Obstetric complications and outcomes of singleton pregnancy with previous caesarean section according to maternal age.

INTRODUCTION: To delineate obstetric complications and neonatal outcomes by maternal age in singleton pregnancies with previous caesarean section (CS). METHODS: A retrospective study involved 7715 singleton gestations with previous CS was conducted in a single centre. Statistical methods were used to describe and analyse the incidence of various complications and adverse outcomes classified by maternal ages. After selecting the reference group (30-34 years), multivariate logistic-binomial regression model was used to investigate the outcomes using SPSS. RESULTS: From 2013 to 2017, the proportion of advanced maternal age (AMA, ≥35 years) women with a history of CS increased yearly, especially in the 35-39 years age group. AMA women accounted for 39.4% of all pregnancies and has a high incidence of in vitro fertilization(IVF), progesterone therapy in early pregnancy, pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM), placenta previa, premature rupture of membranes (PROM) and postpartum haemorrhage (PPH). Compared to the 30-34 years group, the risks of PIH, GDM, placenta previa, PROM and PPH increased in AMA pregnancies. Very advanced age (≥40 years) may be associated with placenta accreta while young mothers (20-24 years) have a higher prevalence of premature birth. Vaginal bleeding during pregnancy is a risk factor for maternal complications, maternal and neonatal morbidity. DISCUSSION: AMA is associated with increased risk of PIH, GDM, placenta previa, PROM and PPH. Vaginal bleeding may be a predictor during pregnancy.

The safety of misoprostol alone use for second-trimester termination of pregnancy in women with previous caesarean deliveries.

PURPOSE: To investigate the safety of misoprostol use in second-trimester pregnancy termination among women with previous caesarean sections. MATERIALS AND METHODS: This is a retrospective cohort study conducted in a tertiary centre, examining 359 patients whose pregnancy was terminated with misoprostol alone between 14 and 24 weeks with the indication of foetal anomalies. Two dose regimens were administered vaginally or sublingually: (1)400 mcg misoprostol every 3-6 h; (2) 200 mcg misoprostol every 3-6 h following a loading dose of 400 mcg. The patients were divided into three groups according to the number of previous caesarean sections (CSs) and compared in terms of demographic and clinical characteristics and complications. Termination-related complications were the primary outcomes considered. RESULTS: Of the 217 patients, 80 (36.8%) had no previous uterine scar, 79 (36.4%) had one previous CS, and 58 (26.7%) had at least two prior CSs. The overall complication rate was 0.9%. There were no differences among groups in terms of complications (p > 0.05). There was no difference in complications in women with prior CS when they were compared according to the misoprostol regimens used (p > 0.05). The total dose of misoprostol used ranged from200 to 3,600 mcg. The treatment success of misoprostol during the second trimester was 92.1%. According to regression analysis, an increase in the week of gestation increased the failure rate of misoprostol for inducing second-trimester abortion by 2.7 times (95%CI (1.38-5.39)). CONCLUSION: Misoprostol alone is a safe and effective option for terminating second-trimester pregnancies with one or more previous CSs in settings where mifepristone is unavailable.

Epidemiology of placenta accreta spectrum disorders in Chinese pregnant women: A multicenter hospital-based study.

INTRODUCTION: Placenta accreta spectrum disorder (PASD) is a life-threatening obstetric complication. China still lacks high-quality data on the epidemiology of PASD. We intend to examine the major risk factors for PASD, explore the association of PASD with severe adverse perinatal outcomes and describe the geographical variations in China. METHODS: We used data from the China Labor and Delivery Survey, which included a total of 75,132 births from 96 hospitals in 24 provinces in China in 2015 and 2016. Each participating hospital randomly selected 6-10 weeks within a 12-month period. In the selected weeks, all births with gestational age ≥24 weeks or birth weight ≥500 g were included. We analyzed the demographic characteristics and prevalence of PASD in pregnant women. Multivariable logistic regression was used to examine the association of previous caesarean section (CS) and repeated surgical abortion with PASD. We explored the association of PASD with severe adverse perinatal outcomes, which indicated by Weighted Adverse Outcome Score (WAOS) ≥ 20. Multivariable logistic regression was used to examine the association of PASD with WAOS. We also calculated and compared the prevalence of PASD in different regions of China. RESULTS: The weighted prevalence of PASD was 2.20% (95% CI 0.76 to 4.95) in our population，and there was a substantial difference in the prevalence of PASD by geographic regions in China. Two or more previous CS (adjusted OR 2.34, 95%CI 1.41 to 3.88) and repeated surgical abortion (twice: 2.16, 1.20 to 3.92; 3 times: 4.31, 1.70 to 10.96; ≥4 times: 4.76, 3.12 to 7.26) were significant risk factors for PASD. PASD (adjusted OR 3.77, 95% CI 2.80 to 5.06) was a significant risk factor for severe adverse perinatal outcomes indicated by WAOS score. DISCUSSION: The prevalence of PASD in China appeared higher than that in other countries, and varied substantially by geographic regions. Two or more previous CS and repeated surgical abortion were major risk factors for PASD. Pregnant women with PASD had more severe adverse pregnancy outcomes. Reducing primary cesarean section and repeated surgical abortion are the key to decreasing PASD.

Anomalías de inserción placentaria: diagnóstico y tratamiento oportuno / Placental insertion anomalies: timely diagnosis and treatment

Paciente de 34 años, gestante de 34 semanas. Doble cesáreada anterior con estudio ecográfico previo con informe de signos indirectos de ascetismo placentario, sin estudio de Resonancia Magnética Nuclear. Se realizó Operación Cesárea abdominal corporal, se dio nacimiento a recién nacido vivo. Se realizó instilación de 2 ampollas de 2 ml. de polidocanol al 3 % con sonda K33 en cordón umbilical para disminución del riesgo de sangrado, ligadura del mismo, introducción de cordón en cavidad uterina y cierre de Histerorrafia + Histerectomía subtotal El diagnóstico oportuno por medio de estudios de imagen, actuación médica criteriosa y el seguimiento de los protocolos establecidos nos llevara a la excelencia en la resolución de dichos casos.

34-year-old patient, 34 weeks pregnant. Previous double caesarean section with a previous ultrasound study with a report of indirect signs of placental asceticism, without a Nuclear Magnetic Resonance study. An abdominal cesarean section was performed, giving birth to a live newborn. Instillation of 2 ampoules of 2 ml was performed. of 3% polidocanol with a K33 probe in the umbilical cord to reduce the risk of bleeding, ligation of the cord, introduction of the cord into the uterine cavity and closure of hysterorrhaphy + subtotal hysterectomy Timely diagnosis through imaging studies, judicious medical action and following established protocols will lead us to excellence in the resolution of these cases.

Increased risk of obstetric anal sphincter injury in women undergoing vaginal delivery after caesarean section: A systematic review and meta-analysis.

BACKGROUND: There is increased focus on obstetric anal sphincter injury (OASI) and there are several well-established risk factors such as birthweight, instrumental delivery and median episiotomy. Some studies have found increased risk of OASI in women delivering vaginally after a previous caesarean section (VBAC). OBJECTIVE: To evaluate whether there is increased prevalence of OASI in VBAC compared with primiparous women. SEARCH STRATEGY: Literature search using PubMed, Embase and Cochrane databases. SELECTION CRITERIA: All studies with data on both primiparous women and women undergoing VBAC were included. All included studies were evaluated using the "SIGN - methodology checklist" to verify if the quality was acceptable. DATA COLLECTION AND ANALYSIS: This systematic review included 23 articles conducted in 11 countries over 19 years. Included studies were analysed using RevMan version 5.4. MAIN RESULTS: We found increased prevalence of OASI in the VBAC group; 8.18% (95% confidence interval [CI] 8.07-8.29) compared with 6.59% (95% CI 6.56-6.62) in primiparous women. Correspondingly, the meta-analysis revealed increased prevalence for OASI in the VBAC group (odds ratio 1.27, 95% CI 1.10-1.47). We found a high level of heterogeneity (I2  = 98%). CONCLUSION: Women undergoing VBAC had a higher prevalence of OASI compared with primiparous women.

The effectiveness of decision aids for pregnancy related decision-making in women with pre-pregnancy morbidity; systematic review and meta-analysis.

INTRODUCTION: Women with pre-existing morbidity arising from medical conditions or previous caesarean section are at higher risk of adverse pregnancy outcomes compared to women without such morbidity. Women often face complex pregnancy-related decision-making that may be characterized by conflicting maternal and perinatal priorities. The aim of this systematic review and meta-analysis was to assess randomised controlled trials of decision aids to evaluate whether they are effective at reducing decisional conflict scores and to evaluate what type of decision aids are most effective for women with pre-existing morbidity in pregnancy. METHODS: We searched Medline (via Ovid), Embase (via Ovid), CINAHL (via EBSCO) from the earliest entries until September 2021. We selected randomised controlled trials comparing patient decision aids for women with pre-existing morbidity with usual clinical practice or a control intervention. Study characteristics and Jadad risk of bias was recorded. Meta-analysis by pre-existing morbidity type was performed using Stata 17 and the data was presented with a Forest Plot. Random effects models were used to calculate summary estimates if there was substantial clinical or statistical heterogeneity and post mean DCS scores were described in a sensitivity analysis and presented as a line graph, to improve clinical interpretation of results.. A narrative synthesis of the selected studies evaluated what type of decision aid works and for in what circumstances. RESULTS: Ten randomised controlled trials, which reported data from 4028 women, were included. Patient decision aids were evaluated in women with pre-existing morbidity who were undertaking pregnancy-related decision-making. Patient decision aids reduced decisional conflict scale scores by an additional - 3.7, 95% Confidence Interval - 5.9% to - 1.6%) compared to the control group. Women with pre-existing medical conditions were more conflicted at baseline and had greater reductions in decisional conflict scale score (mean difference vs. control group: - 6.6%; 95% CI - 9.8% to - 3.3%), in contrast to those with previous caesarean section (mean difference - 2.4%; 95% CI - 4.8% to - 0.1%). There was limited evidence on the effect of decision aids on health outcomes. Decision aids reduced unwanted variation in decision-making support across maternity settings. CONCLUSION: Patient decision aids are effective tools to support personalised care planning and informed decision-making in women with pre-existing morbidity. Women with pre-existing medical morbidity were more conflicted at baseline and were more likely to benefit from decision aids. Adoption of aids in this population may lead to improve adherence and health outcomes, warranting further research.

Non-haemorrhagic uterine rupture at 28 weeks of pregnancy following previous caesarean section: a case report.

BACKGROUND: There is need to put forward more symptoms and signs that could suggest a diagnosis of uterine rupture so that clinicians' suspicion is increased; there is also need to put forward uncommon intraoperative findings in patients with uterine rupture to correlate with the signs and symptoms of patients. CASE PRESENTATION: A 33 year old Gravida 5 Para 4 + 0 with 2 previous caesarean section scars at 28 weeks of amenorrhoea, presented to hospital complaining of lower abdominal pain for 11 h. She had no vaginal bleeding or vaginal discharge or pain on passing urine. On examination she had no pallor, pulse rate was 84 bpm, blood pressure was 110/80 mm of mercury (mmHg), fundal height was 27 cm (cm), fetal heart rate was regular at 150 beats per minute (bpm) and her cervix had a parous os. She was diagnosed with preterm labour and given dexamethasone intramuscularly, then an obstetric ultrasound scan was done and it revealed severe oligohydramnios. Decision do deliver her by emergency caesarean section was made and intraoperative findings were of a uterine rupture along the uterine scar with a fetal arm protruding through and vernix caseosa in the peritoneal cavity, without active uterine bleeding. The patient recovered well postoperatively. CONCLUSIONS: There is need to suspect uterine rupture in pregnant women with previous caesarean section scars if they present with abdominal pain and are found to have severe oligohydramnios despite having no history of any vaginal discharge, even when the fetal heart rate is normal and they are haemodynamically stable and without vaginal bleeding and remote from term.

The Hormonal Milieu by Different Labor Induction Methods in Women with Previous Cesarean Section: a Prospective Randomized Controlled Trial.

The physiological pattern of hormonal and signaling molecules associated with labor induction is not fully clear. We conducted a preliminary study in order to investigate hormonal changes during labor induction in women with previous cesarean section. Eighty-seven women at term, with previous cesarean section, were randomized to undergo induction of labor by breast stimulation or intracervical balloon and compared with spontaneous labor (controls). Maternal serum levels of oxytocin, prostaglandin F2α, prostaglandin E2, prolactin, estradiol, and cortisol were analyzed at 0, 3, and 6 h post-induction initiation. Fetal umbilical cord hormones were measured. No significant difference was found in the induction-to-delivery time or mode of delivery between the induction groups. Maternal serum oxytocin levels decreased to a lesser extent in the breast stimulation group vs. the control group (p=0.003, p<0.001). In the breast stimulation and control groups, prostaglandin E2 levels increased as labor progressed (p=0.005, 0.002, respectively). Prostaglandin F2α levels decreased over time in the balloon group (p=0.039), but increased in the control group (p=0.037). Both induction methods had similar outcomes. The hormonal studies ascertained the hypothesized mechanisms, with oxytocin level higher during breast stimulation and lower in balloon induction. These observations could help clinicians determine the appropriate method for cervical ripening in women with previous cesarean section. Larger future studies are needed to examine the effect of these hormonal trends on the rate of successful labor induction and complications, such as uterine rupture, in women with previous uterine scars. ClinicalTrials.gov Identifier NCT04244747.

Late registration for antenatal care by pregnant women with previous history of caesarean section.

BACKGROUND: Despite good access to antenatal care (ANC) services for most women, and regular training of healthcare workers in obstetrics and gynaecology, many pregnant women with a previous history of caesarean section (C/S) still presented late for ANC services at Letsholathebe II Memorial Hospital (LIIMH) in Maun, Botswana. This may increase morbidity and mortality in women with previous C/S delivery and neonates. Knowing why women with previous C/S present late for ANC may help in the formulation of interventions that decrease morbidity and mortality amongst these women and neonates. AIM: The aim of this study was to explore the reasons why pregnant women with a previous history of C/S registered late for ANC, at LIIMH. SETTING: This study was performed at LIIMH, a district hospital situated in Maun, Botswana. METHODS: This was a descriptive qualitative study. Consenting pregnant women with previous C/S who presented at LIIMH after the 20 weeks of pregnancy were interviewed until data saturation. The data was analysed for themes. RESULTS: The reasons for late registration at LIIMH include lack of information, misconception on the appropriate booking time and venue, dissatisfaction with the quality of ANC clinic services, use of alternative ANC providers, delayed referral, and pregnancy experience. CONCLUSION: Lack of knowledge of ANC delivery venue, using alternative ANC providers, and dissatisfaction with ANC clinic services, contributed to late registration. Pregnant women with previous history of C/S should be informed about ANC, delivery plans, and the assistance of alternative ANC providers should be explored.

Safety and efficacy of external cephalic version after a previous caesarean delivery: A systematic review.

BACKGROUND: External cephalic version (ECV) is a common procedure and has been shown to be safe and effective in turning a baby from a breech to cephalic presentation. However, whether ECV is safe and effective in women with a scarred uterus from a previous caesarean section remains contentious. AIM: To evaluate the safety and efficacy of external cephalic version in women with a singleton breech pregnancy and at least one previous caesarean delivery. MATERIAL AND METHODS: Literature searches were conducted on MEDLINE, PUBMED, EMBASE, CINAHL and SCOPUS up to June 2020. The search strategy included the following keywords: ('external cephalic version OR ECV') AND ('previous OR prior OR past' AND 'caesarean OR caesarean OR uterine scar'). Studies were included if they evaluated the efficacy and/or safety of external cephalic version in women after 36 weeks' gestation with a singleton breech pregnancy and at least one previous caesarean delivery. RESULTS: Nine studies were included in the review. ECV success rates and subsequent vaginal delivery rates ranged from 50 to 100% and from 50 to 74.9%, respectively. ECV complications reported included abnormal fetal heart rate, abnormal cardiotocography and transient vaginal bleeding. No studies reported cases of uterine rupture. CONCLUSIONS: ECV in women with a previous caesarean delivery is a relatively successful and low-risk procedure compared to women without a previous caesarean delivery. The results from this systematic review provide useful information for professional bodies in updating clinical guidelines such that ECV may be offered to women with one previous caesarean delivery.

Predicting Intra-abdominal Adhesions for Repeat Cesarean Delivery with the Ultrasound Sliding Sign.

OBJECTIVE: To evaluate the diagnostic value of the "sliding sign", a sonographic test, in predicting intra-abdominal adhesions for women undergoing repeat cesarean delivery. METHODS: This was a prospective observational study of women undergoing a scheduled repeat cesarean delivery at a regional hospital. The sliding sign is a sonographic observation of sliding movement between the uterus and the abdominal wall during deep breathing. The absence of the sliding sign was considered indicative of a high risk for dense uterine-abdominal adhesions, and this finding was compared with the operative findings. The primary outcome was the accuracy of the sliding sign in predicting adhesions. Secondary outcomes included incision-to-delivery time, operative time, and blood loss. RESULTS: We examined 112 pregnant women. Dense uterine-abdominal adhesions were found in 15 women, 8 of whom had no sliding sign identified on ultrasound. Therefore, the presence of the sliding sign detected 78 out of 97 women without uterine-abdominal adhesions. The sensitivity, specificity, and positive and negative predictive values of the sliding sign were 53.3%, 80.4%, 29.6%, and 91.8%, respectively. The intra- and inter-observer reliability using the kappa coefficient showed moderate consistency at 0.43 and 0.45, respectively. CONCLUSION: The sliding sign was less predictive than desired for clinical use, and it only detected half of the women with dense uterine-abdominal adhesions. Furthermore, a moderately low kappa coefficient indicates a lack of reproducibility, further emphasizing the sign's limited clinical value.

A propósito de un caso: presentación atípica de rotura uterina / A case report: unusual presentation of uterine rupture

RESUMEN La rotura del útero gestante se define como una solución de continuidad patológica de la pared uterina, situada con mayor frecuencia en el segmento inferior. La rotura de un útero intacto es muy rara, su incidencia está estimada entre 1/5700 y 1/20000 embarazos. Su prevalencia ha aumentado dado el incremento de parto vaginal con cesárea anterior. Actualmente oscila entre el 0.3 y el 1 %, siendo mayor en mujeres en las que tiene lugar un intento de parto vaginal tras cesárea (0,78%) que en aquellas en las que se lleva a cabo una cesárea electiva (0,22%). En cuanto a su diagnóstico, suele ser precoz, dada la clínica de gravedad con la que debutan. En este caso se presenta una evolución atípica de rotura uterina, donde la paciente se mantiene asintomática hasta que acude a urgencias cinco días después del parto con fiebre y dolor abdominal; gracias a la ecografía abdominal y trans-vaginal se pudo establecer rápidamente el diagnóstico y así proceder a su inmediata reparación quirúrgica.

ABSTRACT Rupture of the pregnant uterus is defined as a solution of pathological continuity of the uterine wall, most often located in the lower segment. The rupture of an intact uterus is very rare, its incidence is estimated between 1/5700 and 1/20000 pregnancies. Its prevalence has increased given the increase in vaginal delivery with previous caesarean section. Currently, it ranges between 0.3 and 1%, being higher in women with a vaginal delivery after caesarean section (0.78%) than in those who undergo an elective caesarean section (0.22%). Their diagnosis is usually early given by the severity of the debut. In this case, there is an atypical evolution of uterine rupture where the patient remains asymptomatic until she goes to the emergency room five days after delivery with fever and abdominal pain; Because of the abdominal and transvaginal ultrasound, the diagnosis could be quickly established and thus proceed to immediate surgical repair.

Correlation Between Previous Caesarean Section and Adverse Maternal Outcomes Accordingly With Robson Classification: Systematic Review and Meta-Analysis.

Background: The increasing rates of Caesarean section (CS) beyond the WHO standards (10-15%) pose a significant global health concern. Objective: Systematic review and meta-analysis to identify an association between CS history and maternal adverse outcomes for the subsequent pregnancy and delivery among women classified in Robson classification (RC). Search Strategy: PubMed/Medline, EbscoHost, ProQuest, Embase, Web of Science, BIOSIS, MEDLINE, and Russian Science Citation Index databases were searched from 2008 to 2018. Selection Criteria: Based on Robson classification, studies reporting one or more of the 14 adverse maternal outcomes were considered eligible for this review. Data Collection: Study design data, interventions used, CS history, and adverse maternal outcomes were extracted. Main Results: From 4,084 studies, 28 (n = 1,524,695 women) met the inclusion criteria. RC group 5 showed the highest proportion among deliveries followed by RC10, RC7, and RC8 (67.71, 32.27, 0.02, and 0.001%). Among adverse maternal outcomes, hysterectomy had the highest association after preterm delivery OR = 3.39 (95% CI 1.56-7.36), followed by Severe Maternal Outcomes OR = 2.95 (95% CI 1.00-8.67). We identified over one and a half million pregnant women, of whom the majority were found to belong to RC group 5. Conclusions: Previous CS was observed to be associated with adverse maternal outcomes for the subsequent pregnancies. CS rates need to be monitored given the prospective risks which may occur for maternal and child health in subsequent births.

Cultural perspectives on vaginal birth after previous caesarean section in countries with high and low rates - A hermeneutic study.

BACKGROUND: Caesarean section (CS) rates are increasing worldwide, an increase that is multifactorial and not well understood. There is considerable variation in the rates of vaginal birth after previous Caesarean section (VBAC). Cultural differences could be one explanation of the varying rates. OBJECTIVE: To interpret cultural perspectives on VBAC. METHODS: A hermeneutic approach for analysing findings from four published qualitative studies that were part of the OptiBIRTH study, focusing on clinicians and women's views of important factors for improving the rate of VBAC. 115 clinicians and 73 women participated in individual interviews and focus group interviews in countries with low rates (Germany, Italy and Ireland) and countries with high rates (Sweden, Finland and the Netherlands), in the original studies. RESULTS: Three themes demonstrated how the culture differs between the high and low VBAC rate countries; from being an obvious first alternative to an issue dependent on many factors; from something included in the ordinary care to something special; and from obstetrician making the final decision to a choice by the woman. The fourth theme, preparing for a new birth by early follow-up and leaving the last birth behind, reflects coherence between the cultures. DISCUSSION: The findings deepen our understanding of why the VBAC rates vary across countries and healthcare settings, and can be used for improving the care for women. CONCLUSION: In order to improve VBAC rates both maternity care settings and individual professionals need to reflect on their VBAC culture, and make make changes to develop a 'pro-VBAC culture'.

Massive blood transfusion in relation to delivery: incidence, trends and risk factors: a population-based cohort study.

OBJECTIVE: To estimate incidence, trends over time, and risk factors for massive blood transfusions in obstetric patients. A secondary aim was to evaluate transfusion ratios in relation to massive transfusion. DESIGN: Population-based cohort. SETTING: Five hospitals, in the Stockholm County, Sweden, from 1990 to 2011. POPULATION: All women that gave birth in Stockholm county, Sweden, and who received blood transfusions postpartum between 1990 and 2011. METHODS: Data on pregnancies and deliveries from the Swedish National Medical Birth Registry was cross-linked to the Stockholm transfusion database. Massive blood transfusion was defined as the transfusion of ≥10 units of red blood cells from partus through the next day. MAIN OUTCOME MEASURES: Main primary outcome was massive blood transfusion postpartum. RESULTS: Our cohort comprised 517 874 deliveries. Massive blood transfusion occurred in 277 women, for an incidence of 5.3 per 10 000 deliveries, and increased by 30% (P < 0.001) between the first and the second half of the study period. Major risk factors apparent before delivery were abnormal placentation (odds ratio [OR] 41; 95% CI 29.3-58.1), pre-eclampsia/placental abruption (OR 4; 95% CI 2.8-5.6), and previous caesarean delivery (OR 4; 95% CI 3.1-6.0). Risk factors at time of delivery were uterine rupture, atonic uterus, and caesarean delivery (OR 38, 17, and 3, respectively). CONCLUSION: We found an increasing trend in the postpartum rate of massive transfusion. Women with abnormal placentation were found to have the highest increased risk. Improved antenatal awareness of these women at risk might improve management and reduce the rate of massive transfusion. TWEETABLE ABSTRACT: Risk of massive blood transfusion in obstetric patients increases with placental complications and prior caesarean section.

Embarazo ectópico en cicatriz de cesárea previa, enfoque terapéutico y revisión de la literatura / Ectopic Pregnancy in Previous Cesarean Section Scar Therapeutic Approach and Literature Review

RESUMEN Introducción: El embarazo ectópico en cicatriz de cesárea previa es una forma novedosa y potencialmente mortal de implantación anormal de un saco gestacional dentro del miometrio y el tejido fibroso de la cicatriz. Se desconoce la historia natural de esta condición para lo cual no existe consenso en su manejo. Presentación de caso: Se presenta un caso que se manejó quirúrgicamente de forma conservadora por minilaparotomía, evacuación del tejido trofoblástico, lográndose preservar el útero. Con edad gestacional de 10 semanas, se aplicó metrotexate localmente e intramuscular. La paciente evolucionó satisfactoriamente hacia la mejoría siendo dada de alta. Métodos: Se realiza una revisión bibliográfica en bases de datos Pub Med y Science Direct con las palabras claves obtenidas del MeSH: "Scar ectopic pregnancy" durante los años 2000 y 2018. Se presentan las alternativas de manejo, tanto médico como quirúrgico, sin embargo, ello estará sujeto a las condiciones de la paciente y a la experiencia del médico tratante(AU)

ABSTRACT Introduction: Ectopic pregnancy in a previous caesarean section is a novel and life-threatening form of abnormal implantation of a gestational sac within the myometrium and the fibrous tissue of the scar. The natural history of this condition is unknown, thus there is no consensus in its management. Case report: We report a case that was surgically managed in conservative way by minilaparotomy, trophoblastic tissue evacuation. The uterus was preserved. The gestational age was 10 weeks. Metrotexate was applied locally and intramuscularly. The patient evolved satisfactorily towards improvement and discharge. Methods: A literature review during the years 2000 and 2018 was carried out in Pub Med and Science Direct databases. The keywords from MeSH used were "Scar ectopic pregnancy". Both medical and surgical management alternatives are presented, however the patient condition and the experience of the attending physician will contribute as well(AU)

Induction of Labour With Prostaglandin Gel in Grand Multipara with a Previous Caesarean Delivery.

OBJECTIVE: This study sought to evaluate the safety of induction of labour with prostaglandin E2 (PGE2) gel in grand multiparous (GMP) women and to compare the labour outcome of GMP women who have undergone one previous Caesarean section (CS) with that of GMP women who never had a previous CS. METHODS: This prospective cohort study (Canadian Task Force Classification II-2) evaluated induction of labour with 1 mg of PGE2 gel in 96 GMP women with one previous CS (study group) and in 104 GMP women without previous CS (control group). RESULTS: One uterine rupture occurred in the study group (1%), and another occurred in the control group (0.9%). Additional oxytocin was used in seven patients (7.3%) in the study group and in 28 others (26.9%) in the control group (P = 0.002). Both uterine ruptures occurred with oxytocin augmentation. One case of uterine scar dehiscence was found in the study group. There was no significant difference between the study group and the control group regarding the rate of vaginal delivery (74 [77.1%] vs. 78 [75%]) or the rate of CS (21 [21.9%] vs. 24 [23.1%]), respectively. There was no significant difference between the groups in 5-minute Apgar scores ≤7. There was no neonatal death in either group. CONCLUSION: A low dose (1.0 mg) of PGE2 gel for induction of labour in GMP women with one previous CS is appropriate and appears to be safe for both mother and baby. Augmentation by oxytocin should be used judiciously.

Utilidad y eficacia de la clasificación de Robson para disminuir la tasa de cesáreas / Utility and efficacy of Robson's classification to reduce the rate of cesareas

Resumen Objetivo: Evaluar la eficacia y utilidad de la clasificación de Robson en la reducción de la práctica de cesáreas. Materiales y métodos: Estudio observacional, descriptivo, retrospectivo y de corte transversal efectuado en pacientes de nivel socioeconómico medio y bajo atendidas entre enero y diciembre de 2016 en un hospital de segundo nivel. Para clasificar a las pacientes, según sus características obstétricas, se aplicó el modelo de Robson. Resultados: Se estudiaron 374 pacientes embarazadas; de ellas 91 (24.3%) terminaron la gestación mediante cesárea. Los grupos de Robson con mayor contribución al porcentaje de cesáreas fueron: grupo 1 con 50.5%, grupo 2 con 29.8% y grupo 10 con 8.7%. El grupo 5 reportó que 62.7% de los embarazos terminaron mediante parto. El 89.8% de las pacientes ingresó con trabajo de parto espontáneo. Las principales indicaciones de cesárea fueron, en el grupo 1, trabajo de parto estacionario; en el grupo 2, cesárea iterativa y en el grupo 10, feto pretérmino. Conclusiones: La aplicación del modelo de clasificación de Robson es útil y práctica para identificar los grupos de pacientes en los que es posible disminuir el porcentaje de cesáreas.

Abstract Objective: Evaluate the effectiveness and usefulness of the Robson classification to reduce the practice of cesarean sections. Materials and methods: Observational, descriptive, retrospective and cross section was made in patients of medium and low socioeconomic status attended between January and December 2016 in a second level hospital. For classify the patients, according to their obstetric characteristics, the model of Robson was applied. Results: 374 pregnant patients were studied; in 91 (24.3%) the pregnancy ended by caesarean section. The Robson groups with the greatest percentage contribution of caesarean sections were: group 1 with 50.5%, group 2 with 29.8% and group 10 with 8.7%. Group 5 reported that 62.7% of pregnancies ended by delivery; 89.8% of the patients was admitted with spontaneous labor. The main Cesarean indications were, in group 1, stationary labor; at group 2, iterative caesarean section and group 10, preterm fetus. Conclusions: The application of the Robson classification model is useful and practice to identify groups of patients in who it is possible to decrease the percentage of cesareans.

Evaluation of a modified "Triple-P" procedure in women with morbidly adherent placenta after previous caesarean section.

AIM: To describe a modified "Triple-P" procedure and evaluate its outcome in women with morbidly adherent placenta (MAP) after previous caesarean section (CS). METHODS: A retrospective cohort study of 96 women with MAP after CS was recruited with 45 women receiving the modified "Triple-P" procedure as study group and the other 51 cases receiving the conventional managements as the control. The maternal outcomes were compared. RESULTS: The modified "Triple-P" procedure was described in step by step. Women in study group demonstrated reduction of blood loss, transfusion blood volume and operation time, as well as less hospital days and lower hospitalization cost (P < 0.05). In addition, there was no difference in uterine healing rate, hysterectomy rate, and ICU transferring rate (P > 0.05). CONCLUSION: Our modified "Triple-P" procedure for MAP after previous CS maintained the advantages of Chandraharan's "Triple-P" procedure in preservation of uterus for further fertility, less intraoperative blood loss, shorter hospital stays, and lower hospitalization cost but also advanced in feasibility and convenience during introducing into routine clinical practice.

Morbidly Adherent Placenta: Its Management and Maternal and Perinatal Outcome.

OBJECTIVES: The aim of the study was to identify the risk factors predisposing to morbidly adherent placenta and to study the different modes of management and the obstetric and neonatal outcome of these patients. METHODS: This was a retrospective cum prospective observational study conducted in the Department of Obstetrics and Gynaecology in a tertiary care referral hospital in Mumbai from January 2012 to November 2014. RESULTS: The incidence of morbidly adherent placenta was 1.32 per 1000 pregnancies with patient profile comprising second gravida in the age group 26-28 years; 90 % of the patients in this study had previous Caesarean section and co-existing placenta praevia was diagnosed in 63 %. Fifty-three per cent of the women delivered between 35 and 38 weeks and 40 % had elective deliveries. Caesarean section was the mode of delivery in 90 % of the patients. Prophylactic balloon placement in the internal iliac artery followed by classical Caesarean section, uterine artery embolization and post-operative methotrexate was done in 27 % which preserved the uterus and was associated the blood loss of 1000-2000 mL. CONCLUSION: Antenatal diagnosis of morbidly adherent placenta allows for multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality.