Measurement of Lower Uterine Segment Thickness to Detect Uterine Scar Defect: Comparison of Transabdominal and Transvaginal Ultrasound.

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.

[Trial of labour after c-section in 2022: a narrative review of the literature]. / Accouchement vaginal après une césarienne en 2022 : revue narrative de la littérature.

One in three women in Switzerland gives birth by c-section. This high incidence of c-section frequently exposes obstetricians and midwives to the management of women and their deliveries with a scarred uterus. The decision of couples is multifactorial, but the information that will be delivered by their gynaecologist will necessarily influence the delivery route choice. We propose to review the international recommendations and the literature on the subject, to provide the couple and the attending physician with elements of reflection to guide the choice of delivery route or to monitor adequately when attempting vaginal delivery after a caesarean section.

En Suisse, une femme sur trois donne naissance à son enfant par césarienne. Cette forte incidence de la césarienne expose régulièrement les obstétriciens et les sages-femmes à la gestion de femmes et de leur accouchement avec un utérus cicatriciel. La décision des couples est multifactorielle, mais l'information qui sera délivrée par leur gynécologue va nettement influencer le choix de la voie d'accouchement. Nous proposons ici de passer en revue les recommandations internationales et la littérature sur le sujet, afin de procurer les éléments de réflexion au couple et au médecin traitant afin de guider le choix de la voie d'accouchement et de monitorer adéquatement au cours d'une tentative d'accouchement par voie basse.

Training junior faculty to become clinical teachers: The value of personalized coaching.

Background: Junior clinical faculty require institutional support in the acquisition of feedback and clinical supervision skills of trainees. We tested the effectiveness of a personalized coaching versus guided self-reflection format of a faculty development program at improving faculty skills and self-efficacy.Methods: Participants were evaluated both before and after the program using a four-station Objective Structured Teaching Exercise (OSTE). A gain-score analysis, one-way ANOVA, and paired t-tests were used to evaluate both groups. The impact on the learning environment was measured by resident ratings of the Maastricht Clinical Teaching Questionnaire.Results: One hundred and twenty-seven participants completed the study over a three-year period. Both groups had significant improvements in self-efficacy. Participants in the coaching group demonstrated superior performance in encouraging learner self-reflection, teaching effectiveness, verifying learner understanding, exploring feelings/needs, and defining learning objectives. Over a 5-year period, the overall institutional learning climate significantly improved concerning faculty role-modeling, coaching, articulation, and explorations skills.Conclusion: Offering a contextualized faculty-development program using OSTEs that provides multiple opportunities for feedback and is focused on creating a community of practice is an effective method to facilitate the transfer of skills to the clinical environment, supports teacher identity development, and favorably impacts the learning climate.

Placental mesenchymal dysplasia: An underdiagnosed placental pathology with various clinical outcomes.

BACKGROUND: Placental mesenchymal dysplasia (PMD) is a rare vascular and connective placental anomaly, which is often associated with severe fetal and/or maternal complications. The diversity of presentation of PMD challenges diagnosis and effective pregnancy management. OBJECTIVE: We aimed to review cases presenting at 7 tertiary centers worldwide over the last decade and to study the occurrence of obstetric and neonatal complications. STUDY DESIGN: Pathology databases from 7 tertiary hospitals were screened for cases of PMD (between 2007-2017). Pregnancy history, outcomes and ultrasound images were then reviewed for each case. RESULTS: Twenty-two cases of PMD were identified. Mean gestational age at diagnosis was 23 weeks (16-39 weeks). Prenatal biochemical screening was abnormal in 8 cases (36%). Of the 12 cases that underwent invasive genetic testing, 4 were abnormal. Six patients (27%) developed maternal complications (preeclampsia/gestational hypertension). Fetal growth restriction was identified in 11 cases (50%) and fetal death in 4 (18%). Four (18%) pregnancies were terminated, 9/14 (64%) delivered preterm and only three (14%) progressed normally. Fourteen babies were born alive; 5 (35%) died in the first sixty-one days after birth, 5 (35%) had transient thrombopenia and 1 (7%) had developmental delay at last follow-up. Our series identified four potential new associations with PMD: placental triploidy mosaicism, CHARGE syndrome, fetal pleuropulmonary blastoma and fetal skeletal dysplasia. CONCLUSIONS: PMD was substantially under-diagnosed before delivery in this cohort. Sonographers, fetal medicine specialists, obstetricians and pathologists should all suspect PMD in cases of an enlarged placenta and should look for fetal abnormalities. Diagnostic genetic testing should be discussed to exclude partial molar pregnancy. Close pregnancy follow-up is indicated due to the high risk of associated fetal or maternal adverse outcomes.

Medical students' professional identity development from being actors in an objective structured teaching exercise.

INTRODUCTION: Medical students develop professional identity through structured activities and impromptu interactions in various settings. We explored if contributing to an Objective Structured Teaching Exercise (OSTE) influenced students' professional identity development. METHODS: University clinical faculty members participated in a faculty development program on clinical supervision. Medical students who participated in OSTEs as simulated residents were interviewed in focus groups about what they learnt from the experience and how the experience influenced their vision of learning and teaching. Transcripts were analyzed using the Goldie's personality and social structure perspective model. RESULTS: Twenty-five medical students out of 32 students involved in OSTEs participated. On an institutional level, students developed a feeling of belonging to the institution. At an interactional level, students realized they could influence the teaching interaction by actively seeking or giving feedback. On the personal level, students realized that errors could become sources of learning and felt better prepared to receive faculty feedback. CONCLUSION: Taking part in OSTEs as a simulated resident has a positive impact on students' vision regarding the institution as a learning environment and their own role by actively seeking or giving feedback. OSTEs support their professional identity development regarding learning and teaching while sustaining faculty development.

[Obstetrics]. / Obstétrique.

During the past year, we have renewed interest in old well-known problems. New studies and guidelines have been issued about lung maturation in cases of preterm delivery after 37 weeks of gestation. Short term benefits have been proven but the number of cases needed to treat to prevent one case of respiratory complications is high and with possible neurological long-term effects. Also, several studies have shown the benefits of including the ultrasound measurement of the inferior segment of the uterus in order to attempt vaginal delivery after caesarean section with the lowest risk for uterine rupture, while others studies have shown the best procedure to close the uterus during cesarean section. And finally, we will discuss about an old friend: aspirin to reduce the risk of pre-eclampsia.

Au cours de l'année écoulée, l'intérêt pour de vieux problèmes bien connus de notre spécialité médicale a été renouvelé. De nouvelles études et lignes directrices ont été publiées concernant la maturation pulmonaire en cas d'accouchement prématuré après 37 semaines de gestation. Bien qu'un bénéfice à court terme ait été prouvé, le nombre de cas à traiter pour prévenir une complication respiratoire néonatale est élevé, avec des effets neurologiques potentiels à long terme. Afin de promouvoir la tentative d'accouchement vaginal après césarienne sans augmenter le risque de rupture utérine, différents travaux indiquent qu'il faut intégrer la mesure du segment inférieur de l'utérus dans la discussion de la voie d'accouchement. D'autres ont montré la meilleure procédure pour fermer l'utérus pendant la césarienne. Enfin, nous allons parler d'une vieille amie : l'aspirine pour réduire le risque de prééclampsie.

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

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

Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study.

BACKGROUND: Choice of delivery route after previous cesarean delivery can be difficult because both trial of labor after cesarean delivery and elective repeat cesarean delivery are associated with risks. The major risk that is associated with trial of labor after cesarean delivery is uterine rupture that requires emergency laparotomy. OBJECTIVE: This study aimed to estimate the occurrence of uterine rupture during trial of labor after cesarean delivery when lower uterine segment thickness measurement is included in the decision-making process about the route of delivery. STUDY DESIGN: In 4 tertiary-care centers, we prospectively recruited women between 34 and 38 weeks of gestation who were contemplating a vaginal birth after a previous single low-transverse cesarean delivery. Lower uterine segment thickness was measured by ultrasound imaging and integrated in the decision of delivery route. According to lower uterine segment thickness, women were classified in 3 risk categories for uterine rupture: high risk (<2.0 mm), intermediate risk (2.0-2.4 mm), and low risk (≥2.5 mm). Our primary outcome was symptomatic uterine rupture, which was defined as requiring urgent laparotomy. We calculated that 942 women who were undergoing a trial of labor after cesarean delivery should be included to be able to show a risk of uterine rupture <0.8%. RESULTS: We recruited 1856 women, of whom 1849 (99%) had a complete follow-up data. Lower uterine segment thickness was <2.0 mm in 194 women (11%), 2.0-2.4 mm in 217 women (12%), and ≥2.5 mm in 1438 women (78%). Rate of trial of labor was 9%, 42%, and 61% in the 3 categories, respectively (P<.0001). Of 984 trials of labor, there were no symptomatic uterine ruptures, which is a rate that was lower than the 0.8% expected rate (P=.0001). CONCLUSION: The inclusion of lower uterine segment thickness measurement in the decision of the route of delivery allows a low risk of uterine rupture during trial of labor after cesarean delivery.

Fetal Intra-Peritoneal Transfusion for the Management of Very Early Spontaneous Twin Anemia-Polycythemia Sequence in an Obese Patient With a Whole Anterior Placenta.

Twin anemia-polycythemia sequence (TAPS) is a rare condition in monochorionic twin pregnancies. Small intertwin placental vascular communications allow transfusion, which results in a hemoglobin difference in the twins in the absence of oligohydramnios or polyhydramnios. We report here a case of TAPS diagnosed at 17 weeks' gestation in an obese patient (BMI 42) with a whole anterior placenta. The only possible treatment at this stage of pregnancy was intra-uterine transfusion (IUT), which was repeated weekly until photocoagulation of placental anastomoses was feasible. Fetoscopic laser surgery is the only curative treatment, but is challenging in TAPS because of the absence of polyhydramnios and the presence of minuscule anastomoses. An anterior placenta and high BMI can make the procedure even more challenging. This case report demonstrates that very early and rapidly progressing TAPS with technically complicated conditions (elevated BMI and anterior placenta) can be successfully managed with IUT until laser procedure is achievable.

[Simulation in obstetrics]. / Simulation en obstétrique.

Obstetrical emergencies may represent extremely critical situations with potential dramatic maternal and neonatal consequences. These situations should be managed by an effective and experienced multidisciplinary staff. Simulation allows a regular and repeated practice of these situations with no risk to patient safety and the possibility to analyse participants' performances in a group. This review describes different obstetrical simulation methods and summarizes the evidence for its efficiency in obstetric practice.

Perceived and measured physical activity and mental stress levels in obstetricians.

OBJECTIVES: Obstetric work generates important subjective and objective mental stress and is perceived as a physically demanding activity by obstetricians. The aim of this study was to quantify physical and mental stress levels in obstetricians at work and during leisure activities to investigate their association with overall physical activity levels and professional experience. STUDY DESIGN: 18 obstetricians at the maternity unit of the University of Geneva Hospitals were enrolled in a prospective observational study. Physical activity and stress levels were measured in two different activity sectors (delivery room and outpatient clinic) and outside work. Physical activity was assessed by questionnaire, visual analogue scale (VAS), and accelerometer. Mental stress levels were assessed by validated questionnaires, VAS, measurement of urine catecholamines and salivary cortisol, and night-time heart rate variability indices. RESULTS: Daily stress levels were higher at work compared to outside work (all, P = 0.002). Adrenalin (P = 0.002) and dopamine (P = 0.09) levels were elevated after a labour suite shift and a trend was observed for reduced heart rate variability during the night after this shift. The median average daily number of steps was 7132 (range, 5283-8649). Subjects reached a median of 32 min (range, 19-49 min) of moderate or higher intensity (≥ 1952 counts/min) daily physical activity. CONCLUSIONS: Contrary to perception, obstetrics work is not physically demanding. It is, however, accompanied by important subjective and objective mental stress that may have a negative impact on health when combined with a lack of regular daily physical activity.

Adverse obstetric outcomes in women with previous cesarean for dystocia in second stage of labor.

OBJECTIVE: To evaluate obstetric outcomes in women undergoing a trial of labor (TOL) after a previous cesarean for dystocia in second stage of labor. METHODS: A retrospective cohort study of women with one previous low transverse cesarean undergoing a first TOL was performed. Women with previous cesarean for dystocia in first stage and those with previous dystocia in second stage were compared with those with previous cesarean for nonrecurrent reasons (controls). Multivariable regressions analyses were performed. RESULTS: Of 1655 women, those with previous dystocia in second stage of labor (n = 204) had greater risks than controls (n = 880) to have an operative delivery [odds ratio (OR): 1.5; 95% confidence intervals (CI) 1.1 to 2.2], shoulder dystocia (OR: 2.9; 95% CI 1.1 to 8.0), and uterine rupture in the second stage of labor (OR: 4.9; 95% CI 1.1 to 23), and especially in case of fetal macrosomia (OR: 29.6; 95% CI 4.4 to 202). The median second stage of labor duration before uterine rupture was 2.5 hours (interquartile range: 1.5 to 3.2 hours) in these women. CONCLUSION: Previous cesarean for dystocia in the second stage of labor is associated with second-stage uterine rupture at next delivery, especially in cases of suspected fetal macrosomia and prolonged second stage of labor.

Reliability of 3-dimensional transvaginal sonographic measurement of lower uterine segment thickness.

OBJECTIVES: The purpose of this study was to report the intraobserver and interobserver reliability of transvaginal 3-dimensional (3D) sonographic measurement of lower uterine segment thickness. METHODS: A prospective study of 60 pregnant women with previous low transverse cesarean deliveries was performed between 35 and 39 weeks' gestation. Two observers, blinded to the clinical data, independently measured the full lower uterine segment thickness by 2-dimensional (2D) transvaginal sonography. Three-dimensional volume data sets of the lower uterine segment were captured and analyzed more than 2 months later by both observers independently. Intraobserver, interobserver, and intermethod reliability was evaluated by median absolute differences, nonparametric limits of agreement, intraclass correlation coefficients (ICCs), and κ coefficients. RESULTS: The median full lower uterine segment thickness was 3.6 mm (range, 0.9-8.0 mm). Intraobserver reliability (median difference, 0.3 mm [interquartile range (IQR), 0.1-0.6 mm]; ICC, 0.88 [95% confidence interval (CI), 0.81-0.93]; κ, 0.87 [95% CI, 0.69-1.00]) and interobserver reliability (median difference, 0.3 mm [IQR, 0.1-0.5 mm]; ICC, 0.88 [95% CI, 0.81-0.93]; κ, 0.86 [95% CI, 0.66-1.00]) were excellent. Reliability between 3D and 2D sonography was moderate (median difference, 0.6 mm [IQR, 0.2-0.9 mm]; ICC, 0.78 [95% CI, 0.66-0.86]; κ, 0.56 [95% CI, 0.28-0.85]). However, intermethod reproducibility was improved when the full lower uterine segment thickness was less than 3.0 mm (median difference, 0.4 mm [IQR, 0.2-0.9 mm]). CONCLUSIONS: Full lower uterine segment thickness measured with 3D transvaginal sonographic data sets has excellent intraobserver and interobserver reliability. It also has good reproducibility with 2D sonography when the full lower uterine segment thickness is less than 3.0 mm.

Reliability of two-dimensional transvaginal sonographic measurement of lower uterine segment thickness using video sequences.

OBJECTIVES: To report the intra- and interobserver reliability of measurement of the lower uterine segment (LUS) thickness using transvaginal sonographic videos. METHODS: A prospective study of 60 women with previous, low-transverse cesarean undergoing LUS examination (36 to 39 weeks) was performed. Two observers independently measured full LUS thickness using transvaginal sonography. A video of the LUS was recorded and analyzed more than 2 months later by both observers. Intra- and interobserver reliability was assessed with median absolute differences and interquartile range (IQR), nonparametric limits of agreement, intraclass correlation coefficients (ICC) with 95% confidence interval (95% CI), and kappa coefficients. RESULTS: Median full LUS thickness was 3.6 mm (range: 0.9 to 8.0 mm). Intraobserver repeatability was excellent (median difference: 0.2 mm, IQR: 0.1 to 0.4; ICC: 0.94, 95% CI: 0.90 to 0.96; kappa: 1.00). Interobserver (median difference: 0.3 mm, IQR: 0.2 to 1.3; ICC: 0.91, 95% CI: 0.86 to 0.95; kappa: 0.76, 95% CI: 0.54 to 0.98) and intermethod reproducibility (median difference: 0.4 mm, IQR: 0.2 to 0.8; ICC: 0.82, 95% CI: 0.72 to 0.89; kappa: 0.69, 95% CI: 0.43 to 0.94) were good. However, both interobserver and intermethod reproducibility were improved when LUS thickness was below 3 mm. CONCLUSION: Full LUS thickness measured from transvaginal sonographic videos has excellent intra- and interobserver reproducibility and good reproducibility with live transvaginal ultrasound.

Systematic review of cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect.

OBJECTIVE: To review the ability of imaging techniques to predict incomplete healing of uterine cesarean scars before the next pregnancy. STUDY DESIGN: A systematic literature review searched for studies on women who underwent previous low-transverse cesarean, evaluated by hysterography, sonohysterography (SHG), or transvaginal ultrasound (TVU). The median prevalence of scar defects was computed with 95% confidence intervals (95% CIs). Odds ratio (OR, 95% CI) identified risk factors of incomplete healing. RESULTS: The analysis included 21 studies. The proportions of suspected scar defects detected by hysterography, SGH, and TVU were 58% (33 to 70), 59% (58 to 85), and 37% (20 to 65), respectively. Two studies found that women with a large uterine scar defect had a higher risk of uterine rupture or uterine scar dehiscence than those with no scar defect or small scar defect (OR: 26.05 [2.36 to 287.61], p <0.001). The only reported risk factor for scar defect was the occurrence of more than one previous cesarean (OR: 2.24 [1.13, 4.45], p = 0.02). CONCLUSION: Hysterography, SGH, and TVU can detect uterine scar defects in ~50% of women with previous cesarean.

Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture.

OBJECTIVE: To evaluate the best available evidence regarding the association between single-layer closure and uterine rupture. METHODS: The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant observational and experimental studies that included women with a previous single, low, transverse cesarean delivery who had attempted a trial of labor (TOL). The risks of uterine rupture and uterine dehiscence were assessed by pooled odds ratios (OR) calculated with a random effects model. RESULTS: Nine studies including 5810 women were reviewed. Overall, the risk of uterine rupture during TOL after a single-layer closure was not significantly different from that after a double-layer closure (OR 1.71; 95% confidence interval [CI] 0.66-4.44). However, a sensitivity analysis indicated that the risk of uterine rupture was increased after a locked single-layer closure (OR 4.96; 95% CI 2.58-9.52, P<0.001) but not after an unlocked single-layer closure (OR 0.49; 95% CI 0.21-1.16), compared with a double-layer closure. CONCLUSION: Locked but not unlocked single-layer closures were associated with a higher uterine rupture risk than double-layer closure in women attempting a TOL.

Prediction of complications in pregnant women with cardiac diseases referred to a tertiary center.

BACKGROUND: Prediction of adverse maternal and neonatal events in women with heart disease is not well established. We aimed to assess cardiac, obstetrical and neonatal complications in pregnant women with heart disease referred to our tertiary care center and validate a previously proposed risk index. METHODS: We included 227 women with cardiac disease followed for 312 pregnancies at our tertiary center from 1992 to 2007. Cardiac risk was assessed using the previously proposed Cardiac Disease in Pregnancy (CARPREG) score and its association with maternal and neonatal outcomes was determined. RESULTS: Maternal cardiac lesions were predominantly congenital (81.4%). CARPREG risk was low (score=0) in 66.3% and intermediate (score=1) in 33.7% pregnancies. Maternal cardiac events complicated 7.4% pregnancies, with pulmonary edema occurring most frequently (3.8%). An intermediate score was associated with a higher rate of cardiac events (19.0% vs. 1.4%, odds ratio [OR] 15.6, 95% confidence interval (95%CI) 4.5-54.4, p<0.0001). Adverse events occurred in 27.5% neonates. Preterm deliveries occurred in 16.7% pregnancies, more commonly in patients with intermediate scores (OR 2.4, 95%CI 1.2-4.6, p=0.01). The sensitivity and negative predictive values of a low score were respectively 87% and 99% for total cardiac events and both 100% for primary cardiac events including pulmonary edema and sustained arrhythmia. CONCLUSION: The CARPREG risk index has a high sensitivity and negative predictive value with regards to cardiac complications in pregnant women with heart disease. It may, therefore, be routinely used to improve the assessment of cardiac risk before and during pregnancy.