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686: Evaluation of caesarian section scar tissue using special stains and immunohistochemical methods
Poster Session IV
Operative Obstetrics, Clinical Obstetrics, Intrapartum, Medical-Surgical www.AJOG.org
RESULTS: Successful TOLs were carried out in 81% (726/896). Failed TOLs occurred in 12.9 % (37/287) of late preterm twins and 21.8% (133/609) of term twins. Failure to progress and failed induction of labor were the main indications of CD (77%, 131/170). Comparisons of neonatal outcomes between the VD and CD groups showed no significant differences in 5-min Apgar score <7, cord pH <7.2, NICU admission, ventilator use, composite morbidity, and neonatal death. According to univariable analysis, nulliparity, preterm birth, preeclampsia, induction of labor, excessive weight gain during pregnancy, BMI at delivery >25, and intertwin birth weight discordance >30% showed significant associations with failed TOLs. However, failed TOLs were not related to a pre-pregnancy BMI of >25, IVF pregnancy, or nonvertex second twins. Multiple logistic regression analysis revealed nulliparity and maternal preeclampsia to be significantly associated with failed TOLs. CONCLUSION: In late preterm and term twins, a trial of labor can be performed successfully without a significant increase in adverse neonatal outcomes. Nulliparity and maternal preeclampsia are clinical factors associated with failed TOL in twin pregnancy.
Factors associated with a failed trial of labor in twin pregnancy
686 Evaluation of caesarian section scar tissue using special stains and immunohistochemical methods Ciara Murphy2, Nikhil Purandare1, Peter Kelehan2 1
Rotunda Hospital, Dept. of Obstetrics and Gynaecology, Dublin, Ireland, National Maternity Hospital, Dept. of Pathology, Dublin, Ireland
2
OBJECTIVE: Prior Caesarian section (C/S) results in chronic
dysfunctional changes in the lower uterine segment. Emergency C/S in particular may be associated with circumstances that cause the incision repair to be sub-optimal. On examining hysterectomy specimens, pathologists see considerable variation in the morphology of the lower uterine segment repair, sometimes with persistent inflammatory foci many years after the last C/S. STUDY DESIGN: We selected 22 uteri with previous lower segment C/S and 8 unscarred uteri as controls. Hysterectomy was for benign symptomatic disease. Sections were stained using several techniques to characterize tissue components in the lower segment and scar. Based on our subjective interpretation of muscle fiber integrity, good or poor inter-digitation of myometrial muscle fibers, deposition of collagen scar, scar contraction and measurable loss of tissue, we identified strong, weak and intermediate scar. RESULTS: Mean thickness of the lower segment anterior wall of control uteri was: 1.5cm. (range 1.4—1.5cm.). Mean thickness for previous C/S uteri was 0.47cm. Strong scar tissue had a large quantity of muscle; fibers were oriented longitudinally with little separate collagen or elastin deposition and little evidence of excess scar contraction. 5 of 22 scars studied were classed as strong scars. 10 of 22 were weak scars with gaps in the muscle layers, smaller amounts of muscle and larger masses of dense collagen, often oriented transversely. In some, endometrium or serosa was invaginated deep into the scar site. Persistent inflammation and residual stitch material was present in others. CONCLUSION: The recent increase in placenta praevia/accreta may be associated with changing practice in Obstetrics. As the rates of C/S are increasing, the seniority of the operator is often decreasing. Stitch tension and edema can cause myonecrosis and incisional necrosis. Any cause of chronic inflammation will weaken a scar and predispose to stretching, diverticulum and rupture.
BMI: body mass index, OR: odds ratio, CI: confidence interval, *Adjusted for gestational age and birth weight.
S336 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
Operative Obstetrics, Clinical Obstetrics, Intrapartum, Medical-Surgical www.AJOG.org
RESULTS: Successful TOLs were carried out in 81% (726/896). Failed TOLs occurred in 12.9 % (37/287) of late preterm twins and 21.8% (133/609) of term twins. Failure to progress and failed induction of labor were the main indications of CD (77%, 131/170). Comparisons of neonatal outcomes between the VD and CD groups showed no significant differences in 5-min Apgar score <7, cord pH <7.2, NICU admission, ventilator use, composite morbidity, and neonatal death. According to univariable analysis, nulliparity, preterm birth, preeclampsia, induction of labor, excessive weight gain during pregnancy, BMI at delivery >25, and intertwin birth weight discordance >30% showed significant associations with failed TOLs. However, failed TOLs were not related to a pre-pregnancy BMI of >25, IVF pregnancy, or nonvertex second twins. Multiple logistic regression analysis revealed nulliparity and maternal preeclampsia to be significantly associated with failed TOLs. CONCLUSION: In late preterm and term twins, a trial of labor can be performed successfully without a significant increase in adverse neonatal outcomes. Nulliparity and maternal preeclampsia are clinical factors associated with failed TOL in twin pregnancy.
Factors associated with a failed trial of labor in twin pregnancy
686 Evaluation of caesarian section scar tissue using special stains and immunohistochemical methods Ciara Murphy2, Nikhil Purandare1, Peter Kelehan2 1
Rotunda Hospital, Dept. of Obstetrics and Gynaecology, Dublin, Ireland, National Maternity Hospital, Dept. of Pathology, Dublin, Ireland
2
OBJECTIVE: Prior Caesarian section (C/S) results in chronic
dysfunctional changes in the lower uterine segment. Emergency C/S in particular may be associated with circumstances that cause the incision repair to be sub-optimal. On examining hysterectomy specimens, pathologists see considerable variation in the morphology of the lower uterine segment repair, sometimes with persistent inflammatory foci many years after the last C/S. STUDY DESIGN: We selected 22 uteri with previous lower segment C/S and 8 unscarred uteri as controls. Hysterectomy was for benign symptomatic disease. Sections were stained using several techniques to characterize tissue components in the lower segment and scar. Based on our subjective interpretation of muscle fiber integrity, good or poor inter-digitation of myometrial muscle fibers, deposition of collagen scar, scar contraction and measurable loss of tissue, we identified strong, weak and intermediate scar. RESULTS: Mean thickness of the lower segment anterior wall of control uteri was: 1.5cm. (range 1.4—1.5cm.). Mean thickness for previous C/S uteri was 0.47cm. Strong scar tissue had a large quantity of muscle; fibers were oriented longitudinally with little separate collagen or elastin deposition and little evidence of excess scar contraction. 5 of 22 scars studied were classed as strong scars. 10 of 22 were weak scars with gaps in the muscle layers, smaller amounts of muscle and larger masses of dense collagen, often oriented transversely. In some, endometrium or serosa was invaginated deep into the scar site. Persistent inflammation and residual stitch material was present in others. CONCLUSION: The recent increase in placenta praevia/accreta may be associated with changing practice in Obstetrics. As the rates of C/S are increasing, the seniority of the operator is often decreasing. Stitch tension and edema can cause myonecrosis and incisional necrosis. Any cause of chronic inflammation will weaken a scar and predispose to stretching, diverticulum and rupture.
BMI: body mass index, OR: odds ratio, CI: confidence interval, *Adjusted for gestational age and birth weight.
S336 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014