Cesarean delivery scar

Incomplete healing of the uterine incision after elective second cesarean section

PURPOSE

To evaluate the possible associations between the single-layer locked- and unlocked-uterine closure technique and closure area biometry, and cesarean scar healing in recurrent cesarean section.

MATERIAL AND METHODS

In this randomized prospective study, elective second cesarean section of 120 singleton pregnant women were randomized into the single-layer locked- and unlocked-continuous uterus closure technique. During the operation, the upper and lower edge thickness of the uterine incision were measured. In order to evaluate the healing in the cesarean scar area, all women were examined with vaginal ultrasonography 6-8 months after the cesarean section. The possible associations between locked- and unlocked-uterine closure technique and closure area biometry and cesarean scar healing were evaluated.

RESULTS

After the drop-outs, a total of 86 women, 45 in the locked-continuous closure group and 41 in the unlocked-continuous closure group were evaluated. There was no statistically significant difference between the groups in terms of demographic and clinical parameters, such as perioperative uterine closure area biometry, need for additional suture, duration of operation and amount of bleeding. However, a significantly greater number of additional sutures for hemostasis was necessary in the unlocked-continuous compared to the locked-continuous closure group. The rate of cesarean scar defect (CSD) and residual myometrium thickness were comparable whereas the healing rate was significantly higher in the locked-continuous closure group compared to the unlocked-continuous closure group (0.71 ± 0.90 vs. 0.64 ± 0.10, p = .032). In women with CSD, the lower edge was 4 mm thinner than the women without CSD (10.48 ± 6.13 mm vs. 14.53 ± 7.13 mm, p = .006). Moreover, the thickness difference between the lower and upper edge was significantly greater if CSD was present compared to the absence of CSD (5.88 ± 4.04 mm vs. 3.70 ± 3.00 mm, p = .006).

CONCLUSIONS

There was no association between CSD and locked versus unlocked suture technique used for the closure of uterine incision in the second cesarean section. The biometric evaluation of the scar area has shown that the thin lower wound edge and unevenness between the lower and the upper wound edges may play a role in incomplete healing of the uterine incision.

Niches after cesarean section in a population seeking hysteroscopic sterilization

OBJECTIVE

To study the prevalence of hysteroscopically evaluated disruptions of the integrity of the uterine wall ('niches') in women with and without a previous cesarean section.

STUDY DESIGN

A prospective cohort study was performed in a teaching hospital in the Netherlands. Women seeking hysteroscopic sterilization were included. A hysteroscopic evaluation of the anterior wall of the uterus and cervix to identify the existence of disruptions (niches) was performed in a standard manner. Primary outcome was the presence of a uterine niche, defined as any visible defect, disruption, or concavity (gap) in the anterior wall. Secondary outcome was to develop a registration form of niche features for hysteroscopic evaluation.

RESULTS

In total, 713 women were included, 603 without and 110 with a previous cesarean section. In women with a previous cesarean Section 83 (75%) niches were observed using hysteroscopy. Anterior wall disruptions were not observed in women without a cesarean section. The following niche features were identified and incorporated in a registration form: polyps, cysts, myometrium defect, fibrotic tissue, (abnormal) vascular pattern, lateral branches, mucus production inside the defect, and bleeding.

CONCLUSION

In a prospective cohort study among women undergoing hysteroscopic sterilization, a uterine niche could be detected by hysteroscopy in 75% of women with a previous cesarean section.

Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position

OBJECTIVES

To determine the prevalence of clinical symptoms associated with Cesarean scar defects, and to determine the association between the size of these defects, clinical complaints, uterine position, and a history of multiple Cesarean sections.

METHODS

In this cross-sectional study, Cesarean scar defects in women with a history of transverse lower-segment Cesarean section were measured by transvaginal ultrasound while being assessed for other gynecological conditions. The relationships between the size of the Cesarean scar defect and the clinical symptoms, uterine position and number of previous Cesarean sections were evaluated. Patients with other uterine pathologies, including endometrial hyperplasia, polyps, malignancy and submucosal myomas, were excluded from the study.

RESULTS

During a 3-year period, 4250 women were assessed by transvaginal sonography, of whom 293 (6.9%) were diagnosed with Cesarean scar defects. Eighty-six patients were excluded due to other uterine pathologies. Altogether, 207 patients with Cesarean scar defects were included in this study. Women who had undergone multiple Cesarean sections tended to have larger scar defects (in width and depth) than did those who had undergone a single Cesarean section. Women with retroflexed uteri also tended to have wider defects than those with anteflexed uteri. Defect width was significantly greater in women with postmenstrual spotting, dysmenorrhea and chronic pelvic pain.

CONCLUSIONS

Multiple Cesarean sections and retroflexed uteri are risk factors for larger Cesarean scar defects. The size of the Cesarean scar defect is associated with clinical symptoms such as postmenstrual spotting, dysmenorrhea and chronic pelvic pain.

Placenta Accreta: A Review of Current Advances in Prenatal Diagnosis

Placenta accreta is a life-threatening obstetrical condition requiring a multidisciplinary approach. Despite identified obstetrical risk factors, the diagnosis is often made at the time of delivery. Recent advances in biology could allow a prenatal screening of placenta accreta with the identification of biological markers in maternal blood including cell-free fetal DNA, placental mRNA, and DNA microarray. These promising technologies can detect the presence of anomalies and should play a future role in developing a better understanding of placental invasion. Ultrasound imaging is popular due to its low cost and accessibility and widely used for the screening of placenta location and potential abnormal development. This exam is associated with high sensitivity and specificity for diagnosis of placenta accreta when specific defined criteria are used for the diagnosis. A placental MRI provides a morphological description, as well as recently demonstrated topographical information that optimizes diagnosis and surgical management. The screening of placenta accreta should be improved with the use of a combination of these diagnostic techniques and benefit high-risk populations with a reduction in morbidity.

Three-dimensional power Doppler ultrasound diagnosis and conservative treatment of ectopic pregnancy in a cesarean section scar

OBJECTIVE

To describe three-dimensional ultrasonographic features of an ectopic pregnancy in a cesarean scar.

DESIGN

Description of a case.

SETTING

Case report of one patient.

PATIENT(S)

A 38-year-old women with three previous cesarean deliveries.

INTERVENTION(S)

Three-dimensional ultrasonography was performed for diagnosis and treatment.

MAIN OUTCOME MEASURE(S)

Local administration of methotrexate under ultrasonographic guidance.

RESULT(S)

Ultrasonographic study revealed a gestational sac in the anterior wall of the uterine isthmus with peritrophoblastic flow. It was treated conservatively and successfully with local methotrexate administration under ultrasonographic guidance.

CONCLUSION(S)

The early diagnosis of ectopic cesarean scar pregnancy allows the conservative treatment with local administration of methotrexate under ultrasonographic guidance.

Vaginal Ultrasonographic and Hysterosonographic Evaluation of the Low Transverse Incision after Caesarean Section: Correlation with Gynaecological Symptoms

AIM

We investigated whether there is a correlation between morphological changes of the lower uterine segment after caesarean section (CS), visualized by means of either a transvaginal sonography (TVS) or a sonohysterography (SHG), and the frequency of abnormal uterine bleedings reported by the women.

METHODS

By means of a random selection of our population, anamnesis, medical records, and TVS and SHG images of the lower uterine segment were collected in 217 women (116 with previous CS and 101 with previous vaginal birth), and an observational case-control study was performed.

RESULTS

The uterine incision was identified in almost all women after CS (102/116) using TVS. It was observed that abnormal uterine bleeding was significantly more frequent in the CS group in comparison with the group of women who delivered vaginally. A correlation between the presence of abnormal uterine bleeding and the presence of significant sonographic findings in the lower uterine transverse incision in the women after CS was found. In the CS group, TVS findings were confirmed by those obtained by SHG, and, with this technique, a triangular anechoic area at the presumed site of incision (the niche) was identified in 69 of the 116 women (59.5%).

CONCLUSIONS

In this study, we found a correlation between abnormal uterine bleeding and sonographic findings in women after CS. This correlation appears to be more significant in women who had CS 5-10 years ago. A significant difference exists between the CS group and the group of women who delivered vaginally for both frequency of abnormal uterine bleeding and sonographic findings.

Incomplete healing of the uterine incision after caesarean section: Is it preventable?

OBJECTIVE

To find out whether a change in suturing technique might affect the healing of the uterine scar after caesarean section (CS).

STUDY DESIGN

In this randomised prospective study, 78 term pregnant patients delivered by CS were allocated to two different suturing techniques either including or excluding the endometrial layer. The integrity of the uterine incision was checked by ultrasound 40-42 days after the operation. Any deviation from the full thickness apposition of the anterior uterine wall (with the ratio: [anterior wall thickness/(anterior wall thickness+height of the wedge shaped defect)]<1) was considered to represent incomplete healing. Both groups were then compared in terms of the frequency of incomplete healing. Chi square and Student's t-test were used where appropriate. A logistic regression model was used to adjust for confounding factors.

RESULTS

The frequency of incomplete healing was significantly lower in the group treated by full thickness suturing (44.7% versus 68.8%); (OR: 2.718; CI: 1.016-7.268). Similarly the mean values for the incomplete healing ratio were 0.77+/-0.17 and 0.86+/-0.17 (p = 0.03) in split and full thickness groups, respectively. After adjusting for other confounding factors the suture technique still remained as a significant determinant of the incisional healing (p = 0.04).

CONCLUSION

By selecting full thickness suturing technique one may significantly lower the incidence of incomplete healing of the uterine incision after CS.

Sonographic imaging of cervical scars after Cesarean section

OBJECTIVE

To investigate whether uterine contractions at the time of a Cesarean section have an impact on future presence and location of a cervical Cesarean scar.

METHODS

A targeted transvaginal ultrasound examination of the fetus, uterus and cervix was done in 2973 consecutive women at 14-16 weeks' gestation. The sonographer was blinded to the women's previous obstetric histories. The presence and location of a sonographic cervical hypoechogenic line, which probably represented a Cesarean scar, was recorded.

RESULTS

There were 180 women with a previous Cesarean section performed before the start of uterine contractions and 173 with a Cesarean section performed during contractions in labor. The cervical hypoechogenic line was more common in sections performed during contractions (75.7% vs. 52.7%; P < 0.001) and was more distally located from the internal os (17.9 +/- 9.4 vs. 14.6 +/- 9.1 mm; P = 0.01). A hypoechogenic line was observed in 21/2620 women without a previous Cesarean section, representing a false-positive rate of 0.8%.

CONCLUSION

Cesarean sections, especially those done during uterine contractions, are actually performed through cervical tissue. This finding is in agreement with the physiological process of cervical effacement during contractions.

Cesarean section scar evaluation by saline contrast sonohysterography

OBJECTIVE

To investigate the frequency of images suggesting the existence of a dehiscence at the site of the uterine scar after Cesarean section.

METHODS

Thirty-three women with a past history of Cesarean section who were planning a further pregnancy were involved in the study. Saline contrast sonohysterography (SCSH) was performed a minimum of 3 months following Cesarean section. The thickness of the residual myometrium, the thickness of the myometrium bordering the scar and the depth of the filling defect in the scar (i.e. the 'niche', defined as a triangular, anechoic area at the presumed site of incision) were recorded in each case. A 'dehiscence' was defined as a niche whose depth was at least 80% of the anterior myometrium.

RESULTS

In 19/33 (57.5%) patients a niche with a depth of 4.2 +/- 2.5 (range, 1.2-11.7) mm was identified. In these patients the residual myometrium measured 6.5 +/- 2.7 (range, 0-10.9) mm vs. 8.9 +/- 2.0 (range, 6.9-13.9) mm in the remaining 14 patients without a niche. Within the 19 niches, two dehiscences were identified.

CONCLUSION

Niches can be identified by SCSH following a Cesarean section in about 60% of patients. The prevalence of scar dehiscence (in the present series 2/33 or 6%) is much higher than the reported risk of uterine rupture (0.4%).

First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar

OBJECTIVE

To describe first-trimester ultrasound diagnosis and management of pregnancies implanted into uterine Cesarean section scars.

METHODS

All women referred for an ultrasound scan because of suspected early pregnancy complications were screened for pregnancies implanted into a previous Cesarean section scar. The management of Cesarean section scar pregnancies included transvaginal surgical evacuation, medical treatment with local injection of 25 mg methotrexate into the exocelomic cavity and expectant management.

RESULTS

Eighteen Cesarean section scar pregnancies were diagnosed in a 4-year period. The prevalence in the local population was 1 : 1800 pregnancies. Surgical treatment was used in eight women and it was successful in all cases. The respective success rates of medical treatment and expectant management were 5/7 (71%) and 1/3 (33%). Five women (28%) required blood transfusion and one woman (6%) had a hysterectomy.

CONCLUSIONS

Cesarean section scar pregnancies are more common than previously thought. When the diagnosis is made in the first trimester the prognosis is good and the risk of hysterectomy is relatively low.