the postpartum uterus - lieberman's...

Riley Bove, MS IIIGillian Lieberman, MD

The Post-Cesarean Uterus

Riley Bove, HMS IIIGillian Lieberman, MD

January 2006


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Our patient…• LD is a 33 yo woman, G4P2, with a prior history of

two Cesarean deliveries (C/S).

• She asks, “What effect could my C/S have on any future pregnancies?”

• Let’s review Cesarean deliveries and explore the imaging of their more dangerous sequelae.

• And hope for a good outcome for LD.


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Normal pregnancy and the risks of C/SNormal

Implantation

Placentation

Uterine integrity

Sequelae of C/S

Ectopic implantation

Placenta previa and accreta

Dehiscence and rupture

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Cesarean deliveries: increasingly common

• The 1990s: efforts to curb increasing rates of cesarean deliveries.

• But since 1996: 40% increase in C/S rates– Now 30% nationwide– Approaching 40% at the BIDMC

• Britney Spears and her 21st Century poster child

www.shmater.com


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Overview of cesarian incisions

www.emedicinehealth.com/ articles/12168-8.asp

Most risky as LUSexpands in late pregnancy


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Sonographic assessment of LD’s uterus post C/S

www.nlm.nih.gov

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TV PROBE

TA PROBE


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LD: C/S scar on sonohysterogram

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TV view

Cervix

Intact Posterior myometrium

Scar defect

Thinned anteriormyometrium

TV SCSH SAGPACS - BIDMC

BIDMC


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C/S scar defect

TV US SAGPACS - BIDMC

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DelAnechoic filling defect w/ enhanced through transmission

BIDMC


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C/S scar defects are common• Fluid collections in cesarean scars

• Present in 42-58% of women with prior C/S1,2

• Ultrasound is an accurate diagnostic tool1– Real time TV US: 100% se 100% sp– Stored image review of TV US: 87% se 100% sp

• Clinical significance: reservoirs of menstrual blood – Associated with spotting and bleeding

1. Armstrong et al Obstet Gynecol 2003 101:61-52. Regnard et al.. Ultrasound Obstet Gynecol 2004. 23:289-92.


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LD is pregnant

• Six months later, a urine hCG level confirms that LD is pregnant.

• Let’s verify proper implantation with an Early Obstetric US ...

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TV US TRVPACS - BIDMC

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Fetal pole

Decidual reaction

Outer uterine wall

LD: Normal implantation near uterine fundus

Hypoechoic Gestational Sac

Confirmation: Size = Dates

BIDMC


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CL: A pregnant patient with C/S scar

• CL is a 34 year old woman

• prior history of C/S

• +ve hCG

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CL: Ectopic pregnancy in C/S scar

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M-Mode confirms fetal HR

Decidual reaction

Fetal pole

Thinned 0.3 mmanterior myometrium inlower uterine segment

SONOGRAPHIC CRITERIA:

1. Trophoblast btwn bladder & ant uterine wall2. No fetal parts within uterine cavity3. Discontinuity in uterine ant wall on SAG view

running through the amniotic sac

TV USPACS - BIDMC

BIDMC


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Ectopic pregnancy in C/S scar• Rare

• Diagnosis: TV Ultrasound +/- MRI 1

• Life threatening– Risk of rupture– Risk of excessive hemorrhage

• Differential Diagnosis:– Cervical pregnancy, – Cervico-isthmic pregnancy– Spontaneous abortion in progress

1. Dialiani and Levine. Ultrasound Quarterly 2004 20(3):105-117.


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Management of C/S scar pregnancy• Surgical:

– Excise sac and repair scar• Laparoscopic 1

– allows simulatenous repair of uterine defect by suturing.

• Mini-laparotomy

• Medical:– KCl + MTX +/- curettage 2

• Systemic MTX preferred over local since less risk rupture and hemorrhage

1. Wang et al J Minim Invasive Gynecol 2005 ;12(1):73-9.2. Graesslin et al. Obstet Gynecol 2005 105:869-71.


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US-guided reduction of ectopic pregnancy

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Confirmation of Reduction 4 d later

Hyperechoic needle -- Injection of KCl- Aspiration of fluid- Injection of MTX

Gestational Sac


BIDMC


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LD in second trimester

• LD returns for a Full Fetal Survey early in the second trimester.

• Let’s evaluate her placenta.– Imaging ideal in 2nd Trimester since

placenta formed but fetus remains small

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Normal placenta at 18 wk US

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No hyperechoic placenta discernible overlyinginternal cervical os -

Cervical length

TA US SAGPACS - BIDMC


BIDMC


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MK : Vaginal spotting at 18 wks

•MK, a 28 year old G5P2123

•Prior history •C/S x2, w/ complete previa x 2•Ectopic pregnancy x1, s/p D&C

•MK presents at 18 wks gestation complaining of vaginal spotting

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MK: Complete placenta previa


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Placental tip covers internal cervical os

Cervix closed? Fluid in cervix

Abnl placenta?(More to follow)

BIDMC


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Placenta previa

www.obfocus.com/ images/previa.gif

•Incidence: Complicates 4/1,000 pregnancies after T2

•Risk Factors: •Age & parity, C/S, Abortions

•Complications: •Bleeding in T3•dDx T3 bleeding:

•Abruption (31%)•Previa (22%)•Other (47%)

Types of Previa:


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Companion image: placenta previa with Doppler


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Placental blood flowadjacent to internal os

BIDMC


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Companion image: Placenta previa on MRI

T1-weighted MRI SAGBIDMC - Atlas of Fetal MRIwww.bidmc.harvard.edu

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Complete placenta previa

Placental blood clot

Cervix

BIDMC


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MK cont’d: Vaginal bleeding at 28 wks

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•Presents to Ob Triage c/o vaginal bleeding

•Clot expressed by obstetrician on call

•MK maintained on bed rest

•At 30 wks: sudden gush of vaginal bleeding


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MK: Placenta accreta

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Placental flow abutting bladderNo discernible hypoechoic myometrium

TA Doppler US SAG

BIDMC


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Placenta accreta• Abnormal attachment of placenta to uterine wall

• Incidence: formerly 1/3000 deliveries, now 1/500 deliveries

• Risk factors1: prior C/S, placenta previa, AMA

• Complications: – Hemorrhage at time of attempted placental separation – With bladder invasion: hematuria and uterine rupture

1. Wu et al. Am J Obstet Gynecol 2005 192:1458-61.


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Grades of placenta accreta

TA US TRV

Chorionic Villus invasion ...

Into serosa: Placenta percreta (5%)

Into myometrium: Placenta increta (15%)

In contact w/ myometrium: Placenta accreta (80%)

Fetal skull with distal shadowing

Abdominal wall

Placenta:Abnormal outer contour? lacunae

BIDMC


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Companion image: Placenta accreta on MRI

MRI T2 TRVBIDMC - Atlas of Fetal MRIwww.bidmc.harvard.edu

Ill-defined placental-myometrialjunction

•MRI: soft tissue detail to enhance US findings•US: 63% se 43% sp 76% PPV1

1. Maria et al. Acta Obstet Gynecol Scand 2003 82:294


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MK: Complications of placenta accreta

•Emergency C/S at 30 wks•Supracervical hysterectomy•Blood loss anemia•Hypovolemic shock•Dilutional coagulopathy

•Hospital-associated complications•Ventilator-associated pneumonia•Clostridium difficile colitis

•But... a healthy baby was born.

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LD is now 32 wks pregnant

• Imaging reveals normal placentation

• However...

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LD: Uterine thinning at 32 wks

TV US TRV

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Full bladder

Myometrial wall thinningThickness: 2.6 mm

Fetal skull

BIDMC


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LD: MRI confirms uterine thinning

MRI T2 SAG

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Marked myometrial wall thinning in LUSThin black line = myometrium

BIDMC


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A thinned LUS risks rupture• Prior C/S primary risk factor for thinned LUS1

• Adverse outcomes in 4% C/S scars 2– 10 dehiscences (loss of 80% myometrial depth)– 15 ruptures (risk incr from 0.4% to 3% w/ C/S)

• Threshold myometrial thickness of LUS @ 36-38 wks – 4 mm threshold at BIDMC– < 3.5 mm - risk of rupture or dehiscence

• Sens 88%, specificity 73.2%, PPV 11.8*, NPV 99.3%2

– < 2 mm:• 74% women had uterine dehiscence3

– < 1.5 mm - risk of paper thin or dehisced LUS• Se 88.9%, sp 59.5%, PPV 32% and NPV 96.2%4

1. Sambaziotis et al. J Ultrasound Med 23:907-9112. Rozenberg et al. Lancet 1996 347:281-4.

3. Gotoh et al. Obstet Gynecol 2000 95:596-6004. Cheung. J Obstet Gynaecol Can. 2005 27(7):674-81.


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Companion image: Uterine rupture on CT

CT TRV

Extrusion of contents w/ fluid throughout abdominal cavity

Myometrium interrupted

BIDMC


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Companion US: Uterine scar s/p rupture

TV US SAG

Hyperechoic line from endometrium to serosa

BIDMC


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How should LD be managed?

• Repair:– Combined laparoscopic and vaginal repair of uterine scar

dehiscence s/p C/S in 5 patients1

– Abdominal repair of uterine dehiscence at 28 wks and delivery at 34 wks after FLM2

• Imaging in expectant management:– At the BIDMC: Uterine dehiscence documented on US and MRI

in a patient at 20 wks. Managed on modified bed rest. At 31 wks C/S performed due to fetal HR decels. 3

1. Klemm et al.. J Perinatal Med 2005 33(4):324-312. Matsunaga et al. Obstet Gynecol 2004 104:1211-2.3. Hamar et al. Obstet Gynecol 2003 102:1139-42

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LD delivers• At 32 weeks, LD is placed on bed rest• At 36 wks, she c/o pain over LUS• Cesarean delivery, without trial of labor • A healthy girl is born• Uncomplicated post-op

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Summary: The risks of C/SNormal

Implantation

Placentation

Uterine integrity

Sequelae of C/S

Ectopic implantation

Placenta previa and accreta

Dehiscence and rupture

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Not covered: Abscess, infectious necrosis


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References• Armstrong CA, Harding S, Matthews T and Dickinson JE. Is placenta accreta catchingup

with us? Aust N Z J Obstet Gynaecol 2004 44(3):210-3.• Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH. Detection of cesarean scars by

transvaginal ultrasound. Obstet Gynecol 2003 101:61-5• Ben Nagi J, Ofili-Yebovi D, Marsh M, Jurkovic D. First-trimester cesarean scar pregnancy

evolving into placenta previa/accreta at term. J Ultrasound Med 2005 24(11):1569-73.• Cheung VY. Sonographic measurement of the lower uterine segment thickness in owmen

with previous caesarean section. J Obstet Gynaecol Can. 2005 27(7):674-81.• Dialiani V, Levine D. Ectopic pregnancy: A review. Ultrasound Quarterly 2004 20(3):105-

117.• Gotoh H, Masuzaki H, Yoshida A, Yoshimura s, Miyamura T and Ishimaru T. Predicting

incomplete uterine rupture with vaginal sonography during the late second trimester in women with prior cesarean. Obstet Gynecol 2000 95:596-600

• Graesslin O, Dedecker F, Quereux C, Gabriel R. Conservative treatment of ectopic pregnancy in a Cesarean scar. Ovstet Gynecol 2005 105:869-71.

• Guise JM, McDonagh MS, Osterweil P, Nyfren P, Chan BKS, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous cesarean section. BMJ 2004 329:1-7.

• Hamar B, Levine D, Katz NL, Lim KH. Expectant management of uterine dehiscence in the second trimester of pregnancy. Obstet Gynecol 2003 102:1139-42.

• Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound. J Perinatal Med 2005 33(4):324-31.


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References (Cont’d)• Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of rupture during labor among

women with a prior cesarean delivery. N Engl J Med 2001 345(1):345-8.• Liang HS, Jeng CJ, Sheen TC, Lee FK, Yang YC, Tzeng CR. First-trimester uterine

rupture from a placenta percreta. A case report. J Reprod Med 2003 48(6):474-8.• Maria NE, Mishra N, Mubarek M, Reginald PW. Silent dehiscence of cesarean section

scar with placenta accreta: a case report. Acta Obstet Gynecol Scand 2003: 82:294.• Matsunaga JS, Daly CB, Bochner CJ, Agnew CL. Repair of uterine dehiscence with

continuation of pregnancy. Obstet Gynecol 2004 104:1211-2.• Quinones JN, Stamilio DM, Pare E, Peipert JE, Stevens E, Macones GA. The effect of

prematurity on vaginal birth after cesarean delivery: Success and maternal morbidity. Obstet Gynecol 2005 105(3):519-524.

• Regnard C, Nosbusch M, Fellemans C et al. Cesarean section scar evaluation by saline contrast sonohysterography. Ultrasound Obstet Gynecol 2004. 23:289-92.

• Rozenberg P, Goffinet P, Pjilippe HJ, Nisand I. Ultrasonographic measurement of lower uterine segment to assess risk of defects of scarred uterus. Lancet 1996 347:281-4.

• Sambaziotis, H, Conway C, Figueroa R, Elimian A and Garry D. Second-trimester sonographic comparison of the lower uterine segment in pregnant women with and without a previous Cesarean delivery. J Ultrasound Med 23:907-911.

• Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obestet Gynecol 2000 16:592-3.

• Wang YL; Su TH; Chen HS . Laparoscopic management of an ectopic pregnancy in a lower segment cesarean section scar: a review and case report. J Minim Invasive Gynecol 2005 Jan-Feb;12(1):73-9.

• Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: Twenty-year analysis. Am J Obstet Gynecol 2005 192:1458-61


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Many thanks to:

• Deborah Levine, M.D.• Gillian Lieberman, M.D.• Erik Stien, M.D.• Larry Barbaras• Pamela Lepkowski

the postpartum uterus - lieberman's...

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