Evaluation of incision healing status after transverse uterine fundal incision for cesarean delivery and postoperative pregnancy: a ten-year single-center retrospective study.

BACKGROUND: Transverse uterine fundal incision (TUFI) is a beneficial procedure for mothers and babies at risk due to placenta previa-accreta, and has been implemented worldwide. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. We therefore evaluated the TUFI wound scar to determine the approval criteria for pregnancy after this surgery. METHODS: Between April 2012 and August 2022, we performed TUFI on 150 women. Among 132 of the 150 women whose uteruses were preserved after TUFI, 84 women wished to conceive again. The wound healing status, scar thickness, and resumption of blood flow were evaluated in these women by magnetic resonance imaging (MRI) and sonohysterogram at 12 months postoperatively. Furthermore, TUFI scars were directly observed during the Cesarean sections in women who subsequently conceived. RESULTS: Twelve women were lost to follow-up and one conceived before the evaluation, therefore 71 cases were analyzed. MRI scans revealed that the "scar thickness", the thinnest part of the scar compared with the normal surrounding area, was ≥ 50% in all cases. The TUFI scars were enhanced in dynamic contrast-enhanced MRI except for four women. However, the scar thickness in these four patients was greater than 80%. Twenty-three of the 71 women conceived after TUFI and delivered live babies without notable problems until August 2022. Their MRI scans before pregnancy revealed scar thicknesses of 50-69% in two cases and ≥ 70% in the remaining 21 cases. And resumption of blood flow was confirmed in all patients except two cases whose scar thickness ≥ 90%. No evidence of scar healing failure was detected at subsequent Cesarean sections, but partial thinning was found in two patients whose scar thicknesses were 50-69%. In one woman who conceived seven months after TUFI and before the evaluation, uterine rupture occurred at 26 weeks of gestation. CONCLUSIONS: Certain criteria, including an appropriate suture method, delayed conception for at least 12 months, evaluation of the TUFI scar at 12 months postoperatively, and cautious postoperative management, must all be met in order to approve a post-TUFI pregnancy. Possible scar condition criteria for permitting a subsequent pregnancy could include the scar thickness being ≥ 70% of the surrounding area on MRI scans, at least partially resumed blood flow, and no abnormalities on the sonohysterogram. TRIAL REGISTRATION: Retrospectively registered.

Updated criteria for the approval of subsequent pregnancy after cesarean section with a transverse uterine fundal incision based on 17 years of experience.

In the case of placenta previa-accreta when the placenta covers the entire anterior uterine wall, it is difficult to avoid transecting the placenta by traditional low-transverse cesarean section (CS), resulting in catastrophic hemorrhage and fetal anemia. To prevent this critical risk, we developed the CS with transverse uterine fundal incision (TUFI) and this technique has been widely used as a beneficial surgical method in clinical practice owing to its safety advantages for the mother and neonate since our first report. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. Based on our 17 years of experience, patients who require TUFI do not need to avoid this beneficial operative method simply because of their desire to conceive again, as long as certain conditions can be met. To approve a post-TUFI pregnancy, an appropriate suture method, delay in conception for at least 12 months with evaluation of the TUFI scar, and cautious postoperative management are at a minimum essential. In this article, we showed our recommendation for operative procedure and discuss the current status of the management of post-TUFI pregnancies based on the evaluation of the TUFI wound scar and experience with postoperative pregnancies.

A novel extraperitoneal cesarean section of supravesical approach: Operative techniques.

AIM: We have established a novel extraperitoneal cesarean section technique by supravesical approach. An advantage of this technique over the conventional paravesical approach is that the lower uterine segment is broadly exposed and that all operative procedures can be performed under direct vision. We present the details of this novel technique. METHODS: The bladder and the peritoneum are exposed by removing the transversalis and extraperitoneal fasciae. Subsequently, a triangular area between the median umbilical ligament, the peritoneum, and the bladder is exposed. The median umbilical ligament is dissected at this site. Bladder dissection from the peritoneum is also initiated from this area and proceeds toward the lower uterine segment. RESULTS: Operative times for pelvic fascia dissection and bladder removal from the peritoneal surface are currently around 15-25 min. During the process of development of this technique, there have been no bladder injuries in 501 patients that caused urine leakage. DISCUSSION: The supravesical approach has been considered difficult due to the strong adhesion between the perivesical fascia and the peritoneum at the bladder fundus. In this paper, we show how to safely remove the bladder fundus from the peritoneum. The bladder can then be easily lowered down toward the lower uterine segment. Although this technique allows the lower uterine segment to be broadly exposed and all operative procedures can be performed under direct vision, a disadvantage is the comparatively long time currently required to perform it. CONCLUSIONS: This technique could be a valuable option for extraperitoneal cesarean section, but disadvantages must also be considered.

Colporrhaphy using elastic tissue continuous with and obscured behind the fibromuscular layer of the vaginal wall.

AIM: Due to the U.S. Food and Drug Administration's order to cease the use of surgical mesh for transvaginal repair, an improvement of the native tissue repair (NTR) of pelvic organ prolapse (POP) could become important as one of the first-line operative methods. This study details the surgical technique of an NTR method we developed, with report of our 5 years of experience. METHODS: Operative technique: A new fibromuscular layer (FL) was constructed using a thick and elastic tissue continuous with and obscured behind the original FL of the vaginal wall. PATIENTS: Between April 2017 and March 2020, we performed our novel repair technique on 87 women with POP of either quantification stage III or IV. RESULTS: We followed up 80 of the 87 women for over 24 months up to 60 months (follow-up rate: 91.2%). POP recurred (defined as stage II or higher) in four patients (5.0%). Operation time was 49-70 min. The bleeding volume was 70-250 g. There were no intra- or postoperative complications that required further treatment. CONCLUSIONS: This procedure could potentially become one of the first-line operative methods for repairing POP.

Difficult maintenance of serum drug concentration in methicillin-resistant Staphylococcus aureus toxic shock syndrome during early puerperium.

Toxic shock syndrome can be caused by methicillin-resistant Staphylococcus aureus (MRSA). During puerperium this condition is rare, and proper treatment during this period has not been clarified. Two patients developed toxic shock syndrome caused by MRSA soon after cesarean section. Despite the administration of antibiotics, both developed severe conditions and one of them required hysterectomy. The dosage was adjusted in the same way as nonpregnancy, but the actual drug concentration was significantly different from expectation. When there is severe infection during the early postpartum period, maintaining drug concentration at optimal levels may be difficult, and this could be life-threatening. Better understanding of the pharmacokinetics and establishment of a method to determine the optimal drug dose during puerperium is required.

Minimizing abdominal incision for transverse uterine fundal incision by aspiration of amniotic fluid and reduction of uterine size.

AIM: Transverse uterine fundal incision (TUFI) was developed to avoid catastrophic hemorrhage associated with cesarean section of the placenta previa-accreta. Abdominal incisions extend as far as the upper abdomen in patients in the third trimester of pregnancy and require general anesthesia. Instead, we tried to aspirate amniotic fluid (AF) to reduce the uterine size. METHODS: TUFI was performed in 19 of our patients in the third trimester in whom placenta previa accreta could not be ruled out between June 2012 and August 2016. After the lower abdominal vertical incision, we attempted to exteriorize the uterine fundus. If this was impossible, we inserted an 18-gauge spinal needle into the amniotic space. We aspirated AF until the uterine fundus could be exteriorized. RESULTS: We exteriorized the uterine fundus without extending the incision to the upper abdomen by aspirating 250-670 mL of AF in 12 patients who were between the 33rd and 37th week of pregnancy, and TUFI was performed under spinal anesthesia. AF aspiration was not required in four patients who were in the 30th or 31st week of pregnancy and in two patients with oligohydramnios in the 35th week of pregnancy. In one case, the trial was canceled due to hemorrhagic AF aspiration. No serious complications were observed in mothers or neonates. CONCLUSION: TUFI could be made by abdominal incision to the left of the umbilicus under spinal anesthesia without anesthesia by reducing the uterine size through AF aspiration, even for patients in the third trimester of pregnancy.

Complete rupture of unscarred uterus with delayed symptoms: Case report and possible mechanism.

Uterine ruptures typically occur suddenly, have obvious symptoms, and may require urgent treatment. We experienced a case of complete rupture of an unscarred uterus that was undetected for 9 days. We report the clinical course and possible factors that led to it. Nine days after delivery, complete rupture of the posterior uterine wall was diagnosed by magnetic resonance imaging. The colon and ovaries were tightly adhered to the posterior uterine body. When this adhesive lesion was detached, 7 cm horizontal defects of the muscular layer were revealed. The ruptured wound was repaired. Magnetic resonance imaging 1 year postoperatively showed no thinning of the repaired lesion and suggested successful reperfusion. Mild clinical course despite complete uterine rupture was presumably because of adhesion of the ovaries and intestines to the rupture site.

A disadvantage of cesarean section en caul: Umbilical velamentous insertion, a risk factor and proposed mechanism of neonatal anemia.

Cesarean section en caul could cause neonatal anemia, but the mechanism remains unknown. We demonstrate an association between neonatal anemia and velamentous insertion of the umbilical cord in cesarean section en caul, and suggest a way to make this procedure safer. We performed cesarean section en caul, but the placenta and the membrane sac were delivered separately. The neonate was severely anemic. The umbilical cord was attached to the membrane and the blood vessel connecting the umbilical cord and placenta was torn. The amniotic membrane covering the placental surface had peeled away. Velamentous insertion of the umbilical cord could be a cause of neonatal anemia associated with cesarean section en caul.

Treatment strategy for failed repair of uterine rupture: Cleansing an abscess via the cervical Canal.

We present a new, conservative treatment strategy for the cases in which an initial repair surgery of uterine rupture failed. In a case presented here, the patient underwent a repair surgery for the uterine rupture that became apparent 4 days after the cesarean delivery, but a part of the wound did not heal and an abscess formed in the surrounding area. The patient had purulent discharge from vagina, which led us to try to insert a Nelaton tube from vagina via cervical canal and to cleanse the abscess cavity. This procedure was successful and the abscess disappeared 38 days later, allowing the healing of the ruptured wound. The patient could deliver a baby 2 years later. Even if the initial repair treatment fails, a possibility of preserving the uterus should be considered for next pregnancy. One of the concrete treatment strategies for this purpose was presented.

Bleeding in the retroperitoneal space under the broad ligament as a result of uterine perforation after dilatation and curettage: Report of a case.

Uterine perforation, a complication of dilation and curettage, is typically recognized immediately after the procedure by clinical symptoms of peritoneal irritation resulting from intraperitoneal bleeding. Our patient complained of having an uncomfortable feeling, slight dizziness, palpitation in the sitting position and abdominal discomfort but did not show signs of peritoneal irritation 24 h after dilation and curettage. However, she suddenly complained of abdominal pain. Tenderness and rebound tenderness were detected at the lower abdominal wall. Ultrasonography and magnetic resonance imaging suggested uterine perforation. When the abdominal cavity was opened, a hematoma under the broad ligament of the uterus, laceration of the side wall of the uterine cervix and a small amount of bloody ascites and small clots in the abdominal cavity were observed. The uterine cervical wall was sutured. Physicians should postpone discharge and observe the clinical course carefully when a patient complains of inexplicable discomfort after dilation and curettage.

Twin pregnancy in a 51-year-old woman who underwent autologous cryopreservation at the age of 36 years: case report.

Climacteric women are able to become pregnant using oocytes donated earlier in life. However, adverse effects on such donated oocytes have been identified. We report a case of a successful dichorionic diamniotic twin pregnancy achieved using autologous fertilized cryopreserved oocytes in a climacteric woman. A 51-year-old woman became pregnant using autologous fertilized oocytes that had been frozen for 15 years. On her first visit, multiple leiomyoma of the uterus and gestational diabetes mellitus were diagnosed, and proteinuria began to appear at 30 weeks. In spite of our concerns these complications did not exacerbate and the clinical course for both mother and neonates was favorable. This is the first report of a live twin birth achieved using autologous cryopreserved oocytes in a climacteric woman. This case report may be of value to women who desire postponement of their infertility treatment and the professional assisted reproduction community.

Cardiac tamponade in pregnancy during the treatment of severe pre-eclampsia: report of a case.

We present a case of cardiac tamponade that occurred during the course of treatment for severe pre-eclampsia. A 37-year-old woman who underwent cesarean section for severe pre-eclampsia developed cardiac tamponade after delivery. While percutaneous pericardiocentesis temporarily improved her condition, pericardial effusion, dyspnea and tachycardia reappeared 5 days after delivery. A continuous drainage tube placed in the pericardial cavity for 5 days was required to maintain maternal cardiac function. Her clinical course was uneventful after continuous drainage and she was discharged 20 days after delivery. No such causes of symptomatic pericardial effusion were detected in the present case. Physicians should be aware of this complication when dyspnea is accompanied by tachycardia and enlargement of the cardiac silhouette with hypolucent lungs on chest X-ray. Immediate pericardiocentesis is also required to prevent life-threatening cardiac tamponade in such cases.

Pelvic inflammatory disease associated with cytomegalovirus infection in an immunocompetent adult: Case report and literature review.

Pelvic inflammatory disease associated with cytomegalovirus infection in immunocompetent adults might be difficult to diagnose because of the rarity and relatively inconspicuous symptoms of infectious mononucleosis. Even if the main complaint is lower abdominal pain, careful search for symptoms latent outside the abdomen could lead to the diagnosis.

Adenocarcinoma arising from vaginal stump: unusual vaginal carcinogenesis 7 years after hysterectomy due to cervical intraepithelial neoplasia.

Primary vaginal adenocarcinomas are one of the rarest malignant neoplasms, which develop in the female genital tract. Because of the extremely low incidence, their clinical and pathologic characteristics are still obscure. Recently, we experienced a case of vaginal adenocarcinoma that appeared 7 yr after hysterectomy because of cervical intraepithelial neoplasia. The patient, a 65-yr-old obese woman, was diagnosed as having adenocarcinoma in the vaginal stump and was treated by simple tumor excision and radiation. Immunohistochemical and molecular biologic examinations indicated a potential association with human papilloma virus infection in the development of the vaginal adenocarcinoma. There has been no evidence of recurrence for 3 yr after the operation.

Management strategy of umbilical artery aneurysm complicated by cardiac anomaly: case study and literature review.

OBJECTIVE: Key considerations for managing an umbilical artery aneurysm (UAA) are a timely termination and the prevention of rupture of the UAA during delivery. Herein, we propose a treatment strategy based on our experience of UAA complicated by a fetal cardiac anomaly. CASE: A case of UAA was referred to our hospital at 23 weeks of gestation. The UAA increased its size to 6 cm. The blood reservoir within the UAA was presumed to be equivalent to the circulating blood volume of the fetus. At 28 weeks, small echogenic components suspected to be hematomas appeared in the umbilical vein, and the umbilical interstitial substance became edematous. An improvement in the fetus' condition could not be expected unless the UAA size was smaller. Thus, a cesarean delivery was performed at 30 weeks during which the UAA ruptured. The baby was anemic, disseminated intravascular coagulation (DIC) and later died. CONCLUSION: We present an assessment of a large blood reservoir within an UAA that may indicate the likelihood of high-output cardiac failure of the fetus. Either a classical cesarean section or a transverse uterine fundal incision should be performed when the UAA size is greater than 5 cm to prevent rupture of the UAA.

Management of severe pregnancy-induced hypertension after 34 weeks of gestation: A prospective study to reduce the rate of cesarean section.

OBJECTIVE: The aim of this study was to reduce the rate of cesarean section (CS) in severe pregnancy-induced hypertension (PIH) by introducing a set of indicative criteria for CS. METHODS: Labor induction was attempted in Japanese patients (n = 41) with severe PIH after 34 weeks of gestation. Vital signs and symptoms that may increase the risk of serious complications were defined. Following the appearance of one or more signs or symptoms, labor induction was suspended and CS was performed. The impact of using specific indicative criteria was evaluated by comparing the CS rate among patients who delivered before and after the criteria were introduced. RESULTS: Labor induction was attempted in 36 of 41 patients. Among the 36 patients in whom vaginal delivery was started, 12 patients required CS, and the remaining 24 patients succeeded in vaginal delivery. The introduction of specific indicative criteria for CS was associated with a significant reduction in the CS rate, from 95% (43/45) to 41% (17/41). CONCLUSIONS: Unnecessary CS may be avoided by defining the limits of safe labor induction.

p53 Tumor suppressor protein content in human uterine leiomyomas and its down-regulation by 17 beta-estradiol.

p53 protein, a tumor suppressor gene product, has been reported to play a crucial role in suppressing the growth of a variety of cancer cells. However, little information is currently available regarding the content of p53 protein in human leiomyomas. The present study was conducted to elucidate the p53 protein content in human leiomyomas and its regulation by sex steroid hormones. The content of p53 protein in leiomyomas was examined by immunohistochemical staining and Western blot analysis in comparison with that in the adjacent normal myometrium or leiomyoma specimens from GnRH agonist-treated patients. In addition, isolated human leiomyoma cells were subcultured in phenol red-free DMEM supplemented with 10% FBS for 120 h and then stepped down to serum-free conditions for an additional 72 h in the absence or presence of 17 beta-estradiol (E2; 10 ng/ml), progesterone (P4; 100 ng/ml), or E2 (10 ng/ml) plus P4 (100 ng/ml). The effects of sex steroids on p53 protein content in cultured leiomyoma cells were also assessed by Western immunoblot analysis. Immunohistochemical staining and Western blot analysis revealed that p53 protein content was highest in leiomyomas treated with GnRH agonist for 16 wk, lower in leiomyomas in the secretory, P4-dominated phase, and lowest in leiomyomas in the proliferative, E2-dominated phase of the menstrual cycle. There was no difference in p53 content between leiomyomas and the adjacent normal myometrium. Western blot analysis of cultured leiomyoma cell extracts revealed that E2 treatment significantly decreased p53 protein content compared with the control cultures, whereas either P4 treatment or combined treatment with E2 and P4 did not affect p53 protein content in cultured leiomyoma cells. The concentrations of sex steroid hormones used were within the physiological tissue concentrations in leiomyomas and myometrium described earlier. The present study suggests that E2 down-regulates p53 protein content, whereas P4 is ineffective in those cells. The E2-induced decrease in p53 protein content in leiomyoma cells leads us to propose that E2 may regulate human leiomyoma growth in part by down-regulating p53 tumor suppressor protein content in those cells.