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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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Huang SY, Chen YY, Tsai CC, Lin H, Ou YC. Evaluating resectoscopy and the levonorgestrel intrauterine system for intermenstrual bleeding associated with cesarean scar defects: A retrospective study of treatment outcomes. J Obstet Gynaecol Res 2024; 50:253-261. [PMID: 37990626 DOI: 10.1111/jog.15840] [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: 06/09/2023] [Accepted: 11/12/2023] [Indexed: 11/23/2023]
Abstract
AIM To compare and evaluate the efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUD) and resectoscopy remodeling procedure for intermenstrual bleeding associated with previous cesarean delivery scar defect (PCDS). METHODS A retrospective comparative study was conducted on patients with PCDS receiving LNG-IUD (levonorgestrel 20 μg/24 h, N = 33) or resectoscopy remodeling (N = 27). Treatment outcomes were compared over 1, 6, and 12 months. Outcomes in patients with a retroverted or large uterus size, defect size, and local vascularization also were evaluated. RESULTS At 12 months post-treatment, there were no significant differences between groups in efficacy rate; however, the reduction of intermenstrual bleeding days was higher in the LNG-IUD group than in the resectoscopy group (13.6 vs. 8.5 days, p = 0.015). Within the first year, both groups experienced a reduction in bleeding days, but the decrease was greater in the LNG-IUD group. Individuals exhibiting increased local vascularization at the defect site experienced more favorable outcomes in the LNG-IUD group than the resectoscopy group (p = 0.016), and who responded poorly tended to have a significantly larger uterus in the LNG-IUD group (p = 0.019). No significant differences were observed in treatment outcomes for patients with a retroverted uterus or large defect in either group. CONCLUSIONS Our findings support that the LNG-IUD is as effective as resectoscopy in reducing intermenstrual bleeding days associated with PCDS and can be safely applied to patients without recent fertility aspirations. Patients with increased local vascularization observed during hysteroscopy may benefit more from LNG-IUD intervention than resectoscopy.
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Affiliation(s)
- Szu-Yu Huang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Yi Chen
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Chang Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hao Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Che Ou
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chia-Yi, Taiwan
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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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Vissers J, Klein Meuleman SJM, de Leeuw RA, van Eekelen R, Groenman FA, Mol BW, Hehenkamp WJK, Huirne JAF. Effectiveness of laparoscopic niche resection versus expectant management in patients with unexplained infertility and a large uterine caesarean scar defect (uterine niche): protocol for a randomised controlled trial (the LAPRES study). BMJ Open 2023; 13:e070950. [PMID: 37451732 PMCID: PMC10351273 DOI: 10.1136/bmjopen-2022-070950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/12/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION A uterine niche is a defect at the site of the uterine caesarean scar that is associated with gynaecological symptoms and infertility. Promising results are reported in cohort studies after a laparoscopic niche resection concerning reduction of gynaecological symptoms in relation to baseline and concerning pregnancy outcomes. However, randomised controlled trials to study the effect of a laparoscopic niche resection on reproductive outcomes in infertile women are lacking. This study will answer the question if laparoscopic niche resection in comparison to expectant management improves reproductive outcomes in infertile women with a large uterine niche. METHODS AND ANALYSIS The LAPRES study is a randomised, non-blinded, controlled trial, including 200 infertile women with a total follow-up of 2 years. Women with the presence of a large niche in the uterine caesarean scar and unexplained infertility of at least 1 year or failed IVF will be randomly allocated to a laparoscopic niche resection within 6 weeks or to expectant management for at least 9 months. A large niche is defined as a niche with a depth of >50% of the myometrial thickness and a residual myometrium of ≤3 mm on transvaginal ultrasound. Those receiving expectant management will be allowed to receive fertility therapies, including assisted reproductive techniques, if indicated. The primary outcome is time to ongoing pregnancy, defined as a viable intrauterine pregnancy at 12 weeks' gestation. Secondary outcome measures are time to conception leading to a live birth, other pregnancy outcomes, received fertility therapies after randomisation, menstruation characteristics, patient satisfaction, quality of life, additional interventions, and surgical and ultrasound outcomes (intervention group). Questionnaires will be filled out at baseline, 6, 12 and 24 months after randomisation. Ultrasound evaluation will be performed at baseline and at 3 months after surgery. ETHICS AND DISSEMINATION The study protocol was approved by the medical ethics committee of the Amsterdam University Medical Centre. (Ref. No. 2017.030). Participants will sign a written informed consent before participation. The results of this study will be submitted to a peer-reviewed journal for publication. TRIAL REGISTRATION NUMBER DUTCH TRIAL REGISTER REF NO NL6350 : http://www.trialregister.nl.
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Affiliation(s)
- Jolijn Vissers
- Department of Gynaecology and Obstetrics, Amsterdam, The Netherlands
- Department of Gynaecology and Obstetrics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Robert A de Leeuw
- Department of Gynaecology and Obstetrics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Rik van Eekelen
- Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Freek A Groenman
- Department of Gynaecology and Obstetrics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Ben W Mol
- OB/GYN, School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Wouter J K Hehenkamp
- Department of Gynaecology and Obstetrics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Judith A F Huirne
- Department of Gynaecology and Obstetrics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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Zhang J, Zhu C, Yan L, Wang Y, Zhu Q, He C, He X, Ji S, Tian Y, Xie L, Liang Y, Xia W, Mol BW, Huirne JAF. Comparing levonorgestrel intrauterine system with hysteroscopic niche resection in women with postmenstrual spotting related to a niche in the uterine cesarean scar: a randomized, open-label, controlled trial. Am J Obstet Gynecol 2023; 228:712.e1-712.e16. [PMID: 36935068 DOI: 10.1016/j.ajog.2023.03.020] [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: 12/02/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Postmenstrual spotting and chronic pelvic pain after cesarean delivery are associated with the presence of niches. Levonorgestrel intrauterine system (52 mg) and hysteroscopic niche resection have been shown to relieve niche-related symptoms at 6 months after the intervention. OBJECTIVE This trial aimed to compare the effectiveness of 52-mg levonorgestrel intrauterine system with that of hysteroscopic niche resection in reducing niche-related postmenstrual spotting. STUDY DESIGN This randomized, open-label, controlled trial was conducted at a medical center in Shanghai, China. Women with symptoms of postmenstrual spotting after cesarean delivery, with a niche depth of at least 2 mm and residual myometrium of at least 2.2 mm on magnetic resonance imaging, and no intention to conceive within the next year were randomly assigned to receive treatment with 52-mg levonorgestrel intrauterine system or hysteroscopic niche resection. The primary outcome was the reduction in postmenstrual spotting at 6 months after randomization, defined as the percentage of women with a reduction of at least 50% in spotting days relative to baseline. Efficacy and safety were assessed using intention-to-treat analysis. RESULTS Between September 2019 and January 2022, 208 women were randomized into the levonorgestrel intrauterine system group (N=104) or the hysteroscopic niche resection group (N=104). At the 6-month follow-up, a 50% reduction in spotting had occurred in 78.4% (80/102) of women in the levonorgestrel intrauterine system group and in 73.1% (76/104) of women in the hysteroscopic niche resection group (relative risk, 1.07 [95% confidence interval, 0.92-1.25]; P=.370). Spotting decreased over time (Ptrend=.001), with a stronger reduction observed in the levonorgestrel intrauterine system group (P=.001). There was also a significant interaction between time and treatment (P=.007). From 9 months onward, a more significant reduction in spotting was observed in the levonorgestrel intrauterine system group than in the hysteroscopic niche resection group (9 months, 89.2% vs 72.1%; relative risk, 1.24 [95% confidence interval, 1.08-1.42]; 12 months, 90.2% vs 70.2%; relative risk, 1.29 [95% confidence interval, 1.12-1.48]). Moreover, compared with the hysteroscopic niche resection group, the levonorgestrel intrauterine system group had significantly fewer postmenstrual spotting days and total bleeding days from 6 months onward (all P<.001), and less pelvic pain from 3 months onward (all P<.010). No intervention-related complications were reported in any group. During follow-up, 11 (10.8%) women reported hormone-related side effects, and 2 women (2.0%) in the levonorgestrel intrauterine system group had spontaneous partial expulsion. Meanwhile, 3 unintended pregnancies were reported in the hysteroscopic niche resection group. CONCLUSION In women with niche-related postmenstrual spotting, the levonorgestrel intrauterine system was not more effective than hysteroscopic niche resection in reducing the number of spotting days by at least 50% at 6 months. However, the levonorgestrel intrauterine system was superior in reducing spotting from 9 months onward, and it reduced the absolute number of spotting days from 6 months onward and pelvic pain from 3 months onward.
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Affiliation(s)
- Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.
| | - Chenfeng Zhu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Li Yan
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Yang Wang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Qian Zhu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Chuqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Xiaoqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Sifan Ji
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Yuan Tian
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Liang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Wei Xia
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia; Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Judith A F Huirne
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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You SH. The symptomatic cesarean scar defect with oral contraceptive pills treatment following evacuation of a cesarean scar pregnancy. Taiwan J Obstet Gynecol 2023; 62:181-183. [PMID: 36720538 DOI: 10.1016/j.tjog.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 01/30/2023] Open
Affiliation(s)
- Shu-Han You
- Department of Obstetrics and Gynecology, Chang-Gung Memorial Hospital, Linkou, Taiwan.
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Tsuji S, Nobuta Y, Hanada T, Takebayashi A, Inatomi A, Takahashi A, Amano T, Murakami T. Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review. Reprod Med Biol 2023; 22:e12532. [PMID: 37577060 PMCID: PMC10412910 DOI: 10.1002/rmb2.12532] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/05/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Background Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi). Methods This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery. Main findings The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective. Conclusion The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Yuri Nobuta
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tetsuro Hanada
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Aike Takebayashi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Ayako Inatomi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Akimasa Takahashi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
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Mc Gowan S, Goumalatsou C, Kent A. Fantastic niches and where to find them: the current diagnosis and management of uterine niche. Facts Views Vis Obgyn 2022; 14:37-47. [PMID: 35373546 PMCID: PMC9612856 DOI: 10.52054/fvvo.14.1.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Caesarean section (CS) scar niche is a well recognised complication of caesarean delivery and is defined as an indentation at the site of the CS scar with a depth of at least 2mm. Objectives To review systematically the medical literature regarding the current diagnosis and management of uterine niche Materials and methods We carried out a systematic review using MeSH terms ‘niche’ OR ‘sacculation’ OR ‘caesarean scar defect’ OR ‘caesarean section scar’ OR ‘uterine defect’ OR ‘isthmocele.’ Articles included were peer-reviewed and in English language. Main outcome measures Prevalence, symptoms, diagnosis, pathophysiology and management of uterine niche. Results CS scar niche is common and, in a subgroup, produces a range of symptoms including post-menstrual bleeding, dyspareunia and subfertility. It may be linked to use of locked sutures during CS closure. Niche repair can be achieved laparoscopically or hysteroscopically and appears to improve symptoms, although solid conclusions regarding fertility outcomes cannot be drawn. Conclusions CS scar niche is associated with a range of symptoms. Repair may aid subfertile patients and those with post-menstrual spotting. The presence of a niche is probably irrelevant in the absence of symptoms. What is new? LNG-IUS and surgical repair appear to improve symptoms in those with a niche.
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Rupa R, Kushvaha S, Venkatesh K. Uterine Isthmocele-A Frequently Overlooked Complication of Cesarean Sections. Indian J Radiol Imaging 2021; 31:601-604. [PMID: 34790304 PMCID: PMC8590568 DOI: 10.1055/s-0041-1736393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Uterine isthmocele or uterine niche is a late complication of cesarean deliveries and causes chronic pelvic pain, menorrhagia or postmenstrual spotting, and infertility. As the number of cesarean sections are constantly increasing, it is important to be aware of this entity so as to make an early diagnosis. This would enable the clinicians to manage these patients efficiently. We present three patients of uterine isthmocele who were evaluated and managed at our institution.
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Affiliation(s)
- R Rupa
- Division of Women's Imaging, Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Suchana Kushvaha
- Division of Women's Imaging, Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - K Venkatesh
- Division of Women's Imaging, Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
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Ou YC, Chen YY, Lan KC, Tsai CC, Chu LC, Cheng LY. Levonorgestrel intrauterine system for the treatment of intermenstrual spotting in patients with previous cesarean delivery scar defect. J Obstet Gynaecol Res 2021; 48:155-160. [PMID: 34734462 DOI: 10.1111/jog.15062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/08/2021] [Accepted: 10/03/2021] [Indexed: 12/01/2022]
Abstract
AIM To evaluate the efficacy of levonorgestrel 52 mg intrauterine system for intermenstrual bleeding in patients with previous cesarean delivery scar defects (PCDSs). METHODS The medical records of 28 consecutive patients with previous cesarean delivery scar defect and intermenstrual bleeding who had undergone conservative treatment with levonorgestrel 52 mg intrauterine system were reviewed. The efficacy of treatment and frequency of adverse events were measured retrospectively. RESULTS After 1 year of treatment, 22 patients (78.6%) reported an improvement in symptoms. The mean duration of menstruation were 18 and 5 days before and after treatment, respectively. No uterine perforations or pelvic inflammatory diseases occurred during or after the insertion procedures. Eighteen (64.3%) patients did not experience any adverse events, and the patients with adverse events reported that they could be managed by adjusting their medications or observation. CONCLUSION Levonorgestrel intrauterine system may have a role in the safe and effective management of intermenstrual spotting in patients with PCDSs.
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Affiliation(s)
- Yu-Che Ou
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Obstetrics and Gynecology, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Ying-Yi Chen
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Chung Lan
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Chang Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Li-Ching Chu
- Department of Obstetrics and Gynecology, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Ling-Yun Cheng
- Department of Obstetrics and Gynecology, Chiayi Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Chiayi, Taiwan
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Torre A, Verspyck E, Hamamah S, Thomassin I, Thornton J, Fauconnier A, Crochet P. [Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]. ACTA ACUST UNITED AC 2021; 49:858-868. [PMID: 34144220 DOI: 10.1016/j.gofs.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche. METHODS Review of the literature, critical reflection, and pragmatic advice. RESULTS There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases. CONCLUSIONS A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.
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Affiliation(s)
- A Torre
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Maternity building of the City Hospital, Hucknall Road, NG5 1PB Nottingham, Royaume-Uni; Service de gynécologie-obstétrique, CHU de Rouen, Université de Rouen, Rouen, France.
| | - E Verspyck
- Service de gynécologie-obstétrique, CHU de Rouen, Université de Rouen, Rouen, France
| | - S Hamamah
- Univ Montpellier, Inserm U1203, EmbryoPluripotency, Montpellier, France; IRMB, Univ Montpellier, Inserm, Montpellier, France; CHU Montpellier, ART/PGD Department, Arnaud de Villeneuve Hospital, Montpellier, France
| | - I Thomassin
- Department of Imaging, Hopital Tenon, AP-HP, 75020 Paris, France
| | - J Thornton
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Maternity building of the City Hospital, Hucknall Road, NG5 1PB Nottingham, Royaume-Uni
| | - A Fauconnier
- Department of Biology, Medicine and Health, Research unit EA7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, Versailles St-Quentin University, Montigny-le-Bretonneux, France; Department of Gynecology and Obstetrics, Intercommunal Hospital Center of Poissy-St Germain en Laye, Poissy, France
| | - P Crochet
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Marseille, La Conception Hospital, Aix Marseille Université, Marseille, France
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12
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Al Mutairi BH, Alrumaih I. Hysteroscopy in the Treatment of Myometrial Scar Defect (Diverticulum) Following Cesarean Section Delivery: A Systematic Review and Meta-Analysis. Cureus 2020; 12:e11317. [PMID: 33282592 PMCID: PMC7716384 DOI: 10.7759/cureus.11317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
| | - Ibtehal Alrumaih
- Obstetrics and Gynecology, Maternity and Children Hospital, Qassim, SAU
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13
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Donnez O. Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased. Fertil Steril 2020; 113:704-716. [PMID: 32228874 DOI: 10.1016/j.fertnstert.2020.01.037] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/17/2020] [Accepted: 01/29/2020] [Indexed: 02/01/2023]
Abstract
Around 20% of pregnant women undergo cesarean section (CS), and in most regions of the world CS rates continue to grow. There is still no clear definition of what is considered a normal physiologic aspect of a CS scar and what is abnormal. Cesarean scar defects (CSDs) should be suspected in women presenting with spotting, dysmenorrhea, pelvic pain, or infertility and a history of CS. CSDs can be visualized with the use of hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging. 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 contemplated according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and residual myometrium thickness (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 if the RMT is <3 mm, in which case repair is essential and can be achieved by only laparoscopic or vaginal approach. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made. Because prevention is better than cure, risk factors should be identified early to ensure appropriate management.
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Affiliation(s)
- Olivier Donnez
- Institut du Sein et de Chirurgie Gynécologique d'Avignon, Polyclinique Urbain V (Elsan Group), Avignon, France; and Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
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14
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Shi H, He J, Gao Y, Qin S, Fan J, Xiao Q, Li K, Liang H. Treatment of C-section diverticula with hysteroscopic resection in women without childbearing intention: a retrospective cohort study. BMC WOMENS HEALTH 2020; 20:75. [PMID: 32316946 PMCID: PMC7171842 DOI: 10.1186/s12905-020-00928-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 03/18/2020] [Indexed: 11/11/2022]
Abstract
Background Diverticulum, one of the long-term sequelae of cesarean section, can cause abnormal uterine bleeding, dysmenorrhea and chronic pelvic pain. Hysteroscopic resection of diverticula is thought to reduce abnormal uterine bleeding and chronic pelvic pain. In this study, we aim to describe the improvement after hysteroscopic resection of cesarean section diverticula (CSD) in women without childbearing intention, and to explore the variables associated with poor prognosis. Methods A retrospective cohort study of women aged 25–48 with CSD diagnosis by transvaginal ultrasonography (TVS) and hysteroscopy that were enrolled at Guangzhou Women and Children’s Medical Center between June 2017 and December 2018. A total of 124 women met the inclusion criteria and all patients had undergone hysteroscopic resection and accepted a follow-up interview at the 3rd and 6th months postoperatively to record symptom improvement. Result The mean of intraoperative blood loss and operative time of hysteroscopic resection were (12.94 ± 12.63) ml and (33.63 ± 6.87) min in 124 patients. Overall observed improvement rates of CSD symptom were 47.2 and 65.6% in the first 3 and 6 months, respectively. Multivariable logistic regression models revealed that timing of surgery < 14 days was a good prognostic factor associated with both 3-month improvement (OR, 16.59; 95% CI, 2.62–104.90; P = 0.003) and 6-month improvement (OR, 15.51; 95%CI, 1.63–148.00; P = 0.02); Patients with numbers of cesarean section (CS) ≥2 had a lower rate of improvement after 6 months of CSD repair surgery compared with patients who underwent one CS (OR, 8.29; 95%CI, 1.05–65.75; P = 0.04). Conclusions A hysteroscopic repair might be an appropriate method for CSD in women who no childbearing intentions. The timing of surgery and the number of CS seems to be factors influencing the postoperative improvement of CSD.
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Affiliation(s)
- Hui Shi
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Zhujiang Newtown, Tianhe District, Guangzhou, 510623, China
| | - Jingyan He
- Department of Obstetrics & Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yunhe Gao
- Department of Obstetrics & Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Shuang Qin
- Department of Obstetrics & Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jiaying Fan
- Department of Obstetrics & Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Qing Xiao
- Department of Obstetrics & Gynaecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Kuanrong Li
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Zhujiang Newtown, Tianhe District, Guangzhou, 510623, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Zhujiang Newtown, Tianhe District, Guangzhou, 510623, China.
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15
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Vitale SG, Ludwin A, Vilos GA, Török P, Tesarik J, Vitagliano A, Lasmar RB, Chiofalo B. From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis. Arch Gynecol Obstet 2020; 301:33-52. [PMID: 31989288 DOI: 10.1007/s00404-020-05438-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/13/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. METHODS PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. RESULTS We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). CONCLUSIONS We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
| | - Artur Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland.,Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - George Angelos Vilos
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Péter Török
- Faculty of Medicine, Institute of Obstetrics and Gynaecology, University of Debrecen, Debrecen, Hungary
| | | | - Amerigo Vitagliano
- Unit of Gynecology and Obstetrics, Department of Women and Children's Health, University of Padua, Padua, Italy
| | - Ricardo Bassil Lasmar
- Department of Surgery and Specialities, Federal Fluminense University, Niterói, Brazil
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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16
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Chen Y, Tsai C, Lan K, Ou Y. Preliminary report on the use of a levonorgestrel intrauterine system for the treatment of intermenstrual bleeding due to previous cesarean delivery scar defect. J Obstet Gynaecol Res 2019; 45:2015-2020. [DOI: 10.1111/jog.14060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 06/23/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Ying‐Yi Chen
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial HospitalChang Gung University College of Medicine Kaohsiung Taiwan
| | - Ching‐Chang Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial HospitalChang Gung University College of Medicine Kaohsiung Taiwan
| | - Kuo‐Chung Lan
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial HospitalChang Gung University College of Medicine Kaohsiung Taiwan
| | - Yu‐Che Ou
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial HospitalChang Gung University College of Medicine Kaohsiung Taiwan
- Department of Obstetrics and GynecologyChiayi Chang Gung Memorial Hospital, Chang Gung University College of Medicine Chiayi Taiwan
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17
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Association between hysteroscopic findings of previous cesarean delivery scar defects and abnormal uterine bleeding. Taiwan J Obstet Gynecol 2019; 58:541-544. [DOI: 10.1016/j.tjog.2019.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2019] [Indexed: 11/22/2022] Open
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18
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Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. ACTA ACUST UNITED AC 2019; 65:714-721. [PMID: 31166450 DOI: 10.1590/1806-9282.65.5.714] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/31/2018] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Thaysa Guglieri Kremer
- Department of Medicine at the Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Isadora Bueloni Ghiorzi
- Department of Medicine at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil
| | - Raquel Papandreus Dibi
- Department of Gynecology and Obstetrics at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil
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19
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Zhang D, Liang S, Zhu L. Comparison of transvaginal repair versus laparoscopic repair of lower-segment cesarean scar defects. Int J Gynaecol Obstet 2019; 145:199-204. [PMID: 30801700 DOI: 10.1002/ijgo.12797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/21/2018] [Accepted: 02/21/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate transvaginal repair versus laparoscopic repair of cesarean scar defects (CSDs). METHODS A retrospective cohort study was conducted among 67 symptomatic women with CSDs who attended a tertiary hospital in Beijing, China, between July 1, 2013, and March 31, 2017. The participants underwent either transvaginal repair (n=31) or laparoscopic repair (n=36). Medical costs, perioperative outcomes, and surgical outcomes were compared. RESULTS No statistically significant between-group differences were found at baseline. The mean thickness of the residual myometrium increased from 1.71 ± 0.67 mm before surgery to 4.41 ± 2.09 mm after surgery in the transvaginal repair group (P<0.001), and from 1.81 ± 0.93 to 4.68 ± 1.96 mm in the laparoscopic repair group (P<0.001). The duration of menses after surgery was less than 10 days in both the transvaginal repair group (n=30, 96.3%) and the laparoscopic repair group (n=30, 83.9%; P=0.113). Operative time and medical costs were both lower in the transvaginal repair group than in the laparoscopic repair group (P<0.001). Conception rates for the two groups were similar among women who desired fertility. CONCLUSION Transvaginal repair of CSD was associated with reduced operative times and medical costs when compared with laparoscopic repair.
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Affiliation(s)
- Duoduo Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Shuo Liang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
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20
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Mariya T, Umemoto M, Sugita N, Suzuki M, Saito T. Recurrent Massive Uterine Bleeding from a Cesarean Scar Treated Successfully by Laparoscopic Surgery. Gynecol Minim Invasive Ther 2019; 8:36-39. [PMID: 30783588 PMCID: PMC6367910 DOI: 10.4103/gmit.gmit_69_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/05/2018] [Accepted: 10/19/2018] [Indexed: 11/30/2022] Open
Abstract
A cesarean scar can cause abnormal uterine bleeding including prolonged menstruation or postmenstrual spotting. Our patient showed massive uterine bleeding from a cesarean scar and needed blood transfusion for hemorrhagic shock. A cesarean section had only been performed once for delivery stop 9 years ago. Recurrent hemorrhage could not be controlled by conservative treatment, and we performed laparoscopic scar resection and repair. The abnormal uterine bleeding was successfully stopped, and the menstrual cycle was normalized after surgical treatment. We should be aware that even an uneventful cesarean section may have a risk of massive hemorrhage postoperatively as in the present case.
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Affiliation(s)
- Tasuku Mariya
- Department of Obstetrics and Gynecology, School of Medicine, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Mina Umemoto
- Department of Obstetrics and Gynecology, Hokkaido Institutional Society Obihiro Hospital, Obihiro, Japan
| | - Naoko Sugita
- Department of Obstetrics and Gynecology, Hokkaido Institutional Society Obihiro Hospital, Obihiro, Japan
| | - Masahiro Suzuki
- Department of Obstetrics and Gynecology, Hokkaido Institutional Society Obihiro Hospital, Obihiro, Japan
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology, School of Medicine, Sapporo Medical University, Sapporo, Hokkaido, Japan
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Iannone P, Nencini G, Bonaccorsi G, Martinello R, Pontrelli G, Scioscia M, Nappi L, Greco P, Scutiero G. Isthmocele: From Risk Factors to Management. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2019; 41:44-52. [PMID: 30646424 PMCID: PMC10416161 DOI: 10.1055/s-0038-1676109] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/10/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition. METHODS A comprehensive review of the literature was performed to identify the most relevant studies about this topic. RESULTS Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data. CONCLUSION Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.
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Affiliation(s)
- Piergiorgio Iannone
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Giulia Nencini
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Gloria Bonaccorsi
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Ruby Martinello
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Giovanni Pontrelli
- Section of Obstetrics and Gynaecology, Policlinico di Abano Terme, Abano Terme, Padova, Italy
| | - Marco Scioscia
- Section of Obstetrics and Gynaecology, Policlinico di Abano Terme, Abano Terme, Padova, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Pantaleo Greco
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Gennaro Scutiero
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
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22
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Fan D, Wu S, Ye S, Wang W, Guo X, Liu Z. Umbilical cord mesenchyme stem cell local intramuscular injection for treatment of uterine niche: Protocol for a prospective, randomized, double-blinded, placebo-controlled clinical trial. Medicine (Baltimore) 2017; 96:e8480. [PMID: 29095305 PMCID: PMC5682824 DOI: 10.1097/md.0000000000008480] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Uterine niche is defined as a triangular anechoic structure at the site of the scar or a gap in the myometrium at the site of a previous caesarean section. The main clinical manifestations are postmenstrual spotting and intrauterine infection, which may seriously affect the daily life of nonpregnant women. Trials have shown an excellent safety and efficacy for the potential of mesenchymal stem cells (MSCs) as a therapeutic option for scar reconstruction. Therefore, this study is designed to investigate the safety and efficacy of using MSCs in the treatment for the uterine niche. METHODS/DESIGN This phase II clinical trial is a single-center, prospective, randomized, double-blind, placebo-controlled with 2 arms. One hundred twenty primiparous participants will be randomly (1:1 ratio) assigned to receive direct intramuscular injection of MSCs (a dose of 1*10 cells in 1 mL of 0.9% saline) (MSCs group) or an identical-appearing 1 mL of 0.9% saline (placebo-controlled group) near the uterine incision. The primary outcome of this trial is to evaluate the proportion of participants at 6 months who is found uterine niche in the uterus by transvaginal utrasonography. Adverse events will be documented in a case report form. The study will be conducted at the Department of Obstetric of Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan. DISCUSSION This trial is the first investigation of the potential for therapeutic use of MSCs for the management of uterine niche after cesarean delivery. CONCLUSION This protocol will help to determine the efficacy and safety of MSCs treatment in uterine niche and bridge the gap with regards to the current preclinical and clinical evidence. TRIAL REGISTRATION NUMBER NCT02968459 (Clinical Trials.gov: http://clinicaltrials.gov/).
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Affiliation(s)
- Dazhi Fan
- Foshan Institute of Fetal Medicine
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Shuzhen Wu
- Foshan Institute of Fetal Medicine
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Shaoxin Ye
- Foshan Institute of Fetal Medicine
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Wen Wang
- Foshan Institute of Fetal Medicine
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Xiaoling Guo
- Foshan Institute of Fetal Medicine
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
| | - Zhengping Liu
- Foshan Institute of Fetal Medicine
- Department of Obstetrics, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong
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23
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Setubal A, Alves J, Osório F, Guerra A, Fernandes R, Albornoz J, Sidiroupoulou Z. Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar. J Minim Invasive Gynecol 2017; 25:38-46. [PMID: 29024799 DOI: 10.1016/j.jmig.2017.09.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/03/2017] [Accepted: 09/05/2017] [Indexed: 12/31/2022]
Abstract
An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmocele's characteristics and surgeon expertise.
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Affiliation(s)
| | | | | | | | - Rodrigo Fernandes
- Instituto do Câncer da Cidade de São Paulo/Faculdade de Medicina da Universidade de São Paulo Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | | | - Zacharoula Sidiroupoulou
- General Surgery Department, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
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Abacjew-Chmylko A, Wydra DG, Olszewska H. Hysteroscopy in the treatment of uterine cesarean section scar diverticulum: A systematic review. Adv Med Sci 2017; 62:230-239. [PMID: 28500899 DOI: 10.1016/j.advms.2017.01.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/12/2016] [Accepted: 01/24/2017] [Indexed: 10/19/2022]
Abstract
The aim of this paper is to review and to analyze the results of previous studies dealing with hysteroscopic treatment of postcesarean scar defects. A systematic review of publications indexed in MEDLINE/PubMed database identified a total of 11 studies dealing with resectoscopic treatment of postcesarean scar defect. The review was conducted in line with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and the PRISMA statement. In only few studies, patients were qualified for hysteroscopic surgery based on the measurement of the defect depth and thickness of residual myometrium above the pouch. Two principal techniques were used for the hysteroscopic treatment: resection of one edge of the scar diverticulum, and resection of the inferior and superior edges of the defect. Additionally, most authors performed electrocauterization of the niche bottom. Resectoscopic treatment turned out to be highly effective in the case of women with AUB. No complications of the hysteroscopic procedure have been reported. Methodological value of the reviewed studies was relatively low due to non-unified selection/verification criteria and incomplete, non-systematic postoperative assessment. In conclusion, hysteroscopic treatment seems to be a promising option in the management of postcesarean scar defects, but still further research is needed on the problem in question.
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Vervoort A, Vissers J, Hehenkamp W, Brölmann H, Huirne J. The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study. BJOG 2017; 125:317-325. [PMID: 28703935 PMCID: PMC5811817 DOI: 10.1111/1471-0528.14822] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 11/18/2022]
Abstract
Objective To evaluate the effectiveness of a laparoscopic niche resection on niche‐related symptoms and/or fertility‐related problems, ultrasound findings and quality of life. Design Prospective cohort study. Setting University hospital. Population Women with a large niche (residual myometrium <3 mm) and complaints of either postmenstrual spotting, dysmenorrhoea, intrauterine fluid accumulation and/or difficulties with embryo transfer due to distorted anatomy. Methods Women filled out questionnaires and a validated menstrual score chart at baseline and 6 months after the laparoscopic niche resection. At baseline and between 3 and 6 months follow up niches were evaluated by transvaginal ultrasound. Main outcome measures The primary outcome was reduction of the main problem 6 months after the intervention. Secondary outcomes were complications, menstrual characteristics, dysmenorrhoea, niche measurements, intrauterine fluid, surgical outcomes, satisfaction and quality of life. Results In all, 101 women underwent a laparoscopic niche resection. In 80 women (79.2%) the main problem was improved or resolved. Postmenstrual spotting was significantly reduced by 7 days at 6 months follow up compared with baseline. Dysmenorrhoea and discomfort related to spotting was also significantly reduced. The residual myometrium was increased significantly at follow up. The intrauterine fluid was resolved in 86.9% of the women with intrauterine fluid at baseline; 83.3% of women were (very) satisfied. The physical component of quality of life increased, the mental component did not change. Conclusions A laparoscopic niche resection reduced postmenstrual spotting, discomfort due to spotting, dysmenorrhoea and the presence of intrauterine fluid in the majority of women and increased the residual myometrium. Tweetable abstract Laparoscopic niche resection reduces niche‐related problems and enlarges the residual myometrium. Laparoscopic niche resection reduces niche‐related problems and enlarges the residual myometrium.
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Affiliation(s)
- Ajmw Vervoort
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, the Netherlands
| | - J Vissers
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, the Netherlands
| | - Wjk Hehenkamp
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, the Netherlands
| | - Ham Brölmann
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, the Netherlands
| | - Jaf Huirne
- Department of Obstetrics and Gynaecology, VU University Medical Centre, Amsterdam, the Netherlands
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The minimally invasive approach to the symptomatic isthmocele – what does the literature say? A step-by-step primer on laparoscopic isthmocele – excision and repair. Curr Opin Obstet Gynecol 2017; 29:257-265. [DOI: 10.1097/gco.0000000000000380] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Defect width: the prognostic index for vaginal repair of cesarean section diverticula. Arch Gynecol Obstet 2016; 295:623-630. [PMID: 27885429 DOI: 10.1007/s00404-016-4245-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the clinical parameter associated with cesarean section diverticula anatomic healing via vaginal repair management. METHODS Observational cohort study. From Jul 2014 to Dec 2015, 143 women with CSD underwent vaginal repair surgery in Shanghai First Maternity and Infant Hospital, and 137(95.80%) were diagnosed using both transvaginal ultrasound and MRI. A total of 124 patients (86.71%) who were followed-up for more than 6 months after surgery were enrolled in this study. Excision and suture of CSD was performed through the vaginal approach. The defect sizes of the width, length, depth and TRM before or after repair were evaluated. RESULTS The mean preoperative duration of menstruation was 14.47 ± 3.30 days and the thickness of the remaining muscular layer was 2.65 ± 1.13 mm before surgery. The study revealed that the healing effects of CSD repair stabilized 3 months after surgery. At the median follow-up time (11.28 months), CSD disappeared after surgery in 64.52% of patients (80/124), and 60.0% of patients (48/80) reached ≤7 days of menstruation. Meanwhile, for 35.48% of patients (44/124), CSD persisted at the median follow-up after surgery, and 31.82% (14/44) of these patients reached ≤7 days of menstruation(P < 0.05). TRM at a median follow-up time after vaginal repair >7.88 mm, 92.11% (70/76) of CSD disappeared. Moreover, when preoperative CSD width ≤18.85 mm indicates that only 18.75% (12/64) of patients will present with CSD after vaginal repair, as determined by MRI (95% CI 0.515-0.737). CONCLUSION The defect width of the preoperative CSD was the prognostic index of CSD anatomical repair effect. When the preoperative CSD width >18.85 mm, we should pay more attention to the edge of the defect during vaginal repairing.
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Liu SJ, Lv W, Li W. Laparoscopic repair with hysteroscopy of cesarean scar diverticulum. J Obstet Gynaecol Res 2016; 42:1719-1723. [PMID: 27775189 DOI: 10.1111/jog.13146] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 06/21/2016] [Accepted: 07/30/2016] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to investigate the clinical data of laparoscopic repair with hysteroscopy of cesarean scar diverticulum (CSD). METHODS We retrospectively evaluated 49 patients with CSD in our hospital who had undergone laparoscopic repair with hysteroscopy from January 2014 to June 2015. All patients had a history of cesarean section deliveries and prolonged postmenstrual spotting (duration 16.1 ± 3.4 days). The diagnosis of CSD was established by using 2-D transvaginal ultrasound. RESULTS All patients underwent the surgical repair successfully, without evident complications. The mean operation time was 90.4 ± 9.1 min, the mean volume of blood loss was 31.2 ± 14.3 mL, and the mean length of hospital stay was 4.1 ± 0.3 days. All patients were followed for 6 months after the operation; the mean duration of menstruation was 7.5 ± 2.5 days shorter on average than the pre-surgical menstrual days, and the difference was statistically significant (P = 0.001). According to the clinical symptoms assessment, 89.8% (44/49) of the surgeries were effective, while according to the anatomic assessment, 95.9% (47/49) were effective. CONCLUSION Laparoscopic repair with hysteroscopy of CSD was confirmed to be a safe, effective, and minimally invasive treatment, and should be widely used to treat patients with CSD.
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Affiliation(s)
- Song-Jun Liu
- Department of Gynecology, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Wen Lv
- Department of Gynecology, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Wu Li
- Department of Gynecology, Tongde Hospital of Zhejiang Province, Hangzhou, China
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Emerging Manifestations of Cesarean Scar Defect in Reproductive-aged Women. J Minim Invasive Gynecol 2016; 23:893-902. [DOI: 10.1016/j.jmig.2016.06.020] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/11/2016] [Accepted: 06/29/2016] [Indexed: 11/17/2022]
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Zhang X, Yang M, Wang Q, Chen J, Ding J, Hua K. Prospective evaluation of five methods used to treat cesarean scar defects. Int J Gynaecol Obstet 2016; 134:336-9. [PMID: 27473332 DOI: 10.1016/j.ijgo.2016.04.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 03/23/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate operative and nonoperative therapies for cesarean scar defects (CSDs). METHODS A prospective study was conducted among patients who underwent treatment of CSDs at a hospital in Shanghai, China, between April 1, 2010, and December 31, 2014. Treatment included laparoscopy (group 1), vaginal surgery (group 2), hysteroscopy (group 3), combined oral contraceptives (group 4), and the levonorgestrel intrauterine system (group 5). RESULTS Among 142 participants, 119 patients underwent surgical repair and 23 received nonsurgical (conservative) treatment. Operation time, blood loss, and length of hospital stay reported for patients in group 3 (n=19) were all lower than those reported for patients in group 1 (n=86) and group 2 (n=14; P<0.001 for all comparisons). Patients who underwent surgery and those in group 4 (n=18) experienced shortened menstrual periods after treatment (P<0.001 for all comparisons). For group 5 (n=5), the duration of menstruation was similar before and after therapy (P=0.89). All 32 women who desired fertility underwent laparoscopy; 12 (37.5%) became pregnant after this procedure. CONCLUSION All treatments for CSDs other than the levonorgestrel intrauterine system shortened menstrual periods. Laparoscopic surgery was effective for patients with fertility requirements.
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Affiliation(s)
- Xuyin Zhang
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Mengyi Yang
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Qing Wang
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; Department of Obstetrics and Gynecology, Maternal and Child Health Hospital of Pudong New Area, Shanghai, China
| | - Jianliang Chen
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; Department of Obstetrics and Gynecology, First People's Hospital of Xiaoshan Area, Hangzhou, China
| | - Jingxin Ding
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Keqin Hua
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China.
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A Comparative Study of Transvaginal Repair and Laparoscopic Repair in the Management of Patients With Previous Cesarean Scar Defect. J Minim Invasive Gynecol 2016; 23:535-41. [DOI: 10.1016/j.jmig.2016.01.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 11/21/2022]
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The HysNiche trial: hysteroscopic resection of uterine caesarean scar defect (niche) in patients with abnormal bleeding, a randomised controlled trial. BMC WOMENS HEALTH 2015; 15:103. [PMID: 26563197 PMCID: PMC4642644 DOI: 10.1186/s12905-015-0260-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 10/27/2015] [Indexed: 11/10/2022]
Abstract
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
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Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study. J Minim Invasive Gynecol 2014; 22:297-301. [PMID: 25285773 DOI: 10.1016/j.jmig.2014.09.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/23/2014] [Accepted: 09/27/2014] [Indexed: 11/20/2022]
Abstract
An isthmocele, also known as a cesarean scar defect, is an emerging condition that typically affects women with a history of previous cesarean section, and its presence is a novel under-recognized cause of postmenstrual abnormal uterine bleeding and/or pelvic pain. The incidence of symptoms and their resolution after hysteroscopic surgery were evaluated prospectively in 120 consecutive isthmocele patients. Patients included only symptomatic premenopausal women. Transvaginal ultrasound and office hysteroscopy were used to diagnose isthmocele. Operative hysteroscopy was performed to correct the cesarean scar defect, and histologic findings were evaluated. Correction of an isthmocele via operative hysteroscopy was successful in all cases evaluated. Isthmoplasty resulted in the resolution of postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in 80% of patients. In the remaining cases, 7% of patients had an improvement of symptoms, whereas 13% did not obtain any relief. Considering the recent diagnostic recognition of isthmoceles, we conclude that surgical treatment of this pathology by operative hysteroscopy may represent the best choice in symptomatic women because of its minimal invasiveness and beneficial therapeutic results.
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Chen Y, Chang Y, Yao S. Transvaginal management of cesarean scar section diverticulum: a novel surgical treatment. Med Sci Monit 2014; 20:1395-9. [PMID: 25104647 PMCID: PMC4136942 DOI: 10.12659/msm.890642] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this study was to investigate the clinical value of transvaginal management of cesarean section scar diverticulum. Material/Methods We evaluated 64 patients receiving transvaginal management of previous cesarean scar defect (PCSD). Results The PCSD was successfully treated by transvaginal surgery, without evident complications. The mean operation time was 33.6±4.1 min, blood loss was 37.9±16.8 ml, and the mean hospital stay after surgery was 6±2.9 days. Symptoms related to the prolonged menstruation in 53 patients were improved after surgery, vaginal bleeding time was reduced by an average of 7.3±2.8 days, and a significant difference was noted between the mean pre- and post-operative duration of menstruation (P<0.01). Of 11 patients with guttate between menstrual periods, guttate was absent in 9 patients and improved in 2. Clinical improvement was observed in 85.9% (55/64). Conclusions Transvaginal intervention is feasible and safe for the management of PCSD.
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Affiliation(s)
- Yuqing Chen
- Department of Gynecology and Obstetrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China (mainland)
| | - Yajie Chang
- Reproductive Medicine Research Centre, Sixt Affiliated Hospital, Sun Yat-sen University, Guangzhou, China (mainland)
| | - Shuzhong Yao
- Department of Gynecology and Obstetrics, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China (mainland)
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Allornuvor GFN, Xue M, Zhu X, Xu D. The definition, aetiology, presentation, diagnosis and management of previous caesarean scar defects. J OBSTET GYNAECOL 2014; 33:759-63. [PMID: 24219709 DOI: 10.3109/01443615.2013.816663] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Caesarean sections are the most commonly performed surgical procedures involving the uterus in fertile women. Typically, this surgery involves a transverse incision in the anterior lower uterine segment. The incidence of caesarean sections is on the increase worldwide, and consequently, the complications associated with them are becoming more common. One such complication that is gaining more attention is previous lower uterine segment caesarean scar defect (PCSD). In this review, we sought to explore the definition, aetiology, presentation, diagnosis and management of PCSD.
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Affiliation(s)
- G F N Allornuvor
- Department of Obstetrics and Gynaecology, Third Xiangya Hospital, Central South University , Changsha, Hunan , China
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van der Voet LF, Vervoort AJ, Veersema S, BijdeVaate AJ, Brölmann HAM, Huirne JAF. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review. BJOG 2013; 121:145-56. [DOI: 10.1111/1471-0528.12537] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2013] [Indexed: 11/29/2022]
Affiliation(s)
- LF van der Voet
- Department of Obstetrics and Gynaecology; Deventer Hospital; Deventer The Netherlands
| | - AJ Vervoort
- Department of Obstetrics and Gynaecology; VU University Medical Centre; Amsterdam The Netherlands
| | - S Veersema
- Department of Obstetrics and Gynaecology; St Antonius Hospital; Nieuwegein The Netherlands
| | - AJ BijdeVaate
- Department of Obstetrics and Gynaecology; VU University Medical Centre; Amsterdam The Netherlands
| | - HAM Brölmann
- Department of Obstetrics and Gynaecology; VU University Medical Centre; Amsterdam The Netherlands
| | - JAF Huirne
- Department of Obstetrics and Gynaecology; VU University Medical Centre; Amsterdam The Netherlands
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Abstract
A pediatric robot and 5-mm trocars were used to effect a repair of a cesarean scar dehiscence, also known as a cesarean scar defect. Background and Objectives: During the past few decades, there has been a significant increase in the number of cesarean deliveries, and thus an increase in the number of complications. A common complication of multiple cesarean deliveries is symptomatic uterine scar dehiscence, for which there are no treatment guidelines available. We report a case of uterine scar dehiscence—the repair of it by robotic surgery—and review the literature on this defect. Case: The patient was a 39-year-old woman, gravida 4 para 2022, complaining of persistent vaginal spotting for the prior 5 months with a history of a cesarean delivery 3 months before the onset of the symptoms. Discussion: We report a case of a successful robotic repair of a symptomatic cesarean scar defect. Conclusion: We propose further studies that include more patients so this technique may become the standard for cesarean scar defect.
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Florio P, Gubbini G, Marra E, Dores D, Nascetti D, Bruni L, Battista R, Moncini I, Filippeschi M, Petraglia F. A retrospective case-control study comparing hysteroscopic resection versus hormonal modulation in treating menstrual disorders due to isthmocele. Gynecol Endocrinol 2011; 27:434-8. [PMID: 21204608 DOI: 10.3109/09513590.2010.495431] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In a retrospective case-control study, we compared the effectiveness of hysteroscopic correction and hormonal treatment to improve symptoms [postmestrual abnormal uterine bleeding (PAUB), pelvic pain localized in suprapubic site] associated with isthmocele. Women (n = 39; mean age ± SD, 35 ± 4.1 years) were subdivided in Group A [patients (n = 19) subjected to hysteroscopic surgery (isthmoplasty)] and, Group B [women (n = 20) undergoing hormonal treatment consisting of one oral tablet containing 0.075 mg of Gestodene and 0.030 mg of Ethynylestradiol for 21 days, followed by 7 days of suspension]. Resolution and/or improvement of menstrual disorders; patients degree of satisfaction with the treatment were measured 3 months later, by office hysteroscopy (Grop A) or phone call. PAUB and pelvic pain resolution was achieved in all patients: Group A had significant lower numbers of days of menstrual bleeding (P < 0.001), prevalence of pelvic pain in the suprapubic area (P = 0.04) and, higher degree of satisfaction (P < 0.001) compared to Group B. In conclusion, resectoscopic surgery is a valid way to treat patients with symptoms of prolonged postmenstrual uterine bleeding caused by isthmocele. Data from this study also indicate that resectoscopy may be the first choice because it is minimally invasive and yields good therapeutic results.
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Affiliation(s)
- Pasquale Florio
- Department of Pediatrics, Obstetrics & Reproductive Medicine, Section of Obstetrics and Gynecology, University of Siena, Siena, Italy.
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Challenges in the transvaginal management of abnormal uterine bleeding secondary to cesarean section scar defect. Eur J Obstet Gynecol Reprod Biol 2011; 154:218-22. [DOI: 10.1016/j.ejogrb.2010.10.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Revised: 09/13/2010] [Accepted: 10/13/2010] [Indexed: 11/23/2022]
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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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Wang CB, Chiu WWC, Lee CY, Sun YL, Lin YH, Tseng CJ. Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:85-89. [PMID: 19565535 DOI: 10.1002/uog.6405] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To determine the prevalence of clinical symptoms associated with Cesarean scar defects, and to determine the association between the size of these defects, clinical complaints, uterine position, and a history of multiple Cesarean sections. METHODS In this cross-sectional study, Cesarean scar defects in women with a history of transverse lower-segment Cesarean section were measured by transvaginal ultrasound while being assessed for other gynecological conditions. The relationships between the size of the Cesarean scar defect and the clinical symptoms, uterine position and number of previous Cesarean sections were evaluated. Patients with other uterine pathologies, including endometrial hyperplasia, polyps, malignancy and submucosal myomas, were excluded from the study. RESULTS During a 3-year period, 4250 women were assessed by transvaginal sonography, of whom 293 (6.9%) were diagnosed with Cesarean scar defects. Eighty-six patients were excluded due to other uterine pathologies. Altogether, 207 patients with Cesarean scar defects were included in this study. Women who had undergone multiple Cesarean sections tended to have larger scar defects (in width and depth) than did those who had undergone a single Cesarean section. Women with retroflexed uteri also tended to have wider defects than those with anteflexed uteri. Defect width was significantly greater in women with postmenstrual spotting, dysmenorrhea and chronic pelvic pain. CONCLUSIONS Multiple Cesarean sections and retroflexed uteri are risk factors for larger Cesarean scar defects. The size of the Cesarean scar defect is associated with clinical symptoms such as postmenstrual spotting, dysmenorrhea and chronic pelvic pain.
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Affiliation(s)
- C-B Wang
- Department of Obstetrics and Gynecology, Chia Yi Chang Gung Memorial Hospital and Chang Gung University, Pu Tz City, Taiwan.
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Chang Y, Tsai EM, Long CY, Lee CL, Kay N. Resectoscopic treatment combined with sonohysterographic evaluation of women with postmenstrual bleeding as a result of previous cesarean delivery scar defects. Am J Obstet Gynecol 2009; 200:370.e1-4. [PMID: 19318145 DOI: 10.1016/j.ajog.2008.11.038] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Accepted: 11/25/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of this study was to assess the detection rate of previous cesarean delivery scar (PCDS) defect by transvaginal ultrasonography (TVU) and to evaluate the effectiveness of resectoscopic surgery to correct this anatomic defect. STUDY DESIGN In all, 57 women were included in our study. A diagnosis of a PCDS defect was established by TVU. We used resectoscopy to remove the flaplike fibrotic tissue that appeared underneath the pouchlike defect. RESULTS A total of 22 patients received resectoscopic treatment. The detection rate of PCDS defects was 88% by TVU. The duration of postmenstrual bleeding shortened significantly after resectoscopic therapy. CONCLUSION TVU examination performed during the period of postmenstrual bleeding allows us to readily identify this anatomic defect. Resectoscopy, in our opinion, should be considered the first choice to correct this defect because it is minimally invasive and yields good therapeutic results.
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Ceci O, Scioscia M, Vicino M, Pinto L, Pontrelli G, Bettocchi S. Recurrent intermenstrual bleeding secondary to cesarean section scars? Fertil Steril 2007; 88:757; author reply 757-8. [PMID: 17681341 DOI: 10.1016/j.fertnstert.2007.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Tahara M, Shimizu T, Shimoura H. Letter to the Editor. Fertil Steril 2007. [DOI: 10.1016/j.fertnstert.2007.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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