Faculty Bibliography

OBJECTIVES/OBJECTIVE:To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). METHODS:Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. RESULTS:A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. CONCLUSIONS:While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.

The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.

BACKGROUND:The last four decades have seen increased complications after Cesarean Deliveries (CDs). Despite an incomplete understanding of their etiology, surgical practices have been adopted, creating disproportionate morbidity and the absence of preventive strategies. Additional research tools are needed for further investigation. OBJECTIVE:To evaluate the VITOM high-definition (HD) optical recording system as a tool to highlight Cesarean operative steps and surgical techniques and assess the use of its video recordings for operating room team teaching and for research potential. STUDY DESIGN/METHODS:Contemporaneous Cesarean delivery (CD) techniques offer no resolve to long-term post-Cesarean sequelae. From March 2015 to February 2022, a novel tool, VITOM exoscope, was evaluated and used to photograph and video record 104 elective CDs. The images were projected on a large screen to be viewed by scrubbed-in and unscrubbed personnel and recorded for future use. During this period, staff participants in three designated operating rooms numbered 514, including 168 trainee residents, 5 nurse practitioners, 6 physician assistants, 21 medical students, 70 surgical technicians, and 110 circulating nurses. Maternal ages of patients varied from 21 to 49 years. Gestational ages ranged from 28 to 41 weeks and 6 days. Selected photographs of critical Cesarean surgical steps were taken and printed. Video recordings were stored in designated institutional data storage and uploaded onto a secure drive for further use. After every case, debriefing was held, and subjective opinions were obtained from the various participants. RESULTS:The VITOM was used for 104 CDs. Set-up time was reduced from 7 minutes initially to 3 minutes with more experience. All staff participants had only positive evaluations and remarks about the image quality and the clear delineation of specific anatomic landmarks. By polling medical students and residents in training, the VITOM experience was described as very useful and, in a few cases, only somewhat useful. The scrubbed surgical technicians and circulating nurses gained a better understanding of surgical layers, improving their ability to anticipate subsequent surgical steps, thereby streamlining operating flow and efficiency. Unscrubbed personnel could also follow the operation's progression despite being remote from the sterile field. Anesthesiologists could follow the operative field and eventual blood loss in plain view. Recorded videos and still photographs were used at clinical teaching conferences and in peer-reviewed publications, enhancing understanding of Cesarean delivery techniques. CONCLUSION/CONCLUSIONS:The VITOM exoscope provided superb image quality enabling a clear vision of anatomic structures of the Cesarean operation. It is a promising additional research tool to capture crucial details of the employed surgical techniques and provides a possible insight into long-term post-Cesarean sequelae.

OBJECTIVE:To compare the prevalence and size of residual niche in the nongravid uterus following Cesarean delivery (CD) with different hysterotomy closure techniques (HCTs). METHODS:, T-test (ANOVA), and analyzed using logistic regression and two-sided test (P < .05). RESULTS:Forty-five women had SIS performed, 25 and 20 via Technique A and B, respectively. Technique groups varied by average interval time from CD to SIS (13.6 versus 74.5 months, P = 0.006) but were otherwise similar. Twenty niches were diagnosed, 85% of which were clinically significant, including five following Technique A, nine following Technique B with double-layer closure, and three following Technique B with single-layer (P = .018). The average niche depth was 2.4 mm and 4.9 mm among the two-layer subgroups following Techniques A and B, respectively (P = .005). A clinically significant niche development was six times higher with Technique B when compared to Technique A (OR 6.0, 95% CI 1.6-22.6, P = .008); this significance persisted after controlling for SIS interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3, P = .04). The average niche depth was 5.7 ± 2.9 mm following Technique B with single-layer. CONCLUSION/CONCLUSIONS:Hysterotomy closure techniques determine the prevalence of post-Cesarean delivery niche formation and size. Exclusion of the endometrium at uterine closure reduces the development of significant scar defects.

Placenta accreta spectrum (PAS) disorders involve an abnormality in the implantation of the placenta, being rarely diagnosed in the first trimester. To conduct a systematic review of the risk factors, clinical and imaging features, and outcomes of histopathologically confirmed cases of PAS disorders in the first trimester of pregnancy. Different databases including PubMed, MEDLINE Complete, Scopus, Web of Science, EMBASE, SciELO, LILACS, and Ovid were reviewed up to November 2018. 55 patients with a definitive histopathological diagnosis were reported. About 18 had a history of prior curettage and 47 of previous caesarean deliveries (CD). About 74.54% presented with miscarriage and ultrasound signs of caesarean scar pregnancy (CSP) were reported in 22.49%. Temporal sequence of diagnostic studies could be determined in 52 women, and, among these, PAS disorders were defined through imaging techniques in 11 (21.15%) while surgical findings unveiled them in 15 (28.84%). Nonetheless, in half of the cases, the diagnosis was concluded only on histopathological samples. PAS disorders in the first trimester of pregnancy are rarely diagnosed through imaging techniques and lead to hysterectomy in most cases. Ultrasound training to detect PAS disorders in women with risk factors is crucial for early diagnosis and prevention of adverse outcomes.

Background: Placenta accreta spectrum (PAS) disorders involve an abnormality in the implantation of the placenta, being rarely diagnosed in the first semester.
Objective(s): To conduct a systematic review about the risk factors, clinical and imaging features, and outcomes of histopathologically-confirmed cases of PAS disorders in the first trimester of pregnancy.
Method(s): Different databases including PubMed, MEDLINE Complete, Scopus, SciELO, Web of Science, EMBASE, LILACS, and Ovid were reviewed up to November 2018. Case reports and series with histopathological confirmation of PAS disorders before week 14 of pregnancy were included.
Result(s): 53 patients with a definitive histopathological diagnosis were reported in the final list of 50 articles. 18 (33.96%) had a history of at least one curettage and 45 (84.90%) had prior cesarean deliveries (CD). Only 9 (16.98%) patients were diagnosed during first trimester using imaging techniques, and signs of cesarean scar pregnancy (CSP) were as well seen in 9 patients with ultrasound report. PAS disorders were diagnosed upon miscarriage in 41 (77.35%) patients, 15 (30%) were identify in surgery, and 26 (52%) were confirmed based solely on the histopathological report. Hysterectomy was performed in 48 (90.56%) patients. 8 (15.09%) cases of placenta accreta, 17 (32.07%) of increta, and 28 (52.83%) of percreta were reported.
Conclusion(s): PAS disorders in the first trimester of pregnancy are rarely diagnose through imaging techniques and lead to hysterectomy in almost every case. Training in ultrasound to detect PAS disorders in women with risk factors is crucial for early diagnose and prevention of adverse outcomes