Study of various treatment modalities of caesarean scar pregnancy

Background: Caesarean scar pregnancy (CSP) can be defined as the implantation of the gestational sac within the scar of a previous caesarean surgery. Incidence of CSP is 1 in 1800 pregnancies.Methods: It is a retrospective study based on clinical diagnosis and management of CSP of women who presented to the obstetrics and gynaecology department SVP hospital from January 2008 to August 2021. Total number of cases of CSP were 28. Incidence, gestational age, ultrasound findings, serum β-human chorionic gonadotropin (β-hCG) levels, flow profiles of color Doppler, and different methods of treatment were recorded. Diagnosis was confirmed by ultrasound.Results: In this study, all 28 cases of CSP considered were offered definitive management. In present study 5 cases (17.88%) showed torrential haemorrhage during dilatation and evacuation (D and E) which was treated by various methods like 1 (3.57%) Foley’s tamponade, 1 (3.57%) uterine artery embolization (UAE) and 3 (10.71%) hysterectomy. Hysterotomy was performed in 13 cases (46.42%) and (7.69%) of heterotrophic CSP (HCSP). One case (3.84%) of CSP presented at 26 weeks of gestation with haemorrhagic shock, underwent obstetric hysterectomy.Conclusions: There is a rise in the incidence of CSP because of increase in the global rate of caesarean sections and early transvaginal USG in pregnancy. Transvaginal sonography is the best diagnostic tool. Medical management can be offered when diagnosis is made at gestational age of <7 weeks. Whereas, surgical modalities have shown better results at >7 weeks of gestational age. Surgical management has an advantage of shorter follow up.

A prospective study of prediction of preterm delivery by cervical assessment by transvaginal sonography

Preterm birth is a major cause of death and a significant cause of long-term loss of human potential amongst survivors all around the world. Complications of preterm birth are the single largest direct cause of neonatal deaths, responsible for 35% of the world’s 3.1 million deaths a year, and the second most common cause of under-5 deaths after pneumonia. In this study, an attempt has been made to evaluate the usefulness of cervical assessment by TVS in prediction of risk of preterm delivery in low risk pregnant women, thereby earlier management option can be planned and patients specific treatment can be given at the earliest. The present study was carried out in tertiary care teaching hospital for 1 year from 1 Jan 2019 to 31 Dec 2019. Total of 100 study participants who underwent TVS assessments of cervix regularly followed up who underwent TVS assessment of cervix and were regularly follow up and delivered. The mean cervical length in all these women was 30±6.68 mm. It was observed that 51.72% of patients with short cervical length less than 25 mm had preterm labour compared to the patients with cervical length more than 25mm i.e. 4.22%. Cervical assessment by TVS is effective in predicting preterm labour.

Diagnostic Accuracy of Lower Uterine Segment Scar Thickness ≤1.6mm in Prediction of Scar Dehiscence in patients

Background: Cesarean section uterine scar dehiscence (CSD) is a rare but notable complication of Lower segment cesarean section (LSCS) surgery. The cause for a uterine scar dehiscence is based on the etiology behind the uterine scar defect or any event that would predispose the cesarean scar to dehisce. Globally accepted option for assessing the CS scar is transvaginal ultrasonography of the non-pregnant uterus. Objective: To determine the diagnostic accuracy of lower uterine segment scar thickness≤1.6mm in the prediction of scar dehiscence in patients with previous one LSCS who are undergoing repeat LSCS after trial of labour taking intraoperative findings as gold standard. Material and methods: This cross sectional study was conducted in Services Hospital, Lahore for 6 months. The Non probability consecutive sampling technique was used to include women with previous one LSCS at 36-38 weeks were asked to get their TVS done for scar thickness. Women with scar thickness≤1.6mm and scar thickness>1.6mm were identified. Their intraoperative findings of scar dehiscence were confirmed. All the data was entered and analyzed on SPSS version 20. Results: The mean age of patients was 29.87±6.07 years. The emergency LSCS was done in 599(49.1%) patients and elective LSCS was done in 621(50.9%) patients. The sensitivity, specificity & diagnostic accuracy of TVS was 98.31%, 99.05% & 98.69% respectively. Conclusion: According to our study results the TVS for uterine scar is a very useful and effective tool in the prediction of scar dehiscence in patients with previous one LSCS taking intraoperative findings as gold standard. Keywords: Transvaginal sonography, TVS, Uterine, Scar, dehiscence, LSCS, Intraoperative

The implementation of routine procedural transvaginal sonography to decrease retained products of conception: a quality improvement initiative

Background Retained products of conception (POC) following uterine evacuation can lead to adverse sequelae, including hemorrhage, endometritis, intrauterine adhesions, and reoperation. Use of procedural transvaginal sonography (TVUS) in the operating room has been proposed to help decrease retained POC. Methods A retrospective review of all first trimester uterine evacuation procedures from 1/2015 to 2/2017 was performed, noting use of transabdominal ultrasonography, retained products of conception, and complications. A practice change was implemented in May 2018, in which routine intra-procedural TVUS use was initiated. A second retrospective chart review was conducted to assess for post-implementation incidence of retained POC, re-operation, and associated complications. Results Prior to intra-procedural TVUS implementation, 130 eligible procedures were performed during the specified timeframe, with 9/130 (6.9%) incidence of retained products of conception. TAUS was performed in 59/130 (45.4%) of procedures, and 4/9 (44.4%) of those with retained products. There were eight re-operative procedures in seven patients, and two patients were treated with misoprostol. Complications included hemorrhage, Asherman’s syndrome and endometritis. Following implementation, 95 first trimester procedures were performed with transvaginal sonography, with 0 (0%) cases of retained POC (p = 0.01), no incidences of re-operation (p = 0.02), and one case of Asherman’s syndrome. TVUS findings led to additional focused suction curettage in 20/95 (21.0%) of procedures. The endometrium was measured on procedure completion in 64 procedures, with a mean thickness of 5.5 mm (1–12 mm). Conclusion Implementation of routine TVUS during uterine evacuation may reduce the incidence of retained POC and associated reoperation rates. Further multi-center trials are needed to confirm this finding.

Evaluation of the diagnostic accuracy of transvaginal sonography versus hysteroscopy in detection of submucous myomas in peri and postmenopausal women with abnormal uterine bleeding

Background: Abnormal uterine bleeding is a very common gynaecological condition that affects all age groups. This study was aimed at assessing the usefulness of TVS in comparison with hysteroscopy in AUB evaluation. Aim was to evaluate the diagnostic accuracy of transvaginal sonography versus hysteroscopy in detection of submucous myomas in peri and postmenopausal women with abnormal uterine bleeding.Methods: The present study was prospective cross sectional study conducted in the Department of Obstetrics and Gynaecology, Kamla Nehru State Hospital for Mother and Child Indira Gandhi Medical College Shimla for period of one year w.e.f. 1st May 2018 to 30th April 2019. The study was started after hospital ethical committee approval. 76 patients peri and post-menopausal women were enrolled in the study after taking written consent.Results: On TVS- all the study subjects underwent TVS examination, submucous fibroid was detected in 10 subjects (n= 76) i.e. 13.1% (all perimenopausal). On hysteroscopy submucous fibroid was detected in 11 (14.4%) subjects, on histopathology it was confirmed in 11 subjects (14.4%). Out of 11, 8 patients underwent hysterectomy, 1 myomectomy, 2 patients had hysteroscopic removal of fibroid. 1 subject with AUB-LSM was wrongly diagnosed as AUB-P. Sensitivity, specificity, positive and negative predictive values of transvaginal sonography versus hysteroscopy was 90.09%, 100%, 100%, 98.5% respectively.Conclusions: TVS is an important initial modality for evaluating the patient of AUB. It is quick, simple, painless, least invasive, less expensive and readily available procedure and does not need full bladder like TAS. On the other hand, hysteroscopy has a better diagnostic accuracy as it provides the option of see and treat which is recommended for peri and post-menopausal women with AUB.

PILOT STUDY OF LOWER UTERINE SEGMENT CESAREAN SCAR THICKNESS PREOPERATIVELY BY TRANSVAGINAL SONOGRAPHY AND ITS CORRELATION WITH INTRA-OPERATIVE FINDINGS

Objectives: Cesarean section rates are increasing with a decrease in the rate of trial of labor after first cesarean section. Proper assessment of uterus especially scar of the previous lower segment cesarean sections (LSCS) in pregnant females is the key stone for the successful vaginal birth after cesarean section. The objective of this pilot study was to evaluate LSCS scar thickness using transvaginal sonography (TVS) and to determine the correlation between TVS and intraoperatively measured lower uterine segment cesarean scar thickness. Methods: This prospective observational analytic pilot study was carried out jointly by the Departments of Obstetrics and Gynaecology and Radiodiagnosis, Government Medical College and Rajindra Hospital, Patiala after due ethical and research committee approval. 100 women at term with history of previous LSCS and who were scheduled for elective LSCS were recruited for the study after taking the informed consent. Pre-operative scar measurement as on TVS was compared with and analyzed with intraoperative (I/o) scar measurements taken by Calipers. Results: The cutoff value for TVS readings was found to be ≤2.5 mm using receiver operating characteristic analysis. It has significant correlation with I/o scar measurements. It also has a significant relationship with age, pre-pregnancy overweight, number of the previous LSCS, and gestational age. Conclusion: Assessment of the scar integrity and quality by TVS will be helpful in selecting candidates for trial of labor with an optimally informed decision but still a number of studies have to be done to develop a robust scoring system.