine scar, even after one cesarean section, should be considered at high risk for the development of complications. Visual diagnostic methods, such as ultrasound, magnetic resonance imaging, can only detect anatomical defects. Predicting the viability of a uterine scar is based, first of all, on a thorough analysis of data on a previous cesarean section. The choice of delivery method for pregnant women with a uterine scar is determined by its viability. It is not just the anatomical consistency of the uterine scar that is important, but also the functional one. The review presents criteria for diagnosing failure of the uterine scar according to ultrasound examination, data on the relationship between the initial thickness of the residual myometrium in the first trimester of pregnancy and the outcomes of pregnancy and childbirth. Considering that the functional viability of the uterine scar in subsequent pregnancies is largely determined by the course of reparative processes in the myometrium, especially the nature of angiogenesis, original studies are aimed at searching for diagnostic markers of the intensity of reparative angiogenesis. Generalization of existing knowledge about the possibilities of preclinical diagnosis of the consistency of the uterine scar will increase the number of vaginal births after cesarean section, reducing the number of abdominal births.

Prediction of intrapartum cesarean delivery among women with obesity: A retrospective cohort study

AbstractObjectiveTo determine risk factors and design a clinically based predictive model for the risk of intrapartum cesarean delivery (CD) in women with obesity.MethodsA retrospective cohort study was conducted in a single tertiary medical center between 2012 and 2022 and included all consecutive women with a pre‐gestational body mass index (BMI) ≥30 who planned a trial of labor. Uni‐ and multivariate analyses compared maternal and neonatal characteristics of women who delivered vaginally to those who underwent intrapartum CD. A specific risk prediction score was developed in accordance with the relative risk to predict the need for intrapartum CD.ResultsOf the 5663 women with obesity included in the study cohort, 424 (7.5%) underwent intrapartum CD and 5239 (92.5%) delivered vaginally. The independent risk factors for CD were maternal age >35 years, pre‐gestational BMI category (BMI 35–40 and BMI >40), nulliparity, epidural anesthesia, induction of labor, antibiotic administration during labor, multiple gestation, previous uterine scar, and pre‐eclampsia. The intrapartum CD prediction score model demonstrated predictive performance with 85% sensitivity and 70% specificity.ConclusionScore model for intrapartum CD can be used by caregivers to offer a more informed consultation to women with obesity facing the decision of mode of delivery.

Association between duration of urinary catheterization and post-operative mobilization following elective cesarean section: A retrospective case-control study in Espoo, Finland.

Cesarean section is the most common surgery performed on women. The enhanced recovery recommendations are early urinary catheter removal and early mobilization, as essential elements of post-operative care. This study aimed to analyze the association between these elements and whether limiting the catheter treatment duration affects the timing of post-operative mobilization. This retrospective case-control study compared the mobilization of healthy elective cesarean patients under different instructions on urinary catheter removal: cases with a preset catheter removal time (8-12 hours) and controls with catheter removal based on midwife considerations. Apart from the preset time of catheter removal, the routine post-operative care was given by the same personnel without any advice on patient mobilization. Data on patient demographics, surgery details, post-operative medication, first upright mobilization, the length of hospital stay, and patient satisfaction were analyzed. The study comprised 52 cases and one control for each case (N=104). The mean duration of urinary catheterization was 20.15 ± 6.59 and 11.30 ± 4.20 hours in the control and intervention groups, respectively (p<0.001). A linear regression analysis showed a significant association between the catheter removal time and patient mobilization, when adjusted for maternal background parameters (age, BMI, fear of childbirth diagnosis, prior uterine scar), duration and timing of the surgery, bleeding and post-operative analgesic use (R2=0.444, p<0.001). No difference was detected in the length of hospital stay, or patient satisfaction. Limiting the duration of urinary catheter therapy is associated with shorter time to post-operative mobilization. A prospective randomized trial would provide more detailed information.

Risk of Association of Placenta Praevia with History of Uterine Scar

Background: In Placenta Previa the placenta is implanted in the lower uterine segment in pregnancy with previous Caesarian Section there is risk of placenta being adherent with the scar, leading to devastating hemorrhage. The aim of this study was to find out the risk of association of placenta praevia with history of uterine scar. Methods: It was a hospital based observational cross-sectional study and was carried out in Department of Obstetrics and Gynecology. Dhaka Medical College and Hospital, Dhaka from May 2013 to October 2013. Total 50 patients were enrolled as diagnosed case of placental praevia. Patients clinical condition and course of management, perinatal outcome were observed, recorded &amp; categorized Data were analyzed using computer with Statistical Package for Social Sciences (SPSS) software for Windows version 20. Results: This study shows commonest age group was 26-30 years, which included 46%, 36% belonged to 31-35 years age group. The average age was 29.80 years. Most (94%) of the patients were multigravida Maximum (54%) number of cases were admitted during the gestational period of 35-38 weeks. Common clinical presentations were anaemia (80%) and per vaginal bleeding (84%). Regarding management, 76% patients were managed actively and 24% patients were managed expectantly. It was observed that placenta praevia with uterine scar is seen more frequently (66%) in cases of previous caesarean sections. Among 30 patients, 84% were live births, 10% were still births and 6% were neonatal deaths. No maternal death was observed in this study. Conclusion: This study shows strong association between previous caesarean section, uterine curettage and hysterotomy and placenta praevia. Most of the patients were provided with active modality of management. Hence the study advocates the use of contraceptive, advanced antenatal care &amp; early referral to hospital and expectant management of patients after proper selection to reduce the premature birth.

The effectiveness of surgical and conservative treatment of patients with endometriosis of the uterine scar after cesarean section

Target. To analyze the effectiveness of surgical and conservative treatment of patients with an incompetent uterine scar and endometriosis in the scar after cesarean section.Materials and methods of research. A retrospective analysis of 64 medical records of patients with a uterine scar and endometriosis in the scar for the period from 2021 to 2023 was carried out at the medical center, which is the clinical base of the Department of Obstetrics and Gynecology No. 2 of the Stavropol State Medical University.Results. The analysis showed the high effectiveness of surgical treatment of patients interested in subsequent pregnancies with an incompetent uterine scar and endometriosis in the scar. Conservative treatment given to patients not interested in subsequent pregnancies with an incompetent uterine scar and endometriosis in the scar has also demonstrated its effectiveness.

Secondary Uterine Scar Pregnancy after Curettage Surgery: A Case Report

Secondary Uterine Scar Pregnancy after Curettage Surgery: A Case Report

Maternal health in conflict-affected settings: a case study from a frozen conflict zone

Abstract Background Reproductive, maternal, newborn and child health are negatively impacted in conflict-affected settings, and may be acutely affected in frozen conflicts due to fragile health systems and uncertain geopolitical contexts. To better understand maternal health in a frozen conflict zone, we examined maternal health outcomes in Nagorno-Karabakh during a ceasefire period prior to the forced displacement of the entire population. Methods Multistage cluster sampling was used to sample 1023 households in Nagorno-Karabakh during the summer of 2022. From each household, one woman, age 18 to 49, participated in an interviewer-administered survey. Maternal health outcomes were assessed among all married women who had ever given birth. Women with at least one child under 5 years were also asked about their most recent pregnancy. Results Among all married women, 85.5% had ever given birth, 19.0% ever had a miscarriage, and 2.8% ever had a stillbirth. Of the 299 women with at least one child under 5, 97.7% received antenatal care, of which 90.4% had at least 4 visits. Over half experienced toxicosis (51.8%), 16.4% high blood pressure, 13.0% anemia, and 6.4% hemorrhage during their most recent pregnancy. The most common delivery complications were uterine scarring (19.7%), breached birth (7.0%), prolonged labor (6.4%) and hemorrhage (5.7%). Age was found to be a significant factor, with the odds of toxicosis (p = 0.039) and breached birth (p = 0.009) decreasing, yet the odds of miscarriage (p = 0.001) and hypertension (p = 0.007) increasing with age. Conclusions Almost all women reported adequate antenatal care with birth outcomes comparable to global statistics, demonstrating the ability of Nagorno-Karabakh to provide sufficient maternal healthcare while in a frozen conflict. Fortifying and ensuring access to maternal and reproductive healthcare, particularly antenatal care, is vital for ensuring the health and wellbeing of women and children in conflict-affected settings. Key messages • Women in Nagorno-Karabakh received antenatal care and experienced birth outcomes similar to global rates, demonstrating the value of access to reproductive healthcare in conflict-affected settings. • Future studies should examine the impact of forced displacement on the women of Nagorno-Karabakh to better understand the effect of conflict on reproductive and maternal health.

Care of late intrauterine fetal death and stillbirth: Green-top Guideline No. 55.

A combination of mifepristone and a prostaglandin preparation should usually be recommended as the first-line intervention for induction of labour (Grade B). A single 200 milligram dose of mifepristone is appropriate for this indication, followed by: 24+0-24+6 weeks of gestation - 400 micrograms buccal/sublingual/vaginal/oral of misoprostol every 3 hours; 25+0-27+6 weeks of gestation - 200 micrograms buccal/sublingual/vaginal/oral of misoprostol every 4 hours; from 28+0 weeks of gestation - 25-50 micrograms vaginal every 4 hours, or 50-100 micrograms oral every 2 hours [Grade C]. There is insufficient evidence available to recommend a specific regimen of misoprostol for use at more than 28+0 weeks of gestation in women who have had a previous caesarean birth or transmural uterine scar [Grade D]. Women with more than two lower segment caesarean births or atypical scars should be advised that the safety of induction of labour is unknown [Grade D]. Staff should be educated in discussing mode of birth with bereaved parents. Vaginal birth is recommended for most women, but caesarean birth will need to be considered for some [Grade D]. A detailed informed discussion should be undertaken with parents of both physical and psychological aspects of a vaginal birth versus a caesarean birth [Grade C]. Parents should be cared for in an environment that provides adequate safety according to individual clinical circumstance, while meeting their needs to grieve and feel supported in doing so (GPP). Clinical and laboratory tests should be recommended to assess maternal wellbeing (including coagulopathy) and to determine the cause of fetal death, the chance of recurrence and possible means of avoiding future pregnancy complications [GradeD]. Parents should be advised that with full investigation (including postmortem and placental histology) a possible or probable cause can be found in up to three-quarters of late intrauterine fetal deaths [Grade B]. All parents should be offered cytogenetic testing of their baby, which should be performed after written consent is given (GPP). Parents should be advised that postmortem examination can provide information that can sometimes be crucial to the management of future pregnancy [Grade B].

A new approach to the diagnosis and surgical treatment of uterine scar defect after cesarean section

Introduction. An increase in the number of cesarean sections in the world leads to an increase in cases of formation of scar defects on the uterus, which requires attention and the use of new diagnostic and treatment methods. Studying the healing processes of the myometrium is key to preventing the formation of a uterine scar defect, and improvements in diagnostic methods and surgical techniques can reduce the risk of recurrence of a uterine scar defect.Purpose of the study. To develop an effective algorithm for the management of women with a uterine scar defect at the stage of preparation for pregnancy.Materials and methods. A prospective randomized cohort study was conducted using a random number generator method with the participation of 100 women with a uterine scar defect after cesarean section. The participants were divided into two groups: in the first group (35 women), surgical treatment was performed using an anchor thread and a collagen-based hemostatic matrix, while in the second group (65 women), surgical treatment was carried out in the traditional way (laparoscopic metroplasty without the use of additional techniques).Results. A mathematical model has been developed for predicting the risk of recurrence of a uterine scar defect. Using the method of step-by-step discriminant analysis, the most informative predictors of the formation of a recurrent uterine scar defect were identified: shear wave magnitude indicators according to ultrasound elastography, the presence of a cyst in the uterine scar area, the expression of receptors for progesterone and estradiol in the endometrial glands, the expression of CD20 cells and CD138 cells. plasma cells according to an immunohistochemical study of the endometrium.Conclusion. Understanding the main reasons for the formation of a scar defect and the risk factors for its recurrence will make it possible to more accurately predict the outcomes of laparoscopic metroplasty and choose the most appropriate treatment tactics for each specific patient, which, in turn, can improve the overall treatment results and the quality of life of women

Association of Placenta Previa with Previously Scarred and Non Scarred Uterus: A Descriptive Cross-Sectional Study

Introduction: Placenta previa, where the placenta is partially or completely placed in the lower uterine segment, is a major contributor to vaginal bleeding during pregnancy and affects 0.4-0.5% of all labors. Its exact cause is uncertain but is believed to be linked to aberrant endometrial vascularization caused by scarring or atrophy from prior trauma, surgery, or infection. Objective: The objective of this study was to establish an association between the placenta previa and the scarring of uterus. Methods: A cross-sectional study was conducted on pregnant women at Nobel Medical College Teaching Hospital, Biratnagar, from November 2021 to October, 2023. Ethical approval and written consent were obtained from all participants. Using convenient sampling technique, the study involved 57 participants out of 3576 patients who were admitted for Lower Segment Cesarian Section. Results: A study of 3576 patients admitted for Lower Segment Cesarian Section at Nobel Medical College Teaching Hospital, we found 57 cases of placenta previa over 24 months. The incidence was 1.59%, with 1.82% in patients with a previous history of LSCS and 1.51% without any history of scarring. The results showed no association between placenta previa and uterine scarring. Conclusion: The study found no association between the incidence of placenta previa and scarred/non-scarred uterus, but a slightly higher likelihood of having placenta previa in those with a history of uterine scarring.

Surgical treatment of cesarean scar pregnancy based on the three-category system: a retrospective analysis

BackgroundCesarean scar pregnancy (CSP), a distinct form of ectopic pregnancy, presents challenges in effective management. It is categorized into three subtypes according to the location of placental implantation and the thickness of the myometrium at the uterine scar. Nevertheless, the optimal choice of treatment modalities for these subtypes remains largely unexamined.MethodsIn this retrospective analysis, we investigated the cases of 130 patients diagnosed with CSP who underwent diverse treatment approaches, namely ultrasound-guided dilation and curettage (D&C), hysteroscopic surgery alone or in combination with laparoscopic surgery (HCoLC), or uterine artery embolization (UAE) followed by curettage. Clinical data were meticulously retrieved from medical records and follow-up data, and a comparative analysis of relevant indicators was carried out across the different CSP subtypes.ResultsFrom January 2017 to December 2021, 35 patients underwent D&C, 85 underwent HCoLC, and 10 received UAE as a pretreatment. In the D&C group, the success rates for Type I and Type II CSP were 64.29% (18/28) and 14.28% (1/7), respectively. Significant differences were observed between the success and failure groups in terms of gestational sac size and clinical classification. Compared to Type I CSP, Type II CSP exhibited significantly longer surgical durations and higher hospitalization costs (P < 0.05). Three patients classified as Type III underwent simultaneous hysteroscopic evacuation of cesarean scar pregnancy and laparoscopic repair of the cesarean scar defect, achieving a 100% success rate in their initial treatment. HCoLC showed no significant differences in surgical duration and hospitalization costs but had higher success rates and shorter hospital stays compared to the D&C and UAE groups (P < 0.05). The UAE group had significantly longer surgical durations, higher hospitalization costs, and a higher incidence of postoperative complications (P < 0.05). However, these factors did not result in improved surgical success rates.ConclusionThe classification of CSP and the measurement of gestational sac are of crucial importance in determining the most appropriate surgical intervention strategy. For patients diagnosed with Type I CSP, D&C and hysteroscopy are reliable treatment choices. In cases with larger gestational sacs or Type II CSP, hysteroscopy, either alone or in combination with laparoscopy, is regarded as a reliable and effective treatment approach. In patients with type III CSP, lesion excision with uterine repair is the recommended treatment.

Clinical and morphological features of the myometrium in patients with placental adherent and invasive pathology

BACKGROUND: The fast increase in the frequency of placental adherent and invasive pathology worldwide accounts for the growing interest in studying the pathogenesis of placenta accreta. According to the literature, the clinical and morphological features of the myometrium from the placental attachment area in placental adherent and invasive pathology are described in single articles. Study of morphological features using proteolytic markers in the myometrium from the placenta accreta area could help in understanding the pathogenesis of placental adherent and invasive pathology. For the first time in this study, the clinical and morphological features of the myometrium from the placental attachment area in patients with uterine scar and placental adherent and invasive pathology are compared with the myometrium of women with uterine scar without placenta accreta and intact myometrium. AIM: The aim of this study was to evaluate the expression of matrix metalloproteinase 2 and tissue inhibitors of matrix metalloproteinases 1 and 2 in myometrial biopsies in placental adherent and invasive pathology. MATERIALS AND METHODS: This study included 15 myometrial biopsies from the placental site, which were divided into three groups according to the clinical diagnosis of the patients: group 1 (main group), with a uterine scar after cesarean section and placental adherent and invasive pathology (n = 5); group 2 (comparison group), with a uterine scar after cesarean section (n = 5); group 3 (control group), with a normal pregnancy without a uterine scar (n = 5). Histological examination was carried out using the standard procedure. Immunohistochemical study was performed using antibodies to matrix metalloproteinase 2 and tissue inhibitors of matrix metalloproteinases 1 and 2 (Abcam, USA). Morphometry was carried out using the VideoTesT-Morphology 5.2 program (Videotest Ltd., Russia). The statistical analysis was performed using the IBM SPSS Statistics 26.0 software. RESULTS: In the biopsies of the main group, we verified terminal chorionic villi with hypervascularization and uneven plethora of the vascular bed among hypertrophied muscle fibers, a basal plate with lumen ectasia of unevenly full-blooded vessels, and the absence of a decidual membrane, in contrast to groups 2 and 3. The matrix metalloproteinase 2 expression area in the main group was higher than in the comparison and control groups (p = 0.008; p1–2 = 0.049*, p1–3 = 0.011), the matrix metalloproteinase 2 optical density not differing between the groups (p = 0.122). The tissue inhibitors of matrix metalloproteinases 1 expression area was higher in the comparison group compared to the main group (p = 0.035; p2–3 = 0.032), and the tissue inhibitors of matrix metalloproteinases 1 and 2 optical density was higher in the comparison group compared to control (p = 0.008; p2–3 = 0.005). CONCLUSIONS: In myometrial biopsies of patients with a uterine scar and placental adherent and invasive pathology, we verified pathology of the basal plate of the placenta, increased matrix metalloproteinase 2 expression and decreased tissue inhibitors of matrix metalloproteinases 1 expression, which may indicate the peculiarities of the inflammatory response in the myometrium in placental adherent and invasive pathology.

How two-child policy affects cesarean section in women with advanced maternal age (AMA): using the Robson classification system

ObjectivesTo study the possible associations between advanced maternal age and cesarean section(CS) under the two child policy.MethodsThis study used a cohort study from Dongguan People’s Hospital in Guangdong Province, China from 2017 to 2020. The cohort was restricted to women aged ≥ 20 who give birth to babies with a gestational age of > 28 weeks and a weight of > 1000 g. Divide the advanced maternal age (AMA) pregnant women into two age groups: 35–39 years old and 40 years old or older age. We analyzed CS rate and CS contribution using the modified Robson classification system. Frequency of cesarean was determined for each group and compared by using χ2 and prevalence ratio.ResultsOverall, 47654 women were included, of which 7924 (16.63%) were between the ages of 35 and 39, and 1529 (3.21%) were aged 40 or older. The total CS rate is 40.64%, with 36.10% for mothers aged 20 to 34, 57.90% for women aged 35 to 40, and 64.75% for women aged 40 or older age. In the AMA groups (n = 9453), Robson group 2’ was the most common, followed by groups 5 and 10. Women at 40 years or older age were 3 times more likely to undergo a cesarean delivery in Robson group 1’, and 1.76 times more likely in group 10. The CS rate in group 2’ were statistically significantly higher in the very AMA group.ConclusionsThe CS rates increased noticeably with maternal age under the two child policy. Based on the modified Robson classification system, AMA women should pay more attention to primiparous women with single pregnancy, uterine scars, and premature birth in multiple pregnancies.

Diagnostic Correlation between Saline Infused Sono Hysterography and Three-Dimensional Transvaginal Ultrasound in the Assessment of Cesarean Section Scar Defect. A Study of a Diagnostic Test Accuracy

Abstract Background The evolution of Sono hysterography over the past years has contributed significantly to the assessment of uterine cavity. Saline infused Sono hysterography (SIS) may be recommended as an alternative to Diagnostic Hysteroscopy for the assessment of the uterine cavity and uterine scar in women with previous Cesarean Section. Three-dimensional (3D) ultrasonography that enhances visualization of the lower uterine segment (LUS), myometrial thickness and the size of uterine diverticulum is a more recent tool used to diagnose post- cesarean section uterine diverticulum. Objective To compare accuracy of three-dimensional transvaginal ultrasound versus saline infused sonography for assessing the characteristics, frequency of caesarean scar defects in symptomatic patients with a history of cesarean section. Patients and Methods This study was conducted with 72 women. patients were recruited from the ultrasound unit underwent both three-dimensional transvaginal ultrasound and saline infused son hysterography. This study, conforming to the declaration of Helsinki, was approved by the ethical committee of Obstetrics and Gynecology department, Ain Shams University, ethical committee number FMASU M D 52 \2021. Results 3D transvaginal ultrasound and Sono hysterography showed almost good agreement regarding prevalence of niche with kappa (κ) 0.780 with p-value (p &amp;lt; 0.001). Both imaging modalities show statistically significant higher mean value of volume in SIS was 591.67±271.05 comparing to 3D TVUS was 444.36±219.42, with p-value (p = 0.004). Conclusion There is a substantial agreement between 3D TVUS and SIS in evaluating various niche characteristics, encompassing depth, length, width, volume, AMT and RMT. The data strongly supports the advantages of 3D TVUS over SIS for assessing Cesarean scar defects, commonly known as “Niche.” These benefits encompass cost-effectiveness, improved time efficiency, enhanced patient tolerability, and heightened patient satisfaction associated with the 3D TVUS procedure.

Evaluation of El-Demerdash Maternity Hospital Experience in Management of Pregnant Women Diagnosed with Placenta Previa

Abstract Background Placenta previa is a potentially dangerous condition that can affect pregnant women, leading to significant maternal morbidity and adverse perinatal outcomes. Aim of the Work Evaluation of placenta previa management, study of maternal and perinatal outcomes in cases of placenta previa, and study of risk factors for placenta previa. Patients and Methods The study included 80 women with placenta previa who were diagnosed and managed at El-Demerdash Maternity Hospital. Results The sociodemographic characteristics of the included patients showed a preponderance of the ages above 30 years, multiparity, history of previous cesarean section, and history of uterine scarring. Maternal outcomes showed a reasonable decrease in the hemoglobin level postoperatively compared with preoperatively. However, there was a high incidence of blood transfusion. There was an overabundance of general anesthesia performance during surgical intervention. The majority of the placenta previa patients had cesarean delivery; however, there was a low incidence of maternal surgical injuries and mortality. Regarding neonatal outcomes, most of the neonates belonged to the preterm group. The neonatal intensive care unit (NICU) admission was reported in nearly half of the included patients, attributed to preterm, respiratory distress (RD), and intrauterine growth restriction (IUGR). There was a low incidence of perinatal mortality. Conclusion In El-Demerdash Maternity Hospital, risk factors for placenta previa were age above 30 years, multiparity, history of previous cesarean section, and history of uterine scarring. Most placenta previa patients received conservative surgical management rather than cesarean hysterectomy. Despite the higher rate of conservative surgical management compared to cesarean hysterectomy, maternal surgical morbidity and mortality were low. However, there was a higher frequency of blood transfusion to manage postpartum hemorrhage. Most of the neonates were preterm, and neonatal intensive care unit admission was reported in nearly half of the included patients. There was a low incidence of perinatal mortality.

Scar matrix drives Piezo1 mediated stromal inflammation leading to placenta accreta spectrum.

Scar tissue formation is a hallmark of wound repair in adults and can chronically affect tissue architecture and function. To understand the general phenomena, we sought to explore scar-driven imbalance in tissue homeostasis caused by a common, and standardized surgical procedure, the uterine scar due to cesarean surgery. Deep uterine scar is associated with a rapidly increasing condition in pregnant women, placenta accreta spectrum (PAS), characterized by aggressive trophoblast invasion into the uterus, frequently necessitating hysterectomy at parturition. We created a model of uterine scar, recapitulating PAS-like invasive phenotype, showing that scar matrix activates mechanosensitive ion channel, Piezo1, through glycolysis-fueled cellular contraction. Piezo1 activation increases intracellular calcium activity and Protein kinase C activation, leading to NF-κB nuclear translocation, and MafG stabilization. This inflammatory transformation of decidua leads to production of IL-8 and G-CSF, chemotactically recruiting invading trophoblasts towards scar, initiating PAS. Our study demonstrates aberrant mechanics of scar disturbs stroma-epithelia homeostasis in placentation, with implications in cancer dissemination.

Emergency delivery in case of suspected placenta accreta spectrum: Can it be predicted?

The main goal of placenta accreta spectrum (PAS) screening is to enable delivery in an expert center in the presence of an experienced team at an appropriate time. Our study aimed to identify independent risk factors for emergency deliveries within the IS-PAS 2.0 database cohort and establish a multivariate predictive model. A retrospective analysis of prospectively collected PAS cases from the IS-PAS database between January 2020 and June 2022 by 23 international expert centers was performed. All PAS cases (singleton and multiple pregnancies) managed according to local protocols were included. Individuals with emergent delivery were identified and compared to those with scheduled delivery. A multivariate analysis was conducted to identify the possible risk factors for emergency delivery and was used to establish a predictive model. Maternal outcomes were compared. Overall, 315 women were included in the study. Of these, 182 participants (89 with emergent and 93 with scheduled delivery) were included in the final analysis after exclusion of those with unsuspected PAS antenatally or who lacked information about the urgency of delivery. Gestational age at delivery was higher in the scheduled group (34.7 vs. 32.9, p < 0.001). Antenatal bleeding (OR 2.9, p = 0.02) and a placenta located over a uterine scar (OR 0.38, p = 0.001) were the independent predictive factors for emergent delivery (AUC 0.68). Ultrasound (US) markers: loss of clear zone (p = 0.001), placental lacunae (p = 0.01), placental bulge (p = 0.02), and presence of bridging vessels (p = 0.02) were more frequently documented in the scheduled group. None of these markers improved the predictive values of the model. Higher PAS grades were identified in the scheduled group (p = 0.01). There were no significant differences in maternal outcomes. Antenatal bleeding and the placental location away from the uterine scar remained the most significant predictors for emergent delivery among patients with PAS, even when combining more predictive risk factors, including US markers. Based on these results, patients who bleed antenatally may benefit from transfer to an expert center, as we found no differences in maternal outcomes between groups delivered in expert centers. Earlier-scheduled delivery is not supported due to the low predictive value of our model.

Management of blood loss in second-trimester abortion.

While major complications in second-trimester abortion are rare, blood loss and hemorrhage are among the most common and have the potential for high morbidity. Here, we review the current literature on risk factors, prevention, and treatment of blood loss in second-trimester abortion. A comprehensive approach to hemorrhage during second-trimester abortions is essential. Understanding hemorrhage risk factors, prevention strategies, and treatment options makes second-trimester abortion safer. Some pharmacologic methods may both prevent and treat excessive blood loss. Mechanical methods are primarily used for treatment. Key risk factors include prior uterine scars, gestational duration, insufficient cervical preparation, high BMI, procedural inexperience, fetal demise, and halogenated anesthetics. Developing evidence-based protocols for and further research into hemorrhage related complications are crucial for improving safety in second-trimester abortion care. Prevention of hemorrhage improves outcomes. However data are limited. For treatment, this includes using pharmacological interventions and mechanical methods. Identifying high-risk patients and implementing preprocedural optimization are proactive measures that aid in decreasing the occurrence and severity of blood loss and hemorrhage.

Structured hysteroscopic examination of uterine niches: a modified Delphi procedure.

Uterine niches in the Caesarean section scar are seen in approximately half of women with a history of caesarean delivery. Whilst a structured ultrasound assessment of caesarean defects has been described, there is no consensus on a structured hysteroscopic evaluation. To propose a methodology for a structured hysteroscopic evaluation of uterine niches. We conducted a modified Delphi procedure, including two online rounds and two face-to-face meetings of the members of the ESGE Uterine Niches Working Group. The taskforce members have extensive experience in hysteroscopic niche evaluation. The consensus was predefined as a Rate of Agreement of at least 75%. Thirteen experts participated in this modified Delphi procedure. There was consensus on the need for a standardised methodology and the hysteroscopic definition of a niche as any indentation in the myometrium at the site of a previous CS. There was consensus that a hysteroscopic evaluation of a niche must be combined with ultrasound to measure the residual myometrial thickness. In addition, it was agreed that niches should be subclassified as 'simple', 'simple with one branch', or 'complex'. There was consensus that the following items should be described during a hysteroscopic niche evaluation: the number of niches, the size in relation to the size of cervical canal, the presence of polyps, crypts, cysts, fibrotic tissue, blood, mucus, placental remnants, a dynamic valve, the appearance of the endometrium, the number of blood vessels and bleeding from blood vessels within the defect. Using a modified Delphi procedure with international experts, consensus was achieved on the hysteroscopic evaluation and classification of niches in the uterine caesarean section scar. A structured registration form was developed to aid consistency in hysteroscopic niche reporting.