UNASSIGNED: This study examined the efficacy of pulling down the cervix and packing it in the vaginal fornix (PC-PVF) on postpartum hemorrhage in the lower uterine segment (PPH-LUS).
UNASSIGNED: All cases of PPH-LUS after vaginal delivery at two tertiary hospitals between January 2019 and December 2022 were retrospectively investigated. Patients treated successfully with conservative measures were divided into routine treatment only (40 patients), routine treatment + early PC-PVF (33 patients), and routine treatment + late PC-PVF (51 patients) groups. Routine treatment consisted of uterine massage, uterotonics, and tranexamic acid administration. The therapeutic effect was evaluated by comparing the volume and rate of bleeding within 24 h after delivery.
UNASSIGNED: A total of 124 patients were treated conservatively, except for three patients who underwent laparotomy for hemostasis after PC-PVF failed for incomplete rupture of the lower uterine segment. The efficacy of treatment was 44% (40/91) for routine treatment only and 100% when combined with PC-PVF for PPH-LUS. There was no significant difference in maternal age, gestational week, neonatal weight, and Apgar score. But the total blood loss in the conventional treatment + early PC-PVF group (657.27 ml ± 131.61 ml) was significantly lower than that in the other two groups, which was 847.13 ml ± 250.37 ml(p < .01) and 1040.78 ml ± 242.70 ml (p < .01), respectively. The bleeding rate in the routine treatment + early PC-PVF group decreased significantly after tamponade.
UNASSIGNED: PC-PVF is a safe and effective treatment for PPH-LUS. Early identification of PPH-LUS and prompt application of PC-PVF can effectively reduce blood loss after vaginal delivery.
Postpartum hemorrhage is a serious threat to maternal safety and remains to be the leading cause of maternal death. At present, there is a lack of early identification and targeted conservative treatment of PPH-LUS after vaginal delivery. Innovations for the treatment of PPH-LUS are still greatly needed because, with currently available management strategies, there is still inconsistency in outcomes, increased risk of complications, and limited access in primary hospitals. Based on clinical data statistics and comparison, it is proved that PC-PVF is a simple, rapid, and noninvasive method for the treatment of PPH-LUS after vaginal delivery in this study. Because of its simple technical requirements, easily accessible materials, and low cost, PC-PVF is suitable for hospitals at all levels.

OBJECTIVE: To evaluate hemostatic efficacy, complications, and subsequent pregnancy outcomes in women with placenta previa who underwent combined vertical compression sutures in the lower uterine segment and intrauterine balloon tamponade (Hot-Dog method) to achieve hemostasis after cesarean section.
METHODS: We retrospectively reviewed data for 117 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between 29 and 38 weeks\' gestation. Treatments were as follows: (1) conventional-intravenous oxytocin administration after placental detachment and suturing of bleeding points at the detachment site as needed (conventional group) (n = 47). (2) Intrauterine balloon tamponade alone (balloon group) (n = 41). (3) Vertical compression sutures + intrauterine balloon tamponade (Hot-Dog group) (n = 29).
RESULTS: The placenta accreta spectrum prevalence was significantly higher in the balloon and Hot-Dog groups versus the conventional group. The prevalence of anteriorly located placenta was significantly higher in the Hot-Dog versus balloon groups. Intraoperative and total blood loss were significantly higher in the Hot-Dog versus conventional groups. Postoperative blood loss was significantly lower in the Hot-Dog versus balloon groups. Fewer additional procedures for managing postoperative hemorrhage were required in the Hot-Dog versus conventional and balloon groups. The number of subsequent pregnancies in the conventional, balloon, and Hot-Dog groups was 11 (23.4%), 8 (19.5%), and 4 (13.8%), respectively; all resulted in live births at term without serious obstetric complications.
CONCLUSIONS: The Hot-Dog method is a straightforward and safe hemostasis technique for placenta previa that preserves fertility and controls severe bleeding.

OBJECTIVE: To assess the accuracy of ultrasound measurement of the lower uterine segment (LUS) thickness against findings at laparotomy, and to investigate its correlation with the success rate of vaginal birth after one previous caesarean delivery (CD) in a resource-limited setting.
METHODS: Prospective study.
METHODS: Obstetrics and Gynaecology department in a tertiary hospital in Ghana.
METHODS: Women with one previous CD undergoing either a trial of labour (TOLAC) or elective CD.
METHODS: Myometrial lower uterine segment thickness (mLUS) and full lower uterine segment thickness (fLUS) were measured with transvaginal ultrasound (TVUS). The women were managed according to local protocols with the clinicians blinded to the ultrasound measurements. The LUS was measured intraoperatively for comparison with ultrasound measurements.
METHODS: Lower uterine segment findings at laparotomy, successful vaginal birth.
RESULTS: A total of 311 pregnant women with one previous CD were enrolled; 147 women underwent elective CD and 164 women underwent a TOLAC. Of the women that underwent TOLAC, 96 (58.5%) women had a successful vaginal birth. The mLUS was comparable to the intraoperative measurement in the elective CD group with LUS thickness <5 mm (bias of 0.01, 95% CI -0.10 to 0.12 mm) whereas fLUS overestimated LUS <5 mm (bias of 0.93, 95% CI 0.80-1.06 mm). Successful vaginal birth rate correlated with increasing mLUS values (odds ratio 1.30, 95% CI 1.03-1.64). Twelve cases of uterine defect were recorded. LUS measurement ≤2.0 mm was associated with an increased risk of uterine defects with a sensitivity of 91.7% (95% CI 61.5-99.8%) and specificity of 81.8% (95% CI 75.8-86.8%).
CONCLUSIONS: Accurate TVUS measurement of the LUS is technically feasible in a resource-limited setting. This approach could help in making safer decisions on mode of birth in limited-resource settings.

Given the high risk of complications associated with cesarean hysterectomy for placenta accreta spectrum (PAS), any surgical approach and technique can yield utility in reducing the surgical morbidity. Here, we propose the 3-2-1 approach as a schema to be implemented in the proper setting for the surgical management of a PAS cesarean hysterectomy. The 3-2-1 approach begins with the surgical dissection of three anatomical landmarks that ultimately facilitate a safe surgical site for the ligation and transection of the uterine vessels. First-step is identification of the three anatomical landmarks which are (i) posterior lower uterine segment peritoneum de-serosalization, (ii) identification of the ureters laterally, and (iii) anterior bladder dissection. Posterior-to-anterior progression avoids encountering dense adhesions and hypervascularity in the anterior lower uterine segment early in the surgery. Further, allows better mobilization of the uterus to identify the anatomical landmarks laterally and anteriorly. Second-step is to deploy the 2-hand technique where the surgeon places one hand anteriorly and the other hand posteriorly in the lower uterine segment below the placental bed. The surgeon brings both hands together with flexed fingers perpendicular to the uterine tissue and gently elevates the uterus and placenta out of the pelvis and ensures safe anatomical distance to surrounding structures. Third-step is the consideration of a supracervical hysterectomy. In summary, this 3-2-1 approach to reflect the anatomy of enlarged lower uterine segment in PAS is a stepwise schema that can aid surgeons in the completion of a cesarean hysterectomy, with the goal to improve surgical outcomes.

BACKGROUND: Limited data suggests lower uterine segment involvement (LUSI) in endometrial cancer may be associated with other poor prognostic factors. We assessed the unclear impact of LUSI on prognosis in endometrial cancer.
METHODS: ology: A revision of pathological samples following surgical staging between the years 2002-2022 was performed and clinical data collected from patients\' records. Characteristics and outcomes of women with and without LUSI were compared and analysed. Kaplan Meyer survival curves compared overall survival (OS) and progression-free survival (PFS).
RESULTS: 429 women were included, of which 45 (10.5%) had LUSI. No differences were found between the groups regarding demographic or clinical characteristics. LUSI was significantly associated with lympho-vascular space invasion (40% vs. 22% p = 0.01), lymph node involvement (6.4% vs. 9.1%, p = 0.05), shorter PFS (4 vs. 5.5 years, p = 0.01) and OS (5.6 vs. 11.5 years, p = 0.03). Multivariate analysis showed higher hazard ratios for OS and PFS (1.55 95%CI 0.79-3.04 and 1.29 95%CI 0.66-2.53, respectively) but these were insignificant even in a sub-analysis of endometrioid histology (1.76 95%CI 0.89-3.46 and 1.35 95%CI 0.69-2.65, respectively). A trend towards decreased PFS and OS was demonstrated in the Kaplan Meyer survival curves for all cases (log rank test p = 0.5 and 0.29 respectively), endometrioid histology (log rank test p = 0.06 and 0.51 respectively) and early-stage disease (log rank test p = 0.63 and 0.3 respectively).
CONCLUSIONS: LUSI may be related to poorer outcome of endometrial cancer and may represent an additional factor to consider when contemplating adjuvant treatment, especially in endometrioid-type and early-stage disease.

UNASSIGNED: The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing (SRSS) of a lower uterine segment.
UNASSIGNED: In this retrospective study conducted at Department of Obstetrics & Gynecology Unit-II of Nishtar Medical University, Multan between December 2018 to January 2021, one hundred and thirty consenting patients\' clinical records were reviewed with major degree placenta previa/placenta accrete spectrum, either operated electively or presented in an emergency, with or without a history of previous cesarean section. The enrolled patients underwent SRSS, procedure\'s efficacy and safety were measured by the number of obstetrical hysterectomies, the time required for the procedure, estimated blood loss, blood transfusion volume, need for any other hemostatic technique, bladder trauma, pelvic infection, scar site hematoma or abscess, sepsis, duration of hospital stay and maternal mortality.
UNASSIGNED: Out of 130 patients, 17(12.6%) had Placenta Accreta, 86(66.3%) Increta, and 27(21%) Percreta. The Placenta location was anterior dominant in 102(78.4%) cases and posterior in 17(8.4%). Of the patients who underwent surgery, only two required obstetrical hysterectomy due to uncontrolled bleeding. The procedure took three to five minutes in 127 patients and five to seven minutes in three patients. Regarding intraoperative blood transfusion, 54.6% of patients were transfused 1000-2000 ml blood, and 5.38% required > 3000 ml. No blood transfusion was required postoperatively in any patient. Postpartum hemorrhage, infection, fever, and sepsis were not observed in any patient postoperatively. None of the patients suffered bladder injury. All patients were discharged as per routine.
UNASSIGNED: SRSS is an innovative, safe, effective, and simple suturing technique for patients with Placenta Previa and Accreta spectrum.

An accurate transvaginal ultrasound cervical length is paramount to obtain the best prediction for preterm birth. Transvaginal ultrasound cervical length should be optimally obtained when a lower uterine segment contraction is not seen. For universal transvaginal ultrasound cervical length screening at approximately 20 weeks of gestation, the options are to do the transvaginal ultrasound soon after bladder void (lower uterine segment contractions present in 16%-43% of this approach) or to wait until the end of the anatomy scan (ideally within 30 minutes after bladder voiding) to decrease the chance of a lower uterine segment contraction. If the lower uterine segment contraction persists even after waiting up to 20 minutes or more, only the true transvaginal ultrasound cervical length should be reported. In particular, in patients with a previous spontaneous preterm birth, if the lower uterine segment contraction persists, the transvaginal ultrasound cervical length can be repeated in ≤7 days even in the presence of a normal (>25 mm) cervical length. Similar to a blood pressure cuff that must be of the right size for proper blood pressure measurement and a glucometer that must be properly calibrated, screening with transvaginal ultrasound cervical length should only be performed following a proper and standardized technique, including avoiding as much as feasible the presence of lower uterine segment contractions.

The uterus is a highly innervated organ, and during labor, this innervation is at its highest level. Oxytocinergic fibers play an important role in labor and delivery and, in particular, the Lower Uterine Segment, cervix, and fundus are all controlled by motor neurofibers. Oxytocin is a neurohormone that acts on receptors located on the membrane of the smooth cells of the myometrium. During the stages of labor and delivery, its binding causes myofibers to contract, which enables the fundus of the uterus to act as a mediator. The aim of this study was to investigate the presence of oxytocinergic fibers in prolonged and non-prolonged dystocic delivery in a cohort of 90 patients, evaluated during the first and second stages of labor. Myometrial tissue samples were collected and evaluated by electron microscopy, in order to quantify differences in neurofibers concentrations between the investigated and control cohorts of patients. The authors of this experiment showed that the concentration of oxytocinergic fibers differs between non-prolonged and prolonged dystocic delivery. In particular, in prolonged dystocic delivery, compared to non-prolonged dystocic delivery, there is a lower amount of oxytocin fiber. The increase in oxytocin appeared to be ineffective in patients who experienced prolonged dystocic delivery, since the dystocic labor ended as a result of the altered presence of oxytocinergic fibers detected in this group of patients.

Transvaginal ultrasound imaging has become an essential tool in the prenatal evaluation of the lower uterine segment and anatomy of the cervix, but there are only limited data on the role of transvaginal ultrasound in the management of patients at high risk of placenta accreta spectrum at birth.
This study aimed to evaluate the role of transvaginal sonography in the third trimester of pregnancy in predicting outcomes in patients with a high probability of placenta accreta spectrum at birth.
This was a retrospective analysis of prospectively collected data of patients presenting with a singleton pregnancy and a history of at least 1 previous cesarean delivery and patients diagnosed prenatally with an anterior low-lying placenta or placenta previa delivered electively after 32 weeks of gestation. All patients had a least 1 detailed ultrasound examination, including transabdominal and transvaginal scans, within 2 weeks before delivery. Of note, 2 experienced operators, blinded to the clinical data, were asked to make a judgment on the likelihood of placenta accreta spectrum as a binary, low or high-probability of placenta accreta spectrum, and to predict the main surgical outcome (conservative vs peripartum hysterectomy). The diagnosis of accreta placentation was confirmed when one or more placental cotyledons could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens.
A total of 111 patients were included in the study. Abnormal placental tissue attachment was found in 76 patients (68.5%) at birth, and histologic examination confirmed superficial villous attachment (creta) and deep villous attachment (increta) in 11 and 65 cases, respectively. Of note, 72 patients (64.9%) had a peripartum hysterectomy, including 13 cases with no evidence of placenta accreta spectrum at birth because of failure to reconstruct the lower uterine segment and/or excessive bleeding. There was a significant difference in the distribution of placental location (X2=12.66; P=.002) between transabdominal and transvaginal ultrasound examinations, but both ultrasound techniques had similar likelihood scores in identifying accreta placentation that was confirmed at birth. On transabdominal scan, only a high lacuna score was significantly associated (P=.02) with an increased chance of hysterectomy, whereas on transvaginal scan, significant associations were found between the need for hysterectomy and the thickness of the distal part of the lower uterine segment (P=.003), changes in the cervix structure (P=.01), cervix increased vascularity (P=.001), and the presence of placental lacunae (P=.005). The odds ratio for peripartum hysterectomy were 5.01 (95% confidence interval, 1.25-20.1) for a very thin (<1-mm) distal lower uterine segment and 5.62 (95% confidence interval, 1.41-22.5) for a lacuna score of 3+.
Transvaginal ultrasound examination contributes to both prenatal management and the prediction of surgical outcomes in patients with a history of previous cesarean delivery with and without ultrasound signs suggestive of placenta accreta spectrum. Transvaginal ultrasound examination of the lower uterine segment and cervix should be included in clinical protocols for the preoperative evaluation of patients at risk of complex cesarean delivery.

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