Review

Authors: Thaysa Guglieri Kremer, Isadora Bueloni Ghiorzi, Raquel Papandreus Dibi...

An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

Topics: Cesarean Section; Cicatrix; Female; Humans; Hysteroscopy; Metrorrhagia; Risk Factors; Uterine Diseases

PubMed: 31166450
DOI: 10.1590/1806-9282.65.5.714

Comparative Study Randomized Controlled Trial

Authors: N Scott Adzick, Elizabeth A Thom, Catherine Y Spong...

BACKGROUND

Prenatal repair of myelomeningocele, the most common form of spina bifida, may result in better neurologic function than repair deferred until after delivery. We compared outcomes of in utero repair with standard postnatal repair.

METHODS

We randomly assigned eligible women to undergo either prenatal surgery before 26 weeks of gestation or standard postnatal repair. One primary outcome was a composite of fetal or neonatal death or the need for placement of a cerebrospinal fluid shunt by the age of 12 months. Another primary outcome at 30 months was a composite of mental development and motor function.

RESULTS

The trial was stopped for efficacy of prenatal surgery after the recruitment of 183 of a planned 200 patients. This report is based on results in 158 patients whose children were evaluated at 12 months. The first primary outcome occurred in 68% of the infants in the prenatal-surgery group and in 98% of those in the postnatal-surgery group (relative risk, 0.70; 97.7% confidence interval [CI], 0.58 to 0.84; P<0.001). Actual rates of shunt placement were 40% in the prenatal-surgery group and 82% in the postnatal-surgery group (relative risk, 0.48; 97.7% CI, 0.36 to 0.64; P<0.001). Prenatal surgery also resulted in improvement in the composite score for mental development and motor function at 30 months (P=0.007) and in improvement in several secondary outcomes, including hindbrain herniation by 12 months and ambulation by 30 months. However, prenatal surgery was associated with an increased risk of preterm delivery and uterine dehiscence at delivery.

CONCLUSIONS

Prenatal surgery for myelomeningocele reduced the need for shunting and improved motor outcomes at 30 months but was associated with maternal and fetal risks. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00060606.).

Topics: Cerebrospinal Fluid Shunts; Child, Preschool; Encephalocele; Female; Fetal Death; Fetal Diseases; Fetal Therapies; Fetus; Follow-Up Studies; Gestational Age; Humans; Hysterotomy; Infant; Infant Care; Infant Mortality; Infant, Newborn; Intelligence; Intention to Treat Analysis; Male; Meningomyelocele; Postoperative Complications; Pregnancy; Treatment Outcome; Walking

PubMed: 21306277
DOI: 10.1056/NEJMoa1014379

Authors:

“Surgical Management of Cesarean Scar Ectopic Pregnancy with Totally Extraperitoneal Hysterotomy via Transvaginal Approach” by Ying-Han Chen, Dan-Bo Wang, Peng Chen and Fang Ren.The above article, published online on 23 January 2014 in Wiley Online Library as an accepted article (wileyonlinelibrary. com; doi/10.1111/aogs.12341/abstract), has been retracted by agreement between the authors, the journal Chief Editor, Professor Reynir Tomas Geirsson, and John Wiley & Sons Ltd. The retraction has been agreed due to prior publication of a substantially similar article in Fertility and Sterility (http://www.fertstert.org/article/S0015-0282(13)03170-1/abstract).

PubMed: 24450806
DOI: 10.1111/aogs.12341

Review

Authors: C Knapp, K Bhatia

Maternal collapse is a rare life-threatening event that can occur at any stage of pregnancy or up to 6 weeks postpartum. Prompt identification and timely intervention by a multidisciplinary team that includes an obstetrician, midwifery staff and an obstetric anaesthetist are essential to improve maternal and fetal outcomes. Standard adult resuscitation guidelines need to be followed with some modifications, taking into account the maternal-fetal physiology, which clinicians should be familiar with. During cardiac arrest, the emphasis is on advanced airway management, manual uterine displacement to relieve aortocaval compression and performing a resuscitative hysterotomy (peri-mortem caesarean delivery) swiftly in patients who are more than 20 weeks gestation to improve maternal survival. Annual multidisciplinary simulation training is recommended for all professionals involved in maternity care; this can improve teamwork, communication and emergency preparedness during maternal collapse.

Topics: Adult; Pregnancy; Humans; Female; Maternal Health Services; Heart Arrest; Cesarean Section; Resuscitation; Pregnancy Complications, Cardiovascular

PubMed: 36594762
DOI: 10.12968/hmed.2022.0259

Authors: Amano Kan

Cesarean section is the most common surgery in obstetrics. Several techniques are proposed according to the indication and the degree of urgency. Usually laparotomy followed by hysterotomy with a low transverse incision is preferable. However, in cases in which it is difficult to access the lower uterine segment, such as that in preterm labor, dense adhesion, placenta previa/accrete a vertical hysterotomy (classical cesarean section) may be needed. Although a smooth and gentle delivery of the fetus is possible through the vertical incision, uterine closure is technically difficult. To decrease the risks of hemorrhage and adhesion, a speedy and skillful technique is mandatory. The most serious risk of vertical incision in the contractile corpus is uterine rupture in the subsequent pregnancy. Therefore, cases of prior classical cesarean section are contraindicated for trial of labor after cesarean section.

PubMed: 32760792
DOI: 10.1055/s-0039-3402072

Decreased Maternal Morbidity and Improved Perinatal Results of Magnesium-Free Tocolysis and Classical Hysterotomy in Fetal Open Surgery for Myelomeningocele Repair: A Single-Center Study.

Authors: Mateusz Zamłyński, Anita Olejek, Ewa Horzelska...

Fetal and maternal risks associated with open fetal surgery (OFS) in the management of meningomyelocele (MMC) are considerable and necessitate improvement. A modified technique of hysterotomy (without a uterine stapler) and magnesium-free tocolysis (with Sevoflurane as the only uterine muscle relaxant) was implemented in our new magnesium-free tocolysis and classical hysterotomy (MgFTCH) protocol. The aim of the study was to assess the introduction of the MgFTCH protocol in reducing maternal and fetal complications. The prospective study cohort (SC) included 64 OFS performed with MgFTCH at the Fetal Surgery Centre Bytom (FSCB) (2015-2020). Fetal and maternal outcomes were compared with the retrospective cohort (RC; = 46), and data from the Zurich Center for Fetal Diagnosis and Therapy (ZCFDT; = 40) and the Children's Hospital of Philadelphia (CHOP; = 100), all using traditional tocolysis. The analysis included five major perinatal complications (Clavien-Dindo classification, C-Dc) which developed before the end of 34 weeks of gestation (GA, gestational age). None of the newborns was delivered before 30 GA. Only two women presented with grade 3 complications and none with 4th or 5th grade (C-Dc). The incidence of perinatal death (3.3%) was comparable with the RC (4.3%) and CHOP data (6.1%). MgFTCH lowers the risk of major maternal and fetal complications.

PubMed: 36830929
DOI: 10.3390/biomedicines11020392

Review

Authors: Claire E Graves, Michael R Harrison, Benjamin E Padilla...

Fetal surgery corrects severe congenital anomalies in utero to prevent their severe consequences on fetal development. The significant risk of open fetal operations to the pregnant mother has driven innovation toward minimally invasive procedures that decrease the risks inherent to hysterotomy. In this article, we discuss the basic principles of minimally invasive fetal surgery, the general history of its development, specific conditions and procedures used to treat them, and the future of the field.

Topics: Amniotic Band Syndrome; Blood Transfusion, Intrauterine; Congenital Abnormalities; Female; Fetal Diseases; Fetal Therapies; Fetofetal Transfusion; Fetoscopy; Fetus; Hernias, Diaphragmatic, Congenital; History, 20th Century; History, 21st Century; Humans; Laser Therapy; Meningomyelocele; Minimally Invasive Surgical Procedures; Pregnancy; Surgery, Computer-Assisted; Ultrasonography, Prenatal

PubMed: 29127956
DOI: 10.1016/j.clp.2017.08.001

Review

Authors: Xiafei Wu, Huan Yang, Xinyang Yu...

Placenta accreta spectrum (PAS) disorders refers to a heterogeneous group of anomalies distinguished by abnormal adhesion or invasion of chorionic villi through the myometrium and uterine serosa. PAS frequently results in life-threatening complications, including postpartum hemorrhage and hysterotomy. The incidence of PAS has increased recently as a result of rising cesarean section rates. Consequently, prenatal screening for PAS is essential. Despite the need to increase specificity, ultrasound is still considered a primary adjunct. Given the dangers and adverse effects of PAS, it is necessary to identify pertinent markers and validate indicators to improve prenatal diagnosis. This article summarizes the predictors regarding biomarkers, ultrasound indicators, and magnetic resonance imaging (MRI) features. In addition, we discuss the effectiveness of joint diagnosis and the most recent research on PAS. In particular, we focus on (a) posterior placental implantation and (b) accreta after in vitro fertilization-embryo transfer, both of which have low diagnostic rates. At last, we graphically display the prenatal diagnostic indicators and each diagnostic performance.

PubMed: 37234657
DOI: 10.1016/j.heliyon.2023.e16241