A new conservative surgical approach for placenta accreta spectrum in a low-resource setting.

OBJECTIVE: To assess the efficacy and safety of a new surgical approach for uterine preservation among patients with placenta accreta spectrum in a low-resource setting. METHODS: The present prospective cohort included 63 women diagnosed with placenta accreta spectrum undergoing cesarean deliveries who desired future fertility at the obstetrics department of Menoufia University Hospital from January 2018 to November 2019. Surgical management involved direct bilateral uterine arteries clamping below placental bed after broad ligament opening by round ligaments division and ligation and gentle downward dissection of vesical from myometrial tissues from lateral aspect toward trigone of the bladder. Outcomes included intraoperative and postoperative adverse events, hysterectomy rate, and postoperative hospitalization. RESULTS: Mean operative blood loss was 1860 ± 537 mL (range, 1040-3111 mL) and the incidence of bladder and ureteric injuries were 6.3% (n = 4) and 0%, respectively. The mean length of hospital stay was 4.46 ± 1.39 days. Overall, 7 patients (11.1%) required postoperative blood transfusion, and 2 patients (3.2%) required ICU admission. Five patients required peripartum hysterectomy (7.9%). CONCLUSION: Our conservative surgical approach is a safe alternative to peripartum hysterectomy with high uterine preservation rate, less intraoperative and postoperative morbidity and less need for blood transfusion in low resource settings. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; NCT04161521.

A new technique for uterine incision closure at the time of cesarean section: does it make a difference?

The purpose of this study was to compare the short-term operative outcomes of three different surgical techniques for uterine incision closure during caesarean section (CS). This trial enrolled 120 patients scheduled for primary caesarean delivery. Patients were randomised into either classical double-layer uterine closure, purse-string double-layer uterine closure (Turan), or our new approach of uterine closure (double layer step up-step down technique). For short-term comparison, transvaginal ultrasonography was planned for all patients 6 weeks after surgery. Compared to group II and Group III, residual myometrial thickness was significantly thinner in group I (p < .001). The number of patients with uterine niche was 10 (50% of all scar defects) in group I whereas it was 4 (20%) in group II and 6 (30%) in group III. Operative time was significantly longer in group II (p < .001). This led to our conclusion that Turan technique and our new approach are associated with thicker myometrial thickness and less frequency of uterine scar defect than classical double-layer uterine incision closure; however, our approach takes less operative time. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT04681378Impact statementWhat is already known on this subject? Many variations in CS technique have been studied. For example, single-layer uterine incision closure has been compared to double-layer uterine incision closure. Purse string double layer (Turan) has been also compared to the traditional double-layer technique. Double layer unlocked closure has been shown to result in a thicker residual myometrium and as a consequence can possibly lead to the decrease of niche development after a CS compared to single-layer closure with lower frequency of uterine scar defect with Turan technique.What do the results of this study add? Here we introduce a new uterine closure technique, which we have named double-layer step up-step down technique, as an alternative method. With this technique, the uterine incision contract more than with the traditional double layer technique and has similar results to the Turan technique; however, our approach takes less operative time.What are the implications of these findings for clinical practice and/or further research? These alternative techniques of uterine incision closure decrease the frequency of uterine niche that may be associated with many clinical problems such as ectopic pregnancy at the CS scar, placenta accreta, rupture of the uterus during a subsequent pregnancy. Future studies are needed to investigate the frequency of uterine rupture in a subsequent pregnancy following different uterine incision closure techniques.

Does Autologous Platelet-Rich Plasma Improve Wound Healing and Pain Perception after Cesarean Section in High-Risk Patients?

OBJECTIVE: The aim of the present study was to evaluate the effect of autologous platelet-rich plasma (PRP) on wound healing and pain perception after cesarean section in high-risk patients. DESIGN: This was a prospective randomized controlled trial. Participants/Materials, Settings, and Methods: This was a randomized controlled trial of 200 patients who came to the outpatient clinic of Menoufia University Hospital for elective cesarean surgery. The women were randomly assigned to 2 equal groups. The intervention group received PRP subcutaneous injection in the wound after surgery; however, the control group received the usual care. Outcome variables included the redness, edema, ecchymosis, discharge, approximation (REEDA) scale, Vancouver scar scale (VSS), and in addition to the visual analog scale (VAS). RESULTS: From April 2018 to July 2020, the PRP group showed a greater reduction in the REEDA score compared to the control group on day 1, day 7, and this was continued till 6 months (1.51 ± 0.90 vs. 2.49 ± 1.12, p < 0.001). Compared with the control group, the PRP group had a significantly greater reduction in the VSS and VAS scores beginning on the seventh day (3.71 ± 0.99 vs. 4.67 ± 1.25, p < 0.001) and (5.06 ± 1.10 vs. 6.02 ± 1.15, p < 0.001), respectively, and continued till 6 months. LIMITATIONS: Pain was not measured by the use of analgesics, and we did not investigate the effects of varying platelet concentrations, centrifuge duration, or speed. CONCLUSIONS: PRP has positive effects on wound healing and pain reduction in high-risk patients undergoing cesarean section in low-resource settings.

Different analgesics prior to intrauterine device insertion: is there any evidence of efficacy?

OBJECTIVES: The aims of this study were to compare three different interventions to reduce pain related to insertion of the intrauterine device (IUD), namely, lidocaine, misoprostol and a non-steroidal anti-inflammatory drug, against a placebo, and to assess the advantages of one drug over another, if any. METHODS: This was an open-label randomised placebo-controlled trial of 200 women assigned to receive one of the following medications prior to IUD insertion: 10 ml 1% lidocaine paracervical block, 400 µg oral misoprostol, oral naproxen or placebo tablets. The primary outcome measure was the level of pain experienced at different steps of IUD insertion and 15 min after the procedure, measured by a visual analogue scale (VAS). RESULTS: Between July 2015 and March 2016, 208 women were invited to participate in the study: eight refused and the remaining 200 women were randomised equally into four treatment groups (50 participants in each group). All characteristics were similar between the groups. The mean pain scores recorded during speculum placement, tenaculum application, uterine sounding, IUD insertion and 15 min after insertion were similar among the four groups (p > .05). Adjuvant methods to facilitate insertion, insertion failure or device expulsion were similar between the groups (p > .05). Complications were reported in 17 participants (8.5%); all resolved spontaneously with no further management (p > .05). CONCLUSION: Despite finding that none of the study drugs seemed effective prior to IUD insertion, insertion did not cause severe pain. The negative findings indicate the need for future research into new strategies to decrease pain during IUD placement.

A randomized trial of local endometrial injury during ovulation induction cycles.

OBJECTIVE: To investigate the effect of endometrial injury on pregnancy outcomes among infertile women taking clomifene citrate. METHODS: A prospective randomized trial was undertaken at an Egyptian hospital between January 26, 2015, and July 17, 2016. Eligible women (≥1 year primary/secondary/unexplained infertility, aged 20-35 years, day-2 follicle-stimulating hormone <12 IU/L, normal prolactin/thyroid function/uterine cavity, ≥1 patent tube, male partner with normal semen count and motility, 3 cycles of clomifene citrate without success) were randomly allocated (1:1) using computer-generated numbers into intervention (received endometrial injury on cycle day 15-24) or control groups (sham procedure). Women began ovulation induction on days 3-5 of the following cycle. Participants and investigators were not masked to group assignment. The primary outcomes were clinical pregnancy, spontaneous abortion, and multiple pregnancy rates. Women who completed follow-up were included in analyses. RESULTS: The intervention group included 52 women and the control group 53 women. The clinical pregnancy rate was significantly higher in the intervention group (37% [n=19]) than in the control group (13% [n=7]; P=0.006). No differences between the intervention and control groups were noted for spontaneous abortion rate (11% [2/19] vs 29% [2/7]; P=0.287) or multiple pregnancy rate (11% [2/19] vs 14% [1/7]; P=0.790). No adverse effects were reported. CONCLUSION: Endometrial injury before ovulation induction could improve chances of pregnancy and its outcomes. CLINICALTRIALS.GOV: NCT02345837.