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Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women. Arch Gynecol Obstet 2014; 291:1417-23. [PMID: 25516174 DOI: 10.1007/s00404-014-3582-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Caesarean delivery (c-section) scar dehiscences may cause bleeding abnormalities, e.g. postmenstrual spotting, dysmenorrhea and abdominal pain, secondary sterility and at worst peripartum uterine rupture. The purpose of this study was firstly to identify the correlation of women's complaints after c-section with scar-related clinical symptoms. Secondly, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic. METHODS We present data of a retrospective study of 13 premenopausal, non-pregnant women with symptomatic c-section scars. In 9 out of 13 patients, a microsurgical uterus reconstruction was performed by mini-laparotomy. The postoperative changes of scar-associated symptoms were assessed by a questionnaire as earliest as 4 months after surgery (N = 5). RESULTS The c-section scar was visualised by transvaginal sonography in 12 out of 13 women by a typical U- or V-shaped hypoechoic or anechoic fluid accumulation in the region of former uterotomy and in all 13 patients by hysteroscopy. Bleeding disorders were often accompanied by dysmenorrhea/abdominal pain (38.5%, N = 5) and secondary sterility (46.2%, N = 6). Blood residues in the scar pouch and bleeding disorders/postmenstrual spotting were found in 30.8% of patients (N = 4) and combined with secondary sterility in 38.5% of patients (N = 5). Reconstructive surgeries resulted in discontinuation of bleeding disorders in all women and a pregnancy in three out of five patients (60%) with secondary sterility. CONCLUSION Clinical symptoms, e.g. "bleeding disorders" like postmenstrual spotting, "pain/dysmenorrhea" and "secondary sterility" could be specific indicators for the diagnosis of uterine dehiscence after c-section. Scar dehiscences can be diagnosed by obtaining the patients medical history and asking for typical symptoms followed by vaginal sonography and diagnostic hysteroscopy. If a c-section scar defect is confirmed, microsurgical uterus reconstruction can stop postmenstrual spotting, reduce abdominal pain/dysmenorrhea and improve fertility.
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Bij de Vaate AJM, van der Voet LF, Naji O, Witmer M, Veersema S, Brölmann HAM, Bourne T, Huirne JAF. Reply: Niche risk factor for uterine rupture? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:371-372. [PMID: 25154488 DOI: 10.1002/uog.14632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- A J M Bij de Vaate
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
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Gonser M. Re: Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:371. [PMID: 25154489 DOI: 10.1002/uog.14631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 07/11/2014] [Indexed: 06/03/2023]
Affiliation(s)
- M Gonser
- Clinic of Obstetrics and Prenatal Medicine, Ludwig-Erhard-Str. 100, Wiesbaden 65199, Germany.
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Bij de Vaate AJM, van der Voet LF, Naji O, Witmer M, Veersema S, Brölmann HAM, Bourne T, Huirne JAF. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:372-382. [PMID: 23996650 DOI: 10.1002/uog.13199] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/07/2013] [Accepted: 08/27/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To review systematically the medical literature reporting on the prevalence of a niche at the site of a Cesarean section (CS) scar using various diagnostic methods, on potential risk factors for the development of a niche and on niche-related gynecological symptoms in non-pregnant women. METHODS The PubMed and EMBASE databases were searched. All types of clinical study reporting on the prevalence, risk factors and/or symptoms of a niche in non-pregnant women with a history of CS were included, apart from case reports and case series. RESULTS Twenty-one papers were selected for inclusion in the review. A wide range in the prevalence of a niche was found. Using contrast-enhanced sonohysterography in a random population of women with a history of CS, the prevalence was found to vary between 56% and 84%. Nine studies reported on risk factors and each study evaluated different factors, which made it difficult to compare studies. Risk factors could be classified into four categories: those related to closure technique, to development of the lower uterine segment or location of the incision or to wound healing, and miscellaneous factors. Probable risk factors are single-layer myometrium closure, multiple CSs and uterine retroflexion. Six out of eight studies that evaluated niche-related symptoms described an association between the presence of a niche and postmenstrual spotting. CONCLUSIONS The reported prevalence of a niche in non-pregnant women varies depending on the method of detection, the criteria used to define a niche and the study population. Potential risk factors can be categorized into four main categories, which may be useful for future research and meta-analyses. The predominant symptom associated with a niche is postmenstrual spotting.
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Affiliation(s)
- A J M Bij de Vaate
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
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Demers S, Roberge S, Drouin O, Bujold E. [S. Demers et al. in reply to the article by J. Boujenah et al]. ACTA ACUST UNITED AC 2014; 42:194-5. [PMID: 24582207 DOI: 10.1016/j.gyobfe.2014.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Indexed: 11/28/2022]
Affiliation(s)
- S Demers
- Centre mère-enfant du CHU de Québec, département d'obstétrique-gynécologie, faculté de médecine, université Laval, 2705, boulevard Laurier, Québec, Qc, G1V 4G2 Canada
| | - S Roberge
- Département de médecine sociale et préventive, faculté de médecine, université Laval, Québec, Qc, Canada
| | - O Drouin
- Centre mère-enfant du CHU de Québec, département d'obstétrique-gynécologie, faculté de médecine, université Laval, 2705, boulevard Laurier, Québec, Qc, G1V 4G2 Canada
| | - E Bujold
- Centre mère-enfant du CHU de Québec, département d'obstétrique-gynécologie, faculté de médecine, université Laval, 2705, boulevard Laurier, Québec, Qc, G1V 4G2 Canada; Département de médecine sociale et préventive, faculté de médecine, université Laval, Québec, Qc, Canada.
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Roberge S, Demers S, Boutin A, Bujold E. Isthmocele. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 35:1069. [PMID: 24405872 DOI: 10.1016/s1701-2163(15)30755-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Stéphanie Roberge
- Department of Social and Preventive Medicine, Université Laval, Quebec QC
| | - Suzanne Demers
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec QC
| | - Amélie Boutin
- Department of Social and Preventive Medicine, Université Laval, Quebec QC
| | - Emmanuel Bujold
- Department of Social and Preventive Medicine, Université Laval, Quebec QC; Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec QC
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[Uterine ishtmique transmural hernia: results of its repair on symptoms and fertility]. ACTA ACUST UNITED AC 2013; 41:588-96. [PMID: 24094595 DOI: 10.1016/j.gyobfe.2013.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 08/09/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To study the effect of the surgical repair (isthmorraphy) of the large scar dehiscence after cesarean on symptoms and fertility for women who desire pregnancy. PATIENTS AND METHODS In this retrospective study, 14 symptomatic patients, who desire a new pregnancy underwent a surgical repair by laparotomy, laparoscopic or vaginal technique. Five women experienced failure of Assistance Reproductive Technique (IVF or ICSI) for idiopathic secondary infertility. The dehiscent scars were evaluated by ultrasound, hysterography, hysteroscopy and magnetic resonance imaging. OUTCOME Symptoms improvement was found in 92% of case. Ten pregnancy (71%) was obtained after surgical repair, 6 spontaneous and 4 after Assistance Reproductive Technique. Among the 5 women initially followed in the reproductive unit, 4 became pregnant, 3 after IVF or ICSI and 1 spontaneous. No operative complication occurred. The subsequent pregnancy was unremarkable with no uterine rupture. DISCUSSION Large scar defect after cesarean can take shape of a complete absent of the anterior wall of the uterus. No incident has been proved in this condition. There is a lack of data concerning these isthmocele. The experience of hysteroscopic repair cannot be applied to these real large diverticule of the scar cesarean. The results of this study suggest a link between the isthmocele and reversible symptoms after surgery. The first results concerning the subsequent fertility after surgical repair seem interesting CONCLUSION When a large scare defect (isthmocele) is found in symptomatic woman (pelvic pain, bleeding uterine, infertility), a surgical repair can be proposed, especially for woman who desire a new pregnancy.
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Glavind J, Madsen LD, Uldbjerg N, Dueholm M. Ultrasound evaluation of Cesarean scar after single- and double-layer uterotomy closure: a cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:207-212. [PMID: 23288683 DOI: 10.1002/uog.12376] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To compare residual myometrial thickness (RMT) and size of the Cesarean scar defect after single- and double-layer uterotomy closure following first elective Cesarean section. METHODS A retrospective cohort study was conducted in 149 women at least 6 months after an uncomplicated, elective Cesarean delivery. Two-dimensional transvaginal ultrasonographic measures of RMT, scar defect depth, width and length and myometrial thickness adjacent to the scar were compared in 68 women with single-layer and 81 women with double-layer closure delivered before and after, respectively, a change in the surgical procedure. Outcomes between the two groups were compared. RESULTS Median RMT was 5.8 (interquartile range (IQR), 4.1-7.8) mm in women with double-layer closure vs 4.6 (IQR, 3.4-6.5) mm in those with single-layer closure (P = 0.04). Scar defect length was greater in women with single-layer closure (median, 6.8 (IQR, 4.4-8.5) mm) than in those with double-layer closure (median, 5.6 (IQR, 3.9-6.8) mm) (P = 0.01). Measurements of defect depth and width, and the proportion of scars with RMT < 2.3 mm were similar in the two groups. CONCLUSIONS RMT was greater and defect length, but not defect depth and width, was smaller following double-layer compared with single-layer closure, which may indicate some limited benefit of double-layer closure following first elective Cesarean section.
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Affiliation(s)
- J Glavind
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus N, Denmark.
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Demers S, Roberge S, Afiuni YA, Chaillet N, Girard I, Bujold E. Survey on uterine closure and other techniques for Caesarean section among Quebec's obstetrician-gynaecologists. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013; 35:329-333. [PMID: 23660040 DOI: 10.1016/s1701-2163(15)30960-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the preferred types of uterine closure at Caesarean section among Quebec's obstetrician-gynaecologists. METHODS An anonymous survey with multiple-choice and open questions was sent by email to all members of the Association des Obstétriciens-Gynécologues du Québec in clinical practice. The primary response of interest was the type of uterine closure that would be favoured for a primigravida undergoing an elective CS at term for a breech fetus. Secondary responses of interest included type of uterine closure for CS performed for other indications, and methods of closure for the bladder flap, parietal peritoneum, rectus abdominis muscle, subcutaneous tissue, and skin. Results were stratified according to the number of years in practice. RESULTS Of 454 persons targeted, 176 (39%) responded. Responders were more likely to have fewer years in practice than the targeted population in general. The closures for a primigravida undergoing an elective CS at term for a breech presentation were, in order of preference: (1) a double-layer closure combining a first locked layer and an imbricating second layer (61%), (2) a double-layer closure combining a first unlocked layer and an imbricating second layer (28%), (3) a locked single layer (5%), (4) an unlocked single layer (5%), and (5) other techniques (1%). A locked single-layer closure was more frequently used for repeat CS (29%), and it was the favoured technique (40%) when tubal ligation was performed at the time of CS (P < 0.05). CONCLUSION Double-layer closure is the type of uterine closure most preferred by obstetricians in Quebec. However, the first layer is locked by two thirds of obstetricians and unlocked by the remainder.
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Affiliation(s)
- Suzanne Demers
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec City QC
| | - Stéphanie Roberge
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City QC
| | - Yamal A Afiuni
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec City QC
| | - Nils Chaillet
- Department of Obstetrics and Gynecology, University of Montreal, Montreal QC
| | - Isabelle Girard
- Department of Obstetrics and Gynecology, St-Mary's Hospital, McGill University, Montreal QC
| | - Emmanuel Bujold
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec City QC
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Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy. Am J Obstet Gynecol 2012; 207:386.e1-6. [PMID: 23107082 DOI: 10.1016/j.ajog.2012.09.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 07/14/2012] [Accepted: 09/12/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of the study was to assess the efficacy of uterine arteries embolization (UAE) for the treatment of cesarean scar pregnancies (CSP). STUDY DESIGN Forty-six women with CSP were identified between March 2008 and March 2010. All of the patients underwent UAE combined with local methotrexate. RESULTS Forty-five patients were successfully treated. One patient had an emergency hysterectomy after 20 days because of massive vaginal hemorrhage. The mean time until normalization of serum β-human chorionic gonadotrophin was 37.7 days, and the mean time until CSP mass disappearance was 33.3 days. The mean hospitalization time was 10.5 days. The complications were mainly fever and pain, which were alleviated with symptomatic treatment. All 45 patients had recovered their normal menstruation at follow-up. CONCLUSION Bilateral uterine artery chemoembolization with methotrexate appears to be a safe and effective treatment for CSP and causes less morbidity than current approaches.
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Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol 2012; 24:180-6. [PMID: 22395067 DOI: 10.1097/gco.0b013e3283521202] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review the treatments of the cesarean-induced isthmocele in restoring infertility, associated techniques, and the risks of complications associated with their use. RECENT FINDINGS Isthmocele is a reservoir-like pouch defect on the anterior wall of the uterine isthmus located at the site of a previous cesarean delivery scar. The flow of menstrual blood through the cervix may be slowed by the presence of isthmocele, as the blood may accumulate in the niche because of the presence of fibrotic tissue, causing pelvic pain in the suprapubic area. Moreover, persistence of the menstrual blood after menstruation in the cervix may negatively influence the mucus quality and sperm quality, obstruct sperm transport through the cervical canal, interfere with embryo implantation, leading to secondary infertility. The removal of the local inflamed tissue may be performed by laparoscopic, combined laparoscopic-vaginal, or vaginal surgery, and operative hysteroscopy, a minimally invasive approach to improve symptoms and restore fertility. SUMMARY Isthmocele occurs after cesarean section, a common method of delivery and one of the most frequent surgical procedures, so that its upward incidence appears likely to continue in the near future. Because of its minimal invasiveness, resectoscopy may be the better choice for treatment, yielding good therapeutic results.
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Yazicioglu HF, Sevket O, Ekin M, Ozyurt O, Aygun M. Incomplete Healing of the Uterine Incision after Cesarean Section: Is It Preventable by Intraoperative Digital Dilatation of the Internal Cervical Ostium? Gynecol Obstet Invest 2012; 74:131-5. [DOI: 10.1159/000339936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 06/03/2012] [Indexed: 11/19/2022]
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Roberge S, Chaillet N, Boutin A, Moore L, Jastrow N, Brassard N, Gauthier RJ, Hudic I, Shipp TD, Weimar CH, Fatusic Z, Demers S, Bujold E. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. Int J Gynaecol Obstet 2011; 115:5-10. [DOI: 10.1016/j.ijgo.2011.04.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 04/17/2011] [Accepted: 06/27/2011] [Indexed: 10/17/2022]
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Vikhareva Osser O, Valentin L. Risk factors for incomplete healing of the uterine incision after caesarean section. BJOG 2010; 117:1119-26. [DOI: 10.1111/j.1471-0528.2010.02631.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Borges LM, Scapinelli A, de Baptista Depes D, Lippi UG, Coelho Lopes RG. Findings in patients with postmenstrual spotting with prior cesarean section. J Minim Invasive Gynecol 2010; 17:361-4. [PMID: 20417429 DOI: 10.1016/j.jmig.2010.02.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 02/24/2010] [Accepted: 02/24/2010] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE Throughout the years, patients previously submitted to C-sections may have abnormal uterine bleeding (AUB) of the post-menstrual spotting type. This symptom has been correlated to an anatomical defect on the anterior uterine wall. The objective of the present investigation was to assess the hysteroscopy findings of women at reproductive age, previously submitted to cesarean sections and complaining of post-menstrual spotting, stressing the diagnosis of isthmocele. DESIGN Prospective study (Canadian Task Force II). SETTING State public hospital-Department of Gynecological Endoscopy. PATIENTS Forty-three patients at reproductive age previously submitted to one or more cesarean sections, complaining of AUB of the post-menstrual spotting type, were submitted to diagnostic hysteroscopy in order to assess the presence of anterior uterine wall isthmocele. INTERVENTIONS Hysteroscopic diagnoses. MEASUREMENTS AND MAIN RESULTS The mean number of previous C-sections was 2, the average time of post-menstrual spotting observation was 6 years and the mean duration of each episode was 6 days. The hysteroscopic diagnosis of isthmocele was conclusive in 38 patients (88.37%). CONCLUSION Patients with previous C-sections complaining of postmenstrual spotting type of AUB have a high prevalence of isthmocele, and this condition is likely diagnosed through diagnostic hysteroscopy.
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Affiliation(s)
- Layza Merizio Borges
- Hospital Servidor Publico Estual São Paolo, Endoscopia Ginecologica, São Paolo, Brazil.
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Yazicioglu HF. Assessment of Cesarean section scars with transvaginal sonography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:250-252. [PMID: 20069682 DOI: 10.1002/uog.7539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Hofmeyr JG, Novikova N, Mathai M, Shah A. Techniques for cesarean section. Am J Obstet Gynecol 2009; 201:431-44. [PMID: 19879392 DOI: 10.1016/j.ajog.2009.03.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 02/26/2009] [Accepted: 03/06/2009] [Indexed: 10/20/2022]
Abstract
The effects of complete methods of cesarean section (CS) were compared. Metaanalysis of randomized controlled trials of intention to perform CS using different techniques was carried out. Joel-Cohen-based CS compared with Pfannenstiel CS was associated with reduced blood loss, operating time, time to oral intake, fever, duration of postoperative pain, analgesic injections, and time from skin incision to birth of the baby. Misgav-Ladach compared with the traditional method was associated with reduced blood loss, operating time, time to mobilization, and length of postoperative stay for the mother. Joel-Cohen-based methods have advantages compared with Pfannenstiel and traditional (lower midline) CS techniques. However, these trials do not provide information on serious and long-term outcomes.
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Abstract
BACKGROUND Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique. OBJECTIVES To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers. SELECTION CRITERIA Randomised controlled trials of intention to perform caesarean section using different techniques. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies and extracted data. MAIN RESULTS 'Joel-Cohen based' compared with Pfannenstiel CS was associated with: less blood loss, (five trials, 481 women; weighted mean difference (WMD) -64.45 ml; 95% confidence interval (CI) -91.34 to -37.56 ml); shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes); postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours); less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81); shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours); fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); and shorter time from skin incision to birth of the baby (five trials, 575 women; WMD -3.84 minutes; 95% CI -5.41 to -2.27 minutes). Serious complications and blood transfusions were too few for analysis.Misgav-Ladach compared with the traditional method (lower midline abdominal incision) was associated with reduced: blood loss (339 women; WMD -93.00; 95% CI -132.72 to -53.28 ml); operating time (339 women; WMD-7.30; 95% CI -8.32 to -6.28 minutes); time to mobilisation (339 women; WMD -16.06; 95% CI -18.22 to -13.90 hours); and length of postoperative stay for the mother (339 women; WMD -0.82; 95% CI -1.08 to -0.56 days). Misgav-Ladach compared with modified Misgav-Ladach methods was associated with a longer time from skin incision to birth of the baby (116 women; WMD 2.10; 95% CI 1.10 to 3.10 minutes). AUTHORS' CONCLUSIONS 'Joel-Cohen based' methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.
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Affiliation(s)
- G J Hofmeyr
- University of the Witwatersrand, Department of Obstetrics and Gynaecology, East London Hospital Complex, Frere and Cecilia Makiwane Hospitals, Private Bag X 9047, East London, Eastern Cape, South Africa, 5200.
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