Re: Uterine segment
From: James S Smeltzer MD (gaperina@mindspring.com)
Thu Oct 10 23:05:49 2002
Has anyone noted anterior isthmic "nabothian" cysts in the women with prior
cesarean section? Does this change prognosis?
Jim
At 05:17 PM 5/17/2000 -0500, you wrote:
>here are some abstracts you may find helpful -
>
>Eur J Obstet Gynecol Reprod Biol 1999 Nov;87(1):39-45
>
>Thickness of the lower uterine segment: its influence in the management
>of patients with previous cesarean sections.
>
>Rozenberg P, Goffinet F, Philippe HJ, Nisand I
>Department of Gynecology and Obstetrics, Poissy Hospital, University
>Paris V, France. gynobs.poissy@wanadoo.fr
>
>OBJECTIVE: To determine how ultrasound measurement of the lower uterine
>segment affects the decision about delivery for patients with previous
>cesarean sections (CS) and what are the consequences on cesarean section
>rates and uterine rupture or dehiscence. DESIGN: Prospective open
>study. PATIENTS: 198 patients: all women with a previous CS who gave
>birth in our department during 1995 and 1996 to an infant with a
>gestational age of at least 36 weeks and who underwent ultrasound
>measurement of their lower uterine segment (95-96 study group), compared
>with a similar population from 1989 to 1994 whose measurements were not
>provided to the treating obstetrician. RESULTS: Among the patients with
>one previous CS, the vaginal delivery rate did not differ significantly
>during the two periods (70.3% for the 89-94 study period vs. 67.9% for
>the 95-96 study period, P=0.53), but the 95-96 study group experienced a
>significant increase in the rate of elective CS, compensated by a
>reduction in the rate of emergency CS (6.3% and 23.4%, respectively, for
>the 89-94 study period vs. 11.9% and 20.1% for the 95-96 study period,
>P=0.01). There was a very significant increase in the rate of vaginal
>delivery for the 95-96 study period among patients with two previous CS
>(26.7% vs. 8.0% for the 89-95 study period, P=0.01). The lower uterine
>segment was significantly thicker among women with a trial of labor than
>among those with an elective CS (4.5+/-1.4 mm compared with 3.8 +/- 1.5
>mm; P=0.006); and the trial of labor group contained significantly fewer
>women with a lower uterine segment measurement less than 3.5 mm than did
>the elective CS group (24.0% compared with 56.6%; P<0.001). Two
>patients (0.8%) were found to have a defect of the uterine scar, a rate
>significantly lower than that observed in the early group (3.9%,
>P=0.03). CONCLUSIONS: Ultrasound measurement of the lower uterine
>segment can increase the safe use of trial of labor, because it provides
>an additional element for assessing the risk of uterine rupture.
>
>PMID: 10579615, UI: 20044216
>
>Minerva Ginecol 1999 Apr;51(4):107-12
>
>[Transvaginal ultrasonic evaluation of the thickness of the section of
>the uterine wall in previous cesarean sections].
>[Article in Italian]
>
>Montanari L, Alfei A, Drovanti A, Lepadatu C, Lorenzi D, Facchini D,
>Iervasi MT, Sampaolo P
>Istituto di Clinica Ostetrica e Ginecologica, Universita degli Studi,
>IRCCS San Matteo, Pavia.
>
>BACKGROUND: The aim of this study is to evaluate accuracy of
>transvaginal sonographic examination of the lower uterine segment in
>pregnant women with previous cesarean section. METHODS: Sixty-one
>pregnant women between 37 and 40 weeks of gestation, with previous
>cesarean section underwent transvaginal ultrasonography. Wall thickness
>of the lower uterine segment, the length of cervix, dilation of the
>isthmus uteri were measured. On the basis of the surgical findings (in
>53 patients) and outcome of the trial of labor (in 8 patients) a Score
>was assigned to the pregnant women: Score 1 to the women who had good
>healing or a trial of labor without complications; Score 2 to the women
>with a thin or discontinued scar and in case of threatened rupture of
>the uterus in the trial of labor. RESULTS: The mean thickness of the
>lower uterine segment is 3.82 mm +/- 0.99 mm. The Score 1 group shows a
>mean thickness of 4.2 mm +/- 2.5 mm, and the Score 2 group a mean
>thickness of 2.8 mm +/- 1.06 mm. The transvaginal sonographic
>examination provides a sensitivity and a specificity respectively of 100
>and 75%, for a thickness cut-off of 3.5 mm, and a positive and negative
>predictive values of 60.7% and 100% respectively. CONCLUSIONS: The
>transvaginal sonographic evaluation of the lower uterine segment
>improves therefore the obstetrical decision-making regarding the trial
>of labor in women with previous cesarean section.
>
>PMID: 10379144, UI: 99307817
>
>Tohoku J Exp Med 1997 Sep;183(1):55-65
>
>Ultrasonographic evaluation of lower uterine segment to predict the
>integrity and quality of cesarean scar during pregnancy: a prospective
>study.
>
>Qureshi B, Inafuku K, Oshima K, Masamoto H, Kanazawa K
>Department of Obstetrics and Gynecology, School of Medicine, University
>of the Ryukyus, Okinawa, Japan.
>
>A prospective randomized study was conducted to measure the serial
>thickness of the lower uterine segment (LUS) by transvaginal
>ultrasonography in a control group of 80 women having no history of
>uterine surgery and in a study group of 43 women having a history of
>previous cesarean section (C/S). In the study group, more than 2 mm of
>thickness of the LUS was considered as good healing and less than 2 mm
>of thickness as poor healing. After serial sonographic examination, the
>women with good healing were given trial for labor unless an obstetrical
>indication for C/S existed. The appearance of the LUS during surgery
>was compared with antenatal ultrasonographic assessment by direct
>inspection. Twenty two (79%) of 28 women with a well healed scar had
>trial labor with the result that 46% had a successful vaginal birth
>without any uterine rupture of dehiscence. Eight women with poor
>healing all had elective C/S. Seven women with a 2 mm LUS thickness
>were individually categorized for delivery mode. Two of those women
>delivered vaginally. The LUS was found to be thin to translucent in
>these later two groups. Two mm or less as a criterion for poor healing
>had the sensitivity and specificity of 86.7% and 100% respectively. The
>positive predictive value was 100% and the negative predictive value was
>86.7%. Ultrasonographic evaluation is effective in predicting the
>quality of a uterine scar and in differentiating the risk group of
>probable uterine rupture from the non risk group.
>
>Ultrasound Med Biol 1990;16(5):443-7
>
>Observation of cesarean section scar by transvaginal ultrasonography.
>
>Chen HY, Chen SJ, Hsieh FJ
>Department of Obstetrics and Gynecology, National Taiwan University
>Hospital, Taipei, R.O.C.
>
>Transvaginal ultrasonography, with its higher frequency and proximity to
>the pelvic structures has offered us a powerful tool for observing the
>uterine scar of a previous Cesarean section. We have examined 87
>previous Cesarean section scars by transvaginal ultrasonography. Forty
>cases (group A) were in the third trimester. Fifty-two percent of this
>group showed normal patterns. In the remaining cases, thickening of the
>previous incision site was the most common finding. Also, thinning,
>ballooning and wedge defect were noted. Forty-seven cases (group B)
>were examined within 3 months (group B1) or after 3 months of Cesarean
>section (group B2). Similarly half of them showed normal patterns. In
>the remaining cases, wedge defect was the most common finding. The
>others were outward or inward protrusions, hematoma formation and inward
>retraction. An evaluation of the previous section scar, preferably by
>high resolution transvaginal ultrasonography is highly recommended in
>considering a trial of labor after previous Cesarean deliveries
>
>good luck!
>
>art
>
>At Wed, 17 May 2000, Pablo D'Angelo wrote:
>>
>>Thanks for your fast answer, Mr. DuBose.
>>I agree with you that it is important to look for accretism in cesarian
>>scar. But my question is oriented to the prediction of uterine rupture by
>>measuring the segment.
>>
>>Pablo J. D'Angelo
>>pjd@post.com
>>
>>>----- Original Message -----
>>From: <DuboseTerryJ@exchange.uams.edu>
>>To: Multiple recipients of list ULTRASOUND <ultrasound@forum.obgyn.net>
>>Sent: Wednesday, May 17, 2000 4:07 PM
>>Subject: Re: Uterine segment
>>
>>> I mainly pay attention to previous C Section scars in subsequent
>>pregnancies
>>> when there is a low, anterior placenta. There is a higher association
>>with
>>> accreta, increta, or percreta in association with prior C Sections if the
>>> placenta implants over the scar.
>>>
>>> Terry J. DuBose, M.S., RDMS
>>> Director, Diagnostic Medical Sonography Program
>>> CHRP, University of Arkansas for Medical Sciences
>>> Little Rock, Arkansas, USA
>>> 501-686-6510
>>> http://www.io.com/~dubose/ <http://www.io.com/~dubose/>
>>> http://www.uams.edu/CHRP/dmshome.htm
>><http://www.uams.edu/CHRP/dmshome.htm>
>>>
>>> http://www.obgyn.net/us/panel/panel.htm
>>> <http://www.obgyn.net/us/panel/panel.htm>
>>>
>>> -----Original Message-----
>>> From: Pablo D'Angelo [mailto:pablo_@radar.com.ar]
>>> Sent: Wednesday, May 17, 2000 2:01 PM
>>> To: Multiple recipients of list ULTRASOUND
>>> Subject: Uterine segment
>>>
>>> Do you measure the thickness of the uterine segment in
>>> previous cesarean
>>> section, or just look at the integrity of it?
>>> Do you find it useful to measure the segment?
>>>
>>> Pablo J. D'Angelo
>>> pjd@post.com
>>>
>
>--
>art fougner, md
>
>A series of 1000 cases begins with but a single anecdote.
>
