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Background: Human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) have demonstrated efficacy in repairing uterine scars, although the underlying mechanisms remain unclear. Methods: Uterine injury was surgically induced in a rat model, followed by immediate transplantation of 5 × 10 ^ 5 hUC-MSCs to each side of the uterus. Uterine morphology was evaluated at days 14 and 30 using HE and Masson staining. Immunohistochemistry assessed macrophage polarization, angiogenesis and endometrial receptivity in the endometrium. Additionally, the regulatory effects of hUC-MSCs on macrophage polarization were explored through coculture. qRT-PCR quantified the expression of anti-inflammatory (IL10 and Arg1) and pro-inflammatory (iNOS and TNF-α) factors. Western blotting evaluated CD163 expression. Results: Transplantation of hUC-MSCs promoted the healing of uterine injuries and tissue regeneration while inhibiting tissue fibrosis. Immunohistochemistry at days 14 and 30 post-transplantation demonstrated the polarization of macrophages toward the M2 phenotype in the uterine injury area in the presence of hUC-MSCs. Furthermore, hUC-MSC transplantation improved angiogenesis and endometrial receptivity in the uterine injury rat model, associated with increased IL10 expression. hUC-MSC-induced angiogenesis can be resisted by depleted macrophages. In vitro coculture experiments further demonstrated that hUC-MSCs promoted IL10 expression in macrophages while suppressing TNF-α and iNOS expression. Western blotting showed enhanced CD163 expression in macrophages following hUC-MSC treatment. Conclusions: hUC-MSCs contribute to the healing of uterine injuries by targeting macrophages to promote angiogenesis and the expression of anti-inflammatory factors. [ABSTRACT FROM AUTHOR]

Objective To exploring the effect of human amniotic mesenchymal stem cells(hAMSCs) on the repair of rat uterine scars. Methods The hAMSCs were isolated and cultured,Female SPF grade SD rats were selected for full-thickness incision of uterine wall and then implanted with hAMSCs. On the 30th day after operation, the uterine incision was examined histologically.ImageJ image analysis software was used to analyze and to compare the thickness of uterine myometrium and the percentage of fibrotic area in each group.Immunohistochemical method was used for detecting the percentage of positive areas of α-SMA, TGF-β1, and Ki-67. Results Compared with the PBS group, the hAMSCs group showed significant thickening of the uterine muscle layer and fibrotic area was decreased, The positive expression of α-SMA, and Ki-67 significantly increased(P＜0.05), while the expression of TGF-β1 was significantly reduced(P＜0.05). Conclusions The hAMSCs may promote the repair of uterine incision scars by reducing the formation of scar fibrosis and promoting the proliferation of smooth muscle cells in uterine scars.

The frequency of abdominal delivery in the world is steadily rising. Since the latter is associated with a lot of complications compared with vaginal delivery, the increase in the proportion of deliveries in women with a uterine scar through the natural birth canal is an important strategic goal of the obstetrics and gynecology community. In addition, it is established that every second patient after a cesarean section develops a defect in the scar area, which is often accompanied by various disorders of the menstrual cycle (in 25,5% of cases – abnormal uterine bleeding) and can cause secondary infertility. Both assessment of the risk of scar failure at the stage of preconceptional preparation and timely detection and treatment of isthmocele symptoms are still serious challenges facing obstetricians and gynecologists. Clinical guidelines devoted to the cesarean scar defect problem have not yet been developed. This review presents the quintessence of modern data on possible risk factors, clinical manifestations with a detailed consideration of pathophysiological mechanisms, diagnostic tools and correction methods of symptomatic isthmocele and uterine scar defect with a detailed description of indications and a comparative assessment of their effectiveness in order to standardize approaches to the diagnosis and treatment of these pathological conditions.

Objective To exploring the effect of human amniotic mesenchymal stem cells (hAMSCs) on the repair of rat uterine scars. Methods The hAMSCs were isolated and cultured, Female SPF grade SD rats were selected for full-thickness incision of uterine wall and then implanted with hAMSCs. On the 30th day after operation, the uterine incision was examined histologically. ImageJ image analysis software was used to analyze and to compare the thickness of uterine myometrium and the percentage of fibrotic area in each group. Immuno-histochemical method was used for detecting the percentage of positive areas of α-SMA, TGF-β1, and Ki-67. Results Compared with the PBS group, the hAMSCs group showed significant thickening of the uterine muscle layer and fibrotic area was decreased, The positive expression of α-SMA, and Ki-67 significantly increased (P<0.05), while the expression of TGF-B1 was significantly reduced (P<0.05). Conclusions The hAMSCs may promote the repair of uterine incision scars by reducing the formation of sear fibrosis and promoting the proliferation of smooth muscle cells in uterine scars. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions Placenta accreta spectrum (PAS) can lead to major peripartum morbidity. Appropriate management approaches depend on the clinical severity, each individual's preference, and the treating team's expertise. Peripartum hysterectomy is the most frequently used treatment option. However, it can impact psychological well‐being and fertility. We investigated whether conservative treatment with focal resection or leaving the placenta in situ is associated with comparable or lower maternal morbidity than hysterectomy in centers of excellence within the International Society for placenta accreta spectrum (IS‐PAS). Furthermore, a survey was conducted to explore potential barriers to conservative management in antenatal counseling and intraoperative decision‐making.Confirmed PAS cases in the prospective IS‐PAS database from 22 registered centers between January 2020 and June 2022 were included in the analysis. A separate online survey with 21 questions was answered by the IS‐PAS center experts about indications, diagnostic criteria, patient counseling, surgical practice, changes from the preoperative treatment plan, and why conservative management may not be offered.A total of 234 cases were included in the analysis: 186 women received hysterectomy and 38 women were treated by focal resection, and 10 by leaving the placenta in situ. Blood loss was lower in the focal resection group and in the placenta in situ group compared to the hysterectomy group (p = 0.04). 46.4% of the women initially planned for focal resection, and 35.7% of those initially planned for leaving the placenta in situ were ultimately treated by hysterectomy. Our survey showed that the IS‐PAS centers preferred hysterectomy according to a woman's wishes (64%) and when they expected less blood loss and morbidity (41%). Eighteen percent of centers did not offer focal resection at all due to a lack of experience with this technique. Reasons for not offering to leave the placenta in situ were avoidance of unexpected reoperation (36%), puerperal infection (32%), or skepticism about the method (23%).Uterus‐preserving treatment strategies such as focal resection appear to be safe alternatives to peripartum hysterectomy. However, less than half of the IS‐PAS centers perform them. Acceptance of conservative treatments could be increased by standardized criteria for their implementation and by systematic training for PAS experts. [ABSTRACT FROM AUTHOR]

Background. Postpartum hemorrhage is recognized as a leading cause of maternal mortality and morbidity in the world. Predicting postpartum hemorrhage in high-risk patients with uterine scar enables preventive measures to be scheduled and costs of treatment and rehabilitation to be reduced.Objective. To determine antenatal predictors of high postpartum hemorrhage risk in pregnant women with uterine scar in order to improve the prevention of massive blood loss.Methods. An observational cohort study involves the medical records of 4494 maternity women with uterine scar (pregnancy and delivery histories) of the Perinatal Center of Regional Clinical Hospital No. 2, Krasnodar Krai. The study sample included data of maternity women coded O34.2 according to International Classification of Diseases, 10th Edition, for the period from 2017 to 2020. The sample participants were distributed into two groups depending on the blood loss during delivery, determined in compliance with clinical recommendations: a group of patients without massive blood loss during delivery and a group of patients with massive blood loss in labor/early postpartum period. The study was mainly focused on parameters of the prediction performance of bleeding in labor and early postpartum period in pregnant women with uterine scar using a multiparametric, logistic regression models. The study considered demographic data, comorbidity, obstetric history, pregnancy course, ultrasound data, and volume of blood loss at delivery. The performance of prediction for postpartum hemorrhage was calculated using multivariate binary logistic regression. Descriptive statistical analysis was carried out by means of statistical software package SPSS Version 26 (IBM, USA). Two-sided p-value < 0.05 was taken as a statistically significant difference. A prognostic significance of predictors was determined by binary logistic regression. The Wald statistic was used to determine an observed significance. In order to define the performance of the model, the study involved calculating sensitivity, specificity, positive and negative predictive value, Nagelkerke coefficient of determination, as well as performing ROC analysis. The DeLong test was used for paired comparisons of ROC curves.Results. In the retrospective follow-up group (2017–2020) (n = 502), postpartum hemorrhage with massive blood loss occurred in 41 cases (8.17%). For the model based on clinical-anamnestic predictors, the prediction performance for postpartum hemorrhage comprised: sensitivity = 12.2% (95% confidence interval (CI) 4.1–26.2); specificity = 99.3% (95% CI 98.1–99.9); positive predictive value = 62.5% (95% CI 24.5–91.5); negative predictive value = 92.6% (95% CI 89.9–94.8); area under the ROC curve = 0.864 (95% CI 0.807–0.920), p < 0.001. The prediction performance for the model based on three ultrasound predictors (asymmetry coefficient of placental thickness, uterine wall bulging in the scar and myometrial thickness in the placentation zone) comprised: sensitivity = 85.4% (95% CI 70.8–94.4); specificity = 98.5% (95% CI 96.9–99.4); positive predictive value = 83.3% (95% CI 68.6–93.0); negative predictive value = 98.7% (95% CI 97.2–99.5); area under the ROC curve = 0.919 (95% CI 0.855–0.983), p < 0.001. No significant difference was revealed for the performance of the models ( p = 0.170). For the model based on ultrasound predictors and placenta previa, the prediction performance comprised: sensitivity = 85.4% (95% CI 70.8–94.4); specificity = 98.5% (95% CI 96.9–99.4); positive predictive value = 83.3% (95% CI 68.6–93.0); negative predictive value = 98.7% (95% CI 97.2–99.5); area under the ROC curve = 0.955 (95% CI 0.912–0.999), p < 0.001. The model based on clinical-anamnestic and ultrasound indicators predicted postpartum hemorrhage with sensitivity equal to 85.4% (95% CI 70.8–94.4); specificity — 98.9% (95% CI 97.4–99.6); positive predictive value — 87.5% (95% CI 73.2–95.8); negative predictive value — 98.7% (95% CI 97.1–99.5); area under the ROC curve — 0.984 (95% CI 0.966–1.0), р < 0,001. Thus, this model outperformed the model based on clinical-anamnestic data (p < 0.001), based on ultrasound predictors (p = 0.006) and revealed no difference with the model considering placenta previa and ultrasound predictors (p = 0.127). Using prenatal prediction of postpartum hemorrhage based on ultrasound features, the incidence of massive blood loss at delivery decreased from 6.88/1000 deliveries (2019–2020) to 4.18/1000 deliveries (2021–2022) (p < 0.001).Conclusion. Ultrasound predictors in pregnant women with uterine scar increase the sensitivity of antenatal prediction of postpartum hemorrhage based on the assessment of clinical and anamnestic risk factors, thereby enabling preventive measures to be scheduled in the risk group and incidence of massive blood loss to be reduced.

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. [ABSTRACT FROM AUTHOR]

AIM OF STUDY The study of the results of delivery of pregnant women with placenta ingrowth in the uterine scar depending on the clinical status and the methods of blood saving.MATERIAL AND METHODS The design of a selective retrospective study included 54 pregnant women with central placenta previa and uterine scar after caesarean section (CS), with histologically confirmed results of placenta accreta. Among blood-saving methods we used: ligation of three pairs of main vessels of the uterus, ligation of the internal iliac arteries, complex compression hemostasis according to R.G. Shmakov, temporary clamping of the common iliac arteries.RESULTS CS with fundal incision was performed in 47 women (87.0%) out of 54. Hysterectomy was performed in 17 women (31.5%) out of 54. In the remaining 37 cases (68.5%), metroplasty and organ preservation were performed. There was no relaparotomy; there was no maternal mortality; perinatal mortality was 4 (7.4%); forced opening, bladder resection were performed in 7 (13.0%) cases; opening of the bladder without wall resection — in 2 (3.7%); 2 near miss cases; there were no complications associated with temporary clamping of the common iliac arteries; endometritis (recovery after conservative treatment) was revealed in 2 women (3.7%). Histologic examination results: 15 (27.8%) of placenta accreta, 30 (55.6%) of placenta increta, 8 (14.8%) of placenta percreta. In 8 cases, there was a combination of placenta increta into the uterine scar region of different depths, and in 2 (3.7%) cases, a combined deeply invasive lesion of the posterior wall of the lower segment and the body of the uterus.CONCLUSION Complex compression hemostasis according to R.G. Shmakov is the most rational and promising method of blood saving, acceptable among the majority of patients with placenta accreta spectrum. Temporary clamping of the common iliac arteries is advisable in case of damage to the posterior wall of the bladder. Preservation of the uterus: in case of a deeply invasive lesion, including cases of combined damage to the posterior wall of the lower segment of the uterus or the body of the uterus, significant blood loss before the woman enters the hospital, it is not an imperative of surgical tactics.

Abstract Background Clinically silent uterine rupture with complete fetal expulsion into the abdominal cavity is an extremely rare complication. Diagnosis can be difficult and the risk to the mother and fetus is high. Conservative management has been described only in a few cases of partial expulsion of the fetus so far. Case presentation We present a case of 43-year-old tercigravida with a history of previous laparotomic myomectomy and subsequent cesarean section. The subsequent pregnancy was complicated by uterine wall loosening and rupture at the site of the previous uterine scar after myomectomy and complete fetal expulsion into the abdominal cavity. The diagnosis was made at 24 + 6 weeks of gestation. Considering the absence of clinical symptomatology and the good condition of the fetus, a conservative approach was chosen with intensive monitoring of the maternal and fetal conditions. The pregnancy ended by elective cesarean section and hysterectomy at 28 + 0 weeks of gestation. The postpartum course was uneventful and the newborn was discharged to home care 63 days after delivery. Conclusions Fetal expulsion into the abdominal cavity after silent uterine rupture of the scarred uterus may be accompanied by minimal symptomatology making early diagnosis difficult. This rare complication must be considered in the differential diagnosis in women after major uterine surgery. In selected cases and under conditions of intensive maternal and fetal monitoring, conservative management may be chosen to reduce the risks associated with prematurity.

Accurate prenatal discrimination between a simple, non-adherent uterine scar dehiscence with an underlying placenta and the severe end of the placenta accreta spectrum is problematic as the two can appear similar on prenatal imaging. This may lead to the false diagnosis of placenta accreta spectrum resulting obstetric anxiety, overtreatment and potential iatrogenic morbidity. Despite potential similarities in the etiology, the manifestation and management of these two conditions is very different. The prenatal sonographic features of seven confirmed cases of simple uterine scar dehiscence with an underlying placenta previa were examined. The common sonographic features found for scar dehiscence was a thinned myometrium (<1 mm) overlying a generally homogenous placenta and a placental bulge. There was absence of lacunae and features of hypervascularity including bridging vessels. Our findings suggest accurate discrimination between a simple scar dehiscence with the placenta underlying it and placenta accreta spectrum can be made on prenatal ultrasound if the placenta is carefully examined for the vascular features unique to PAS. [ABSTRACT FROM AUTHOR]

We have suggested that adipocytes in uterine scars may affect the development of the placenta accrete spectrum (PAS). In the experimental part, we explored adipocytes in the uterine wall by the twelfth sexual cycle after surgery. In the clinical part, we investigated adipocyte clusters in the cesarean scar of pregnant women with and without PAS. The uterine wall was evaluated in gross and histological sections using morphometry, histochemistry (hematoxylin and eosin stain, Mallory stain), and immunohistochemistry for FABP4 (adipocyte markers), CD68, CD163, CD206 (macrophages), CD 34 (endothelium), cytokeratin 8 (epithelium), aSMA (smooth muscle cells). The design included an experimental study on Sprague–Dawley rats (n = 18) after a full-thickness surgical incision on the seventh (n = 6), 30th (n = 6), and 60th day (n = 6). The clinical groups include pregnant women without uterine scars (n = 10), pregnant women with a uterine scar after previous cesarean sections (n = 10), and women with PAS (n = 11). Statistical processing was carried out using nonparametric methods. Comparisons were conducted using the Mann–Whitney U-test and Kruskal–Wallis test. Statistical significance was considered at p < 0.05. On the seventh day, the rat uterine horn was enveloped by adipose tissue, which contained crown-like structures with FABP4+, CD68+, CD206+, and CD163+ cells. FABP4+ cells in the uterine wall were absent by the 30th day. The number of CD206+ and CD163+ cells in the adipose tissue decreased by the 30th day. On the 60th day, the attachment of fat tissue was revealed in the form of single strands. The serous layer around the damaged area totally recovered on the 60th day. FABP4+ cells were not detected in the uterine wall samples from pregnant women without a previous cesarean section. Adipocytes were found in the scar during non-complicated pregnancy and with PAS. Reducing the number of CD68+ cells in adipocyte clusters, there were in myometrium with PAS. Increased CD206+ and CD163+ cells were revealed in uterine adipocyte clusters of the group. According to the experimental finding, adipocytes should be absent in the uterine wall by the 12th sexual cycle after a full-thickness surgical incision. The presence of adipocyte clusters in cesarean scar indicated the disturbance of cell interaction. Differences in the numbers of CD206 and CD163 cells in adipocyte clusters between groups with and without PAS may be indirect evidence that uterine adipocytes affect the development of PAS. [ABSTRACT FROM AUTHOR]

Objectives: Clinical evaluation of the new Delphi consensus definition of cesarean scar pregnancy (CSP) in early gestation. Methods: A retrospective cohort of 36 women diagnosed with CSP and treated with combined local and systemic methotrexate (MTX) between 2008 and 2021. The CSPs were classified according to the new Delphi consensus criteria into three subgroups based on the depth of the gestational sac herniation in the sagittal plane. Subgroup A included 8 (22.2%) cases in which the largest part of the gestational sac protruded toward the uterine cavity. Subgroup B included 22 (61.1%) cases in which the largest part of the gestational sac was embedded in the myometrium, and subgroup C included 6 (16.7%) cases in which the gestational was partially located outside the outer contour of the cervix or uterus. Results: The β‐HCG level upon admission was significantly lower in subgroup A than in subgroups B or C (11,075 ± 7109, 18,787 ± 16,585, and 58,273 ± 55,267 mIU/mL, respectively, P =.01). All subgroup C patients had repeated courses of MTX and surgical interventions (laparotomy, uterine artery embolization, and operative hysteroscopy) at double the rate of subgroups A or B (100, 50, and 40.9%, respectively, P =.036). The duration of hospitalization was significantly shorter in subgroup A than in subgroups B or C (1.9 ± 1.5, 2.1 ± 1.1, and 5.4 ± 4.9 days, P =.01). Conclusions: The outcome according to Delphi consensus criteria for defining CSP in early gestation has implications for clinical decision‐making, patient care, and the follow‐up of CSP. [ABSTRACT FROM AUTHOR]

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Despite awareness of obstetricians to the constant increase in the number of cesarean sections in recent years, the fear of a uterine scar rupture is still present and influences the choice of the mode of delivery in patients with two previous cesarean sections. However, several clinical studies have suggested that, under certain conditions, vaginal birth after two cesarean sections is usually successful and safe. The objective of this study was to compare maternal and neonatal issues according to the planned mode of delivery in patients with two previous cesarean sections. It was a retrospective observational comparative study at Rennes University Hospital between January 1, 2013, and December 31, 2020. We performed a propensity score for the comparison of neonatal outcomes: cord pH, cord lactates, Apgar scores, transfer to neonatal unit and deaths, according to the planned delivery mode. Secondary outcomes were maternal issues: uterine rupture, post-partum hemorrhage, deaths. A total of 410 patients with two previous cesarean section were eligible for our study. Prophylactic cesarean was performed in 358 cases (87.3%). Trial of labor was attempted in the 52 remaining patients (12.7%), 67.3 % of whom were successful. Neonatal weight, APGAR score at 1–5–10 min, and pH on cord blood were comparable in both groups. One case of uterine rupture occurred in the trial of labor group. Trial of labor seems to be a reasonable option for women with two previous cesarean sections in a selected population. [ABSTRACT FROM AUTHOR]

Vaginal delivery after a Caesarean section remains a controversial topic: there is a lack of reliable data to help doctors and women in labour to determine the best option for delivery during subsequent pregnancy. The review analyzed and summarized the results of the studies devoted to childbirth of pregnant women with scars on the uterus, considered the advantages and disadvantages of vaginal childbirth and repeat Caesarean section, the frequency of complications in the attempt of vaginal childbirth in women with scars on the uterus has been assessed. The modern medical literature available in open sources has been studied: Russian-language scientifc electronic libraries eLibrary and CyberLeninka, Englishlanguage database of medical and biological publications PubMed. It is necessary to consider the data of anamnesis and clinical-instrumental data when choosing the best management tactics of pregnancy and delivery for women with scars on the uterus. Attempting to deliver vaginally helps to reduce maternal and neonatal morbidity, and a large number of studies on this issue should help to reduce the number of unwarranted repeat Caesarean sections. Vaginal delivery after a Caesarean section is an opportunity to avoid severe abdominal surgery and negative consequences associated with repeated Caesarean sections.

Accurate prenatal discrimination between a simple, non-adherent uterine scar dehiscence with an underlying placenta and the severe end of the placenta accreta spectrum is problematic as the two can appear similar on prenatal imaging. This may lead to the false diagnosis of placenta accreta spectrum resulting obstetric anxiety, overtreatment and potential iatrogenic morbidity. Despite potential similarities in the etiology, the manifestation and management of these two conditions is very different. The prenatal sonographic features of seven confirmed cases of simple uterine scar dehiscence with an underlying placenta previa were examined. The common sonographic features found for scar dehiscence was a thinned myometrium (

Objectives: Lower uterine segment (LUS) thickness measurement using transabdominal ultrasound (TA‐US), transvaginal ultrasound (TV‐US), or the combination of both methods can detect scar defect in women with prior cesarean. We aimed to compare the sensitivity of three approaches. Methods: Women with prior cesarean underwent LUS thickness measurement at 34–38 weeks' gestation. Among those who underwent repeat cesarean before labor, we compared the accuracy of TA‐US, TV‐US, and the thinner of the two measurements (the "combined measurement") for uterine scar dehiscence using the area under the curve (AUC) of receiver operating curves with their 95% confidence intervals (CI). We calculated the sensitivity and specificity of the three approaches using a cut‐off of 2.3 mm based on prior literature. Results: We included 747 participants. The mean LUS thickness was greater with TA‐US (3.8 ± 1.6 mm) compared with TV‐US (3.5 ± 1.9 mm) or the combined measurement (3.2 ± 1.5 mm; P <.001). The AUC was 78% (95% CI: 69%–87%), 85% (95% CI: 79%–91%), and 88% (95% CI: 82%–93%), respectively (all with P <.001). The AUC difference between TA‐US and the combined measurement was not significant (P =.057). A LUS below 2.3 mm would have predicted 9 (45%) of the 20 cases of uterine scar dehiscence using TA‐US, 17 (85%) using TV‐US, and 18 (90%) using the combined measurement (P <.01). Conclusion: The choice of ultrasound approach influences the measurement of the LUS thickness. The combination of the TA‐US and TV‐US seems to be superior for the detection of uterine dehiscence. [ABSTRACT FROM AUTHOR]

Uterine rupture is a rare life-threatening complication. It can occur in all 3 trimesters with the first and the second being a rarity. It mainly occurs in the third trimester or during labor in a previously scarred uterus. It is rare in an unscarred uterus. The risk fold is further enhanced by the induction and augmentation with prostaglandins and oxytocin. The clinical diagnosis at this early gestation can be a dilemma to the attending physician as in this case. (1) The patient was a holidaymaker with no documented evidence of a dating scan to suggest any evidence of an ovarian/placental pathology at that stage. (2) The ultrasound findings in our department did suggest a viable intrauterine pregnancy with free fluid within both the adnexa. A 6 cm solid homogenous mass in the midline/right adnexa suggested an ovarian torsion or bowel pathology. The differentials in this particular case were that of a ruptured hemorrhagic cyst, ovarian torsion and even a heterotrophic pregnancy as there had been a few documented cases in the department. Ultrasound diagnosis of an intrauterine pregnancy together with a fluid collection does not suggest by any means that the uterus is intact or there is no ectopic pregnancy.

The features of timely diagnosis and possible risks of the cesarean scar pregnancy are demonstrated on the example of a clinical case. This article presents analysis of pregnancy and childbirth of patient Sh., who was in the Obstetrics Department of the Kyiv City Maternity Hospital No. 1, as well as the results of a detailed morphological study of tissue characteristics during pregnancy in the scar on the uterus. A complete presentation of the chorion with localization in the area of the postoperative scar and a defect in the uterine wall was established at the first and second ultrasound screening. The woman was informed about pregnancy risks, but she insisted on prolonging the pregnancy. A planned surgical intervention was performed in the period of 36–37 weeks. A bottom caesarean section was performed and a girl weighing 3610 g, height 55 cm was removed. Intraoperatively confirmed deformation with a defect of the front uterus wall in the area of a postoperative scar measuring 10 × 12 cm, filled with placental tissue in the form of aneurysmal altered vessels. It was confirmed that placenta grew into the wall of the uterus over the entire area of its location, which occupied the entire lower segment on the entire circumference of the uterine body. At the same time, a significant deformation of the front and back walls of the uterus was noted. Morphological examination revealed hypoxic degenerative changes in the placenta, from the side of the parietal plate, with sclerosis, hyalinosis and deposition of fibrinoid in the villi, as well as the presence of hemorrhages, petrifications and the formation of conglomerates and bridges between them. Conclusions. It was founded the leading role in the mechanism of formation of atypical localization of pregnancy in the area of the scar after previous cesarean section was altered uterus tissue, where implantation occurred. There is a high probability of transition from ectopic pregnancy to scarring from liquid forms of ectopic pregnancy in the category of more frequent pathologies due to the increase in the frequency of cesarean sections.

Purpose: This study aimed to analyse the evolution of uterine scar thickness after open fetal surgery for myelomeningocele (MMC) by ultrasonography, and to establish a cut-off point for uterine scar thickness associated with high-risk of uterine rupture. Methods: A prospective longitudinal study was conducted with 77 pregnant women who underwent open fetal surgery for MMC between 24 and 27 weeks of gestation. After fetal surgery, ultrasound follow-up was performed once a week, and the scar on the uterine wall was evaluated and its thickness was measured by transabdominal ultrasound. At least five measurements of the uterine scar thickness were performed during pregnancy. A receiver operating characteristics (ROC) curve was constructed to obtain a cut-off point for the thickness of the scar capable of detecting the absence of thinning. Kaplan–Meier curves were constructed to evaluate the probability of thinning during pregnancy follow-up. Results: The mean ± standard deviation of maternal age (years), gestational age at surgery (weeks), gestational age at delivery (weeks), and birth weight (g) were 30.6 ± 4.5, 26.1 ± 0.8, 34.3 ± 1.2 and 2287.4 ± 334.4, respectively. Thinning was observed in 23 patients (29.9%). Pregnant women with no thinning had an average of 17.1 ± 5.2 min longer surgery time than pregnant women with thinning. A decrease of 1.0 mm in the thickness of the uterine scar was associated with an increased likelihood of thinning by 1.81-fold (95% confidence interval [CI]: 1.32–2.47; p < 0.001). The area below the ROC curve was 0.899 (95% CI: 0.806–0.954; p < 0.001), and the cut-off point was ≤ 3.0 mm, which simultaneously presented greater sensitivity and specificity. After 63 days of surgery, the probability of uterine scarring was 50% (95% CI: 58–69). Conclusion: A cut-off point of ≤ 3.0 mm in the thickness of the uterine scar after open fetal surgery for MMC may be used during ultrasonography monitoring for decision-making regarding the risk of uterine rupture and indication of caesarean section. [ABSTRACT FROM AUTHOR]

Placenta accreta spectrum is a pregnancy complication associated with severe morbidity and maternal mortality especially when not suspected antenatally and appropriate management instigated. Women in resource‐limited settings are more likely to face adverse outcomes due to logistic, technical, and resource inadequacies. Accurate prenatal imaging is an important step in ensuring good outcomes because it allows adequate preparation and an appropriate management approach. This article provides a simple three‐step approach aimed at guiding clinicians and sonographers with minimal experience in placental accreta spectrum through risk stratification and basic prenatal screening for this condition both with and without Doppler ultrasound. [ABSTRACT FROM AUTHOR]

Distinguishing between urinary bladder varices and retroplacental neovascularization in placenta accreta spectrum in high‐risk patients with placental previa is a diagnostic challenge since they have similar appearances on prenatal ultrasound. Placenta accreta spectrum is associated with massive obstetric haemorrhage while the presence of urinary bladder varices in pregnancy poses a lower surgical risk. Since the clinical implications and management approach for both conditions are entirely different, false positive diagnoses have iatrogenic consequences. In this article, we share our experiences in differentiating these two phenomena on prenatal ultrasound supported by ultrasound and intraoperative images. [ABSTRACT FROM AUTHOR]

Histological examination of uterine scars provides insight into uterine wound healing and helps to develop prevention methods of uterine wall rupture after previous uterine surgery. Therefore, exact intraoperative scar identification is needed for specimen collection from the actual scar tissue. The aim of this study was to correlate pre- and intraoperative ultrasound measurements of the lower uterine segment (LUS) with histological findings of scar tissue and to evaluate the relevance of intraoperative ultrasound. In a prospective observational study, preoperative and intraoperative sonographic measurements of the LUS thickness were performed in 33 women with a history of at least one cesarean delivery. Intraoperative ultrasound with a linear transducer placed directly on the uterus identified the scar area and uterotomy was performed 2 cm cranially. Tissue samples were taken after extraction of the fetus, embedded in paraffin wax, and stained according to Gomori Trichrome to identify scar tissue. Collagen content was evaluated with imaging software Fiji (NIH, Bethesda, USA). Preoperative and intraoperative sonographic measurements were correlated with histologic evidence of scar tissue. Histological evidence of scar tissue was found in 11 out of 33 samples with significantly lower ultrasonographic thickness of the lower uterine segment compared to the other 22 samples, both antepartum (1.4 mm [1.3–1.9] vs. 2.0 mm [1.6–2.6], p=0.03) and intrapartum (1.6 mm [1.3–1.9] vs. 3.7 mm [2.0–4.7], p<0.01). Intraoperative ultrasound had a significantly higher predictive power (AUC difference 0.18 [0.03–0.33], p=0.01). Intraoperative sonography identifies the uterine wall area with histologically confirmable scar tissue far better than preoperative sonography. [ABSTRACT FROM AUTHOR]

Objective: Placenta accreta spectrum (PAS) is a continuum of invasive pathologies associated with significant maternal morbidity and mortality. Pregnancies with short intervals present additional complications which may result from suboptimal wound healing. The impact of short interval pregnancy on placental invasion is unknown our primary objective was to characterize the impact of short interval pregnancy in the subsequent invasive degree of PAS. Methods: Here we present a retrospective case-control analysis of 133 patients with pathology-confirmed PAS who presented to our Placenta Accreta program and assessed for the impact of short interval pregnancy (<18 months) as an independent risk factor for the development of advanced pathology. Results: 33.8% (45/133) of patients with PAS had pregnancies complicated by short intervals between gestations. Short interval pregnancies were significantly associated with placenta percreta/increta pathology (p = .006). Ordinal logistic regression showed an inversely proportional relationship between short-interval pregnancy and the degree of placental invasion (OR 2.91 [95% CI 1.02, 4.05]). Conclusion: Short interval pregnancies are at increased risk for greater degrees of placenta invasion seen in placenta increta and percreta when compared to interpregnancy interval >18 months. This relationship is inversely proportional and consistent at shorter intervals. Thus, when counseling patients on their overall risk of placental invasive pathology, short interval pregnancy may be considered a significant risk factor. [ABSTRACT FROM AUTHOR]

Pregnancies complicated by the placenta praevia are associated with an increased risk of massive obstetric bleeding and high rates of hysterectomy which are often caused by the placenta accreta. The aim of our study was to identify the risk factors for placenta praevia associated with PAS disorders and the efficacy of distal haemostasis during Cesarean delivery. Methods This was a cohort study carried out between 2014 and 2020 in 532 women with abnormal placental localization and attachment. The placental attachment spectrum (PAS) disorder diagnosis was confirmed during the surgery and by the histology results in 164/532 participants. Depending on the surgical approach during the Cesarean delivery, patients were divided into three groups. In Group 1 (n = 52), patients underwent bilateral uterine artery ligation. In Group 2 (n = 33), we used the combined compression haemostasis approach including the placement of tourniquets and insertion of an intrauterine balloon for controlled tamponade. In Group 3 (n = 79), we used the combination of surgical haemostasis with the controlled intrauterine tamponade using the vaginal and intrauterine Zhukovsky balloon. Results PAS was observed in 30.8% of the placenta praevia cases, and in 93.3% was associated with the presence of a uterine scar. Women with the placenta praevia and PAS had a significantly higher number of past deliveries (р = .001). According to the FIGO classification, 53.8% of women with placenta praevia observed during the Cesarean had РА1 and 46.2% PA2. With regards to the PAS disorders observed in 30.8% of patients, 38.4% had PAS3, 34.7% PAS4, 18.3% PAS5 and 8.5% PAS6. The histology analysis showed normal placental attachment in 42.9% of the total number of study participants, placenta accreta in 28.2%, placenta increta in 16.7%, and placenta percreta in 12.2%. In Group 1, we performed the resection of uterine wall with the attached portion of the placenta in 13.5% of women, in Group 2 in 30.3% women, and in Group 3 in 50.6% women. There was a significant 4.8-fold reduction in the number of hysterectomies in Group 3 versus Group 2 (р = .043) and a 4.4-fold reduction in Group 2 versus Group 1 (р = .003). In Group 2, the volume of blood loss was 1.3-fold lower and in Group 3 1.5-fold lower than in Group 1. Conclusion: The techniques of compression distal haemostasis evaluated in this study in women with PAS are efficacious in the reduction of adverse maternal outcomes and should be used more widely in clinical practice. [ABSTRACT FROM AUTHOR]

Objective In an attempt to avoid emergency deliveries of women with multiple prior scars, providers may choose to schedule those repeat cesarean births prior to 39 weeks. Our primary goal was to compare rates of assisted ventilation use between neonates with early term (37°-386 weeks) and full-term (39°–396 weeks) deliveries among women with three or more prior cesarean births. Methods A retrospective cohort study of women with three or more previous cesarean births. The study group consisted of women who delivered at early term (37°–386 weeks). The control group consisted of women who delivered at full term (39°–396 weeks gestation). Women with a history of pre-gestational diabetes, gestational hypertension and chronic hypertension were excluded. Data were extracted from the 2017 United States Natality database. Characteristics were compared between groups for potential confounders. Primary outcome, neonatal assisted ventilation use greater than 6 h, and other secondary outcomes (including immediate assisted ventilation in the neonate and uterine rupture) were compared between groups. Multivariable logistic regression analyses were performed to adjust for potential confounding factors between groups. Results A total of 28,584 women with three or more prior cesarean births were included. There were 12,391 women who delivered at early term, and 16,193 who delivered at full term. Neonates born from women who delivered at early term had an increased risk of assisted ventilation use greater than 6 h compared with neonates who delivered at full term (assisted ventilation greater than 6 h, adjusted odds ratio (aOR) 2.08, 95% confidence interval (CI) [1.59–2.73]). Neonates delivered at early term were also more likely to need immediate ventilation use than were neonates delivered at full term (aOR 1.52, 95% CI [1.33–1.73]). Women who delivered at early term had a higher rate of uterine rupture compared with women who delivered at full term (OR 5.67, 95% CI [2.33–13.79]). [ABSTRACT FROM AUTHOR]

We have suggested that adipocytes in uterine scars may affect the development of the placenta accrete spectrum (PAS). In the experimental part, we explored adipocytes in the uterine wall by the twelfth sexual cycle after surgery. In the clinical part, we investigated adipocyte clusters in the cesarean scar of pregnant women with and without PAS. The uterine wall was evaluated in gross and histological sections using morphometry, histochemistry (hematoxylin and eosin stain, Mallory stain), and immunohistochemistry for FABP4 (adipocyte markers), CD68, CD163, CD206 (macrophages), CD 34 (endothelium), cytokeratin 8 (epithelium), aSMA (smooth muscle cells). The design included an experimental study on Sprague–Dawley rats (n = 18) after a full-thickness surgical incision on the seventh (n = 6), 30th (n = 6), and 60th day (n = 6). The clinical groups include pregnant women without uterine scars (n = 10), pregnant women with a uterine scar after previous cesarean sections (n = 10), and women with PAS (n = 11). Statistical processing was carried out using nonparametric methods. Comparisons were conducted using the Mann–Whitney U-test and Kruskal–Wallis test. Statistical significance was considered at p < 0.05. On the seventh day, the rat uterine horn was enveloped by adipose tissue, which contained crown-like structures with FABP4+, CD68+, CD206+, and CD163+ cells. FABP4+ cells in the uterine wall were absent by the 30th day. The number of CD206+ and CD163+ cells in the adipose tissue decreased by the 30th day. On the 60th day, the attachment of fat tissue was revealed in the form of single strands. The serous layer around the damaged area totally recovered on the 60th day. FABP4+ cells were not detected in the uterine wall samples from pregnant women without a previous cesarean section. Adipocytes were found in the scar during non-complicated pregnancy and with PAS. Reducing the number of CD68+ cells in adipocyte clusters, there were in myometrium with PAS. Increased CD206+ and CD163+ cells were revealed in uterine adipocyte clusters of the group. According to the experimental finding, adipocytes should be absent in the uterine wall by the 12th sexual cycle after a full-thickness surgical incision. The presence of adipocyte clusters in cesarean scar indicated the disturbance of cell interaction. Differences in the numbers of CD206 and CD163 cells in adipocyte clusters between groups with and without PAS may be indirect evidence that uterine adipocytes affect the development of PAS.

One of the rare complications of a previous cesarean section is pregnancy with implantation in the area of the postoperative scar. The literature describes isolated reports of this pathology, which relate to early pregnancy. The forecast and tactics of their management are debatable issues. This article presents a case of successful monitoring of pregnancy and childbirth of a patient with a combined pathology: the placenta in the area of the cesarean scar with its diastase and central placenta previa with the germination of the uterine wall. The 34-year-old pregnant woman (III pregnancy and II expected childbirth) during ultrasound examination central a placenta previa was diagnosed. It had ingrowth into the uterine wall creating defect of the cesarean scar. Informed about the possible risks, patient strongly insisted on prolonging the pregnancy. Since 23 weeks she was in an obstetric hospital for the possibility of urgent surgery. Within 37 weeks, a planned caesarean section was performed by bottom access with subsequent extirpation of the uterus. Literary data from different countries almost all describe the completion of cesarean scar pregnancy in the first and second trimesters. Due to the rarity, heterogeneity of groups and the lack of a single protocol for the management of this pathology, combined or modified approaches to treatment are more often used. Primary prevention should begin at the stage of preventing a high frequency of cesarean section, reviewing the indications for it and conducting a truly justified surgery. Preconceprion care should be mandatory when planning the next pregnancy. Great attention should be paid to the localization of the chorion in the protocol of the screening ultrasound examination of the first trimester if there is uterine scar. In the case of a cesarean scar pregnancy, we cannot recommend an expectant tactics at this stage. Any method that eliminates cesarean scar pregnancy, especially in the early term, will saving the body and future fertility, as well as reduces morbidity and mortality.

Uterine scar was one of the long-term complications cesarean section. In this study, an thermo-responsive injectable hydrogel loaded with human umbilical cord mesenchymal stem cells (UCMSCs) and asiaticoside microspheres (AMs) was used for uterine scar repair, which was prepared by optimizing the mixed ratio of aldehyde-functionalized Pluronic F127 (F127-CHO) and adipic dihydrazide-modified hyaluronic acid (AHA). The asiaticoside was loaded in Poly (DL-lactide- co -gycolide) (PLGA) by emulsion- diffusion-evaporation method. The hydrogel had appropriate pore size, good mechanical property, and slow release ability of asiaticoside. In vitro cell experiments demonstrated that F127-CHO/AHA/AMs could effectively promote stem cell adhesion and proliferation, promote angiogenesis, and provide a suitable microenvironment for cell survival. The F127-CHO/AHA/AMs/UCMSCs hydrogel was further used to repair uterine scar in female SD rats. The results showed that the prepared hydrogel could promote the proliferation of rat endometrial cells, promote the regeneration of glands, reduce the degree of endometrial fibrosis and restore the morphology of uterine cavity. The hydrogel could upregulate expression of Ki67 and IGF-1, downregulate TGF-β1 expression and promote M1-M2 transition of macrophages. This study confirmed that the prepared hydrogel could be used as an effective transplantation strategy, which could be expected to achieve clinical transformation of uterine scar repair. [ABSTRACT FROM AUTHOR]

Background: cesarean scar niche is one of the novels mentioned complications of cesarean section due to the rising numbers of cesarean sections and improved imaging modalities. The causes of cesarean scar niche are still being investigated, one of them is the uterine closure method that should be studied to pick up the best one to decrease the incidence of niche after cesarean delivery. Objective: The aim of this work was to find the best way of uterine closure decreasing the incidence of cesarean section niche. Material and methods: A prospective randomized controlled study that was conducted between May 2021 and April 2022 at the department of Obstetrics and Gynecology, Zagazig University. Full term ninety-eight primigravida undergoing first elective cesarean section were equally randomized to either purse string or double-layer unlocked suture. Six months after cesarean section, Sonohysterography was done for assessment of cesarean scar integrity. Markers of cesarean scar healing included residual myometrial thickness "RMT", niche depth "D", hypoechoic triangular niche width "W” and healing ratio "D/RMT". All these markers were calculated by experienced sonographers who were not aware of the uterine closure technique. Results: In terms of estimated blood loss, there was no significant differences between both groups. However, frequency of appearance of niche in purse-string group was 25% compared to 56.8% in the double layer group (P=0.002). The mean thickness of the residual myometrium covering the defect was significantly higher 7.8 ± 1.1 mm after purse-string than 5.9 ± 0.6 mm after a double-layer closure (P = 0.001). The mean healing ratio in purse-string group was 0.449 versus 0.600 in the double-layer closure (p<0.001). Conclusion: Purse-string uterine closure was associated with better uterine scar healing, higher residual myometrial thickness and lower rate of cesarean scar defect than double layer closure. [ABSTRACT FROM AUTHOR]

Placenta accreta has been described as a spectrum of abnormal attachment of villous tissue to the uterine wall, ranging from superficial attachment to the inner myometrium without interposing decidua to transmural invasion through the entire uterine wall and beyond. These descriptions have prevailed for more than 50 years and form the basis for the diagnosis and grading of accreta placentation. Accreta placentation is essentially the consequence of uterine remodeling after surgery, primarily after cesarean delivery. Large cesarean scar defects in the lower uterine segment are associated with failure of normal decidualization and loss of the subdecidual myometrium. These changes allow the placental anchoring villi to implant, and extravillous trophoblast cells to migrate, close to the serosal surface of the uterus. These microscopic features are central to the misconception that the accreta placental villous tissue is excessively invasive and have led to much confusion and heterogeneity in clinical data. Progressive recruitment of large arteries in the uterine wall, that is, helicine, arcuate, and/or radial arteries, results in high-velocity maternal blood entering the intervillous space from the first trimester of pregnancy and subsequent formation of placental lacunae. Recently, guided sampling of accreta areas at delivery has enabled accurate correlation of prenatal imaging data with intraoperative features and histopathologic findings. In more than 70% of samples, there were thick fibrinoid depositions between the tip of most anchoring villi and the underlying uterine wall and around all deeply implanted villi. The distortion of the uteroplacental interface by these dense depositions and the loss of the normal plane of separation are the main factors leading to abnormal placental attachment. These data challenged the classical concept that placenta accreta is simply owing to villous tissue sitting atop the superficial myometrium without interposed decidua. Moreover, there is no evidence in accreta placentation that the extravillous trophoblast is abnormally invasive or that villous tissue can cross the uterine serosa into the pelvis. It is the size of the scar defect, the amount of placental tissue developing inside the scar, and the residual myometrial thickness in the scar area that determine the distance between the placental basal plate and the uterine serosa and thus the risk of accreta placentation. [ABSTRACT FROM AUTHOR]

Objectives: The study investigated isthmocele rate, residual myometrium thickness, blood loss, and closure lengths through comparing the classical primary continuous suturing (CPCS) and novel technique uterine suturing (NTUS) after caesarian section. Material and methods: A total of 402 C/S patients were included in this single-center prospective clinical study. All patients were divided into two groups according to suture technique. Classical primary continuous suturing (CPCS) was applied to the patients in Group 1, while the novel technique uterine suturing (NTUS) was applied in Group 2 as Z suture on both corners and 8 sutures in the remaining middle part incision closure. Results: Patients in the NTUS group bled less than in the CPCS groups (p < 0.0001). Incision length after closure was longer in the CPCS than in the NTUS (p < 0.0001). Similarly, the number of sutures we applied was higher in the CPCS (p < 0.0001). In comparison of residual myometrium thickness, the mean values measured 197 ± 50 mm in the NTUS and 146 ± 39 mm in the CPCS (p < 0.0001). Residual myometrium thickness showed a negative strong correlation with incision length after closure (r = -0.436; p < 0.0001), how many times the needles have been passed (r = -0.423; p < 0.0001) and time for suturing (r = -0.237; p < 0.0001). NTUS and CPCS groups were similar in comparison to isthmocele. Conclusions: The NTUS, termed as Erkayiran's suture, showed a successful reflection in our surgical cesarean section application compared to the classical suture. Although the occurrence of isthmocele in patients was similar, results were quite successful operationally in terms of both minimal blood loss and increased residual myometrium thickness. [ABSTRACT FROM AUTHOR]

Objective: To ascertain the vaginal birth rate following the trial of uterine scar and its outcomes. Study Design: Cross-sectional Observational study. Setting: Department of Gynecology Bakhtawar Amin Trust Teaching Hospital Multan. Period: 6th August 2020 to 6th August 2021. Material & Methods: After passing through selection criteria, all enrolled women underwent serial ultrasound including pelvis ultrasound to access scar thickness up to thirty-six gestation weeks. All women were evaluated for baseline investigations, clinical history, and underwent cardiotocography (CTG) which was then followed by a trial of labor (TOL). Women who experienced spontaneous labor after TOL were observed through partogram and intrapartum CTG. All maternal and fetal outcomes were observed. Results: Out of these 80 women, 51 (63.7%) had successfully given birth through the vaginal route while 29 (36.2%) underwent emergency CS following TOL. The majority of enrolled women, 62 (77.5%) had age less than 35 years, 45 (56.2%) had parity 1-4, and 74 (92.5%) had gestation age >36 weeks. 3 (5.8%) women had a history of VBAC and all had parity >4. Among the women with successful VBAC, the majority were younger than 35 years (88.2%), parity less than 4 (62.7%), and all were positive for previous successful VBAC. Postpartum hemorrhage was the most reported maternal complication (3.9%). Three (4.4%) experienced intra-uterine deaths which were the major fetal complications. Conclusion: Trial of vaginal birth following cesarean section could be a preferable option given its association with low fetal and maternal complications and considerable success rate. [ABSTRACT FROM AUTHOR]

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. Access the CME test here and search by article title. [ABSTRACT FROM AUTHOR]

Background: Women are at increased risk of developing anxiety or depression disorders after Cesarean section (CS). This study aims to evaluate whether an appointment with a senior obstetrician combined with an ultrasound examination reduces levels of anxiety in women after CS. Methods: A prospective observational study was conducted in Sweden. Women underwent an appointment with an obstetrician 6–9 months after their first CS. Before the appointment, women were asked to fill in the state and trait subscales of the Spielberger State-Trait Anxiety Inventory and the Beck's Depression Inventory. The women's experience of the childbirth was discussed and an ultrasound examination of the hysterotomy scar was performed. After the appointment, the participants filled in the state scale again. The women were divided into low trait anxiety (< 40) and high trait anxiety (≥ 40) groups for comparisons. Results: 147 women were included. Of those, 114 (78%) had lower trait score

Background: The rate of cesarean deliveries is steadily growing worldwide as a result of increasing maternal age at first delivery. Ensuring optimal recovery after surgery, specifically the development of a functionally competent uterine scar to facilitate vaginal birth after a cesarean delivery (VBAC), is one of the challenges in modern obstetrics. Extracellular microvesicles (EMVs) are secreted by multiple cell types and act as mediators of intercellular interaction during tissue reparation. The immunomodulatory and regenerative effects of EMVs of mesenchymal stromal cells (MSCs) have been studied shown in pre-clinical studies. Aim of the study: To evaluate the safety profile of EMVs of mesenchymal stromal placental cells (MSPCs) injected during the cesarean delivery and the impact of this pilot approach on post-surgery recovery. Materials and methods: This pilot study included 53 women undergoing cesarean delivery with (n = 23) or without (n = 30) an injection of 500 μl of MSC EMVs after closing the uterine incision with a single continuous Vicryl suture. Results: All study participants had uncomplicated post-surgery period. The mean inpatient stay duration in women receiving the EMV injection was 4.26 ± 0.09 days vs. 5.33 ± 0.38 in the control group (p<.05). There were no postpartum inflammatory complications in the study group compared with two cases (6.7%) by postpartum endometritis/myometrial infection and one case (3.3%) of lochiometra in the control group. Summary: Intra-surgery injection of MSC EMVs was well-tolerated and associated with a lower rate of infectious post-partum complications in women undergoing cesarean delivery. [ABSTRACT FROM AUTHOR]

Whether there is an association between residual myometrial thickness (RMT) after cesarean section (CS) and the risk of uterine rupture (UR) or uterine scar dehiscence at the subsequent delivery has been sparsely investigated. Our cohort included 149 women with a first CS in whom we measured RMT by transvaginal ultrasonography 6–15 months after their delivery. We did a follow-up study on delivery outcomes in the women's subsequent births. The exposure was scar measurements in the non-pregnant uterus, and the primary outcome was a diagnosis of UR or dehiscence. We calculated likelihood ratios (LRs) with 95% confidence intervals of having UR or dehiscence with a thin RMT (<3 mm). Among the 149 women, 39 had a repeat CS (14 scheduled and 25 unscheduled procedures), and within these, we found one woman with UR and five women with uterine dehiscence. The proportion of women with a thin RMT was significantly higher among cases (4/6) than in controls (4/33); the LR was 5.5 (95% CI 1.9–16.2). The results suggest a significant association between a thin RMT as measured by transvaginal ultrasonography in the non-pregnant uterus after a first scheduled CS and the risk of UR or dehiscence at a subsequent delivery. [ABSTRACT FROM AUTHOR]

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Fibroids are the most common benign tumours of the uterus, often requiring surgery when symptomatic. This study aims to investigate the impact of surgery using two methods, laparoscopy and laparotomy, on the thickness and vascularity of the uterine myometrium at the site of myomectomy scar (comparing sonographic features at the surgical scar site, including thickness, vascularity, and the extent of fibrotic tissue, in both open and laparoscopic surgical approaches). In this clinical trial, 100 women with type 2-5 fibroids and clinical symptoms, seeking surgery et al. Zahra Hospital, were enrolled in two groups: laparoscopy and laparotomy. Inclusion criteria were a maximum fibroid size of 8 cm and, in the case of multiple fibroids, a maximum of three, with the largest being 8 cm. 6 months post-surgery, sonographic assessments of the myomectomy scar site were compared between both groups. Participants showed no significant differences in demographic and obstetric factors. The most common clinical symptom (87%) in both groups was abnormal uterine bleeding (AUB). The mean hospital stay duration was statistically significantly lower in the laparoscopy group at 1.64 (SD 0.56) compared to 1.89 (SD 0.58) in the laparotomy group (p = 0.028). Additionally, the decrease in haemoglobin levels was 0.89 (SD 0.92) and 1.87 (SD 2.24) units, respectively, which showed a statistically significant difference (p = 0.003). The duration of surgery was significantly shorter in the laparotomy group (p = 0.001). Abdominal pressure was not observed in the laparoscopy group, while 12% of the laparotomy group reported complaints (p = 0.013). Based on the results obtained in this study, it can be concluded that there was no difference between these two methods in terms of improving uterine thickness and associated complications. However, the decrease in haemoglobin levels and the length of hospital stay were lower in patients undergoing laparoscopy., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: External cephalic version (ECV) is a common procedure and has been shown to be safe and effective in turning a baby from a breech to cephalic presentation. However, whether ECV is safe and effective in women with a scarred uterus from a previous caesarean section remains contentious. Aim: To evaluate the safety and efficacy of external cephalic version in women with a singleton breech pregnancy and at least one previous caesarean delivery. Material and methods: Literature searches were conducted on MEDLINE, PUBMED, EMBASE, CINAHL and SCOPUS up to June 2020. The search strategy included the following keywords: ('external cephalic version OR ECV') AND ('previous OR prior OR past' AND 'caesarean OR caesarean OR uterine scar'). Studies were included if they evaluated the efficacy and/or safety of external cephalic version in women after 36 weeks' gestation with a singleton breech pregnancy and at least one previous caesarean delivery. Results: Nine studies were included in the review. ECV success rates and subsequent vaginal delivery rates ranged from 50 to 100% and from 50 to 74.9%, respectively. ECV complications reported included abnormal fetal heart rate, abnormal cardiotocography and transient vaginal bleeding. No studies reported cases of uterine rupture. Conclusions: ECV in women with a previous caesarean delivery is a relatively successful and low‐risk procedure compared to women without a previous caesarean delivery. The results from this systematic review provide useful information for professional bodies in updating clinical guidelines such that ECV may be offered to women with one previous caesarean delivery. [ABSTRACT FROM AUTHOR]

Introduction: Uterine rupture is an obstetric emergency associated with maternal and neonatal morbidity. The main risk factor is a prior cesarean section, with rupture occurring in subsequent labor. The aim of this study was to assess the risk of uterine rupture by labor duration and labor management. Material and methods: This is a Swedish register‐based cohort study of women who underwent labor in 2013–2018 after a primary cesarean section (n = 20 046). Duration of labor was the main exposure, calculated from onset of regular labor contractions and birth; both timepoints were retrieved from electronic medical records for 12 583 labors, 63% of the study population. Uterine rupture was calculated as events per 1000 births at different timepoints during labor. Risk estimates for uterine rupture by labor duration, induction of labor, use of oxytocin and epidural analgesia were calculated using Poisson regression, adjusted for maternal and birth characteristics. Estimates were presented as adjusted rate ratios (ARR) with 95% confidence intervals (CI). Results: The prevalence of uterine rupture was 1.4% (282/20 046 deliveries). Labor duration was 9.88 hours (95% CI 8.93–10.83) for women with uterine rupture, 8.20 hours (95% CI 8.10–8.31) for women with vaginal delivery, and 10.71 hours (95% CI 10.46–10.97) for women with cesarean section without uterine rupture. Few women (1.0/1000) experienced uterine rupture during the first 3 hours of labor. Uterine rupture occurred in 15.6/1000 births with labor duration over 12 hours. The highest risk for uterine rupture per hour compared with vaginal delivery was observed at 6 hours (ARR 1.20, 95% CI 1.11–1.30). Induction of labor was associated with uterine rupture (ARR 1.54, 95% CI 1.19–1.99), with a particular high risk seen in those induced with prostaglandins and no risk observed with cervical catheter (ARR 1.19, 95% CI 0.83–1.71). Labor augmentation with oxytocin (ARR 1.60, 95% CI 1.25–2.05) and epidural analgesia (ARR 1.63, 95% CI 1.27–2.10) were also associated with uterine rupture. Conclusions: Labor duration is an independent factor for uterine rupture among women attempting vaginal delivery after cesarean section. Medical induction and augmentation of labor increase the risk, regardless of maternal and birth characteristics. [ABSTRACT FROM AUTHOR]

Placenta accreta spectrum disorders are associated with severe maternal morbidity and mortality. Placenta accreta spectrum disorders involve excessive adherence of the placenta preventing separation at birth. Traditionally, this condition has been attributed to excessive trophoblast invasion; however, an alternative view is a fundamental defect in decidual biology. This study aimed to gain insights into the understanding of placenta accreta spectrum disorder by using single-cell and spatially resolved transcriptomics to characterize cellular heterogeneity at the maternal-fetal interface in placenta accreta spectrum disorders. To assess cellular heterogeneity and the function of cell types, single-cell RNA sequencing and spatially resolved transcriptomics were used. A total of 12 placentas were included, 6 placentas with placenta accreta spectrum disorder and 6 controls. For each placenta with placenta accreta spectrum disorder, multiple biopsies were taken at the following sites: placenta accreta spectrum adherent and nonadherent sites in the same placenta. Of note, 2 platforms were used to generate libraries: the 10× Chromium and NanoString GeoMX Digital Spatial Profiler for single-cell and spatially resolved transcriptomes, respectively. Differential gene expression analysis was performed using a suite of bioinformatic tools (Seurat and GeoMxTools R packages). Correction for multiple testing was performed using Clipper. In situ hybridization was performed with RNAscope, and immunohistochemistry was used to assess protein expression. In creating a placenta accreta cell atlas, there were dramatic difference in the transcriptional profile by site of biopsy between placenta accreta spectrum and controls. Most of the differences were noted at the site of adherence; however, differences existed within the placenta between the adherent and nonadherent site of the same placenta in placenta accreta. Among all cell types, the endothelial-stromal populations exhibited the greatest difference in gene expression, driven by changes in collagen genes, namely collagen type III alpha 1 chain (COL3A1), growth factors, epidermal growth factor–like protein 6 (EGFL6), and hepatocyte growth factor (HGF), and angiogenesis-related genes, namely delta-like noncanonical Notch ligand 1 (DLK1) and platelet endothelial cell adhesion molecule-1 (PECAM1). Intraplacental tropism (adherent versus non-adherent sites in the same placenta) was driven by differences in endothelial-stromal cells with notable differences in bone morphogenic protein 5 (BMP5) and osteopontin (SPP1) in the adherent vs nonadherent site of placenta accreta spectrum. Placenta accreta spectrum disorders were characterized at single-cell resolution to gain insight into the pathophysiology of the disease. An atlas of the placenta at single cell resolution in accreta allows for understanding in the biology of the intimate maternal and fetal interaction. The contributions of stromal and endothelial cells were demonstrated through alterations in the extracellular matrix, growth factors, and angiogenesis. Transcriptional and protein changes in the stroma of placenta accreta spectrum shift the etiologic explanation away from "invasive trophoblast" to "loss of boundary limits" in the decidua. Gene targets identified in this study may be used to refine diagnostic assays in early pregnancy, track disease progression over time, and inform therapeutic discoveries. [Display omitted] [ABSTRACT FROM AUTHOR]