Diagnosing early scar pregnancy in the lower uterine segment after cesarean section by intracavitary ultrasound

BACKGROUND Early scar pregnancy(CSP)in the lower uterine segment after cesarean section is a type of ectopic pregnancy that can cause major complications if left untreated.Transabdominal ultrasound is a common procedure but is influenced by external factors.Thus,intracavitary ultrasound may have better diagnostic efficiency for CSP.AIM To assess the value of intracavitary ultrasound for diagnosing CSP in the lower uterine segment after cesarean section.METHODS Patients diagnosed with CSP in our hospital from October 2019 to April 2021 were recruited.Transabdominal and intracavitary ultrasound examinations were performed to compare the diagnostic differences for CSP and its types.RESULTS Sixty-three patients were diagnosed during the study period.The diagnostic accuracy for CSP was higher in intracavitary ultrasound(96.83%)than in transabdominal ultrasound(84.13%)(P<0.05).The missed diagnosis and misdiagnosis rates did not differ among the ultrasound types(intra:0.00%and 3.17%;trans:4.76%and 11.11%,respectively;P>0.05).For the diagnostic rates for the CSP types,the rates for gestational sac(100.00%vs 90.48%),heterogeneous mass(93.75%vs 75.00%),and part of the uterine cavity(80.00%vs 60.00%)were higher in intracavitary ultrasound than in transabdominal ultrasound,but the difference was not statistically significant(P>0.05).For gestational sac CSP patients,intracavitary ultrasound showed that the gestational sac was located in the lower uterine segment scar with abundant peripheral blood flow;the distance between the gestational sac and the serosal layer was 2.42±0.50 cm.Intracavitary ultrasound for heterogeneous mass CSP patients indicated that the mass mainly occurred in the lower anterior uterine wall,protruding into the bladder,and was surrounded by abundant internal and peripheral blood flow;the distance between the mass and serosal layer was 1.79±0.30 cm.For CSP type partly located in the uterine cavity,the gestational sac was partly located in the lower uterine cavity and partly in the scar with abundant internal and peripheral blood flow;the distance between the gestational sac and the serosal layer was 2.29±0.28 cm.CONCLUSION Intracavitary ultrasound had a higher diagnostic accuracy and application value for diagnosing CSP than transabdominal ultrasound,with reduced risk of missed diagnoses and misdiagnosis,thereby preventing delayed treatment.

Vaginal Cesarean Section, an Alternative to High-Risk Trigger on Scarred Uterus

The objective is to report a clinical case of vaginal cesarean section performed to expel a dead fetus in scarred uterus. For this indication, vaginal hysterectomy constitutes an alternative to vaginal expulsion with a high risk of uterine rupture and to classic abdominal cesarean section with risk of significant surgical trauma, particularly adhesions. However, this surgical technique, described since the 19th century, remains unknown to many practitioners and few publications exist on the subject throughout the world. Considered obsolete by some practitioners, it retains all its advantages in the practice of modern obstetrics. We report this case of expulsion of fetal death on a tri-scarred uterus performed by vaginal cesarean section at the Health District Reference Health Center (District Hospital) of Commune I in Bamako, Mali in a 37-year-old patient with a pregnancy of 27 weeks of amenorrhea.

Emergency internal iliac artery temporary occlusion after massive hemorrhage during surgery of cesarean scar pregnancy:A case report

BACKGROUND Cesarean scar pregnancy(CSP)is rare but may result in uterine rupture during pregnancy or massive hemorrhage during abortion procedures.Awareness of this condition is increasing,and most patients with CSP are now diagnosed early and can be managed safely.However,some atypical patients are misdiagnosed,and their surgical risks are underestimated,increasing the risk of fatal hemorrhage.CASE SUMMARY A 27-year-old Asian woman visited our institution because of abnormal pregnancy,and she was diagnosed with a hydatidiform mole through transvaginal ultrasound(TVS).Under hysteroscopy,a large amount of placental tissue was found in the scar of the lower uterine segment,and a sudden massive hemorrhage occurred during the removal process.The bilateral internal iliac arteries were temporarily blocked under laparoscopy,and scar resection and repair were rapidly performed.She was discharged in good condition 5 d after the operation.CONCLUSION Although TVS is widely used in the diagnosis of CSP,delays in the diagnosis of atypical CSP remain.Surgical treatment following internal iliac artery temporary occlusion may be an appropriate management method for unanticipated massive hemorrhage during CSP surgery.

DIAGNOSIS AND TREATMENT OF CESAREAN SCAR PREGNANCY

Objective To investigate the early diagnosis and treatment of cesarean scar pregnancy （CSP）. Methods Clinical data of 28 patients with CSP in Peking Union Medical College Hospital from January 1994 to April 2007, including age, interval from the last cesarean delivery to diagnosis, clinical presentation, location of the lesion, process of diagnosis and treatment, outcome, and follow-up, were retrospectively analyzed. Re, salts CSP constituted 1.05 % of all ectopic pregnancies, and the ratio of CSP to pregnancy was 1 ： 1 221. The mean age of the group was 31.4 years. Twenty-six women had only one prior cesarean delivery. The interval from the last cesarean delivery to diagnosis ranged from 4 months to 15 years. The most common presenting symptoms of CSP were amenorrhoea and vaginal bleeding. Seventeen cases were misdiagnosed as early intrauterine pregnancies and 2 were misdiagnosed as gestational trophoblastic tumor. The other 9 were diagnosed definitely before treatment. The diagnosis was made based on cesarean delivery history, gynecologic examination, ultrasound, and magnetic resonance imaging （MRI）. The treatment of CSP included systemic or local methotrexate administration, conservative surgery, and hysterectomy. The conservative treatment was successful in 24 cases. All of the 28 women were cured through individual therapies. Conclusions CSP is rare and usually misdiagnosed as other diseases. Ultrasound is valuable for diagnosing CSP, and MRI can be used as an adjunct to ultrasound scan. Early diagnosis offers the options of conservative treatment and greatly improves the outcome of patients. Individual therapy is strongly recommended.

Management of Cesarean Scar Pregnancy: A Case Series

Objective To survey effective treatment strategies for cesarean scar pregnancy(CSP). Methods The clinical data of 78 patients diagnosed with CSP from January 2010 to December 2013 were reviewed. Results Among these patients, 17 patients were first treated at our hospital; of them, 2 were misdiagnosed. The other 61 patients were referred from other hospitals; of them, 21 were initially misdiagnosed. There were 9 patients who were treated with laparotomy, 50 patients with curettage after uterine artery embolization(UAE) with or without local methotrexate(MTX) infusion, 10 patients with dilatation and curettage, 6 patients with transvaginal sonographic guided local intragestational MTX injection, and 3 patients with systemic MTX injection. All patients finally recovered. Patients with excessive vaginal hemorrhage underwent either emergency UAE treatment or laparotomy. These two treatments had similar success rates(81.82% vs. 100%, χ2 =0.289, P>0.05). Conclusions The accurate diagnosis of CSP is important. Curettage after UAE with or without local MTX infusion is a safe and effective method.

Reliable clinical and sonographic findings in the diagnosis of abdominal wall endometriosis near cesarean section scar

AIM: To highlight sonographic and clinical characteristics of scar endometrioma with special emphasis on size-related features. METHODS: Thirty women (mean age 30.6 years, range 20-42 years) with 33 scar endometriomas (mean diameter 27.1 mm, range 7-60 mm) were consecutively studied by Sonography and Color Doppler examination prior to surgery. Pathological examination was available in all cases. RESULTS: The most frequent (24 of 33 nodules, 74%) sonographic B-mode aspect of endometrioma was that of an inhomogenously hypoechoic roundish nodule with fibrotic changes (in the form of hyperechoic spots or strands), a peripheral inflammatory hyperechoic ring, spiculated margins and a single vascular pedicle entering the mass at the periphery. On average, 1.6 cesarean sections were recorded per patient (range 1-3). The median interval between the last cesarean section and admission to hospital was 36 mo (range 12-120 mo) and the median duration of symptoms before admission was 25.7 mo (range 0.5-80 mo). 13 patients had 13 large endometriomas (≥ 30 mm) with a mean lesion diameter of 41.3 ± 9.02 mm (range 30-60 mm). Seventeen women had 20 small endometriomas with a mean lesion size of 18.2 ± 5.17 mm (range 7-26 mm). The mean interval between the last cesarean section and admission to hospital (66.0 mo vs 39.6 mo, P < 0.01) and the mean duration of symptoms before admission (43.0 mo vs 17.4 mo, P < 0.01) were significantly longer in patients with large endometriomas; in addition, a statistically significant higher percentage of patients with large implants had undergone previous inconclusive diagnostic examinations, including either computed tomography/magnetic resonance imaging/fine needle biopsy/laparoscopy (38.4% vs 0%, P < 0.05). On sonography, large endometriomas showed frequent cystic portions and fistulous tracts (P < 0.02), loss of round/oval shape (P < 0.04) along with increased vascularity (P < 0.04). CONCLUSION: Endometrioma near cesarean section scar is an often neglected disease, but knowledge of its clinical and sonographic findings may prevent a delay in diagnosis that typically occurs in patients with larger (≥ 3 cm) endometriomas.

Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy:A case report

BACKGROUND Heterotopic cesarean scar pregnancy(HCSP)is very rare and has a high risk of massive uterine bleeding.Preservation of concurrent intrauterine pregnancy(IUP)is one of the great challenges in the management of HCSP.No universal treatment protocol has been established when IUP is desired to be preserved.CASE SUMMARY We report a case of HCSP at 8+wk gestation in a 34-year-old woman with stable hemodynamics.A two-step intervention was applied.Selective embryo aspiration was performed first,and surgical removal of ectopic gestational tissue by suction and curettage was performed 2 d later.Both steps were performed under ultrasound guidance.The patient had an uneventful course,and a healthy baby was delivered at 34+6 wk gestation.CONCLUSION Selective embryo aspiration followed by suction and curettage was successful in the preservation of IUP in the management of HCSP.This approach is an alternative option for HCSP in the first trimester when the IUP is desired to be preserved.

The Value of Transvaginal Ultrasound in Clinical Surgical Treatment of Cesarean Scar Pregnancy

The clinical value of transvaginal ultrasound in clinical surgical treatment of cesarean scar pregnancy（CSP） was evaluated. The clinical data of 104 patients with CSP admitted at Tongji Hospital from 2013 to 2016 were collected and analyzed retrospectively, including the patients＇ age, gestational age, the size of gestational sac or uneven mass, the uterine scar thickness, β human chorionic gonadotropin（h CG） levels and so on. Of these 104 cases, 30 cases were subjected to laparotomy, 29 cases to laparoscopy, 27 cases to hysteroscopy, 16 cases to ultrasound-guided uterine curettage, and 2 cases to conservative treatment. The transvaginal ultrasound showed that uterine scar thickness and gestational sac or uneven mass size had significant difference（P〈0.05） among different surgical methods by comparatively analyzing the patients＇ data. It was suggested that transvaginal ultrasound may provide the valuable reference for choosing clinical surgical procedures for CSP.

Cesarean Scar Pregnancy: A Report of 11 Cases and Review of the Literature Regarding Subsequent Pregnancy

Background: There is no consensus regarding the optimal treatment for cesarean scar pregnancy (CSP) because treatment efficacy, safety, and the influence on subsequent pregnancy must be taken into consideration. Here we report our experience with 11 cases of CSP and review the literature regarding subsequent pregnancy. Methods: Records of 11 CSP cases that were treated at our hospital were retrospectively reviewed. CSP was treated by local methotrexate (MTX) injection or laparotomic or laparoscopic removal of the gestational mass and myometrial repair. Outcome of subsequent pregnancy after treatment was followed-up until delivery. Results: Local MTX injection was performed for six cases, laparotomic removal of the gestational mass and myometrial repair was performed for two, and laparoscopic removal of the gestational mass and myometrial repair was performed for three. The uterus was preserved in all cases. After CSP treatment, eight pregnancies occurred in five cases, resulting in six live births and two miscarriages. Conclusion: Advantages and disadvantages of various treatment methods for CSP continue to be elucidated. Serum hCG level, location of the gestational mass, thickness of the lower uterine segment at the time of diagnosis, and whether the patient wishes for fertility preservation should be considered when choosing a treatment plan.

Abdominal Wall Endometriomas at Cesarean Section Scars: A Case Series

Endometriosis, a common gynecological condition, is defined as the presence of functioning endometrial tissue outside the uterine cavity. It often presents as a cyclic, hormonally stimulated pain in women during their reproductive years. While endometriosis is usually located within the pelvis, it may also occur at intraperitoneal, intestinal, perineal, and distant ectopic sites. Although often diffuse, a localized, focal mass of endometrial tissue is termed as an endometrioma. In rare occurrences, an endometrioma will present superficially to the peritoneum within the abdominal wall following gynecologic or obstetric surgery. The presence of an abdominal wall endometrioma within a cesarean section scar may pose a diagnostic dilemma, which is often misdiagnosed, and results in surgery referrals for treatment. The clinical symptoms and sonographic appearance of abdominal wall endometriomas occurring at cesarean section scars are highlighted in this case series.

Cesarean scar pregnancy

Cesarean scar ectopic pregnancy is a consequence of a scar from previous cesarean section.It is rare and is associated with catastrophic complications of early pregnancy.It can occur in women with only one prior cesarean delivery.With increasing rate of cesarean section worldwide,more and more cases are diagnosed and reported.The incidence is likely to rise substantially in the near future.A delay in diagnosis and the treatment can lead to uterine rupture,major haemorrhage,hysterectomy and serious maternal morbidity.Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage,thus preserving the uterus and future fertility.Aim of this article is to find the demography,pathophysiology,clinical presentation,most appropriate methods of early diagnosis and management.

The Diagnosis and Treatment for a Special Type of Cesarean Scar Pregnancy

Caesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy, and its incidence has been increased due to the increased rate of Cesarean sections performed. A special type of CSP, concealed CSP, was found in the clinical work in our institution. A retrospective review was performed. From September 2011 to June 2014, 208 women were presented with cesarean scar pregnancy by use of transvaginal color Doppler sonography. The medical records were consulted to collect the demographics and pertinent information. Six of them were determined to be concealed CSP. Four women were diagnosed in the first-trimester pregnancy after termination of pregnancy. The initial ultrasound of the other two women displayed that the gestational sacs were located in the lower uterine cavity. Placenta accrete, increta and previa were diagnosed by the following ultrasounds. Concealed CSP is a very unusual form of CSP. Continued pregnancy may be sufficiently evaluated because of subsequently serious complications. Our results indicate that continued pregnancy increases the risk of laparotomy and hysterectomy. Medical abortion in the first-trimester pregnancy should be considered as the optimal choice for the women with prior cesarean sections who want to terminate the gestation.

Pregnancy Outcomes of Repeat Cesarean Section in Peking Union Medical College Hospital

Objective To evaluate the effect of elective repeat cesarean section on the maternal and neonatal outcomes. Methods A retrospective clinic- and hospital-based survey was designed for comparing the maternal and neonatal outcomes of elective repeat cesarean section [RCS group （one previous cesarean section） and MRCS group （two or more previous cesarean sections）] and primary cesarean section （FCS group） at Peking Union Medical College Hospital from January 1998 to December 2007. Results The incidence of repeat cesarean section increased from 1.26% to 7.32%. The mean gestational age at delivery in RCS group （38.1±1.8 weeks） and MRCS group （37.3±2.5 weeks） were significantly shorter than that in FCS group （38.9±2.1 weeks, all P〈0.01）. The incidence of complication was 33.8% and 33.3% in RCS group and MRCS group respectively, and was significantly higher than that in FCS group （7.9%, P〈0.05）. Dense adhesion （13.5% vs. 0.4%, OR=7.156, 95% CI： 1.7-30.7, P〈0.01） and uterine rupture （1.0% vs. O,P〈0.05） were commoner in RCS group compared with FCS group. Neonatal morbidity was similar among three groups （P〉0.05）. Conclusions Repeat cesarean section is associated with more complicated surgery technique and increased frequency of maternal morbidity. However, the incidence of neonatal morbidity is similar to primary cesarean section.

Vaginal Birth after a Cesarean Section at Good Shepherd Mission Hospital at Tshikaji in Democratic Republic of the Congo (DRC)

Background: The success rate of vaginal birth after cesarean section with a single cesarean scar is greater than 50%, the lack of the information about the safety of vaginal birth after cesarean delivery pushes most of obstetricians to increase the num ber of cesarean sections following a previous cesarean section. Guidelines for Vaginal birth after cesarean (VBAC) indicate that TOLAC offers women with no contraindications and one previous transverse low-segment cesarean. The objective of the current study was to study the outcome of trial of labour after caesarean section (TOLAC), the indications for emergency repeat cesarean section and to determine the maternal and fetal prognosis in vaginal birth after caesarian section (VBAC) at Tshikaji Mission Hospital. Patients, Material and Methods: This is a retrospective study of the records of 126 women were selected to undergo the TOLAC in the department of gynecology and obstetrics at the Tshikaji Mission Hospital over the period from January 1st to December 31st, 2021. The data on demography, antenatal care, labour and delivery and outcomes were collected from the maternity unit of this hospital. The data were analyzed using SPSS version 2.0. Results: The TOLAC in 126 studied women. The course of work allowed vaginal delivery 107 parturient women, a success rate of successful VBAC of 85% after the TOLAC. The repeat emergency cesarean section was necessary for delivery in 15% of cases for failed TOLAC. There was no maternal mortality, but we recorded one fetal death or 0.8% of perinatal mortality, 2 cases of cicatricial dehiscence, the incidence of 1.6%. Maternal morbidity after delivery on cicatricial uterus was dominated by postpartum hemorrhages, with 19 cases or 15.1% of cases. Cervical dilatation of more than 3 cm at the time of admission, the parity more than 3 and were the significant factors in favor of a successful VBAC. Birth weight of more than 3500 g, fetal distress and malpresentation were associated with a lower success rate of VBAC. The TOLAC in selected cases has great importance in the present era of the rising rate of primary CS especially in rural areas. Conclusion: Pregnancy on a cicatricial uterus represents a high-risk pregnancy. Trial of VBAC in selected cases has great importance in the present era of the rising rate of primary CS especially in rural areas. There is a significantly high vaginal birth after caesarian section (VBAC) success rate among selected women undergoing trial of scar in Tshikaji Hospital. TOLAC remains the option for childbirth in low resource settings as Kasai region in DRC. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remain the cornerstone to achieving high VBAC success rate.

Expectant management of cesarean scar pregnancy:a case report and a review of literature

Pregnancy in previous cesarean scar is the rarest form of ectopic pregnancy.Little is known about its natural history and optimal management.All literatures except one reported that the expectant treatments for such patients were unsuccessful or led to complication.This paper presents one case of cesarean scar pregnancy(CSP) with expectant management,and discusses the value of this expectant management.The paper also appears a glimpse of the natural courses of certain cesarean scar pregnancies. A 32-year-old woman with a history of cesarean section presented to our outpatient clinic with amenorrhea and bleeding.Sonography and magnetic resonance imaging(MRI) revealed the diagnosis of CSP without viable gestation sac.The patient opted for expectant treatment.We closely monitored the patient with a detailed plan.The patient had mild bleeding during monitoring and her serumβ-hCG levels dropped quickly to normal range after seven weeks.She was fully recovered with total absorption of the mixed mass in the scar of the anterior wall of uterus. If patient with CSP has no viable gestation sac and serumβ-hCG levels are rapidly decreased,she can be expectantly treated.Such cesarean scar pregnancies may be naturally demised.Patient with CSP should be followed up strictly.Medical or surgical therapy should be considered prior to rupture to remove the gestational sac and retain the patient future fertility.

Clinical observation of hysteroscopic surgery combined with ectopic pregnancy ⅱ decoction and methotrexate in the treatment of cesarean scar pregnancy

Objective:To explore the effectiveness and safety about the treatment of Caesarean Scar Pregnancy combined hysteroscopic surgery with extopic pregnancy Ⅱ decoction and methotrexate(MTX).Methods: A total of 80 cases of CSP patients admitted by our hospital from January 2014 to March 2017 were selected as the subjects. According to the treatment way, the patients were divided into experimental group (n=40) and control group (n=40). The control group was given MTX 50 mg/m2, IM once;and the experimental group was given extopic pregnancy Ⅱ decoction on the basis of the treatment given to the control group;the 8th day hysteroscopic surgery. Routine treatment was given after surgery. Experimental group continued to take extopic pregnancy Ⅱ decoction until monitoring the serum beta-hcg level drops below normal. The general information and curative effect, HCG levels before and after 4, 7 and 11d of treatment;mass diameter before and after 11 d of treatment, menstruation recovery time and the incidence of adverse reactions in 2 groups were observed.Results:After hysteroscopic surgery pretreatment with extopic pregnancy Ⅱ decoction and MTX, HCG levels after 4, 7 and 11d were significantly lower than before, it gradually reduced by time prolonged, and research group was lower than control group, the differences were statistically significant. After treatment with different drugs, the size of pregnancy package in the observation group was significantly smaller than that in the control group. Compared with the control group, the he package block size, beta HCG time and vaginal bleeding time were significantly reduced.Conclusion: It has significant clinical effect of hysteroscopic surgery combined with ectopic pregnancy Ⅱ and MTX in the treatment of CSP. It has worthy of clinical promotion to control the amount of blood, avoid intrauterine adhesion caused by uterine artery embolization and infection et al and reduce burden of the physical and economic of patients.

Experience in Surgical Coordination of Type III Cesarean Scar Pregnancy Removal with Combined Assistance of Hysteroscopy and Laparoscopy

Objective:This paper aims to summarize the operative nursing coordination essentials of type III cesareans car pregnancy removal.Methods:Six patients were recruited for this study,and the patient’s condition was fully evaluated before the operation.In addition,the personnel,environment,and materials were well prepared before the operation,and the preparation of special intraoperative instruments and equipment was perfected.Results:The operation is successfully performed in all six patients.Each surgery lasted 70 to 120 minutes with an average duration of 90 minutes.Postoperative blood loss was about 100-500 ml.Postoperative recovery was good without complications in all the patients.Conclusion:In summary,laparoscopic removal of gestational tissue from type III cesareans car pregnancy in conjunction with hysteroscopy ensures compete removal of gestational tissue,while avoiding damaging the surrounding organs and tissues,thus greatly avoiding common complications which usually occur during the surgery.Effective surgical coordination is helpful to further improve the success rate of the operation.

Local metothrexate treatment of cesarean scar ectopic pregnancy

Myometrial pregnancy developing in a previous caesarean section scar is the rarest of all ectopic pregnancies (EP) and probably one of the most dangerous of all because of the risk of rupture and hemorrhage. The recent recognition of this problem means that diagnosis and management are still in their infancy, and there is no consensus regarding the best management of CSP. Methotrexate (MTX) can be administered systemically or locally, or in both ways, with the aid of ultrasound. Patients diagnosed with caesarean scar pregnancies (CSP) in our clinic underwent transvaginal treatment of ectopic pregnancy. Safe and short treatment under transvaginal ultrasonographic (USG) guidance was performed uneventfully in all cases. The operating time ranged from 5 to 10 minutes with no blood loss. Serum β-hCG (β-subunit of human chorionic gonadotrophin) levels declined to normal levels within a month, and patients were discharged without further complications in two or three hours after the procedure. Our cases show that this treatment is effective, safe, and minimally invasive for patients diagnosed with CSP.

Reproductive Outcomes in Women with Prior Cesarean Section Undergoing In Vitro Fertilization:A Retrospective Case-control Study

The impact of prior cesarean section（CS） on the pregnancy and neonatal outcomes of in vitro fertilization and embryo transfer（IVF-ET） was investigated. A retrospective analysis was performed on 144 patients with prior CS between January 2013 and December 2015. The pregnancy, delivery, and neonatal outcomes of patients who had previous CS delivery and received IVF-ET were analyzed. The control group comprised 166 patients who had only previous vaginal delivery（VD） and received IVF-ET during the same period. The results showed that the basal follicle stimulating hormone level, estradiol level on human chorionic gonadotropin（h CG） day, gonadotrophin dosage, duration of stimulation, retrieved oocytes, fertilization rate, high-quality embryo rate, multiple birth rate, abortion rate and ectopic pregnancy rate had no significant difference between the two groups（P〉0.05）. The pregnancy rate（40.28% vs. 54.22%） and implantation rate（24.01% vs. 34.67%） were significantly lower（P〈0.05）, and the ratio of embryo difficulty transfer（9/144 vs. 0/166） was significantly higher in CS group than in VD group. The risk of pernicious placenta previa and postpartum hemorrhage in twin deliveries was significantly increased in CS group as compared with that in VD group（P〈0.05）, and gestational age and neonatal birth weight were significantly reduced in twin deliveries as compared with singleton deliveries in both groups（P〈0.05）. It was suggested that the existence of CS scar may impact embryo implantation and clinical pregnancy outcome, and increase the difficulty of ET. We should limit the number of transfer embryos to avoid multiple pregnancies and strengthen gestational supervision in patients with cesarean scar.

Unavoidable myomectomy during cesarean section: a case report

Since myomectomy throughout cesarean deliv- ery may lead to hemorrhage and uterinal atony, it is not recommended. But, myomectomy has been reported during cesarean section in recent studies. We presented a patient with large in- tramural myoma who was diagnosed at 34 weeks of pregnancy and operated with an unavoidable cesarean-combined myomectomy. A 33-year-old unpursued primigravida was referred to emer- gency department with abdominal pain and amenorrhea of 34 weeks duration. A sonographic diagnosis of myoma in pregnancy was made. Cesarean section was required for fetal distress and alive 2300 g weighted male infant with Ap- gar score of 6 at one minute, was born. As uterine incision could not be closed because of the myoma, myomectomy was performed dur- ing cesarean section unavoidably. A single 970 g and 15 × 18 cm sized myoma was removed. The physical examinations were unremarkable in the postoperative period. Although there are case series that have demonstrated the safety of myomectomy during cesarean section, we con-cluded that myomectomy during cesarean section is not a safe procedure accept inevitable situa-tions.