Imaging findings of cesarean delivery complications: cesarean scar disease and much more

Outcomes of Image-Guided Percutaneous Drainage versus Other Management Strategies for Infected Post-Cesarean Section Bladder Flap Hematoma

PURPOSE

To evaluate the safety and effectiveness of percutaneous drainage in the management of infected post-cesarean section (CS) bladder flap hematomas (BFHs).

MATERIALS AND METHODS

This retrospective cohort study examined all post-CS imaging examinations performed between January 1, 1999, and April 1, 2022. Of 90,462 CSs performed, 255 patients underwent postpartum pelvic imaging. Images were assessed for BFH and features of infection. Infected BFH was defined by the presence of the systemic inflammatory response syndrome criteria for sepsis, with or without imaging features of infection. Data on treatment approach, outcomes, hospitalization duration, and readmission were obtained when available. The t-test was used for parametric data and Mann-Whitney U test was used for nonparametric data.

RESULTS

BFH was diagnosed in 56 (22%) of 255 patients, with a median age of 31 years (interquartile range, 26.8-35.0 years). Forty-five (80%) of 56 patients presented with infection and were treated either with antibiotics alone (26/45, 58%) or drainage procedures (19/45, 42%) combined with antibiotics (surgical [3/19, 16%] and percutaneous drainage [16/19, 84%]). Percutaneous drainage had a success rate of 94% (15/16). Conservative management with antibiotics alone also had a high success rate of 96% (25/26); however, 1 (4%) of 26 developed uterine scar dehiscence. The median lengths of hospital stay were 4 days (range, 1-12 days) for the antibiotic-only group and 6 days (range, 3-39 days) for the drainage group (P < .01). Readmission within 30 days occurred in 7 (27%) of 26 patients in the antibiotic group compared with 3 (19%) of 16 in the drainage group.

CONCLUSIONS

Percutaneous image-guided drainage is safe and highly effective in managing infected BFHs that do not respond to antibiotics with no increased risk of uterine scar dehiscence.

Conservative treatment of bladder flap hematoma complicated with uterine artery pseudoaneurysm after cesarean section via internal iliac artery embolization: a case report

BACKGROUND

Bladder flap hematoma (BFH) is a rare complication associated with cesarean section (CS). Its pathogenesis is linked to insufficient hemostasis and bleeding at the incision site, leading to the formation of a hematoma between the bladder and the lower uterine segment (LUS). To the best of the authors' knowledge, no specific protocols have been formulated to guide the treatment of BFH.

CASE PRESENTATION

A 29-year-old woman underwent an emergency CS due to relative cephalopelvic disproportion. Twenty-two hours after the CS, she developed pale red hematuria accompanied with a significant decrease in hemoglobin. The patient experienced two fainting episodes after standing and engaging in activity, along with vaginal bleeding. A bedside ultrasound revealed a 50 mm fluid-filled sonolucent area between the lower uterine segment (LUS) and bladder. Subsequently, the patient received conservative treatment with internal iliac artery embolization, antibiotics and blood transfusion, to avoid secondary laparotomy. The angiography and computer tomography examinations revealed the existence of uterine artery pseudoaneurysm and a large BFH. Her vital signs remained stable after the intervention and repeat ultrasonography demonstrated a significant reduction in the hematoma size.

CONCLUSIONS

Selective pelvic artery embolization as a conservative treatment can be a safe and effective option for large BFH, provided the patient remains clinically stable. This interventional therapy presents an innovative, non-surgical approach to a condition that is typically treated surgically and may carry the risk of irreparable complications.

Diagnostic yield of transvaginal ultrasonography versus saline: infused sonohysterography in the evaluation of post-cesarean section uterine niche

BACKGROUND

Caesarean section (CS) defects, also known as niches, refer to the discontinuity in the myometrium at the site of a previous CS. These niches pose a complication in over 50% of CS performed on Egyptian women. The primary method used to diagnose uterine niches is transvaginal ultrasound (TVU). In recent times, the use of TVU with saline- infused sonohysterography (SISH) has significantly improved the detection of uterine niches. Our objective was to assess the diagnostic performance of SISH compared to TVU in diagnosing uterine niches among non-pregnant women with previous cesarean sections (CS), by integrating the findings and demographic features of the participants.

METHODS

For this purpose, we conducted a cross-sectional study involving 60 non-pregnant women with a history of CS but without any known systemic cause. Each participant underwent TVU followed by SISH. We recorded and analyzed the dimensions (depth, length and width) of the niche, as well as the residual myometrial thickness (RMT) adjacent to the niche in both TVU and SISH. Additionally, we collected data on the patients' age and the number of previous CSs.

RESULTS

Our results showed that women with a CS niche detected by SISH had a significantly lower age compared to those detected by TVU. We also found a significant association between the number of previous CSs diagnosed by either TVU or SISH and the rate of CS niche detection, which increased with an increasing number of previous CSs. Furthermore, there was a significant difference in the depth, width, and residual myometrial thickness adjacent to the niche between the two procedures. All niche dimensions were significantly higher among women examined by SISH.

CONCLUSION

Our study confirms that SISH is a superior tool for assessing uterine niches in non-pregnant women with a history of CS compared to TVU. Furthermore, the combined approach of using both SISH and TVU eliminates the need for costly hysteroscopy.

Morphological and Molecular Peculiarities of Healing of Uterine Incision when Using Conditioned Media of Bone Marrow Stromal Cells Cultivated under Hypoxic Condition

We studied the effect of conditioned media (CM) from cultivated bone marrow stromal cells grown at 10% O2 on extracellular matrix and vascular component in the healing zone after surgical incision of the uterine wall in Sprague-Dawley rats (n=17). Control group (n=10) received no treatment. On days 5 and 15 after the surgery, the expression of CoL1a1, CoL4a, MMP9, TIMP1, and FGF2 genes was evaluated and a morphological study was carried out. On day 5, CoL1a1 expression, CD34+ cell content, and the area of newly formed tissue were lower in the experimental group. On day 15, the expression of MMP9, TIMP1, FGF2, and CoL1a1 genes in the control group was lower, while CD34+ cell content and area of healing zone were higher. Thus, the application of CM reduced the damage area and accelerated the recovery process after surgical full-thickness incision of the uterine wall.

Postpartum obstetric complications: a guide for radiologists

The puerperium refers to the 6-8 weeks following delivery, and is a dynamic period in which maternal anatomy and physiology are restored to their prepregnant state. Postpartum complications can be divided into non-obstetric and obstetric. The latter are the topic of this article and can be further classified as infectious, thrombotic, hemorrhagic or cesarean-related. Transvaginal US is often the initial modality in the evaluation of puerperal disorders. CT is probably the most valuable imaging technique when life-threatening conditions are suspected. Pelvic MRI is being increasingly used in cases of inconclusive findings or if further characterization is needed, especially in the setting of postsurgical complications or placental disorders. Diagnostic and interventional radiologists play a pivotal role in the evaluation and management of a variety of puerperal complications. Many of these conditions pose a diagnostic challenge, as imaging findings often overlap with normal postpartum changes, so keeping in mind the patient's clinical information is key.

Sonographic Assessment of Isthmocele and Its Obstetric Complications in Subsequent Pregnancies: A Pictorial Review

Cesarean scar defect represents a significant pathology attributed to the rising prevalence of cesarean deliveries. While not commonplace, these lesions can give rise to severe obstetric consequences during subsequent pregnancies. Given the potential complications, it is advisable to screen for uterine niches using transvaginal ultrasound (TVUS) or contrast-enhanced TVUS for individuals planning to conceive. Surgical repair and correction of these lesions can be crucial in averting obstetric and perinatal complications in future pregnancies. Furthermore, timely sonographic evaluation and reporting of isthmocele-related obstetric complications can help avoid serious issues.

The correlation between chronic endometritis and Caesarean scar diverticulum

PURPOSE

To investigate the risk factors for Caesarean Scar Diverticulum (CSD) with Chronic Endometritis (CE) and the correlation between CE and clinical symptoms of CSD.

METHODS

The frequency of CE in 44 patients with CSD who underwent surgical treatment and 20 control women who underwent total hysterectomy was assessed and the clinical symptoms in the presence and absence of CE were compared. In accordance with the presence of one or more CD138-positive plasma cells per high-power field, CE was classified as mild or severe group.

RESULTS

According to multivariate analysis, the presence of mild CE (OR 8.963, 95 % CI 2.177-36.907, p = 0.002) or severe CE (OR 21.773, 95 % CI 2.285-207.419, p = 0.007) was significantly associated with CSD. Mild CE (OR 12.390, 95 % CI 1.158-132.511, p = 0.037) or severe CE (OR 22.463, 95 % CI 1.657-304.541, P = 0.019) or depth of diverticulum (OR 1.294, 95 % CI 1.003-1.668, p = 0.047) was associated with prolonged menstruation in patients with CSD. The degree of CE in patients with CSD was positively correlated with the days of prolonged menstruation (r = 0.552, p < 0.001) and negatively correlated with haemoglobin level (r = -0.408, p = 0.038).

CONCLUSIONS

CE was associated with CSD and its clinical symptoms, including prolonged menstruation and decreased haemoglobin. The severity of clinical symptoms of CSD is associated with endometrial inflammation.

Uterine window and placenta accreta spectrum in a dichorionic, diamniotic twin gestation complicated by postpartum hemorrhage

Cesarean scar defects encompass a spectrum of separation of the uterine layers that increase risk of uterine rupture during labor and delivery. When coupled with the presence of placenta accreta spectrum, a condition characterized by abnormal adherence to or invasion of the myometrium by the placenta, the risk of life-threatening hemorrhage significantly increases. As rates of cesarean delivery increase, it is important to understand the imaging findings typical of both conditions. We present the case of a 30-year-old patient with a dichorionic, diamniotic twin gestation complicated by uterine window and placenta accreta spectrum.

Effect of previous caesarean section on reproductive and pregnancy outcomes after assisted reproductive technology: A systematic review and meta‑analysis

Pregnancies following previous caesarean section (CS) are associated with higher incidence of infections, postpartum haemorrhage and obstetric complications. The present study aimed to explore the effect of previous CS on reproductive, maternal and neonatal outcomes in women who underwent assisted reproductive techniques (ART). A systematic review and meta-analysis were conducted to assess reproductive and pregnancy outcomes following ART in women with and without a previous CS. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. Eligible language articles written in English, published up to October 2023, were identified in Medline, Google Scholar and Science Direct databases. The quality of the included studies was assessed using the Newcastle Ottawa Scale. A total of 19 articles, reporting on 13 different outcomes met the inclusion criteria. It was revealed that women with previous CS had 9% lower clinical pregnancy rates, 13% lower live birth rates, 11% lower implantation rates and 28% lower multiple pregnancy rates compared with women who had prior natural vaginal deliveries. Additionally, previous CS was associated with an 8-fold higher risk of difficult embryo transfers. No significant differences were noted in ectopic pregnancy rates, miscarriage rates or biochemical pregnancy rates. The present systematic review and meta-analysis demonstrated that previous CS is associated with decreased prospects of clinical pregnancy, live birth and successful embryo implantation during ART. The findings of the present study underscored the need to counsel women with prior CS regarding its potential impact on ART outcomes.

Clinical efficacy analysis of laparoscopic uterine artery pre-ligation combined with hysteroscopic curettage in the treatment of type II cesarean scar pregnancy

Objective

To explore and evaluate the clinical therapeutic effect of laparoscopic uterine artery pre-ligation combined with hysteroscopic curettage in the treatment of type II cesarean scar pregnancy.

Methods

This study analyzed the clinical data of patients with cesarean scar pregnancy (CSP) in the Maternal and Child Health Hospital of Hubei Province from 2018 to 2022. A total of 134 patients with type II cesarean section were enrolled, out of which 78 patients were included in the final analysis. Treatment included either uterine artery embolization (UAE) combined with hysteroscopic curettage (n = 37 patients) or laparoscopic uterine artery pre-ligation (LUAP) combined with hysteroscopic curettage (n = 41 patients). The demographic and clinical characteristics of these two groups were recorded, and their short- and long-term complications on follow-up were compared. For patients with subsequent fertility requirements, we followed up these patients for 2 years after surgery, then collected and analyzed the compared subsequent pregnancy outcome.

Results

We found no significant discrepancies in the success rate of operation, length of hospital stay, and intraoperative blood loss between the two different operation modes. The cost of LUAP was significantly lower than that of UAE. Furthermore, the incidence of short-term postoperative complications such as fever and pelvic pain was lower in patients treated with LUAP than in those treated with UAE. In terms of long-term postoperative complications, the recovery time for menstruation in the LUAP group (49.81 ± 11.47) was earlier than that in the UAE group (34.90 ± 7.41) (p < 0.05). Additionally, 4.9% of patients in the LUAP group had decreased menstrual flow, while 59% of patients in the UAE group had a marked decrease in menstrual flow, and the incidence and severity of intrauterine adhesions were significantly lower in the LUAP group than in the UAE group(p < 0.05). Consistent with the aforementioned observations, patients treated with LUAP had better postoperative re-pregnancy outcomes than those treated with UAE.

Conclusions

Based on the findings, LUAP combined with hysteroscopic curettage is a safe and effective surgical scheme for the treatment of type II CSPs. In addition, compared with UAE, LUAP is associated with a lower surgical cost, fewer short and long-term complications, and better postoperative pregnancy outcomes. Thus, it should be widely applied in patients with type II CSPs.

Increased bladder injury rate during emergency and repeat cesarean section

Objective

Bladder injury is one of the complications of cesarean section (CS). It is reported that the overall incidence of bladder injury is 0.22-0.44% of CS. It is, however, unclear what factors influence this rate. The aim of this study was to determine if there is a difference in bladder injury rate between scheduled and emergency CS, as well as in primary and repeat CS at a large metropolitan hospital that serves a population at high risk for obstetric complications. In addition, the use of urology consultation following bladder injury and whether demographic factors and labor characteristics affect the rate of bladder injury were investigated.

Material and Methods

A total of 8,488 records were reviewed (4,292 primary CS and 4,196 repeat CS) from January 1, 2013 to December 31, 2020. The incidence of bladder injury was calculated and the rate of intraoperative urology/urogynecology consultation was recorded. Then the association between bladder injury and intraoperative urology/urogynecology consultation and between bladder injury and maternal age, body mass index (BMI), and gestational age were compared.

Results

There was a significant increase in risk of bladder injury in repeat CS versus primary CS (p=0.01). There was also a significant increase in risk of bladder injury in emergency CS versus scheduled CS (p=0.04). Intraoperative urogynecology/urology consultations were significantly higher in the bladder injury versus no bladder injury groups (p<0.0001). Both emergency CS and repeat CS are predictors of bladder injury with odd ratios of 5.7 and 7.4, respectively.

Conclusion

These results add to the existing evidence that bladder injury is a rare complication in CS that may occur more often in women undergoing repeat or emergency CS than primary or scheduled CS. Given that the risk increases with repeat or emergency CS, patients should be made aware of such risks and surgeons should make careful intraoperative considerations with close postoperative follow-ups.

Cesarean scar niche, fertility and uterine rupture during labor - A retrospective study

OBJECTIVES

To determine how does a uterine niche diagnosed prior to conception, affects future fertility and obstetrical outcomes, in a group of patients with secondary infertility undergoing fertility treatments.

STUDY DESIGN

A retrospective case-control study was performed, recruiting patients after cesarean delivery, before fertility treatment. Using stored ultrasound photos and video loops, we determined niche's sonographic parameters during the preconception period and retrieved the fertility and obstetrical outcomes thereafter.

RESULTS

104 patients met the inclusion criteria, and 86 were available for analysis. 56 (65%) had uterine niches larger than 2 mm in depth, and 30 (34%) had a uterine scar of 2 mm or less. Demographic characteristics were not different between groups. No statistically significant differences were observed regarding rates of implantation and clinical pregnancy between the groups. There were four cases of cesarean scar rupture during failed trial of labor (TOLAC), all of which were in the group with larger than 2 mm niche (33% of all TOLAC cases in the respected group).

CONCLUSIONS

While it appears that pre-conception presence of uterine niches larger than 2 mm in depth does not adversely affect future fertility, these niches might serve as a risk factor for future uterine rupture during TOLAC.

A case report of an endometriosis cyst at cesarean scar defect and review of literature

BACKGROUND

Cesarean scar defect (CSD) presents as a cystic defect that connects the uterine cavity at the site of the previous cesarean section (CS). Endometriosis refers to the discovery of endometrial glands and stroma outside the uterine cavity. Cases of endometriosis cysts at CSD have not been reported.

CASE PRESENTATION

In this article, we will present a patient with an endometriosis cyst at CSD with symptoms of a prolonged menstrual cycle, periods without cyclic abdominal pain, and a history of cesarean delivery. The gynecologic ultrasound showed a CSD and a mixed mass in the right front of the uterus. After about 1 month, the tumor grew from a diameter of 4.75 cm to 8.06 × 6.23 × 3.66 cm. The patient eventually had an operation, which revealed a mass protruding from the incision in the anterior uterine wall, which was attached to the anterior uterine wall by a thin tip with a smooth surface. Intraoperative rapid cytopathology suggested that endometrial glands were seen within the smooth muscle tissue, similar to endometriosis. Subsequently, the patient underwent resection of the endometriotic cyst. Final paraffin pathology showed smooth muscle with visible endometrial glands and old hemorrhage, and a one-year follow-up showed no recurrence of endometriosis cysts at CSD.

CONCLUSIONS

Endometriosis cysts at CSD are very rare. The clinical symptoms may be less obvious, and the diagnosis relies mainly on the patient's previous surgical history and imaging. A finding of a pelvic mass in the location of the CSD, with or without symptoms of menstrual changes and intermittent abdominal pain, should be considered an endometriotic cyst at CSD. Surgical treatment is a good choice for this disease. Further studies are needed regarding the etiological mechanism of this case and why the mass enlarged rapidly in one mouth.

Complete Cervicouterine Dissociation After Repeat Cesarean Sections: A Case Report

INTRODUCTION

The number of cesarean deliveries (CDs) has extremely increased in the last decades. Although it is a common and relatively safe surgical procedure, there are several potential complications. To the best of our knowledge, complete cervicouterine dissociation after several CDs has not been reported before in the medical literature.

CASE REPORT

A 28-year-old woman with a history of 6 CDs presented with abdominal pain and vaginal bleeding. The patient's most recent CD happened three weeks before the current presentation. Transabdominal ultrasonography examination and magnetic resonance imaging revealed the absence of continuity with the uterine cervix and corpus with associated pelvic hematoma. Laparotomy findings confirmed the imaging findings, and the displaced uterine corpus was removed with the evacuation of the associating pelvic hematoma.

CONCLUSION

Uterine dehiscence and rupture are among the relatively common complications of CD. Uterine rupture and dehiscence are focal disorders, and complete cervicouterine dissociation has not been seen before. Multiple CDs are among the risk factors for complete cervicouterine dissociation, and abnormal uterine bleeding is the most common symptom. Imaging findings allow a quick and definitive diagnosis, and surgical intervention may be planned accordingly based on the imaging findings.

Prediction of the relationship of cesarean section scar niche and postmenstrual spotting: is there any relation?

Background

Postmenstrual spotting has recently been related to a discontinuation of the myometrium at the site of a previous cesarean section called "CS scar niche". There was no consensus regarding the gold standard method for the assessment of the niche. Recently, Magnetic resonance imaging (MRI) has shown promise in the evaluation of the niche. Our study aims to assess the role of MRI in the evaluation of the CS scar niche characters and its association with post-menstrual spotting.

Results

A total of 65 patients with CS niche were prospectively included in this study and subdivided into two groups, according to presence or absence of postmenstrual spotting (Group A; 34 patients with postmenstrual spotting and Group B; 31 patients without spotting). All patients were examined using a 1.5 T MRI unit. CS scar niche volume was significantly higher among women with post-menstrual spotting (0.57 ± 0.07 vs. 0.07 ± 0.05 (cm3); P < 0.001). Also, women with post-menstrual spotting have significantly higher scar length (9.38 ± 3.06 vs. 5.02 ± 2.10 (mm); P < 0.001), scar depth (6.95 ± 3.16 vs. 3.23 ± 0.99 (mm); P < 0.001), scar width (15.78 ± 3.94 vs. 9.87 ± 1.84 (mm); P < 0.001) in comparison to those without post-menstrual spotting.

Scar depth (> 7.4 mm) had 81% sensitivity and 97% specificity for prediction of post-menstrual spotting with overall accuracy was 88.7%. While scar width (> 12.8 mm) had 71% sensitivity and 97% specificity for prediction of post-menstrual spotting with overall accuracy was 83.3%. Scar volume (> 0.15 cm3) had 97% sensitivity and 100% specificity for prediction of post-menstrual spotting with overall accuracy was 98.4%.

Conclusion

MRI measures (CS scar volume, depth, and width) are predictors for postmenstrual spotting in patients with CS scar niche, and scar volume is the most powerful predictor.

Post caesarean section complications conundrum: Role of imaging

Although caesarean delivery is a safe procedure, however, with rising numbers being performed every year globally, increasing number of complications are being encountered by clinicians and radiologists. These complications can be early, occurring over first few days to weeks, or late, which can present months to years later. Also, it must be kept in mind that the normal variations of physiological involution occurring in early postpartum period can mimic pathology in many cases. Clinical history, laboratory parameters, and radiological investigations go hand in hand in identifying acute complications at the earliest, enabling early initiation of treatment. Among radiological investigations, ultrasound is the first line investigation of choice, followed by computed tomography (CT) and magnetic resonance imaging (MRI) in certain conditions which will be described and illustrated further in this article.

The Effect of COVID-19 Pandemic on the Infants' Microbiota and the Probability of Development of Allergic and Autoimmune Diseases

The human microbiota plays a significant role in various mechanisms of the body. The formation of a healthy microbiota, especially in early childhood, has a significant effect on maintaining human health. Since the onset of coronavirus disease 2019 (COVID-19), the disease has caused many changes in human life. According to the available information, many of these factors affect the composition and diversity of the body's microbiota, so this pandemic may alter and disrupt the microbiota and consequently increase the incidence of other diseases such as allergic and autoimmune disorders, especially in children and infants born in this era. In this review, the probable impact of the COVID-19 pandemic on body's microbiota and its relationship with the emergence of future diseases is discussed.

Comparative Study of USG and MRI in Evaluation of Isthmocele

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.

How embryology knowledge can help radiologists in the differential diagnosis of canal of Nuck pathologies

The Canal of Nuck (CN) is an anatomical structure which is often forgotten. It is the female equivalent of the male processus vaginalis and corresponds to a protrusion of parietal peritoneum that extends from the inguinal canal to labia majora. Radiologists rarely encounter patients with pathology of CN, especially in adult population. It is well known that CN diseases can occur in paediatric patient (especially younger than 5 years of age) and they are associated to high morbidity (for example ovarian hernia with high risk of incarceration and torsion). The aim of our work is to review embryology, anatomy and pathologies of the CN thanks to a multi modal approach-ultrasound (US), Computed Tomography (CT) and Magnetic Resonance imaging (MRI)-to make radiologists more aware of such conditions and guarantee a prompt and correct diagnosis not only in paediatric patients but also in the adult population.

A Pictorial Review of Postpartum Complications

The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Multimodality imaging features of desmoid tumors: a head-to-toe spectrum

Desmoid tumors (DTs) are a rare and biologically heterogeneous group of locally aggressive fibroblastic neoplasm: their biological behavior spectrum ranges from indolent to aggressive tumors. DTs are classified as intra-abdominal, extra-abdominal, and within the abdominal wall lesions.It is well known that abdominal and extra-abdominal DTs are associated with familial adenomatous polyposis (FAP) and Gardner syndrome. Possible risk factors are prior trauma/surgery, pregnancy, and oral contraceptives.There was a real revolution in the management of DT: from aggressive first-line approach (surgery and radiation therapy) to a more conservative one (systemic treatment and "wait-and-see policy").In these clinical settings, radiologists play an important role for assessing lesion resectability, evaluating recurrence, monitoring the biological behavior if an expectant management is chosen, and assessing response to systemic treatment as well as to radiation therapy.Awareness of common locations, risk factors, and imaging features is fundamental for a correct diagnosis and an adequate patient management.

Magnetic resonance imaging of the female pelvis after Cesarean section: a pictorial review

The rate of Cesarean sections (C-sections) in Poland increased from 21.7% in 2001 to 43.85% in 2017 even though the Polish Society of Gynecologists and Obstetricians highlights the negative consequences of C-section for both mother and child and recommends to make every possible effort to reduce its percentage, following the World Health Organization recommendations. There is a long list of possible complications related to the uterine scar after C-section, including uterine scar dehiscence, uterine rupture, abdominal and pelvic adhesions, uterine synechiae, ectopic pregnancy, anomalous location of the placenta, placental invasion, and—rarely—vesicouterine or uterocutaneous fistulas. Ultrasound (US) remains the first-line modality; however, its strong operator- and equipment dependence and other limitations require further investigations in some cases. Magnetic resonance imaging (MRI) is the second-line tool which is supposed to confirm, correct, or complete the sonographic diagnosis thanks to its higher tissue resolution and bigger field of view. This article will discuss the spectrum of C-section complications in the MR image-rich form and will provide a systematic discussion of the possible pathology that can occur, showing comprehensive anatomical insight into the pelvis after C-section thanks to MRI that facilitates clinical decisions.

Postnatal diagnosis of an occult uterine scar dehiscence after three uncomplicated vaginal births after Caesarean section: A case report

Introduction

The incidence of Caesarean sections has been increasing in the United Kingdom. Obstetricians have become more inclined to offer a trial of a vaginal birth to women following a single uncomplicated Caesarean section due to growing recognition of the high morbidity associated with repeat abdominal surgeries, and the relative rarity of a Caesarean scar defect causing complications at subsequent vaginal deliveries. The diagnosis of a Caesarean scar defect such as a uterine scar dehiscence in the postnatal period still remains elusive due to its vague presentation. An incorrect diagnosis or a delay in diagnosis can lead to unnecessary interventions or delay the management of patient symptoms.

Case Presentation

A 35-year-old woman with a single Caesarean section and three subsequent uncomplicated vaginal deliveries was diagnosed with an occult scar dehiscence two weeks postnatally. She initially complained of persistent vaginal bleeding and underwent a suction evacuation for suspected retained placental tissue. Her symptoms did not improve, and a CT scan was requested to rule out a uterine perforation following the surgical procedure. The CT scan suggested a uterine dehiscence at the level of the previous scar. As the patient remained clinically well, her symptoms were managed conservatively. She underwent a laparoscopic sterilisation six months later and was discharged as the scar defect had fully resolved.

Conclusion

Clinicians should remain vigilant about the possibility of an occult scar defect in women with a previous Caesarean section who present with persistent vaginal bleeding and pain in the postnatal period.

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Bladder flap haematomas over 5 cm raise the possibility of a Caesarean scar defect.

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Niche formation causes a spectrum of menstrual disorders.

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Contraception should be offered to all women with a Caesarean scar defect.