Surgical techniques at caesarean might modify placenta accreta risk

Sholapurkar, Shashikant L.

doi:10.1111/1471-0528.13017

Cited by 4 publications

(6 citation statements)

References 3 publications

(12 reference statements)

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“…However, not much attention has been paid to the possible etiology of CS defects which would help to reduce the future incidence of CS defects and long-term complications. The author was an early protagonist to propose that surgical technique of uterine incision closure seems the most important factor in poor healing of CS scar leading to CS defect [ 9 , 10 ]. Hence, the formation of CS defect and its long-term sequelae should not be considered inevitable [ 9 , 10 ].…”

Section: Introductionmentioning

confidence: 99%

“…At the same time, it seems impractical (probably impossible) and wasteful to examine/study large number of theoretical etiological factors, many of minor importance, by good quality studies. Hence, this clinical review critically analyzes all the previously suggested etiological hypotheses of CS niche formation [ 9 , 10 , 12 ], in order to identify the key areas where clinical discussion and research (especially RCTs) should focus. This analysis is not an “arm-chair theorist’s approach” but quite the opposite.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

Sholapurkar

2018

J Clin Med Res

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There is an increasing incidence of cesarean scar (CS) defect/niche and its sequelae, probably not entirely explained by better diagnosis or rising cesarean rate. Discussion of possible etiological factors has received scant attention but would be important to formulate preventive strategies. Meaningful informative studies on long-term sequelae of cesarean section are very difficult and none are available for causation of CS defect. Hence, it is crucial to identify key areas in etiology of CS defect for focused research. This practical review proposes an “ischemia and mal-apposition hypothesis for CS niche”, stating that the surgical technique of uterine incision closure is the most important determinant of CS defect formation. Other factors such as cervical location incision, adhesion formation and patient specific factors seem far less important in etiology. Rather than the headline theme of “single versus double-layer closure of uterus”, the finer details of surgical technique which achieve good apposition without inducing tissue ischemia seem more important. Different techniques are discussed and it is proposed that continuous, non-locking absorbable sutures in two layers, without including much of decidua and without undue tight (constricting/devasculaizing) pulling of sutures are likely to result in good healing of uterine scar. Single-layer technique may be best reserved for thin myometrial edges especially during repeat cesareans. Adhesions between uterine isthmus and bladder/abdominal wall seem common associations but not causative for CS niche. It would be desirable to prove these surgical principles by good quality prospective randomized “quantitative” studies but the wait may be very long and this should not hinder the adoption of good surgical principles. Science is much cognitive and not just empirical. To consider a related example, the current recommendation of non-suturing of peritoneal layers during cesarean is mistakenly based on short-term irrelevant surrogate outcomes like analgesic requirements and time-saving, many of which have been already disproven. Evidence is presented recommending simple quick techniques of peritoneal closure to prevent adhesions. More analytical debate in surgical techniques is needed to inspire engaged, critical and insightful practitioners rather than unquestioning dependence on weak evidence/guidance.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

Sholapurkar

2018

J Clin Med Res

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“…Caesarean delivery rate above the WHO’s upper recommended rate of 15% [ 4 ] has not resulted with an improvement in neonatal outcomes but with an increase in maternal morbidity [ 5 – 7 ]. Indeed, caesarean sections lead to an appreciable increase in maternal complications in the short term (thromboembolism, infection, trauma, bleeding) and long term (risk of ectopic pregnancy, infertility, abnormal placental insertion, risk of uterine rupture) [ 8 , 9 ] and an increase in health costs [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

Teaching and performing audits on caesarean delivery reduce the caesarean delivery rate

et al. 2018

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AimTo assess the factors associated with lower rate of caesarean deliveries in the South of France, based on the characteristics and organisation of the region’s 40 maternity facilities and the characteristics of the practitioners in these facilities.MethodA retrospective study from 1 January 2012 to 31 December 2015. Data were collected by the Mediterranean network and a declarative survey was completed by each maternity facility in the region to study factor which could be associated with lower caesarean rate by univariate and multivariate analysis.Results250 564 women gave birth during this period, of which 55 097 by caesarean section. The mean caesarean delivery rate over the four years was 22.0%. The rate was significantly higher in private maternity facilities [23.9% (21.9%– 25.8%), p<0.05] and type III (maximum care level) maternity facilities [24.2% (21.3%– 27.1%), p<0.05]. After a stepwise regression, the factors associated with a decrease in the caesarean delivery rate were audits concerning caesarean delivery (19.83%, β = - 2.48, p = 0.03 over the four years) and the provision of training to trainee doctors at the maternity facility (20.28%, β = - 1.08, p = 0.04 over the four years).ConclusionPerforming audits in relation to caesarean deliveries could affect the caesarean. Teaching trainee doctors could be an indicator of quality of caesarean practices. They should be encouraged in maternity facilities to reduce the rate of caesareans.

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“…The most popular ones include: endometrial-myometrial junction microtraumas, invasion of the endometrium to the myometrium, stem cells metaplasia in the myometrium, infiltration of endometrial cells of menstrual blood retrogradely to the myometrium from the serosal surface of the uterus, induction of adenomyotic lesions by steroid hormones, and so on. 5,8,9,[13][14][15][16][17][18]26 Histological evaluation of the uterus after hysterectomy is the gold-standard method for diagnosis of adenomyosis. Non-invasive methods for diagnosis of adenomyosis are TVS and MRI.…”

Section: Discussionmentioning

confidence: 99%

“…2 Adenomyosis is a common gynecological disease defined by the presence of endometrial stromal glands in the uterine myometrium and can cause severe menstrual bleeding or dysmenorrhea. [14][15][16][17][18][19][20][21][22][23][24] Hypotheses have been proposed that adenomyosis may be an unfavorable factor for uterine myometrial repair. 25 Since it is important to investigate the characteristics of CSD and the consequence of adenomyosis on its evolution, we designed this study to investigate the quantitative characteristics of CSD in patients with and without adenomyosis referred to our radiology department for sonohysterography.…”

mentioning

confidence: 99%

Evaluation of Association Between Adenomyosis and Cesarean Scar Defect

Shakki Katouli,

Zebardast,

Tavoli

et al. 2023

J of Ultrasound Medicine

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PurposeThis study aims to investigate and compare quantitative factors of the cesarean scar defect (CSD) in symptomatic patients with and without uterine adenomyosis.MethodThis study was conducted as a case–control study. Patients who met the inclusion criteria were divided into two groups: with adenomyosis (case) and without adenomyosis (control). The demographic data, medical history, and sonohysterography findings were extracted from the patient's documents and archived images.ResultDuring 2 years, 310 symptomatic women with a history of previous cesarean section underwent sonohysterography. Among them, 204 patients met the inclusion criteria. The most common chief complaints were post‐menstrual bleeding (34.3%) and prolonged bleeding (27%). Cesarean scar depth and width significantly differed between these two groups, and patients with underlying adenomyosis had significantly larger defects (P‐value of .009 and .005, respectively). Mean RMT/AMT ratio was 31.83% in the case group and 42.88% in the control group. In our study, RMT/AMT ratios were significantly lower in the case group (P‐value of .001). In addition, we performed analysis on a subgroup of patients with one prior cesarean section. Similar results were achieved with a lower RMT/AMT ratio in case group (mean of 31.20% in case group and 46.47% in control group; P‐value of .000).ConclusionOur study showed a strong association between the presence of adenomyosis and larger clinically more significant CSDs. To establish a causative relationship, we suggest a prospective cohort study to follow up the patients and compare the evolution of CSD in patients with and without adenomyosis.

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Surgical techniques at caesarean might modify placenta accreta risk

Cited by 4 publications

References 3 publications

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

Teaching and performing audits on caesarean delivery reduce the caesarean delivery rate

Evaluation of Association Between Adenomyosis and Cesarean Scar Defect

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