Uterine Sutures Research Articles

Comparing Cesarean Scar Defect Incidence After Locked and Unlocked Repair Methods Among Primiparous Patients: A Randomized Double-Blinded Trial.

To compare residual myometrial thickness (RMT) and cesarean scar defect (CSD) development after cesarean section using double-layer locked and unlocked closure techniques. We conducted a randomized double-blinded trial comparing double-layer locked and unlocked uterine closure techniques following cesarean section in primiparous women. The locked technique involved continuous suturing of the full myometrial thickness in the first layer, followed by back-and-forth needle maneuvering on both sides of the incision for the second layer. The unlocked method included running suturing of two-thirds of the myometrial thickness in the first layer, followed by suturing the upper half of the myometrial thickness in the second layer. Transvaginal ultrasonography was performed one year post-cesarean section, with RMT as the primary outcome and scar depth and width as secondary outcomes. Independent t-test and Chi-square test were utilized for statistical analysis. All 30 patients from the locked and 26 from the unlocked group in the follow-up were diagnosed with CSD (scar depth>2mm). The mean RMT for the unlocked and locked groups were 4.44±1.07mm and 4.12±0.48mm, respectively, showing no significant difference (p =0.14). There was also no significant difference in mean scar width between the locked and unlocked groups (3.68±1.44mm vs. 3.95±1.00mm, p =0.42). However, the mean scar depth was higher in the unlocked group (3.77±1.11 mm vs. 3.16±1.1mm, p =0.04). We have found no significant differences in the RMT and CSD prevalence between two-layered locked and unlocked uterine closure techniques, while the scar depth was greater in the unlocked group. Nonetheless, future randomized trials implementing larger sample sizes are required to precisely compare the outcomes of the double-layer locked and unlocked uterine suturing techniques.

Management of Gynecological and Obstetrical Peritonitis in the General Surgery Department of the Hospital National Ignace Deen Conakry University Hospital (Guinea)

Aim: Was to highlight the methods of management of gynecological and obstetric peritonitis. Patients and Methods: This was a retrospective and descrıptive study analyzing the records of patients operated on for peritonitis of gynecological or obstetric origin in the general surgery department of the Ignace Deen National Hospital, CHU of Conakry during the period from January 2020 to December 2022. The parameters studied were epidemiological, sociodemographic, clinical and therapeutic. Results: Gynaecological and obstetric peritonitis accounted for 15.6% (n= 58) of all peritonitis. The mean age of the patients was 27.9 years, with extremes of 17 and 46 years. The majority of patients were married, with multiple gestations, and the average consultation time was 13.4 days. The etiology most frequently encountered was uterine perforation (34%), and the surgical procedure most frequently performed was drainage (all patients) and uterine suture (63.4%). We recorded 3 cases of death (5.2%). Conclusion: Gynecological and obstetric peritonitis are both medical and surgical emergencies, mainly affecting sexually active young women, with considerable mortality.

Association of a Modified Uterine Manipulation Method with Improved Recovery after Laparoscopic Radical Hysterectomy: A Retrospective Cohort Study

Objective: Uterine manipulation with an intrauterine device is the surgical method used for early-stage cervical cancer. In this study, we explored a modified uterine manipulation method without the using an intrauterine device during laparoscopic radical hysterectomy (LRH) of patients with early-stage cervical cancer. Methods: We retrospectively collected data of patients with early-stage cervical cancer who underwent LRH between January 2015 and June 2019. The clinicopathological characteristics and surgical outcomes of patients treated with the new method (Group S) were compared to those of patients treated with the conventional uterine manipulator (Group M). Results: A total of 100 patients were included in the study, with 54 patients in Group M and 46 patients in Group S. No significant difference was observed in clinicopathological characteristics between the two groups. Compared to Group M, Group S had a significantly shorter duration of postoperative fever (0 vs. 3 d, P=0.003) and a shorter duration of secondary antibiotic use (4 vs. 5 d, P=0.035). Additionally, the cost of antibiotics was lower in Group S ($95.45 vs. $135.22, P=0.032). The modified uterine manipulation method was associated with a lower risk of postoperative fever (P=0.007). No difference was found in the 2-year disease-free survival (P=0.409) and 2-year overall survival between the two groups (P=0.718). Conclusions: The modified uterine suture suspension method is easy to perform, enhances postoperative recovery, and could be a viable option for patients with early-stage cervical cancer.

Ultrasonographic Evaluation of Cesarean Scar Defect after Double-layered Uterine Suture versus Single-layer Continuous Uterine Suture

Ultrasonographic Evaluation of Cesarean Scar Defect after Double-layered Uterine Suture versus Single-layer Continuous Uterine Suture

The prevention of infectious complications of caesarean section in the context of the global rise of antibiotic resistance

In the context of the global rise of antibiotic resistance, optimising the prevention of infectious complications of caesarean section (CS) with a reassessment of the guidelines for ultra-short antibiotic (AB) regimens is becoming increasingly important. Given the current data on the negative consequences of the use of AB in pregnant women for the fetal microbiota, the role of antiseptics that are used locally, do not pass to the child, and are less likely to cause resistance, have a wider range of antimicrobial activity is increasing.The objective: to provide clinical evidence for the prevention of infectious complications of CS by topical application of an antiseptic with decamethoxin.Materials and methods. A comparative study of two homogeneous groups of women with low infectious risk delivered by elective CS was conducted. In the 1st group (55 women) an antiseptic with decamethoxin was used at all stages of abdominal delivery: preoperative treatment of the skin and vagina, intraoperative irrigation of the inner surface of the uterus, uterine sutures, and subcutaneous tissue. The 2nd group (55 patients) received conventional antibacterial prophylaxis. In the course of clinical and microbiological parallels, ultrasound monitoring of uterine involution, the results of the examination on the 42nd day after CS and information on the condition of the newborn child were used.Results. The absence of infectious complications of puerperium, infection of the surgical site, trends and signs of inflammatory reactions in both groups was revealed.In the 2nd group 5.5% of patients had partial skin suture separation due to seroma formation and transient infiltration of the subcutaneous tissue. The absence of such phenomena in the 1st group should be considered a consequence of the cytoprotective effect of decametoxin. The use of an antiseptic with decametoxin has pharmacoeconomic advantages over antibiotic prophylaxis regimens.Conclusions. The use of antiseptic with decametoxin in the perioperative care of caesarean section combines the possibility of safe reduction of antibiotics, effective antiinfective protection with guaranteed safety for the child.

Postpartum Surgical Emergency, in the General Surgery Department of the District Hospital of the Commune IV/ Bamako

Introduction: Postpartum is a period of physical and psychological upheaval with the possibility of surgical complications. Objective: To analyze the epidemiological-clinical, therapeutic and prognostic profile of postpartum surgical emergencies. Methods: This was a descriptive, cross-sectional study over 8 months (from August 2022 to March 2023) including all patients admitted to the general surgery service for acute surgical abdomen in the postpartum period. Result: Seven patients were retained with an average age of 28.33 6.89years. We found 4 cases (57.1%) of post-operative peritonitis, 1cas (14.3%) of appendicular abscess and 1 case (14.3%) of strangled white line hernia. Clinical signs were dominated by abdominal pain, conjunctival pallor and fever. Anemia was confirmed in 5 (71.4%) patients and we found leukocytosis in all patients. Laparotomy associated with hysterectomy was performed in 2cas, laparotomy avively of the banks and uterine suture in 2 cases, washing of the peritoneal cavity associated with abdominal drainage in 1 case, hernia cure in 1cas, an appendectomy in 1cas and a sigmoidectomy in 1cas; abdominal drainage was performed in all our patients. Conclusion: The occurrence of an abdominal surgical emergency in postpartum is serious and may involve the obstetric and vital prognosis of the patient. The involvement of all actors (surgeon, obstetrician and anesthesiologist resuscitator) in the management, remains essential to secure the periartum period.

Hysteroscopic suture of levonorgestrel-releasing intrauterine system: learning curve for in vitro simulation training.

To simulate hysteroscopic suturing in vitro and analyze the learning curve of gynecologists with different experience levels. Three gynecologists were trained on uterine models in a circulating water box. The posterior uterine wall was sutured 10 times under hysteroscopy for 5 consecutive days, and the time of each suture procedure was recorded. Doctors A, B, and C completed 50 posterior uterine sutures. After Dr. C completed 50 sutures on the posterior wall, he added 50 sutures on the anterior wall (Group D). The mean suturing time was 71.54 ± 68.158 s in Group A, 50.10 ± 28.060 s in Group B, 34.04 ± 10.457 s in Group C, and 30.38 ± 8.734 s in Group D. The difference between Groups C and B and between Groups B and A was statistically significant. There was no statistically significant difference between Groups C and D. Simulation curves were created using the number of features as the abscissa and cumulative sum as the coordinate, with peak curves of 19, 27, and 18 cases for Group A, B, and C, respectively. Doctors with experience in single-hole laparoscopic surgery or hysteroscopic suture surgery can significantly shorten the hysteroscopic suturing time.

The efficacy of three regimes of uterotonic agents for prevention of postpartum blood loss at undergoing cesarean section: a prospective randomized clinical trial.

To compare the efficacy of three regimes of uterotonic agents on PPH in women undergoing cesarean section in our RCT. This study was a randomized controlled study (NCT05083910) performed at the Bezmialem Vakif University between July 2021 and January 2022. All women were randomly allocated into three groups: Group I (n = 52) - oxytocin only; Group II (n = 52) - the combination of oxytocin plus intrauterine misoprostol; Group III (n = 52) - carbetocin only. The primary outcome measures were: PPH to evaluate with the change between the concentrations of preoperative and postoperative hemoglobin, hematocrit and intraoperative blood loss. The blood loss characteristics, including the change in hemoglobin and the change in hematocrit concentration, intraoperative blood loss, intraoperative additional hemostatic uterine sutures and the need for additional uterotonics, were lowest in group III, although all groups were comparable in terms of blood loss parameters. Group III had the highest blood loss ratio, exceeding 1000 mL. For the combination of oxytocin and intrauterine misoprostol, the ARR was 3.8% (95% CI 20.02-12.33), with a RR of 1.18 (95% CI 0.58-2.39) and a NNT of 26 (95% CI 8.1-4.9); for carbetocin, the ARR was 5.8% (95% CI 22.15-10.61), with a RR of 1.27 (95% CI 0.63-2.53) and a NNT of 17 (95% CI 9.41-4.51). Our results demonstrate that carbetocin shows no superiority in the prevention of PPH in women undergoing cesarean section. Oxytocin still seems to be a highly effective alternative to prevent PPH.

Surgical Management of Uterine Fibroids at the Teaching Hospital of Angre Abidjan Cote d’Ivoire: 193 Cases Report

Objective: To evaluate the surgical management of myomas at the Teaching Hospital of Angré according to the FIGO (International Federation of Gynecology and Obstetrics) classification. Patients and methods: This was a cross-sectional study at the Teaching Hospital of Angre from January 1, 2020, to December 31, 2022. Patients whose operative indication was clearly identified were included in the study. Incomplete files were not included. The variables studied were anthropometric parameters, clinical characteristics of myomas, and surgery. Due to the large size and multifocal location of uterine myomas, the therapeutic option remained surgery by laparotomy. Results: Most patients were over 35 years old (71.5%) and nulliparous (52.8%). The first indication for surgery was menometrorrhagia (88.6%), followed by the desire for motherhood (37.8%) and dysmenorrhoea (20.2%) for myomas most often FIGO type 4 (p = 0.0031). Myomectomy under cervical-isthmic tourniquet was the most common procedure for FIGO type 4 myomas (66.1%; p = 0.0543). Hysterectomy was most frequently performed for FIGO type 7 myomas (43.9%; p = 0.0543). For myomectomy, the first complication was anaemia (3.5%) followed by uterine suture haemorrhage (1.7%) (p = 0.5139). Conclusion: Our surgical practice at the Teaching Hospital of Angre is in accordance with FIGO recommendations. However, an effort should be made to promote the minimally invasive surgical approach (laparoscopic, hysteroscopic, transvaginal ablation) for small fibroids (≤ 5 cm) or FIGO type 0 to 3, which is not very frequent in our current practice.

Impact of purse-string uterine suture on scar healing after a cesarean delivery: a randomized controlled trial

Uterine closure technique can affect scar healing, potentially resulting in unfavorable gynecologic and life-threatening obstetrical outcomes. Double-layer continuous unlocked suture has been demonstrated to promote optimal residual myometrial thickness. Recently, the purse-string uterine suture technique has emerged as a viable method to enhance the healing of scars. However, the current lack of randomized trials assessing the relevance of this technique warrants further investigation. This study aimed to evaluate the impact of purse-string uterine sutures on scar healing after cesarean delivery when compared with double-layer continuous unlocked suture. This was a randomized controlled trial; 126 patients with singleton pregnancies undergoing primary cesarean delivery were enrolled in 2 groups. The primary outcome was the mean residual myometrial thickness measured by saline infusion sonography 6 months after surgery by 2 sonographers blinded to uterine closure techniques. Operative time, calculated blood loss, total number of needed threads, and perioperative scar width were used for the perioperative analysis. Healing ratio and cesarean scar defect measurements were used for the 6-month analysis. There was no significant difference in terms of residual myometrial thickness (9.38±2.3 vs 8.4±3.9 mm; P=.187), blood loss (540 [146-982] vs 495 [241-903] mL; P=.815), or operative time (6.2 [5.2-7] vs 6 [5.3-7] minutes; P=.977). Achievement of purse-string uterine suture required significantly fewer threads (1 [1-1] vs 2 [1-2]; P<.001) and fewer hemostatic complementary sutures (1 [1-1] vs 1 [1-2]; P=.013). Scar width was significantly lower with purse-string uterine sutures (50 [40.5-50.5] vs 70 [60-70.5] mm; P<.0001). Purse-string uterine sutures allowed a higher healing ratio (1 [0.9-1] vs 0.84 [0.59-1]; P=.003) and significantly fewer cesarean scar defects (12% vs 35%; P=.018) compared with double-layer continuous unlocked suture. Despite resulting in no difference in residual myometrial thickness, purse-string uterine closure seems to be associated with better uterine scar healing on the basis of a higher healing ratio, and a lower rate of cesarean scar defects compared with double-layer continuous unlocked suture.

Ultrasound evaluation of post-cesarean uterine wound healing based on a figure of eight suturing technique

Link of Video Abstract: https://youtu.be/15Du23GFCWc Introduction: A niche (also called an isthmocele) is a defect or uterine scar that can be detected by ultrasound a few weeks or months after delivery by cesarean section. A niche is often associated with obstetric complications in subsequent pregnancies, including uterine dehiscence and/or rupture, placenta previa, and placenta accreta. Placenta accreta is characterized by abnormal attachment of the placenta to the uterine wall and is one of the leading causes of maternal morbidity and mortality in developing countries. Therefore, this study aims to evaluate the healing of surgical wounds with the figure of eight suturing techniques. Methods: This study included 32 primigravida patients who underwent cesarean section at RSIA (Mother &amp; Child Hospital) Rosiva from March 2006 to July 2006. On day 6 of the puerperium, the uterine sutures were examined with transvaginal ultrasound. Patients were subsequently allowed to return to their homes to receive outpatient treatment. On day 40, the patients were requested to return to the hospital for a follow-up ultrasound examination. Results: On day 6, incomplete wound healing was found in 31 patients (96.9%) and complete wound healing in 1 patient (3.1%). On day 40, 31 patients (96.9%) experienced perfect or complete healing. Statistical analysis showed a significant difference in wound healing between day 6 and day 40 (p = 0.0001). Conclusion: On day 40 after cesarean section, as many as 96.9% of patients showed perfect/complete wound healing (type I) without a niche. Therefore, these patients had a low risk of obstetric complications associated with uterine scarring in subsequent pregnancies.

Laparoscopic treatment of advanced interstitial pregnancy: key steps for a successful management

To describe a conservative laparoscopic treatment of an advanced case of interstitial pregnancy diagnosed in a woman at 14 weeks of gestational age. Video case report with demonstration of diagnostic work-up and laparoscopic management of rare subtypes of ectopic pregnancy SETTING: University tertiary care hospital. A 32-year-old nulliparous woman at 14 weeks of gestational age, presented with moderate abdominal pain. She reported an history of irregular periods however, no risk factor for ectopic pregnancy were identified. HCG levels was 7345 mIU/mL. Transvaginal ultrasound revealed an empty uterine cavity and a complex heterogeneous mass of 6 cm on the left cornual region. Myometrial thickness surrounding the gestational sac was 4 mm. There were several critical strategies for this laparoscopic approach. To reduce intraoperative bleeding, the peritoneum was opened, the ureters were identified, and bulldog clamps were used to temporarily reduce uterine vascularization. An intramyometrial injection of vasopressin was performed. After a first cornuostomy attempt, we had to get on a cornual resection to achieve a complete removal of the ectopic mass. Multilayer uterine suture and anatomical restoration to prevent adhesion was then accomplished. Institutional review board approval was not required for this case report as per our institution's policy; patient consent was obtained for publication of the case. Description of a laparoscopic management of huge interstitial pregnancy RESULTS: The overall operation time was 55 minutes, and the estimated blood loss was 55cl. A successfully conservative treatment was achieved with no short-term complications. Postoperative ultrasound showed a normal uterus and complete regression of hCG was obtained two weeks after surgery. Interstitial ectopic pregnancy presents a high risk of maternal mortality considering that the interstitial part of the tube, because of its thickness, has a great capacity to expand before rupture.

Acute Generalized Post-Cesarean Peritonitis Complicated by Abdominal Gangrene at Conakry University Hospital: A Case Report

Purpose: To discuss the difficult diagnosis of a rare case of post-cesarean peritonitis complicated by abdominal wall gangrene. Case Report: Mrs. A.D, 25 years old, admitted on 9/24/2018 for fluid flow through the operative wound, abdominal pain, fever, cough. Evolution 6 days. Onset: edema, redness, blisters of the abdominal wall then fluid flow through the surgical wound of a cesarean section (breech presentation) at 38 weeks, performed on 9/15/2018 in a medico-communal center in Conakry. Patient readmitted on D6: abdominal necrosis+blisters: dressing of the operative wound, Ampicillin 1 g, Perfalgan 1 g then referred to visceral surgery at Donka National Hospital. No specific background. No known allergy. Use of dermocorticoids for skin depigmentation for the duration of 2 years. G2, P2, Cesarean section 1, Alive 1, Died 1. Patient conscious, hypocoloured in teguments and conjunctivae: BP=110/70 mm Hg, pulse=104/min, FR=24 cycles/min, temperature=37.8°C. Abdomen: wound extending from the hypogastrium up to 3 cm above the umbilical bone, also involving the flanks, with necrotic background+foulsmelling whitish pus. TV: vulva covered with sero-hematic secretions. Leukocytes 16 G/l Hb 9 g/l VS accelerated. At laparotomy: necrotic areas of the skin at the parietal peritoneum, discharge of 1 liter of foul-smelling purulent fluid. Then midline above and below umbilical incision connecting the transverse incision: deposits of fibrin throughout the cavity, intact uterine sutures: removal of fibrin. Peritoneal toilet. Aponeurotic approximation. Stripping of necrotic tissue. Parietal washing, dressing. Peritoneal fluid: Staphylococcus aureus, ceftriaxone 1 g IV twice a day. postoperative follow-up: iterative necrosectomies, complete healing on postoperative eventration. Conclusion: Possibility of post-cesarean peritonitis with progression to abdominal gangrene.

Manejo quirúrgico conservador de la hemorragia posparto mediante sutura compresiva uterina (Técnica de Hayman). Reporte de caso

Postpartum hemorrhage is one of the most frequent complications in obstetrics, being the second cause of maternal mortality worldwide. Uterine atony is its main cause. Once the hemorrhage is established, the time and management of it will depend on the expertise of the obstetrician. Initially, treatment focuses on the use of uterotonic drugs, but in the absence of an adequate response, conservative surgical management may be chosen. Compressive uterine sutures are considered a good treatment option. An effective and simple surgical technique is described by Hayman, a valuable tool for the control of postpartum hemorrhage. We present the case of a 17-year-old patient, 37 weeks pregnant and diagnosed with severe preeclampsia, who presents placental abruption and posterior uterine atony, who underwent uterine compressive suture by Hayman technique, with satisfactory evolution.

The use of sealing hemostat patch (HEMOPATCH®) in laparotomic myomectomy: a prospective case-control study.

Uterine myomas are the most common gynecological disease. In these cases, a myomectomy is performed traditionally laparotomically. However, alternatives have been widely used, including laparoscopic, endoscopic, and robotic surgery. During these techniques, diffuse parenchymatous bleeding remains one of the main intraoperative and postoperative complications and sometimes requires unplanned hysterectomies. Recently, hemostatic agents and sealants have been used to prevent excessive blood loss during surgical repair. We propose a prospective case-control study on the use of a sealing hemostat patch (HEMOPATCH®) on uterine sutures in laparotomic myomectomy. In the period between July 2016 and April 2017, 46 patients with symptomatic uterine fibromatosis underwent surgery. They were divided into two groups of 23 patients, with different treatments in the hemostatic phase of oozing bleeding. HEMOPATCH® is applied in group A, and spray electrocoagulation is applied in group B. In group A, we achieve faster hemostasis (p < 0.05), than in group B. We report a significantly lower C-reactive protein value on the second and third days after surgery for group A compared to group B. HEMOPATCH®, during laparotomic myomectomy, is a valid alternative solution for obtaining rapid hemostasis and consequently intraoperative and postoperative bleeding. Furthermore, we suggest that a lower inflammatory peritoneal state is probably correlated with the barrier effect of the patch on the suture.

Poštedni hirurški tretman nekroze šava na uterusu nakon carskog reza - prikaz serije slučajeva

Introduction: Delivery by caesarean section (CS) accounts for approximately 32% of all deliveries worldwide, and it may be associated with early and late complications. Although postpartum uterine suture necrosis is not a common condition, it is associated with high morbidity and mortality in puerperal women, as well as permanent loss of fertility in these patients. In this article, we present seven patients successfully treated conservatively, who were diagnosed with uterine suture necrosis, during puerperium, after caesarean section. Case series report: We present 12 female patients in whom, in the period between February 1, 2019 and November 10, 2022, infection occurred after caesarean section was performed at the Clinic for Gynecology and Obstetrics of the University Clinical Center of Serbia (CGO, UCCS), and clinical suspicion of the presence of uterine suture necrosis arose. Of the total number of patients diagnosed with uterine suture necrosis, seven patients were successfully treated conservatively. Conclusion: The uterus-sparing surgical treatment approach to uterine suture necrosis is a possible alternative to standard treatment, which may allow fertility preservation in patients who have not completed reproduction.

Перспективы микроволновой радиотермометрии в ранней диагностике эндометрита и несостоятельности шва на матке после абдоминального родоразрешения

Aim: To assess the capabilities of microwave radiothermometry (MRTM) in early diagnosis of Postpartum endometritis and uterine suture failure after caesarean section. Design: Prospective non-randomized clinical trial. Materials and methods. A comparative analysis of the sensitivity of ultrasound (ultrasound) with dopplerometry and MRTM in the diagnosis of endometritis and suture failure on the uterus after cesarean section was carried out. The study included puerperal women after abdominal delivery (n = 90): 24 patients with a puerperia complication in the form of endometritis (group I), 16 — with suture failure on the uterus (group II), 50 — with a physiologically occurring postoperative period (control group). Assessment of the condition of the uterus and the postoperative suture on it was carried out on the 3–4th day after the operation. Results. Despite the fact that ultrasound with dopplerometry assessment of blood flow in the branches of the uterine arteries makes it possible to assess the structure of the myometrium and with a fairly high degree of probability to identify its inflammatory changes and defects in the suture, the sensitivity of this method in the early (3–4th day of the postoperative period) diagnosis of endometritis after abdominal delivery reaches an average of 54.2 ± 23.5%, and in the insolvency of the suture on the uterus — 31.25 ± 14.65%. At the same time, the MRTM study revealed indirect signs of endometritis in 66.7 ± 7.9% (if the conclusion is based on only one parameter — the thermoassymetry index, ITA) and 87.5 ± 8.3% (taking into account the combination of three signs), and for the insolvency of the suture on the uterus, the sensitivity of the method is 81.25 ± 4.75% for both ITA and three thermogram parameters, which is 2.6 times higher, than with ultrasound. Conclusion. Despite the rather high diagnostic effectiveness of the ultrasound method for assessing the condition of the scar on the uterus after cesarean section, the MRTM method has advantages in the form of higher sensitivity, ease of implementation, no need for expensive equipment and specialized medical qualifications. The greatest effectiveness of the diagnosis of postpartum purulent-septic complications can be achieved only with an integrated approach with clinical and laboratory tests and functional diagnostics, and timely prevention and an integrated approach to the treatment of purulent-inflammatory diseases of postoperative puerperia contribute to a significant reduction in the frequency of severe forms of postpartum infection. Keywords: caesarean section, endometritis, uterine suture failure, ultrasound, microwave radiothermometry, hysteroscopy.

Risk of Severe Postpartum Hemorrhage in Twin Pregnancies According to the Sum of Birth Weights.

To characterize the strength and patterns of association between birth weights and severe postpartum hemorrhage in twin pregnancies. This was a secondary analysis of the JUMODA (JUmeaux Mode d'Accouchement) cohort, a national, prospective, population-based study of twin deliveries, conducted from February 2014 to March 2015 in France. We excluded patients with a fetal death, medically indicated termination of pregnancy, antepartum hemorrhage, placenta previa, placental abruption, or missing birth weight. The primary outcome was severe postpartum hemorrhage , defined as a postpartum hemorrhage requiring at least one of the following: transfusion of 4 or more units of red blood cells, uterine artery embolization, uterine balloon tamponade, vascular ligation, uterine suture, emergency hysterectomy, admission to an intensive care unit, or postpartum hemorrhage considered severe by the obstetrician or leading to maternal death. The exposure was the sum of the birth weights of the two twins. To assess the association between the sum of twins' birth weights and severe postpartum hemorrhage, we used multilevel multivariable modified Poisson regression modeling. Analyses were conducted for the overall population and by planned and actual mode of delivery. A total of 8,373 patients were analyzed. Severe postpartum hemorrhage occurred in 4.5% (379/8,372, 95% CI 4.1-5.0), from 2.1% (15/722) for a sum of twins' birth weights less than 3,000 g up to 8.8% (12/136) for a sum exceeding 6,500 g. In the multivariable analysis, the association between the sum of the twins' birth weights and severe postpartum hemorrhage was linear, with an adjusted relative risk of severe postpartum hemorrhage of 1.36 (95% CI 1.24-1.49) for each 500-g increase in the sum of twins' birth weights. In twin pregnancies, the risk of severe postpartum hemorrhage increased linearly with the sum of the twins' birth weights.

Antepartal Spontaneous Complete Fundal Non-Scarred Uterine Rupture in Twin Pregnancy.

A 31-year-old, otherwise healthy patient (G1/P0) had a history of left salpingectomy for ectopic (tubal) pregnancy followed by diagnostic laparoscopy and uterine septal incision. Because of primary infertility, she underwent assisted reproduction (in vitro fertilization/embryo transfer), which resulted in a bichorial-biamniotic twin pregnancy. The further course was uneventful until 36 weeks when she felt pain in the epigastrium, leading her to be admitted to the hospital under suspicion of epigastric hernia. On admission, cardiotocographic and ultrasound findings showed a normal state of pregnancy with a palpable mobile, painless epigastric formation, without contractions and other symptoms. Two days after admission, she developed sudden pain and acute abdomen without labor, so an urgent laparotomy for suspected uterine rupture was performed, revealing a complete (12 cm) fundal rupture ([Fig. 1]) with prolapsed amniotic sac and twin legs. Live eutrophic twins (2710 g/48 cm, Apgar 10/10; 2790 g/48 cm, Apgar 10/10) were delivered through Kerr’s transverse isthmic hysterotomy, the placenta was removed, and a primary two-layer uterine suture was performed. The postoperative course was complicated by febrile puerperium, which was resolved by antibiotic treatment with complete maternal recovery.

Third-trimester ultrasound for antenatal diagnosis of placenta accreta spectrum in women with placenta previa: results from the ADoPAD study.

ABSTRACTObjectiveTo evaluate the performance of third‐trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low‐lying placenta or placenta previa.MethodsThis was a prospective multicenter study of pregnant women aged ≥ 18 years who were diagnosed with low‐lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at ≥ 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post‐test probability was assessed using Fagan nomograms.ResultsA total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6–34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post‐test probability of clinically significant PAS from 21% to 5% in women with low‐lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post‐test probability of clinically significant PAS from 21% to 9% in women with low‐lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post‐test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post‐test probability for clinically significant PAS from 21% to 85% in women with low‐lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post‐test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta.ConclusionsGrayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high‐risk population of women with low‐lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.