Cesarean section scar evaluation by saline contrast sonohysterography

Contrast Hysterosonographic Evaluation of Niche Prevalence Following a Standardized Suturing Technique for Caesarean Sections

Introduction

After caesarean section a uterine niche can be detected in 42-84% of all women and in 11-45% large defects with a residual myometrium < 2.2 mm occur. If the niche compromises > 50% of myometrial thickness, risk of uterine rupture during birth increases. The suturing technique might contribute substantially on pathogenesis of niches. The objective of this study is to investigate the effect of the suturing technique on niche prevalence by using a standardized two-layer surgical technique.

Methods

Women with one previous caesarean section were examined within 6-23 months after caesarean section using contrast medium-supported transvaginal sonography regarding the prevalence, sonomorphological aspect and clinical symptoms of a uterine niche. The surgical technique used was: dilatation of the cervix, interrupted suture of the first layer (excluding the endometrium), continuous closure of the visceral and parietal peritoneum.

Results

Using native vaginal sonography, no niches were visible in the whole cohort. In three cases, there was a small niche detectable with a depth between 2.3 and 3.9 mm by contrast hysterosonography. Regarding the total myometrial thickness, the niche depth compromised less than 50%. All patients were symptom-free.

Conclusion

In our study population, there were only three cases (9.1%) with a small uterine niche. Residual myometrium and niche percentage on myometrial thickness were excellent in all three cases. Thus, our results show that the uterotomy closure technique used in the study cohort might be superior with respect to the development of uterine niches compared with the expected prevalence.

Barbed vs conventional sutures for cesarean uterine scar defects: a randomized clinical trial

BACKGROUND

The role of barbed sutures in preventing myometrial defects and enhancing postpartum outcomes after cesarean section (C-section) is uncertain.

OBJECTIVE

This study compared clinical and ultrasonographic outcomes of uterine scar defects after C-section with barbed and conventional smooth thread sutures.

STUDY DESIGN

This was a multicenter, parallel-group, randomized, controlled clinical trial. Four obstetrics and gynecology departments across three Japanese healthcare regions were included. The participants were women requiring their first cesarean delivery between May 2020 and March 2023. Of the 1211 participants enrolled, 298 underwent C-section and 253 were followed up until July 2023. Participants with singleton pregnancies were randomly assigned (1:1 ratio) to receive either conventional or spiral thread sutures with a double-layer continuous suture. The study period comprised the time of consent to the 6- to 7-month examination. The primary endpoint was the rate of scar niches >2 mm evaluated using transvaginal ultrasonography at 6 to 7 months after surgery. Additional metrics included the total operative time, suture application time, operative blood loss, number of additional sutures required for hemostasis, maternal surgical complications, postoperative infections, surgeon's years of experience, and individual subscale scores.

RESULTS

All data of the 220 participants (barbed suture group: 110; conventional suture group: 110) were available, thus enabling a full analysis set. A comparison of the barbed and conventional suture groups, respectively, revealed the following: niche length, 2.45±1.65 mm (range: 1.0-6.7) vs 3.79±1.84 mm (range: 1.0-11.0) (P<.001); niche depth, 1.78±1.07 mm (range: 1.0-5.7) vs 2.70±1.34 mm (range: 1.0-7.3) (P<.001); residual myometrial thickness (RMT), 8.46±1.74 mm (range: 4.8-13.0) vs 7.07±2.186 mm (range: 2.2-16.2) (P<.001); and niche width, 1.58±2.73 mm (range: 0.0-14.0) vs 2.88±2.36 mm (range: 0.0-11.0) (P<.001), respectively. The barbed suture group exhibited no defects and an RMT <3 mm. Furthermore, the barbed suture group had a lower rate of uterine niches (29.1%; n=32/110) than the conventional suture group (68.2%; n=75/110). Secondary outcomes showed no significant differences in operative times, maternal surgical complications, or postoperative complications.

CONCLUSION

Double-layer barbed sutures during cesarean delivery may prevent C-section scar defects and postoperative complications.

Uterine Scar Evaluation during the Postpartum: Pleading for Extradecidual Suturing during Cesarean Section

OBJECTIVE

Our objective is to evaluate ultrasound differences in uterine scar between techniques using extramucosal suturing and full thickness suturing of the uterine incision.

STUDY DESIGN

A retrospective observational study included cases of primary cesarean section. At 6-week postpartum, we evaluated by endovaginal ultrasound two elements in the sagittal view: the thickness of the uterine scar and the surface of defect (niche). Hysterotomy sites closed using a running full-thickness technique including the uterine mucosa (group 1) were compared to hysterotomies operated by the same surgeon but with extramucosal suturing (group 2). The operator switched from the running suture technique to extramucosal in 2013.

RESULTS

The study included 241 patients (115 cases in group 1 that were compared to 126 cases in group 2). There were no significant differences in age or body mass index between the two groups. Cesarean scar and niche were detectable in the entire studied population. There was a significant difference in both uterine scar thickness (5.8 vs. 6.2 mm, p = 0.02) and the presence and size of the niche (49 vs. 40 mm2, p = 0.001) in transvaginal ultrasound performed at 6-week postpartum.

CONCLUSION

Extramucosal suturing of the uterine scar seems to be associated with a better outcome on the postpartum ultrasound evaluation.

KEY POINTS

· The technique for suturing the hysterotomy can be the source of healing changes.. · An extramucosal suturing of the uterus seems to give a better aspect at the postpartum ultrasound.. · Decreasing the niche at cesarean scar may be beneficial for future pregnancies..

Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy

OBJECTIVE

To evaluate Cesarean scar defects using saline contrast sonohysterography (SCSH) in women with a history of Cesarean scar pregnancy (CSP).

METHODS

A cohort of 38 non-pregnant women with a history of CSP treated with combined local and systemic methotrexate was investigated prospectively by SCSH. For the purpose of analysis, they were classified, according to the modified Delphi consensus criteria for CSP in early gestation, into three subgroups based on the depth of the gestational sac herniation in the midsagittal plane. Subgroup A included eight (21.1%) cases, in which the largest part of the gestational sac protruded towards the uterine cavity; Subgroup B included 20 (52.6%) cases, in which the largest part of the gestational sac was embedded in the myometrium; and Subgroup C included 10 (26.3%) cases, in which the gestational sac was located partially outside the outer contour of the cervix or uterus.

RESULTS

SCSH revealed that all women in Subgroup C had a uterine niche. The median niche length (P = 0.006) and depth (P = 0.015) were significantly greater in Subgroup C than in Subgroups A or B. The median residual myometrial thickness (RMT) was significantly lower in Subgroup C than in Subgroups A or B (P = 0.006).

CONCLUSIONS

Women with prior CSP who had a gestational sac protruding beyond the serosal line had a significantly greater niche length and depth, and lower RMT. This knowledge may guide individualized risk counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

The degree of risk factor and accumulation effect for large niche in individuals after cesarean section

BACKGROUND

The risk factors associated with niche on the cesarean scar have been reported, however, the degree of these factors associated with large niche and the accumulation effects of these risk factors on the development of large niche are unclear.

METHODS

Large niche was evaluated by transvaginal sonography during mid-follicular phase. Logistic regression model was used to assess 32 risk factors by univariate analysis. Then, a scoring model based on the screened risk factors was generated. The performance of this model was evaluated by area under curve (AUC). Finally, the scoring model was applied in 123 women to assess the external validation.

RESULT(S)

In the training cohort study, 163 women were diagnosed with large niche. The final scoring model involves eight risk factors with the rating scores including age at delivery (30-34 years: 1 point; ≥ 35 years: 4.5 points), retroflexed uterus (8.5 points), meconium-stained amniotic fluid (4.5 points), twice CSs (4.0 points), postpartum endometritis (4.5 points), premature rupture of membranes (2.5 points), intrahepatic cholestasis of pregnancy (mild to moderate: 3 points; severe: 6.5 points), and cervical dilatation (1-3 cm: 2.0 points; 4-10 cm: 4.5 points). The accumulation effect with a cut-off value of 8.0 in the scoring was associated with the large niche after CS.

CONCLUSION(S)

This is the first scoring model to objectively quantify the risk of a large niche after CS. Optimal risk factors control by avoiding high score factors and multiple factors accumulation may eliminate the risk of large niche development.

The definition, diagnosis, and symptoms of the uterine niche - A systematic review

Of all neonates, 21% are delivered by cesarean section (CS). A long-term maternal complication of an SC is a uterine niche. The aim of this review is to provide an overview of the current literature on imaging techniques and niche-related symptomatology. We performed systematic searches on imaging and niche symptoms. For both searches, 87 new studies were included. Niche evaluation by transvaginal sonography (TVS) or contrast sonohysterography (SHG) proved superior over hysteroscopy or magnetic resonance imaging. Studies that used SHG in a random population identified a niche prevalence of 42%-84%. Niche prevalence differed based on niche definition, symptomatology, and imaging technique. Most studies reported an association with gynecological symptoms, poor reproductive outcomes, obstetrical complications, and reduced quality of life. In conclusion, non-invasive TVS and SHG are the superior imaging modalities to diagnose a niche. Niches are prevalent and strongly associated with gynecological symptoms and poor reproductive outcomes.

The association between uterine scar defect (niche) and the presence of symptoms

RESEARCH QUESTION

Is there association between the presence of a uterine niche and the presence of symptoms?

DESIGN

This cross-sectional study was conducted at a single tertiary medical centre. All women who underwent Caesarean section from January 2017 to June 2020 were invited to the gynaecological clinics, and requested to complete a questionnaire regarding symptoms related to the presence of a niche (heavy menstrual bleeding, intermenstrual spotting, pelvic pain, infertility). Transvaginal two-dimensional ultrasonography was performed to assess the uterus and uterine scar characteristics. The primary outcome was defined as the presence of a uterine niche, evaluated by length, depth, residual myometrial thickness (RMT) and ratio between the residual myometrial thickness (RMT) and adjacent myometrial thickness (AMT).

RESULTS

Of 524 women who were eligible and scheduled for evaluation, 282 (54%) completed the follow-up; 173 (61.3%) were symptomatic and 109 (38.6%) asymptomatic. Niche measurements, including RMT/AMT ratio, were comparable between the groups. In a sub-analysis of each symptom, heavy menstrual bleeding and intermenstrual spotting were associated with reduced RMT (P = 0.02 and P = 0.04, respectively) compared with women with normal menstrual bleeding. An RMT less than 2.5 mm was significantly more prevalent in women reporting heavy menstrual bleeding (11 [25.6%] versus 27 [11.3%]; P = 0.01] and new infertility (7 [16.3%] versus 6 [2.5%]; P = 0.001]. In logistic regression analysis, infertility was the only symptom associated with an RMT less than 2.5 mm (B = 1.9; P = 0.002).

CONCLUSIONS

A reduced RMT was found to be associated with heavy menstrual bleeding and intermenstrual spotting, while values below 2.5 mm were also associated with infertility.

Outcomes of Laparoscopic Cesarean Scar Defect Repair: Retrospective and Observational Study

Cesarean scar defect, also known as niche, isthmocele, uteroperitoneal fistula and uterine diverticulum, is a known complication after cesarean delivery. Due to the rising cesarean delivery rates, niche has become more common and can present as irregular bleeding, pelvic pain, infertility, cesarean scar pregnancy and uterine rupture. Treatments for symptomatic cesarean scar defect vary and include hormonal therapy, hysteroscopic resection, vaginal or laparoscopic repair, and hysterectomy. We report on the safety and efficacy of our method of repairing cesarean scar defects in 27 patients without adverse outcomes: two-layer repair where the suture does not enter the uterine cavity. Our method of laparoscopic niche repair improves symptoms in nearly 77% of patients, restores fertility in 73% of patients, and decreases the time to conception.

Extravillous trophoblast invasion and decidualization in cesarean scar pregnancies

INTRODUCTION

The increasing cesarean section rate has led to an increase in the number of subsequent pregnancies resulting in a cesarean scar pregnancy. There appears to be preferential attachment of the blastocyst to the scar site, which may be associated with defective decidua in that region, resulting in abnormal implantation, which can in turn negatively affect the success of the pregnancy. The aim of the current study was to evaluate the extravillous trophoblast, decidua, and myometrium in scar and adjacent non-scar regions of the implantation site of a cesarean scar pregnancy.

MATERIAL AND METHODS

Samples containing a gestational mass were obtained by laparoscopic excision from patients with a cesarean scar pregnancy at 6-11 weeks of gestation as diagnosed by transvaginal or transabdominal ultrasound (n = 8 type II cesarean scar pregnancy). Cesarean scar pregnancy tissues were separated into scar and non-scar regions, and the scar regions were sub-separated into non-implantation and implantation sites. Serial sections were histologically examined after hematoxylin and eosin, Masson's trichrome and immunochemical staining, and changes in the myometrium, extravillous trophoblast, and decidua were evaluated.

RESULTS

In cesarean scar pregnancy, compared with scars not in the implantation site, scars in the implantation site displayed increased fibrosis, and had disrupted myometrium, which was related to varying patterns of E-cadherin expression as a response to extravillous trophoblast invasion. In addition, local decidua was found at the non-scar implantation sites, with multinucleated trophoblast giant cell accumulation and shallow invasion. These features were not evident in the scar implantation sites.

CONCLUSIONS

This study emphasizes that the decidua drives multinucleated trophoblast giant cell differentiation, limiting the degree of invasion. Better characterization of this differentiation process may be helpful for better management and avoidance of the consequences of cesarean scar pregnancy.

Complications of Caesarean delivery part 2: Non-pregnant and pregnancy-related complications

INTRODUCTION

With the rise in Caesarean deliveries, complications related to the procedure are increasingly encountered. Sonography has an indispensable role in the assessment of these complications and is often the first-line investigation of choice.Topic description: Part 2 of this pictorial review summarises the non-pregnant and pregnancy-related complications of Caesarean deliveries.

DISCUSSION

Non-pregnant complications include Caesarean scar defects, scar endometriosis and malpositioned intrauterine devices. Complications related to future gestations include scar ectopic pregnancy, abnormal placentation and intrapartum uterine dehiscence or rupture. Key sonographic features of these conditions are illustrated. Pitfalls, mimics, limitations and indications for cross-sectional imaging are discussed.

CONCLUSION

Sound knowledge of the sonographic features of common non-pregnant and pregnancy-related complications of Caesarean delivery will facilitate accurate diagnosis, timely management and improved patient outcomes.

Definition of large niche after Cesarean section based on prediction of postmenstrual spotting: Chinese cohort study in non-pregnant women

OBJECTIVE

A large niche after Cesarean section (CS) is associated with long-term complications, of which postmenstrual spotting is associated positively with the size of the niche. However, the diagnosis of a large niche in the literature is inconsistent and the definition is largely subjective. The aim of this study was to generate a definition for a large niche in non-pregnant women based on the presence of postmenstrual spotting.

METHODS

Women who had undergone CS in our hospital between January 2012 and June 2017 were selected randomly from our database, contacted by telephone and subsequently examined between January 2016 and June 2020. Eligible for inclusion were non-pregnant women who had their last CS more than 1 year earlier and agreed to undergo transvaginal sonography (TVS). All participants underwent examination of their CS scar by TVS (two-dimensional color Doppler) during the midfollicular phase. Niche depth, length, width, residual myometrial thickness (RMT), adjacent myometrial thickness (AMT) and ratio of niche depth/AMT were recorded. Women diagnosed with a niche, defined as an indentation at the site of the CS with a depth of at least 2 mm, were classified into two groups (symptomatic or asymptomatic) according to whether they experienced postmenstrual spotting. Logistic regression analysis was used to establish the best cut-off values for the niche parameters to predict postmenstrual spotting. A new definition was generated based on the niche parameters with the highest area under the receiver-operating-characteristics (ROC) curve (AUC) for the prediction of postmenstrual spotting.

RESULTS

A total of 727 women who had a CS > 1 year earlier underwent TVS examination, of whom 263 were diagnosed with a niche (prevalence of 36.2%). Of these, 160 women experienced postmenstrual spotting and 103 were asymptomatic. The three variables with the highest AUC for prediction of postmenstrual spotting were niche depth/AMT ratio (AUC, 0.798; 95% CI, 0.745-0.852), niche depth (AUC, 0.731; 95% CI, 0.668-0.795) and RMT (AUC, 0.683; 95% CI, 0.618-0.748). Based on the best cut-offs according to ROC-curve analysis, a large niche was defined as: niche depth ≥ 0.50 cm, RMT ≤ 0.21 cm or niche depth/AMT ratio ≥ 0.56. The prevalence of a large niche according to this definition was 22.4% (163/727). The new definition had a specificity of 61.17% (95% CI, 52.34-70.41%) and sensitivity of 76.87% (95% CI, 70.28-84.16%) for a large niche.

CONCLUSION

This study has provided a new definition for a large niche after CS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Prospective Evaluation of the Ultrasound Signs Proposed for the Description of Uterine Niche in Nonpregnant Women

OBJECTIVES

To evaluate the new ultrasound-based signs for the diagnosis of post-cesarean section uterine niche in nonpregnant women.

METHODS

We investigated prospectively a cohort of 160 consecutive women with one previous term cesarean delivery (CD) between December 2019 and 2020. All women were separated into two subgroups according to different stages of labor at the time of their CD: subgroup A (n = 109; 68.1%) for elective CD and CD performed in latent labor at a cervical dilatation (≤4 cm) and subgroup B (n = 51; 31.9%); for CD performed during the active stage of labor (>4 cm).

RESULTS

Overall, the incidence of a uterine niche was significantly (P < .001) higher in women who had an elective (20/45; 44.4%) compared with those who had an emergent (21/115; 18.3%) CD. Compared with subgroup B, subgroup A presented with a significantly (P = .012) higher incidence of uterine niche located above the vesicovaginal fold and with a significantly (P = .0002) lower proportion of cesarean scar positioned below the vesicovaginal fold. There was a significantly (P < .001) higher proportion of women with a residual myometrial thickness (RMT) > 3 mm in subgroup A than in subgroup B and a significant negative relationship was found between the RMT and the cervical dilatation at CD (r = -0.22; P = .008).

CONCLUSIONS

Sonographic cesarean section scar assessment indicates that the type of CD and the stage of labor at which the hysterotomy is performed have an impact on the location of the scar and the scarification process including the niche formation and RMT.

Pregnancy Outcomes of Different Endometrial Preparation in Patients With a History of Cesarean Section

OBJECTIVE

To investigate the efficacies of three cycle regimens in women receiving frozen embryo transfer with a history of cesarean section: natural cycle treatment, hormone replacement therapy and treatment with gonadotropin-releasing hormone agonist.

DESIGN

Retrospective cohort study.

METHODS

patients (N = 6,159) with a history of caesarean section who fulfilled the inclusion criteria were enrolled in the study from January 2014 to December 2019 at the CITIC-Xiangya Hospital of Reproduction and Genetics. Reproductive outcomes of patients in the natural cycle (n = 4,306) versus hormone replacement therapy (n = 1,007) versus gonadotropin-releasing hormone agonist + hormone replacement therapy groups (n = 846) were compared. Continuous data were analyzed using Student's t-test, and categorical variables were analyzed using the χ2 test. Multivariable logistic regression was used to evaluate the possible relationships between the types of endometrial preparation and pregnancy outcomes after adjusting for confounding factors.

RESULTS

The unadjusted odds of the miscarriage rate of singleton pregnancies were significantly higher in the hormone replacement therapy compared with the natural cycle (25.5% versus 20.4%, respectively). After adjusting for possible confounding factors, the early miscarriage rate and the miscarriage rate of singleton pregnancies remained significantly higher in the hormone replacement therapy than the natural cycle. The clinical pregnancy rates in the natural cycle, hormone replacement therapy and gonadotropin- releasing hormone agonist + hormone replacement therapy of women with a history of cesarean section was 48.8%, 48% and 47.1%, respectively, and the live birth rates were 37%, 34.1% and 35.7%, respectively.

CONCLUSIONS

In women undergoing frozen embryo transfer with a history of cesarean section, hormone replacement therapy for endometrial preparation was associated with a higher early miscarriage rate, albeit after statistical adjustment for confounding factors. However, the risk observed was little and did not influence the overall reproductive performances.

Laparoscopic Isthmocele Repair: Efficacy and Benefits before and after Subsequent Cesarean Section

OBJECTIVE

To evaluate the effect of laparoscopic isthmocele repair on isthmocele-related symptoms and/or fertility-related problems. The residual myometrial thickness before and after subsequent cesarean section was also evaluated.

DESIGN

Retrospective, case series.

SETTING

Public university hospital.

POPULATION

Women with isthmocele (residual myometrium < 5 mm) complaining of abnormal uterine bleeding, chronic pelvic pain or secondary infertility not otherwise specified.

METHODS

Women's complaints and the residual myometrium were assessed pre-operatively and at three to six months post-operatively. In patients who conceived after surgery, the latter was measured at least six months after delivery by cesarean section.

MAIN OUTCOME MEASURES

Resolution of the main symptom three to six months after surgery and persistence of laparoscopic repair benefits after subsequent cesarean section were considered as primary outcome measures.

RESULTS

Overall, 31 women underwent laparoscopic isthmocele repair. The success rates of the surgery as improvement of abnormal uterine bleeding, chronic pelvic pain and secondary infertility were 71.4% (10 of 14), 83.3% (10 of 12) and 83.3% (10 of 12), respectively. Mean residual myometrial thickness increased significantly from 1.77 mm pre-operatively to 6.67 mm, three to six months post-operatively. Mean myometrial thickness in patients who underwent subsequent cesarean section (N = 7) was 4.49 mm. In this sub-group, there was no significant difference between the mean myometrial thickness measured after the laparoscopic isthmocele repair and that measured after the subsequent cesarean section. None of these patients reported recurrence of their symptoms after delivery.

CONCLUSION

Our findings suggest that the laparoscopic isthmocele excision and repair is an appropriate approach for the treatment of isthmocele-related symptoms when done by skilled laparoscopic surgeons. The benefit of this new surgical approach seems to persist even after a subsequent cesarean section. Further investigations and prospective studies are required to confirm this finding.

A new technique for uterine incision closure at the time of cesarean section: does it make a difference?

The purpose of this study was to compare the short-term operative outcomes of three different surgical techniques for uterine incision closure during caesarean section (CS). This trial enrolled 120 patients scheduled for primary caesarean delivery. Patients were randomised into either classical double-layer uterine closure, purse-string double-layer uterine closure (Turan), or our new approach of uterine closure (double layer step up-step down technique). For short-term comparison, transvaginal ultrasonography was planned for all patients 6 weeks after surgery. Compared to group II and Group III, residual myometrial thickness was significantly thinner in group I (p < .001). The number of patients with uterine niche was 10 (50% of all scar defects) in group I whereas it was 4 (20%) in group II and 6 (30%) in group III. Operative time was significantly longer in group II (p < .001). This led to our conclusion that Turan technique and our new approach are associated with thicker myometrial thickness and less frequency of uterine scar defect than classical double-layer uterine incision closure; however, our approach takes less operative time. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT04681378Impact statementWhat is already known on this subject? Many variations in CS technique have been studied. For example, single-layer uterine incision closure has been compared to double-layer uterine incision closure. Purse string double layer (Turan) has been also compared to the traditional double-layer technique. Double layer unlocked closure has been shown to result in a thicker residual myometrium and as a consequence can possibly lead to the decrease of niche development after a CS compared to single-layer closure with lower frequency of uterine scar defect with Turan technique.What do the results of this study add? Here we introduce a new uterine closure technique, which we have named double-layer step up-step down technique, as an alternative method. With this technique, the uterine incision contract more than with the traditional double layer technique and has similar results to the Turan technique; however, our approach takes less operative time.What are the implications of these findings for clinical practice and/or further research? These alternative techniques of uterine incision closure decrease the frequency of uterine niche that may be associated with many clinical problems such as ectopic pregnancy at the CS scar, placenta accreta, rupture of the uterus during a subsequent pregnancy. Future studies are needed to investigate the frequency of uterine rupture in a subsequent pregnancy following different uterine incision closure techniques.

The Spiral Trial: A multicenter, randomized, controlled trial of Spiral thread sutures versus conventional thread sutures to prevent thinning of uterine scars following elective cesarean section

BACKGROUND

The aim of this randomized controlled trial (RCT) is to investigate whether Spiral-thread sutures are superior to conventional sutures (0-Vicryl) for preventing uterine scar thinning following elective cesarean section.

METHODS

This multicenter, parallel-group RCT will be conducted in four hospitals across three medical regions in Japan to assess 200 women (≥20 years old) with singleton pregnancies who are scheduled to undergo cesarean sections. Eligible women will be randomly assigned (1:1 ratio) to receive either the conventional uterine suture continuous absorption thread, which is most commonly used in Japan, or the Spiral thread. The primary endpoint is the degree of scar thinning, measured by transvaginal ultrasonography 6-7 months postoperatively, to evaluate the position of the uterus (anterior or posterior tilt) and myometrial wound thickness. The degree of thinning will be compared between the groups, and four measurements (mm) of the thinning area, including caudal distance, depth of the depression, remaining thickness of the myometrium on the serous side of the most depressed area, and width of the depression, will be recorded in the sagittal view on transvaginal ultrasound. Secondary endpoints will include total operative time, suture application time (from birth to the end of uterine suturing), operative blood loss, number of additional Z-sutures or continuous sutures required to stop bleeding, maternal abnormality frequency (surgical complications and postoperative infections), surgeon's years of experience, and clinical interpretation of individual subscale scores.

DISCUSSION

This study shall provide important evidence on the optimal suture for preventing hysterotomy wound thinning after the first cesarean section.

TRIAL REGISTRATION

National Institute of Public Health, Japan: jRCT1062200001 (May 7, 2020; https://rctportal.niph.go.jp/en/detail?trial_id=jRCT1062200001) and Okayama University Certified Review Board: CRB6180001 (April 9, 2020, version 3.0).

Evaluation of uterine scar healing by transvaginal ultrasound in 607 nonpregnant women with a history of cesarean section

BACKGROUND

Caesarean scar defect (CSD) seriously affects female reproductive health. In this study, we aim to evaluate uterine scar healing by transvaginal ultrasound (TVS) in nonpregnant women with cesarean section (CS) history and to build a predictive model for cesarean scar defects is very necessary.

METHODS

A total of 607 nonpregnant women with previous CS who have transvaginal ultrasound measurements of the thickness of the lower uterine segment. The related clinical data were recorded and analyzed.

RESULTS

All patients were divided into two groups according to their clinical symptoms: Group A (N = 405) who had no cesarean scar symptoms, and Group B (N = 141) who had cesarean scar symptoms. The difference in frequency of CS, uterine position, detection rate of CSD and the residual muscular layer (TRM) of the CSD were statistically significant between groups; the TRM measurements of the two groups were (mm) 5.39 ± 3.34 versus 3.22 ± 2.33, P < 0.05. All patients were divided into two groups according to whether they had CSDs: Group C (N = 337) who had no CSDs, Group D (N = 209) who had CSDs on ultrasound examination. The differences in frequency of CS, uterine position, TRM between groups were statistically significant (P < 0.05). In the model predicting CSDs by TRM with TVS, the area under the ROC curve was 0.771, the cut-off value was 4.15 mm. The sensitivity and specificity were 87.8% and 71.3%, respectively.

CONCLUSIONS

Patients with no clinical symptoms had a mean TRM on transvaginal ultrasonography of 5.39 ± 3.34 mm, which could be used as a good reference to predict the recovery of patients with CSDs after repair surgery.

Position and integrity of uterine scar are determined by degree of cervical dilatation at time of Cesarean section

OBJECTIVE

Abnormal placental invasion is more common after an elective Cesarean delivery, suggesting that prelabor Cesarean section (CS) increases the likelihood of the CS scar being above the internal cervical os and predisposing to a scar pregnancy in the future. The aim of this study was to assess the location and integrity of the CS scar in postpartum women delivered by CS at different stages of labor.

METHODS

This was a prospective cohort study of women at term who underwent a CS for the first time. In all women, cervical dilatation was determined by digital examination at the time of the CS. All patients had a transvaginal ultrasound examination to assess the location of the CS scar in relation to the internal cervical os, as well as the presence of a scar niche.

RESULTS

A total of 407 pregnant women were recruited into the study: 103 with cervical dilatation ≤ 2 cm, 261 with cervical dilatation 3-7 cm and 43 with cervical dilatation ≥ 8 cm at the time of the CS. A statistically significant correlation was observed between cervical dilatation at the time of the CS and the position of the CS scar. The scar was positioned in the uterus above the internal cervical os in 97.1% (100/103) of women delivered at a cervical dilatation of 0-2 cm, whereas the scar was located at or below the internal cervical os in 97.7% (42/43) of cases delivered at a cervical dilatation of 8-10 cm (P < 0.001). A uterine-scar defect (niche) was observed in 38.1% (64/168) of women with the scar located above, compared with 18.0% (43/239) of those with the scar situated at or below, the internal cervical os (P < 0.001).

CONCLUSIONS

Prelabor and early-labor Cesarean delivery are associated with an increased prevalence of a scar in the uterine cavity as well as a scar niche. CS in late labor is associated with the uterine scar being situated in the endocervical canal and with a lower incidence of a niche. The position and integrity of the CS scar after prelabor and early-labor Cesarean delivery explain the predisposition to abnormal placental invasion in subsequent pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Hysteroscopy in the Treatment of Myometrial Scar Defect (Diverticulum) Following Cesarean Section Delivery: A Systematic Review and Meta-Analysis

Various management approaches have been developed to treat symptoms and prevent complications of the cesarean diverticulum. This systematic review aims to report the outcomes and fertility-related effects of hysteroscopy on women with myometrial scar defects after the cesarean section. Following the formulation of the patient/population, intervention, comparison, and outcomes (PICO) criteria, a systematic search was conducted on seven databases. Finally, a total of 18 studies were included for this systematic review and meta-analysis. All of the included patients suffered from post-cesarean section scars and presented with abnormal bleeding, pain, or secondary infertility. The overall pooled symptomatic improvement rate was 78.83% (95% CI: 72.46-85.76%); however, there was significant heterogeneity among the analyzed studies (I²=87%; p-value: <0.001) and a significant risk of bias (p-value: <0.001). The overall resolution/improvement rate after adjusting for possible bias was higher, 92.82% (95% CI: 85.17-100%). The overall pregnancy rate was 69.77% (95% CI: 59.03-82.48%), while in the individual studies the rates varied, ranging from 25% to 80%. Nevertheless, there was moderate heterogeneity among the included studies (I²=56%; p-value=0.011). In contrast, there was no significant risk of bias among the included studies (p-value=0.100). Furthermore, the meta-regression analyses did not show any significant effect of different follow-up durations on the overall effect size for both outcomes. In conclusion, there is still a need for high-quality, comparative studies with larger sample sizes and long-term follow-up periods to draw firm conclusions. Moreover, future studies should consider the minimum myometrial thickness that is sufficient to complete a healthy pregnancy.

A comparison of the effects of Two suture materials on isthmocele formation: A cohort study

OBJECTIVE

Cesarean scar defects (CSD) are a problem that may lead to complications and excessive cost. The optimal way to suture the uterus is a matter of debate. The aim of this study was to evaluate the effect of two suture materials on cesarean scar niches.

STUDY DESIGN

This was a cohort study that allocated women into two groups: uterotomy closure with vicryl or catgut sutures. Transvaginal ultrasound (TVUS) was performed six months after the cesarean section (CS) to assess the scar.

RESULTS

Totally, 250 patients enrolled in this study. After six months, 20 (18.2 %) patients in the catgut suture group and 13 (9.3 %) patients in the vicryl group had isthmocele according to their sonography reports. The prevalence of isthmocele was higher in the catgut group (p = 0.03). The residual myometrial thickness was greater in the vicryl group (4.98 cm ± 2.18) compared to the catgut suture group (3.70 cm ± 1.50; p = 0.001). The prevalence of postoperative gynecological sequelae such as postmenstrual spotting and pain were similar between the two groups.

CONCLUSION

Vicryl sutures were associated with a lower risk of CSD formation in comparison with catgut sutures.

Endoscopic Treatment of Previous Cesarean Scar Defect in Women with Postmenstrual Bleeding: A Retrospective Cohort Study

OBJECTIVE

To compare the incidence of postmenstrual bleeding after hysteroscopic resection versus laparoscopic repair of previous cesarean scar defect (PCSD).

MATERIALS AND METHODS

Retrospective analysis of computerized patient records. For the diagnosis of PCSD, patients underwent transvaginal ultrasound first without and then with saline-assisted sonohysterography. Hysteroscopic PCSD resection was performed under sonographic guidance, while laparoscopic repair was guided by hysteroscopy for the confirmation of scar margins.

RESULTS

Records of 62 patients presenting with PCSD-related postmenstrual bleeding were included in analysis. Hysteroscopic surgery had significantly shorter operative time compared to the laparoscopic approach (Mean =30.9 vs 71.0 minutes; p < 0.001). Blood loss and hospital stay were significantly less (p < 0.001) in hysteroscopic resection (10.4 ± 4.6 ml and 2.1 ± 0.4 days) than in laparoscopic repair (36.6 ± 4 ml, and 4.6 ± 1 days). After surgical interventions, the postmenstrual bleeding was resolved or improved. The effectiveness rates of hysteroscopic resection and laparoscopic repair were 91.4% and 96.3%, respectively. Incidence of post-treatment postmenstrual bleeding was not significantly different between hysteroscopy and laparoscopy (OR= 1.29 [95% confidence interval 0.367, 4.86]; p = 0.662). Pretreatment postmenstrual bleeding was associated with time since cesarean section (B= -0.091 [-0.158, -0.023]; p = 0.01) and PCSD length (B = 0.502 [0.085, 0.919]; p = 0.019).

CONCLUSION

Both hysteroscopic resection and laparoscopic repair of PCSD yield comparable efficacy in reducing postmenstrual bleeding. However, hysteoroscopic resection of PCSD is associated with comparatively shorter operative time, less blood loss, and shorter hospital stay.

Identifying possible risk factors for cesarean scar pregnancy based on a retrospective study of 291 cases

Aim

Cesarean scar pregnancy (CSP) is a rare but life‐threatening type of ectopic pregnancy. This study's aim is to investigate the clinical characteristics and possible risk factors for cesarean scar pregnancy.

Methods

A clinically randomized, unpaired and retrospective case–control study was implemented. A study group of 291 CSP patients and a control group of 317 full‐term pregnant women with a history of cesarean section (CS) were recruited in our hospital from May 2013 to October 2018. Their demographic characteristics and medical and obstetric history were collected.

Results

Only symptoms suggestive of an impending abortion, such as vaginal bleeding with or without abdominal pain, were identified as the clinical characteristics of CSP. Maternal age older than 35 years, gravidity higher than 3 (especially gravidity higher than 5), more than two induced abortions (especially more than five abortions), an interval of less than 5 years (especially less than 2 years) between the current pregnancy and the last CS, history of CS performed in a rural hospital, history of induced abortions after CS and retroposition of the uterus were possible independent risk factors for CSP.

Conclusion

CSP is a result of a combination of multiple factors associated with CS. There are no unique early clinical features of CSP. As a unique type of ectopic pregnancy, early diagnosis, early termination and early clearance should be the treatment principles. Further research is needed to evaluate the relationship between the cesarean scar defect and CSP in the future.

Imaging findings of cesarean delivery complications: cesarean scar disease and much more

In the last years, there has been a significant increase in the number of cesarean deliveries and, with it, of the number of complications following the procedure. They can be divided into early and late ones. We will illustrate herein the most common complications following cesarean section to help radiologists to recognize them. To familiarize with these various pathologic conditions is crucial to alert referring clinicians for a prompt and appropriate maternal and fetal management. Special attention will be given to the cesarean scar defect (CSD), the most common but also the most unknown of such conditions. Although often asymptomatic, a severe CSD represents a predisposing factor for subsequent complications especially in future pregnancies.

Isthmocele: an overview of diagnosis and treatment

An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

Hysterotomy level at Cesarean section and occurrence of large scar defects: a randomized single-blind trial

OBJECTIVE

To study the association between the level of Cesarean hysterotomy and the presence of large uterine scar defects 6-9 months after delivery.

METHODS

This was a two-center, randomized, single-blind trial of a surgical procedure with masked assessment of the principal outcome under study. Women without a history of Cesarean section (CS) who underwent emergency CS at cervical dilatation ≥ 5 cm were randomized to high or low incision. Hysterotomy was performed 2 cm above and 2 cm below the plica vesicouterina in the high and low incision groups, respectively. Women were examined using saline contrast sonohysterography to assess the appearance of the hysterotomy scar 6-9 months after delivery. The main outcome was presence of a large scar defect, defined as the remaining myometrial thickness over the defect being ≤ 2.5 mm. Secondary outcomes were perinatal outcome, operative complications within 8 weeks after delivery and long-term outcome in a subsequent pregnancy.

RESULTS

Of 122 patients enrolled in the trial, 114 were assessed by ultrasound examination, of whom 55 were randomized to high and 59 to low CS incision. Large scar defects were seen in four (7%) women in the high-incision group and in 24 (41%) in the low-incision group (P < 0.001; odds ratio, 8.7 (95% CI, 2.8-27.4)). There were no differences in operative complications and perinatal outcomes between the two groups. The median follow-up time was 4 years and 7 months, during which 56 (49%) women had a subsequent pregnancy. No significant differences were observed in the rate of complications in subsequent pregnancy and delivery between women who had low and those who had high incision at the index CS.

CONCLUSION

Low Cesarean hysterotomy level in women in advanced labor is associated with higher incidence of large scar defects detected by transvaginal ultrasound examination 6-9 months after delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

New ultrasound grading system for cesarean scar pregnancy and its implications for management strategies: An observational cohort study

A cesarean section pregnancy (CSP) indicated the gestational sac (GS) implanted in the previous cesarean scar. The clinical manifestations of CSP present a wide range of variations, and the optimal management is yet to be defined. We retrospectively enrolled 109 patients with the diagnosis of CSP from our department and categorized them into four grades based on the ultrasound presentation. Grade I CSP indicated the GS embedded in less than one-half thickness of the lower anterior corpus; and grade II CSP represented the GS extended to more than one-half thickness of overlying myometrium. Grade III CSP implied the GS bulged out of the cesarean scar; and grade IV CSP denoted that GS became an amorphous tumor with rich vascularity at the cesarean scar. Seventy-eight women received surgery, and the complication rate was 14.1% (11/78). Linear regression analysis demonstrated a significant association between the invasiveness of the surgery and their ultrasound gradings. The mainstream operation for grade I CSP was transcervical resection, while the majority of grade III and IV patients required hysterotomy or hysterectomy. Another 31 women received chemotherapy with methotrexate as their initial treatment. The success rate for chemotherapy was 61.3%; the remaining patients required further surgery due to persistent CSP or heavy bleeding during or after chemotherapy. Fifteen patients (48.3%) receiving chemotherapy suffered from complications (mostly bleeding). Among them, 7 (22.6%) patients experienced bleeding of more than 1,000 mL, and 9 (29.0%) of these 31 patients required blood transfusions. Our novel ultrasound grading system for CSP may help to communicate between physicians, and determine the optimal surgical strategy. Chemotherapy with methotrexate for CSP is not satisfactory and is associated with a higher rate of complications.

Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta-analysis

BACKGROUND

Caesarean section (CS) rates are rising globally. Long-term adverse outcomes after CS might be reduced when the optimal uterine closure technique becomes evident.

OBJECTIVE

To determine the effect of uterine closure techniques after CS on maternal and ultrasound outcomes.

SEARCH STRATEGY

Literature search in electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or prospective cohort studies that evaluated uterine closure techniques and reported on ultrasound findings, perioperative or long-term outcomes.

DATA COLLECTION AND ANALYSIS

Twenty studies (15 053 women) were included in our meta-analyses for various outcomes. We calculated pooled risk ratios (RR) and weighted mean differences (WMD) with 95% CI through random-effect analysis.

MAIN RESULTS

Residual myometrium thickness (RMT), reported in eight studies (508 women), decreased by 1.26 mm after single- compared with double-layer closure (95% CI -1.93 to -0.58), particularly when locked sutures were used. Healing ratio [RMT/adjacent myometrium thickness (AMT)] decreased after single-layer closure (WMD -7.74%, 95% CI -13.31 to -2.17), particularly in the case of locked sutures. Niche prevalence increased (RR 1.71, 95% CI 1.11-2.62) when the decidua was excluded. Dysmenorrhea occurred more often in the single-layer group (RR 1.23, 95% CI 1.01-1.48), whereas incidence of uterine rupture was similar (RR 1.91, 95% CI 0.63-5.74).

CONCLUSION

Double-layer unlocked sutures are preferable to single-layer locked sutures regarding RMT, healing ratio and dysmenorrhoea. Excluding the decidua seems to result in higher niche prevalence. As thin residual myometrium or niches may serve as intermediates for gynaecological and reproductive outcomes, future studies should focus on these outcomes. TWEETABLE ABSTRACT: #Uterineclosuretechniques after #caesarean affect #longtermoutcomes.

Research on the expression of integrin β3 and leukaemia inhibitory factor in the decidua of women with cesarean scar pregnancy

Background

Cesarean scar pregnancy (CSP) is a late serious complication of cesarean section. There has been an increase in the incidence of CSP worldwide in recent years. It’s a life-threatening condition because of the high risk of uncontrolled hemorrhage and uterine rupture. The mechanism of CSP is still unclear. The endometrial receptivity might be different in the cesarean scar between CSP and normal pregnancies. Endometrial expression of integrin β3 and LIF positively correlates with endometrial receptivity and embryo implantation. The purpose of the study is to explore the mechanism of CSP.

Methods

The EnVision two-step immunohistochemical staining technique was used to detect the expression of integrin β3 and LIF in the decidua of women with CSP (20 cases) and normal pregnancies (20 cases). The distribution and staining intensity of integrin β3 and LIF in the two groups were observed. Observation of the staining were done using microscope within five randomly selected high-power fields (HPF, 10 × 40). All data analyses were conducted with SPSS 17.0 and the statistical significance was set at P <0.05.

Results

The decidua in the different parts of both two groups that stained with the anti-integrin β3 and anti-LIF antibody: most of the integrin β3 and LIF positive cells were located in glandular epithelium. The expression intensity of integrin β3 in the cesarean scar in CSP group was significant higher than the uterine cavity in CSP group and the cesarean scar in normal pregnancy group. It’s similar with the uterine cavity in normal pregnancy group. The expression intensity of LIF in the cesarean scar in CSP group was significant higher than the uterine cavity in CSP group and the cesarean scar in normal pregnancy group. It’s significant lower than the uterine cavity in normal pregnancy group.

Conclusions

The decidual integrin β3 and LIF might play an important role in the mechanism of CSP. The increase expression of integrin β3 and LIF in the cesarean scar decidua might be associated with embryo implantation in cesarean scar. The occurrence of CSP might be related to the changes of endometrial receptivity in local cesarean scar.

[Interest of saline contrast sonohysterography for the diagnosis of cesarean scar defects]

OBJECTIVES

To determine the interest of saline contrast sonohysterography in the evaluation of number, size and shape of cesarean scar defects in comparison with 3D-transvaginal ultrasound examination.

METHODS

Patients who had surgical reparation of cesarean scar defect by operative hysteroscopy were included in this retrospective study. Before surgery, they all had 3D-transvaginal ultrasound examination and saline contrast sonohysterography to establish the diagnosis. Then those two exams were compared to determine which one is better for cesarean scar defect evaluation, in terms of diagnosis and severity.

RESULTS

Fourteen patients were enrolled, they underwent transvaginal ultrasound and saline contrast sonohysterography before the surgery. 3D-transvaginal ultrasound examination made the diagnosis in 50% of patients with cesarean scar defect, whereas saline contrast sonohysterography enabled to detect 86% of defects, in comparison with hysteroscopy (100%). In 29% of patients, the size and depth of the cesarean scar defect was more important with saline contrast sonohysterography and hysteroscopy than expected by 3D-transvaginal ultrasound examination. After surgical repair, symptoms improvement was found in 82% of case (pain or abnormal uterine bleeding), and fertility was restored in 67%.

CONCLUSION

Saline contrast sonohysterography is better to characterize cesarean scar defects than 3D-transvaginal ultrasound, with a higher sensibility. Moreover, it evaluates more precisely the size and shape of the defect, thus severity.

Comparison of the primary cesarean hysterotomy scars after single- and double-layer interrupted closure

INTRODUCTION

It is unclear whether hysterotomy closure techniques can affect niche development. Therefore, this study aimed to analyze the effect of single-layer and double-layer interrupted closures of hysterotomy incisions during primary cesarean section on the formation of uterine niches.

MATERIAL AND METHODS

A prospective cohort study of women undergoing primary cesarean section was performed between June 2011 and July 2014. Saline contrast sonohysterography was used to measure the niche depth and residual myometrium. The ratio of the niche depth to the sum of the niche depth and residual myometrium thickness (niche ratio) was calculated.

RESULTS

Niches were identified in 14/58 (24.1%) women with single-layer sutures and 55/209 (26.3%) women with double-layer sutures (p = 0.74). Single-layer closure was associated with more than a five-fold increase in the odds of a niche ratio ≥0.4 (odds ratio 5.59; 95% CI 1.71-18.28).

CONCLUSION

Single-layer closure may be associated with an increased risk of larger niches (niche ratio ≥0.4), although it may not increase the overall frequency of niche formation.

Impact of a prior cesarean delivery on embryo transfer: a prospective study

OBJECTIVE

To determine whether a history of prior cesarean delivery (CD) makes ET more difficult and impacts pregnancy outcomes.

DESIGN

Prospective cohort study.

SETTING

Tertiary care military facility.

PATIENT(S)

One hundred ninety-four patients with previous delivery undergoing IVF/intracytoplasmic sperm injection (ICSI)-ET.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth (primary), positive hCG, clinical pregnancy, and time to perform ET.

RESULT(S)

There was no statistically significant difference between patients with a history of only vaginal deliveries versus those with a history of CD for live birth (39% vs. 32%), positive hCG (56% vs. 53%), or clinical pregnancy (49% vs. 41%). Embryo transfers took longer in the history of CD group (157 vs. 187 seconds) and were more likely to have mucus (27% vs. 45%) or blood (8% vs. 21%) on the catheter.

CONCLUSION(S)

Embryo transfers performed on patients with a prior CD took 30 seconds longer. They were also more likely to have blood or mucus on the catheter. Despite the apparently more difficult transfers, pregnancy outcomes were not different between the two groups.

Assessment of Cesarean hysterotomy scar in non-pregnant women: reliability of transvaginal sonography with and without contrast enhancement

OBJECTIVES

To determine intra- and interobserver reliability of evaluating the appearance and measurement of Cesarean hysterotomy scars using transvaginal ultrasound (TVS), with and without saline contrast sonohysterography (SCSH), in non-pregnant women.

METHODS

Fifty-six women with one previous Cesarean delivery were examined by TVS, with and without contrast enhancement, 6-9 months after the Cesarean delivery. Two observers, blinded to their own and each other's measurements, evaluated the appearance of the hysterotomy scar and measured the myometrial thickness adjacent to the scar or scar defect (MTS). If a scar defect was noted, the remaining myometrial thickness over the defect (RMT) was measured. A scar defect was defined as large if RMT was ≤ 2.2 mm on conventional TVS and ≤ 2.5 mm when SCSH was performed. Intra- and interobserver reliability of conventional TVS and SCSH were assessed.

RESULTS

Intraobserver reliability was good, with intraclass correlation coefficients (ICCs) of ≥ 0.97 for measurements of MTS and RMT on conventional TVS and SCSH. Interobserver ICCs for measurements obtained on SCSH were 0.85 (95% CI, 0.76-0.91) for MTS and 0.96 (95% CI, 0.93-0.98) for RMT, compared with 0.82 (95% CI, 0.72-0.89) for MTS and 0.87 (95% CI, 0.68-0.95) for RMT measured on conventional TVS. The kappa coefficient for measurements obtained on SCSH was 0.92, compared with 0.85 for conventional TVS. Intermethod ICC was 0.86 (95% CI, 0.78-0.92) for measurement of MTS and 0.89 (95% CI, 0.78-0.95) for measurement of RMT, with a kappa coefficient of 0.57.

CONCLUSIONS

Measurement of RMT using SCSH is a reliable method for assessing Cesarean hysterotomy scars in non-pregnant women and can be used in clinical practice. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound diagnosis of caesarean scar defects

Caesarean section (CS) scar defects are seen in up to 19% of women post lower segment caesarean section. Ultrasound and in particular transvaginal ultrasound, with or without saline, is the imaging modality of choice to delineate such defects. There are limited data available however which enable clinicians to quantify the risk of potential sequelae in women with a demonstrable CS scar defect.

Menstrual Pattern following Tubal Ligation: A Historical Cohort Study

Background

Tubal ligation (TL) is recommended for women who have completed their family planning. The existence of the menstrual disorders following this procedure has been the subject of debate for decades. This study was conducted to identify the relationship between tubal ligation and menstrual disorders.

Materials and Methods

A historical cohort study was carried out on 140 women undergoing tubal ligation (TL group) and on 140 women using condom as the main contraceptive method (Non-TL group). They aged between 20 and 40 years and were selected from a health care center in Rudsar, Guilan Province, Iran, during 2013-2014. The two groups were comparable in demographic characteristics, obstetrical features and menstrual bleeding pattern using a routine questionnaire. A validated pictorial blood loss assessment chart (PBLAC) was also used to measure the menstrual blood loss.

Results

Women with TL had more menstrual irregularity than those without TL (24.3 vs. 10%, P=0.002). Women with TL had more polymenorrhea (9.3 vs. 1.4%, P=0.006), hypermenorrhea (12.1 vs. 2.1%, P=0.002), menorrhagia (62.9 vs. 22.1%, P<0.0001) and menometrorrhagia (15.7 vs. 3.6%, P=0.001) than those without TL. There is a significant difference in the PBLAC score between women with and without TL (P<0.0001). According to logistic regression, age odds ratio [(OR=1.08, con- fidence interval (CI):1.07-1.17, P=0.03)], TL (OR=5.95, CI:3.45-10.26, P<0.0001) and cesarean section (OR=2.72, CI:1.49-4.97, P=0.001) were significantly associated with menorrhagia.

Conclusion

We found significant differences in menstrual disorders between women with and without TL. Therefore, women should be informed by the health providers regarding the advantages and disadvantages of TL before the procedures.

The HysNiche trial: hysteroscopic resection of uterine caesarean scar defect (niche) in patients with abnormal bleeding, a randomised controlled trial

Background

A caesarean section (CS) can cause a defect or disruption of the myometrium at the site of the uterine scar, called a niche. In recent years, an association between a niche and postmenstrual spotting after a CS has been demonstrated. Hysteroscopic resection of these niches is thought to reduce spotting and menstrual pain. However, there are no randomised trials assessing the effectiveness of a hysteroscopic niche resection.

Methods/Design

We planned a multicentre randomised trial comparing hysteroscopic niche resection to no intervention. We study women with postmenstrual spotting after a CS and a niche with a residual myometrium of at least 3 mm during sonohysterography. After informed consent is obtained, eligible women will be randomly allocated to hysteroscopic resection of the niche or expectant management for 6 months.

The primary outcome is the number of days with postmenstrual spotting during one menstrual cycle 6 months after randomisation. Secondary outcomes are menstrual characteristics, menstruation related pain and experienced discomfort due to spotting or menstrual pain, quality of life, patient satisfaction, sexual function, urological symptoms, medical consultations, medication use, complications, lost productivity and medical costs. Measurements will be performed at baseline and at 3 and 6 months after randomisation. A cost-effectiveness analysis will be performed from a societal perspective at 6 months after randomisation.

Discussion

This trial will provide insight in the (cost)effectiveness of hysteroscopic resection of a niche versus expectant management in women who have postmenstrual spotting and a niche with sufficient residual myometrium to perform a hysteroscopic niche resection.

Trial registration

Dutch Trial Register NTR3269. Registered 1 February 2012. ZonMw Grant number 80-82305-97-12030

Successful management of a cesarean scar defect with dehiscence of the uterine incision by using wound lavage

Cesarean scar defects (CSDs) that can be visualized using transvaginal ultrasonography (TVUS) may cause prolonged menstruation, irregular genital bleeding, and secondary infertility; surgical repair is sometimes necessary. We present a case of CSD, with dehiscence of the uterine incision, which was managed using wound lavage. A 38-year-old woman (gravida 4, para 4) had delivered her third and fourth children by cesarean section. Upon the resumption of menstruation, 9 months after her second cesarean section, she demonstrated prolonged menstruation and the presence of a menstrual fistula due to dehiscence of the cesarean section incision from the myometrium to the serosa. We treated the defect by lavaging with a physiological saline solution. After lavaging the wound 3 times, spontaneous healing of the dehiscent muscle layer was successfully achieved. The treatment was complication-free and the healing of the muscle layer has been maintained for more than 8 months.

Transvaginal ultrasound assessment of uterine scar after previous caesarean section: comparison with 3T-magnetic resonance diffusion tensor imaging

PURPOSE

This study aimed to evaluate 3-T magnetic resonance imaging in the analysis of caesarean scars in women with prior caesarean section (pCS) and investigate the potential added value of diffusion tensor imaging (3T-MR-DTI) with fibre tracking reconstruction, compared with transvaginal ultrasound (TVUS).

METHODS

Thirty women who had previously undergone elective CS in a singleton pregnancy at term were examined (19 women with one pCS formed group 1 and 11 women with two pCS formed group 2). Patients underwent TVUS and 3T-MR-DTI within 2 days. Twelve women with prior vaginal delivery served as controls and underwent only 3T-MR. Uterine fibre architecture was depicted by MR-DTI with 3D tractography reconstruction providing quali-quantitative analysis of fibre, described as the reduction of number of longitudinal fibres that run through the uterine scar.

RESULTS

Six subjects were excluded. According to 3T-MR morphology, scars were described as linear (n = 12) and retracting (n = 12); disagreement with TVUS was 54 %. The thickness of myometrium at the scar level was found to be significantly greater with 3T-MR compared to TVUS in linear scars (p = 0.01). No difference was found among retracting scars. In controls, according to 3T-MR-DTI, longitudinal myometrial fibres running in the anterior wall were similar to those in the posterior wall at same level -2 %; -27 % + 22 %). In groups 1 and 2 there was significant reduction in anterior fibres compared to posterior ones (-53 %; -77 % - 34 %; p = 0.0001). Among retracting scars, fibre reduction was significantly higher compared to linear scars, p < 0.016.

CONCLUSIONS

The added value of 3T-MR with DTI lies in the prompt evaluation of muscle fibre remaining at scar level.