Search Results (55)

Background: Interstitial ectopic pregnancy (IEP) is a rare but potentially life-threatening form of ectopic pregnancy because rupture can result in catastrophic hemorrhage. Accurate diagnosis is particularly challenging when implantation occurs near a previously operated interstitial/cornual region, where postoperative scarring and anatomical distortion may mimic recurrent IEP. We report a case of two surgically managed interstitial/cornual pregnancies at the same anatomical site, followed by a third pregnancy that initially appeared to be recurrent IEP but ultimately progressed to term delivery. Case Presentation: A 35-year-old woman underwent IVF-ET after unsuccessful intrauterine insemination and a prior failed IVF-ET attempt. After a missed abortion from the second IVF-ET cycle requiring dilatation and curettage, she conceived again through a third IVF-ET cycle. Transvaginal ultrasound demonstrated a gestational sac in the right interstitial/cornual region with outward bulging, thinning of the overlying myometrium, and delayed embryonic growth. Because of the high risk of rupture, laparoscopic wedge-shaped excision of the bulging gestational sac with uterine repair was performed. Three months later, she conceived spontaneously, and the gestational sac again developed at the previous interstitial/cornual surgical site. The surrounding myometrium was extremely thin, and serum β-hCG increased despite methotrexate treatment. Laparoscopic cornuostomy with right salpingectomy was therefore performed. After another 3-month recovery period, she conceived spontaneously again. The third pregnancy was initially suspected to represent recurrent IEP because the gestational sac was located near the same right posterior interstitial/cornual region. However, unlike the previous pregnancies, the gestational sac maintained broad contact with the endometrial cavity, showed no narrowed connection, preserved myometrial thickness of at least 5 mm, and expanded inward toward the uterine cavity rather than outward. With intensive ultrasound surveillance and fully informed consent, expectant management was continued. A healthy male infant weighing 2930 g was delivered by planned cesarean section at 37 + 0 weeks of gestation. Conclusions: This case highlights the importance of serial sonographic assessment in pregnancies suspected to be recurrent IEP. In a surgically altered cornual region, eccentric intrauterine implantation may mimic recurrent interstitial ectopic pregnancy at initial presentation. Broad communication with the endometrial cavity, absence of a narrowed connection, maintained myometrial thickness, and inward progression may help distinguish such cases from true recurrent IEP. Expectant management should be considered only in exceptional cases with hemodynamic stability, intensive imaging surveillance, immediate surgical availability, and fully informed patient consent. Full article

Background: Cervical pregnancy and cesarean scar pregnancy are rare forms of non-tubal ectopic pregnancy associated with a high risk of severe hemorrhage, surgical intervention, and potential loss of fertility. We describe a unique case of sequential abnormal implantation in which a cervical pregnancy was followed by a cesarean scar pregnancy one year later. The occurrence of two distinct forms of non-tubal ectopic pregnancy in a single patient represents an exceptionally uncommon clinical scenario, underscoring the importance of early diagnosis and carefully planned treatment. Case presentation: A 39-year-old woman, gravida 4 para 3, was diagnosed with two distinct non-tubal ectopic pregnancies over a 1-year period. The first pregnancy was implanted in the cervical canal, whereas the second was located within the cesarean section scar. In each episode, the diagnosis was established early by transvaginal ultrasound. As the patient was hemodynamically stable and wished to preserve fertility, minimally invasive hysteroscopic evacuation was performed in both pregnancies. The procedures were completed without significant intraoperative bleeding, and no additional hemostatic interventions were required. Follow-up serum β-hCG levels became negative after treatment, confirming complete resolution of pregnancies. Conclusions: This case demonstrates that early ultrasonographic diagnosis and careful individualized management may enable successful fertility-preserving treatment even in exceptionally rare cases. It also supports the potential role of minimally invasive approaches in selected hemodynamically stable patients and highlights the need for standardized management protocols for cervical and cesarean scar pregnancy. Full article

Background/Objectives: Post-cesarean section scar niche pregnancy is one of the rarest forms. It is characterized by implantation of the gestation sac within the scar niche and is often associated with chorionic villi adhesion into the thinned cesarean section scar. The increasing incidence of this condition is associated with the increasing frequency of cesarean sections and the widespread use of ultrasound in early pregnancy. The most significant clinical findings are the detection of chorionic villus invasion and uterine wall insufficiency, which may be detected using magnetic resonance imaging, including contrast, and are crucial for determining patient management. This pathology may be considered life-threatening due to complications such as early uterine rupture with bleeding, which, if not diagnosed promptly, can lead to hysterectomy and loss of the woman’s reproductive health. Early diagnosis allows for the use of conservative treatment methods, preserving the uterus. The aim of the study is to clarify the clinical practices to follow in cases where an MRI examination with contrast agent is indicated to be performed on a pregnant patient. Methods: Ultrasound and MRI examination with counter-rotation, as well as histological and immunohistochemical examination of the remnants of the gestational sac were performed. Results: A 36-year-old pregnant woman was hospitalized in her eighth week of pregnancy with complaints of vaginal bleeding and persistent abdominal pain. An ultrasound scan revealed a pregnancy of 8 weeks and 5 days, and a low-lying chorion in the isthmus of the uterus, along with thinning of the cesarean scar and the formation of a scar niche resembling a hernia. Early signs of chorionic invasion were not treated. An MRI revealed signs of superficial chorionic adhesion to the cesarean scar, both to the isthmus and the internal os. Given that the woman did not wish to continue the pregnancy, uterine artery embolization was performed to reduce potential blood loss. Subsequently, laparoscopy, adhesiolysis, vacuum aspiration of the gestational sac, uterine curettage, hysteroresectoscopy, and coagulation of the fetal bed were performed. Histological and immunohistochemical examination revealed signs of inflammation in the area of the suspected lesion. Conclusions: This case report shows the potential value of MRI in complex cases of ultrasound detection of a gestational sac within scar tissue. MRI was used to assess the location of the gestational sac and evaluate the thickness of the cesarean scar to detect its dysfunction. Furthermore, contrast enhancement of the MRI may be useful in the most complex cases but requires an informed consent discussion with the patient. However, the latter issue requires discussion and proof of its safety for the fetus. Full article

Background/Objectives: Among women with a history of cesarean section (CS), scar abnormalities are observed in 20–32% of cases. The presence of a scar in the lower abdomen may cause pain, dysmenorrhea, dyspareunia, and postural dysfunction. The aim of the study was to conduct a feasibility study and secondary exploratory analysis of the factors determining scar stiffness and elasticity in women after CS. Methods: The study involved 30 women aged 26 to 45 who had undergone at least one CS no earlier than six months before the start of the study. The following feasibility endpoints were analyzed: recruitment rate, completion rate, protocol deviations, and device usability. Myotonometry was performed to quantify the stiffness and decrement (a parameter that inversely reflects tissue elasticity) of the CS scar. The correlation between stiffness and decrement and age, BMI, time since the las CS, and the number of CSs was assessed. Results: All predefined feasibility criteria were met. Recruitment exceeded the target rate (3.3 participants/week), with a high completion rate (90%). One minor protocol deviation occurred without impact on safety or data integrity. The MyotonPro device showed good usability, with no reported discomfort and successful completion of all measurements. Secondary exploratory correlation analyses suggested a tendency toward a negative correlation between BMI and the stiffness and decrement (indicating increased elasticity) across most scar regions. No consistent correlations were observed between age and the examined scar parameters. Exploratory analyses further indicated a probable positive correlation between time elapsed since the last CS and stiffness and decrement (indicating reduced elasticity), which was observed only in the central region of the scar. The number of cesarean section procedures showed sporadic, region-specific correlations with scar parameters, limited to selected measurement points. Conclusions: These findings suggest that the study design is feasible and acceptable. Future research protocols should also include a comparison with healthy skin in the scar area. Preliminary exploratory analyses suggest a potential influence of BMI and time since last CS on scar stiffness and elasticity. However, due to the limitations of the pilot study, these observations should be considered preliminary and hypothesis-generating and may be used to design future confirmatory studies. Full article

Placenta Accreta Spectrum (PAS) disorders, including placenta accreta, increta, and percreta, are serious obstetric conditions characterized by abnormal placental adherence to the uterine wall. With increasing incidence, PAS poses significant risks, primarily through massive hemorrhage during or after delivery, often necessitating hysterectomy. Key risk factors include prior cesarean sections, uterine surgery, and placenta previa diagnosis. In this review, we will examine the pathophysiology of PAS, with a focus on the mechanisms underlying abnormal trophoblast invasion and defective decidualization. We will highlight the role of uterine scarring, extracellular matrix remodeling, dysregulated signaling pathways, and immune and vascular alterations in disrupting the maternal-fetal interface, ultimately predisposing to morbid placentation and delivery complications. We will also discuss the life-threatening complications of PAS, such as shock and multi-organ failure, which require urgent multidisciplinary intensive care, as well as the optimization of management through preoperative planning and intraoperative blood loss control to reduce maternal morbidity and mortality. Full article

Background: Cesarean section (CS) frequently results in abdominal scarring, affecting recovery, aesthetics, and quality of life. Platelet-rich plasma (PRP), an autologous concentrate rich in growth factors, may enhance wound healing. This pilot trial assessed the effect of intraoperative PRP on CS scar outcomes. Methods: In this single-center, single-blind randomized controlled trial (February 2023–December 2024), 100 women undergoing elective CS were randomized to PRP treatment (n = 50) or standard care (n = 50). PRP, prepared from 20 mL autologous blood, was infiltrated into uterine incision margins and subcutaneously before skin closure. Scar healing was evaluated at day 7 and day 40 postpartum using the Patient and Observer Scar Assessment Scale (POSAS; physician and patient), Vancouver Scar Scale, Manchester Scar Scale, REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation) Scale, Visual Analog Scale (VAS), and Numeric Rating Scale (NRS). Mann–Whitney U tests and Cohen’s d effect sizes were calculated. Results: Follow-up was complete for all participants. On day 7, PRP-treated patients had lower mean scores across most scales (e.g., Vancouver: 1.74 ± 1.58 vs. 2.54 ± 2.30; p = 0.063). At day 40, improvements persisted, with POSAS Patient scores significantly lower in the PRP group (7.24 ± 1.81 vs. 8.00 ± 2.06; p = 0.029). Effect sizes were small-to-moderate (<0.5), suggesting underpowering. No adverse events occurred. Conclusions: PRP administration during CS showed favorable trends toward improved scar quality and reduced patient-reported discomfort, with statistical significance for POSAS Patient scores at 40 days. Larger, multicenter trials with extended follow-up are needed to confirm these findings. Full article

Background: Cesarean delivery is a frequent surgical procedure associated with postoperative scarring, which may impact both the aesthetic and functional recovery of patients. Platelet-rich plasma (PRP), a concentration of autologous platelets containing bioactive growth factors, has shown promising effects in promoting wound healing and tissue regeneration. However, its efficacy in enhancing cesarean wound healing remains underexplored. Methods: This single-arm prospective observational study included 50 patients undergoing cesarean section who received intraoperative PRP in two stages: 5 mL applied before hysterorrhaphy and 5 mL injected subcutaneously before skin closure. Scars were assessed at 7 and 40 days using six validated scales (Manchester, Patient and Observer Scar Assessment Scale (POSAS), Vancouver, Visual Analog Scale (VAS), Numeric Rating Scale (NRS), and REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation). Hematological parameters (hemoglobin, hematocrit, leukocyte count, and platelet count) were monitored to correlate systemic inflammatory response and healing progression. Statistical analysis included the Wilcoxon signed-rank test and Pearson correlation. Results: Mean scar scores improved significantly from 8.88 ± 2.13 at day 7 to 6.46 ± 1.23 at day 40 (p < 0.001). Hematological parameters improved between day 7 and day 40, reflecting the expected course of postoperative recovery; these were considered secondary outcomes. Exploratory analyses revealed correlations between hemoglobin and POSAS (r = 0.42, p < 0.05), leukocyte count and REEDA (r = 0.68, p < 0.01), and platelet count and POSAS (r = −0.48, p < 0.05). Conclusions: Intraoperative PRP administration significantly enhanced postoperative scar healing after cesarean delivery and was associated with reduced inflammation and improved hematological recovery. These findings support the use of PRP as an adjunctive regenerative therapy in obstetric surgery. Randomized controlled trials are warranted to validate efficacy of the intervention, and moreover long-term outcomes. Full article

Objectives: Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers significant benefits in hysterectomy, including reduced postoperative pain, minimal scarring, and faster recovery. However, the cost and accessibility of surgical ports can be limiting factors. This study aimed to evaluate the feasibility, outcomes, and cost-effectiveness of using the Lagis LapBase Cap as an alternative port system in 107 vNOTES hysterectomy cases at a single institution. Methods: A retrospective analysis was conducted on 107 patients who underwent vNOTES hysterectomy between January 2017 and April 2022. Patients with benign gynecologic conditions and no suspected malignancy or deep infiltrating endometriosis were included. The Lagis LapBase Cap was used for access via an Alexis wound retractor. Surgical parameters—including operation time, estimated blood loss, and length of hospital stay—were analyzed by uterine weight, BMI, and obstetric history. Results: Of the 107 cases, 104 were completed using vNOTES, with only 3 conversions to laparoscopy. The average operation time was 88 min, and the mean estimated blood loss was higher in patients with larger uteri or BMI ≥ 24. Nulliparous women and those with a history of multiple cesarean sections also had longer operation times. There were no major complications, and most patients were discharged within three days postoperatively. Conclusions: The Lagis LapBase Cap is a practical and cost-efficient tool for vNOTES hysterectomy. It provides reliable sealing and instrument access, while maintaining favorable surgical outcomes. Patient selection based on uterine size, BMI, and delivery history may help optimize procedural efficiency. Full article

Objective: This study aimed to determine the prevalence of isthmocele in patients who had undergone cesarean delivery and to investigate its association with abnormal uterine bleeding (AUB). Additionally, a novel volume-based classification system (Er-Kay Classification) was developed to provide a more precise assessment of cesarean scar defects and their correlation with clinical symptoms. Material and Methods: This retrospective, hospital-based cohort study was conducted at Ankara Etlik Zübeyde Hanım Women’s Health Training and Research Hospital between October 2017 and March 2018. A total of 1098 patients who had undergone cesarean delivery and attended follow-up visits were included. Patients were categorized based on the presence of isthmocele (study group: n = 134) and its absence (control group: n = 964). Isthmocele volume was calculated using the formula (Height × Width × Depth)/3, and patients were classified as Grade 1 (≤50 mm³) or Grade 2 (>50 mm³) based on the novel Er-Kay Classification. Clinical symptoms, including AUB (pre-, inter-, postmenstrual bleeding), dysmenorrhea, dyspareunia, and postcoital bleeding, were compared between groups. Statistical analyses were performed using SPSS 27.0 (NY, USA),with a significance level of p < 0.05. Results: The prevalence of isthmocele was 12.2% (134/1098). Patients with isthmocele had significantly shorter menstrual cycles compared to those without (26.64 ± 5.35 vs. 28.08 ± 4.97 days, p = 0.038). Postmenstrual bleeding (47.0% vs. 4.7%, p < 0.001), dysmenorrhea (38.8% vs. 18.3%, p < 0.001), and dyspareunia (39.6% vs. 14.7%, p < 0.001) were significantly more frequent in the isthmocele group. According to the Er-Kay Classification, intermenstrual bleeding was significantly higher in Grade 2 (23.1%) than in Grade 1 (4.3%) (p = 0.001). Similarly, postmenstrual bleeding was more common in Grade 2 (56.9%) than in Grade 1 (37.7%) (p = 0.026). No significant differences were found for premenstrual bleeding, dysmenorrhea, or dyspareunia between the Er-Kay Classification groups (p > 0.05). Conclusions: The findings indicate that isthmocele is significantly associated with AUB, dysmenorrhea, and dyspareunia. The Er-Kay Classification, based on isthmocele volume, provides a more precise assessment of symptom severity, particularly in intermenstrual and postmenstrual bleeding cases. These results suggest that volume-based evaluations should be incorporated into clinical practice for better patient management and diagnosis of cesarean scar defects. Full article

Background/Objectives: Heterotopic cesarean scar pregnancy (HCSP) is an exceptionally rare and potentially life-threatening form of ectopic pregnancy, characterized by the coexistence of a viable intrauterine pregnancy and an ectopic implantation within a previous cesarean section scar. Its incidence has risen in recent years, primarily due to the increased rate of cesarean deliveries and the widespread use of assisted reproductive technologies (ART). This systematic review aims to provide a comprehensive synthesis of published evidence on HCSP, with a focus on epidemiology, diagnostic challenges, therapeutic strategies, complications, and maternal-fetal outcomes. Methods: A systematic literature search was conducted in PubMed, Scopus, and Web of Science up to May 2025, in accordance with PRISMA guidelines. Included studies comprised case reports, case series and retrospective reviews documenting confirmed HCSP cases. Data were extracted on clinical presentation, imaging, treatment approaches, outcomes, and complications. Results: Thirty studies reporting 40 confirmed HCSP cases were included. Transvaginal ultrasonography was the primary diagnostic tool, although diagnosis was often delayed by the presence of a viable intrauterine pregnancy. Management strategies included surgical intervention, local medical therapy and conservative approaches or expectant management. Maternal complications included hemorrhage and uterine rupture, while fetal outcomes were variable. In selected cases, intrauterine pregnancy continued to term. Conclusions: HCSP is a rare but high-risk obstetric entity requiring early recognition and multidisciplinary management. Prompt ultrasound-based diagnosis and individualized treatment can significantly reduce maternal morbidity and improve fetal outcomes. Further multicenter studies are warranted to establish standardized diagnostic and management protocols. Full article

Background and Objectives: A cesarean scar defect (CSD), also referred to as a niche or isthmocele, is often detected incidentally during transvaginal sonography (TVS) and is typically asymptomatic. However, the exact prevalence of symptomatic niches remains unclear. This study aimed to evaluate the incidence of cesarean scar niches and identify potential risk factors in a prospectively gathered cohort of Egyptian women. Materials and Methods: The primary endpoint was to determine the incidence of isthmoceles after six months following a cesarean section (CS) and to investigate any associated symptoms and risk factors. The study included 420 women, divided into three groups: Group A included 140 women who had undergone their first CS, Group B included 140 women with a history of two CSs, and Group C consisted of 140 women with more than two prior CSs. Results: Niches were identified in 23.8% of the participants via TVS. The highest incidence was observed in women with more than two previous CSs (31.2%, 39/125), followed by those with two prior CSs (24.4%, 30/123), and the lowest was among women with one previous CS (16.3%, 22/135). Of the 91 women diagnosed with a CS niche, only 23 (25.27%) reported symptoms—most commonly postmenstrual spotting (7.7%) and dyspareunia (8.8%). Conclusions: The findings indicate that multiple cesarean deliveries, the uterine positioning (as assessed via TVS), a postpartum fever, breastfeeding, low post-cesarean platelet counts, and maternal anemia are contributing factors to the development of cesarean scar niches. Full article

Background: Abdominal wall endometriosis (AWE) is a rare pathological condition that mostly occurs in the post-cesarean section. This study aimed to describe the surgical approach employed in treating 31 patients at our center over the past decade and compare the outcomes with those reported in scientific literature. Methods: We retrospectively evaluated the data of 31 patients with a cesarean section history who underwent surgery for AWE excision between 1 November 2012, and 31 January 2023, at the University of Naples Federico II, Italy. Subsequently, we reviewed the scientific literature for all AWE-related studies published between 1 January 1995, and 31 July 2024. Results: Most women presented with a palpable abdominal mass (90.3%) at the previous surgical site associated with cyclic abdominal pain (80.6%) concomitant with menstruation. All patients underwent preoperative abdominal ultrasound and magnetic resonance imaging, 71% underwent computed tomography, and 32.2% received ultrasound-guided needle biopsies. Furthermore, 90.3% and 9.7% had previous Pfannenstiel and median vertical surgical incisions, respectively. All patients underwent laparotomic excision and abdominal wall reconstruction, with prosthetic reinforcement used in 73.5% of cases. No recurrent nodules were detected in any patient at the 12-month follow-up. Conclusions: AWE should be suspected in women with a history of cesarean section presenting with palpable, cyclically painful abdominal mass associated with the menstrual cycle. Preoperative ultrasound and magnetic resonance imaging are essential, and surgical excision must ensure clear margins. Abdominal wall reconstruction should include prosthetic reinforcement, except when the defect is minimal (≤1.5 cm). An ultrasound follow-up at 12 months is recommended to confirm the absence of recurrence. Full article

Background and Objectives: The isthmocele is a pouch-shaped defect in the anterior uterine wall, site of a previous cesarean section, due to a scar defect or dehiscence. The prevalence could be underestimated, but the rate of cesarean section is still high in the world. The preferable technique to correct this anomaly is not clearly indicated in the literature. Our objective is to evaluate the literature on the surgical treatment of isthmocele in pre-Cesarean women treated with minimally invasive technique. Our hypothesis is that robotic treatment is more effective than other procedures in women desirous of having children. Materials and Methods: The words “isthmocele”, “laparoscopy”, “robot” and “cesarean scar pregnancy” were searched on the main online scientific search sources (PubMed, Google Scholar, Scopus, WES, and Embase, etc.). We included articles in English and French, chosen for the relevance to the topic. We have decided to include also surgical corrections of isthmocele linked to pregnancies at the site of the defect, with particular attention to video training explanation. Results: We analyzed the literature about the minimally invasive surgery for the repair of an isthmocele, evaluating 20 articles. Comparing several surgical techniques, robotic-assisted laparoscopy could be an effective method to correct the defect, without high risk of intraoperative complications. Conclusions: As indicated in the literature, robotic tailored excision and repair of isthmocele (and of concomitant cesarean scar pregnancy) could be advantageous and safe, and it is necessary to promote video-training about this technique. Full article

Background: Ectopic pregnancy (EP) is defined as the implantation of an embryo outside the uterine cavity, which can lead to high morbidity and mortality if not diagnosed and treated promptly. A rare form of EP is myomectomy scar pregnancy (MSP), where the embryo implants in a scar from a prior myomectomy. Due to its rarity, MSP presents unique diagnostic and therapeutic challenges. This scoping review aims to map the existing literature on MSP to better understand the diagnostic strategies, management options, and clinical outcomes associated with this condition, and to identify gaps in current research. Methods: We conducted a scoping review by searching databases such as PubMed, Scopus, Web of Science, and MEDLINE for studies published between 2003 and 2023. Keywords used in combination included “myomectomy scar pregnancy”, “scar pregnancy”, “leiomyoma”, “uterine myomectomy”, “PAS disorders”, “placenta previa”, and “placenta accreta”. Studies were screened for relevance and eligibility by two independent reviewers. Data were extracted from case reports, retrospective studies, and reviews discussing MSP. Results: From an initial set of 111 studies, 28 papers met the inclusion criteria, comprising 4 retrospective studies and 24 case reports. A total of 44 cases of MSP were analyzed. The majority of diagnoses were made through ultrasound, with magnetic resonance imaging (MRI) used in more complex cases. Surgical interventions, primarily cesarean sections and myometrial repairs, were the most common treatments, while medical therapy with methotrexate was less frequently applied. Conclusions: This scoping review highlights the challenges of diagnosing and managing MSP due to its rarity. Although surgical management remains the primary approach, there is a lack of consensus on the optimal treatment for different clinical scenarios. Further research is needed to establish standardized diagnostic and therapeutic protocols for MSP and to evaluate the long-term outcomes of affected patients. Full article

Background/Objectives: Vernix caseosa is a natural protective barrier with moisturizing, wound healing, and antioxidant properties. This study aimed to evaluate the effects of vernix caseosa on skin pigmentation and wound healing in cesarean section incisions. Methods: This randomized, double-blind, placebo-controlled trial was conducted at Ankara Etlik City Hospital, Gynecology and Obstetrics Clinic. A total of 210 first-time cesarean section patients were included. Vernix caseosa, collected from newborns, was applied to the incision site in half of the participants, while the other half received a placebo. Scar assessment was performed using the Manchester Scar Scale and the Patient and Observer Scar Assessment Scale (POSAS). Results: The vernix group showed significantly lower Manchester Scar Scale scores (9.00 ± 2.07 vs. 12.60 ± 2.72, p < 0.001) and POSAS total scores (53.57 ± 20.48 vs. 89.60 ± 26.54, p < 0.001) compared to the control group. These results suggest that vernix caseosa accelerates wound healing and improves cosmetic outcomes. Conclusions: Vernix caseosa emerges as a natural, effective, and low-cost method to promote wound healing in cesarean section incisions. Its medical and cosmetic benefits support its use in postoperative care. Future studies could further validate these findings in broader populations and explore additional clinical applications. Full article