Definition and sonographic reporting system for Cesarean scar pregnancy in early gestation: modified Delphi method.

OBJECTIVE: To develop a standardized sonographic evaluation and reporting system for Cesarean scar pregnancy (CSP) in the first trimester, for use by both general gynecology and expert clinics. METHODS: A modified Delphi procedure was carried out, in which 28 international experts in obstetric and gynecological ultrasonography were invited to participate. Extensive experience in the use of ultrasound to evaluate Cesarean section (CS) scars in early pregnancy and/or publications concerning CSP or niche evaluation was required to participate. Relevant items for the detection and evaluation of CSP were determined based on the results of a literature search. Consensus was predefined as a level of agreement of at least 70% for each item, and a minimum of three Delphi rounds were planned (two online questionnaires and one group meeting). RESULTS: Sixteen experts participated in the Delphi study and four Delphi rounds were performed. In total, 58 items were determined to be relevant. We differentiated between basic measurements to be performed in general practice and advanced measurements for expert centers or for research purposes. The panel also formulated advice on indications for referral to an expert clinic. Consensus was reached for all 58 items on the definition, terminology, relevant items for evaluation and reporting of CSP. It was recommended that the first CS scar evaluation to determine the location of the pregnancy should be performed at 6-7 weeks' gestation using transvaginal ultrasound. The use of magnetic resonance imaging was not considered to add value in the diagnosis of CSP. A CSP was defined as a pregnancy with implantation in, or in close contact with, the niche. The experts agreed that a CSP can occur only when a niche is present and not in relation to a healed CS scar. Relevant sonographic items to record included gestational sac (GS) size, vascularity, location in relation to the uterine vessels, thickness of the residual myometrium and location of the pregnancy in relation to the uterine cavity and serosa. According to its location, a CSP can be classified as: (1) CSP in which the largest part of the GS protrudes towards the uterine cavity; (2) CSP in which the largest part of the GS is embedded in the myometrium but does not cross the serosal contour; and (3) CSP in which the GS is partially located beyond the outer contour of the cervix or uterus. The type of CSP may change with advancing gestation. Future studies are needed to validate this reporting system and the value of the different CSP types. CONCLUSION: Consensus was achieved among experts regarding the sonographic evaluation and reporting of CSP in the first trimester. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Hysterotomy level at Cesarean section and occurrence of large scar defects: a randomized single-blind trial.

OBJECTIVE: To study the association between the level of Cesarean hysterotomy and the presence of large uterine scar defects 6-9 months after delivery. METHODS: This was a two-center, randomized, single-blind trial of a surgical procedure with masked assessment of the principal outcome under study. Women without a history of Cesarean section (CS) who underwent emergency CS at cervical dilatation ≥ 5 cm were randomized to high or low incision. Hysterotomy was performed 2 cm above and 2 cm below the plica vesicouterina in the high and low incision groups, respectively. Women were examined using saline contrast sonohysterography to assess the appearance of the hysterotomy scar 6-9 months after delivery. The main outcome was presence of a large scar defect, defined as the remaining myometrial thickness over the defect being ≤ 2.5 mm. Secondary outcomes were perinatal outcome, operative complications within 8 weeks after delivery and long-term outcome in a subsequent pregnancy. RESULTS: Of 122 patients enrolled in the trial, 114 were assessed by ultrasound examination, of whom 55 were randomized to high and 59 to low CS incision. Large scar defects were seen in four (7%) women in the high-incision group and in 24 (41%) in the low-incision group (P < 0.001; odds ratio, 8.7 (95% CI, 2.8-27.4)). There were no differences in operative complications and perinatal outcomes between the two groups. The median follow-up time was 4 years and 7 months, during which 56 (49%) women had a subsequent pregnancy. No significant differences were observed in the rate of complications in subsequent pregnancy and delivery between women who had low and those who had high incision at the index CS. CONCLUSION: Low Cesarean hysterotomy level in women in advanced labor is associated with higher incidence of large scar defects detected by transvaginal ultrasound examination 6-9 months after delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Nivel de histerotomía por cesárea y presencia de grandes defectos cicatriciales: un ensayo aleatorizado ciego simple OBJETIVO: Estudiar la asociación entre el nivel de histerotomía por cesárea y la presencia de grandes defectos de cicatrices uterinas a los 6-9 meses después del parto. MÉTODOS: Este fue un ensayo en dos centros de tipo aleatorizado y ciego simple de un procedimiento quirúrgico con evaluación encubierta del resultado principal que era el objeto de estudio. Las mujeres sin antecedentes de cesárea que se sometieron a una cesárea de emergencia con dilatación cervical ≥ 5 cm fueron asignadas al azar a una incisión alta o baja. La histerotomía se realizó 2 cm por encima y 2 cm por debajo del pliegue vesicouterino en los grupos de incisión alta y baja, respectivamente. Las mujeres se examinaron mediante sonohisterografía con contraste salino para evaluar la apariencia de la cicatriz de la histerotomía a los 6-9 meses después del parto. El resultado principal fue la presencia de un gran defecto de cicatriz, definido como el grosor restante del miometrio sobre el defecto de un tamaño ≤ 2,5 mm. Los resultados secundarios fueron el resultado perinatal, las complicaciones quirúrgicas dentro de las 8 semanas después del parto y el resultado a largo plazo en un embarazo posterior. RESULTADOS: De las 122 pacientes inscritas en el ensayo, 114 fueron examinadas mediante ecografía, de las cuales 55 fueron asignadas al azar a una incisión alta y 59 a una incisión baja en la cesárea. Se observaron defectos de cicatrices grandes en cuatro (7%) mujeres en el grupo de incisión alta y en 24 (41%) en el grupo de incisión baja (P<0.001; razón de momios 8.7 (IC 95%, 2.8-27.4)) No hubo diferencias entre los dos grupos en las complicaciones quirúrgicas o en los resultados perinatales. La mediana del tiempo de seguimiento fue de 4 años y 7 meses, durante los cuales 56 (49%) mujeres tuvieron un embarazo posterior. No se observaron diferencias significativas en la tasa de complicaciones en el embarazo posterior entre las mujeres del grupo de incisión baja y las de incisión alta en el índice de cesárea. CONCLUSIÓN: El nivel bajo de histerotomía por cesárea en mujeres con un parto avanzado se asocia con una mayor incidencia de grandes defectos de cicatrices detectados por ecografía transvaginal entre 6-9 meses después del parto.

Validation of prediction model for successful vaginal birth after Cesarean delivery based on sonographic assessment of hysterotomy scar.

OBJECTIVE: To validate a prediction model for successful vaginal birth after Cesarean delivery (VBAC) based on sonographic assessment of the hysterotomy scar, in a Swedish population. METHODS: Data were collected from a prospective cohort study. We recruited non-pregnant women aged 18-35 years who had undergone one previous low-transverse Cesarean delivery at ≥ 37 gestational weeks and had had no other uterine surgery. Participants who subsequently became pregnant underwent transvaginal ultrasound examination of the Cesarean hysterotomy scar at 11 + 0 to 13 + 6 and at 19 + 0 to 21 + 6 gestational weeks. Thickness of the myometrium at the thinnest part of the scar area was measured. After delivery, information on pregnancy outcome was retrieved from hospital records. Individual probabilities of successful VBAC were calculated using a previously published model. Predicted individual probabilities were divided into deciles. For each decile, observed VBAC rates were calculated. To assess the accuracy of the prediction model, receiver-operating characteristics curves were constructed and the areas under the curves (AUC) were calculated. RESULTS: Complete sonographic data were available for 120 women. Eighty (67%) women underwent trial of labor after Cesarean delivery (TOLAC) with VBAC occurring in 70 (88%) cases. The scar was visible in all 80 women at the first-trimester scan and in 54 (68%) women at the second-trimester scan. AUC was 0.44 (95% CI, 0.28-0.60) among all women who underwent TOLAC and 0.51 (95% CI, 0.32-0.71) among those with the scar visible sonographically at both ultrasound examinations. CONCLUSION: The prediction model demonstrated poor accuracy for prediction of successful VBAC in our Swedish population. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Assessment of Cesarean hysterotomy scar before pregnancy and at 11-14 weeks of gestation: a prospective cohort study.

OBJECTIVE: To compare the appearance and measurement of Cesarean hysterotomy scar before pregnancy and at 11-14 weeks in a subsequent pregnancy. METHODS: This was a prospective cohort study of women aged 18-35 years who had one previous Cesarean delivery (CD) at ≥ 37 weeks. Women were examined with saline contrast sonohysterography 6-9 months after CD. A scar defect was defined as large if scar thickness was ≤ 2.5 mm. Women were followed up and those who became pregnant were examined by transvaginal ultrasound at 11-14 weeks. Scar thickness was measured and scars were classified subjectively as a scar with or without a large defect. A receiver-operating characteristics curve was constructed to determine the best cut-off value for scar thickness to define a large scar defect at the 11-14-week scan. RESULTS: A total of 111 women with a previous CD were scanned in the non-pregnant state and at 11-14 weeks in a subsequent pregnancy. The best cut-off value for scar thickness to define a large scar defect at 11-14 weeks was 2.85 mm, which had 90% sensitivity (18/20), 97% specificity (88/91) and 95% accuracy (106/111). In the non-pregnant state, large scar defects were found in 18 (16%) women and all were confirmed at the 11-14-week scan. In addition, a large defect was found in three women at 11-14 weeks that was not identified in the non-pregnant state. CONCLUSION: The appearance of the Cesarean hysterotomy scar was similar in the non-pregnant state and at 11-14 weeks in a subsequent pregnancy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Assessment of Cesarean hysterotomy scar in non-pregnant women: reliability of transvaginal sonography with and without contrast enhancement.

OBJECTIVES: To determine intra- and interobserver reliability of evaluating the appearance and measurement of Cesarean hysterotomy scars using transvaginal ultrasound (TVS), with and without saline contrast sonohysterography (SCSH), in non-pregnant women. METHODS: Fifty-six women with one previous Cesarean delivery were examined by TVS, with and without contrast enhancement, 6-9 months after the Cesarean delivery. Two observers, blinded to their own and each other's measurements, evaluated the appearance of the hysterotomy scar and measured the myometrial thickness adjacent to the scar or scar defect (MTS). If a scar defect was noted, the remaining myometrial thickness over the defect (RMT) was measured. A scar defect was defined as large if RMT was ≤ 2.2 mm on conventional TVS and ≤ 2.5 mm when SCSH was performed. Intra- and interobserver reliability of conventional TVS and SCSH were assessed. RESULTS: Intraobserver reliability was good, with intraclass correlation coefficients (ICCs) of ≥ 0.97 for measurements of MTS and RMT on conventional TVS and SCSH. Interobserver ICCs for measurements obtained on SCSH were 0.85 (95% CI, 0.76-0.91) for MTS and 0.96 (95% CI, 0.93-0.98) for RMT, compared with 0.82 (95% CI, 0.72-0.89) for MTS and 0.87 (95% CI, 0.68-0.95) for RMT measured on conventional TVS. The kappa coefficient for measurements obtained on SCSH was 0.92, compared with 0.85 for conventional TVS. Intermethod ICC was 0.86 (95% CI, 0.78-0.92) for measurement of MTS and 0.89 (95% CI, 0.78-0.95) for measurement of RMT, with a kappa coefficient of 0.57. CONCLUSIONS: Measurement of RMT using SCSH is a reliable method for assessing Cesarean hysterotomy scars in non-pregnant women and can be used in clinical practice. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Imaging of gynecological disease (2): clinical and ultrasound characteristics of Sertoli cell tumors, Sertoli-Leydig cell tumors and Leydig cell tumors.

OBJECTIVE: To describe the clinical history and ultrasound findings in women with ovarian Sertoli cell, Sertoli-Leydig cell and Leydig cell tumors. METHODS: Women with a histological diagnosis of Sertoli cell tumor, Sertoli-Leydig cell tumor or Leydig cell tumor who had undergone preoperative ultrasound examination were identified from the databases of each of three participating ultrasound centers. The tumors were characterized on the basis of ultrasound images, ultrasound reports and research protocols (when applicable) using the terms and definitions published by the International Ovarian Tumor Analysis (IOTA) group. In addition, all images were reviewed and described using pattern recognition. RESULTS: Of 22 patients identified, 15 had Sertoli-Leydig cell tumors, two had Sertoli cell tumors and five had Leydig cell tumors. Four patients were postmenopausal, one 48-year-old woman had undergone hysterectomy, 16 were of fertile age and one was a 4-year-old girl. Most patients (82%, 18/22) had endocrine symptoms, the most common being bleeding disturbance (64%, 14/22) and hirsutism (32%, 7/22). Twenty-two (96%) of 23 tumors (one woman had bilateral tumors) contained a solid component; 16 (70%) were purely solid. Pattern recognition showed that the Leydig cell tumors were small solid tumors (four of five had a largest diameter of 1-3 cm) and the two Sertoli cell tumors were somewhat larger solid tumors (4 cm and 7 cm); the Sertoli-Leydig cell tumors were either small (3-4 cm) or medium-sized (6-7 cm) solid tumors, or multilocular solid tumors of any size (3-18 cm) with purely solid areas mixed with areas of innumerable closely packed small cyst locules. CONCLUSIONS: On the basis of endocrine symptoms, the woman's age and ultrasound findings, it should be possible to suggest a correct preoperative diagnosis of Sertoli cell, Sertoli-Leydig cell or Leydig cell tumors in many cases.