Tomasz Fuchs

Prediction of uterine dehiscence using ultrasonographic parameters of cesarean section scar in the nonpregnant uterus: a prospective observational study

BackgroundEvery year 1.5 million cesarean section procedures are performed worldwide. As many women decide to get pregnant again, the population of pregnant women with a history of cesarean section is growing rapidly. For these women prediction of cesarean section scar performance is still a serious clinical problem.The purpose of the study was to assess whether the parameters of cesarean section scar in the nonpregnant uterus as determined using ultrasound can be used to predict uterine dehiscence in the next pregnancy.MethodsStarting in 2005, the study included 308 nonpregnant women with a history of low transverse cesarean section. The following ultrasonographic parameters of the cesarean section scar in the nonpregnant uterus were assessed: the residual myometrial thickness (RMT) and the width (W) and the depth (D) of the triangular hypoechoic scar niche. During 8 years of follow-up, 41 of these women were referred to our department for delivery. In all cases, a repeat cesarean section was performed and the lower uterine segment was assessed. Two independent statistical methods namely the logit model and Decision Tree analysis were used to determine the relation between the appearance of the cesarean section scar in the nonpregnat state and the performance of the scar in the next pregnancy.ResultsThe logit model revealed that the D/RMT ratio showed significant correlation with cesarean section scar dehiscence (P-value of 0.007). Specifically, a D/RMT ratio value greater than 1.3035 indicated that the likelihood of dehiscence was greater than 50%. The Decision Tree analysis revealed that a diagnosis of dehiscence versus non-dehiscence could be based solely on one criterion, a D/RMT ratio of at least 0.785. The sensitivity of this method was 71%, and the specificity was 94%.ConclusionsAssessment of the cesarean section scar in the nonpregant uterus can be used to predict the occurrence of scar dehiscence in the next pregnancy.

Quantitative assessment of placental vasculature and placental volume in normal pregnancies with the use of 3D Power Doppler

PURPOSE The aim of the study was to determine reference values for placental vascular indices and placental volume according to gestational age. MATERIAL/METHODS The assessment of placental vascular indices and placental volume using 3D Power Doppler and the Virtual Organ Computer-aided Analysis (VOCAL) technique was performed on 100 normal fetuses between 22 and 41 weeks of gestation. In this study the method of the individual setting of the power Doppler gain value was used. Only patients with entirely visualized placenta were included in the study. RESULTS No statistically relevant difference in the values of placental vascular indices and placental volume between different localizations of the placenta was detected. No statistically significant changes to placental vascular indices depending on gestational age were found. It enabled to determine the 10th, 50th and 90th percentile values for the vascularization index (VI), flow index (FI), vascularization-flow index (VFI), which are independent of gestational age. No correlation was found between placental volume and placental vascular indices. CONCLUSIONS The values of placental vascular indices are constant between the 22nd and 41st week of a normal pregnancy. Placental volume measured with the use of the VOCAL program increases between 22nd and 41st week of a normal pregnancy. In a normal pregnancy the placental vasculature increases adequately to the increase of its volume. The method of the individual setting of the power Doppler gain value makes it possible to achieve comparable values of placental vascular indices regardless of the distance between the probe and the placenta.

Standardized ultrasonographic approach for the assessment of risk factors of incomplete healing of the cesarean section scar in the uterus

OBJECTIVE To identify factors related to the healing of a Cesarean uterine incision using the standardized ultrasonographic approach of scar assessment in the non-pregnant uterus. STUDY DESIGN Measurements of the uterine scar were taken from 409 women with a history of at least one low transverse cesarean section (CS) with a single layer uterine closure. Residual myometrial thickness (RMT), width (W) and depth (D) of the triangular hypoechoic scar niche, D/RMT ratio and clinical characteristics were analyzed. For statistical analysis, the Mann-Whitney U test, chi-square test, Spearmans rank correlation coefficient, ANOVA test, and logistic regression were used. RESULTS 268 women presented with a scar defect. RMT values were significantly correlated with the number of CSs (R=-0.17) and uterus retroflection (R=-0.15). The presence of a scar defect was significantly associated with lower RMT values (R=-0.33), greater gestational age (R=0.10), and younger maternal age (R=-0.11). The mean RMT value was significantly smaller in women with CSs performed in the second stage of labor (0.62) when compared to women with CSs in the first stage of labor (0.97) or without cervical dilatation (0.91). CONCLUSION A standardized approach of CS scar assessment in the non-pregnant uterus helps to identify women at risk of long-term complications of CS.

Quantitative cervical elastography in pregnancy

We find the ongoing discussion regarding the use of cervical elastography very interesting. The original article by Molina et al.1 attempted to standardize this diagnostic method. The comments offered by Fruscalzo and Schmitz2, to which Molina et al. then replied3, are justified and constitute a worthy input to the discussion. However, our team, carrying out diagnostic tests independently, adopted assumptions similar to those of Molina et al.1,4; using a vaginal probe, we marked a region of interest 1.0 cm in diameter on both anterior and posterior cervical lips (Figure 1). With respect to the pressure on the cervix, we followed the guidelines regarding the minimum conditions required to measure stiffness of tissue that were provided by the supplier of the ultrasound equipment (EUB 7500, Hitachi Medical Systems, Wiesbaden, Germany), along with the examination information displayed on the ultrasound screen4. In an attempt to objectify the method we determined the ‘strain ratio’ to assess the stiffness of tissues, which facilitates comparison of results of subsequent exams. This is in contrast both to the method offered by Świa̧tkowskaFreund et al.5, who used subjective assessment of the cervix on the basis of visual assessment of the colors shown on the color-coded image of the cervix, and to the standardization method described by Fruscalzo et al.6. The latter seems difficult to apply and reproduce consistently in a clinical setting as the structure of the cervix may differ from patient to patient, not to mention the different conditions of individual exams. In the course of examinations carried out by a member of our team4, we observed a negative correlation between the length of the cervical canal and the condition of the anterior cervical lip assessed by means of elastography, proving that shortening of the cervix causes structural changes that may be assessed by elastography, and encouraging us to carry out further research into the application of elastography to cervical diagnostics during gestation. At the same time, we are aware of the limitations imposed by the fact that the assumed assessment criteria may not be applicable in each and every case.

Sonographic evaluation of surgical repair of uterine cesarean scar defects.

The aim of the study was to assess the clinical outcomes of surgical repair of uterine cesarean scar defects with sonography (US).

OC20.04: Ultrasonographic features of Cesarean scars in non-pregnant uterus after single and multiple Cesarean sections

Objectives: To assess the association between ultrasonographic parameters of the Cesarean scar in non-pregnant uterus and the number of previously performed Cesarean sections. Methods: The study group included 310 non-pregnant women with a history of low transverse Cesarean section with single-layer uterine closure. The transvaginal ultrasound was performed to assess the following parameters of the Cesarean section scar: the thickness of the knit tissue scar segment (G) and in case of visualization of a triangular shaped anechoic scar defect the basis (P) and height (W) of this triangle. G/P index and G/W index values were also calculated. Results: Transvaginal sonography enabled the visualization of the Cesarean section scar in 308/310 of the examined women (99.4%). In 55/310 cases (17.7%) the completely knit hysterotomy scar tissue was identified. In the remaining group of 255/310 women (82.2%) an anechoic triangle, defined as scar defect, was observed. The mean thickness of the knit tissue scar segment (G) after single, two and three Cesarean sections was: 9.9 mm, 8.0 mm and 4.1 mm, respectively. Statistically important decrease in the G values with the number of previous performed Cesarean sections was observed. The mean G/P index values after single, two and three Cesarean sections were as follows: 1.68, 1.53 and 0.8. The mean G/W index values were: 2.8, 1.9, 0. 9, respectively. No significant difference in the G/P index values was found between patients after one and two Cesarean sections. Statistically important decrease in G/P index values in the group of patients after three Cesarean sections comparing to the patients after one (0.80 vs. 1.68, P < 0.05) and two Cesarean sections (0.8 vs. 1.53, P < 0.05) was observed. Statistically important decrease in the G/W index values was found between the groups of women after one, two and three Cesarean sections. Conclusions: The thickness of the knit tissue scar segment (G) and the G/W index values decrease with the number of previous performed Cesarean sections.

P34.03: Ultrasonographic parameters of cesarean scars in nonpregnant uterus

can result in considerable morbidity and mortality. Undiagnosed; a choledochal cyst can lead to development of serious complications such as hepatic fibrosis, pancreatitis, cholangitis, and liver failure in infants. Prenatal diagnosis, postnatal ultrasound evaluation and early surgical treatment can reduce the development of serious complications. We report a case of a choledochal cyst diagnosed prenatally by ultrasound. A 24 year old woman, gravida2, para1, presented at 29 weeks gestation to our hospital for a routine ultrasound evaluation. Ultrasound examination revealed a singleton fetus with normal amniotic fluid volume and measurements consistent with 29 weeks. Assessment of the fetal abdomen demonstrated an ovoid shaped well defined anechoic mass measuring 1.2 × 1.2 cm. in the right upper quadrant, located medially and communicating with the gall bladder. The postnatal ultrasound confirmed the diagnosis and it was classified as Type 1 choledochal cyst.

Morphology of the cesarean section scar in the non-pregnant uterus after one elective cesarean section.

OBJECTIVES A growing number of studies suggest that the incomplete healing of the CS scar in the uterus increase the risk of uterine dehiscence or rupture during subsequent pregnancies. Thus, the factors that affect wound healing should be evaluated. We aimed to determine whether the morphology of the CS scar in non-pregnant women after one elective CS was affected by the site of the uterine incision, uterine flexion, maternal age, and fetal birth weight. MATERIAL AND METHODS 208 non-pregnant women were invited for participation in the study, but only 101 of them met inclusion criteria. Standardized scar parameters (residual myometrial thickness (RMT), depth (D) and width (W) of the hypoechoic niche) were measured using ultrasonography at least 6 weeks after the CS. RESULTS Scar defect was detected in 26 of 101 subjects. Women without scar defect had significantly higher RMT values (1.87 vs. 0.87), lower newborn birth weight (3127 g vs. 3295 g), and higher scar location above the internal cervical os (62% vs. 16%), than those with scar defect. Maternal age was significantly correlated with D value (R = 0.40). Uterine retroflexion was significantly correlated with a larger D value (R = 0.63) and a larger D/RMT ratio (R = 0.24). CONCLUSIONS In low-risk women who have undergone one elective CS, several risk factors are associated with development of the scar defect, but only scar location can be modified during surgery. Future research is needed to determine whether a relatively higher incision location in the uterus can ensure optimal healing of the CS scar.

Fetal Heart Rate Monitoring Using Maternal Abdominal Surface Electrodes in Third Trimester: Can We Obtain Additional Information Other than CTG Trace?

BACKGROUND Cardiotocography (CTG) is the most widely used procedure despite its low specificity for fetal acidosis and poor perinatal outcome. Fetal electrocardiography (fECG) with transabdominal electrodes is a new, non-invasive and promising method with greater potential for detecting impairment of fetal circulation. This study is the first that attempts to assess the usefulness of fECG in comparison to CTG during antepartum period. OBJECTIVES To determine if a single fECG examination along with CTG tracing and Doppler flow measurement in the fetal vessels has any additional clinical value in normal and intrauterine growth restricted (IUGR) fetuses. MATERIAL AND METHODS The study included 93 pregnancies with IUGR, 37 pregnancies with IUGR and brain sparing effect, and 324 healthy pregnant women. The T/QRS ratio, cerebro-placental ratio (CRP), and CTG tracings were analyzed. One-way analysis of variance and Spearmans rank correlation coefficient were applied. The relationship between results of the T/QRS ratio and CTG examination among the study groups was analyzed. RESULTS The highest average mean value of the T/QRS ratio was recorded in the IUGR group with a normal CPR and a pathologic CTG (0.235 ± 0.014). The highest average maximum values were observed in the groups of IUGR pregnancies with a reduced CPR with normal (0.309 ± 0.100), suspicious (0.330 ± 0.102) and pathologic (0.319 ± 0.056) CTGs. Analysis of variance revealed differences between study groups regarding maximum values and the difference between maximum and minimal values of T/QRS. Correlations between groups were insignificant. CONCLUSIONS Higher values of T/QRS ratio in IUGR pregnancies with normal and reduced CPR than in control group regardless of the result of CTG examination may indicate minimal worsening of intrauterine fetal well-being in growth retarded fetuses. No relationship between fECG examination and CTG tracings suggests that a single fECG does not provide any additional clinically significant information determining the condition of the fetus; however, further studies are required.

Neonatal Outcome from Triplet Interval Delayed Delivery: A Case Report

In the past decades, we have observed a large increase in the number of multifetal pregnancies, which is mainly associated with the introduction of assisted reproductive techniques. Even though neonatal intensive care of very premature infants has improved significantly, the risk of mortality and long-term morbidity is still much higher among these newborns. A longer interdelivery period may reduce perinatal mortality and morbidity. The authors report the case of a delayed interval delivery in trichorionic, triamniotic triplet pregnancy. After the labor of the first fetus in the 22nd week of gestation, a 75-day interval was achieved before the delayed delivery. To save the surviving fetuses, the umbilical cord was ligated at the cervical level immediately after the first delivery. The patient received antibiotics, tocolytics, and corticosteroids. A baby boy who weighed 1750 g and a girl who weighed 1700 g were successfully delivered by cesarean section in the 33rd week of pregnancy. The babies were discharged home at the age of 28 days. A follow-up examination 20 weeks later showed that their neurological development was normal and without any major problems. The maternal postpartum course was uneventful; the patient stayed in hospital taking care of the babies.