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We briefly present our experience with trial labour in the presence of a Caesarean section scar and review some of the literature on the management of such patients. [ABSTRACT FROM AUTHOR]

Caesarean section involves the delivery of the fetus through a direct incision in the abdominal wall and the uterus. Women with scarred uterus are considered at risk of uterine rupture during subsequent pregnancies and labour. Although trial of labour is usually given to patients having past history of previous one lower segment caesarean section (LSCS) due to non recurrent cause with a considerable success rate but most obstetricians opt an elective LSCS in women having past history of two or more LSCS. We report a case of three consecutive successful vaginal deliveries with an intact scar in a woman having history of previous 3 LSCS [ABSTRACT FROM AUTHOR]

Cesarean scar ectopic pregnancy (SEP), a rare type of ectopic pregnancy, is the implantation of a gestational sac in the myometrium and fibrous tissues at the site of a previous uterine scar (mostly cesarean section scar). The condition can be catastrophic if not managed on time, leading to significant morbidity and mortality. Early diagnosis made by transvaginal ultrasonography and a high degree of suspicion for the probability of SEP in previous uterine surgery patients may help in the initiation and success of conservative treatment, prevention of complications, and preservation of fertility. We present here the analysis of 22 cases of SEP managed at our institute between 2013 to 2020. The mean gestational age at the time of diagnosis was 8.6±2.2 weeks. The majority of the women presented with either pain or bleeding, but few cases (7 cases) were asymptomatic and were diagnosed with SEP during routine obstetric ultrasonography. Out of these cases, a single case was admitted with shock due to uterine rupture. The mean serum β-hCG level was 29,543 mIU/ml (range, 2105-61590). Asymptomatic patients with low serum β-hCG levels(<15,000 mIU/ml) were given a single dose of methotrexate. Methotrexate was given as a single dose or 4 doses regimen in total 13 cases. Laparotomy with wedge resection of the scar ectopic was done in 8 cases. Overall primary treatment success was recorded in 20 of 22 cases (91%). 2 cases underwent dilatation and curettage due to retained product of conception after primary treatment with methotrexate. The serum β-hCG levels were normalized in an average time period of 53 days. This retrospective case series has proved the role of early and accurate diagnosis of SEP for initiating the treatment in order to minimize maternal morbidity and mortality related to this rare and unusual form of ectopic pregnancy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Mohapatra et al.)

Simple Summary: The presence of an invasive alien species is one of the main causes of biodiversity loss, which occurs through the reduction or even the extinction of native populations. In this context, the EU 2020 biodiversity strategy calls for research on invasive alien species in order to prevent their introduction and spread more effectively. The grey squirrel (Sciurus carolinensis), which is native to North America, provides one of the best-known examples of competitive exclusion of a native one, the European red squirrel (Sciurus vulgaris). A grey squirrel population, living in central Italy (Umbria), was studied to provide parameters on its population dynamics, growth rates, and viability, in order to understand its adaptation to its non-native range. Our data revealed that the Umbrian grey squirrel population is well-adapted to its new range, undergoing two annual mating periods and experiencing high reproductive success. Therefore, these invasive grey squirrels pose a substantial threat to the local European red squirrel population. The reproductive cycle of an invasive alien Italian grey squirrel population was studied to understand its adaptation and limit its spread, in order to conserve the autochthonous red squirrel. Female and male genital traits were evaluated throughout the reproductive cycle, including the ovary, uterus, testicle, epididymis, seminiferous tubule morphometry, and germinative epithelium histology. Moreover, individual female fecundity was determined by counting uterine scars. Ovary width and uterus weight, length, and width reached their highest values in the luteal and pregnancy phases. On conducting a histological evaluation of the testicular germinal epithelium, four morphotypes related to the different reproductive phases of the male squirrels were identified: immature, pubertal, spermatogenesis, and regressive. Testicle and epididymis weights and seminiferous tubule diameters reached their largest values during spermatogenesis. Uterine scar analysis showed that 69% of the females had given birth to one or two litters, while 31% had no uterine scars. Litters were larger in the first breeding period than in the second; annual fecundity was 4.52 ± 1.88 uterine scars/female. Umbrian grey squirrels have adapted to their non-native range, showing two annual mating periods at times similar to those in their native range, and high reproductive success. [ABSTRACT FROM AUTHOR]

Background: Wound complications are a major source of morbidity after cesarean section (CS) and contribute to increased risks in subsequent pregnancies. In the present study, we aim to investigate the wound healing potential of a kind of oligopeptide compound, mainly derived from the marine fish peptides (MFPs), in rats after CS by biomechanical, biochemical, and histological methods., Methods: Eighty-four pregnant Sprague-Dawleyrats were randomly assigned to four groups, namely the control group and 1.1, 2.2, and 4.4 mg/kg MFP groups, respectively. The MFPs or normal saline of the equal volume was intragastrically administered every morning on the second day after CS. On days 5, 10, and 15 after the surgery, seven rats from each group were randomly selected. The samples of skin wound and uterus were harvested and then used for the following experiments and analyses., Results: Using the CS rat model, this study demonstrated that in the MFP groups, the skin tensile strength, uterine bursting pressure, and hydroxyproline (Hyp) were significantly higher than those in the control group at all three time points ( P < 0.05). The formation of collagen and smooth muscle fibers and the expression of CD34 and connective tissue growth factor at the incision site were increasingly observed in the MFP groups ( P < 0.05)., Conclusions: MFPs have a great potential to accelerate the process and quality of wound healing in rats after CS., Competing Interests: The authors have no conflicts of interest to disclose. This study was jointly funded by grants from the Applied Basic Research Program and Key Research Program of the Science & Technology Department of Sichuan Province, China (2018JY0575, 2018SZ0248). The funders did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript., (© 2020 Xue Peng et al.)

Introduction. The incidence of pregnancy on the uterine scar is 1/1800-1/2500 pregnancies, increasing in the last 20 years, with the increase of the caesarean section. Case presentation. A 34-year-old patient, at her fifth pregnancy, with four births by caesarean section in the past (the last one seven months ago), presented at the emergency room with reduced genital bleeding and hypogastric pain. Transvaginal ultrasound established the diagnosis of pregnancy on uterine scar, and a 5-week embryo with present cardiac activity. Methotrexate 1 mg/kg intramuscular was administered, the patient being reviewed after five days, when the cardiac activity was absent, with the persistence of peripheral vascularization at the level of the uterine scar. Uterine dilatation and curettage were performed, and the trophoblastic fragments were extracted under ultrasound control. Two days later there were confirmed the HCG regression and the ultrasound evacuation of the pregnancy from the level of the uterine scar. The risk factors for pregnancy on the uterine scar are: thin uterine segment below 5 mm, the ultrasound visualization of a gestational sac that protrudes into the bladder-vaginal space, and a history of irregular vaginal bleeding. Discussion. The early diagnosis allows for conservative treatment with better results, and the subsequent follow-up by early ultrasound on a new pregnancy is important. There is no consensus on the most effective treatment, the options including: administration of methotrexate, either locally, in the sac, or by systemic intramuscular treatment, uterine artery embolization, uterine and hemostatic uterine bleeding, or hysteroscopic excision that offers minimal complication rates. Conclusions. Pregnancies on the uterine scar are rare, but with increasing incidence, having a major impact on the woman's subsequent fertility. [ABSTRACT FROM AUTHOR]

A uterine scar throughout pregnancy is a potentially omnious aspect, as there can be a great deal of evolution variation from normal pregnancy outcome to major feto-maternal loss. Uterine scars and niches with and without any pregnancy have been widely evaluated ranging normal, 3D ultrasound to magnetic resonance imaging. Herein we present the case of a normal pregnancy outcome involving a uterine niche evaluated before and throughout gestation. Despite the normal uterine appearance with a normal caesarean scar ultrasound before pregnancy, in the late first-trimester frontal middle caesarean scar buldging was observed, showing a typical appearance enhanced until the late second to early third trimester. In the third trimester, no evident ultrasound caesarean scar dehiscence was observed, despite the operative room aspect. In conclusion, we emphasise the simple ultrasound signs relevant for early diagnosis which can contribute to pathology prevention. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficiency and safety of inducing labour with oxytocin in women with a single prior Caesarean section, with particular focus on the Bishop score., Methods: Between January 1, 2013 and March 31, 2017, we included all women with a singleton full-term pregnancy and single prior Caesarean section in this monocentric retrospective observational study. Women for whom vaginal delivery was not recommended and those who went into spontaneous labour were excluded. The choice between induction of labour and caesarean section was made by the obstetrician and the patient, taking into account both the patient's personal medical history and the clinical observations on admission to hospital. The primary outcome was the rate of vaginal delivery., Results: Out of 966 women with no contraindication to trial of labour after previous caesarean delivery (TOLAC), 248 were induced, with a vaginal delivery rate of 58.5% (95% CI [52.06; 64.67]). This rate was 81.7% (67/82) among women with Bishop ≥6 and 47% (78/166) if Bishop was <6. Eight cases of uterine rupture were reported in the induction of labour group. Regarding maternal morbidity, this was the main difference between the caesarean section and the induction of labour groups (p=0.049). Neonatal morbidity was low in both groups., Conclusions: The rate of vaginal delivery after induction of labour with oxytocin infusion was satisfactory. Nevertheless, maternal morbidity and especially the risk of uterine rupture were not minor. It is thus essential before inducing labour to inform the woman about the rate of success of TOLAC and the risks of uterine rupture., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

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

Peptides and neuropeptides influence the uterine disorders of healing or cicatrization, chronic pelvic pain and disorder of pregnancy, labor and puerperium. They also promote changes in the lower uterine segment (LUS) during pregnancy, labor and delivery. We investigated the tissue quantity of neurotensin (NT), neuropeptide tyrosin (NPY) and Protein Gene Product 9.5 (PGP 9.5) in women submitted to elective cesarean section (CS) and urgent CS. During surgery, authors biopsied tissue samples of vesico-uterine space (VUS) to detect nerve fibers, and compared them. VUS samples from 106 patients have been evaluated with light microscopy, immunochemistry and Immunohistochemistry, and finally by Quantimet Leica analyzer software. Significantly higher amount of nerve fibers, containing NT, NPY and PGP 9.5 have been found in VUS tissue samples obtained during the first elective CS and during the first urgent CS were respectively 5±0.7, 7±0.6 and 5±0.9 CU and 2.5±0.5, 3.6±0.4 and 3.5±0.9 CU (p<0.05). This neurotransmitter reduction should indicate the inflammatory damage of cervical tissue for LUS over distension in dystocic-prolonged labor before CS. These results may be correlated with the decrease of NT, NPY and PGP 9.5, responsible for an optimal healing and LUS functions. In our opinion, the presence of neuropeptides reduction in uterine samples of women undergoing urgent CS may be due to a prolonged fetal head station in LUS, with a tissue denervation, in consequence of both overdistension and inflammatory process of the dystocic LUS., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Objectives: A growing number of studies suggest that the incomplete healing of the CS scar in the uterus increase the risk of uterine dehiscence or rupture during subsequent pregnancies. Thus, the factors that affect wound healing should be evaluated. We aimed to determine whether the morphology of the CS scar in non-pregnant women after one elective CS was affected by the site of the uterine incision, uterine flexion, maternal age, and fetal birth weight., Material and Methods: 208 non-pregnant women were invited for participation in the study, but only 101 of them met inclusion criteria. Standardized scar parameters (residual myometrial thickness (RMT), depth (D) and width (W) of the hypoechoic niche) were measured using ultrasonography at least 6 weeks after the CS., Results: Scar defect was detected in 26 of 101 subjects. Women without scar defect had significantly higher RMT values (1.87 vs. 0.87), lower newborn birth weight (3127 g vs. 3295 g), and higher scar location above the internal cervical os (62% vs. 16%), than those with scar defect. Maternal age was significantly correlated with D value (R = 0.40). Uterine retroflexion was significantly correlated with a larger D value (R = 0.63) and a larger D/RMT ratio (R = 0.24)., Conclusions: In low-risk women who have undergone one elective CS, several risk factors are associated with development of the scar defect, but only scar location can be modified during surgery. Future research is needed to determine whether a relatively higher incision location in the uterus can ensure optimal healing of the CS scar.

Objective The purpose of this study was to investigate prelabor and intrapartum cesarean delivery in overweight and obese women by parity, previous cesarean delivery, and labor induction to assess what preventive actions might be possible. Study Design We modeled relative risks (RRs) and risk differences of prelabor and intrapartum cesarean delivery by prepregnancy body mass index (obese, ≥30 kg/m 2 ; overweight, 25-29.9 kg/m 2 ; normal weight, 18.5-24.9 kg/m 2 ) in a nationally representative sample of 12,297 French women. Models were stratified by parity and previous cesarean status. Covariates included maternal sociodemographic characteristics, medical conditions, pregnancy complications, and induction of labor. Results Risks of prelabor cesarean delivery were elevated only for obese multiparous women. This reflected not only a higher prevalence of previous cesarean delivery (26.4% vs 17.9% for normal-weight women) but also higher risks of prelabor cesarean delivery for multiparous women with no previous cesarean delivery after adjustment for medico-obstetric factors (RR, 1.82; 95% confidence interval [CI], 1.25–2.64). Obese primiparous women and multiparous women with no previous cesarean delivery had similarly increased adjusted RRs for intrapartum cesarean delivery (RR, 1.64; 95% CI, 1.36–1.98; and RR, 1.66; 95% CI, 1.15–2.39, respectively), but the risk difference was higher for primiparous women, with an absolute increase of 0.10 (95% CI, 0.05–0.14) compared with 0.02 (95% CI, 0.00–0.04) for multiparous women. Increased intrapartum cesarean delivery risks for primiparous women were related to more frequent labor induction (42.6% vs 23.8% for normal-weight women). Conclusion It may be possible to reduce primary and thus repeat cesarean delivery rates among obese women by preventive actions targeting labor induction in primiparous women and prelabor cesarean deliveries in multiparous women. Further research is needed on the impact of limiting inductions on cesarean delivery risks for obese primiparous women. [ABSTRACT FROM AUTHOR]

Despite awareness of obstetricians to the constant increase in the number of caesarean sections in recent years, certain dogmas concerning uterine scar still persist in our practices and influence clinical decisions. Fear of a uterine scar rupture, a major obstetric complication, is always in mind. As for bi-uterine scar, it was considered, until recently in Belgium, as a full and definitive indication against an attempted vaginal delivery. However, several previous clinical studies clearly showed that, under certain conditions, vaginal birth after two caesarean sections was usually successful with very good results in terms of maternal and fetal morbidities. Even if such a clinical situation is not common, this article aims to sensitize obstetricians to the lack of objective clinical arguments to reject a vaginal delivery in a patient having a previous history of two caesarean sections. Such a patient must be motivated and followed up within a specific framework. Moreover, this type of delivery should receive optimal monitoring.

Objectives: To evaluate the normal ranges of lower uterine segment (LUS) thickness throughout pregnancy in women without a previous cesarean and to evaluate the relationship between ultrasound and intraoperative LUS thickness., Methods: We assessed LUS thickness using transabdominal and transperineal longitudinal scan at each week of gestation, during labour, and in the postpartum period in 1000 pregnant women without previous CS. Secondly, we assessed LUS thickness immediately before CS (using ultrasound) and intraoperatively (using ophthalmic calipers) immediately before delivery of the fetus in 35 women with a previous CS and 29 women without previous CS undergoing elective CS before labour., Results: We performed 20 307 LUS thickness measurements in between 119 and 944 women at each week of gestation, in 944 women during labour, and in 936 women after delivery. We observed a strong relationship between transabdominal and transperineal ultrasound (P < 0.001) and an inverse correlation between LUS thickness and gestational age (P < 0.001), with a mean thickness of 5.1 ± 1.4 mm at 20 weeks, 3.6 ± 1.3 mm at 30 weeks, and 2.3 ± 0.6 mm at 40 weeks of gestation. In women undergoing elective CS, we observed a strong relationship between antepartum and intraoperative LUS thickness (P < 0.001), with mean thicknesses of 2.2 ± 0.7 mm in 28 women without thinning of LUS; 0.8 ± 0.1 mm in four women with grade II uterine scar dehiscence; and 0.4 ± 0.1 mm in three women with grade III dehiscence. A LUS myometrial thickness less than 1.2 mm could have predicted all grade II and grade III uterine scar dehiscences without false-positive cases., Conclusion: LUS thickness decreases with gestational age and correlates strongly with the intraoperative LUS thickness in women with a previous CS., (Copyright © 2016 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to determine whether breech presentation at term is more common among women with at least 1 previous cesarean delivery. Study Design: This historic cohort study (n = 84,688) included women with a singleton term pregnancy and at least 1 previous delivery. Results were expressed as crude relative risks and adjusted odds ratios. Results: While 2.46% of women had a fetus in breech presentation at term, 14.91% of women had had 1 or more previous cesareans. The relative risk of a breech presentation at term for women with a history of cesarean was 2.18 (95%CI: 1.98-2.39). It did not differ according to the number of previous cesareans. The logistic regression analysis took into account confounding factors including gestational age, maternal age, parity, birthweight, and oligohydramnios. The adjusted odds ratio was 2.12 (95%CI: 1.91-2.36). Conclusion: Women with previous cesarean deliveries have a risk of breech presentation at term twice that of women with previous vaginal deliveries. [Copyright &y& Elsevier]

Objective: To investigate the effects of lipoic acid in the prevention of postoperative pelvic adhesions by a visual scoring system and immunohistochemistry in a rat uterine horn model with full thickness injury., Material and Methods: Twenty-eight female Wistar albino rats were randomised into four groups: uterine trauma control, 15 days and 30 days, and uterine trauma + lipoic acid, 15 days and 30 days. A full thickness defect was established by incising a segment of approximately 1.0 cm in length from each uterine horn, leaving the mesometrium intact. Extension and severity of the adhesions in each group were scored by a visual scoring system and evaluated immunohistochemically., Results: Adhesion scores were 2.00±0.81, 2.14±0.69 0.71±0.75, and 0.85±0.69 for extent and 2.28±0.48, 2.14±0.69, 0.85±0.69, and 1.14±0.69 for severity in Groups 1, 2, 3 and 4, respectively. Adhesion extent and severity were significantly less for groups treated by lipoic acid but no difference was observed between long and short administration. Both Vitronectin and u-PAR staining were significantly increased in treatment groups when compared to the control group., Conclusion: Lipoic acid was found to be effective in reducing postoperative adhesion formation in a rat model.