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Pekar-Zlotin M, Maymon R, Nimrodi M, Zur-Naaman H, Melcer Y. Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:551-555. [PMID: 37983614 DOI: 10.1002/uog.27540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To evaluate Cesarean scar defects using saline contrast sonohysterography (SCSH) in women with a history of Cesarean scar pregnancy (CSP). METHODS A cohort of 38 non-pregnant women with a history of CSP treated with combined local and systemic methotrexate was investigated prospectively by SCSH. For the purpose of analysis, they were classified, according to the modified Delphi consensus criteria for CSP in early gestation, into three subgroups based on the depth of the gestational sac herniation in the midsagittal plane. Subgroup A included eight (21.1%) cases, in which the largest part of the gestational sac protruded towards the uterine cavity; Subgroup B included 20 (52.6%) cases, in which the largest part of the gestational sac was embedded in the myometrium; and Subgroup C included 10 (26.3%) cases, in which the gestational sac was located partially outside the outer contour of the cervix or uterus. RESULTS SCSH revealed that all women in Subgroup C had a uterine niche. The median niche length (P = 0.006) and depth (P = 0.015) were significantly greater in Subgroup C than in Subgroups A or B. The median residual myometrial thickness (RMT) was significantly lower in Subgroup C than in Subgroups A or B (P = 0.006). CONCLUSIONS Women with prior CSP who had a gestational sac protruding beyond the serosal line had a significantly greater niche length and depth, and lower RMT. This knowledge may guide individualized risk counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Pekar-Zlotin
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - R Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - M Nimrodi
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - H Zur-Naaman
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Y Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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Banerjee A, Ivan M, Nazarenko T, Solda R, Bredaki EF, Casagrandi D, Tetteh A, Greenwold N, Zaikin A, Jurkovic D, Napolitano R, David AL. Prediction of spontaneous preterm birth in women with previous full dilatation cesarean delivery. Am J Obstet Gynecol MFM 2024; 6:101298. [PMID: 38278178 DOI: 10.1016/j.ajogmf.2024.101298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/19/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND A previous term (≥37 weeks' gestation), full-dilatation cesarean delivery is associated with an increased risk for a subsequent spontaneous preterm birth. The mechanism is unknown. We hypothesized that the cesarean delivery scar characteristics and scar position relative to the internal cervical os may compromise cervical function, thereby leading to shortening of the cervical length and spontaneous preterm birth. OBJECTIVE This study aimed to determine the relationship of cesarean delivery scar characteristics and position, assessed by transvaginal ultrasound, in pregnant women with previous full-dilatation cesarean delivery with the risk of shortening cervical length and spontaneous preterm birth. STUDY DESIGN This was a single-center, prospective cohort study of singleton pregnant women (14 to 24 weeks' gestation) with a previous term full-dilatation cesarean delivery who attended a high-risk preterm birth surveillance clinic (2017-2021). Women underwent transvaginal ultrasound assessment of cervical length, cesarean delivery scar distance relative to the internal cervical os, and scar niche parameters using a reproducible transvaginal ultrasound technique. Spontaneous preterm birth prophylactic interventions (vaginal cervical cerclage or vaginal progesterone) were offered for short cervical length (≤25 mm) and to women with a history of spontaneous preterm birth or late miscarriage after full-dilatation cesarean delivery. The primary outcome was spontaneous preterm birth; secondary outcomes included short cervical length and a need for prophylactic interventions. A multivariable logistic regression analysis was used to develop multiparameter models that combined cesarean delivery scar parameters, cervical length, history of full-dilatation cesarean delivery, and maternal characteristics. The predictive performance of models was examined using the area under the receiver operating characteristics curve and the detection rate at various fixed false positive rates. The optimal cutoff for cesarean delivery scar distance to best predict a short cervical length and spontaneous preterm birth was analyzed. RESULTS Cesarean delivery scars were visualized in 90.5% (220/243) of the included women. The spontaneous preterm birth rate was 4.1% (10/243), and 12.8% (31/243) of women developed a short cervical length. A history- (n=4) or ultrasound-indicated (n=19) cervical cerclage was performed in 23 of 243 (9.5%) women; among those, 2 (8.7%) spontaneously delivered prematurely. A multiparameter model based on absolute scar distance from the internal os best predicted spontaneous preterm birth (area under the receiver operating characteristics curve, 0.73; 95% confidence interval, 0.57-0.89; detection rate of 60% for a fixed 25% false positive rate). Models based on the relative anatomic position of the cesarean delivery scar to the internal os and the cesarean delivery scar position with niche parameters (length, depth, and width) best predicted the development of a short cervical length (area under the receiver operating characteristics curve, 0.79 [95% confidence interval, 0.71-0.87]; and 0.81 [95% confidence interval, 0.73-0.89], respectively; detection rate of 73% at a fixed 25% false positive rate). Spontaneous preterm birth was significantly more likely when the cesarean delivery scar was <5.0 mm above or below the internal os (adjusted odds ratio, 6.87; 95% confidence interval, 1.34-58; P =.035). CONCLUSION In pregnancies following a full-dilatation cesarean delivery, cesarean delivery scar characteristics and distance from the internal os identified women who were at risk for spontaneous preterm birth and developing short cervical length. Overall, the spontaneous preterm birth rate was low, but it was significantly increased among women with a scar located <5.0 mm above or below the internal cervical os. Shortening of cervical length was strongly associated with a low scar position. Our novel findings indicate that a low cesarean delivery scar can compromise the functional integrity of the internal cervical os, leading to cervical shortening and/or spontaneous preterm birth. Assessment of the cesarean delivery scar characteristics and position seem to have use in preterm birth clinical surveillance among women with a previous, full-dilatation cesarean delivery and could better identify women who would benefit from prophylactic interventions.
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Affiliation(s)
- Amrita Banerjee
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David); Research Department of Maternal Fetal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Drs Banerjee, Ivan, Nazarenko, Casagrandi, Napolitano and Profs Zaikin, Jurkovic, and David)
| | - Maria Ivan
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David); Research Department of Maternal Fetal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Drs Banerjee, Ivan, Nazarenko, Casagrandi, Napolitano and Profs Zaikin, Jurkovic, and David)
| | - Tatiana Nazarenko
- Research Department of Maternal Fetal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Drs Banerjee, Ivan, Nazarenko, Casagrandi, Napolitano and Profs Zaikin, Jurkovic, and David); Department of Mathematics, University College London, London, United Kingdom (Dr Nazarenko and Prof Zaikin)
| | - Roberta Solda
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David)
| | - Emmanouella F Bredaki
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David)
| | - Davide Casagrandi
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David); Research Department of Maternal Fetal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Drs Banerjee, Ivan, Nazarenko, Casagrandi, Napolitano and Profs Zaikin, Jurkovic, and David)
| | - Amos Tetteh
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David)
| | - Natalie Greenwold
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David)
| | - Alexey Zaikin
- Research Department of Maternal Fetal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Drs Banerjee, Ivan, Nazarenko, Casagrandi, Napolitano and Profs Zaikin, Jurkovic, and David); Department of Mathematics, University College London, London, United Kingdom (Dr Nazarenko and Prof Zaikin)
| | - Davor Jurkovic
- Research Department of Maternal Fetal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Drs Banerjee, Ivan, Nazarenko, Casagrandi, Napolitano and Profs Zaikin, Jurkovic, and David); Department of Gynecology, Elizabeth Garrett Anderson Wing, University College London Hospital NHS Foundation Trust, London, United Kingdom (Prof Jurkovic)
| | - Raffaele Napolitano
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David); Research Department of Maternal Fetal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Drs Banerjee, Ivan, Nazarenko, Casagrandi, Napolitano and Profs Zaikin, Jurkovic, and David)
| | - Anna L David
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, London, United Kingdom (Drs Banerjee, Ivan, Solda, Bredaki, Casagrandi Tetteh, Greenwold, Napolitano and Prof David); Research Department of Maternal Fetal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Drs Banerjee, Ivan, Nazarenko, Casagrandi, Napolitano and Profs Zaikin, Jurkovic, and David); National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre, London, United Kingdom (Prof David).
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Dogru S, Akkus F, Altınordu Atcı A, Memnune Erdoğan K, Acar A. Effect of cervical changes on the cesarean scar area and niche formation after preterm and term cesarean sections. J Ultrasound 2023; 26:717-724. [PMID: 36972013 PMCID: PMC10469159 DOI: 10.1007/s40477-022-00767-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/12/2022] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE The purpose of this study is to assess the scar area and niche formation after cesarean section in women who had preterm or term deliveries and underwent cesarean section at various stages of labor. METHOD This prospective cohort study consists of cases who underwent the first cesarean section for different obstetric reasons. The patients were divided into four groups regarding gestational age and cervical dilatation. After a cesarean section, all patients were called for vaginal ultrasonography control at 12 weeks. The location of the scar and the presence of a niche were evaluated. The residual (RMT), proximal, and distal myometrial thicknesses were evaluated where the scar and niche were located. RESULTS A total of 87 cases were included in the study. There was no difference in the prevalence of niche between the groups (p > 0.05). RMT and proximal and distal myometrial thickness were not different between the 37 ≥ week and 37 < week groups, while RMT and proximal and distal myometrial thickness were significantly lower in women with active labor (p =0.001, p= 0.006, p =0.016). The location of the scar was the isthmus at 37 weeks and above (p= 0.002), it was in the cervical canal in the group below 37 weeks (p= 0.017). CONCLUSION The gestational week and cervical changes did not affect the prevalence of the niche. In cases of active labor and preterm deliveries, the CS scar defect was located in the cervical canal; however, in cases of term deliveries, it was located in the isthmic area.
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Affiliation(s)
- Sukran Dogru
- Division of Perinatology, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Hocacihan Neighborhood, Abdulhamidhan Street, No: 3 Selçuklu, Konya, Turkey.
| | - Fatih Akkus
- Division of Perinatology, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Hocacihan Neighborhood, Abdulhamidhan Street, No: 3 Selçuklu, Konya, Turkey
| | - Aslı Altınordu Atcı
- Division of Perinatology, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Hocacihan Neighborhood, Abdulhamidhan Street, No: 3 Selçuklu, Konya, Turkey
| | - Kübra Memnune Erdoğan
- Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
| | - Ali Acar
- Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
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Sako Y, Hirata T. Hysteroscopic management of uterine diverticulum after myomectomy: a case report. BMC Womens Health 2023; 23:452. [PMID: 37641054 PMCID: PMC10464432 DOI: 10.1186/s12905-023-02606-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND A uterine diverticulum is defined as the presence of a niche within the inner contour of the uterine myometrial wall. Although secondary uterine diverticula can occur after hysterotomy such as cesarean section, reports of diverticula after myomectomy are extremely rare. CASE PRESENTATION A 45-year-old nulliparous woman undergoing infertility treatment was referred to our hospital because of abnormal postmenstrual bleeding after myomectomy. Transvaginal sonography and magnetic resonance imaging revealed a diverticulum in the isthmus. Fat-saturated T1 image showed a blood reservoir in the diverticulum. Hysteroscopic surgery was performed to remove the lowed edge of the defect and coagulate the hypervascularized area. Two months after surgery, the abnormal postmenstrual bleeding and chronic endometritis improved. DISCUSSION AND CONCLUSIONS This report highlights the similarities of the patient's diverticulum to cesarean scar defects in terms of symptoms and pathophysiology. First, this patient developed a diverticulum with hypervascularity after myomectomy and persistent abnormal bleeding. Second, after hysteroscopic surgery, the symptoms of irregular bleeding disappeared. Third, endometrial glands were identified within the resected scar tissue. Fourth, preoperatively identified CD138-positive cells in endometrial tissue spontaneously disappeared after hysteroscopic resection. To the best of our knowledge, this is the first report of symptomatic improvement following hysteroscopic surgery in a patient with an iatrogenic uterine diverticulum with persistent irregular bleeding after myomectomy.
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Affiliation(s)
- Yusuke Sako
- Department of Obstetrics and Gynecology, St Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan
| | - Tetsuya Hirata
- Department of Obstetrics and Gynecology, St Luke's International Hospital, 9-1 Akashi-Cho, Chuo-Ku, Tokyo, 104-8560, Japan.
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo, Japan.
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Verberkt C, Lemmers M, de Vries R, Stegwee SI, de Leeuw RA, Huirne JAF. Aetiology, risk factors and preventive strategies for niche development: A review. Best Pract Res Clin Obstet Gynaecol 2023; 90:102363. [PMID: 37385157 DOI: 10.1016/j.bpobgyn.2023.102363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 07/01/2023]
Abstract
The increase in caesarean sections (CS) has resulted in an increase in women with a uterine niche. The exact aetiology of niche development has yet to be elucidated but is likely multifactorial. This study aimed to give a systematic overview of the available literature on histopathological features, risk factors and results of preventive strategies on niche development to gain more insight into the underlying mechanisms. Based on current published data histopathological findings associated with niche development were necrosis, fibrosis, inflammation, adenomyosis and insufficient approximation. Patient-related risk factors included multiple CS, BMI and smoking. Labour-related factors were CS before onset of labour, extended cervical dilatation, premature rupture of membranes and presenting part of the fetus at CS below the pelvic inlet. Preventive strategies should focus on the optimal level of incision, training of surgeons and full-thickness closure of the myometrium (single or double-layer) using non-locking sutures. Conflicting data exist concerning the effect of endometrial inclusion. Future studies without heterogeneity in population, using standardized performance of the CS after proper training and using standardized niche evaluation with a relevant core outcome set are required to allow meta-analyses and to develop evidence-based preventive strategies. These studies are needed to reduce the prevalence of niches and prevent complications in subsequent pregnancies such as caesarean scar pregnancies.
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Affiliation(s)
- C Verberkt
- Department of Obstetrics and Gynecology, Research Institute "Amsterdam Reproduction and Development", Amsterdam UMC, Location VU Medical Center, Amsterdam, the Netherlands
| | - M Lemmers
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - R de Vries
- Medical Library, Vrije Universiteit, 1081 HV, Amsterdam, the Netherlands
| | - S I Stegwee
- Department of Obstetrics and Gynecology, Research Institute "Amsterdam Reproduction and Development", Amsterdam UMC, Location VU Medical Center, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - J A F Huirne
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands.
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Donnez O. Cesarean scar disorder: Management and repair. Best Pract Res Clin Obstet Gynaecol 2023; 90:102398. [PMID: 37598564 DOI: 10.1016/j.bpobgyn.2023.102398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/14/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023]
Abstract
Cesarean scar disorder (CSD) is an entity recently defined as uterine niche with at least one primary or 2 secondary symptoms. CSDs can be visualized by hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging, but diagnosis should be performed by exams able to measure the residual myometrial thickness (RMT). Although there is a limited number of studies evaluating fertility and reproductive outcomes after different types of surgery, the following consideration should be kept in mind. Asymptomatic women should not be operated with the hope of improving obstetrical outcomes. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be offered according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and RMT measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique in case of RMT <3 mm. In this instance, repair is essential and can only be achieved by a laparoscopic or vaginal approach. The benefit of laparoscopic approach seems to persist after subsequent CS. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made.
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Affiliation(s)
- Olivier Donnez
- Complex Endometriosis Center (CEC), Polyclinique Urbain V (Elsan Group), Avignon, France.
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Katsura D, Tsuji S, Hoshiyama T, Zen R, Inatomi A, Murakami T. A Trimming Technique: A Case Report of a Novel Surgical Approach for Cesarean Scar Dehiscence During Cesarean Section. Yonago Acta Med 2023; 66:287-291. [PMID: 37229375 PMCID: PMC10203637 DOI: 10.33160/yam.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/16/2023] [Indexed: 05/27/2023]
Abstract
Cesarean section can lead to residual myometrial thickness thinning and cesarean scar syndrome. We report a novel trimming technique for residual myometrial thickness recovery in women with cesarean scar syndrome. Case 1: A 33-year-old woman who developed cesarean scar syndrome (CSS) and abnormal uterine bleeding post-cesarean scar became pregnant following hysteroscopic treatment. The myometrium at previous scar was dehiscent; therefore, a transverse incision was made above the scar. Post-operative uterine recovery failed owing to lochia retention, and developed cesarean scar syndrome again. Case 2: A 29-year-old woman who developed cesarean scar syndrome post-cesarean section became pregnant spontaneously. The myometrium at the previous scar was dehiscent like case 1. Scar repair was performed using a trimming technique during cesarean section; there were no subsequent complications and she conceived again spontaneously. Performing this novel surgical procedure during cesarean section may contribute to residual myometrial thickness recovery in women with cesarean scar syndrome.
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Affiliation(s)
- Daisuke Katsura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Takako Hoshiyama
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Rika Zen
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Ayako Inatomi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
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8
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Stegwee SI, van der Voet LFL, Heymans MW, Kapiteijn K, van Laar JOEH, van Baal WMM, de Groot CJM, Huirne JAF. Prognostic model on niche development after a first caesarean section: development and internal validation. Eur J Obstet Gynecol Reprod Biol 2023; 283:59-67. [PMID: 36796129 DOI: 10.1016/j.ejogrb.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/06/2023] [Accepted: 01/15/2023] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To develop and internally validate a prognostic prediction model for development of a niche in the uterine scar after a first caesarean section (CS). STUDY DESIGN Secondary analyses on data of a randomized controlled trial, performed in 32 hospitals in the Netherlands among women undergoing a first caesarean section. We used multivariable backward logistic regression. Missing data were handled using multiple imputation. Model performance was assessed by calibration and discrimination. Internal validation using bootstrapping techniques took place. The outcome was 'development of a niche in the uterus', defined as an indentation of ≥ 2 mm in the myometrium. RESULTS We developed two models to predict niche development: in the total population and after elective CS. Patient related risk factors were: gestational age, twin pregnancy and smoking, and surgery related risk factors were double-layer closure and less surgical experience. Multiparity and Vicryl suture material were protective factors. The prediction model in women undergoing elective CS revealed similar results. After internal validation, Nagelkerke R2 ranged from 0.01 to 0.05 and was considered low; median area under the curve (AUC) ranged from 0.56 to 0.62, indicating failed to poor discriminative ability. CONCLUSIONS The model cannot be used to accurately predict the development of a niche after a first CS. However, several factors seem to influence scar healing which indicates possibilities for future prevention such as surgical experience and suture material. The search for additional risk factors that play a role in development of a niche should be continued to improve the discriminative ability.
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Affiliation(s)
- Sanne I Stegwee
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands.
| | | | - Martijn W Heymans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology & Data Science, Amsterdam, Netherlands
| | - Kitty Kapiteijn
- Reinier de Graaf Gasthuis, Department of Obstetrics and Gynecology, Delft, Netherlands
| | - Judith O E H van Laar
- Máxima Medisch Centrum, Department of Obstetrics and Gynecology, Veldhoven, Netherlands
| | | | - Christianne J M de Groot
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands; Amsterdam UMC, Universiteit van Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Judith A F Huirne
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands; Amsterdam UMC, Universiteit van Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands.
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9
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Tsuji S, Nobuta Y, Hanada T, Takebayashi A, Inatomi A, Takahashi A, Amano T, Murakami T. Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review. Reprod Med Biol 2023; 22:e12532. [PMID: 37577060 PMCID: PMC10412910 DOI: 10.1002/rmb2.12532] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/05/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Background Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi). Methods This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery. Main findings The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective. Conclusion The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Yuri Nobuta
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tetsuro Hanada
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Aike Takebayashi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Ayako Inatomi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Akimasa Takahashi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
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Prediction of Scar Myometrium Thickness and Previous Cesarean Scar Defect Using the Three-Dimensional Vaginal Ultrasound. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3584572. [PMID: 36262982 PMCID: PMC9556220 DOI: 10.1155/2022/3584572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 01/26/2023]
Abstract
This research aimed to explore the related factors of scar myometrial thickness and scar diverticulum formation and then predict the occurrence of uterine diverticula. 140 patients with cesarean section were selected as the research objects. According to the three-dimensional (3D) vaginal ultrasound echo and the diagnostic criteria of uterine diverticulum, the research objects were divided into a diverticulum group and a control group, with 70 cases in each group. Data such as age, number of cesarean sections, endometrial thickness, uterine position, and diverticulum size was collected, and their relationship with uterine diverticulum was compared and analyzed. The results showed that there were significant differences in menstrual days, cesarean section times, and uterine position between the two groups (P < 0.05). The height (9.02 ± 2.97), width (14.02 ± 3.08), and depth (5.14 ± 1.23) of the posterior uterine diverticula in the scar diverticulum group were all greater than the anterior uterine height (6.69 ± 1.36), the width (10.69 ± 2.15), and the depth (3.86 ± 0.69), respectively. The residual myometrium thickness in posterior position of the uterus (2.98 ± 0.75) was < anterior position of uterus (3.43 ± 0.47), and the difference was statistically significant (P < 0.05). Multivariate analysis showed that the frequency of cesarean section (1 time, 2 times), uterine position, and abnormal menstruation were independent risk factors in the scar diverticulum group (P < 0.05). In conclusion, menstrual abnormalities, the number of cesarean sections (1 time or twice), and the position of the uterus are independent risk factors for the formation of uterine scar diverticula. The deeper the diverticula, the more likely to have menstrual abnormalities, the more prone to diverticulum in patients with posterior uterus, and the deeper the diverticula in patients with 2 dissections.
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11
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Antoine C, Meyer JA, Silverstein JS, Alexander J, Oh C, Timor-Tritsch IE. The Impact of Uterine Incision Closure Techniques on Post-cesarean Delivery Niche Formation and Size: Sonohysterographic Examination of Nonpregnant Women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1763-1771. [PMID: 34726789 DOI: 10.1002/jum.15859] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/24/2021] [Accepted: 09/19/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare the prevalence and size of residual niche in the nongravid uterus following Cesarean delivery (CD) with different hysterotomy closure techniques (HCTs). METHODS Saline infusion sonohysterogram (SIS) was performed in women after one prior CD, documenting the presence or absence of a postoperative niche and measuring its depth, width, length, and residual myometrial thickness. Women were grouped by HCT: Technique A (endometrium-free) and Technique B (routine non-endometrium-free). The primary outcome was the prevalence of a clinically significant niche, defined as a depth of >2 mm. HCT groups were compared using χ2 , T-test (ANOVA), and analyzed using logistic regression and two-sided test (P < .05). RESULTS Forty-five women had SIS performed, 25 and 20 via Technique A and B, respectively. Technique groups varied by average interval time from CD to SIS (13.6 versus 74.5 months, P = 0.006) but were otherwise similar. Twenty niches were diagnosed, 85% of which were clinically significant, including five following Technique A, nine following Technique B with double-layer closure, and three following Technique B with single-layer (P = .018). The average niche depth was 2.4 mm and 4.9 mm among the two-layer subgroups following Techniques A and B, respectively (P = .005). A clinically significant niche development was six times higher with Technique B when compared to Technique A (OR 6.0, 95% CI 1.6-22.6, P = .008); this significance persisted after controlling for SIS interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3, P = .04). The average niche depth was 5.7 ± 2.9 mm following Technique B with single-layer. CONCLUSION Hysterotomy closure techniques determine the prevalence of post-Cesarean delivery niche formation and size. Exclusion of the endometrium at uterine closure reduces the development of significant scar defects.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | - Jessica A Meyer
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | - Jenna S Silverstein
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Cheongeun Oh
- Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York, USA
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12
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Wang J, Pang Q, Wei W, Cheng L, Huang F, Cao Y, Hu M, Yan S, He Y, Wei Z. Definition of large niche after Cesarean section based on prediction of postmenstrual spotting: Chinese cohort study in non-pregnant women. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:450-456. [PMID: 34806258 DOI: 10.1002/uog.24817] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE A large niche after Cesarean section (CS) is associated with long-term complications, of which postmenstrual spotting is associated positively with the size of the niche. However, the diagnosis of a large niche in the literature is inconsistent and the definition is largely subjective. The aim of this study was to generate a definition for a large niche in non-pregnant women based on the presence of postmenstrual spotting. METHODS Women who had undergone CS in our hospital between January 2012 and June 2017 were selected randomly from our database, contacted by telephone and subsequently examined between January 2016 and June 2020. Eligible for inclusion were non-pregnant women who had their last CS more than 1 year earlier and agreed to undergo transvaginal sonography (TVS). All participants underwent examination of their CS scar by TVS (two-dimensional color Doppler) during the midfollicular phase. Niche depth, length, width, residual myometrial thickness (RMT), adjacent myometrial thickness (AMT) and ratio of niche depth/AMT were recorded. Women diagnosed with a niche, defined as an indentation at the site of the CS with a depth of at least 2 mm, were classified into two groups (symptomatic or asymptomatic) according to whether they experienced postmenstrual spotting. Logistic regression analysis was used to establish the best cut-off values for the niche parameters to predict postmenstrual spotting. A new definition was generated based on the niche parameters with the highest area under the receiver-operating-characteristics (ROC) curve (AUC) for the prediction of postmenstrual spotting. RESULTS A total of 727 women who had a CS > 1 year earlier underwent TVS examination, of whom 263 were diagnosed with a niche (prevalence of 36.2%). Of these, 160 women experienced postmenstrual spotting and 103 were asymptomatic. The three variables with the highest AUC for prediction of postmenstrual spotting were niche depth/AMT ratio (AUC, 0.798; 95% CI, 0.745-0.852), niche depth (AUC, 0.731; 95% CI, 0.668-0.795) and RMT (AUC, 0.683; 95% CI, 0.618-0.748). Based on the best cut-offs according to ROC-curve analysis, a large niche was defined as: niche depth ≥ 0.50 cm, RMT ≤ 0.21 cm or niche depth/AMT ratio ≥ 0.56. The prevalence of a large niche according to this definition was 22.4% (163/727). The new definition had a specificity of 61.17% (95% CI, 52.34-70.41%) and sensitivity of 76.87% (95% CI, 70.28-84.16%) for a large niche. CONCLUSION This study has provided a new definition for a large niche after CS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Wang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - Q Pang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - W Wei
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - L Cheng
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - F Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Y Cao
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - M Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - S Yan
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Y He
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - Z Wei
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
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13
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Feldman N, Maymon R, Jauniaux E, Manoach D, Mor M, Marczak E, Melcer Y. Prospective Evaluation of the Ultrasound Signs Proposed for the Description of Uterine Niche in Nonpregnant Women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:917-923. [PMID: 34196967 DOI: 10.1002/jum.15776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/29/2021] [Accepted: 06/04/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To evaluate the new ultrasound-based signs for the diagnosis of post-cesarean section uterine niche in nonpregnant women. METHODS We investigated prospectively a cohort of 160 consecutive women with one previous term cesarean delivery (CD) between December 2019 and 2020. All women were separated into two subgroups according to different stages of labor at the time of their CD: subgroup A (n = 109; 68.1%) for elective CD and CD performed in latent labor at a cervical dilatation (≤4 cm) and subgroup B (n = 51; 31.9%); for CD performed during the active stage of labor (>4 cm). RESULTS Overall, the incidence of a uterine niche was significantly (P < .001) higher in women who had an elective (20/45; 44.4%) compared with those who had an emergent (21/115; 18.3%) CD. Compared with subgroup B, subgroup A presented with a significantly (P = .012) higher incidence of uterine niche located above the vesicovaginal fold and with a significantly (P = .0002) lower proportion of cesarean scar positioned below the vesicovaginal fold. There was a significantly (P < .001) higher proportion of women with a residual myometrial thickness (RMT) > 3 mm in subgroup A than in subgroup B and a significant negative relationship was found between the RMT and the cervical dilatation at CD (r = -0.22; P = .008). CONCLUSIONS Sonographic cesarean section scar assessment indicates that the type of CD and the stage of labor at which the hysterotomy is performed have an impact on the location of the scar and the scarification process including the niche formation and RMT.
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Affiliation(s)
- Noa Feldman
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - Danielle Manoach
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Matan Mor
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ewa Marczak
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Mc Gowan S, Goumalatsou C, Kent A. Fantastic niches and where to find them: the current diagnosis and management of uterine niche. Facts Views Vis Obgyn 2022; 14:37-47. [PMID: 35373546 PMCID: PMC9612856 DOI: 10.52054/fvvo.14.1.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Caesarean section (CS) scar niche is a well recognised complication of caesarean delivery and is defined as an indentation at the site of the CS scar with a depth of at least 2mm. Objectives To review systematically the medical literature regarding the current diagnosis and management of uterine niche Materials and methods We carried out a systematic review using MeSH terms ‘niche’ OR ‘sacculation’ OR ‘caesarean scar defect’ OR ‘caesarean section scar’ OR ‘uterine defect’ OR ‘isthmocele.’ Articles included were peer-reviewed and in English language. Main outcome measures Prevalence, symptoms, diagnosis, pathophysiology and management of uterine niche. Results CS scar niche is common and, in a subgroup, produces a range of symptoms including post-menstrual bleeding, dyspareunia and subfertility. It may be linked to use of locked sutures during CS closure. Niche repair can be achieved laparoscopically or hysteroscopically and appears to improve symptoms, although solid conclusions regarding fertility outcomes cannot be drawn. Conclusions CS scar niche is associated with a range of symptoms. Repair may aid subfertile patients and those with post-menstrual spotting. The presence of a niche is probably irrelevant in the absence of symptoms. What is new? LNG-IUS and surgical repair appear to improve symptoms in those with a niche.
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15
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de Luget CD, Becchis E, Fernandez H, Donnez O, Quarello E. Can uterine niche be prevented? J Gynecol Obstet Hum Reprod 2021; 51:102299. [PMID: 34958983 DOI: 10.1016/j.jogoh.2021.102299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/12/2021] [Accepted: 12/20/2021] [Indexed: 12/31/2022]
Abstract
Uterine niche is a potential significant consequence of Caesarean section and is diagnosed by ultrasound. The timing of Caesarean section (during pre, early or advanced labour), location of the incision (distance from the internal os), techniques for opening and closing the uterine cavity, and bladder flap have been frequently mentioned in the literature, however, these factors continue to be a source of disagreement with respect to whether they increase the risk of uterine niche or protect against this complication. In this review, we outline and discuss the possible risk factors that may be responsible for this entity. The main factor upon which obstetricians can act is the rate of first Caesarean section, which can and should be reduced. Moreover, a rather high incision at a distance from the internal os, and a sparing use of bladder detachment should be always kept in mind as well.
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Affiliation(s)
- Claire Delage de Luget
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France
| | - Elise Becchis
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France
| | - Hervé Fernandez
- Service de gynécologie et obstétrique, Hôpital de Bicêtre, AP-HP, Le Kremlin Bicêtre, France, Université Paris-Saclay
| | - Olivier Donnez
- Institut du sein et de Chirurgie gynécologique d'Avignon (ICA), Polyclinique Urbain V (Groupe Elsan), Avignon, France
| | - Edwin Quarello
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France.; Centre Image2, 6 rue Rocca, 13008 Marseille, France..
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16
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Zhang Q, Lei L, Zhang A, Zou L, Xu D. Comparative effectiveness of laparoscopic versus hysteroscopic approach in patients with previous cesarean scar defect: a retrospective cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1529. [PMID: 34790735 PMCID: PMC8576701 DOI: 10.21037/atm-21-4339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
Background The aim of this study was to evaluate the clinical effectiveness and obstetric outcomes of laparoscopic and hysteroscopic surgery in patients with previous cesarean scar defect (PCSD). Methods A retrospective cohort analysis was performed on women who underwent laparoscopic or hysteroscopic surgery for PCSD from 2016 to 2019 at the Third Xiangya Hospital of Central South University. Among these participants, 13 underwent laparoscopic surgery and 33 received hysteroscopic surgery. Results Significant differences were displayed in the operative times (156.9±42.3 vs. 40.7±38.9 min, P<0.05), intra-operative blood loss (80.0±61.0 vs. 17.9±51.2 mL, P<0.05), hospital stay (7.1±1.6 vs. 4.1±2.1 days, P<0.05), postoperative hospital stay (4.3±0.8 vs. 1.5±1.1 days, P<0.05), and hospitalization expenses (22,240.3±249.9 vs. 9,547.1±4,747.2 yuan, P<0.05) between the laparoscopic surgery and hysteroscopic group. No significant difference was observed in the incidence of clinical efficacy between the laparoscopic and hysteroscopic surgery group. A total of 2 of the 4 patients in the laparoscopic surgery group, and 9 of 11 patients in the hysteroscopic surgery group delivered successfully. All 2 participants in the laparoscopic surgery group and 2 participants in the hysteroscopic surgery group were diagnosed with placenta previa. No uterine rupture was reported in our study. Conclusions Both laparoscopic and hysteroscopic surgery are safe and effective treatments for PCSD patients, and hysteroscopic surgery is more efficient for PCSD patients.
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Affiliation(s)
- Qi Zhang
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Lei Lei
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China.,Medical Center of Hysteroscopy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Aiqian Zhang
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Lingxiao Zou
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Dabao Xu
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
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Doulaveris G, Vani K, Saccone G, Chauhan SP, Berghella V. Number and quality of randomized controlled trials in obstetrics published in the top general medical and obstetrics and gynecology journals. Am J Obstet Gynecol MFM 2021; 4:100509. [PMID: 34656731 DOI: 10.1016/j.ajogmf.2021.100509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/26/2021] [Accepted: 10/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND There has been an increasing number of randomized controlled trials published in obstetrics and maternal-fetal medicine to reduce biases of treatment effect and to provide insights on the cause-effect of the relationship between treatment and outcomes. OBJECTIVE This study aimed to identify obstetrical randomized controlled trials published in top weekly general medical journals and monthly obstetrics and gynecology journals, to assess their quality in reporting and identify factors associated with publication in different journals. STUDY DESIGN The 4 weekly medical journals with the highest 2019 impact factor (New England Journal of Medicine, The Lancet, The Journal of the American Medical Association, and British Medical Journal), the top 4 monthly obstetrics and gynecology journals with obstetrics-related research (American Journal of Obstetrics & Gynecology, Ultrasound in Obstetrics & Gynecology, Obstetrics & Gynecology, and the British Journal of Obstetrics and Gynaecology), and the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine were searched for obstetrical randomized controlled trials in the years 2018 to 2020. The primary outcome was the number of obstetrical randomized controlled trials published in the obstetrics and gynecology journals vs the weekly medical journals and the percentage of trials published, overall and per journal. The secondary outcomes included the proportion of positive vs negative trials overall and per journal and the assessment of the study characteristics of published trials, including quality assessment criteria. RESULTS Of the 4024 original research articles published in the 9 journals during the 3-year study period, 1221 (30.3%) were randomized controlled trials, with 137 (11.2%) randomized controlled trials being in obstetrics (46 in 2018, 47 in 2019, and 44 studies in 2020). Furthermore, 33 (24.1%) were published in weekly medical journals, and 104 (75.9%) were published in obstetrics and gynecology journals. The percentage of obstetrical randomized controlled trials published ranged from 1.5% to 9.6% per journal. Overall, 34.3% of obstetrical trials were statistically significant or "positive" for the primary outcome. Notably, 24.8% of the trials were retrospectively registered after the enrollment of the first study patient. Trials published in the 4 weekly medical journals enrolled significantly more patients (1801 vs 180; P<.001), received more often funding from the federal government (78.8% vs 35.6%; P<.001), and were more likely to be multicenter (90.9% vs 42.3%; P<.001), non-United States based (69.7% vs 49.0%; P=.03), and double blinded (45.5% vs 18.3%; P=.003) than trials published in the obstetrics and gynecology journals. There was no difference in study type (noninferiority vs superiority) and trial quality characteristics, including pretrial registration, ethics approval statement, informed consent statement, and adherence to the Consolidated Standards of Reporting Trials guidelines statement between studies published in weekly medical journals and studies published in obstetrics and gynecology journals. CONCLUSION Approximately 45 trials in obstetrics are being published every year in the highest impact journals, with one-fourth being in the weekly medical journals and the remainder in the obstetrics and gynecology journals. Only about a third of published obstetrical trials are positive. Trials published in weekly medical journals are larger, more likely to be funded by the government, multicenter, international, and double blinded. Quality metrics are similar between weekly medical journals and obstetrics and gynecology journals.
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Affiliation(s)
- Georgios Doulaveris
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Drs Doulaveris and Vani).
| | - Kavita Vani
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Drs Doulaveris and Vani)
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Dr Saccone)
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Dr Chauhan)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
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18
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Higher risk of hemorrhage and maternal morbidity in vaginal birth after second stage of labor C-section. Arch Gynecol Obstet 2021; 305:1431-1438. [DOI: 10.1007/s00404-021-06254-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
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19
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Gupta T, Singal K, Gupta N, Kohli S, Kanyal M. Comparative Study of USG and MRI in Evaluation of Isthmocele. J Obstet Gynaecol India 2021; 71:292-296. [PMID: 34408349 DOI: 10.1007/s13224-021-01433-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022] Open
Abstract
Objective To study the presence of isthmocele in post-cesarean women using USG and MRI and its correlation with risk factors. Method This was a prospective observational study. A total of 90 patients were enrolled at the time of discharge of cesarean delivery and were advised to come for follow-up at 3-4 months for detection of isthmocele. A total of 82 patients reported for follow-up, and TVS and MRI Pelvis were done for visualization of isthmocele. If isthmocele was diagnosed, its correlation with risk factors was studied. Results On TVS isthmocele was present in 11 patients and on MRI in 16 patients. Detection rate was 77.07% in comparison with previous studies. Compared to MRI, sensitivity of USG was 68.75%; however, the specificity and positive predictive value for both were 100%. The negative predictive value for USG compared to MRI was 92.96%. Shape of the isthmocele was triangular in most women. Obesity, prior history of cesarean delivery, elective cesarean, gestational diabetes, preeclampsia and prolonged active labor were associated with development of isthmocele. Conclusion The study concluded that yield of diagnosis of isthmocele by MRI was better than TVS but not statistically significant. Further study with large sample size is needed to identify the best tool for diagnosis of isthmocele. Obesity, gestational diabetes, preeclampsia, prior history of cesarean, elective cesarean and prolonged active labor were associated with development of isthmocele.
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Affiliation(s)
- Taru Gupta
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Khushbu Singal
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Nupur Gupta
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Supreeti Kohli
- Department of Radiology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Monica Kanyal
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
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20
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Stegwee SI, Ben ÂJ, El Alili M, van der Voet LF, de Groot CJM, Bosmans JE, Huirne JAF. Cost-effectiveness of single-layer versus double-layer uterine closure during caesarean section on postmenstrual spotting: economic evaluation alongside a randomised controlled trial. BMJ Open 2021; 11:e044340. [PMID: 34215598 PMCID: PMC8256741 DOI: 10.1136/bmjopen-2020-044340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of double-layer compared with single-layer uterine closure after a first caesarean section (CS) from a societal and healthcare perspective. DESIGN Economic evaluation alongside a multicentre, double-blind, randomised controlled trial. SETTING 32 hospitals in the Netherlands, 2016-2018. PARTICIPANTS 2292 women ≥18 years undergoing a first CS were randomly assigned (1:1). Exclusion criteria were: inability for counselling, previous uterine surgery, known menstrual disorder, placenta increta or percreta, pregnant with three or more fetuses. 1144 women were assigned to single-layer and 1148 to double-layer closure. We included 1620 women with a menstrual cycle in the main analysis. INTERVENTIONS Single-layer unlocked uterine closure and double-layer unlocked uterine closure with the second layer imbricating the first. MAIN OUTCOME MEASURES Spotting days, quality-adjusted life-years (QALYs), and societal costs at 9 months of follow-up. Missing data were imputed using multiple imputation. RESULTS No significant differences were found between single-layer versus double-layer closure in mean spotting days (1.44 and 1.39 days; mean difference (md) -0.056, 95% CI -0.374 to 0.263), QALYs (0.663 and 0.658; md -0.005, 95% CI -0.015 to 0.005), total healthcare costs (€744 and €727; md €-17, 95% CI -273 to 143), and total societal costs (€5689 and €5927; md €238, 95% CI -624 to 1108). The probability of the intervention being cost-effective at willingness-to-pay of €0, €10 000 and €20 000/QALY gained was 0.30, 0.27 and 0.25, respectively, (societal perspective), and 0.55, 0.41 and 0.32, respectively, (healthcare perspective). CONCLUSION Double-layer uterine closure is not cost-effective compared with single-layer uterine closure from both perspectives. If this is confirmed by our long-term reproductive follow-up, we suggest to adjust uterine closure technique guidelines. TRIAL REGISTRATION NUMBER NTR5480/NL5380.
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Affiliation(s)
- Sanne I Stegwee
- Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ângela J Ben
- Health Sciences, Amsterdam Public Health, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Mohamed El Alili
- Health Sciences, Amsterdam Public Health, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Christianne J M de Groot
- Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Judith E Bosmans
- Health Sciences, Amsterdam Public Health, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Judith A F Huirne
- Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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21
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Torre A, Verspyck E, Hamamah S, Thomassin I, Thornton J, Fauconnier A, Crochet P. [Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]. ACTA ACUST UNITED AC 2021; 49:858-868. [PMID: 34144220 DOI: 10.1016/j.gofs.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche. METHODS Review of the literature, critical reflection, and pragmatic advice. RESULTS There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases. CONCLUSIONS A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.
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Affiliation(s)
- A Torre
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Maternity building of the City Hospital, Hucknall Road, NG5 1PB Nottingham, Royaume-Uni; Service de gynécologie-obstétrique, CHU de Rouen, Université de Rouen, Rouen, France.
| | - E Verspyck
- Service de gynécologie-obstétrique, CHU de Rouen, Université de Rouen, Rouen, France
| | - S Hamamah
- Univ Montpellier, Inserm U1203, EmbryoPluripotency, Montpellier, France; IRMB, Univ Montpellier, Inserm, Montpellier, France; CHU Montpellier, ART/PGD Department, Arnaud de Villeneuve Hospital, Montpellier, France
| | - I Thomassin
- Department of Imaging, Hopital Tenon, AP-HP, 75020 Paris, France
| | - J Thornton
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Maternity building of the City Hospital, Hucknall Road, NG5 1PB Nottingham, Royaume-Uni
| | - A Fauconnier
- Department of Biology, Medicine and Health, Research unit EA7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, Versailles St-Quentin University, Montigny-le-Bretonneux, France; Department of Gynecology and Obstetrics, Intercommunal Hospital Center of Poissy-St Germain en Laye, Poissy, France
| | - P Crochet
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Marseille, La Conception Hospital, Aix Marseille Université, Marseille, France
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22
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Al Naimi A, Jennewein L, Mouzakiti N, Louwen F, Bahlmann F. The effect of the onset of labor on the characteristics of the cesarean scar. Int J Gynaecol Obstet 2021; 157:322-326. [PMID: 34077556 DOI: 10.1002/ijgo.13775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/19/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the effect of cesarean section (CS) timing, elective versus unplanned, on the residual myometrial thickness (RMT) and CS scars. METHODS This is a prospective single-blinded observational cohort study with 186 observations. Patients indicated to undergo first singleton CS were preoperatively recruited. Exclusion criteria were history of repeated CS, vertical hysterotomy, diabetes, and additional uterine surgeries. Sonographic examination was performed for assessing the RMT ratio, the presence of a niche, fibrosis, and the distance from the scar to the internal os (SO) 1 year after CS. Power analysis was performed with 0.05 α, 0.1 β, and all statistical analyses were conducted with Stata® . RESULTS Wilcoxon rank-sum test for the association between CS timing, RMT ratio and SO showed Z values of -0.59 and -4.94 (P = 0.553 and P < 0.001), respectively. There was no association between CS timing and niches and fibrosis (P > 0.99 and P = 0.268, respectively). Linear regression between SO and the extent of cervical dilatation showed a -0.45 β (95% confidence interval -0.68 to -0.21) and a 10.22-mm intercept (P < 0.001). CONCLUSION RMT is independent of the timing of CS, but the SO distance shows a negative linear relationship with the cervical dilatation.
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Affiliation(s)
- Ammar Al Naimi
- Department of Obstetrics and Gynecology, Goethe University Frankfurt am Main, University Hospital, Frankfurt, Hessen, Germany.,Department of Obstetrics and Gynecology, Buergerhospital-Dr. Senckenbergische Stiftung, Frankfurt, Hessen, Germany
| | - Lukas Jennewein
- Department of Obstetrics and Gynecology, Goethe University Frankfurt am Main, University Hospital, Frankfurt, Hessen, Germany
| | - Niki Mouzakiti
- Department of Obstetrics and Gynecology, Buergerhospital-Dr. Senckenbergische Stiftung, Frankfurt, Hessen, Germany
| | - Frank Louwen
- Department of Obstetrics and Gynecology, Goethe University Frankfurt am Main, University Hospital, Frankfurt, Hessen, Germany
| | - Franz Bahlmann
- Department of Obstetrics and Gynecology, Buergerhospital-Dr. Senckenbergische Stiftung, Frankfurt, Hessen, Germany
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23
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Gull B, Klerelid V, Jormeus A, Strandell A. Potential risk factors for caesarean scar pregnancy: a retrospective case-control study. Hum Reprod Open 2021; 2021:hoab019. [PMID: 33959686 PMCID: PMC8087894 DOI: 10.1093/hropen/hoab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/22/2021] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What are the important risk factors for having a caesarean scar pregnancy (CSP)? SUMMARY ANSWER Independent risk factors were smoking in the first trimester, higher parity, and previous caesarean section (CS) before the index caesarean delivery. WHAT IS KNOWN ALREADY A spectrum of risk factors for CSP has been suggested but not proven: parity, number of previous caesarean section, elective as opposed to emergency CS, IVF-pregnancy, breech presentation, previous gynaecological surgery as well as suture technique. STUDY DESIGN SIZE DURATION This retrospective case-control study included 31 women with a CSP during the period 2003-2018 treated at a tertiary care centre for gynaecology and reproduction. A control cohort of 8300 women with a history of a CS and a subsequent delivery during the same time period was formed. PARTICIPANTS/MATERIALS SETTING METHODS Variables describing demography, lifestyle factors, and reproductive and obstetric history were retrieved from medical records and the obstetric hospital database. Logistic regression analyses were applied to identify potential risk factors. MAIN RESULTS AND THE ROLE OF CHANCE In a multivariable analysis, smoking in first trimester (adjusted odds ratio (OR) 3.03, 95% CI 1.01-9.07), higher parity (adjusted OR 1.30, 95% CI 1.03-1.64) and previous CS in addition to the preceding CS (adjusted OR 3.43, 95% CI 1.35-8.66) were independently predictive of a CSP. An elective CS at the index pregnancy was associated with an increased risk of CSP but did not remain significant in the multivariable analysis. LIMITATIONS REASONS FOR CAUTION CSP is a very rare phenomenon and several of the risk factor estimates are imprecise. Nevertheless, significant risk factors could be identified. Another limitation is the lack of electronically recorded details on suture techniques. WIDER IMPLICATIONS OF THE FINDINGS The identified factors, namely higher parity and previous CS before the index caesarean section, are in accordance with previously suggested risk factors. Whether there is a true risk association between elective CS and future CSP needs to be investigated further. Smoking in the first trimester is a new finding, which has a plausible rationale. These factors should be recognised when counselling women after a caesarean delivery, particularly in a subsequent pregnancy with early complications. STUDY FUNDING/COMPETING INTERESTS This work was supported by a grant from the Swedish state under the agreement between the Swedish government and the county councils the ALF-agreement (ALFGBG-720291). None of the authors has any conflict of interest to declare.
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Affiliation(s)
- B Gull
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - V Klerelid
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - A Jormeus
- Department of Gynecology, Närhälsan Kungshöjd, Gothenburg, Region Västra Götaland, Sweden
| | - A Strandell
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden.,Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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24
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Kamel R, Eissa T, Sharaf M, Negm S, Thilaganathan B. Position and integrity of uterine scar are determined by degree of cervical dilatation at time of Cesarean section. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:466-470. [PMID: 32330331 DOI: 10.1002/uog.22053] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/02/2020] [Accepted: 04/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Abnormal placental invasion is more common after an elective Cesarean delivery, suggesting that prelabor Cesarean section (CS) increases the likelihood of the CS scar being above the internal cervical os and predisposing to a scar pregnancy in the future. The aim of this study was to assess the location and integrity of the CS scar in postpartum women delivered by CS at different stages of labor. METHODS This was a prospective cohort study of women at term who underwent a CS for the first time. In all women, cervical dilatation was determined by digital examination at the time of the CS. All patients had a transvaginal ultrasound examination to assess the location of the CS scar in relation to the internal cervical os, as well as the presence of a scar niche. RESULTS A total of 407 pregnant women were recruited into the study: 103 with cervical dilatation ≤ 2 cm, 261 with cervical dilatation 3-7 cm and 43 with cervical dilatation ≥ 8 cm at the time of the CS. A statistically significant correlation was observed between cervical dilatation at the time of the CS and the position of the CS scar. The scar was positioned in the uterus above the internal cervical os in 97.1% (100/103) of women delivered at a cervical dilatation of 0-2 cm, whereas the scar was located at or below the internal cervical os in 97.7% (42/43) of cases delivered at a cervical dilatation of 8-10 cm (P < 0.001). A uterine-scar defect (niche) was observed in 38.1% (64/168) of women with the scar located above, compared with 18.0% (43/239) of those with the scar situated at or below, the internal cervical os (P < 0.001). CONCLUSIONS Prelabor and early-labor Cesarean delivery are associated with an increased prevalence of a scar in the uterine cavity as well as a scar niche. CS in late labor is associated with the uterine scar being situated in the endocervical canal and with a lower incidence of a niche. The position and integrity of the CS scar after prelabor and early-labor Cesarean delivery explain the predisposition to abnormal placental invasion in subsequent pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Kamel
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Kasr Al-Ainy University Hospital, Egypt
| | - T Eissa
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Kasr Al-Ainy University Hospital, Egypt
| | - M Sharaf
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Kasr Al-Ainy University Hospital, Egypt
| | - S Negm
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Kasr Al-Ainy University Hospital, Egypt
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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25
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Bitensky S, Pariente G, Rotem R, Sergienko R, Weintraub AY. Risk for complications in the subsequent pregnancy following first versus second-stage cesarean delivery: 25 years follow-up in a large cohort. J Matern Fetal Neonatal Med 2021; 35:4485-4490. [PMID: 33455467 DOI: 10.1080/14767058.2020.1852211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cesarean delivery is a prevalent procedure worldwide, and an established risk factor for subsequent pregnancies. AIMS To examine if a prior cesarean delivery due to first vs. second stage non-progressive labor carries different risk profiles for adverse outcomes in the subsequent pregnancy. MATERIALS AND METHODS A retrospective cohort study, based on data accumulated over the years 1988-2013 at the Soroka University Medical Center. We compared pregnancy complications and adverse perinatal outcomes in subsequent delivery following a cesarean delivery due to first vs. second stage non-progressive labor. Multiple logistic regression models were constructed. RESULTS There were 3828 subsequent deliveries of patients who underwent prior cesarean delivery due to first vs. second stage non-progressive labor, 2791 (72.91%) and 1037 (27.09%), respectively. Patients with a prior cesarean delivery due to first stage non-progressive labor were more likely to have hypertensive disorders of pregnancy (7.4% vs 3.8% in first vs. second stage non-progressive labor, respectively, p = .002), and repeated cesarean delivery at the subsequent pregnancy (70% vs 62% in first vs. second stage non-progressive labor, respectively, p < .001). Patients with prior cesarean delivery due to second stage non-progressive labor were more likely to have preterm birth (10% vs 6.8% in second vs. first stage non-progressive labor, respectively, p = .001). Prior cesarean delivery due to first stage non-progressive labor was independently associated with a recurrent cesarean delivery in the subsequent pregnancy. In addition, prior cesarean delivery due to second stage non-progressive labor was independently associated with preterm birth. CONCLUSIONS Cesarean delivery due to first stage non-progressive labor carries higher rates of hypertensive disorders of pregnancy and recurrent cesarean delivery in the subsequent pregnancy. Prior cesarean delivery due to second stage non-progressive labor carries higher rates of subsequent preterm birth.
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Affiliation(s)
- Shira Bitensky
- Faculty of Health Sciences, Joyce & Irving Goldman Medical School, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Gali Pariente
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, affiliated with the Hebrew University Medical School of Jerusalem, Jerusalem, Israel
| | - Ruslan Sergienko
- Advanced Data Management & Statistical Programming Services for Academic & Clinical Research. Faculty of Health Sciences, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Adi Yehuda Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
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26
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Stegwee SI, van der Voet LF, Ben AJ, de Leeuw RA, van de Ven PM, Duijnhoven RG, Bongers MY, Lambalk CB, de Groot C, Huirne J. Effect of single- versus double-layer uterine closure during caesarean section on postmenstrual spotting (2Close): multicentre, double-blind, randomised controlled superiority trial. BJOG 2020; 128:866-878. [PMID: 32892392 PMCID: PMC7983985 DOI: 10.1111/1471-0528.16472] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate whether double-layer uterine closure after a first caesarean section (CS) is superior compared with single-layer uterine closure in terms of postmenstrual spotting and niche development in the uterine caesarean scar. DESIGN Multicentre, double-blind, randomised controlled superiority trial. SETTING Thirty-two hospitals in the Netherlands. POPULATION A total of 2292 women aged ≥18 years undergoing a first CS were randomly assigned to each procedure (1:1): 1144 women were assigned to single-layer uterine closure and 1148 women were assigned to double-layer uterine closure. METHODS Single-layer unlocked closure and double-layer unlocked closure, with the second layer imbricating the first. MAIN OUTCOME MEASURES Number of days with postmenstrual spotting during one menstrual cycle 9 months after CS. SECONDARY OUTCOMES perioperative and menstrual characteristics; transvaginal ultrasound measurements. RESULTS A total of 774 (67.7%) women from the single-layer group and 770 (67.1%) women from the double-layer group were evaluable for the primary outcome, as a result of drop-out and amenorrhoea. The mean number of postmenstrual spotting days was 1.33 (bootstrapped 95% CI 1.12-1.54) after single-layer closure and 1.26 (bootstrapped 95% CI 1.07-1.45) after double-layer closure (adjusted mean difference -0.07, 95% CI -0.37 to 0.22, P = 0.810). The operative time was 3.9 minutes longer (95% CI 3.0-4.9 minutes, P < 0.001) and niche prevalence was 4.7% higher (95% CI 0.7-8.7%, P = 0.022) after double-layer closure. CONCLUSIONS The superiority of double-layer closure compared with single-layer closure in terms of postmenstrual spotting after a first CS was not shown. Long-term obstetric follow-up of our trial is needed to assess whether uterine caesarean closure guidelines should be adapted. TWEETABLE ABSTRACT Double-layer uterine closure is not superior for postmenstrual spotting after a first caesarean; single-layer closure performs slightly better on other outcomes.
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Affiliation(s)
- S I Stegwee
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - L F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, the Netherlands
| | - A J Ben
- Department of Health Sciences, Amsterdam Public Health, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - P M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - R G Duijnhoven
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - M Y Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Research School Grow Maastricht University, Veldhoven, the Netherlands
| | - C B Lambalk
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cjm de Groot
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - Jaf Huirne
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
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27
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Donnez O. Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased. Fertil Steril 2020; 113:704-716. [PMID: 32228874 DOI: 10.1016/j.fertnstert.2020.01.037] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/17/2020] [Accepted: 01/29/2020] [Indexed: 02/01/2023]
Abstract
Around 20% of pregnant women undergo cesarean section (CS), and in most regions of the world CS rates continue to grow. There is still no clear definition of what is considered a normal physiologic aspect of a CS scar and what is abnormal. Cesarean scar defects (CSDs) should be suspected in women presenting with spotting, dysmenorrhea, pelvic pain, or infertility and a history of CS. CSDs can be visualized with the use of hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be contemplated according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and residual myometrium thickness (RMT) measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique if the RMT is <3 mm, in which case repair is essential and can be achieved by only laparoscopic or vaginal approach. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made. Because prevention is better than cure, risk factors should be identified early to ensure appropriate management.
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Affiliation(s)
- Olivier Donnez
- Institut du Sein et de Chirurgie Gynécologique d'Avignon, Polyclinique Urbain V (Elsan Group), Avignon, France; and Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
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28
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di Pasquo E, Kiener AJO, DallAsta A, Commare A, Angeli L, Frusca T, Ghi T. Evaluation of the uterine scar stiffness in women with previous Cesarean section by ultrasound elastography: A cohort study. Clin Imaging 2020; 64:53-56. [PMID: 32325262 DOI: 10.1016/j.clinimag.2020.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE To evaluate by means of elastography if the quantitative assessment of the cesarean scar elasticity is feasible using as reference the surrounding intact myometrium and to investigate if the cesarean scar stiffness is influenced by the clinical characteristics of the previous cesarean delivery. METHODS Prospective study including women with a previous Cesarean Section (CS) ≥ 37 weeks' gestation performed 12-15 months before. By transvaginal ultrasound two regions of interest (ROI) were selected: uterine scar (Region 1) and surrounding myometrium (Region 2). Strain index (SI) for each ROI was calculated and the Strain Ratio (SR) was defined as Region 1 SI/Region 2 SI. The primary outcome was to compare SR among women who were grouped in accordance to presence of previous vaginal delivery, CS during labor, type of suture or pyrexia during post-partum. The secondary outcome of this study was to evaluate the correlation between SR and maternal, neonatal and labor characteristics. RESULTS 68 women were included. The mean SR was 1.8 ± 0.7 thus indicating an increased stiffness of the uterine scar compared to the surrounding myometrium. No significant differences were found in terms of SR according to presence of previous VD, CS during labor, type of suture or pyrexia during post-partum period. Strain Ratio was not correlated to maternal characteristics nor to labor and neonatal outcome. CONCLUSIONS Evaluation of uterine scar stiffness is feasible by using elastography. The stiffness of the uterine scar is higher than that of the surrounding myometrium and is not correlated to maternal and labor characteristics.
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Affiliation(s)
- Elvira di Pasquo
- Department of Obstetrics and Gynecology, University of Parma, Italy
| | | | - Andrea DallAsta
- Department of Obstetrics and Gynecology, University of Parma, Italy
| | - Arianna Commare
- Department of Obstetrics and Gynecology, University of Parma, Italy
| | - Laura Angeli
- Department of Obstetrics and Gynecology, University of Parma, Italy
| | - Tiziana Frusca
- Department of Obstetrics and Gynecology, University of Parma, Italy
| | - Tullio Ghi
- Department of Obstetrics and Gynecology, University of Parma, Italy.
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Townsend R, Duffy JMN, Khalil A. Increasing value and reducing research waste in obstetrics: towards woman-centered research. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:151-156. [PMID: 30980569 DOI: 10.1002/uog.20294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/24/2019] [Accepted: 04/05/2019] [Indexed: 06/09/2023]
Affiliation(s)
- R Townsend
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J M N Duffy
- Balliol College, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Glazewska‐Hallin A, Story L, Suff N, Shennan A. Late-stage Cesarean section causes recurrent early preterm birth: how to tackle this problem? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:293-296. [PMID: 30937984 PMCID: PMC6771870 DOI: 10.1002/uog.20276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 06/09/2023]
Affiliation(s)
- A. Glazewska‐Hallin
- Department of Women and Children's HealthKing's College London, St Thomas' HospitalLondonUK
| | - L. Story
- Department of Women and Children's HealthKing's College London, St Thomas' HospitalLondonUK
| | - N. Suff
- Department of Women and Children's HealthKing's College London, St Thomas' HospitalLondonUK
| | - A. Shennan
- Department of Women and Children's HealthKing's College London, St Thomas' HospitalLondonUK
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