Spontaneous rupture of an unscarred uterus at the early third trimester due to placenta percreta: a case report.

Uterine rupture during pregnancy is a complication of placenta percreta. We present the case of a woman in her early 30s with a history of incomplete abortion treated by dilatation and curettage who was admitted with abdominal pain and vomiting at 30 weeks of gestation. She was diagnosed with thrombophilia and was administered anticoagulant drugs. After 10 hours of monitoring, the patient abruptly deteriorated. An emergency cesarean delivery showed a ruptured uterus due to placenta percreta. She accepted localized excision and uterine repair, and recovered well. Rupture of an unscarred uterus due to placental percreta is an extremely rare obstetric complication with high maternal and fetal mortality. This condition should be suspected in all pregnant women who have severe abdominal pain without being in labor. The treatment of uterine rupture due to placental percreta should be individualized, and repair of the uterus is possible in the majority of women.

Uterine rupture following prostaglandins use in second trimester medical abortion: Fact or fiction? A systematic review.

BACKGROUND: Prostaglandins (PGs) have emerged as key drugs in second trimester medical abortion (STMA) and are currently a cornerstone in obstetric practice. Nevertheless, the application of PGs, integral to labor and abortion procedures, is not risk-free, and has been associated with several complications, particularly maternal fever and uterine rupture (UR). OBJECTIVES: The main outcome of the present systematic review was to assess the safety of PGs use in STMA, particularly in scarred uterus (SC). SEARCH STRATEGY: The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a comprehensive systematic review by searching multiple databases, including MEDLINE, EMBASE, Global Health, The Cochrane Library, Health Technology Assessment Database, and the research registers of Web of Science during the years 1990-2022. SELECTION CRITERIA: Only articles regarding cases of UR occurred after the use of PGs for STMA were included in the article. We excluded papers regarding UR during first trimester abortion induction of labor or pregnancy or unrelated to PGs use for STMA. Risk of bias was assessed employing a modified version of the "Newcastle-Ottawa Scale" (NOS). DATA COLLECTION AND ANALYSIS: A total of 178 studies were initially identified as potentially meeting the criteria for inclusion in the review. After full text evaluation, 110 other articles were excluded and 67 studies that suited the inclusion criteria were included. A total of 19 of the included studies were judged to have a high risk of bias. Given the heterogeneous nature of the findings, we opted for a narrative synthesis of the results. MAIN RESULTS AND CONCLUSIONS: PGs appear to be an effective pharmacologic tool for STMA; however, their use is not entirely risk-free. STMA requires well-equipped obstetric centers with skilled clinicians and surgeons prepared for emergencies. Ultrasonographic scans should be routinely performed during STMA management, since a UR can also be silent during the induction of labor. Intrapartum transabdominal, transperineal, and transvaginal ultrasound may have the diagnostic potential to early recognize this obstetric emergency, to facilitate rapid medical and surgical treatment, improving the outcome.

Early Challenges: A Case Report of a Premature Baby with Down Syndrome and Uterine Rupture.

Introduction Uterine rupture represents one of the most severe obstetric affections. It is defined as a complete or a partial tearing of the uterine wall. Women with a prior cesarean section are reported to have a higher risk of having this situation. Moreover, maternal death and most of all middle- and long-term adverse consequences remain a great preoccupation. On another scale, neonatal death and ulterior deterioration remain very high, especially in low-income countries. Case Description A 24-year-old woman with a history of previous cesarean section presented at 35 weeks of gestation with pelvic pain without bleeding. Emergency cesarean section revealed a complete uterine rupture at the scar site from the previous cesarean section. Remarkably, the fetus managed to seal the rupture using the right temporal region, forearm, and right leg, avoiding significant complications. The mother had an uncomplicated postoperative course and was discharged after 48 hours of surveillance. Conclusion We present with this case an extraordinary case of a uterine rupture where both mother and child had a good outcome. This rare evolution was reported only one time in literature. For this reason, a history of caesarean delivery might present a huge challenge for obstetricians and neonates.

Case Report: The first case of successful pregnancy and live birth following laparoscopic resection of adenomyosis under real-time intraoperative ultrasound elastography guidance.

Objective: Adenomyosis-related infertility is increasingly being diagnosed, and surgical intervention has been suggested to improve fertility. Elastography, a noninvasive ultrasound technique, is promising for diagnosing and guiding the resection of adenomyosis. This report presents the first case of successful delivery after twin pregnancies achieved with IVF following intraoperative elastography-guided laparoscopic adenomyomectomy. Case report: A 35-year-old Japanese woman with uterine adenomyosis received a gonadotropin analog before surgery. Preoperative MRI revealed a 5.0 × 7.0 cm adenomyoma, leading to scheduled laparoscopic adenomyomectomy with intraoperative elastography. During surgery, elastography ensured the complete resection of the adenomyotic tissue while preserving the endometrium. Postoperative MRI confirmed the absence of residual adenomyosis. The patient underwent in vitro fertilization and embryo transfer, leading to a successful twin pregnancy after double blastocyst transfer. Despite a stable perinatal course, she required hospitalization to prevent preterm labor. At 32 weeks, an elective cesarean section delivered healthy twins. The intra- and post-operation was uncomplicated, and the patient and infants had an optimal health. Conclusion: This is the first reported case of a twin pregnancy resulting from vitrified-warmed embryo transfer after elastography-guided laparoscopic adenomyomectomy, culminating in a successful delivery via cesarean section. This technique allows precise resection and mitigates the risks of uterine rupture and placenta accreta spectrum disorders. Although promising, further studies are required to validate the safety and efficacy of this innovative surgical approach.

Comparison of maternal and neonatal outcomes between vaginal birth after cesarean section and normal vaginal birth.

OBJECTIVE: This study aimed to compare the outcomes of vaginal birth after cesarean (VBAC) with those of normal vaginal birth (NVB) in a tertiary hospital in China. METHODS: This retrospective cohort study analyzed 1,024 women who birthed vaginally between January 2019 and December 2020. The VBAC group (n = 512) included women with one previous cesarean, while the NVB group (n = 512) had no previous caesareans. All women used epidural analgesia. We assessed maternal and neonatal complications using descriptive statistics, chi-square tests, and logistic regression. Statistical analysis was performed using SPSS version 25.0. RESULTS: The VBAC group had an 87.5% success rate for vaginal birth under epidural analgesia, whereas the NVB group had a 100% success rate. A primary focus of the study was uterine rupture. Vaginal birth after cesarean was associated with a higher incidence of uterine rupture (0.8% vs 0%, p = 0.031), postpartum hemorrhage (6.6% vs 3.5%, p = 0.021) and the need for blood transfusions (2.7% vs 0.8%, p = 0.012) compared with NVB. There were no substantial differences in maternal infections, wound infections or perineal lacerations between the groups. Although neonatal outcomes were generally similar, the VBAC group experienced higher rates of 5-minute Apgar scores <7 (2.3% vs 0.6%, p = 0.009) and admissions to neonatal intensive care units (3.1% vs 1.2%, p = 0.016 Even after adjusting for confounders, VBAC remained an independent risk factor for several complications. CONCLUSION: Although VBAC is feasible and mostly safe, it is associated with a higher risk of specific complications compared with NVB. Careful selection of candidates and close monitoring are essential for optimizing outcomes in VBAC cases.

Lived experiences of women with uterine rupture who were managed at Nekemte specialized hospital: a qualitative study.

BACKGROUND: Uterine rupture is a rare but severe obstetric complication that poses significant risks to maternal and fetal health. Understanding the lived experiences of individuals who have undergone uterine rupture is crucial for improving care and support for those affected by this condition. This qualitative phenomenological study aimed to explore the experiences of individuals who have experienced uterine rupture. METHOD: The study employed a qualitative phenomenological approach, conducting 12 in-depth interviews and four key informant interviews with individuals who had experienced uterine rupture. Data analysis was conducted thematically using Atlas ti software to identify patterns and themes within the participants' narratives. RESULTS: The analysis of the interviews highlighted six key themes: experience during diagnosis and initial symptoms, perceived predisposing factors of uterine rupture, challenges faced by individuals with uterine rupture, impacts on their lives, and coping and resilience strategies. The findings revealed that women often failed to recognise the initial symptoms of uterine rupture due to a lack of preparation, a preference for home deliveries, husband refusal, and a general lack of awareness. This delay in seeking care resulted in severe consequences, including the loss of their babies, infertility, fistula, psychological trauma, and disruptions to daily life and relationships. To cope, many women resorted to accepting their situation, isolating themselves, and using traditional healing techniques. CONCLUSIONS: This study's findings provide valuable insights into the complex and multifaceted nature of uterine rupture, shedding light on the experiences of those affected by this condition. To address the challenges, it is essential to enhance awareness and education through community education programs and comprehensive antenatal classes. Additionally, improving access to healthcare by strengthening health infrastructure and deploying mobile health clinics can ensure better prenatal care. Furthermore, encouraging hospital deliveries through incentives and the support of community health workers can reduce risks. Providing psychological counselling and establishing support groups can help affected women cope with the consequences. Moreover, engaging men in maternal health through educational programs and involving them in antenatal care can foster better support. Finally, promoting safe traditional practices by integrating traditional healers and respecting cultural sensitivities can increase acceptance and adherence.

Timing of four or more scheduled cesarean sections.

OBJECTIVE: With the increasing number of cesarean sections worldwide, the need to determine the gestational age for scheduled cesarean sections has increased. The literature needs clear information, especially about cesarean sections four or more times. Our study aims to determine the ideal gestational week for mothers and babies in patients who are not in labor and who will have four or more cesarean sections. METHODS: In our retrospective study, the records of 2318 pregnant women were accessed, and those with singleton pregnancies, without medication use during pregnancy, and without any complicated pregnancies, such as newly defined preeclampsia, diabetes, and thyroid disease, and those over 18 years of age were included. All of the cesarean sections were under scheduled conditions (no beginning of labor and no pain/contraction). The exclusion criteria were patients with vaginal dilatation and effacement, a history of uterine rupture, and a diagnosis of placental adhesion spectrum disorder. Maternal and neonatal outcomes were evaluated. RESULTS: Although there was no significant difference in neonatal outcomes according to gestational week, regardless of the number of cesarean sections, transient tachypnea of the newborn increased significantly in scheduled cesareans performed at the 37th week compared with other weeks (p < 0.01). The results can be expected at 39 weeks and above. CONCLUSION: As a result, patients should not undergo cesarean section before 39 weeks unless they are in labor, and it seems safe to wait until 39 weeks.

Spontaneous Rupture of a Non-scarring Gravid Uterus: A Late and Haphazard Diagnosis in the Postpartum Period.

This paper reports the case of a spontaneous rupture of a non-scarring gravid uterus seen four days after vaginal delivery and provides an update on this rare pathology, which can be functionally and vitally life-threatening. Uterine rupture of a healthy gravid uterus can occur as a result of structural abnormalities of the uterine tissue framework or uterine parietal fragility due to pathological phenomena such as septic states. On admission, the clinical picture is generally that of an acute abdomen with a hypogastric origin, with or without hemodynamic instability and an altered general condition, depending on the presence of an underlying advanced uterine infection. Medical imaging, mainly ultrasound and CT scan with iodine contrast, enables visualization of the uterine breach and a precise assessment of the damage. Surgery is the treatment of choice for repairing the breach and ensuring hemostasis. This case study sheds light on this pathology, familiarizing us with its clinical and radiological picture, as well as its post-treatment prognosis.

In-hospital outcomes of repair and hysterectomy for uterine rupture: A nationwide observational study.

OBJECTIVE: Uterine rupture, though rare, poses significant risks to both mother and child. Its occurrence varies globally, with a noted 0.015% prevalence in Japan. This condition usually requires surgical intervention, either as uterine repair or hysterectomy. Past studies, largely single-center and outdated, offer limited insights into these treatment options. To assess and compare the clinical outcomes of repair and hysterectomy for uterine rupture among patients included in a large inpatient database in Japan. STUDY DESIGN: We analyzed the Diagnosis Procedure Combination inpatient database from July 2010 to March 2022. Patients with uterine rupture who underwent uterine repair or hysterectomy were extracted. Patient characteristics, in-hospital care, and outcomes were compared between the uterine repair group and the hysterectomy group. Main outcomes are reoperation during hospitalization, total volume of blood transfusion, complications (bowel injury, urinary tract injury, wound infection, deep vein thrombosis, or pulmonary embolism), maternal mortality, and postoperative length of stay. RESULTS: We identified 644 patients with uterine rupture. Of those, 287 (44.6 %) underwent uterine repair and 357 (55.4 %) underwent hysterectomy. The hysterectomy group was significantly older, had significantly more comorbidities, and had a significantly higher prevalence of consciousness impairment than the uterine repair group. Compared with the uterine repair group, the hysterectomy group required significantly more in-hospital care and had a significantly greater incidence of reoperation (1.0 % versus 6.4 %; P<0.001). Other complications were not significantly different between the groups. The hysterectomy group had significantly more blood transfusions and a significantly longer postoperative length of hospital stay than the uterine repair group. The results remained consistent even after the adjusted analysis. CONCLUSION: This study highlights the differences between repair and hysterectomy for uterine rupture, providing valuable insights for clinical decision-making in these cases.

Trial of labor following cesarean among patients with polyhydramnios: a multicenter retrospective study.

PURPOSE: This study aimed to assess maternal and neonatal outcomes in patients with polyhydramnios attempting trial of labor after cesarean (TOLAC) compared to those undergoing planned repeat cesarean delivery (PRCD). METHODS: A multi-center retrospective cohort study was conducted and included women with term singleton viable pregnancies following a single low-segment transverse cesarean delivery (CD) with a polyhydramnios diagnosis (maximal vertical pocket > 8 cm and/or Amniotic Fluid Index > 24 cm) within 14 days before birth who delivered between the years 2017 and 2021. Maternal and neonatal outcomes were compared between those attempting TOLAC and those opting for PRCD. The primary outcome was composite adverse maternal. Univariate analysis was followed by multivariate analysis to control for potential confounders. RESULTS: Out of 358 included births with a previous CD, 208 (58.1%) attempted TOLAC, while 150 had PRCD (41.9%). The successful vaginal birth after cesarean (VBAC) rate was 82.2%, and no cases of uterine rupture, hysterectomy, or maternal intensive care unit admission occurred in either group. After controlling for potential confounders, no independent association between TOLAC and composite adverse maternal (adjusted odds ratio [aOR] 0.62, 95% confidence interval [CI] 0.32-1.20, p = 0.16) and neonatal (aOR 0.89, 95% CI 0.51-1.53, p = 0.67) adverse outcomes was demonstrated. CONCLUSION: In patients with a term diagnosed polyhydramnios, TOLAC appears to be a reasonable alternative associated with favorable outcomes. Larger prospective studies are needed to refine management strategies and enhance maternal and neonatal outcomes in this context.

Pregnancy after advanced ovarian cancer with spontaneous uterine rupture in second trimester: A case report and review of the literature.

Fertility-preserving surgery (FPS) in advanced ovarian cancer (AOC) is extremely rare and consequently, information about the pregnancies of these patients is anecdotal. Therefore, management of the pregnancy after AOC is challenging, especially if an unexpected situation arises. A 31-year-old nulliparous woman was admitted to our tertiary hospital in the 18th week of twin pregnancy with sudden severe abdominal pain. Her medical history included a low-grade AOC stage IIIc diagnosed 2 years before pregnancy and treated by debulking FPS and systemic therapy with carboplatin/paclitaxel and bevacizumab. Clinical examination described normal vital signs and peritoneal irritation without any vaginal discharge. Sonography revealed free fluid in the pouch of Douglas and intact twin pregnancy. Laboratory work showed elevated leukocytes with neutrophilia. To evaluate appendicitis magnetic resonance imaging of the abdomen was indicated. This revealed a uterine rupture with the now extra-cavitary position of the twins. Simultaneously, the patient's symptoms deteriorated, and emergency surgery was necessary where hemoperitoneum with avital fetuses were present. Despite excessive blood loss the uterus could be repaired and preserved. Previous resection of the uterine serosa during her debulking FPS, administration of bevacizumab affecting smooth muscles, and overstretching the uterus in the twin pregnancy were considered as possible risk factors for the presenting uterine rupture. Pregnancy after AOC is possible but should be monitored closely, especially due to the hidden long-term consequences of its therapy. In the differential diagnosis of sudden abdominal pain during pregnancy uterine rupture should be considered even in patients with an unscared uterus.

Trial of labor after caesarean section in low risk pregnancies: is it risky?

PURPOSE: To evaluate the influence of a previous caesarean section on adverse composite maternal and perinatal outcome in women who attempted a trial of labor. METHODS: This historical cohort study analyzed maternal and perinatal outcome in women with otherwise low risk pregnancies at term who underwent a trial of labor after a caesarean section (TOLAC). The primary outcome measure was the adverse composite outcome. Secondary outcome measures were amongst others the caesarean section rate and the mode of vaginal delivery. RESULTS: The adverse composite outcome was more frequently in the previous caesarean section group compared to women with no previous caesarean Sect. (22.3% vs. 15.6%, p < 0.0001). The percentage of caesarean Sect. (15.4% vs. 8.2%, p < 0,0001), uterine rupture (1.0% vs. 0.02%, p < 0.0001), placental abruption (1.1% vs. 0.3%, p = 0.0014), vaginal operative delivery (16.0% vs. 8.6%, p < 0.0001), pH < 7.10 (3.7% vs. 2.5%, p = 0.0151), base excess < -12 (3.2% vs. 2.2%, p = 0.0297), abnormal cardiotocography (22.5% vs. 13.9%, p < 0,0001) and fetal blood analysis (6.2% vs. 2.6%, p < 0.0001) was significantly higher in women with a previous caesarean section. Taking the parity into account, these differences could only been seen in women without a previous vaginal delivery. In parous women with a previous vaginal delivery and a caesarean section in history, the adverse composite did not differ between the groups. Only the rate of pH < 7.1 was higher in women after a caesarean Sect. (4.5% vs. 1.8%, p = 0.0436). CONCLUSION: Trial of labor after caesarean in otherwise low risk pregnancies is associated with a higher rate of complications especially if there is no history of vaginal delivery.

Pregnancy and delivery outcomes after abdominal vs. laparoscopic myomectomy: an evaluation of an American population database.

OBJECTIVE: To evaluate population characteristics and obstetric complications after abdominal myomectomy vs. laparoscopic myomectomy. DESIGN: Retrospective cohort study. SETTING: Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) data representative of over 20% of all hospital admissions in the United States. PATIENT(S): A total of 13,868 and 338 pregnancies after abdominal or laparoscopic myomectomy, respectively. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Obstetric outcomes after abdominal or laparoscopic myomectomies were collected using hospital discharges from 2004 to 2014 inclusively, and adjusted using multiple and binomial logistic regression in different models for age, obesity, chronic hypertension, and pregestational diabetes mellitus. Pregnancy, delivery, and neonatal outcomes were analyzed. RESULT(S): Abdominal myomectomy were characterized by younger patients, lower rates of White chronic hypertension, pregestational diabetes, active smoking, illicit drug use, and higher rates of previous cesarean delivery, and multiple gestations when compared with laparoscopic myomectomy. Pregnant women with laparoscopic myomectomy had decreased rates of pregnancy-induced hypertension (adjusted risk ratios [aRR], 0.12; 95% confidence intervals [CI], 0.006-0.24]), gestational hypertension (aRR, 0.24; 95% CI, 0.08-0.76), pre-eclampsia (aRR, 0.18; 95% CI, 0.07-0.48), and pre-eclampsia or eclampsia superimposed on chronic hypertension (aRR, 0.03; 95% CI, 0.005-0.3), gestational diabetes mellitus (aRR, 0.14; 95% CI, 0.06-0.34), preterm premature rupture of membranes (aRR, 0.14; 95% CI, 0.02-0.96), preterm delivery (aRR, 0.36; 95% CI, 0.23-0.55), and cesarean delivery (aRR, 0.01; 95% CI, 0.007-0.01) and small for gestational age (aRR, 0.15; 95% CI, 0.005-0.04), compared with abdominal myomectomy group. Laparoscopic myomectomy group had a higher rate of spontaneous (aRR, 35.57; 95% CI, 22.53-62.66), and operative vaginal delivery (aRR, 10.2; 95% CI, 8.3-12.56), uterine rupture (aRR, 6.1; 95% CI, 3.2-11.63), postpartum hemorrhage (aRR, 3.54; 95% CI, 2.62-4.8), hysterectomy (aRR, 7.74; 95% CI, 5.27-11.4), transfusion (aRR, 3.34; 95% CI, 2.54-4.4), pulmonary embolism (aRR, 7.44; 95% CI, 2.44-22.71), disseminated intravascular coagulation (aRR, 2.77; 95% CI, 1.47-5.21), maternal infection (aRR, 1.66; 95% CI, 1.1-2.5), death (aRR, 2.04; 95% CI, 1.31-3.2), and intrauterine fetal death (aRR, 2.99; 95% CI, 1.72-5.2) compared with the abdominal myomectomy group. CONCLUSION(S): Women who had a previous abdominal myomectomy have underlying risk factors for hypertension disorders of pregnancy and gestational diabetes. Women who underwent laparoscopic myomectomies have higher risks of bleeding, uterine rupture, resultant complications, and death, and should be monitored as high-risk patients, like abdominal myomectomies.

The global burden, risk and inequality of maternal obstructed labor and uterine rupture from 1990 to 2019.

BACKGROUND: Obstructed labor (OL) and uterine rupture (UR) are common obstetric complications. This study explored the burden, risk factors, decomposition, and health inequalities associated with OL and UR to improve global maternal health. METHODS: This was a cross-sectional analysis study including data on OL and UR from the Global Burden of Diseases, and Risk Factors Study (GBD) 2019. The main outcome measures included the number and age-standardized rate (ASR) of incidence, disability-adjusted life years (DALYs), prevalence, and deaths. RESULTS: The global burden of OL and UR has declined, with a decrease in incidence (number in 2019: 9,410,500.87, 95%UI 11,730,030.94 to 7,564,568.91; ASR in 2019: 119.64 per 100,000, 95%UI 149.15 to 96.21; estimated annual percentage change [EAPC] from 1990 to 2019: -1.34, 95% CI -1.41 to -1.27) and prevalence over time. However, DALYs (number in 2019: 999,540.67, 95%UI 1,209,749.35 to 817,352.49; ASR in 2019: 12.92, 95%UI 15.63 to 10.56; EAPC from 1990 to 2019: -0.91, 95% CI -1.26 to -0.57) and deaths remain significant. ASR of DALYs increased for the 10-14 year-old age group (2.01, 95% CI 1.53 to 2.5), the 15-19 year-old age group (0.07, 95% CI -0.47 to 0.61), Andean Latin America (3.47, 95% CI 3.05 to 3.89), and Caribbean (4.16, 95% CI 6 to 4.76). Iron deficiency was identified as a risk factor for OL and UR, and its impact varied across different socio-demographic indices (SDIs). Decomposition analysis showed that population growth primarily contributed to the burden, especially in low SDI regions. Health inequalities were evident, the slope and intercept for DALYs were - 47.95 (95% CI -52.87 to -43.02) and - 29.29 (95% CI -32.95 to -25.63) in 1990, 39.37 (95%CI 36.29 to 42.45) and 24.87 (95%CI 22.56 to 27.18) in 2019. Concentration indices of ASR-DALYs were - 0.2908 in 1990 and - 0.2922 in 2019. CONCLUSION: This study highlights the significant burden of OL and UR and emphasizes the need for continuous efforts to reduce maternal mortality and morbidity. Understanding risk factors and addressing health inequalities are crucial for the development of effective interventions and policies to improve maternal health outcomes globally.

Maternal Morbidity following Trial of Labor after Cesarean in Women Experiencing Antepartum Fetal Death.

This study aims to investigate whether trial of labor after cesarean delivery (TOLAC) in women with antepartum fetal death, is associated with an elevated risk of maternal morbidity. A retrospective multicenter. TOLAC of singleton pregnancies following a single low-segment incision were included. Maternal adverse outcomes were compared between women with antepartum fetal death and women with a viable fetus. Controls were matched with cases in a 1:4 ratio based on their previous vaginal births and induction of labor rates. Univariate analysis was followed by multiple logistic regression modeling. During the study period, 181 women experienced antepartum fetal death and were matched with 724 women with viable fetuses. Univariate analysis revealed that women with antepartum fetal death had significantly lower rates of TOLAC failure (4.4% vs. 25.1%, p < 0.01), but similar rates of composite adverse maternal outcomes (6.1% vs. 8.0%, p = 0.38) and uterine rupture (0.6% vs. 0.3%, p = 0.56). Multivariable analyses controlling for confounders showed that an antepartum fetal death vs. live birth isn't associated with the composite adverse maternal outcomes (aOR 0.96, 95% CI 0.21-4.44, p = 0.95). TOLAC in women with antepartum fetal death is not associated with an increased risk of adverse maternal outcomes while showing high rates of successful vaginal birth after cesarean (VBAC).

Pyometra Puzzler: Unraveling Senile Endometritis in an Unconventional Presentation.

Pyometra is a very uncommon condition in postmenopausal women that rarely improves with standard antibiotic treatments. It is usually overlooked as the patient presents with vague symptoms. Our case presented a postmenopausal woman with sepsis due to a huge pyometra. Swabs for sensitivity, tubercular gene testing, and basic blood workup were done, and the patient was started on intravenous antibiotic therapy. Pyometra drainage could not be done due to thin, friable uterine walls. When the patient had improved, a clinically total abdominal hysterectomy was done after ruling out malignant causes. Delay in the diagnosis of this condition may lead to perforation, which may, in turn, cause peritonitis, which may gravely affect the patient.

Accidental uterine extensions in cesarean deliveries - outcome of subsequent pregnancy.

OBJECTIVES: To explore the obstetric, maternal and neonatal outcome in the subsequent pregnancy after a pregnancy with an accidental uterine extension (AUE) during cesarean delivery (CD), as well as the relationship between the different types of AUE (inferior, lateral and superior). METHODS: A retrospective cohort study of all CD with AUE in a tertiary medical center between 01/2011-01/2022. Women with a prior CD with AUE were compared to a 1:3 ratio matched control group of women with a prior CD without AUE. All AUE were defined in their direction, size and mode of suturing. CD with deliberate uterine extensions were excluded. We evaluated obstetric, maternal and neonatal outcomes in the subsequent pregnancy after a pregnancy with AUE during CD. RESULTS: Comparing women with a prior CD with AUE (n=177) to the matched control group of women with a prior CD without AUE (n=528), we found no significant differences in proportions of uterine rupture or any other major complication or adverse outcome between the groups. There were no significant differences in the outcomes of the subsequent pregnancy in relation to the characteristics of the AUE (direction, size and mode of suturing). CONCLUSIONS: Subsequent pregnancies after AUE are not associated with higher maternal or neonatal adverse outcomes including higher proportions of uterine rupture compared to pregnancies without previous AUE. Different characteristics of the AUE do not impact the outcome.

A cesarean section scar dehiscence during the first trimester of an intrauterine pregnancy: a rare case report and literature review.

Uterine rupture is specified as a complete laceration of the uterine wall, including its serosa, leading to a connection between the endometrial and peritoneal chambers. It can occur in any stage of pregnancy and is considered a severe and perhaps fatal complication. A 35-year-old woman at 9 weeks of gestation with a medical history of five prior cesarean sections presented with lower abdominal pain that had lasted for 5 hr. We detected small amounts of free fluid in the Douglas pouch using ultrasound. Subsequently, a laparotomy revealed a cesarean scar dehiscence from a non-cesarean scar pregnancy. Patients who experience a uterine rupture may have vague symptoms, severe abdominal discomfort, abnormal uterine bleeding, and severe hemorrhagic shock, depending on their gestational age. Ultrasound imaging can be used to diagnose this fatal condition in addition to laparoscopy to immediately identify and treat the issue in urgent cases.

Accuracy of sonographic lower segment thickness and prediction of vaginal birth after caesarean in a resourced-limited setting; Prospective study.

OBJECTIVES: To assess the accuracy of ultrasound measurement of the lower uterine segment (LUS) thickness against findings at laparotomy, and to investigate its correlation with the success rate of vaginal birth after one previous caesarean delivery (CD) in a resource-limited setting. DESIGN: Prospective study. SETTING: Obstetrics and Gynaecology department in a tertiary hospital in Ghana. POPULATION: Women with one previous CD undergoing either a trial of labour (TOLAC) or elective CD. METHODS: Myometrial lower uterine segment thickness (mLUS) and full lower uterine segment thickness (fLUS) were measured with transvaginal ultrasound (TVUS). The women were managed according to local protocols with the clinicians blinded to the ultrasound measurements. The LUS was measured intraoperatively for comparison with ultrasound measurements. MAIN OUTCOME MEASURES: Lower uterine segment findings at laparotomy, successful vaginal birth. RESULTS: A total of 311 pregnant women with one previous CD were enrolled; 147 women underwent elective CD and 164 women underwent a TOLAC. Of the women that underwent TOLAC, 96 (58.5%) women had a successful vaginal birth. The mLUS was comparable to the intraoperative measurement in the elective CD group with LUS thickness <5 mm (bias of 0.01, 95% CI -0.10 to 0.12 mm) whereas fLUS overestimated LUS <5 mm (bias of 0.93, 95% CI 0.80-1.06 mm). Successful vaginal birth rate correlated with increasing mLUS values (odds ratio 1.30, 95% CI 1.03-1.64). Twelve cases of uterine defect were recorded. LUS measurement ≤2.0 mm was associated with an increased risk of uterine defects with a sensitivity of 91.7% (95% CI 61.5-99.8%) and specificity of 81.8% (95% CI 75.8-86.8%). CONCLUSION: Accurate TVUS measurement of the LUS is technically feasible in a resource-limited setting. This approach could help in making safer decisions on mode of birth in limited-resource settings.

Perioperative complications in women undergoing thermal balloon endometrial ablation after one or more cesarean deliveries.

OBJECTIVE: To determine whether thermal ballon endometrial ablation can be safely performed after one or more cesarean sections. STUDY DESIGN: Retrospective cohort study including all women who underwent thermal balloon endometrial ablation at the Kepler University Hospital, Austria, between November 2017 and December 2022. For the analysis of the study endpoints, the dataset was divided into two groups: women with at least one cesarean section, and women without a history of cesarean section. Complications were classified according to the Clavien-Dindo classification. Association was tested using Fisher's exact test. RESULTS: Of the 361 women included, 29.3 % (n = 105) had at least one previous cesarean section. The association between intraoperative uterine rupture and previous cesarean section was not statistically significant (0 % vs. 1 %; p = 0.292). Only one uterine rupture was observed in the cesarean section group, which was located at the uterine fundus after a preoperatively unknown previous uterine perforation during IUD insertion. Secondary endpoints (overall complication rate, postoperative endometritis, vesicouterine fistula, different grades of Clavien-Dindo-classification) showed no significant associations either, even when considering the number of previous cesarean sections. The readmission rate to the clinic for bleeding disorders was 11.4 % in both groups (p = 1.00). CONCLUSION: Women who have had one or more prior cesarean sections with transverse isthmocervical hysterotomy do not appear to have an increased risk of complications in a subsequent thermal balloon endometrial ablation.