Cesarean scar niche: An evolving concern in clinical practice.

Increasing cesarean section rates have led to an increased awareness of associated complications such as the formation of cesarean scar niche, defined as an indentation at the site of the cesarean scar with a depth of at least 2 mm, diagnosed by ultrasound or magnetic resonance imaging. The precise prevalence of cesarean scar niche is unclear. The cause of a cesarean scar niche appears to be multifactorial and likely a combination of technical factors (low incision location), anatomical factors (uterine retroflexion), and patient factors, which might impair healing (body mass index, smoking, maternal age). Most patients with cesarean scar niche are asymptomatic; however, women can present with postmenstrual bleeding, pelvic pain, and subfertility. In pregnancy, cesarean scar niches have been associated with placenta accreta spectrum disorder and uterine rupture. Treatment should be reserved for symptomatic women. Hormonal treatment using either the combined oral contraceptive pill or a progesterone-containing intrauterine device may address irregular vaginal bleeding. Surgical management should be reserved for those in whom hormonal manipulation has failed or is contraindicated. The aim of this review was to summarize current literature pertaining to the cause, prevalence, diagnosis, and symptoms of cesarean scar niche and to make recommendations for managing this relatively new condition.

Fetal Deaths in Ireland Due to SARS-CoV-2 Placentitis Caused by SARS-CoV-2 Alpha.

CONTEXT.­: A severe third wave of COVID-19 disease affected Ireland in the first 3 months of 2021. In this wave, 1 second-trimester miscarriage and 6 stillbirths were observed in the Irish population because of placental insufficiency as a result of SARS-CoV-2 placentitis. This observation was at odds with the country's previous experience with COVID-19 disease in pregnant mothers. OBJECTIVE.­: To describe the clinical and pathologic features of these pregnancy losses. DESIGN.­: Retrospective review of clinical and pathologic data of cases of second-trimester miscarriage, stillbirth, or neonatal death identified by perinatal pathologists as being due to SARS-CoV-2 placentitis during the third wave of COVID-19 in Ireland. RESULTS.­: Clinical and pathologic data were available for review in 6 pregnancies. Sequencing or genotyping of the virus identified SARS-CoV-2 alpha (B.1.1.7) in all cases. Three of the 6 cases had maternal thrombocytopenia, and fetal growth restriction was not prominent, suggesting a rapidly progressive placental disease. CONCLUSIONS.­: The identification of SARS-CoV-2 alpha in all these cases suggests that the emergence of the variant was associated with an increased risk of fetal death due to SARS-CoV-2 placentitis when compared with the original virus. Maternal thrombocytopenia may have potential as a clinical marker of placentitis, but other inflammatory markers need investigation. Three of the 6 women had been assessed for reduced fetal movements in hospital some days before the fetal deaths actually occurred; this could suggest that there may be a window for intervention in some cases.

Comparing three-dimensional models of placenta accreta spectrum with surgical findings.

OBJECTIVE: Placenta accreta spectrum (PAS) is associated with significant maternal morbidity mainly related to blood loss. Pre-operative planning is aided by antenatal ultrasound and magnetic resonance imaging. We sought to assess whether three-dimensional (3D) models from MR images were accurate when compared with surgical and pathological findings. METHODS: Digital Imaging and Communications in Medicine files containing MR images with varying severity of PAS (n = 4) were modeled using 3D Slicer. Placenta, bladder, and myometrial defects were modeled. Myometrial defects at three different uterine locations were included-anterior, lateral and inferior. 3D models were used to identify the relationship between the myometrial defect and the internal cervical os. Findings were validated in a larger series of PAS cases (n = 14) where patterns of invasion were compared with estimated blood loss and distance from defect to the internal os. RESULTS: The defect illustrated in the four 3D models correlates to both surgical and pathological findings in terms of depth and pattern of invasion, location of defect, bladder involvement. Blood loss and topography of the defect from 3D modeling were examined in 14 further cases. Inferior defects were associated with increased blood loss compared with anterior defects. Increased distance from cervix was associated with reduced blood loss (R2  = 0.352, P = 0.01). CONCLUSION: Three-dimensional models of PAS provide an accurate preoperative description of placental invasion and should be investigated as a tool for selecting patients for uterine-conserving surgery. Accurate 3D models of placenta accreta spectrum are achievable and may provide additional information, such as distance of the defect from the internal os.

The prevalence of positive urine dipstick testing and urine culture in the asymptomatic pregnant woman: A cross-sectional study.

OBJECTIVE: Pregnancy induces unique physiological changes to the urinary tract, leaving pregnant women more susceptible to pyelonephritis. Urinary tract infections are generally diagnosed using urine sampling and testing with reagent sticks (dipstick) or laboratory culture. This study aimed to establish the prevalence of positive urine reagent strip and urine culture in asymptomatic pregnant women. STUDY DESIGN: This was a cross-sectional study of 300 women attending routine antenatal clinics. Samples were analysed using an automated urine dipstick analyser for the presence of glucose, protein, leucocyte esterase, blood, and nitrites. All samples were cultured. Multinomial logistic regression was performed to investigate risk factors for urine contamination and infection. Sensitivities and specificities were calculated for common dipstick findings for positive and mixed urine culture. RESULTS: One-in-three (37.0 % [111/300], 95 % CI 31.6-42.8 %) women had at least one positive finding on reagent strip testing. Ten per cent ([29/300], 95 % CI 6.7-13.7 %) of samples had a positive culture for a single organism, whereas 46.7 % ([140/300], 95 % CI 40.9-52.5 %) of samples were positive for multiple organisms (mixed culture). 43.7 % ([131/300], 95 % CI 38.0-49.5 %) of samples had a negative culture. Organisms cultured were similar to previous reports from high-income countries. BMI was identified on regression analysis as a risk factor for contamination. CONCLUSIONS: There is a high prevalence of positive urine dipstick and contaminated culture in asymptomatic pregnant women. BMI is a risk factor for urine culture contamination and further research into this topic is essential given trends in obesity worldwide.