New ultrasonographic risk assessment of uterine scar dehiscence in pregnancy after cesarean section.

PURPOSE: We performed a new ultrasonographic risk assessment of uterine scar dehiscence, which is a potential risk factor for uterine rupture, in pregnancy after cesarean section. We attempted to shed light on the natural course of the change in the lower uterine segment by means of a longitudinal investigation through quantitative and qualitative evaluations. METHODS: This retrospective single-center study involved 31 women with a normal singleton pregnancy delivered by elective cesarean section between 2020 and 2021, with all women showing a "niche" in the lower uterine segments. The lower uterine segments were assessed qualitatively and quantitatively using transvaginal ultrasonography at 16-21, 22-27, and 28-33 weeks of gestation, and subjects were divided into two groups: those with uterine dehiscence (12 women) and those without uterine dehiscence (19 women), depending on the gross findings of the lower uterine segments at cesarean section. Analyses were performed using Wilcoxon's rank-sum and Mann-Whitney U test with a significance level of P < 0.05. RESULTS: The lower uterine segments changed from V-shaped to U-shaped to thin as gestation progressed and was more prominent in the uterine dehiscence group, occurring mostly at 22-27 weeks. At 22-27 weeks, the median myometrial thickness in the uterine dehiscence group was lower than in the group without uterine dehiscence (P = 0.0030). Thinning of the lower uterine segments had moved the cephalad at 22-27 and 28-33 weeks in cases with and without uterine dehiscence. CONCLUSION: A model of morphological changes in the niche was constructed based on qualitative and quantitative assessments. The morphological changes and actual thinning of the lower uterine segments were prominent in the second trimester in women considered to have uterine scar dehiscence.

Complete Cervicouterine Dissociation After Repeat Cesarean Sections: A Case Report.

INTRODUCTION: The number of cesarean deliveries (CDs) has extremely increased in the last decades. Although it is a common and relatively safe surgical procedure, there are several potential complications. To the best of our knowledge, complete cervicouterine dissociation after several CDs has not been reported before in the medical literature. CASE REPORT: A 28-year-old woman with a history of 6 CDs presented with abdominal pain and vaginal bleeding. The patient's most recent CD happened three weeks before the current presentation. Transabdominal ultrasonography examination and magnetic resonance imaging revealed the absence of continuity with the uterine cervix and corpus with associated pelvic hematoma. Laparotomy findings confirmed the imaging findings, and the displaced uterine corpus was removed with the evacuation of the associating pelvic hematoma. CONCLUSION: Uterine dehiscence and rupture are among the relatively common complications of CD. Uterine rupture and dehiscence are focal disorders, and complete cervicouterine dissociation has not been seen before. Multiple CDs are among the risk factors for complete cervicouterine dissociation, and abnormal uterine bleeding is the most common symptom. Imaging findings allow a quick and definitive diagnosis, and surgical intervention may be planned accordingly based on the imaging findings.

Intrapartum ultrasound measurement of the lower uterine segment thickness in parturients with previous scar in labor: a cross-sectional study.

BACKGROUND: There is a lack of reliable methods to estimate the risk of uterine rupture or dehiscence during a trial of labor in women with previous cesarean sections. This study aimed to assess the lower uterine segment and myometrial thickness by ultrasonography in women with previous cesarean sections during labor and assess their association with the uterine defect. METHODS: A cross-sectional study was conducted on 161 women in the active phase of labor having one previous cesarean section. The study was conducted et al.-Azhar University Hospital, Assiut City, Egypt, from March 2018 to March 2019. Ultrasound measurements of lower uterine segment thickness and myometrial thickness were conducted by vaginal and abdominal ultrasound by two observers. The correlation of both thicknesses with the uterine defect was analyzed. RESULTS: Uterine defects were reported in 42 women (25.9%), uterine rupture in four women (2.5%), and dehiscence in 38 women (23.5%). The uterine defects were not associated with maternal factors (maternal age, gestational age at labor, body mass index, birth weight, interpregnancy, and inter-delivery interval). Receiver operating curve analysis demonstrated that lower uterine segment thickness was linked with uterine defect, with an area under the curve of 60% (95% CI, 51-70%, P = 0.044). Myometrial thickness was also linked to the uterine defect, with an area under the curve of 61% (95% CI, 52-71%, P = 0.025). Full lower uterine segment thickness of 2.3 mm and myometrial thickness of 1.9 mm were the cutoff value with the best combination of sensitivity and specificity for the uterine defect. Lower uterine segment thickness (OR = 0.49, 95%CI 0.24-0.96) and myometrial thickness (OR = 0.44, 95%CI 0.20-0.94) were significantly associated with the uterine defect. Lower uterine segment thickness (OR = 0.41, 95%CI 0.22-0.76) and myometrial thickness (OR = 0.33, 95%CI 0.16-0.66) were also significantly associated with cesarean section delivery. CONCLUSION: A lower uterine segment thickness of 2.3 mm and myometrial thickness of 1.9 mm during the first stage of labor are associated with a high risk of uterine defects during a labor trial. These measurements during labor can have a practical application in deciding the mode of delivery in women with previous cesarean sections and might reduce uterine rupture.

Near fatal interstitial pregnancy.

Interstitial pregnancies are a rare form of ectopic pregnancy that occur when there is implantation of a fetus into the interstitial portion of the uterus. These can be particularly challenging to diagnose and have a high risk of morbidity and mortality due to the relatively late presentation compared to other ectopic pregnancies. Here we present a gravida 3, para 2 female patient at 14 weeks gestational age who suffered uterine rupture and hemoperitoneum leading to cardiac arrest in the Emergency Department. This case demonstrates the importance of ultrasound as a critical tool in the diagnosis of interstitial pregnancy and the sonographic findings. It is essential for emergency clinicians to be aware of this rare diagnosis.

Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk.

BACKGROUND: The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri. OBJECTIVE: Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy. METHODS: From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group. RESULTS: The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors. CONCLUSION: In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.

Cesarean scar thickness in non-pregnant women as a risk factor for uterine rupture.

INTRODUCTION: Whether there is an association between residual myometrial thickness (RMT) after cesarean section (CS) and the risk of uterine rupture (UR) or uterine scar dehiscence at the subsequent delivery has been sparsely investigated. MATERIALS AND METHODS: Our cohort included 149 women with a first CS in whom we measured RMT by transvaginal ultrasonography 6-15 months after their delivery. We did a follow-up study on delivery outcomes in the women's subsequent births. The exposure was scar measurements in the non-pregnant uterus, and the primary outcome was a diagnosis of UR or dehiscence. We calculated likelihood ratios (LRs) with 95% confidence intervals of having UR or dehiscence with a thin RMT (<3 mm). RESULTS: Among the 149 women, 39 had a repeat CS (14 scheduled and 25 unscheduled procedures), and within these, we found one woman with UR and five women with uterine dehiscence. The proportion of women with a thin RMT was significantly higher among cases (4/6) than in controls (4/33); the LR was 5.5 (95% CI 1.9-16.2). CONCLUSIONS: The results suggest a significant association between a thin RMT as measured by transvaginal ultrasonography in the non-pregnant uterus after a first scheduled CS and the risk of UR or dehiscence at a subsequent delivery.

UTERINE RUPTURE IN THIRD TRIMESTER OF PREGNANCY FOLLOWING CORNUAL RESECTION DUE TO ECTOPIC PREGNANCY.

Uterine rupture during pregnancy is a critical obstetric complication associated with maternal and fetal mortality and morbidity. The risk is increased in patients with a history of previous uterine surgery including cesarean section, myomectomy, salpingectomy, as well as uterine and placental anomalies and polyhydramnios. It can also occur spontaneously. We present a case of uterine rupture in the early third trimester in a woman who had undergone previous laparoscopic removal of the left fallopian tube due to sactosalpinx and laparotomic removal of left uterine horn due to ectopic pregnancy.

Imaging evaluation of uterine perforation and rupture.

Uterine perforation and rupture, denoting iatrogenic and non-iatrogenic uterine wall injury, respectively, are associated with substantial morbidity,and at times mortality. Diverse conditions can result in injury to both the gravid and the non-gravid uterus, and imaging plays a central role in diagnosis of such suspected cases. Ultrasound (US) is the initial imaging modality of choice, depicting the secondary signs associated with uterine wall injury and occasionally revealing the site of perforation. Computed tomography can be selectively used to complement US findings, to provide a more comprehensive picture, and to investigate complications beyond the reach of US, such as bowel injury. In certain scenarios, magnetic resonance imaging can be an important problem-solving tool as well. Finally, catheter angiography is a valuable tool with both diagnostic and therapeutic capability, with potential for fertility preservation. In this manuscript, we will highlight the clinical and imaging approach to uterine perforation and rupture, while emphasizing the value of various imaging modalities in this context. In addition, we will review the multi-modality imaging features of uterine perforation and rupture and will address the role of the radiologist as a crucial member of the management team. Finally, a summary diagrammatic depiction of imaging approach to patients presenting with uterine perforation or rupture is provided.

Ultrasonic diagnosis of asymptomatic rupture of uterine in second trimester of pregnancy after laparoscopic surgery for interstitial pregnancy: a case report.

BACKGROUND: Uterine rupture is a rare, life-threatening event in obstetrics that may be fatal for the mother and fetus. Therefore, obstetricians need to pay attention to and should consider the antenatal diagnosis of uterine rupture in women having its risk factors. Successful conservative management for asymptomatic uterine rupture due to previous laparoscopic surgery for interstitial pregnancy has already been reported but remains understudied. CASE PRESENTATION: A 39-year-old woman was diagnosed asymptomatic uterine rupture at 22 weeks gestation by a routine second-trimester ultrasound scan. She had a history of laparoscopic salpingectomy with cornual wedge resection for interstitial pregnancy 10 months before this pregnancy. Refusing doctor's twice advice of terminating the pregnancy, the patient insisted carrying on the pregnancy, and followed up by ultrasound and magnetic resonance imaging. Fetal growth was appropriate, fetal movements were good and the patient had no symptoms, without uterine contraction or amniotic fluid loss throughout follow-up period. Caesarean section was carried out at 34 + 1 weeks with a good maternal and neonatal outcome. CONCLUSIONS: A previous history of laparoscopic salpingectomy with cornual wedge resection could be a risk factor for uterine rupture in pregnant women. Sonographers should be alert to this potential risk in pregnant women with a history of laparoscopic salpingectomy with cornual wedge resection even in asymptomatic patients.

Assessing lateral uterine wall defects and residual myometrial thickness after cesarean section.

OBJECTIVE: Lateral wall ruptures in women with a history of cesarean section are less common but more complicated than anterior wall ruptures. Residual myometrial thickness (RMT) is believed to be valuable for assessing the probability of ruptures. This study aimed to assess the utility of OmniView (a sonographic reslicing technique) in evaluating the lateral uterine wall after cesarean section and evaluate the relationship between lateral and anterior wall RMT using OmniView and sagittal two-dimensional ultrasound. STUDY DESIGN: This cross-sectional study examined changes in both the anterior and lateral uterine wall in women with a history of cesarean section in the past 12-18 months. OmniView with volume contrast imaging with a 2-mm slice thickness was used to generate coronal planes, and the OmniView RMT (OV-RMT) was calculated as a percentage. Blinded to the OV-RMT results, sonographic multiplanar views were used to acquire the optimum sagittal plane for evaluating the RMT, and the sagittal RMT (S-RMT) was calculated as a percentage. The reproducibility of OV-RMT and S-RMT between two observers was tested using interclass correlation (ICC). The relationship between two variables was tested using Spearman's rank correlation. RESULTS: In 208 recruited patients, the prevalence of lateral uterine wall defects was 79 %. The interobserver and intraobserver reproducibility of S-RMT and OV-RMT had ICC coefficients over 0.9 with a p-value <0.001. S-RMT and OV-RMT did not follow a normal distribution, and the medians were significantly different (55.5 and 85.7, respectively). Spearman's rank correlation between OV-RMT and S-RMT had a rho (ρ) value of 0.24 (p < 0.05). Passing-Bablok regression had an intercept of 47.95 and a slope of 0.65. CONCLUSION: OmniView can be used to assess lateral uterine wall defects, and OV-RMT is a reproducible and reliable method for quantifying this assessment. The RMT on the coronal plane was independently more intact than that on the sagittal plane, which might account for the lower incidence of lateral ruptures. Further studies could reveal a critical OV-RMT value that is safe for a trial of labor.

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.

Uterine Dehiscence and Subsequent Pregnancy Management: A Review of the Literature.

IMPORTANCE: Uterine dehiscence is a separation of the uterine musculature with intact uterine serosa. Uterine dehiscence can be encountered at the time of cesarean delivery, be suspected on obstetric ultrasound, or be diagnosed in between pregnancies. Management is a conundrum for obstetricians, regardless of timing of onset. EVIDENCE ACQUISITION: A literature search was undertaken by our research librarian using the search engines PubMed, CINAHL, and Web of Science. The search term used was "uterine dehiscence." The search was limited to the English language, and there was no limit on the years searched. RESULTS: The search identified 152 articles, 32 of which are the basis for this review. Risk factors, treatment, and management in subsequent pregnancies are discussed. The number of prior cesarean deliveries is the greatest risk factor for uterine dehiscence. Unrepaired uterine dehiscence can cause symptoms outside of pregnancies and may require repair for alleviation of these symptoms. Dehiscence should also be repaired prior to subsequent pregnancies. CONCLUSION AND RELEVANCE: Planned delivery prior to the onset of labor with careful monitoring of maternal symptoms is the preferred management strategy of women with prior uterine dehiscence. Careful attention should be paid to the lower uterine segment thickness when ultrasonography is performed in women with prior cesarean delivery. RELEVANCE STATEMENT: An evidence-based review of uterine dehiscence in pregnancy and how to manage subsequent pregnancies following uterine dehiscence.

Ultrasonic manifestations and clinical analysis of 25 uterine rupture cases.

PURPOSE: To explore the risk factors, ultrasonic manifestations, clinical features, and maternal and neonatal outcomes associated with complete uterine rupture. BASIC PROCEDURES: All cases of complete uterine rupture diagnosed and treated in Jiangxi Maternal and Child Health Hospital from January 2012 to July 2018 were retrospectively analyzed. Risk factors, ultrasonic manifestations, clinical features, and maternal and infant outcomes were analyzed. RESULT: All patients had a history of uterine surgery or induced abortion. Ultrasound examination revealed 15 cases of complete rupture of the uterus, five cases of missed diagnosis, three cases of misdiagnosis, and two cases of direct emergency operation without ultrasonography because of typical clinical manifestations and critical conditions. The clinical manifestations of 25 cases of uterine rupture varied from asymptomatic to clinical signs of "resting" rupture of the uterus to severe pain, hypotension, shock, and coma. All patients underwent surgical treatment, of which one case underwent DIC and died after rescue. The maternal mortality rate was 4% (1/25), the mortality rate of newborns (two pregnant women was twins) was 44% (12/27). CONCLUSION: A history of uterine surgery is a major risk factor for uterine rupture. Attention should be paid not only to women who are pregnant again after cesarean section but also to those who have undergone other uterine operations (such as laparoscopic myomectomy, laparoscopic cornual pregnancy removal, etc.), delivery plans should be formulated accordingly. In cases of sudden abdominal pain during pregnancy or childbirth, the possibility of uterine rupture should be considered to achieve a timely and correct diagnosis and treatment.