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Lin PL, Hou JH, Chen CH. A common problem between gynecology, obstetrics, and reproductive medicine: Cesarean section scar defect. Taiwan J Obstet Gynecol 2024; 63:459-470. [PMID: 39004471 DOI: 10.1016/j.tjog.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 07/16/2024] Open
Abstract
Approximately 60% of patients undergoing Cesarean sections may develop Cesarean Scar Defect (CSD), presenting a significant clinical challenge amidst the increasing Cesarean section rates. This condition, marked by a notch in the anterior uterine wall, has evolved as a notable topic in gynecological research. The multifactorial origins of CSD can be broadly classified into labor-related factors, patients' physical conditions, and surgical quality. However, conflicting influences of certain factors across studies make it challenging to determine effective preventive strategies. Additionally, CSD manifests with diverse symptoms, such as abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, dyspareunia, secondary infertility, and Cesarean scar pregnancy. Some symptoms are often attributed to other diagnoses, leading to delayed treatment. The quandary of when and how to manage CSD also adds to the complexity. Despite the development of various therapies, clear indications and optimal methods for specific conditions remain elusive. This longstanding challenge has troubled clinicians in both identifying and addressing this iatrogenic disease. Recent studies have yielded some compelling consensuses on various aspects of CSD. This review aims to consolidate the current literature on every facet of CSD. We hope to raise awareness among clinicians about this clinical problem, encouraging more relevant research to unveil the complete picture of CSD.
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Affiliation(s)
- Ping-Lun Lin
- Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Taipei Medical University Hospital, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan.
| | - Jung-Hsiu Hou
- Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Taipei Medical University Hospital, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan; Graduate Institute of Medical Science, College of Medicine, Taipei Medical University, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan.
| | - Chi-Huang Chen
- Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Taipei Medical University Hospital, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan; Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan.
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Meyer JA, Silverstein J, Timor-Tritsch IE, Antoine C. The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries. J Perinat Med 2024; 52:150-157. [PMID: 38081042 DOI: 10.1515/jpm-2023-0211] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/26/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVES To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). METHODS Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. RESULTS A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. CONCLUSIONS While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.
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Affiliation(s)
- Jessica A Meyer
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jenna Silverstein
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ilan E Timor-Tritsch
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Maternal Resources, Hoboken, NJ, USA
| | - Clarel Antoine
- Department of Obstetrics & Gynecology, NYU Grossman School of Medicine, New York, NY, USA
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Donnez O. Cesarean scar disorder: Management and repair. Best Pract Res Clin Obstet Gynaecol 2023; 90:102398. [PMID: 37598564 DOI: 10.1016/j.bpobgyn.2023.102398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/14/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023]
Abstract
Cesarean scar disorder (CSD) is an entity recently defined as uterine niche with at least one primary or 2 secondary symptoms. CSDs can be visualized by hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging, but diagnosis should be performed by exams able to measure the residual myometrial thickness (RMT). Although there is a limited number of studies evaluating fertility and reproductive outcomes after different types of surgery, the following consideration should be kept in mind. Asymptomatic women should not be operated with the hope of improving obstetrical outcomes. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be offered according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and RMT measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique in case of RMT <3 mm. In this instance, repair is essential and can only be achieved by a laparoscopic or vaginal approach. The benefit of laparoscopic approach seems to persist after subsequent CS. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made.
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Affiliation(s)
- Olivier Donnez
- Complex Endometriosis Center (CEC), Polyclinique Urbain V (Elsan Group), Avignon, France.
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Klein Meuleman SJM, Min N, Hehenkamp WJK, Post Uiterweer ED, Huirne JAF, de Leeuw RA. The definition, diagnosis, and symptoms of the uterine niche - A systematic review. Best Pract Res Clin Obstet Gynaecol 2023; 90:102390. [PMID: 37506497 DOI: 10.1016/j.bpobgyn.2023.102390] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023]
Abstract
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.
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Affiliation(s)
- S J M Klein Meuleman
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - N Min
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - W J K Hehenkamp
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - E D Post Uiterweer
- Amsterdam University Medical Center, Location Amsterdam Medical Center, Uterine Repair Center, Department of Obstetrics & Gynaecology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - J A F Huirne
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - R A de Leeuw
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
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Xia W, Wang X, Wang Y, Tian Y, He C, Zhu C, Zhu Q, Huang H, Shi L, Zhang J. Comparative effectiveness of transvaginal repair vs. hysteroscopic resection in patients with symptomatic uterine niche. Front Surg 2023; 10:1019237. [PMID: 36843994 PMCID: PMC9947358 DOI: 10.3389/fsurg.2023.1019237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Abstract
Objective To compare the efficacy of transvaginal repair and hysteroscopic resection in improving niche associated postmenstrual spotting. Methods The improvement rate of postmenstrual spotting in women who underwent transvaginal repair or hysteroscopic resection treatment was assessed retrospectively in patients accepted at the Niche Sub-Specialty Clinic in International Peace Maternity and Child Health Hospital between June 2017 and June 2019. Postoperative spotting symptom within one year after surgery, pre- and postoperative anatomical indicators, women' satisfaction with menstruation and other perioperative parameters were compared between the two groups. Results 68 patients in the transvaginal group and 70 patients in the hysteroscopic group were included for analysis. The improvement rate of postmenstrual spotting in the transvaginal group at the 3rd, 6th, 9th, and 12th months after surgery was 87%, 88%, 84%, and 85%, significantly higher than 61%, 68%, 66%, and 68% in the hysteroscopic group, respectively (P < 0.05). The total days of spotting improved significantly at the 3rd month after surgery but did not change over time within one year in each group (P > 0.05). After surgery, the disappearance rates of the niche are 68% in transvaginal group and 38% in hysteroscopic group, however, hysteroscopic resection had shorter operative time and hospitalization duration, less complications, and lower hospitalization costs. Conclusion Both treatments can improve the spotting symptom and anatomical structures of uterine lower segments with niches. Transvaginal repair is better in thickening the residual myometrium than hysteroscopic resection, however, hysteroscopic resection has shorter operative time and hospitalization duration, less complications, and lower hospitalization costs.
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Affiliation(s)
- Wei Xia
- Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Xiaofeng Wang
- Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Yang Wang
- Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Yuan Tian
- Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Chuqing He
- Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Chenfeng Zhu
- Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Qian Zhu
- Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
| | - Hefeng Huang
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China,Obstetrics and Gynecology Hospital, Institute of Reproduction and Development, Fudan University, Shanghai, China,Correspondence: Hefeng Huang Liye Shi Jian Zhang
| | - Liye Shi
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China,Department of Ultrasound, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Correspondence: Hefeng Huang Liye Shi Jian Zhang
| | - Jian Zhang
- Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China,Correspondence: Hefeng Huang Liye Shi Jian Zhang
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