Lower uterine segment thickness measurement in pregnant women with previous Cesarean section: reliability analysis using two- and three-dimensional transabdominal and transvaginal ultrasound

Objective To evaluate the reliability of two- and three-dimensional ultrasonographic measurement of the thickness of the lower uterine segment (LUS) in pregnant women by transvaginal and transabdominal approaches. Methods This was a study of 30 pregnant women who bad bad at least one previous Cesarean section and were between 36 and 39 weeks` gestation, with singleton pregnancies in cephalic presentation. Sonographic examinations were performed by two observers using both 4-7-MHz transabdominal and 5-8-MHz transvaginal volumetric probes. LUS measurements were performed using two- and three-dimensional ultrasound, evaluating the entire LUS thickness transabdominally and the LUS muscular thickness transvaginally. Each observer measured the LUS four times by each method. Reliability was analyzed by comparing the mean of the absolute differences, the intraclass correlation coefficients, the 95% limits of agreement and the proportion of differences <1 mm. Results Transvaginal ultrasound provided greater reliability in LUS measurements than did transabdominal ultrasound. The use of three-dimensional ultrasound improved significantly the reliability of the LUS muscular thickness measurement obtained transvaginally. Conclusions Ultrasonographic measurement of the LUS muscular thickness transvaginally appears more reliable than does that of the entire LUS thickness transabdominally. The use of three-dimensional ultrasound should be considered to improve measurement reliability. Copyright (c) 2009 ISUOG. Published by John Wiley & Sons, Ltd.

Rotura Uterina em Mulheres com Cesariana Anterior em Prova de Trabalho de Parto

Uterine rupture during a trial of labor after previous cesarean (TOLAC) delivery is a rare, but serious complication. Several factors can increase the risk of uterine rupture, so the assessment of individual risks with adequate counseling is ne - cessary. The initial signs and symptoms are usually nonspecific, hampering timely diagnosis and prompt delivery of the fetus, necessary for optimal outcome. The purpose of this document is to review the risks factors for uterine rupture during TOLAC, as well as the current clinical value of the classically described premonitory signs and symptoms.

Obstetric outcomes in the second birth of women with a previous caesarean delivery: a retrospective cohort study from Peru

PURPOSE: To examine obstetric outcomes in the second birth of women who had undergone a previous cesarean delivery. METHODS: This was a large hospital-based retrospective cohort study. We included pregnant women who had a previous delivery (vaginal or cesarean) attending their second birth from 2001 to 2009. Main inclusion criteria were singleton pregnancies and delivery between a gestation of 24 and 41 weeks. Two cohorts were selected, being women with a previous cesarean delivery (n=7,215) and those with a vaginal one (n=23,720). Both groups were compared and logistic regression was performed to adjust for confounding variables. The obstetric outcomes included uterine rupture, placenta previa, and placental-related complications such as placental abruption, preeclampsia, and spontaneous preterm delivery. RESULTS: Women with previous cesarean delivery were more likely to have adverse outcomes such as uterine rupture (OR=12.4, 95%CI 6.8-22.3), placental abruption (OR=1.4, 95%CI 1.1-2.1), preeclampsia (OR=1.4, 95%CI 1.2-1.6), and spontaneous preterm delivery (OR=1.4, 95%CI 1.1-1.7). CONCLUSIONS: Individuals with previous cesarean section have adverse obstetric outcomes in the subsequent pregnancy, including uterine rupture, and placental-related disorders such as preeclampsia, spontaneous preterm delivery, and placental abruption.

Impacto de la cesarea en la morbimortalidad materna y perinatal

Introducción: La cesárea es un procedimiento quirúrgico considerado como inocuo por algunas personas, sin tener en cuenta las posibles consecuencias en los embarazos siguientes. Existe literatura que evidencia un aumento en el riesgo para abrupcio de placenta, acretismo placentario, placenta previa, mortalidad materna, sepsis materna, ingreso a UCI, al igual que apgar bajo, bajo peso neonatal, distress respiratorio,entre otros.El objetivo de este estudio fue evaluar el impacto del antecedente de cesárea en la morbilidad materna y neonatal mediante una revisión sistemática de literatura. Metodología Se realizó una búsqueda en diferentes bases de datos desde 1996 hasta 2011 sobre el antecedente de cesárea y sus posibles riesgos en el desenlace maternos y perinatales. Se utilizaron variaciones de términos MeSH. Resultados La búsqueda arrojó un total de 2.483 artículos, entre los cuales fueron escogidos 247 por criterios de elegibilidad.Estos fueron evaluados en su totalidad. Posteriormente se realizó el análisis metanalítico de cada uno de los desenlaces. Los resultados deben interpretarse con precaución pues la calidad metodológica de algunos estudios fue variable. En el riesgo conjunto se encontraron resultados estadísticamente significativos en placenta previa, apgar bajo, histerectomía periparto. Discusión El antecedente de cesárea presenta un riesgo aumentado para los siguientes embarazos en la morbilidad tanto materna como neonatal. Faltan más estudios analíticos para definir el verdadero papel de la cesarea.

Mummified papyraceous fetuses in the abdominal cavity of an elderly female dog with pyometra

This paper reports on a rare case of fetal papyraceous mummification after asymptomatic uterine rupture in an elderly female dog with pyometra. The patient had a history of mating six months before the examination but no apparent signs of gestation or parturition. Exploratory laparotomy was used to identify a rupture of the left uterine horn and the presence of cystic endometrial hyperplasia and pyometra. Two mummified papyraceous fetuses were observed in the abdominal cavity and had adhered to the spleen, pancreas, intestine and omentum. Ovariehysterectomy and corrective surgery were performed. The patient had remained healthy after uterine rupture until a new estrous cycle and the development of pyometra. Bitches that are 10 years old or more are predisposed to implantation failure, pregnancy or parturition problems and they should not be breed to avoid complications.

Behavioral Economics and Physician Behavior

This study seeks to answer whether the availability heuristic leads physicians to utilize more medical care than is economically efficient. Do rare, salient events alter physicians' perceptions about the probability of patient harm? Do these events lead physicians to overutilize certain medical procedures? This study uses Pennsylvania inpatient hospital admissions data from 2009 aggregated at the physician level to investigate these questions. The data come from the 2009 Pennsylvania Health Care Cost Containment Council (PHC4). The study is divided into two parts. In Part I, we examine whether bad outcomes during childbirth (defined as maternal mortality, an obstetric fistula or a uterine rupture) lead physicians to utilize more cesarean sections on future patients. In Part II, we examine whether bad outcomes associated with appendicitis (defined as patient death, a perforated or ruptured appendix or sepsis) lead physicians to perform more negative appendectomies (appendectomies performed when the patient did not have appendicitis) on future patients. Overall the study does not find evidence to support the claim that the availability heuristic leads physicians to overutilize medical care on future patients. However, the study does find evidence that variations in health care utilization are strongly correlated with individual physician practice patterns. The results of the study also imply that physicians' financial incentives may be a source of variation in health care utilization.

The Rendez-vous technique for treatment of caesarean scar defects: a novel combined endoscopic approach.

BACKGROUND A caesarean scar defect is a late complication of caesarean birth with a wide range of prevalence between 56 and 84 % depending on which diagnostic tool and which definition is used [1]. The referred symptoms which include postmenstrual spotting and infertility are fortunately rare. Moreover, severe complications such as caesarean scar pregnancy and uterine rupture in the following pregnancy may occur. Given the increasing incidence of caesarean births, the potential morbidity associated with caesarean scars is likely to become more important. Recently, a few repair techniques were described in the literature including the hysteroscopic resection of scarred tissue or the laparoscopic repair with or without robotic assistance [2, 3]. METHODS Between June 2009 and February 2014, 21 women with caesarean scar defects were operated with the Rendez-vous technique, a minimally invasive surgery combining the laparoscopic and hysteroscopic approach. Data were retrospectively collected. The indications for this surgery included secondary infertility, previous caesarean scar pregnancy, recurrent miscarriage and postmenstrual spotting. Prior to operation, a transvaginal ultrasound was performed to examine the uterine wall defect. RESULTS The patient characteristics are provided in Table 1. In all cases, the operation was successfully completed laparoscopically. The median operation time was 125 min. One case was complicated by recurrence of the scar defect 6 weeks after the operation. No other intra- or post-operative complications were observed, and the median in-patient stay was 3 days. CONCLUSIONS The benefits of the technique include the feasibility and safety of the procedure, the "Halloween sign" (Fig. 1) which indicates the exact extent and localization of the scar defect and the immediate assessment of repair through the hysteroscopy at the end of the surgery. However, before further studies evaluate the efficacy of this method, the routine repair of caesarean scar defects cannot be recommended. A video of the technique is presented.

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group. Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.

Impact des techniques de fermeture utérine lors de la césarienne

Contexte: La césarienne est une procédure chirurgicale qui survient dans plus du quart des accouchements en Amérique du Nord. Les techniques chirurgicales de fermeture de l’utérus lors de la césarienne sont variées, influencent la cicatrisation et le risque de complications chez la femme à court et long terme. Il a été suggéré que la fermeture en un plan barré augmentait le risque de rupture de l’utérus et de défaut de cicatrisation de l’utérus. Cependant, en l’absence d’un haut niveau d’évidence, cette technique est toujours pratiquée au Canada et en Amérique du Nord. Objectif: Comparer l’impact des différentes techniques de fermeture de l’utérus lors de la césarienne sur les complications maternelles à court et long terme. Méthode : Trois revues systématiques et méta-analyses d’études observationnelles ou d’essais randomisés contrôlés (ECR) ont été réalisées. La prévalence des défauts de cicatrisation et les issues à court et long terme ont été comparées entre les techniques de fermeture de l’utérus. Par la suite, un essai randomisé contrôlé a évalué trois techniques de fermeture de l’utérus : un plan barré, deux plans barrés et deux plans non barrés excluant la déciduale, chez 81 femmes avec une césarienne primaire élective à ≥ 38 semaines de grossesse. L’épaisseur du myomètre résiduel a été mesurée six mois après la césarienne à l’aide d’une échographie transvaginale et comparée par un test t de Student. Résultats : Les résultats des revues systématiques et méta-analyses ont montré que 37% à 59% des femmes présentaient un défaut de cicatrisation de l’utérus après leur césarienne. Concernant les complications à court terme, les types de fermeture de l’utérus étudiés sont comparables, à l’exception de la fermeture en un plan barré qui est associée à un temps opératoire plus court que celle en deux plans (-6.1 minutes, 95% intervalle de confiance (IC) -8.7 à -3.4, p<0.001). Les fermetures de l’utérus en un plan barré sont associées à plus de risque de rupture utérine qu’une fermeture en deux plans barrés (rapport de cote 4.96; IC 95%: 2.58–9.52, P< 0.001). L’ECR a également démontré que la fermeture de l’utérus en un plan barré était associée à une épaisseur du myomètre résiduel plus mince que la fermeture en deux plans non barrés excluant la déciduale (3.8 ± 1.6 mm vs 6.1 ± 2.2 mm; p< 0.001). Finalement, aucune différence significative n’a été détectée concernant la fréquence des points d’hémostases entre les techniques (p=1.000). Conclusion : Lors d’une césarienne élective primaire à terme, une fermeture en deux plans non barrés est associée à un myomètre plus épais qu’une fermeture en un plan barré, sans augmenter le recours à des points d’hémostase. De plus, il est suggéré que la fermeture en deux plans réduirait le risque de rupture utérine lors d’une prochaine grossesse. Finalement, la fermeture chez les femmes en travail doit être plus étudiée.

Spontaneous Dissection of the Renal Artery in Vascular Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) is a rare heterogeneous group of connective tissue disorders. The vascular type (vEDS) is an autosomal dominant disorder caused by heterozygous mutations in the COL3A1 gene predisposing to premature arterial, intestinal, or uterine rupture. We report a case of a 38-year-old woman with a recent diagnosis of vEDS admitted in the Emergency Department with a suspicion of a pyelonephritis that evolved to a cardiopulmonary arrest. A fatal retroperitoneal hematoma related with a haemorrhagic dissection of the right renal artery was found after emergency surgery. This case highlights the need to be aware of the particular characteristics of vEDS, such as a severe vascular complication that can lead to a fatal outcome.

Effects of uterine cervix constriction on Wistar rats

PURPOSE: To verify if uterine cerclage can induce craniosynostosis or any cranial deformity in new born Wistar rats. METHODS: One pregnant female Wistar rat underwent laparotomy on day 18 of gestation and the uterus cervix was closed with a 3-0 nylon suture to avoid delivery, that occurs normally on the 21 day. The suture was released after 48 hours beyond the normal gestation period. The female rat delivered 11 pups. Six surviving rats from the delivery (group A - constrained group). Two rats were born from another mother and in the same age were used as control group (group B - 2 nonconstrained controls) were allowed to grow. They were sacrificed 1.2 years after their birth all the eight animals. Linear measurement, routine histology and computed tomography of the skull were performed at the time of their death to evaluate the cranial asymmetries by mesurements of the anatomical landmarks of the craniofacial skeleton of the rats on the two groups and compared then. RESULTS: We did not observe statistically significant differences in any of the compared measurements (p>0.05) obtained through the morphologic and radiologic methods. Histologic examinations did not reveal any sign of premature fusion or suture imbrications. Critical decrease in longitudinal body size was noticed as the limbs too in all the animals of group A. CONCLUSION: Constriction of uterine cervix leads to fetus suffering, even death for a few animals, associated to small body size, but not to craniosynostosis.

Glycosaminoglycan distribution in the rat uterine cervix during the estrous cycle

OBJECTIVE: To analyze the amount of glycosaminoglycans in the uterine cervix during each phase of the rat estrous cycle. DESIGN: Based on vaginal smears, forty female, regularly cycling rats were divided into four groups (n = 10 for each group): GI - proestrous, GII - estrous, GIII - metaestrous and GIV - diestrous. Animals were sacrificed at each phase of the cycle, and the cervix was immediately removed and submitted to biochemical extraction and determination of sulfated glycosaminoglycans and hyaluronic acid. The results were analyzed by ANOVA followed by the Bonferroni post-hoc test. RESULTS: The uterine cervix had the highest amount of total sulfated glycosaminoglycans and dermatan sulfate during the estrous phase (8.90 ± 0.55 mg/g of cetonic extract, p<0.001; and 8.86 ± 0.57 mg/g of cetonic extract, p<0.001). In addition, there was more heparan sulfate at the cervix during the proestrous phase (0.185 ± 0.03 mg/g of cetonic extract) than during any other phase (p<0.001). There were no significant changes in the concentration of hyaluronic acid in the uterine cervix during the estrous cycle. CONCLUSION: Our data suggest that the amount of total sulfated glycosaminoglycans may be influenced by hormonal fluctuations related to the estrous cycle, with dermatan sulfate and heparan sulfate being the glycosaminoglycans most sensitive to hormonal change.

Menopausal status: a possible predictive factor for recurrence in women with cancer of the uterine cervix without pelvic lymph node metastasis

Abstract Objectives to evaluate risk factors for recurrence of carcinoma of the uterine cervix among women who had undergone radical hysterectomy without pelvic lymph node metastasis, while taking into consideration not only the classical histopathological factors but also sociodemographic, clinical and treatment-related factors. Study desin This was an exploratory analysis on 233 women with carcinoma of the uterine cervix (stages IB and IIA) who were treated by means of radical hysterectomy and pelvic lymphadenectomy, with free surgical margins and without lymph node metastases on conventional histopathological examination. Women with histologically normal lymph nodes but with micrometastases in the immunohistochemical analysis (AE1/AE3) were excluded. Disease-free survival for sociodemographic, clinical and histopathological variables was calculated using the Kaplan-Meier method. The Cox proportional hazards model was used to identify the independent risk factors for recurrence. Twenty-seven recurrences were recorded (11.6%), of which 18 were pelvic, four were distant, four were pelvic + distant and one was of unknown location. The five-year disease-free survival rate among the study population was 88.4%. The independent risk factors for recurrence in the multivariate analysis were: postmenopausal status (HR 14.1; 95% CI: 3.7-53.6; P < 0.001), absence of or slight inflammatory reaction (HR 7.9; 95% CI: 1.7-36.5; P = 0.008) and invasion of the deepest third of the cervix (HR 6.1; 95% CI: 1.3-29.1; P = 0.021). Postoperative radiotherapy was identified as a protective factor against recurrence (HR 0.02; 95% CI: 0.001-0.25; P = 0.003). (To continue) Postmenopausal status is a possible independent risk factor for recurrence even when adjusted for classical prognostic factors (such as tumour size, depth of tumour invasion, capillary embolisation) and treatment-related factors (period of treatment and postoperative radiotherapy status)

Hormone-regulated expression and distribution of versican in mouse uterine tissues

Background: Remodeling of the extracellular matrix is one of the most striking features observed in the uterus during the estrous cycle and after hormone replacement. Versican (VER) is a hyaluronan-binding proteoglycan that undergoes RNA alternative splicing, generating four distinct isoforms. This study analyzed the synthesis and distribution of VER in mouse uterine tissues during the estrous cycle, in ovariectomized (OVX) animals and after 17beta-estradiol (E2) and medroxyprogesterone (MPA) treatments, either alone or in combination. Methods: Uteri from mice in all phases of the estrous cycle, and animals subjected to ovariectomy and hormone replacement were collected for immunoperoxidase staining for versican, as well as PCR and quantitative Real Time PCR. Results: In diestrus and proestrus, VER was exclusively expressed in the endometrial stroma. In estrus and metaestrus, VER was present in both endometrial stroma and myometrium. In OVX mice, VER immunoreaction was abolished in all uterine tissues. VER expression was restored by E2, MPA and E2+MPA treatments. Real Time PCR analysis showed that VER expression increases considerably in the MPA-treated group. Analysis of mRNA identified isoforms V0, V1 and V3 in the mouse uterus. Conclusion: These results show that the expression of versican in uterine tissues is modulated by ovarian steroid hormones, in a tissue-specific manner. VER is induced in the myometrium exclusively by E2, whereas MPA induces VER deposition only in the endometrial stroma.

Comparison of the Rupture and Disintegration Tests for Soft-Shell Capsules

The USP General Chapter < 2040 > Disintegration and Dissolution of Dietary Supplements introduced a rupture test as a performance test of soft-shell capsules. Traditionally, the disintegration test was used for determining the disintegration time of all solid oral dosage forms. The aim of this investigation was to investigate differences between the rupture test and the disintegration test using soft-shell capsules. Five different soft-shell capsule products were chosen based on their filling contents and treated to simulate a production deficiency. The study design compared capsules as received with capsules that were treated by coating them with the liquid contents of another capsule. The capsules were incubated at room temperature and at 40 degrees C. The tests were repeated after two weeks, and at each time point, twelve capsules of each product were tested using the rupture and the disintegration tests. Six capsules were tested untreated, while the other six capsules were treated. Rupture and disintegration times were recorded as dependent variables in each experiment. Thedata were analyzed using ANOVA. According to the USP definition for disintegration, the rupture of a soft-shell capsule can be seen as fulfilling the disintegration criterion if the capsule contents is a semisolid or liquid. Statistical analysis showed no advantage of the rupture test over the disintegration test. On a product-by-product basis, both tests were sensitive to certain investigated parameters. A noticeable difference between both tests was that in most cases, the rupture test reached the defined endpoint faster than the disintegration test. Soft-shell capsules that are subject to a Quality by Design approach should be tested with both methods to determine which performance test is the most appropriate test for a specific product.