Development of the utero-placental circulation in cesarean scar pregnancies: a case-control study.

BACKGROUND: Cesarean scar pregnancies carry a high risk of pregnancy complications including placenta previa with antepartum hemorrhage, placenta accreta spectrum, and uterine rupture. OBJECTIVE: To evaluate the development of utero-placental circulation in the first half of pregnancy in ongoing cesarean scar pregnancies and compare it with pregnancies implanted in the lower uterine segment above a previous cesarean delivery scar with no evidence of placenta accreta spectrum at delivery STUDY DESIGN: This was a retrospective case-control study conducted in 2 tertiary referral centers. The study group included 27 women who were diagnosed with a live cesarean scar pregnancy in the first trimester of pregnancy and who elected to conservative management. The control group included 27 women diagnosed with an anterior low-lying placenta or placenta previa at 19 to 22 weeks of gestation who had first and early second trimester ultrasound examinations. In both groups, the first ultrasound examination was carried out at 6 to 10 weeks to establish the pregnancy location, viability, and to confirm the gestational age. The utero-placental and intraplacental vasculatures were examined using color Doppler imaging and were described semiquantitatively using a score of 1 to 4. The remaining myometrial thickness was recorded in the study group, whereas the ultrasound features of a previous cesarean delivery scar including the presence of a niche were noted in the controls. Both the cesarean scar pregnancies and the controls had ultrasound examinations at 11 to 14 and 19 to 22 weeks of gestation. RESULTS: The mean color Doppler imaging vascularity score in the ultrasound examination at 6 to 10 weeks was significantly (P<.001) higher in the cesarean scar pregnancy group than in the controls. High vascularity scores of 3 and 4 were recorded in 20 of 27 (74%) cases of the cesarean scar pregnancy group. There was no vascularity score of 4, and only 3 of 27 (11%) controls had a vascularity score of 3. In 15 of the 27 (55.6%) cesarean scar pregnancies, the residual myometrial thickness was <2 mm. In the ultrasound examination at 11 to 14 weeks, there was no significant difference between the groups in the number of cases with an increased subplacental vascularity. However, 12 cesarean scar pregnancies (44%) presented with 1 or more placental lacunae whereas there was no case with lacunae in the controls. Of the 18 cesarean scar pregnancies that progressed into the third trimester, 10 of them were diagnosed with placenta previa accreta at birth, including 4 creta and 6 increta. In the 19 to 22 weeks ultrasound examination, 8 of the 10 placenta accreta spectrum patients presented with subplacental hypervascularity, out of which 6 showed placental lacunae. CONCLUSION: The vascular changes in the utero-placental and intervillous circulations in cesarean scar pregnancies are due to the loss of the normal uterine structure in the scar area and the development of placental tissue in proximity of large diameter arteries of the outer uterine wall. The intensity of these vascular changes, the development of placenta accreta spectrum, and the risk of uterine rupture are probably related to the residual myometrial thickness of the scar defect at the start of pregnancy. A better understanding of the pathophysiology of the utero-placental vascular changes associated with cesarean scar pregnancies should help in identifying those cases that may develop major complications. It will contribute to providing counseling for women about the risks associated with different management strategies.

INVESTIGACIÓN DE LA INCIDENCIA Y COMPLICACIONES DEL PERIPARTO DE EMERGENCIA HISTERECTOMÍA / 9 INVESTIGATION OF INCIDENCE AND COMPLICATIONS OF EMERGENCY PERIPARTUM HYSTERECTOMY

Introduction: The emergency peripartum hysterectomy is a high-risk surgery, which is mostly performed after vaginal delivery or Cesarean section. Given the importance of complications and mortality of pregnant mothers for the health system, the present study aimed to investigate the incidence and complications of emergency peripartum hysterectomy in general and teaching hospitals of Zahedan University of Medical Sciences. Materials and Methods: In this cross-sectional descriptive-analytic study, after obtaining the Ethics Committee approval, the medical record of patients with emergency peripartum hysterectomy admitted to Ali ibn Abitaleb hospital of Zahedan for pregnancy termination during 2017-2018 were investigated. were studied. After evaluating demographic characteristics, including age, education, and occupation, causes, and complications of emergency hysterectomy were investigated. Finally, data were analyzed by SPSS software. Results: Out of 2438 cases, 50 cases of hysterectomy were investigated. The mean age of mothers and the average number of pregnancies was 31.06±5.21 and 5.72±2.31, respectively. In this study, 35 cesarean sections (70%) and 15 normal vaginal delivery (30%) were recorded, with only 2% leading to emergency hysterectomy. The most common causes of emergency hysterectomy included placenta accreta (28%), uterine atony (24%), and uterine rupture (20%). The complications also included fever (24%), coagulopathy (14%), and wound infection (12%). Conclusion: Placenta accreta and uterine atony are the most important causes of hysterectomy. The most common complications of emergency hysterectomy are fever, coagulopathy, and wound infections. A decrease in elective caesarean delivery and further encouraging to natural vaginal delivery could significantly reduce the incidence of peripartum hysterectomy and maternal mortality.

Ultrasonographic Features of Uterine Scar after Laparoscopic and Laparoscopy-Assisted Minilaparotomy Myomectomy: A Comparative Study.

STUDY OBJECTIVE: To evaluate uterine scar features after laparoscopic myomectomy (LM) compared with myomectomy performed by laparoscopy initially and then completed with minilaparotomy (LAM). DESIGN: Prospective cohort study. SETTING: An academic center for advanced endoscopic gynecologic surgery. PATIENTS: Sixty-nine symptomatic women who underwent myomectomy between July and December 2018. INTERVENTION: Patients underwent LM or LAM and 3-month follow-up ultrasonography. MEASUREMENTS AND MAIN RESULTS: Forty-four patients underwent LM and 25 underwent LAM. Demographic data, intraoperative parameters, and postoperative outcomes were collected. Two-dimensional color Doppler ultrasound was done at a 3-month follow-up to evaluate myomectomy scar features, myometrial thickness, and the presence of and vascularity of a heterogeneous mass. These features were compared with those of the intact myometrium on the opposite wall of the patient's uterus. The 2 groups had similar demographic characteristics, and there were no significant between-group differences in the number, maximum diameter, type, or location of myomas. The mean myometrial thickness at the scar site was 18.9 ± 3.22 mm in the LM group and 19.7 ± 3.50 mm in the LAM group, with no significant difference between the 2 groups. There was no meaningful difference in vascularity between the scar and normal myometrium. Heterogeneous masses were detected in 23% of patients in the LM group and in 24% of those in the LAM group. Other than mean operative time (207 minutes for LM vs 150 minutes for LAM; p < .001) and mean postoperative reduction in hemoglobin (1.77 mg/dL for LM vs 2.35 mg/dL for LAM; p = .023), there were no other statistical differences between the 2 groups. One patient in the LM group experienced a bowel injury resulting from morcellation. CONCLUSION: There were no differences in myometrial scar features after LM compared with after LAM, implying effective suturing via both approaches.

Maternal and fetal death at 22 weeks following uterine rupture at the site of the placenta percreta in a C-section scar.

Placenta percreta is the abnormal invasion of the placenta through the myometrium and serosa of the uterus. It is the most invasive of the placenta accreta spectrum followed by placenta increta. This paper presents a case of a maternal and fetal death in the second trimester due to rupture of the uterus at the site of placenta percreta in a C-section scar. Postmortem MRI showed a large hemoperitoneum and thinning of the anterolateral uterine wall. Internal examination revealed two liters of blood in the abdomen and rupture of the anterolateral uterine wall at the site of placenta percreta in a previous C-section scar. Placenta percreta is a rare complication of pregnancy, however, it is becoming more common with the increasing rate of C-section, the most common and significant risk factor.

Uterine rupture in patients with a history of laparoscopy or hysteroscopy procedures: Three case reports.

RATIONALE: Uterine rupture is a rare incidence but can lead to catastrophic maternal and fetal consequences. We still need to place a high premium on these cases. PATIENT CONCERNS: The patients all showed hemodynamic shock with complaints of serious pain in the abdomen. They all had a history of laparoscopy or hysteroscopy procedures. DIAGNOSES: Case 1 and 2 were diagnosed during surgery. Case 3 was diagnosed by an urgent abdominal ultrasonogram before surgery. INTERVENTIONS: We performed emergency surgeries for the 3 cases. OUTCOMES: Three patients all recovered well. But only the child in case 2 survived. LESSONS: It must be emphasized that pregnant women with a history of such surgeries should be aware of uterine rupture during pregnancy.

Complicated primary cesarean delivery increases the risk for uterine rupture at subsequent trial of labor after cesarean.

PURPOSE: To evaluate whether cesarean delivery (CD) indication, labor status, and other primary CD characteristics affect the risk for uterine rupture in subsequent deliveries. METHODS: A case-control study of women attempting trial of labor after cesarean (TOLAC) in a single, tertiary, university-affiliated medical center (2007-2016). Deliveries complicated by uterine rupture were matched to successful vaginal birth after cesarean (VBAC) deliveries in a 1:3 ratio. Indication, labor status and post-partum complications (postpartum hemorrhage and postpartum infection) at primary CD were compared between study and control group. RESULTS: During study period, there were 75,682 deliveries, of them, 3937 (5.2%) were TOLAC. Study group included 53 cases of uterine rupture at TOLAC and 159 women with successful VBAC. Women in study group had significantly lower rates of previous VBAC (15.1 vs. 28.9%, p = 0.047). Rate of postpartum complications at primary CD was significantly higher in women with TOLAC complicated by uterine rupture (7.5 vs. 1.9%, respectively, p = 0.042). Utilizing the multivariate logistic regression analysis, postpartum complications remained an independent risk factor for uterine rupture in the following TOLAC (aOR 4.07, 95% CI 1.14-14.58, p = 0.031). CONCLUSION: Postpartum hemorrhage and infection, in primary CD, seem to be associated with increased risk for uterine rupture during subsequent TOLAC.

[Asymptomatic spontaneous rupture of the uterus without previous sectio].

Rupture of the uterus is rare but catastrophic. Rupture often results in fetal bradycardia, abdominal pain, haemodynamic changes and vaginal bleeding. A 36-year-old healthy woman, gravida 3, para 1, went into spontaneous labour at gestation age 39 + 4, and at orificium 7 cm she received epidural analgesia. Following the epidural, the fetal heartbeat could not be registered by external cardiotocography, and caput could not be palpated. Spontaneous birth was attempted, but a caesarean section was necessary. The baby was found in the abdomen. Uterus was successfully contracted, thus preventing fatal bleeding. Asymptomatic rupture of the unscarred uterus is rare and difficult to diagnose.

Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy.

BACKGROUND: Uterine rupture is a potential life-threatening complication during a trial of labor after cesarean delivery. Single-layer closure of the uterus at cesarean delivery has been associated with an increased risk of uterine rupture compared with double-layer closure. Lower uterine segment thickness measurement by ultrasound has been used to evaluate the quality of the uterine scar after cesarean delivery and is associated with the risk of uterine rupture. OBJECTIVE: To estimate the impact of previous uterine closure on lower uterine segment thickness. STUDY DESIGN: Women with a previous single low-transverse cesarean delivery were recruited at 34-38 weeks' gestation. Transabdominal and transvaginal ultrasound evaluation of the lower uterine segment thickness was performed by a sonographer blinded to clinical data. Previous operative reports were reviewed to obtain the type of previous uterine closure. Third-trimester lower uterine segment thickness at the next pregnancy was compared according to the number of layers sutured and according to the type of thread for uterine closure, using weighted mean differences and multivariate logistic regression analyses. RESULTS: Of 1613 women recruited, with operative reports available, 495 (31%) had a single-layer and 1118 (69%) had a double-layer closure. The mean third-trimester lower uterine segment thickness was 3.3 ± 1.3 mm and the proportion with lower uterine segment thickness <2.0 mm was 10.5%. Double-layer closure of the uterus was associated with a thicker lower uterine segment than single-layer closure (weighted mean difference: 0.11 mm; 95% confidence interval [CI], 0.02 to 0.21 mm). In multivariate logistic regression analyses, a double-layer closure also was associated with a reduced risk of lower uterine segment thickness <2.0 mm (odd ratio [OR], 0.68; 95% CI, 0.51 to 0.90). Compared with synthetic thread, the use of catgut for uterine closure had no significant impact on third-trimester lower uterine segment thickness (WMD: -0.10 mm; 95% CI, -0.22 to 0.02 mm) or on the risk of lower uterine segment thickness <2.0 mm (OR, 0.95; 95% CI, 0.67 to 1.33). Finally, double-layer closure was associated with a reduced risk of uterine scar defect (RR, 0.32; 95% CI, 0.17 to 0.61) at birth. CONCLUSION: Compared with single-layer closure, a double-layer closure of the uterus at previous cesarean delivery is associated with a thicker third-trimester lower uterine segment and a reduced risk of lower uterine segment thickness <2.0 mm in the next pregnancy. The type of thread for uterine closure has no significant impact on lower uterine segment thickness.

Management of uterine rupture: a case report and review of the literature.

BACKGROUND: Maternal morbidity and mortality has been a major World Health Organization concern over the years, especially in sub-Saharan Africa. This paper reports uterine rupture with severe hypovolemic shock managed at the Douala General Hospital, Cameroon. Early clinical diagnosis is paramount to maternal survival. CASE PRESENTATION: Mrs. MM aged 25 years, G3P2012, of the Bamileke tribe in Cameroon was admitted to our Department in hypovolemic shock BP = 70/40 mmHg, pulse 120 beats per minute, with altered consciousness (Glasgow Coma Scale = 13). She has a history of missed abortion at 19 weeks gestation and an attempt to evacuate the uterus with misoprostol that led to uterine rupture. She underwent a total abdominal hysterectomy and blood transfusion. Her post-operative stay in hospital was uneventful. CONCLUSION: Uterine rupture is a complication that can be eliminated under conditions of best obstetric practice. To attain this objective, use of misoprostol in primary health facilities should be stopped or proper management of the medication instituted. The survival of patients after uterine rupture depends on the time interval between rupture and intervention, and the availability of blood products for transfusion.

Uterine Rupture in a Common Marmoset (Callithrix jacchus).

A 5-y-old multiparous female common marmoset (Callithrix jacchus) presented with acute weight loss of approximately 25% over a 1-wk period. An abdominal mass was apparent on physical examination, and radiographs suggested peritoneal effusion. Exploratory laparotomy revealed hemoperitoneum and an enlarged, gray, hemorrhaging uterus; ovariohysterectomy was performed, and the marmoset recovered. Histologic evaluation of the ovaries and uterus revealed uterine rupture, with invasion of placental villi lined by trophoblasts through the myometrium to the serosal layer. Primary uterine rupture is a rare but serious obstetric event in humans and has been reported only rarely in NHP. This report is the first description of primary uterine rupture during early pregnancy in a common marmoset.

Uterine rupture at 10 weeks of gestation after laparoscopic myomectomy.

The patient had a previous history of laparoscopic myomectomy. At 10 weeks of gestation, she visited our emergency center due to sudden abdominal pain. An ultrasound examination and MRI showed complete rupture of the uterine myometrium in the fundal wall and a floating gestation sac in Douglas' fossa with fluid. Emergency abdominal laparotomy was immediately performed due to the diagnosis of uterine rupture. During surgery, a small defect of the myometrium was found in the posterior fundal wall of the uterus. Two-layer suturing was performed at the perforation hole. The occasional occurrence of uterine rupture after surgery of the uterus even in the first trimester should be considered.

Spontaneous Uterine Rupture Due to Placenta Percreta in a 17-Week Twin Pregnancy.

Spontaneous rupture of previous uterine scar due to placenta percreta in early second trimester is a very rare and serious complication. A27-year fourth gravida, second para with previous two lower segment caesarean sections, presented at 17-week of twin pregnancy with acute abdominal pain. Ultrasonograghy revealed 17-week diamniotic-dichorionic twin pregnancy with alive fetuses. The placenta of the first twin was anterior, low lying covering the internal os and penetrating through the entire thickness of the lower uterine wall laterally. Significant hemoperitoneum was seen. Emergency laparotomy showed rupture of previous uterine scar with placenta percreta bleeding actively. Atransverse fundal incision was given to deliver the twins and total abdominal hysterectomy with preservation of both ovaries was performed. The patient was discharged on fourth postoperative day without any complication. Histopathology of specimen of the uterus confirmed placenta percreta to be the cause of uterine rupture.

Hemoperitoneum in a patient with spontaneous rupture of the posterior wall of an unscarred uterus in the second trimester of pregnancy.

BACKGROUND: Hemoperitoneum resulting from a rupture of an unscarred uterus is a rare condition. Uterine rupture in patients without evident risk factors is associated with non-specific signs and symptoms that can delay the diagnosis. This is a report of spontaneous rupture of posterior wall of the uterus in the second trimester of pregnancy presented as intra-abdominal bleeding. CASE PRESENTATION: Here, we report the case of a 31-year-old Caucasian multiparous female (gravida 3, para 1) who had a sudden onset of abdominal pain at 28 weeks of gestation. The patient had no history of caesarean section. Exploratory laparotomy was performed due to deterioration of the patient's clinical condition, and ultrasound results were suspicious for hemoperitoneum. Uterine rupture in the posterior wall with active bleeding from the defect was confirmed. A caesarean section was performed, and a live female infant weighing 1000 g, with an Apgar score of three, was delivered. A hysterectomy was performed during the caesarean section. CONCLUSION: Diagnostic difficulties arise from the rarity of the disease, a nonspecific clinical picture and the absence of the main risk factors. Uterine rupture should be considered in the differential diagnosis of hemoperitoneum in patients with an unscarred uterus.

ABDOMINAL PREGNANCY IN A SERVAL (LEPTAILURUS SERVAL) SECONDARY TO UTERINE RUPTURE.

A 14-yr-old female serval (Leptailurus serval) died unexpectedly after 2 wk of inappetence and lethargy. Necropsy revealed a pyoabdomen with a full-term, well-developed fetus in the caudal abdomen covered by a mesenteric sac. The mesenteric sac communicated with a tear in the wall of the right uterine horn, supporting a diagnosis of secondary abdominal pregnancy. The uterine wall had evidence of adenomyosis at the rupture site with no evidence of pyometra. The fetus, supporting mesentery, and peritoneum were coated with mixed bacteria, which may have ascended through an open cervix to the site of uterine rupture. This is the first case of abdominal pregnancy related to uterine rupture reported in a large felid species.

[Uterine rupture without preexisting caesarean section after perforation of the uterus during evacuation]. / Uterusruptur uden forudgående kejsersnit ti år efter perforation i forbindelse med udskrabning.

Uterine rupture is a serious complication, associated with perinatal and maternal morbidity and mortality. This case report describes uterine rupture in a patient who did not have any previous caesarean section. The patient had acute abdominal pain, hypertonic uterus, blood in the amniotic fluid and abnormal cardiotocographic values. An abruption of the placenta was suspected, and an acute caesarean section was performed during which a rupture in fundus uteri was found. It was later experienced that the patient ten years earlier had suffered a uterine perforation during evacuation after a late abortion.

UTERINE RUPTURE FOLLOWING MYOMECTOMY IN THIRD TRIMESTER.

Rupture of gravid uterus is surgical emergency causing maternal and fetal morbidity and mortality. The risk of uterine rupture is associated with uterine scars caused by previous cesarean section, myomectomy, hysteroscopic procedures, and curettage. We report a case of a 40-year-old woman in 31st week of gestation with spontaneous uterine rupture. It was her third pregnancy. She had two healthy children from previous pregnancies. Her symptoms were abdominal pain, vomiting and pain in the right shoulder lasting for 12 hours prior to admission. Ultrasound examination at admission revealed a dead fetus in the abdomen and free fluid in the abdominal cavity. She had previously undergone laparoscopic myomectomy. After myomectomy, she had one successful vaginal delivery. Every abdominal pain in pregnant woman with uterine scar should be carefully and promptly examined to exclude uterine rupture before further diagnostic procedures. This early time frame is essential for survival of the fetus and sometimes even of the mother. Uterine rupture represents indication for immediate cesarean section and it should be performed within 25 minutes of the first signs of uterine rupture. As shown in the case presented, one successful vaginal delivery after myomectomy is no guarantee for future pregnancies.