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• Cesarean scar defects can result in secondary infertility and uterine rupture. • The defects showed thin residual myometrial thickness and/or complex shape. • Abdominal repair for cesarean scar defect had favorable reproductive outcomes. • Twin pregnancy (double blastocyst transfer) must be avoided in women with repair surgery. To clarify the reproductive outcomes of women who underwent abdominal repair surgery for cesarean scar defect (CSD). This is a retrospective observational study performed in a tertiary center. We retrospectively reviewed 20 women who underwent abdominal repair between 2007 and 2021. The indication for the repair was a minimal residual myometrial thickness (RMT) of ≦3.0 mm. We investigated surgical complications, changes in minimal RMT before and three-months after the repair, and reproductive outcomes. The median age at the time of repair was 36 years (27–40), with a median body mass index of 21.0 (17.7–28.7) and a median of 1 prior cesarean section (1–5). Twelve women reported secondary infertility, while eight women were concerned about the potential risk of uterine rupture in future pregnancies due to thin RMT. Additionally, one woman had a co-existing vesicouterine fistula, two had abscess and hematoma formation at the precedent cesarean section, and three showed remarkable dehiscence of the defect. The median minimal RMT significantly increased to 5.05 mm (range; 2.5–14.2 mm) after the repair. Seven women had a total of eight live births, with a median duration from the repair to a live-birth pregnancy of 11.5 months (range; 4–20 months). No surgical complications occurred during the repair, and there were no instances of uterine rupture in subsequent pregnancies. However, one woman who became pregnant with twins following double blastocyst transfer required a cesarean section at 25 weeks of pregnancy due to bulging towards the bladder side of the repaired CSD. Abdominal repair for CSD is feasible in women with thin RMT who experience secondary infertility. Twin pregnancies can promote thinning of the CSD repair site, potentially increasing the risk of uterine rupture. [ABSTRACT FROM AUTHOR]

To report a patient with prolonged intermenstrual bleeding and a cystic mass at a cesarean scar treated with laparoscopic folding sutures and hysteroscopic canalization. A 4.0 cm-cystic mass formed at the uterine scar caused continuous menstrual blood outflow in the diverticulum and was treated with hysteroscopy combined with laparoscopy. University hospital. A 38-year-old woman of childbearing age who had undergone two cesarean sections and two abortions reported vaginal bleeding for 10 years, which began shortly after the second cesarean section. Curettage was performed, but no abnormality was found. The patient unsuccessfully tried to manage her symptoms with traditional Chinese medicine and hormone drugs. The muscular layer of the lower end of the anterior wall of the uterus was weak, and there were cystic masses on the right side. The bladder was stripped from the lower uterine segment under laparoscopy, and the surrounding tissue of the mass at the uterine scar was separated. The position of the cesarean scar defect was identified by hysteroscopy combined with laparoscopy, and the relationship between the uterine mass and surrounding tissues was analyzed. An electric cutting ring resection on both sides of the obstruction was performed to eliminate the valve effect. The active intima of the scar diverticulum was destroyed by electrocoagulation, followed by laparoscopic treatment of the uterine scar diverticulum mass. An intraoperative tumor incision revealed visible bloody fluid mixed with intimal material. The uterine scar diverticulum defect was repaired using 1–0 absorbable barbed continuous full-thickness mattress fold sutures. Finally, the bilateral round ligament length was adjusted so that the uterus tilted forward. Recovery of menstruation and anatomy of the uterine isthmus. The operation was successful, and the postoperative recovery was fast. There was no interphase bleeding at the 1-month follow-up, and the uterine scar diverticulum was repaired, with the thickness of the uterine scar muscle layer increasing to 0.91 cm. The simple, straightforward procedure to resolve the abnormal cystic, solid mass formed because of the continuous deposition of blood in the uterine scar diverticulum involved laparoscopic folding and docking sutures combined with hysteroscopic canal opening. [ABSTRACT FROM AUTHOR]

The rising rate of cesarean deliveries has led to an increased incidence of long long-term complications, including niche formation in the uterine scar. Niche development is associated with various gynecologic complaints and complications in subsequent pregnancies, such as uterine rupture and placenta accreta spectrum disorders. Although uterine closure technique is considered a potential risk factor for niche development, consensus on the optimal technique remains elusive. We aimed to evaluate the effect of single-layer vs double-layer closure of the uterine incision on live birth rate at a 3-year follow-up with secondary objectives focusing on gynecologic, fertility, and obstetrical outcomes at the same follow-up. A multicenter, double-blind, randomized controlled trial was performed at 32 hospitals in the Netherlands. Women ≥18 years old undergoing a first cesarean delivery were randomly assigned (1:1) to receive either single-layer or double-layer closure of the uterine incision. The primary outcome of the long-term follow-up was the live birth rate; with secondary outcomes, including pregnancy rate, the need for fertility treatment, mode of delivery, and obstetrical and gynecologic complications. This trial is registered on the International Clinical Trials Registry Platform www.who.int (NTR5480; trial finished). Between 2016 and 2018, the 2Close study randomly assigned 2292 women, with 830 of 1144 and 818 of 1148 responding to the 3-year questionnaire in the single-layer and double-layer closure. No differences were observed in live birth rates; also there were no differences in pregnancy rate, need for fertility treatments, mode of delivery, or uterine ruptures in subsequent pregnancies. High rates of gynecologic symptoms, including spotting (30%–32%), dysmenorrhea (47%–49%), and sexual dysfunction (Female Sexual Function Index score, 23) are reported in both groups. The study did not demonstrate the superiority of double-layer closure over single-layer closure in terms of reproductive outcomes after a first cesarean delivery. This challenges the current recommendation favoring double-layer closure, and we propose that surgeons can choose their preferred technique. Furthermore, the high risk of gynecologic symptoms after a cesarean delivery should be discussed with patients. [ABSTRACT FROM AUTHOR]

Objective: Lateral wall ruptures in women with a history of cesarean section are less common but more complicated than anterior wall ruptures. Residual myometrial thickness (RMT) is believed to be valuable for assessing the probability of ruptures. This study aimed to assess the utility of OmniView (a sonographic reslicing technique) in evaluating the lateral uterine wall after cesarean section and evaluate the relationship between lateral and anterior wall RMT using OmniView and sagittal two-dimensional ultrasound.Study Design: This cross-sectional study examined changes in both the anterior and lateral uterine wall in women with a history of cesarean section in the past 12-18 months. OmniView with volume contrast imaging with a 2-mm slice thickness was used to generate coronal planes, and the OmniView RMT (OV-RMT) was calculated as a percentage. Blinded to the OV-RMT results, sonographic multiplanar views were used to acquire the optimum sagittal plane for evaluating the RMT, and the sagittal RMT (S-RMT) was calculated as a percentage. The reproducibility of OV-RMT and S-RMT between two observers was tested using interclass correlation (ICC). The relationship between two variables was tested using Spearman's rank correlation.Results: In 208 recruited patients, the prevalence of lateral uterine wall defects was 79 %. The interobserver and intraobserver reproducibility of S-RMT and OV-RMT had ICC coefficients over 0.9 with a p-value <0.001. S-RMT and OV-RMT did not follow a normal distribution, and the medians were significantly different (55.5 and 85.7, respectively). Spearman's rank correlation between OV-RMT and S-RMT had a rho (ρ) value of 0.24 (p < 0.05). Passing-Bablok regression had an intercept of 47.95 and a slope of 0.65.Conclusion: OmniView can be used to assess lateral uterine wall defects, and OV-RMT is a reproducible and reliable method for quantifying this assessment. The RMT on the coronal plane was independently more intact than that on the sagittal plane, which might account for the lower incidence of lateral ruptures. Further studies could reveal a critical OV-RMT value that is safe for a trial of labor. [ABSTRACT FROM AUTHOR]

Objective: To determine whether a history of prior cesarean delivery (CD) makes ET more difficult and impacts pregnancy outcomes.Design: Prospective cohort study.Setting: Tertiary care military facility.Patient(s): One hundred ninety-four patients with previous delivery undergoing IVF/intracytoplasmic sperm injection (ICSI)-ET.Intervention(s): None.Main Outcome Measure(s): Live birth (primary), positive hCG, clinical pregnancy, and time to perform ET.Result(s): There was no statistically significant difference between patients with a history of only vaginal deliveries versus those with a history of CD for live birth (39% vs. 32%), positive hCG (56% vs. 53%), or clinical pregnancy (49% vs. 41%). Embryo transfers took longer in the history of CD group (157 vs. 187 seconds) and were more likely to have mucus (27% vs. 45%) or blood (8% vs. 21%) on the catheter.Conclusion(s): Embryo transfers performed on patients with a prior CD took 30 seconds longer. They were also more likely to have blood or mucus on the catheter. Despite the apparently more difficult transfers, pregnancy outcomes were not different between the two groups. [ABSTRACT FROM AUTHOR]

Several obstetric complications due to inappropriately healed cesarean scar such as placenta accreta, scar dehiscence, and ectopic scar pregnancy are increasingly reported along with rising cesarean rates. Furthermore, many gynecologic conditions, including abnormal uterine bleeding, pelvic pain and infertility, are imputed to deficient cesarean scar healing. Hysteroscopy is the most commonly reported approach for the revision of cesarean scar defects (CSDs). Nevertheless, existing evidence is inadequate to conclude that either hysteroscopy or laparoscopy is effective or superior to each other. Although several management options have been suggested recently, the laparoscopic approach has not been thoroughly scrutinized. We present a case and reviewed the data related to the laparoscopic repair of CSDs and compared the hysteroscopic and laparoscopic management options based on the data from previously published articles. As a result of our analyses, the laparoscopic approach increases uterine wall thickness when compared with the hysteroscopic approach, and both surgical techniques seem to be effective for the resolution of gynecologic symptoms. Hysteroscopic treatment most likely corrects the scar defect but does not strengthen the uterine wall; thus, the potential risk of dehiscence or rupture in subsequent pregnancies does not seem to be improved. Because large uterine defects are known risk factors for scar dehiscence, the repair of the defect to reinforce the myometrial endurance seems to be an appropriate method of treatment. [ABSTRACT FROM AUTHOR]

Abnormal uterine bleeding and other gynecologic complications associated with a previous cesarean section scar are only recently being identified and described. Herein we report a rare case of a woman with recurring massive uterine bleeding after 2 cesarean sections. Curettage and hormone therapy were unsuccessfully used in an attempt to control the bleeding. After she was transferred to our hospital, she had another episode of vaginal bleeding that was successfully managed with oxytocin and hemostatic. Diagnostic hysteroscopy performed under anesthesia revealed an abnormal transected artery in the cesarean section scar with a thrombus visible. In the treatment at the beginning of laparoscopic management, we adopted temporary bilateral uterine artery occlusion with titanium clips to prevent massive hemorrhage. Secondly, with the aid of hysteroscopy, the bleeding site was opened, and then the cesarean scar was wedge resected and stitched interruptedly with 1-0 absorbable sutures. The postoperative recovery was uneventful. It would seem that the worldwide use of cesarean section delivery may contribute to the risk of gynecologic disturbances including some unrecognized and complex conditions as seen in this case. [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: To describe temporary bilateral uterine artery occlusion with titanium clips in combination with vasopressin as an effective surgical intervention to control hemorrhage during laparoscopic management of cesarean scar pregnancies (CSPs). Design: Retrospective study (Canadian Task Force classification III). Setting: University hospital in an obstetrics and gynecology department. Interventions: Five patients with CSPs underwent removal of gestational ectopic masses via laparoscopy. At the beginning of the procedure, all 5 women had temporary bilateral uterine artery occlusion with titanium clips, and vasopressin 6 U was injected into the myometrium. Measurements and Main Results: Clinical data, serum β-human chorionic gonadotropin levels, operative times, and operative blood loss levels were recorded. The mean gestational age at the time of CSP diagnosis was 9.2 ± 1.9 weeks. The mean serum β-hCG level on the day of surgery was 14262 ± 12870 IU/L. The mean operative time was 86 ± 21.6 minutes, the mean uterine artery occlusion time was 58 ± 13.8 minutes, and the mean blood loss was 144 ± 79.6 mL. No cases were converted to laparotomy, no blood transfusions were required, and there were no complications. Conclusions: Laparoscopy combined with titanium clip occlusion of the uterine arteries bilaterally with vasopressin injection is an effective, minimally invasive procedure to preserve the uterus in patients with a CSP. [Copyright &y& Elsevier]

Ectopic pregnancy is a very common diagnosis (2% of pregnancies), and implantation location varies. Although 97% of ectopics are implanted within the fallopian tube, associated with commonly recognized risk factors, ectopic implantation can occur in other pelvic and abdominal locations that may not have such predisposing risk factors. After an extensive review of the literature, along with the author''s personal experience, implantation frequency, etiologic possibilities, and treatment options for each ectopic pregnancy location are presented. When ectopic pregnancy is diagnosed early, before rupture, regardless of location, conservative, fertility-sparing treatment options can be successful in terminating the pregnancy. Predisposing risk factors and treatment options can vary and can be ectopic-location specific. [Copyright &y& Elsevier]

Abstract: Study Objective: To describe our experience with endoscopic removal of cesarean scar pregnancy. Design: Retrospective study (Canadian Task Force classification II-3). Setting: Tertiary-care university hospital. Patients: Twenty-one patients with cesarean scar pregnancy. Interventions: All the patients underwent removal of pregnancy mass at hysteroscopy or combined with laparoscopy. Nine patients received a methotrexate injection before the operation, and 13 underwent uterine artery embolization before surgery. Measurements and Main Results: Clinical data, serum β-human chorionic gonadotropin concentration, findings of ultrasound or magnetic resonance imaging examinations, therapeutic options, operative time, operative blood loss, and duration of hospitalization time were recorded. The mean serum β-human chorionic gonadotropin concentration at diagnosis was 53 350.4 IU/ L. Seventeen patients underwent hysteroscopy, which failed in 2, and the other 4 patients underwent hysteroscopy combined with laparoscopy. Mean operative time was 51.4 minutes, and mean blood loss was estimated at 48.1 mL. A gestational mass can be removed at hysteroscopy, with rapid recovery and a high success rate. If a cesarean scar pregnancy mass grows toward the bladder and abdominal cavity, hysteroscopy combined with laparoscopy is more appropriate. Preoperative uterine artery embolization can decrease blood loss substantially during the operation. No patients underwent hysterectomy. Conclusions: Endoscopy seems to be the optimal surgical management in patients with a cesarean scar pregnancy and who desire to preserve the uterus and fertility. However, further study is warranted. [ABSTRACT FROM AUTHOR]

Objective: To compare the clinical effects in women with cesarean scar pregnancy (CSP) who were treated with either methotrexate (MTX) regimen only or MTX regimen followed by dilation and curettage (D&C).Design: Prospective consecutive clinical cohort study.Setting: University hospital for obstetrics, gynecology, and reproductive medicine.Subject(s): Seventy-one cases of CSP.Intervention(s): The subjects were treated with either MTX only (MTX group, 21 cases) or MTX followed by D&C (combined therapy group, 50 cases).Main Outcome Measure(s): Success rates, hysterectomy rates, and time to resolution of serum beta-hCG and the CSP mass were compared between the two groups.Result(s): Compared with the MTX group, the combined therapy group had a shorter time to resolution of the CSP mass and serum beta-hCG. There was no significant difference between the MTX and combined therapy groups regarding success rates (76.2% vs. 90.0%, respectively) and hysterectomy rates (19.0% vs. 8.0%, respectively).Conclusion(s): Both therapies could treat the majority of CSP patients successfully, but the combined therapy resulted in a shorter time of therapy and indicated a more favorable effect. [ABSTRACT FROM AUTHOR]

Objective: To report a cesarean scar pregnancy (CSP) with a coexistent viable intrauterine pregnancy. Design: Case report. Setting: Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, Taiwan. Patient(s): A 31-year-old woman, with previous cesarean delivery, presented with vaginal bleeding, was transferred to our hospital at 7 weeks'' gestation for heterotopic pregnancy after an IVF–embryo transfer. A diagnosis of intrauterine pregnancy combined with CSP was made by ultrasonography. Intervention(s): Hysteroscopic-directed evacuation of CSP. Main Outcome Measure(s): Good hemostasis at cesarean site and ongoing intrauterine pregnancy. Result(s): A healthy baby was delivered by cesarean delivery at term. Conclusion(s): With the increasing number of IVF–embryo transfers, the amount of heterotopic pregnancies is also increasing. Hysteroscopic management of CSP is a minimally invasive procedure that leads to successful obstetric outcomes in the corresponding intrauterine pregnancies. [Copyright &y& Elsevier]

Objective: The objective of the study was to compare the efficacy and safety of uterine artery embolization (UAE) vs systemic methotrexate (MTX) for pregnancy within a cesarean scar. Study Design: Seventy-two women with pregnancy within cesarean scar were randomly allocated to a UAE group (37 cases) or an MTX group (35 cases), which all was followed by suction curettage. The primary outpoints include bleeding loss, serum β-human chorionic gonadotropin level, and side effects. Results: The bleeding volumes were 36.93 ± 6.01 mL in the UAE group and 415.63 ± 68.37 mL in the MTX group (P < .001). The hospitalization time was 11.73 ± 0.80 days in the UAE group and 39.63 ± 4.57 days in the MTX group (P < .001). There was no severe side effect in both groups. Conclusion: For pregnancy within a cesarean scar, UAE followed by suction curettage appears to have more advantage and may be a priority option. [Copyright &y& Elsevier]

Objective: To describe three-dimensional ultrasonographic features of an ectopic pregnancy in a cesarean scar. Design: Description of a case. Setting: Case report of one patient. Patient(s): A 38-year-old women with three previous cesarean deliveries. Intervention(s): Three-dimensional ultrasonography was performed for diagnosis and treatment. Main Outcome Measure(s): Local administration of methotrexate under ultrasonographic guidance. Result(s): Ultrasonographic study revealed a gestational sac in the anterior wall of the uterine isthmus with peritrophoblastic flow. It was treated conservatively and successfully with local methotrexate administration under ultrasonographic guidance. Conclusion(s): The early diagnosis of ectopic cesarean scar pregnancy allows the conservative treatment with local administration of methotrexate under ultrasonographic guidance. [Copyright &y& Elsevier]

Objective: To describe our experiences with the diagnosis and endoscopic treatment of cesarean scar pregnancy. Design: Prospective clinical study. Setting: Tertiary care university hospital. Patient(s): Eleven women treated in our division between 1999 and 2004 who had been diagnosed with cesarean scar pregnancy. Intervention(s): Transvaginal ultrasound was used for diagnosis, and endoscopy (laparoscopy and/or hysteroscopy) was used to treat cesarean scar pregnancy and preserve fertility. Main Outcome Measure(s): Operative blood loss, hospital stay, and time to resolution of serum β-hCG were recorded. Result(s): The gestational age at diagnosis ranged between 6 and 11 weeks. Laparoscopic treatment was used in four women, hysteroscopic treatment in six women, and one woman underwent combined treatment with laparoscopy and hysteroscopy. The average blood loss during surgery was 110.9 mL (range, 20–300 mL), and average hospital stay was 1.7 days (range, 0.25–3 days). No complications occurred, and no blood transfusion was required. All patients’ uteri were successfully preserved, and serum β-hCG levels declined to a normal limit within 4 weeks postoperatively. Conclusion(s): When the diagnosis of cesarean scar pregnancy is made in the first trimester, endoscopy can be an alternative surgical treatment; the prognosis is good, and fertility can be preserved. [Copyright &y& Elsevier]