剖宫产术后再次妊娠子宫切口愈合的超声观察

剖宫产术后再次妊娠的分娩方式 ,依赖于前次剖宫产子宫切口的术式和切口愈合情况。如何准确地评定子宫切口愈合程度 ,成为临床工作的一个难题。超声检查是唯一能直接观察子宫切口愈合情况的手段。本文对剖宫产术后再次妊娠 81例孕妇进行了再次剖宫产术前B超诊断子宫下段厚度比较 ,现报道如下。1　资料与方法1.1　一般资料全部病例来自 1988年 1月至 2 0 0 1年 12月在我院住院剖宫产分娩的产妇。年龄最小 2 4岁 ,最大 4 8岁 ,平均2 9 75岁。其中第 2胎 77例 ,第 3胎 4例 ,二次剖宫产史 2例。再次妊娠间隔年限 >2年者 71例 ,≤ 2年者 10例。…     

妊娠晚期瘢痕子宫隐性破裂六例分析

目的　探讨隐性子宫破裂发生的原因、诊断、预防及处理方法。　方法　回顾性分析1978年 1月至 1998年 12月 ,在我院剖宫产后再次妊娠住院的产妇 141例 ,共发现隐性子宫破裂 6例。结果　 6例产妇均经入院后检查、B超检查 ,并复习前次剖宫产病历及时作出了诊断而行剖宫产术 ,母婴无一死亡。　结论　前次剖宫产的术式与缝合技术、前次剖宫产术后切口愈合情况、宫壁的压力不均匀、妊娠晚期子宫自发性的收缩等均为子宫隐性破裂的诱因。提高剖宫产术中的手术技巧和缝合技术 ,预防感染可预防下次妊娠时子宫破裂 ,对于怀疑有子宫隐性破裂的产妇 ,应高度警惕。     

疤痕子宫妊娠的引产与催产

子宫疤痕形成的常见原因有剖宫产术、子宫肌瘤剔除术、子宫畸形矫治术等 ,其中以剖宫产术最为常见。近年来 ,随着剖宫产率的升高 ,剖宫产术后疤痕子宫再次妊娠者也随之增加。因此 ,有关疤痕子宫的再次妊娠及其阴道试产、引产、催产等有关方面的问题 ,越来越受到产科界同仁们的关注。现在本文就围绕这种病理性妊娠及其与引产、催产相关问题讨论如下。1　子宫切口愈合的病理过程及其评价1.1　子宫切口愈合的病理　　Ｋａｕｍｏｂ[1] 对动物子宫切口的愈合过程做了仔细的观察后发现 ,在剖宫产术后最初数小时内 ,切口边缘部分便很好地粘合在一起…     

剖宫产术后2年内再次妊娠的安全性评价

目的:探讨剖宫产术后2年内再次妊娠的安全性及各因素对妊娠结局及新生儿的影响。方法:选取2018年1月至7月于吉林大学第二医院行剖宫产分娩的瘢痕子宫妊娠孕妇162例。按此次妊娠距前次剖宫产的时间将患者分为4组:6个月组、6～12个月组、12～24个月组、24个月组,比较4组的妊娠结局。结果:4组的妊娠期并发症发生率比较,差异无统计学意义(P0.05)。4组的手术时间、监护时间、术后感染、术后出血、术后止疼剂使用情况及新生儿结局等比较,差异均无统计学意义(P0.05)。6个月组、6～12个月组的子宫瘢痕厚度与12～24组和24个月组比较,差异有统计学意义(P0.05)。结论:剖宫产术后1年内选择再次分娩的孕妇,分娩前子宫瘢痕厚度较薄,再次妊娠可能增加子宫破裂风险,剖宫产后1～2年再次妊娠者,子宫瘢痕愈合情况良好,且未增加产科并发症及新生儿的风险,如有生育要求者,可继续妊娠。     

剖宫产后再次妊娠1463例临床分析

近年来,随着剖宫产率的升高,剖宫产后再次妊娠分娩问题已成为产科临床上的突出课题。本文通过安徽省肥西县三河医院等5个单位1463例临床资料分析,探讨剖宫产后再次妊娠分娩方式的选择。临床资料一、发生率:本文报告1965年1月至1987年9月间,安徽省肥西县三河医院等五个单位曾行剖宫产术再次妊娠临产共1463例,占同期分娩总数45623例的3.2%。二、分娩方式:本文五个单位的作者,依据病人的具体情况,制定了试产条件,现归纳如下:①本次妊娠距前次手术2年以上;②前次手术指征本次妊娠已不存在;③前次术式为子宫下段剖宫产,并无子宫损伤史,如子宫穿孔、肌瘤剔除等;④前次术后无感染情况(子宫内膜炎、腹部伤口感染、产褥感染、术后发热等);⑤前次术后无晚期产后出血及下腹痛等;⑥本次妊娠无严重内科合并症及产科并发症,无头盆     

剖宫产术后子宫瘢痕妊娠的研究进展

剖宫产术后子宫瘢痕妊娠简称剖宫产瘢痕部妊娠（cesarean scar pregnancy,CSP）,是指有剖宫产史的妇女再次妊娠时,受精卵或胚胎着床于前次剖宫产切口瘢痕处,它是剖宫产术后远期并发症之一,属于子宫特殊部位的异位妊娠,亦是异位妊娠中的罕见类型。CSP一旦形成,     

前次剖宫产手术对再次妊娠胎盘植入及其类型的影响

目的:探讨前次剖宫产手术对再次妊娠胎盘植入及其类型的影响。方法:回顾性分析2012年1月至2016年12月在成都市妇女儿童中心医院分娩的11025例瘢痕子宫(前次剖宫产术)孕妇的临床资料,其中再次妊娠时1274例发生胎盘植入(粘连型905例,植入型309例,穿透型60例)。分析前次剖宫产是否伴发产后出血、前次剖宫产是否为产程中转急诊手术以及前次剖宫产距离本次妊娠时间与再次妊娠胎盘植入发生以及类型的关系。结果:(1)前次剖宫产伴发产后出血再次妊娠时胎盘植入总的发生率及3种类型的发生率均高于剖宫产后无产后出血组,差异有统计学意义(P0.05)。(2)前次剖宫产为产程中转急诊手术再次妊娠时胎盘植入总的发生率及3种类型的发生率均高于前次剖宫产为非产程中转手术,差异有统计学意义(P0.05)。(3)前次剖宫产距离本次妊娠的不同时间与再次妊娠时胎盘植入总的发生率及三种类型的发生率,差异无统计学意义(P0.05)。结论:前次剖宫产手术伴发产后出血、产程中转急诊剖宫产手术与再次妊娠时胎盘植入的发生可能有关,孕期应加强对这部分孕妇的管理。     

疤痕子宫短期内妊娠的安全性分析

目的:了解子宫手术疤痕形成后两年内妊娠的结局,并评估疤痕子宫再次妊娠的安全性和可行性。方法:收集我院2003年1月1日至2009年4月30日101例子宫疤痕形成后两年内妊娠的中晚期孕妇,前次手术系子宫肌瘤剔除术43例(42.6%),前次手术系剖宫产58例(57.4%)。分析再次妊娠原因、再次妊娠距离前次手术的时间、再次妊娠的结局。结果:不同部位、不同大小肌瘤、不同手术途径、肌瘤剔除术后不同阶段的妊娠结局,差异均无统计学意义(P>0.05)。结论:有妊娠要求的疤痕子宫患者可考虑手术6个月后开始妊娠,但应密切注意子宫收缩情况和予以适当的产科处理。     

剖宫产后再次妊娠并发子宫破裂的早期诊断

疤痕子宫在再次妊娠的晚期或分娩期易发生子宫破裂或子宫切口裂开 ,是再次妊娠灾难性的并发症之一 ,Guise等进行多样本的调查 ,查阅了 5 6 8篇论文 ,得出与选择性重复剖宫产比较 ,剖宫产后再次妊娠阴道试产过程中子宫破裂的危险增加2 .7‰ ,围生儿死亡增加 1.4‰ ,子宫切除增加 3.4‰的结果。导致疤痕子宫的主要原因是前次剖宫产 ,其次为妊娠子宫破裂或子宫穿孔后子宫修补术 ,子宫肌瘤挖出术 ,特别是子宫肌瘤较大 ,深达子宫内膜时 ,手术后在子宫肌层留下薄弱点 ,在再次妊娠时 ,尤其是在妊娠晚期 ,子宫容积增大 ,加上分娩期的子宫羊膜腔内压…     

剖宫产后再次妊娠经阴道分娩成功的相关因素分析

目的:探讨剖宫产后再次妊娠经阴道分娩成功的相关因素。方法:选取2010年10月至2013年11月在我院住院分娩的剖宫产后再次妊娠且有阴道分娩条件的164例孕妇,分析孕妇的意愿、子宫下段厚度及距前次剖宫产时间等因素。结果:164例中选择经阴试产者96例,其中经阴分娩成功72例,试产成功率75%;二次剖宫产分娩92例。选择经阴分娩的96例孕妇中,子宫下段厚度2.0~2.9mm和≥3.0mm者的经阴分娩成功率显著高于1.0~1.9mm者(79.48%、75.55%vs 58.33%)。距前次剖宫产1~2年、2~3年、3~5年、5~9年及9年以上者分别有1例、46例、35例、12例和2例,其中经阴分娩成功者分别有1例、35例、30例、4例和0例。结论:剖宫产后孕产妇再次分娩方式与孕妇分娩意愿、距前次剖宫产时间、超声测量子宫下段厚度等因素相关,综合因素分析决定无高危因素的剖宫产后再次妊娠经阴道分娩方式是可行和安全的。     

Single- versus double-layer uterine incision closure and uterine rupture.

OBJECTIVE: To evaluate whether closure of the uterine incision with one or two layers changes uterine rupture or vaginal birth after cesarean section (VBAC) success rates. METHODS: Subjects with one previous cesarean section by documented transverse uterine incision that attempted VBAC were identified. Exclusion criteria included lack of documentation of the type of closure of the previous uterine incision, multiple gestation, more than one previous cesarean section, and previous scar other than low transverse.Uterine rupture and VBAC success rates were compared between those with single-layer and double-layer uterine closure. Time interval between deliveries, birth weight, body mass index (BMI), and history of previous VBAC were evaluated as possible confounders. RESULTS: Of 948 subjects identified, 913 had double-layer closure and 35 had single-layer closure. The uterine rupture rate was significantly higher in the single-layer closure group (8.6% vs. 1.3%, p = 0.015). This finding persisted when controlling for previous VBAC, induction, birth weight >4000 g, delivery interval >19 months, and BMI >29 (OR 8.01, 95% CI 1.96-32.79). There was no difference in VBAC success rate (74.3% vs. 77%, p = 0.685). CONCLUSION: Single-layer uterine closure may be more likely to result in uterine rupture.     

The counselling of patient with prior C-section

A trial of labor after prior cesarean delivery is associated with a greater perinatal risk than is elective repeated cesarean delivery without labor, although absolute risks are low. Information and counselling aim to estimate specific risks and to balance these risks according to individual factors. Therefore, the physician has to answer two questions: (i) which would be the probability of successful vaginal delivery? (ii) which would be the risk of uterine rupture with a trial of labor? The risk factors for failure of trial of labor are: increased maternal age, obesity, and fetal macrosomia. The risk factors for uterine rupture are: increased maternal age, postpartum fever after the previous cesarean delivery, short interdelivery interval, history of at least two previous cesarean deliveries, and a history of classical incision. Conversely, other factors are of good prognosis: a prior vaginal delivery and, particularly, a prior VBAC (Vaginal Birth After Caesarean) are associated with a higher rate of successful trial of labor compared with patients with no prior vaginal delivery; ultrasonographic measurement of the lower uterine segment thickness>3.5 mm has an excellent negative predictive value for the risk of uterine defect. Finally, the wish for additional pregnancies following a cesarean section must be considered as an argument in favour of a trial of labor after accounting for the increasing risks correlated with repeated elective cesarean deliveries.     

Single- versus double-layer uterine incision closure and uterine rupture

Objective. To evaluate whether closure of the uterine incision with one or two layers changes uterine rupture or vaginal birth after cesarean section (VBAC) success rates.

Methods. Subjects with one previous cesarean section by documented transverse uterine incision that attempted VBAC were identified. Exclusion criteria included lack of documentation of the type of closure of the previous uterine incision, multiple gestation, more than one previous cesarean section, and previous scar other than low transverse.

Uterine rupture and VBAC success rates were compared between those with single-layer and double-layer uterine closure. Time interval between deliveries, birth weight, body mass index (BMI), and history of previous VBAC were evaluated as possible confounders.

Results. Of 948 subjects identified, 913 had double-layer closure and 35 had single-layer closure. The uterine rupture rate was significantly higher in the single-layer closure group (8.6% vs. 1.3%, p = 0.015). This finding persisted when controlling for previous VBAC, induction, birth weight >4000 g, delivery interval >19 months, and BMI >29 (OR 8.01, 95% CI 1.96–32.79). There was no difference in VBAC success rate (74.3% vs. 77%, p = 0.685).

Conclusion. Single-layer uterine closure may be more likely to result in uterine rupture.     

Previous cesarean section and trial of labor. Factors related to uterine dehiscence

Patients with previous cesarean section generally are subjected to repeat cesarean section for fear of uterine rupture and its subsequent catastrophic complications. Recently, however, since the practice of repeat cesarean section has been challenged, a select group of patients has been permitted a trial of labor (TOL) after they have fulfilled certain selection criteria. These criteria include not more than one previous low segment transverse incision, a nonrecurrent indication and absence of macrosomia with this pregnancy. We performed a retrospective study on 836 patients with previous cesarean sections. Of them, 308 were given a TOL. Factors considered to increase the risk of dehiscence were analyzed. On statistical analysis, none of the factors appeared to have any impact on the rate of uterine dehiscence.     

二次剖宫产行子宫瘢痕切除术预防剖宫产切口瘢痕憩室效果的临床研究

目的:比较二次剖宫产术中原子宫切口瘢痕切除与否对剖宫产切口瘢痕憩室(PCSD)形成的影响,为临床PCSD的预防提供依据。方法:选取择期二次剖宫产的产妇共360例,其中采用先行原子宫切口瘢痕切除,再双层连续缝合子宫的产妇为研究组,直接行双层连续缝合子宫的产妇为对照组。统计两组手术时间、术中出血量、术后血性恶露持续时间、肛门排气时间、住院天数。术后6月至1年进行随访,评估是否出现异常阴道流血,并在术后1年应用阴道三维超声评估子宫切口愈合情况,分别统计两组产妇形成PCSD的例数,憩室残余子宫肌层厚度及憩室的大小。结果:两组的手术时间、术中出血量、术后血性恶露持续时间、肛门排气时间、住院天数差异均无统计学意义(P0.05);研究组与对照组形成PCSD的例数分别为4例(2.2%)、15例(8.3%);憩室残余子宫肌层厚度均值分别为7.35±1.89 mm、4.98±2.03 mm;憩室容积分别为0.36±0.17 ml、0.53±0.13 ml(P0.01)。结论:二次剖宫产术中切除原子宫切口瘢痕更利于切口愈合,减少PCSD的形成,减轻所形成的PCSD的程度。     

Neonatal status in relation to incision intervals, obstetric factors, and anesthesia at cesarean delivery

Uterine incision to delivery interval has been suggested as a critical determinant of neonatal outcome; however, studies of skin incision and uterine incision to delivery intervals have usually not analyzed the contribution of obstetric factors relative to time factors in determining outcome. A group of 204 patients undergoing cesarean delivery were studied. Stepwise multivariate regression was used to examine the relative contribution of obstetric and anesthetic factors to Apgar scores and umbilical cord blood gases. Apgar scores and umbilical cord blood gases were significantly influenced by labor complications (fetal distress, meconium, and pre-eclampsia), infant weight, type of cesarean delivery (primary vs. repeat), and type of anesthesia. Skin incision and uterine incision to delivery intervals did not significantly contribute to Apgar scores nor umbilical cord blood gases when corrected for these factors. We conclude that careful attention to maternal status prior to cesarean delivery and optimal anesthetic management appear to be the most important factors for good neonatal outcome. Surgical techniques should be directed at gentle, atraumatic delivery of the fetus for the good of the fetus and the mother.     

剖宫产后子宫瘢痕憩室形成因素的研究进展

剖宫产后子宫瘢痕憩室(cesarean scar diverticula,CSD)是继发于剖宫产的一种妇科疾病,指剖宫产术后子宫切口肌层愈合不良,在子宫峡部出现突向浆膜层,并与宫腔相通的一个囊状缺陷,导致异常子宫出血、慢性盆腔痛、瘢痕妊娠、胎盘植入,甚至再次妊娠子宫破裂等严重并发症.目前CSD形成因素尚未完全阐明,可能...     

Failed vaginal birth after a cesarean section: How risky is it?: I. Maternal morbidity

OBJECTIVE: Our purpose was to determine the maternal risks associated with failed attempt at vaginal birth after cesarean compared with elective repeat cesarean delivery or successful vaginal birth after cesarean. STUDY DESIGN: From 1989 to 1998 all patients attempting vaginal birth after cesarean and all patients undergoing repeat cesarean deliveries were reviewed. Data were extracted from a computerized obstetric database and from medical charts. The following three groups were defined: women who had successful vaginal birth after cesarean, women who had failed vaginal birth after cesarean, and women who underwent elective repeat cesarean. Criteria for the elective repeat cesarean group included no more than two previous low transverse or vertical incisions, fetus in cephalic or breech presentation, no previous uterine surgery, no active herpes, and adequate pelvis. Predictor variables included age, parity, type and number of previous incisions, reasons for repeat cesarean delivery, gestational age, and infant weight. Outcome variables included uterine rupture or dehiscence, hemorrhage >1000 mL, hemorrhage >2000 mL, need for transfusion, chorioamnionitis, endometritis, and length of hospital stay. The Student t test and the chi(2) test were used to compare categoric variables and means; maternal complications and factors associated with successful vaginal birth after cesarean were analyzed with multivariate logistic regression, allowing odds ratios, adjusted odds ratios, 95% confidence intervals, and P values to be calculated. RESULTS: A total of 29,255 patients were delivered during the study period, with 2450 having previously had cesarean delivery. Repeat cesarean deliveries were performed in 1461 women (5.0%), and 989 successful vaginal births after cesarean delivery occurred (3.4%). Charts were reviewed for 97.6% of all women who underwent repeat cesarean delivery and for 93% of all women who had vaginal birth after cesarean. Vaginal birth after cesarean was attempted by 1344 patients or 75% of all appropriate candidates. Vaginal birth after cesarean was successful in 921 women (69%) and unsuccessful in 424 women. Four hundred fifty-one patients undergoing cesarean delivery were deemed appropriate for vaginal birth after cesarean. Multiple gestations were excluded from analysis. Final groups included 431 repeat cesarean deliveries and 1324 attempted vaginal births after cesarean; in the latter group 908 were successful and 416 failed. The overall rate of uterine disruption was 1.1% of all women attempting labor; the rate of true rupture was 0.8%; and the rate of hysterectomy was 0.5%. Blood loss was lower (odds ratio, 0.5%; 95% confidence interval, 0.3-0.9) and chorioamnionitis was higher (odds ratio, 3.8%; 95% confidence interval, 2.3-6.4) in women who attempted vaginal births after cesarean. Compared with women who had successful vaginal births after cesarean, women who experienced failed vaginal births after cesarean had a rate of uterine rupture that was 8.9% (95% confidence interval, 1.9-42) higher, a rate of transfusion that was 3.9% (95% confidence interval, 1.1-13.3) higher, a rate of chorioamnionitis that was 1.5% (95% confidence interval, 1.1-2.1) higher, and a rate of endometritis that was 6.4% (95% confidence interval, 4.1-9.8) higher. CONCLUSION: Patients who experience failed vaginal birth after cesarean have higher risks of uterine disruption and infectious morbidity compared with patients who have successful vaginal birth after cesarean or elective repeat cesarean delivery. Because actual numbers of morbid events are small, caution should be exercised in interpreting results and counseling patients. More accurate prediction for safe, successful vaginal birth after cesarean delivery is needed.     

Vaginal delivery after Misgav–Ladach cesarean section – Is the risk of uterine rupture acceptable?

Objective.?To evaluate whether the single-layer closure as is a routine by the Misgav–Ladach method compared to the double-layer closure as used by the Dörfler cesarean method is associated with an increased risk of uterine rupture in the subsequent pregnancy and delivery.

Methods.?The analysis is retrospective and is based on medical documentation of the Clinic for Gynecology and Obstetrics, University Clinical Centre, Tuzla, Bosnia and Herzegovina. All patients with one previous cesarean section who attempted vaginal birth following cesarean section were managed from 1 January 2002 to 31 December 2008. Exclusion criteria included multiple gestation, greater than one previous cesarean section, previous incision other than low transverse, gestational age at delivery less than 37 weeks and induction of delivery. We identified 448 patients who met inclusion criteria.

Results.?We found that 303 patients had a single-layer closure (Misgav–Ladach) and 145 had a double-layer closure (Dörffler) of the previous uterine incision. There were 35 cases of uterine rupture. Of those patients with previous single-layer closure, 5.28% (16/303) had a uterine rupture compared to 13.11% (19/145) in the double-layer closure group (p?<?0.05).

Conclusion.?We have not found that a Misgav–Ladach cesarean section method (single-layer uterine closure) might be more likely to result in uterine rupture in women who attempted a vaginal birth after a previous cesarean delivery. This cesarean section method should find its confirmation in everyday clinical practice.     

Acute myometritis and chorioamnionitis during cesarean section of asymptomatic women

Postoperative endomyometritis develops in as many as 85% of women undergoing cesarean section, which is 10- to 30-fold higher than after vaginal delivery. The timing and mechanism by which the infecting organisms gain access to the uterine cavity are unclear. One possibility is that the infection may occur postpartum by ascending colonization of the wound. Alternatively, myometritis may be already present at the time the cesarean section is performed in asymptomatic patients. With tissue necrosis, the stage is then set for puerperal endomyometritis. To study this second alternative mechanism, myometrial and placental biopsy specimens were obtained in 91 asymptomatic patients at the time of cesarean section. Histologic evidence of chorioamnionitis was identified in 10% (9/91) of patients. Acute myometritis was present in 11% (10/91) of the myometrial biopsy specimens. Seven of the nine women (77%) with subclinical acute chorioamnionitis demonstrated extension of the inflammation into the myometrium. Thirty-two percent (8/25) of women in labor and 31% (5/16) of those with rupture of membranes for greater than 6 hours had acute chorioamnionitis or myometritis, which is significantly higher (p less than 0.01) than in women without these risk factors. These findings suggest that approximately one third of asymptomatic women with rupture of the membranes for more than 6 hours or who are in labor at the time of cesarean section demonstrate histologic evidence of subclinical chorioamnionitis. In most of these patients the myometrium is also involved. The uterine incision is then performed through infected myometrium, possibly setting the stage for puerperal endomyometritis.