1
|
Mohr-Sasson A, Castel E, Dadon T, Brandt A, Etinger R, Cohen A, Zajicek M, Haas J, Mashiach R. The association of endometrial closure during cesarean section to the risk of developing uterine scar defect: a randomized control trial. Arch Gynecol Obstet 2024; 309:2063-2070. [PMID: 38498161 DOI: 10.1007/s00404-024-07417-1] [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: 12/17/2023] [Accepted: 02/04/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms. METHODS A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range. RESULTS 130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0-7.7) vs. 4.6 (3.0-6.5) mm for the endometrial closure and non-closure groups, respectively (p = 0.38). Substantially low RMT (< 2.5 mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group (p = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups. CONCLUSION Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6 months follow-up.
Collapse
Affiliation(s)
- Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel.
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Elias Castel
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tal Dadon
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
| | - Ariel Brandt
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
| | - Roie Etinger
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
| | - Adiel Cohen
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
| | - Michal Zajicek
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Mashiach
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
2
|
Candiani M, Dolci C, Schimberni M, Bartiromo L, Villanacci R, Grisafi G, Tandoi I, Salvatore S, Ferrari SM. Reproductive outcomes after vaginal repair of isthmocele: A preliminary study and systematic review of the literature. Eur J Obstet Gynecol Reprod Biol 2024; 296:163-169. [PMID: 38447278 DOI: 10.1016/j.ejogrb.2024.02.025] [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: 12/15/2023] [Revised: 02/06/2024] [Accepted: 02/11/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE Although vaginal repair of isthmocele is an effective and safe surgical option, data on reproductive and obstetrical outcomes are lacking. The aim of this study is to evaluate reproductive outcomes of women undergone vaginal repair of isthmocele. We also systematically reviewed the existent literature to offer a general view of available data. STUDY DESIGN Retrospective analysis of a database prospectively collected between January 2018 and January 2022 at San Raffaele Hospital, Milan, Italy. We included secondary infertile women with ultrasound documented isthmocele who undergone vaginal repair. Post-surgical clinical, reproductive and obstetric outcomes were recorded. An advanced systematic search of the literature up to January 2023 was conducted. RESULTS 17 women were included. The mean age of the included patients was 37.2 ± 2.7 years. The median of previous caesarian sections was 1 (1-2). One intra-operative complication (5.9 %) was reported (bladder injury, repaired at the time of surgery). At follow up, bleeding was successfully treated in 8 women (8/10; 80 %). Pregnancy was obtained in 7 women (7/17; 41.2 %): the conception was spontaneous in 4 women (4/7; 57.1 %) and trough assisted reproductive technology in 3 patients (3/7; 42.9 %). The mean time from surgery to pregnancy was 10.8 (±6.7) months. One spontaneous abortion was reported (1/7; 14.3 %), while live birth was achieved in 6 pregnancies (6/7; 85.7 %). All deliveries were by caesarian section at a median gestational age of 37.5 (36-38.25) weeks. No obstetrical complications were reported. At the time of caesarean section, no defects on the lower segment were retrieved. Regarding the systematic research, among the 21 studies screened, only 4 articles were included in the review. Pregnancy rate was around 60-70 % with very few obstetrical complications (0.01 %) such as abnormal placentation or preterm birth. CONCLUSIONS Vaginal repair of isthmocele is a minimally invasive, safe and effective surgical approach in terms of postsurgical residual myometrium tichness. Systematic review to date has found low-quality evidences on the impact of vaginal surgery in the management of secondary infertility and obstetrics outcomes in women with isthmocele.
Collapse
Affiliation(s)
- Massimo Candiani
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Carolina Dolci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy.
| | - Matteo Schimberni
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Ludovica Bartiromo
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Roberta Villanacci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Giorgia Grisafi
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Iacopo Tandoi
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefano Salvatore
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefano Maria Ferrari
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| |
Collapse
|
3
|
Gezer Ş, Daryal AS, Aksoy L. Effects of endometrial versus non-endometrial suturing on isthmocele development; a randomized controlled trial. J Gynecol Obstet Hum Reprod 2024; 53:102758. [PMID: 38432626 DOI: 10.1016/j.jogoh.2024.102758] [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: 11/05/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Incomplete healing after cesarean section (CS) can result in isthmocele formation. When suturing the uterus, fully folding the wound lips may embed the endometrial layer into the myometrium, leading to isthmocele development. Hence, this study aimed to compare the effects of endometrial and non-endometrial suturing on isthmocele development. MATERIAL AND METHODS This randomized controlled trial included 274 patients. Women who underwent primary CS were randomly allocated to one of the two study groups: endometrial suturing and non-endometrial suturing. The primary outcome was isthmocele rate at postpartum 6 months. Secondary outcomes were the volume of the isthmocele, thickness of the residual myometrium, menstrual irregularities (intermenstrual spotting), and the relationship between the isthmocele and uterine position. RESULTS A total of 159 patients (81 in the endometrial suturing group and 78 in the non-endometrial suturing group) were analyzed. The incidence of isthmocele was significantly lower in the non-endometrial suturing group than in the endometrial suturing group (12 [15.4%] vs. 24 [29.6%] patients; p = 0.032). Menstrual irregularities, such as intermenstrual spotting, were significantly higher in the endometrial suturing group than in the non-endometrial group (p = 0.019). CONCLUSION Uterine closure with non-endometrial suturing was associated with significantly lower isthmocele development and less intermenstrual spotting compared to that with endometrial suturing.
Collapse
Affiliation(s)
- Şener Gezer
- Kocaeli University School of Medicine, Department of Obstetrics and Gynecology, Turkey
| | - Ayşe Seda Daryal
- Kocaeli University School of Medicine, Department of Obstetrics and Gynecology, Turkey
| | - Lale Aksoy
- Department of Obstetrics and Gynecology, Geyve State Hospital, Geyve, Turkey
| |
Collapse
|
4
|
Baldini GM, Lot D, Malvasi A, Di Nanni D, Laganà AS, Angelucci C, Tinelli A, Baldini D, Trojano G. Isthmocele and Infertility. J Clin Med 2024; 13:2192. [PMID: 38673465 PMCID: PMC11050579 DOI: 10.3390/jcm13082192] [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: 02/10/2024] [Revised: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman's quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5-3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted.
Collapse
Affiliation(s)
- Giorgio Maria Baldini
- MOMO’ FertiLIFE, IVF Clinic, 76011 Bisceglie, Italy
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy;
| | - Dario Lot
- MOMO’ FertiLIFE, IVF Clinic, 76011 Bisceglie, Italy
| | - Antonio Malvasi
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy;
| | - Doriana Di Nanni
- Pathology Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70125 Bari, Italy
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Department of Health Promotion, Mother and Childcare, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Cecilia Angelucci
- Gynecology and Obstetrics Clinic, University of Sassari, 07100 Sassari, Italy;
| | - Andrea Tinelli
- Department of Gynaecology and Obstetrics, “Veris Delli Ponti” Hospital, and CERICSAL (Centro di RIcerca Clinico SALentino), “Veris delli Ponti Hospital”, 73020 Lecce, Italy;
| | | | - Giuseppe Trojano
- Department of Maternal and Child, Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Madonna Delle Grazie Hospital ASM, 75100 Matera, Italy
| |
Collapse
|
5
|
Zhou X, Gao Z, Chen H, Wang Y, Yin Y, Zhang J, Wang X. A Prediction Model for the Efficacy of Transvaginal Repair in Patients With Cesarean Scar Defect: An Evidence-Based Proposal for Patient Selection. J Minim Invasive Gynecol 2024; 31:213-220. [PMID: 38135001 DOI: 10.1016/j.jmig.2023.12.006] [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: 06/18/2023] [Revised: 11/24/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
STUDY OBJECTIVE To establish a prediction model to help doctors determine which patients with cesarean scar defect are more suitable for transvaginal repair. DESIGN Retrospective analysis. SETTING Xinhua Hospital and Shanghai First Maternity & Infant Hospital between June 2014 and May 2021. PATIENTS 1015 women who underwent transvaginal repair of cesarean scar defect (CSD). INTERVENTIONS All enrolled patients underwent CSD repair performed by the same gynecologist and his team. And followed up a clinic visit at 6 months to record their menstruation and measure multiple parameters of the CSD by Magnetic Resonance Imaging. MAIN OUTCOMES AND MEASURES CSD patients are categorized as optimal healing group when the menstruation duration is no more than 7 days, meanwhile the thickness of residual myometrium is no less than 5.39 mm after vaginal repair. The final nomogram is constructed to predict surgical outcomes based on preoperative variables. RESULTS The key factors that determine optimal healing are the timing of cesarean section (elective or emergency), menstrual cycle, CSD length, width, depth, and the thickness of the lower uterine segment. With the prediction model, scores are given to each parameter according to the statistics. Total scores range from 0 to 25 points, with a cutoff point of 16.5. When a score is greater than 16.5, the transvaginal repair can achieve optimal healing. Uterine position (anteflexion or retroflexion) and preoperative thickness of residual myometrium are the key factors affecting postoperative thickness of residual myometrium. The width of the CSD and the thickness of the lower uterine segment are the key factors affecting abnormal uterine bleeding symptoms (p < 0.01). CONCLUSIONS For the first time, we established a prediction model system that may predict the repair effect of CSD and can potentially be useful in future clinical trials to determine which patients are more suitable for surgery or other treatment options.
Collapse
Affiliation(s)
- Xingchen Zhou
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Zhenyan Gao
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Huihui Chen
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Yizhi Wang
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Yujia Yin
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health (Dr. Zhang), Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xipeng Wang
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang).
| |
Collapse
|
6
|
Vogel JP, Jung J, Lavin T, Simpson G, Kluwgant D, Abalos E, Diaz V, Downe S, Filippi V, Gallos I, Galadanci H, Katageri G, Homer CSE, Hofmeyr GJ, Liabsuetrakul T, Morhason-Bello IO, Osoti A, Souza JP, Thakar R, Thangaratinam S, Oladapo OT. Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward. Lancet Glob Health 2024; 12:e317-e330. [PMID: 38070535 PMCID: PMC10805007 DOI: 10.1016/s2214-109x(23)00454-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 01/22/2024]
Abstract
Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.
Collapse
Affiliation(s)
- Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia.
| | - Jenny Jung
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Tina Lavin
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Grace Simpson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Dvora Kluwgant
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
| | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Soo Downe
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
| | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ioannis Gallos
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Hadiza Galadanci
- Africa Center of Excellence for Population Health and Policy, Bayero University, Kano, Nigeria
| | - Geetanjali Katageri
- S Nijalingappa Medical College and HSK Hospital & Research Centre, Bagalkot, India
| | - Caroline S E Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana; University of the Witwatersrand and Walter Sisulu University, East London, South Africa
| | - Tippawan Liabsuetrakul
- Department of Epidemiology and Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Imran O Morhason-Bello
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences and Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Alfred Osoti
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - João Paulo Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Olufemi T Oladapo
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| |
Collapse
|
7
|
Yang G, Wang J, Chang Y, Chen Y. Comparison of clinical effectiveness and subsequent fertility between hysteroscopic resection and vaginal repair in patients with cesarean scar defect: a prospective observational study. Reprod Biol Endocrinol 2023; 21:119. [PMID: 38082355 PMCID: PMC10712091 DOI: 10.1186/s12958-023-01169-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/01/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE To evaluate the clinical effectiveness and pregnancy rate after hysteroscopic resection (HR) and/or vaginal repair (VR) in patients with cesarean scar defect (CSD). METHODS This prospective observational study enrolled 191 patients who received CSD surgery in the First affiliated hospital of Sun Yat-sen University between September 2019 to February 2022 (96 in HR and 95 in VR, respectively). Patient follow-up were performed three months after surgery in both groups by transvaginal ultrasound to confirm the presence of fluid in the niche, along with the resolution of prolonged menses at the same time. The primary outcome was the clinical effectiveness between HR and VR, identified by the resolution of prolonged menses. RESULTS The rates of niche-fluid disappearance (70.1% vs 60.2%, P = 0.176) and prolonged menses resolution (74.8% vs 80.0%, P = 0.341) were comparable for HR and VR. A subgroup analysis for niche size revealed that HR provides patients with small niche a more favorable rate of menstrual resolution compared to VR (size of niche ≤ 15 mm2, aOR = 3.423, 95% confidence interval [CI] 1.073-10.918), but patients with large niche experience a lower rate of resolution compared to VR (size of niche > 25 mm2, aOR = 0.286, 95% CI 0.087- 0.938). During follow-up, 41 patients who wanted to conceive became pregnant. Kaplan-Meier estimates of the cumulative probability of pregnancy at 12 months and 24 months were 47.1% (95% CI: 34.5%, 58.8%) and 63.8% (95% CI: 52.5%, 72.9%), respectively. The median pregnancy time was 22 months (95% CI: 14.2, 29.8) after VR and 12 months (95% CI: 8.3, 15.7, Gehan-Breslow-Wilcoxon P = 0.021) after HR. Among patients with subsequent infertility, 31.6% achieved pregnancy by unassisted mode and 29.8% by IVF/ICSI. Moreover, among patients with previously failed IVF/ICSI treatment, 60% (12/20) obtained pregnancy, including 71.4% (10/14) after HR and 33.3% (2/6) after VR. CONCLUSIONS Hysteroscopic resection is as effective as vaginal repair at relieving symptoms of CSD-associated prolonged menses. Hysteroscopic resection is the modality of choice with an improvement in prolonged menses for small niche, while vaginal might be considered for a large niche. Furthermore, surgical intervention could improve the clinical pregnancy rate of CSD patients. All of these provide evidence for the individualized management of CSD.
Collapse
Affiliation(s)
- Guoxia Yang
- Reproductive Medical Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, China
| | - Jiamin Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Zhongshan 2 Road, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, China
| | - Yajie Chang
- Reproductive Medical Center, The Six Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yuqing Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-Sen University, Zhongshan 2 Road, Guangzhou, China.
- Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, Guangzhou, China.
| |
Collapse
|
8
|
Morton CC, Sanders AP. Identification and Excision of a Fistulous Cesarean Scar Defect. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102083. [PMID: 36868350 DOI: 10.1016/j.jogc.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/21/2022] [Accepted: 12/29/2022] [Indexed: 03/05/2023]
Affiliation(s)
- Craig Charles Morton
- Department of Obstetrics and Gynecology, Saint John Regional Hospital, Saint John, New Brunswick, Canada; Department of Obstetrics and Gynecology, University of Calgary, Peter Lougheed Centre, Calgary, Alberta, Canada.
| | - Ari Paul Sanders
- Department of Obstetrics and Gynecology, University of Calgary, Peter Lougheed Centre, Calgary, Alberta, Canada
| |
Collapse
|
9
|
Ishikawa H, Saito Y, Koga K, Shozu M. Reproductive outcomes following abdominal repair for cesarean scar defect in women who desire subsequent pregnancies: A single-center retrospective study. Eur J Obstet Gynecol Reprod Biol 2023; 291:141-147. [PMID: 37871351 DOI: 10.1016/j.ejogrb.2023.10.023] [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: 05/01/2023] [Revised: 09/22/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To clarify the reproductive outcomes of women who underwent abdominal repair surgery for cesarean scar defect (CSD). STUDY DESIGN This is a retrospective observational study performed in a tertiary center. We retrospectively reviewed 20 women who underwent abdominal repair between 2007 and 2021. The indication for the repair was a minimal residual myometrial thickness (RMT) of ≦3.0 mm. We investigated surgical complications, changes in minimal RMT before and three-months after the repair, and reproductive outcomes. RESULTS The median age at the time of repair was 36 years (27-40), with a median body mass index of 21.0 (17.7-28.7) and a median of 1 prior cesarean section (1-5). Twelve women reported secondary infertility, while eight women were concerned about the potential risk of uterine rupture in future pregnancies due to thin RMT. Additionally, one woman had a co-existing vesicouterine fistula, two had abscess and hematoma formation at the precedent cesarean section, and three showed remarkable dehiscence of the defect. The median minimal RMT significantly increased to 5.05 mm (range; 2.5-14.2 mm) after the repair. Seven women had a total of eight live births, with a median duration from the repair to a live-birth pregnancy of 11.5 months (range; 4-20 months). No surgical complications occurred during the repair, and there were no instances of uterine rupture in subsequent pregnancies. However, one woman who became pregnant with twins following double blastocyst transfer required a cesarean section at 25 weeks of pregnancy due to bulging towards the bladder side of the repaired CSD. CONCLUSION Abdominal repair for CSD is feasible in women with thin RMT who experience secondary infertility. Twin pregnancies can promote thinning of the CSD repair site, potentially increasing the risk of uterine rupture.
Collapse
Affiliation(s)
- Hiroshi Ishikawa
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.
| | - Yoshiko Saito
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kaori Koga
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makio Shozu
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan; Evolution and Reproductive Biology, Medical Mycology Research Center, Chiba University, Chiba, Japan
| |
Collapse
|
10
|
Fatehnejad M, Hadizadeh A, Tayebi A, Ayati A, Marjani N, Gheshlaghi P, Asgari Z, Hosseini R. Assessment of the clinical outcomes and complications of hysteroscopic and laparoscopic approaches in the treatment of symptomatic isthmocele: An observational study. Int J Gynaecol Obstet 2023; 163:965-971. [PMID: 37350282 DOI: 10.1002/ijgo.14926] [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: 03/26/2023] [Revised: 05/23/2023] [Accepted: 05/28/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES To investigate the outcomes of patients undergoing laparoscopic or hysteroscopic approaches for isthmoplasty. METHODS A total of 99 isthmocele patients with an average age of 38.45 ± 4.72 years were included in the 2 years of this retrospective cohort study. Forty-five underwent laparoscopic and 54 underwent hysteroscopic isthmocele excision and myometrial repair. RESULTS Pain scores were significantly higher in the hysteroscopy group before the procedure, but there were no significant pain score differences after the surgery. In 1 year of follow up, dysmenorrhea and dyspareunia were higher among hysteroscopy patients. Furthermore, hysteroscopy significantly improved postmenstrual spotting after surgery better than laparoscopy, but in the follow up, there was no significant difference between the two groups in this regard (mean rank for hysteroscopy vs. laparoscopy: 32.30 vs. 37.48, U = 418, P = 0.29). CONCLUSION In patients with a history of infertility, ectopic pregnancy, lower gravidity, lower parity, and a lower number of cesarean sections, laparoscopic isthmoplasty is preferred over the hysteroscopic approach. Both methods have similar effects on midcycle vaginal bleeding, duration of postmenstrual spotting, and pain. However, a higher rate of dyspareunia and dysmenorrhea could be associated with hysteroscopy.
Collapse
Affiliation(s)
- Mina Fatehnejad
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Hadizadeh
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Tayebi
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Aryan Ayati
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Narjes Marjani
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parand Gheshlaghi
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Asgari
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reihaneh Hosseini
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
11
|
Walker Z, Gargiulo A. Near-infrared and hysteroscopy-guided robotic excision of uterine isthmocele with laser fiber: a novel high-precision technique. Fertil Steril 2023; 120:1081-1083. [PMID: 37567494 DOI: 10.1016/j.fertnstert.2023.08.006] [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: 02/27/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE To describe a novel high-precision technique for robotic excision of uterine isthmocele, employing a carbon dioxide laser fiber, under hysteroscopic guidance, and near-infrared guidance. DESIGN Video article. PATIENT(S) A 36-year-old multipara with 3 prior cesarean sections presented to our infertility clinic with secondary infertility. The patient had been trying to conceive for 6 months without success. The patient underwent a hystero-salpingo contrast sonography that identified a large cesarean scar defect with a 1.4-mm residual myometrial thickness (RMT). The patient was counseled on surgical management with robotic approach because of RMT <3 mm precluding her from hysteroscopic resection and the potential risk for a cesarean scar ectopic or abnormal placentation if she were to become pregnant in the future. She elected to undergo excision and repair and informed consent was obtained from the patient. INTERVENTION(S) The robot was docked for traditional gynecologic robotic surgery. The uterus was injected with 5 units of vasopressin. We used a carbon dioxide laser fiber (Lumenis FIberLase) at a power of 5 watts as the sole energy source for dissection. The bladder was dissected off the uterus to identify the general area of the isthmocele. At that point, diagnostic hysteroscopy was performed using a 30-degree 5-mm hysteroscope (Karl Storz) to identify and enter the isthmocele. Near-infrared vision (da Vinci Firefly, Intuitive USA) was activated to precisely outline the extent of the isthmocele, which was not visible with simple transillumination from the hysteroscope. We proceeded with laser excision in infrared/gray scale using the laser at a power of 20 watts removing the entire area that was highlighted by the Firefly. After full excision of the isthmocele, the hysteroscope was removed and was eventually replaced by a uterine manipulator (ConMed VCare DX). The hysterotomy was closed with a 2-layer closure: 4 mattress sutures of 2-0 Vicryl (Ethicon) followed by a running 2-0 PDS Stratafix (Ethicon). The peritoneal layer was closed over these 2 layers with 2-0 PDS Stratafix (Ethicon) in a running fashion. The uterine manipulator was removed and a 14 French Malecot catheter (Bard) was placed in the uterine cavity to allow the healing to proceed with minimal risk of cervical stenosis. The bladder was backfilled to ensure integrity of the bladder wall. Interceed adhesion barrier (Gynecare) was then placed over the area of the repair and the procedure was concluded. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.), and other applicable sites. MAIN OUTCOME MEASURE(S) Completion of excision and repair of cesarean scar defect without surgical complications. RESULT(S) Robotic excision and repair of a sizable uterine isthmocele with carbon dioxide laser fiber and da Vinci Firefly was completed successfully without any surgical complications. Diagnostic hysteroscopy was used to positively identify the isthmocele and provide transillumination. However, the thickness of the cervical myometrium only allows the hysteroscopic light to shine through the thinnest portion of myometrium at the apex of the isthmocele, whereas the near-infrared vision allowed by the da Vinci Firefly technology was used to precisely identify the borders of the defect. The carbon dioxide laser was used to completely remove the defect while avoiding damage to delicate reproductive tissue and over-excision. No complications were identified during the postoperative visit. Magnetic resonance imaging 3 months after the surgery revealed an RMT of 10 mm at the location of excision compared with the initial RMT of 1.4 mm. CONCLUSION(S) Currently, there is no gold-standard technique for surgical management of isthmocele. This is the first description of the combined use of hysteroscopy, near-infrared vision, and laser fiber for the robotic excision of isthmocele. This specific setup proves to be a useful technical improvement. The use of near-infrared vision combined with precise hysteroscopic targeting allows much clearer definition of he isthmocele borders, and the flexible laser fiber allows millimetric xcision in the absence of appreciable lateral thermal spread. Further investigation is warranted to identify a gold-standard surgical technique for patients with cesarean scar defect.
Collapse
Affiliation(s)
- Zachary Walker
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Antonio Gargiulo
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
12
|
Wang Y, Hao X, Chen Y, Wang L, Zhou Y, Xue M, Dong Y, Sun L. Treatment of uterine scar cystoid diverticulum by hysteroscopy combined with laparoscopy. Fertil Steril 2023; 120:922-924. [PMID: 37499779 DOI: 10.1016/j.fertnstert.2023.07.013] [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: 11/05/2022] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To report a patient with prolonged intermenstrual bleeding and a cystic mass at a cesarean scar treated with laparoscopic folding sutures and hysteroscopic canalization. DESIGN A 4.0 cm-cystic mass formed at the uterine scar caused continuous menstrual blood outflow in the diverticulum and was treated with hysteroscopy combined with laparoscopy. SETTING University hospital. PATIENTS A 38-year-old woman of childbearing age who had undergone two cesarean sections and two abortions reported vaginal bleeding for 10 years, which began shortly after the second cesarean section. Curettage was performed, but no abnormality was found. The patient unsuccessfully tried to manage her symptoms with traditional Chinese medicine and hormone drugs. The muscular layer of the lower end of the anterior wall of the uterus was weak, and there were cystic masses on the right side. INTERVENTION The bladder was stripped from the lower uterine segment under laparoscopy, and the surrounding tissue of the mass at the uterine scar was separated. The position of the cesarean scar defect was identified by hysteroscopy combined with laparoscopy, and the relationship between the uterine mass and surrounding tissues was analyzed. An electric cutting ring resection on both sides of the obstruction was performed to eliminate the valve effect. The active intima of the scar diverticulum was destroyed by electrocoagulation, followed by laparoscopic treatment of the uterine scar diverticulum mass. An intraoperative tumor incision revealed visible bloody fluid mixed with intimal material. The uterine scar diverticulum defect was repaired using 1-0 absorbable barbed continuous full-thickness mattress fold sutures. Finally, the bilateral round ligament length was adjusted so that the uterus tilted forward. MAIN OUTCOME MEASURES Recovery of menstruation and anatomy of the uterine isthmus. RESULTS The operation was successful, and the postoperative recovery was fast. There was no interphase bleeding at the 1-month follow-up, and the uterine scar diverticulum was repaired, with the thickness of the uterine scar muscle layer increasing to 0.91 cm. CONCLUSION The simple, straightforward procedure to resolve the abnormal cystic, solid mass formed because of the continuous deposition of blood in the uterine scar diverticulum involved laparoscopic folding and docking sutures combined with hysteroscopic canal opening.
Collapse
Affiliation(s)
- Yanan Wang
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Xianhua Hao
- Department of Gynecology, Affiliated Hospital of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Yahui Chen
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Lin Wang
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Yan Zhou
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Mei Xue
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Yan Dong
- Departments of Gynecology and Obstetrics, Clinical Medical College of Jining Medical University, Jining, Shandong, People's Republic of China; Department of Obstetrics, Affiliated Hospital of Jining Medical University, Jining, Shandong, People's Republic of China
| | - Lin Sun
- Department of Gynecology, Affiliated Hospital of Jining Medical University, Jining, Shandong, People's Republic of China.
| |
Collapse
|
13
|
Mensi L, Riccaboni A, Alagna F, Filippi F, Benaglia L, Reschini M, Somigliana E, Vercellini P. Prevalence and clinical effect of caesarean scar defects in women undergoing IVF. Reprod Biomed Online 2023; 47:103240. [PMID: 37542845 DOI: 10.1016/j.rbmo.2023.05.012] [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: 01/25/2023] [Revised: 05/19/2023] [Accepted: 05/27/2023] [Indexed: 08/07/2023]
Abstract
RESEARCH QUESTION How common are caesarean scar defects (isthmocele) among patients who have had previous caesarean delivery undergoing IVF for secondary infertility? Does the presence of isthmocele affect the chances of success of IVF? DESIGN In this cohort study, women referred to an Italian public assisted reproduction centre between January 2016 and April 2021 were retrospectively reviewed. Women with a history of caesarean delivery and an indication for IVF were selected. On the basis of the local policy, all patients with a history of caesarean section underwent saline contrast sonography (SCS). Sonographic evaluation was standardized. RESULTS One hundred and forty-four women were eligible, of whom 22 declined SCS and eight decided to delay pregnancy seeking. Overall, 114 women were available for data analysis. Seventy-six women were diagnosed with caesarean scar defects, corresponding to a prevalence of 67% (95% CI 58 to 75%). Baseline characteristics of women with and without isthmocele were similar. Conversely, the clinical pregnancy rate (adjusted OR 0.31, 95% CI 0.13 to 0.72) and live birth rate (adjusted OR 038, 95% CI 0.17 to 0.86) were significantly lower among affected women. No associations between specific sonographic defect characteristics and IVF outcome could be identified. CONCLUSIONS Caesarean scar defects are common among women with a history of caesarean section requiring IVF. The presence of these lesions may reduce the chance of success of the procedure.
Collapse
Affiliation(s)
- Laura Mensi
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Alessandra Riccaboni
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Alagna
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Filippi
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Benaglia
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Reschini
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Paolo Vercellini
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy; Gynecological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
14
|
Al-Bataineh R, Rawashdeh S, Lataifeh LN, Alzghoul SM, Al Sharie AH, Obeidat R, Altal OF. Cesarean scar ectopic partial molar pregnancy: A case report and a review of literature. Case Rep Womens Health 2023; 39:e00555. [PMID: 37868260 PMCID: PMC10587699 DOI: 10.1016/j.crwh.2023.e00555] [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] [Received: 09/10/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023] Open
Abstract
A scar ectopic pregnancy exhibiting hydatidiform features is an extremely rare and clinically challenging entity. Delayed diagnosis and failure to treat such cases promptly can lead to devastating consequences. In this report, we present a case of cesarean scar ectopic partial molar pregnancy in a 37-year-old woman who presented with complaints of vaginal discharge with streaks of blood and lower abdominal pain. Diagnostic laparoscopy revealed an abnormal mass of brown soft tissue in the anterior wall of the uterus, measuring 13.0 × 9.0 × 2.0 cm, raising suspicion (in the context of elevated serum human chorionic gonadotropin levels) of a scar ectopic pregnancy. Open laparotomy was performed, and the scar ectopic mass was successfully removed. The histologic examination of the tissue revealed a partial hydatidiform mole. The patient experienced a full recovery postoperatively, with serum human chorionic gonadotropin levels gradually declining to normal values. This report is unique in its presentation of the clinicopathological features of cesarean scar ectopic molar pregnancy and the successful management of the condition.
Collapse
Affiliation(s)
- Rania Al-Bataineh
- Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | | | - Leen N. Lataifeh
- Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Saja M. Alzghoul
- Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Ahmed H. Al Sharie
- Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Rawan Obeidat
- Department of Obstetrics & Gynecology, Faculty of Medicine, Jordan University of Science and Technology, King Abdullah University Hospital, Irbid 22110, Jordan
| | - Omar F. Altal
- Department of Obstetrics & Gynecology, Faculty of Medicine, Jordan University of Science and Technology, King Abdullah University Hospital, Irbid 22110, Jordan
| |
Collapse
|
15
|
Al-Ghotani B, Martini N, Alabdallah E, Alawad I, Hussien K. A large post-caesarean Niche (Isthmocele) with amenorrhea, a symptom that was not reported in the medical literature: A rare case report. Int J Surg Case Rep 2023; 109:108528. [PMID: 37499350 PMCID: PMC10413087 DOI: 10.1016/j.ijscr.2023.108528] [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: 06/06/2023] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Isthmocele is identified as an iatrogenic defect in the myometrium of the anterior uterine wall at the site of a previous cesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding (AUB) and pelvic pain. Herein, we report a rare case of a large isthmocele that manifested with secondary amenorrhea; which was not reported in the medical literature previously. CASE PRESENTATION A 30-year-old Syrian woman, G5P5, came to our clinic with a complaint of secondary amenorrhea that began two years ago. She was treated symptomatically with progesterone with no response. She has had five cesarean sections. Ultrasonography findings suggested a large uterine niche. Trans-Abdominal niche repair was the obtained technique, depending on the drainage of the isthmocele, excising the fibrotic tissue from the edges and re-approximating them. On follow-up, menstruation returned to normal. CLINICAL DISCUSSION Isthmocele can be, radiologically, defined as a hypoechoic or anechoic, triangular area at the scar site. Its pathophysiology is still unknown. Although, an isthmocele can be diagnosed using a variety of imaging techniques like ultrasonography (US), magnetic resonance imaging (MRI), sonohysterography, and hysteroscopy; transvaginal ultrasound (TVUS) is the first method described for assessing it. The goal of isthmocele treatment is to alleviate symptoms. CONCLUSION We recommend that health awareness campaigns alert people to the need to see a specialist doctor in the context of a serious complaint. For the uterine niche, many risk factors can be avoided to reduce its probability.
Collapse
Affiliation(s)
- Basel Al-Ghotani
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic.
| | - Nafiza Martini
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Ebaa Alabdallah
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Ieman Alawad
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic; Alassad Medical Complex, Hama, Syrian Arab Republic
| | | |
Collapse
|
16
|
Mohr-Sasson A, Dadon T, Brandt A, Shats M, Axcelrod M, Meyer R, Zajicek M, Haas J, Mashiach R. The association between uterine scar defect (niche) and the presence of symptoms. Reprod Biomed Online 2023; 47:103221. [PMID: 37277298 DOI: 10.1016/j.rbmo.2023.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 06/07/2023]
Abstract
RESEARCH QUESTION Is there association between the presence of a uterine niche and the presence of symptoms? DESIGN This cross-sectional study was conducted at a single tertiary medical centre. All women who underwent Caesarean section from January 2017 to June 2020 were invited to the gynaecological clinics, and requested to complete a questionnaire regarding symptoms related to the presence of a niche (heavy menstrual bleeding, intermenstrual spotting, pelvic pain, infertility). Transvaginal two-dimensional ultrasonography was performed to assess the uterus and uterine scar characteristics. The primary outcome was defined as the presence of a uterine niche, evaluated by length, depth, residual myometrial thickness (RMT) and ratio between the residual myometrial thickness (RMT) and adjacent myometrial thickness (AMT). RESULTS Of 524 women who were eligible and scheduled for evaluation, 282 (54%) completed the follow-up; 173 (61.3%) were symptomatic and 109 (38.6%) asymptomatic. Niche measurements, including RMT/AMT ratio, were comparable between the groups. In a sub-analysis of each symptom, heavy menstrual bleeding and intermenstrual spotting were associated with reduced RMT (P = 0.02 and P = 0.04, respectively) compared with women with normal menstrual bleeding. An RMT less than 2.5 mm was significantly more prevalent in women reporting heavy menstrual bleeding (11 [25.6%] versus 27 [11.3%]; P = 0.01] and new infertility (7 [16.3%] versus 6 [2.5%]; P = 0.001]. In logistic regression analysis, infertility was the only symptom associated with an RMT less than 2.5 mm (B = 1.9; P = 0.002). CONCLUSIONS A reduced RMT was found to be associated with heavy menstrual bleeding and intermenstrual spotting, while values below 2.5 mm were also associated with infertility.
Collapse
Affiliation(s)
- Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel..
| | - Tal Dadon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Ariel Brandt
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Maya Shats
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Axcelrod
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Zajicek
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Mashiach
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
17
|
Nezhat C, Zaghi B, Baek K, Nezhat A, Nezhat F, Lindheim S, Nezhat C. Outcomes of Laparoscopic Cesarean Scar Defect Repair: Retrospective and Observational Study. J Clin Med 2023; 12:jcm12113720. [PMID: 37297915 DOI: 10.3390/jcm12113720] [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: 03/10/2023] [Revised: 05/20/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Cesarean scar defect, also known as niche, isthmocele, uteroperitoneal fistula and uterine diverticulum, is a known complication after cesarean delivery. Due to the rising cesarean delivery rates, niche has become more common and can present as irregular bleeding, pelvic pain, infertility, cesarean scar pregnancy and uterine rupture. Treatments for symptomatic cesarean scar defect vary and include hormonal therapy, hysteroscopic resection, vaginal or laparoscopic repair, and hysterectomy. We report on the safety and efficacy of our method of repairing cesarean scar defects in 27 patients without adverse outcomes: two-layer repair where the suture does not enter the uterine cavity. Our method of laparoscopic niche repair improves symptoms in nearly 77% of patients, restores fertility in 73% of patients, and decreases the time to conception.
Collapse
Affiliation(s)
- Camran Nezhat
- Camran Nezhat Institute, Palo Alto, CA 94061, USA
- Stanford University Medical Center, Stanford, CA 94305, USA
- University of California, San Francisco, CA 94143, USA
| | | | - Kelly Baek
- California Fertility Partners, Los Angeles, CA 90025, USA
| | - Azadeh Nezhat
- Camran Nezhat Institute, Palo Alto, CA 94061, USA
- Stanford University Medical Center, Stanford, CA 94305, USA
- University of California, San Francisco, CA 94143, USA
| | - Farr Nezhat
- Nezhat Surgery for Gynecology/Oncology, New York, NY 10128, USA
- Department of Obstetrics and Gynecology, NYU Hospital, NYU Long Island School of Medicine, Mineola, NY 10016, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College of Cornell University, New York, NY 10065, USA
| | - Steven Lindheim
- Department of Obstetrics and Gynecology, University of Central Florida, Orlando, FL 32827, USA
- Boonshoft School of Medicine, Wright State University, Dayton, OH 45324, USA
| | - Ceana Nezhat
- Nezhat Medical Center, Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, GA 30342, USA
| |
Collapse
|
18
|
Cohen N, Arush L, Younes G, Lavie O, Goldberg Y. Cesarean scar niche, fertility and uterine rupture during labor - A retrospective study. Eur J Obstet Gynecol Reprod Biol 2023; 286:107-111. [PMID: 37235927 DOI: 10.1016/j.ejogrb.2023.05.011] [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: 03/12/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To determine how does a uterine niche diagnosed prior to conception, affects future fertility and obstetrical outcomes, in a group of patients with secondary infertility undergoing fertility treatments. STUDY DESIGN A retrospective case-control study was performed, recruiting patients after cesarean delivery, before fertility treatment. Using stored ultrasound photos and video loops, we determined niche's sonographic parameters during the preconception period and retrieved the fertility and obstetrical outcomes thereafter. RESULTS 104 patients met the inclusion criteria, and 86 were available for analysis. 56 (65%) had uterine niches larger than 2 mm in depth, and 30 (34%) had a uterine scar of 2 mm or less. Demographic characteristics were not different between groups. No statistically significant differences were observed regarding rates of implantation and clinical pregnancy between the groups. There were four cases of cesarean scar rupture during failed trial of labor (TOLAC), all of which were in the group with larger than 2 mm niche (33% of all TOLAC cases in the respected group). CONCLUSIONS While it appears that pre-conception presence of uterine niches larger than 2 mm in depth does not adversely affect future fertility, these niches might serve as a risk factor for future uterine rupture during TOLAC.
Collapse
Affiliation(s)
- Nadav Cohen
- Department of Obstetrics and Gynecology, Carmel Lady Davis Medical Center, Haifa, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Lior Arush
- The Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Grace Younes
- Department of Obstetrics and Gynecology, Carmel Lady Davis Medical Center, Haifa, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel; Division of Reproduction Center, Department of Obstetrics and Gynecology, Carmel Lady Davis Medical Center, Haifa, Israel
| | - Ofer Lavie
- Department of Obstetrics and Gynecology, Carmel Lady Davis Medical Center, Haifa, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yael Goldberg
- Department of Obstetrics and Gynecology, Carmel Lady Davis Medical Center, Haifa, Israel; The Rappaport Faculty of Medicine, Technion, Haifa, Israel; Unit of Gynecological and Obstetrical Ultrasound, Department of Obstetrics and Gynecology, Carmel Lady Davis Medical Center, Haifa, Israel
| |
Collapse
|
19
|
Timmermans M, Nisolle M, Brichant G, Henry L, Gillet E, Kellner B, Karampelas S. Impact of Adenomyosis and Endometriosis on Chronic Pelvic Pain after Niche Repair. J Clin Med 2023; 12:jcm12103484. [PMID: 37240590 DOI: 10.3390/jcm12103484] [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: 03/17/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Chronic pelvic pain (CPP) is one of the main isthmocele symptoms, together with abnormal uterine bleeding and secondary infertility. When patients undergo a laparoscopic niche repair surgery, it is important to determine if they present associated pathologies, such as adenomyosis and/or endometriosis, which are also a cause of CPP. A retrospective study was performed on 31 patients with CPP undergoing a laparoscopic niche repair. The pre-operative ultrasound was analyzed to determine the presence of adenomyosis. Endometriosis was histologically diagnosed. CPP outcome was evaluated at early (3-6 months) and late (12 months) post-operative follow ups. In our population of 31 women presenting CPP, only six of them (19.4%) did not have any associated pathology. In the group of 25 patients with associated pathology, 10 (40%) had no benefit from the reconstructive surgery in terms of CPP at early follow-up (3-6 months) and 8 (32%) in the post-operative period at 12 months. Patients with CPP who undergo niche repair should be carefully selected as CPP does not seem to be a good indication for uterine scar repair in patients with concomitant adenomyosis and endometriosis.
Collapse
Affiliation(s)
- Marie Timmermans
- Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, 4000 Liège, Belgium
| | - Michelle Nisolle
- Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, 4000 Liège, Belgium
| | - Géraldine Brichant
- Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, 4000 Liège, Belgium
| | - Laurie Henry
- Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, 4000 Liège, Belgium
| | - Evy Gillet
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium
| | - Betty Kellner
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium
| | - Stavros Karampelas
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium
| |
Collapse
|
20
|
Yao W, Chen Y, Yao H, Yao Q, Wang L, Wang M, Yue J. Uterine niche is associated with adverse in vitro fertilization and intracytoplasmic sperm injection outcomes: a retrospective cohort study. Fertil Steril 2023; 119:433-441. [PMID: 36493872 DOI: 10.1016/j.fertnstert.2022.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the relationship between uterine niche and reproductive outcomes of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). DESIGN A retrospective cohort study. SETTING A reproductive medicine center. PATIENT(S) A total of 2,449 women with cesarean section history who underwent 2,874 IVF/ICSI cycles between January 2015 and December 2019. INTERVENTION(S) A defect deeper than 2 mm visible under three-dimensional transvaginal sonography or hysteroscopy was defined as uterine niche. The IVF/ICSI outcomes of the first embryo transfer were obtained by telephone interview 1 year after embryo transfer regardless of fresh embryos or frozen-thawed embryos. Generalized estimating equations, logistic regression analyses, and propensity score matching were applied to clarify the relationship between uterine niche and IVF/ICSI outcomes. MAIN OUTCOME MEASURE(S) Primary outcome was live birth rate. Secondary outcomes were positive human chorionic gonadotropin test results, clinical pregnancy rate, implantation rate, miscarriage rate, and ectopic pregnancy rate. RESULTS After excluding 48 cycles for uterine malformation; 18 cycles for chromosome abnormality; 281 cycles for no available embryo or no embryo transfer; 5 cycles for oocyte donation; and 7 cycles for loss of follow-up, we finally included 2,231 women with 2,515 cycles in our study. Compared with women without niche, women with niche had reduced live birth rate (18.99% vs. 31.51%, : 0.51, 95% CI: 0.34-0.77), positive human chorionic gonadotropin test rate (34.08% vs. 46.40%, adjusted odds ratio [aOR]: 0.61, 95% confidence interval [CI]: 0.43-0.87), clinical pregnancy rate (29.05% vs. 42.25%, aOR: 0.57, 95% CI: 0.39-0.82) and implantation rate (25.87% vs. 36.95%, aOR: 0.53, 95% CI: 0.38-0.76). In all the sensitivity analyses, the niche group had a 7.28% to 18.22% increase in miscarriage rate even not all of them were statistically significant. CONCLUSION(S) Uterine niche may have a detrimental effect on subsequent fertility of women with cesarean section history undergoing IVF/ICSI treatment. Practitioners should be noted that women with uterine niches may be associated with adverse IVF/ICSI outcomes.
Collapse
Affiliation(s)
- Wen Yao
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Ying Chen
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Haixia Yao
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Qingyun Yao
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Lan Wang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Meng Wang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jing Yue
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
| |
Collapse
|
21
|
Frequency and associated symptoms of isthmoceles in women 6 months after caesarean section: a prospective cohort study. Arch Gynecol Obstet 2023; 307:841-848. [PMID: 36350429 PMCID: PMC9644016 DOI: 10.1007/s00404-022-06822-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/10/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE The purpose of this study was to determine the frequency of detection of isthmoceles by ultrasound 6 months after caesarean section (CS) and which symptoms associated with isthmocele formation occur after CS. Subsequently, it was determined how often the ultrasound finding "isthmocele" coincided with the presence of complaints. METHODS A prospective multicentre cohort study was conducted with 546 patients from four obstetric centres in Berlin, who gave birth by primary or secondary CS from October 2019 to June 2020. 461 participants were questioned on symptoms 3 months after CS; 329 participants were included in the final follow-up 6 months after CS. The presence of isthmoceles was determined by transvaginal sonography (TVS) 6 months after CS, while symptoms were identified by questionnaire. RESULTS Of the 329 women, 146 (44.4%) displayed an isthmocele in the TVS. There was no statistically significant difference in the manifestation of symptoms between the two groups of women with and without isthmocele; however, when expressed on a scale from 1 to 10 the intensity of both scar pain and lower abdominal pain was significantly higher in the set of women that had shown to have developed an isthmocele (p = 0.014 and p = 0.031, respectively). CONCLUSION The prevalence of isthmoceles 6 months after CS was 44.4%. Additionally, scar pain and lower abdominal pain were more pronounced when an isthmocele was also observed in the TVS. TRIAL REGISTRATION Trial registration number DRKS00024977. Date of registration 17.06.2021, retrospectively registered.
Collapse
|
22
|
He C, Xia W, Yan L, Wang Y, Tian Y, Mol BW, Zhang J, Huirne J. Fertility outcomes after hysteroscopic niche resection compared with expectant management in women with a niche in the uterine cesarean scar. Eur J Obstet Gynecol Reprod Biol 2023; 284:136-142. [PMID: 36989689 DOI: 10.1016/j.ejogrb.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE To determine whether hysteroscopic niche resection (HNR) and expectant management are suitable in women with fertility desire and a niche with a residual myometrium thickness (RMT) ≥ 2.5 mm. STUDY DESIGN This retrospective cohort study was conducted at International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China between September 2016 and December 2021. We reported the fertility outcomes between women (with fertility desire and a niche with RMT ≥ 2.5 mm) who received HNR or expectant management. RESULTS We studied 166 women, of whom 72 accepted HNR and 94 accepted expectant management. The HNR group included more symptomatic women, in terms of postmenstrual spotting or infertility. No differences were found regarding niche measures before treatment. The live birth rate was comparable in both groups (HNR versus expectant management as 55.5% versus 45.7%, risk ratio = 1.48, 95% Cl 0.80-2.75, p = 0.21). The pregnancy rate was higher in HNR group than that in expectant management group (n = 72.2% versus n = 56.4%, risk ratio = 2.01, 95% CI 1.04-3.88, p = 0.04). In a subgroup of women with infertility before entry in the study, HNR resulted in a significant higher live birth rate (p = 0.04) and pregnancy rate (p = 0.01). CONCLUSION In women with infertility with a symptomatic niche with RMT ≥ 2.5 mm, HNR may be superior to expectant management. This retrospective cohort biased selection against a randomized study, our results still need to be validated in the future with larger clinical multicenter randomized controlled trials.
Collapse
Affiliation(s)
- Chuqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong 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 Jiaotong 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 Jiaotong 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 Jiaotong 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 Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, 246 Clayton Road, Clayton 3168, Victoria, Australia; Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.
| | - Jaf Huirne
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Location AMC and VUmc, Amsterdam, The Netherlands
| |
Collapse
|
23
|
Casadio P, Raffone A, Alletto A, Filipponi F, Raimondo D, Arena A, La Rosa M, Virgilio A, Franceschini C, Gubbini G, Franchini M, Paradisi R, Lenzi J, Travaglino A, Mollo A, Carugno J, Seracchioli R. Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique. Int J Gynaecol Obstet 2023; 160:326-333. [PMID: 35929843 PMCID: PMC10086996 DOI: 10.1002/ijgo.14387] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/06/2022] [Accepted: 07/28/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the changes in (1) residual myometrial thickness (RMT), (2) cesarean scar defect (CSD) size, and (3) clinical symptoms, before and after channel-like (360°) hysteroscopic resection for the treatment of CSD. METHODS A single-center, observational, prospective, cohort study was carried out enrolling all symptomatic patients of childbearing age, diagnosed with CSD and routinely scheduled for channel-like (360°) hysteroscopic resection from July 2020 to July 2021 at the Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Univeristaria di Bologna. University of Bologna, Italy. The primary outcome was the difference in mean RMT before and after the procedure. Secondary outcomes were the differences before and 4 months after the surgery in: (1) CSD size measured by transvaginal ultrasound, (2) visual analog scale (VAS) scores for the symptoms, and (3) abnormal uterine bleeding (AUB) rate. Lastly, patients' satisfaction was assessed by the global impression of improvement (PGI-I) score. RESULTS We found a significant difference before and after the procedure in: (1) mean RMT (+2.0 mm; P < 0.001); mean size of the CSD (base: +1.6 mm; height: -2.5 mm; transverse diameter: -3.2 mm; volume: -263.7 mm3 ; P < 0.001); (2) mean VAS score for dyspareunia (-5.84; P < 0.001), dysmenorrhea (-8.94; P < 0.001), pelvic pain (-2.94; P < 0.001); (3) AUB rate (91% vs. 3%; P < 0.001). Lastly, the mean PGI-I score ± SD was 1.7 ± 0.9. CONCLUSION Channel-like (360°) hysteroscopic resection for the treatment of patients with symptomatic CSD may lead to an increase in RMT, decrease in CSD, and improvement of symptoms after the procedure, with high patient satisfaction.
Collapse
Affiliation(s)
- Paolo Casadio
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Raffone
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Alletto
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesco Filipponi
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Diego Raimondo
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Arena
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariangela La Rosa
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Agnese Virgilio
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Camilla Franceschini
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giampietro Gubbini
- Department of Gynecology, Madre Fortunata Toniolo Clinic, Bologna, Italy
| | - Mario Franchini
- Department of Obstetrics and Gynecology, Tuscany Health Agency, Florence, Italy
| | - Roberto Paradisi
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Section of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Josè Carugno
- Obstetrics, Gynecology and Reproductive Science Department, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Renato Seracchioli
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Cardaillac C, Salmon C, Vaucel E, Gueudry P, Lavoue V, Nyangoh Timoh K, Thubert T. Robot-assisted laparoscopy repair of uterine isthmocele: A two-center observational study. Int J Gynaecol Obstet 2023; 160:244-248. [PMID: 35749544 DOI: 10.1002/ijgo.14319] [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: 12/30/2021] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To analyze outcomes and postoperative complications in patients undergoing robot-assisted isthmocele repair. METHOD This retrospective cohort study included 33 patients who had robot-assisted laparoscopic surgical management of an isthmocele between September 2013 and August 2020 in two French university hospitals. All charts were reviewed to identify patient characteristics, preoperative and postoperative anatomical findings, complications, and postoperative fertility and symptoms. Patients who had undergone this procedure were asked to complete a telephone questionnaire about their treatment satisfaction and symptoms. RESULTS The isthmocele was discovered most often as a result of subfertility (57.6%), but also ectopic pregnancy (18.2%), pelvic pain (15.2%), and postmenstrual bleeding (9.1%). Robot-assisted repair of the isthmocele significantly improved myometrial thickness (from 1.55 mm before surgery to 4.26 mm after surgery [mean difference 2.71; 95% confidence interval, 1.91-3.51], P = 0.0005). Among 20 patients who still desired a child after surgery, 15 became pregnant and 14 had full-term live births. Among the nine patients who had surgery for disabling symptoms, five had no persistent symptoms, three reported global improvement, and one had the same gynecologic discomfort. Seventeen patients agreed to complete the questionnaires (51.5%), and all stated that they would choose to have this surgery again. CONCLUSION Robot-assisted repair of an isthmocele is a viable minimally invasive procedure.
Collapse
Affiliation(s)
- Claire Cardaillac
- Department of Obstetrics and Gynecology and Reproductive Medicine, Nantes University Hospital, Nantes, France
| | - Caroline Salmon
- Department of Obstetrics and Gynecology, Cholet Hospital, Cholet, France
| | - Edouard Vaucel
- Department of Obstetrics and Gynecology and Reproductive Medicine, Nantes University Hospital, Nantes, France
| | - Pauline Gueudry
- Department of Obstetrics and Gynecology and Reproductive Medicine, Nantes University Hospital, Nantes, France
| | - Vincent Lavoue
- Department of Obstetrics and Gynecology, Rennes University Hospital, Rennes, France
| | | | - Thibault Thubert
- Department of Obstetrics and Gynecology and Reproductive Medicine, Nantes University Hospital, Nantes, France.,Nantes University, CHU Nantes, Movement-interaction-Performance, Nantes, France.,INSERM, CHU de Nantes, Nantes, France
| |
Collapse
|
26
|
Wei L, Xu C, Zhao Y, Zhang C. Higher Prevalence of Chronic Endometritis in Women with Cesarean Scar Defect: A Retrospective Study Using Propensity Score Matching. J Pers Med 2022; 13:jpm13010039. [PMID: 36675699 PMCID: PMC9863930 DOI: 10.3390/jpm13010039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
(1) Background: A cesarean scar defect may cause localized inflammation of the endometrial tissue, and various researchers believe that the presence of a cesarean scar defect is associated with chronic endometritis. However, there is no report on the possible association between cesarean scar defects and chronic endometritis thus far. This study aimed to assess the role of having a cesarean scar defect in a person's susceptibility to chronic endometritis. (2) Methods: This retrospective propensity-score-matched study comprised 1411 patients with chronic endometritis that were admitted to Henan Provincial People's Hospital in China from 2020 to 2022. Based on whether a cesarean scar defect was present or not, all cases were assigned to the cesarean scar defect group or the control group. (3) Results: Of the 1411 patients, 331 patients with a cesarean scar defect were matched to 170 controls. All unbalanced covariates between groups were balanced after matching. Before matching, the prevalence of chronic endometritis in the cesarean scar defect group and in the control group was 28.8% and 19.6%, respectively. After correcting for all confounding factors, a logistic regression analysis showed that cesarean scar defect occurrence may increase the risk of chronic endometritis (odds ratio (OR), 1.766; 95% confidence interval (CI), 1.217-2.563; p = 0.003). After matching, the prevalence of chronic endometritis was 28.8% in the cesarean scar defect group and 20.5% in the control group. Thus, even after correcting for all confounding factors, the logistic regression analysis still showed that a cesarean scar defect remained an independent risk factor for chronic endometritis prevalence (OR, 1.571; 95% CI, 1.021-2.418; p = 0.040). The findings were consistent throughout the sensitivity analyses. (4) Conclusions: The present results suggest that the onset of a cesarean scar defect may increase the risk of chronic endometritis.
Collapse
Affiliation(s)
- Longlong Wei
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
| | - Chunyu Xu
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
| | - Yan Zhao
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
| | - Cuilian Zhang
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
- Correspondence:
| |
Collapse
|
27
|
Jordans IPM, Vissers J, de Leeuw RA, Hehenkamp WJK, Twisk JWR, de Groot CJM, Huirne JAF. Change of the residual myometrial thickness during pregnancy in women who underwent laparoscopic niche resection compared with controls without niche surgery: a prospective comparative cohort study. Am J Obstet Gynecol 2022; 227:901.e1-901.e12. [PMID: 35841936 DOI: 10.1016/j.ajog.2022.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Reduced residual myometrial thickness before and during pregnancy is associated with uterine rupture or dehiscence after vaginal birth after cesarean delivery. Laparoscopic niche resection performed in case of gynecologic symptoms has shown to increase residual myometrial thickness 6 months after surgery. OBJECTIVE This study aimed to evaluate the change in residual myometrial thickness from baseline value before pregnancy to the third trimester of pregnancy in women with and without laparoscopic niche resection and evaluate niche presence, niche size during pregnancy vs before pregnancy, and obstetrical outcomes, including uterine rupture and dehiscence in both study groups. STUDY DESIGN This was a prospective cohort study conducted in an academic medical center. Of note, 2 groups of pregnant women with a previously diagnosed niche were included: (1) women with a large symptomatic niche (residual myometrial thickness of <3 mm) followed by laparoscopic niche resection (LNR group) and (2) women with a niche without niche resection because of minimal symptoms or a residual myometrial thickness of ≥3 mm diagnosed before current pregnancy (expectant group). Participants underwent a transvaginal ultrasound at 12, 20, and 30 weeks of gestation. Changes in residual myometrial thickness and changes in niche measurements over time were analyzed with linear mixed models. RESULTS A total of 100 women were included, 61 in the LNR group and 39 in the expectant group. The change in residual myometrial thickness from baseline value before niche resection to the third trimester of pregnancy was +2.0 mm in the LNR group vs -1.6 mm in the expectant group (P<.001). Residual myometrial thickness decreased from the first trimester of pregnancy onward in both groups. Although residual myometrial thickness was thinner at baseline in the LNR group, it was thicker in the LNR group than in the expectant group during all trimesters: 3.2 mm (P<.001) in the first trimester of pregnancy, 2.5 mm (P<.001) in the second trimester of pregnancy, and 1.8 mm (P=.001) in the third trimester of pregnancy. Uterine dehiscence was reported in 1 of 50 women (2%) in the LNR group and 7 of 36 women (19%) in the expectant group (P=.007) and was related to the depth of niche-to-residual myometrial thickness ratio before pregnancy (after niche resection) and residual myometrial thickness in the second trimester of pregnancy. No uterine rupture was reported. Most patients received a scheduled cesarean delivery in both groups. There was more blood loss during subsequent cesarean delivery in the LNR group than in the expectant group. CONCLUSION Here, laparoscopic niche resection resulted in an increased residual myometrial thickness during a subsequent pregnancy. Moreover, a lower number of dehiscence was found in the LNR group than in the expectant group without niche surgery. Per-section blood loss was higher in the LNR group than in the expectant group. In general, laparoscopic niche resection is performed to improve gynecologic symptoms. Currently, there is no evidence to support a laparoscopic niche resection to improve obstetrical outcomes, but the trend toward more uterine dehiscence encourages further research.
Collapse
Affiliation(s)
- Inge P M Jordans
- Department of Obstetrics and Gynecology, "Amsterdam Reproduction and Development" Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jolijn Vissers
- Department of Obstetrics and Gynecology, "Amsterdam Reproduction and Development" Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Robert A de Leeuw
- Department of Obstetrics and Gynecology, "Amsterdam Reproduction and Development" Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Wouter J K Hehenkamp
- Department of Obstetrics and Gynecology, "Amsterdam Reproduction and Development" Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Data Science, Vrije Universiteit University, Amsterdam, The Netherlands
| | - Christianne J M de Groot
- Department of Obstetrics and Gynecology, "Amsterdam Reproduction and Development" Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Judith A F Huirne
- Department of Obstetrics and Gynecology, "Amsterdam Reproduction and Development" Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| |
Collapse
|
28
|
Warshafsky C, Kirubarajan A, Chaikof M, Stere A, Chudawala U, Li Q, Huszti E, Mohamed D, Abdalla MH, Hartman A, Sanders A, Murji A, Sobel M. Preventing Isthmocele After Cesarean Section (PICS): A Pilot Randomized Controlled Trial. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1134-1135. [PMID: 35970439 DOI: 10.1016/j.jogc.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Chelsie Warshafsky
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.
| | | | - Michael Chaikof
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Alison Stere
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Umaimah Chudawala
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Quixuan Li
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON
| | - Dina Mohamed
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Mohamed Hassan Abdalla
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | | | - Ari Sanders
- Peter Lougheed Centre, University of Calgary, Calgary, AB
| | - Ally Murji
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Mara Sobel
- Mount Sinai Hospital, Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| |
Collapse
|
29
|
Li W, Lin T, Xie Y, Xu L, Chen Y, Zhu Y, Dong X, Cheng P, Duan C. The effects of hysteroscopy and laparoscopy for scar diverticulum resection and suture on blood loss, operation time and antibiotic time. J OBSTET GYNAECOL 2022; 42:3309-3314. [PMID: 36200382 DOI: 10.1080/01443615.2022.2122708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To evaluate the effect of hysteroscopy and suture on uterine scar diverticulum (CSD) after caesarean section and its influence on blood loss, operation time and antibiotic time. Eighty-nine patients with CSD were divided into observation group (n = 41 cases) and control group (n = 48 cases). Control group received laparoscopic scar diverticulum resection and suture, while the observation group received hysteroscopic resection of scar diverticulum. The operation time of the observation group was longer, while the bleeding volume and antibiotic administration time were significantly lower. The surgical treatment efficiency of the observation group (97.56%) was significantly higher. After treatment, the observation group's diverticulum repair indexes (width, depth and lower uterine muscular layer thickness) were better than those of the control group (p<.05). Hysteroscopic resection of scar diverticulum in CSD reduces intraoperative blood loss and the risk of complications, shortens time of antibiotic administration, and promotes diverticulum repair.Impact StatementWhat is already known on this subject? Uterine scar diverticulum (CSD) after caesarean section, also called postoperative uterine incision defect (PCSD), is due to poor healing of the uterine incision after caesarean section.What do the results of this study add? Hysteroscopic resection of scar diverticulum in CSD has a significant clinical effect, which can effectively reduce intraoperative blood loss and the risk of complications, shorten the time of antibiotic administration, and promote diverticulum repair.What are the implications of these findings for clinical practice and/or further research? Clinical effect of hysteroscopic resection of scar diverticulum in CSD is significant.
Collapse
Affiliation(s)
- Weifeng Li
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Tiecheng Lin
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Yong Xie
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Lijiang Xu
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Yangping Chen
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Yuyuan Zhu
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Xia Dong
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Pei Cheng
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| | - Chunxiang Duan
- Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, Foshan, China
| |
Collapse
|
30
|
Murji A, Sanders AP, Monteiro I, Haiderbhai S, Matelski J, Walsh C, Abbott JA, Munro MG, Maheux-Lacroix S. Cesarean scar defects and abnormal uterine bleeding: a systematic review and meta-analysis. Fertil Steril 2022; 118:758-766. [PMID: 35985862 DOI: 10.1016/j.fertnstert.2022.06.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To synthesize the published literature to better understand the association between cesarean scar defects (CSDs) and abnormal uterine bleeding (AUB). In particular, we aimed to evaluate the risk and pattern(s) of CSD-associated AUB in addition to exploring the relationship between defect morphology with bleeding symptoms. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENTS Patients with CSD and reports of uterine bleeding as an outcome were identified in 60 studies from database searches. INTERVENTIONS Studies that investigated CSD (as defined by investigators) and reported uterine bleeding, menstrual bleeding, or AUB as an outcome were included. MAIN OUTCOME MEASURES The prevalence and risk of AUB (intermenstrual, postmenstrual, and unscheduled bleeding) in patients with confirmed CSD. RESULTS Nine studies reported on the prevalence of AUB in patients with a confirmed CSD. Patients with CSD were more likely to experience AUB, compared with those without CSD (relative risk, 3.47; 95% confidence interval [CI], 2.02-5.97; 6 studies, 1,385 patients; I2 = 67%). In a population of patients with at least 1 cesarean delivery, the prevalence of AUB in those with CSD was 25.5% (95% CI, 14.7-40.5; 6 studies, 667 patients, I2 = 93%). However, symptom prevalence was much higher in patients presenting for imaging for a gynecologic indication where the prevalence of AUB in the presence of a CSD was 76.4% (95% CI, 67.8-83.3; 5 studies, 505 patients; I2 = 71%). The mean menstrual duration in symptomatic patients with CSD was 13.4 days (95% CI, 12.6-14.2; 19 studies, 2,095 patients; I2 = 96%), and the mean duration of early-cycle intermenstrual bleeding was 6.8 days (95% CI, 5.7-7.8 days; 9 studies, 759 patients; I2 = 93%). The most common descriptor of CSD-associated AUB was "brown discharge". Patients with larger CSD experienced more bleeding symptoms. CONCLUSION There is a strong and consistent association between patients with CSD and AUB. These patients experience a unique bleeding pattern, namely prolonged menstruation and early-cycle intermenstrual bleeding. These data should provide impetus for including CSD as a distinct entity in AUB classification systems. High heterogeneity in our results calls for standardization of nomenclature and outcome reporting for this condition.
Collapse
Affiliation(s)
- Ally Murji
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | - Ari P Sanders
- Department of Obstetrics and Gynecology, University of Calgary, Peter Lougheed Centre, Calgary, Alberta, Canada
| | - Ilza Monteiro
- Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences (UNICAMP), Campinas, SP, Brazil
| | - Shabbir Haiderbhai
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Chris Walsh
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada; Sidney Liswood Library, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jason A Abbott
- School of Women's and Children's Health University of New South Wales (UNSW), Sydney, Australia
| | - Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | | | | |
Collapse
|
31
|
Liu T, Xu X. Comparison of efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of cesarean scar pregnancy. J OBSTET GYNAECOL 2022; 42:3041-3047. [PMID: 35672873 DOI: 10.1080/01443615.2022.2081793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
To compare the efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of caesarean scar pregnancy (CSP). 60 patients with CSP admitted to our hospital were selected as the study subjects, and divided into observation group (n = 35) and control group (n = 25) in accordance with the therapeutic options. The observation group was treated with ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, while the control group was treated with hysteroscopic electro-resection after methotrexate chemotherapy. The observation group was superior to the control group in the amount of intraoperative haemorrhage, in-hospital costs, and postoperative time to control vaginal haemorrhage, time to return to a normal serum human chorionic gonadotropin (HCG) level. The observation group had a lower incidence rate of adverse reactions (5.71% vs. 28.00%, p < .05) and a higher first-attempt success rate for treatment (85.71% vs. 84.00%, p > .05) compared with the control group. Ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, exhibiting a higher efficacy, can more effectively shorten the postoperative recovery, reduce adverse reactions, and improve the postoperative quality of life in patients with CSP. IMPACT STATEMENTWhat is already known on this subject? Caesarean scar pregnancy (CSP), a rare form of ectopic pregnancy where the fertilised egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section (CS), is a long-term complication of CS that may be life-threatening for parturients. Some therapies have been used to treat CSP, such as uterine artery embolisation and uterine artery embolisation chemotherapy combined with curettage, but the potential adverse effects may affect the ovarian reserve and even affecting the fertility of patients.What do the results of this study add? This study showed that ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, exhibiting a higher efficacy, can more effectively shorten the postoperative recovery, reduce adverse reactions, and improve the postoperative quality of life in patients with CSP.What are the implications of these findings for clinical practice and/or further research? The findings of this study may provide some references for the clinical practitioners and further research and may contribute to the treatment of CSP.
Collapse
Affiliation(s)
- Ting Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Xiaoqin Xu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| |
Collapse
|
32
|
Verberkt C, Jordans IPM, Van den Bosch T, Timmerman D, Bourne T, de Leeuw RA, Huirne JAF. How to perform standardized sonographic examination of uterine niche in non-pregnant women. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:420-424. [PMID: 35608551 PMCID: PMC9545192 DOI: 10.1002/uog.24953] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/26/2022] [Indexed: 06/15/2023]
Affiliation(s)
- C. Verberkt
- Department of Obstetrics and GynecologyResearch Institute Amsterdam Reproduction and Development, Amsterdam UMC, location VUMCAmsterdamThe Netherlands
| | - I. P. M. Jordans
- Department of Obstetrics and GynecologyResearch Institute Amsterdam Reproduction and Development, Amsterdam UMC, location VUMCAmsterdamThe Netherlands
| | - T. Van den Bosch
- Department of Obstetrics and GynecologyUniversity Hospitals LeuvenLeuvenBelgium
- Department of Development and RegenerationKU LeuvenLeuvenBelgium
| | - D. Timmerman
- Department of Obstetrics and GynecologyUniversity Hospitals LeuvenLeuvenBelgium
- Department of Development and RegenerationKU LeuvenLeuvenBelgium
| | - T. Bourne
- Department of Development and RegenerationKU LeuvenLeuvenBelgium
- Department of Obstetrics and GynaecologyQueen Charlotte's and Chelsea Hospital, Imperial College LondonLondonUK
| | - R. A. de Leeuw
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
| | - J. A. F. Huirne
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
| |
Collapse
|
33
|
Huang D, Chen S, Cai Y, Shi L, Shi Y, Zeng M, Cheng W, Zhang J, Pan H. Adjunctive azithromycin prophylaxis protects women from uterine cesarean scar defect: A randomized controlled trial. Acta Obstet Gynecol Scand 2022; 101:889-900. [PMID: 35645037 DOI: 10.1111/aogs.14387] [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: 01/13/2022] [Revised: 04/10/2022] [Accepted: 05/15/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Cesarean scar defect (CSD) is a long-term outcome of cesarean section (CS) and associated with numerous gynecological and obstetric problems. Previous studies indicate that infection may be a risk factor for CSD. Adjunctive azithromycin was shown to reduce the risk of postoperative infection in patients undergoing non-elective primary cesarean delivery in labor or after the rupture of membranes compared with standard antibiotic prophylaxis. This study investigated the protective effect of adjunctive azithromycin in combination with single-dose cephalosporin against CSD in women undergoing non-elective cesarean delivery. MATERIAL AND METHODS A randomized, double-blind, controlled clinical trial was conducted in a University hospital in Shanghai, China. A total of 242 women who underwent their first non-elective CS were randomly assigned to receive 1500 mg cefuroxime sodium plus 500 mg intravenous azithromycin (n = 121; experimental group) or 1500 mg cefuroxime sodium plus a placebo (n = 121; placebo group). The primary outcome was CSD prevalence, as determined by transvaginal ultrasound and saline infusion sonohysterography within 6 months of delivery. Secondary outcomes were changes in infectious indicators (e.g. hypersensitive C-reactive protein and procalcitonin), postoperative morbidity, and use of postoperative antibiotics. We also examined the operative procedure, pathogenic microorganism cultures, and fetal outcomes. Outcomes were compared between groups with the chi-squared test, Fisher's exact test, or Student's t test. RESULTS Between May 2018 and May 2021, 121 women were randomized to each arm. Because the sonographic follow up was disrupted by the coronavirus disease 2019 pandemic and strict management policies, we merged the follow-up time points (6 weeks and 6 months) into a single time period (6 weeks to 6 months); 104 and 108 women in the experimental and placebo groups, respectively, completed the first sonographic follow up. CSD was diagnosed by sonography in 34/104 (32.7%) and 50/108 (46.3%) patients in the experimental and placebo groups, respectively (relative risk 0.71, 95% confidence interval 0.50-0.99; p = 0.043). Characteristics of CSD and short-term infection outcomes did not differ between groups. CONCLUSIONS A single dose of intravenous 500 mg azithromycin adjunctive to single-dose cefuroxime prophylaxis significantly reduced the incidence of CSD in women undergoing non-elective CS.
Collapse
Affiliation(s)
- Ding Huang
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China.,Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - Sha Chen
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - Yanqing Cai
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Liye Shi
- Department of Ultrasonic Image, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yiru Shi
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Min Zeng
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Weiwei Cheng
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China.,Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - Jian Zhang
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China.,Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - Hongjie Pan
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Obstetrics and Gynecology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
| |
Collapse
|
34
|
Mutlu AE. Assessment of in vitro fertilization outcomes after hysteroscopic isthmoplasty in recurrent implantation failure. J Obstet Gynaecol Res 2022; 48:1829-1835. [PMID: 35623894 DOI: 10.1111/jog.15317] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/28/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to assess the in vitro fertilization (IVF) treatments outcomes of women with recurrent implantation failure (RIF) after hysteroscopic isthmoplasty for isthmocele. METHODS This retrospective, observational study included 61 patients with RIF and isthmocele who presented to IVF Unit of Hüma Obstetrics and Gynecology Hospital between January, 2018 and December, 2020. Thirty-one patient who underwent hysteroscopic isthmoplasty-before IVF procedure-were included. Remaining 30 patients underwent IVF without hysteroscopic isthmoplasty were included as controls. The fertility outcome were compared between groups. RESULTS After 3 months, spontaneous pregnancy was achieved in 18.4% (7/38) of patients with isthmocele who underwent hysteroscopic isthmoplasty. In the isthmoplasty group, implantation rate, clinical pregnancy rate, biochemical pregnancy rate, and the miscarriage rate were 41.9% (13/31), 35.5% (11/31), 6.5% (2/31), and 9.7% (3/31), respectively. The live birth rate after in vitro fertilization was 25.8% (8/31) in the isthmoplasty group and 3.3% (1/30) in the control group (p < 0.05). There were no significant differences in the IVF outcomes such as the biochemical pregnancy rate and miscarriage rate between the isthmoplasty and control groups. CONCLUSION This study demonstrated that hysteroscopic isthmoplasty improves pregnancy and live birth rates for women with a history of RIF and isthmocele. Reproductive results of the IVF cycles after hysteroscopic correction of isthmocele were comparable to those of the patients without any uterine abnormalities and those with diagnosis of unexplained infertility.
Collapse
Affiliation(s)
- Ahmet Emin Mutlu
- Department of Obstetrics and Gynecology, Hüma Obstetrics and Gynecology Hospital, IVF Center, Kayseri, Turkey
| |
Collapse
|
35
|
Gornet ME, Abhari S, Christianson MS. Isthmocele endometriosis: when two is definitely not better than one. Fertil Steril 2022; 117:1337-1338. [PMID: 35618361 DOI: 10.1016/j.fertnstert.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Megan E Gornet
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine; Baltimore, Maryland
| | - Sina Abhari
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine; Baltimore, Maryland
| | - Mindy S Christianson
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine; Baltimore, Maryland
| |
Collapse
|
36
|
Gencer FK, Dincgez B, Yuksel S. Levonorgestrel-Releasing Intrauterine Device Use Can Be a Treatment Option in Symptomatic Patients with Isthmocele. Reprod Sci 2022; 29:2977-2982. [PMID: 35610461 DOI: 10.1007/s43032-022-00976-1] [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: 01/31/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022]
Abstract
Levonorgestrel-releasing intrauterine devices have been used for contraception and treatment of heavy menstrual bleeding. There is only limited data about the effect of this on isthmocele. Here, we aimed to evaluate the effect of levonorgestrel-releasing intrauterine devices in a larger study population with a longer follow-up as compared to the literature on symptomatic patients with isthmocele. A total of 29 patients with symptomatic isthmocele and inserted levonorgestrel-releasing device were included in this prospective study. All patients were included at January 2020 and followed for 18 months. Sociodemographic findings, laboratory parameters, premenstrual spotting, postmenstrual spotting, menorrhagia, dysmenorrhea, and pelvic pain related to isthmocele were recorded. In sonography, width, length, area of isthmocele, and residual myometrial thickness were determined. The frequency of symptoms during follow-up was compared between visits and also compared between groups according to residual myometrial thickness. Premenstrual spotting and pelvic pain were significantly reduced at 6th months (48.3 to 10.3%, p = 0.007 and 34.5 to 10.3%, p = 0.039, respectively) and no significant change was detected until the end of follow-up period. Postmenstrual spotting reduced at 6th months (96.6 to 34.5%, p < 0.001) and also significant change was detected between 6 and 12th months (34.5% vs 13.8%, p = 0.031). Menorrhagia and dysmenorrhea disappeared at 12th months. No association was found between residual myometrial thickness and the frequency of symptoms for each follow-up. Levonorgestrel-releasing intrauterine devices are useful and reliable therapeutic tools for symptomatic isthmocele patients who do not desire fertility, regardless of residual myometrial thickness.
Collapse
Affiliation(s)
- Fatma Ketenci Gencer
- Department of Obstetrics and Gynecology, Istanbul Gaziosmanpasa Training and Research Hospital, University of Health Sciences, Hizirefendi Street, Gaziosmanpasa, 34255, Istanbul, Turkey.
| | - Burcu Dincgez
- Department of Obstetrics and Gynecology, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Semra Yuksel
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| |
Collapse
|
37
|
Wang L, Wang J, Lu N, Liu J, Diao F. Pregnancy and Perinatal Outcomes of Patients With Prior Cesarean Section After a Single Embryo Transfer in IVF/ICSI: A Retrospective Cohort Study. Front Endocrinol (Lausanne) 2022; 13:851213. [PMID: 35677716 PMCID: PMC9167926 DOI: 10.3389/fendo.2022.851213] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/07/2022] [Indexed: 12/20/2022] Open
Abstract
Objective To study the influence of the previous cesarean section on the pregnancy outcomes and perinatal outcomes in single embryo transfer (SET) cycles in an in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) setting compared to those with previous vaginal delivery (VD). In addition, the association between fertility outcomes and different cesarean scar defect (CSD) sizes was studied. Method This was a retrospective cohort study conducted in the Reproductive Center of the First Affiliated Hospital of Nanjing Medical University. A total of 4,879 patients with previous delivery history undergoing SET were included between January 2015 and April 2019. Patients were divided into the VD group and cesarean delivery (CD) group according to different modes of previous delivery. The primary outcome was live birth rate. The pregnancy outcomes of CD were analyzed as a subgroup and the relationship between pregnancy outcomes as well as the different sizes of CSD were explored by logistic regression analysis. Results There were no significant differences in live birth rate, clinical pregnancy rate, and miscarriage rate between the CD group and VD group. The incidence rates of pregnancy complications such as pregnancy hypertension, gestational diabetes mellitus, placenta abnormalities, premature rupture of membrane, and postpartum hemorrhage were similar in the two groups. Live birth rate was significantly lower in the CSD group (23.77% vs 37.01%, aOR: 0.609, 95% CI: 0.476-0.778) comparing to patients without CSD. There were also significant differences in clinical pregnancy rate (37.52% vs 47.64%, aOR: 0.779, 95%CI: 0.623-0.973) and miscarriage rate (34.55% vs 20.59%, aOR: 1.407, 95%CI:1.03-1.923). Large size CSD significantly decreased live birth rate (13.33% vs 26.29%, aOR: 0.422, 95%CI: 0.197-0.902) and clinical pregnancy rate (25.33% vs 40.09%, aOR: 0.503, 95%CI: 0.272-0.930) compared with small size CSD. Conclusion For women with previous cesarean sections, the pregnancy outcomes were similar to those with previous VD without increased perinatal complications following SET. The presence of CSD was associated with a marked reduction in live birth rate, especially in patients with large size CSD.
Collapse
Affiliation(s)
| | | | | | | | - Feiyang Diao
- State Key Laboratory of Reproductive Medicine, Clinical Center of Reproductive Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
38
|
de Vasconcelos Gaspar A, Brandão A. Isthmocele, a rising pathology. Clin Case Rep 2022; 10:e05727. [PMID: 35441019 PMCID: PMC9010728 DOI: 10.1002/ccr3.5727] [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] [Received: 07/15/2021] [Revised: 03/12/2022] [Accepted: 03/27/2022] [Indexed: 11/13/2022] Open
Abstract
Isthmocele is a growing pathology due to the increase in the number of cesarean deliveries. Pelvic pain and abnormal uterine bleeding are common complaints in our clinical practice, and isthmocele should be included in the differential diagnosis, especially in women who underwent previous cesarean sections.
Collapse
Affiliation(s)
| | - Ana Brandão
- Serviço de Ginecologia e Obstetrícia Hospital de Cascais Alcabideche Portugal
| |
Collapse
|
39
|
Isthmocele endometriosis: the relationship between cesarean section and endometriosis. Fertil Steril 2022; 117:1334-1336. [DOI: 10.1016/j.fertnstert.2022.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/11/2022] [Accepted: 02/22/2022] [Indexed: 11/17/2022]
|
40
|
Chen H, Wang W, Wang H, Wang X. Association between the occurrence of adenomyosis and the clinical outcomes of vaginal repair of cesarean section scar defects: an observational study. BMC Pregnancy Childbirth 2022; 22:187. [PMID: 35260110 PMCID: PMC8902808 DOI: 10.1186/s12884-022-04529-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background To examine the correlation between the occurrence of adenomyosis and the outcome of vaginal repair of cesarean section scar defects (CSDs). Methods A total of 278 women with CSD were enrolled in this retrospective observational cohort study at the Shanghai First Maternity & Infant Hospital between January 2013 and August 2017. Patients were divided into two groups according to preoperative magnetic resonance imaging (MRI) findings: the adenomyosis group and the non-adenomyosis group. They all underwent vaginal excision and suturing of CSDs and were required to undergo examinations 3 and 6 months after surgery. Preoperative and postoperative clinical information was collected. Optimal healing was defined as a duration of menstruation of no more than 7 days and a thickness of the residual myometrium (TRM) of no less than 5.8 mm after vaginal repair. Results Before vaginal repair, for patients in the adenomyosis group, the mean duration of menstruation was longer and TRM was significantly thinner than those in patients in the non-adenomyosis group (p < 0.05). The TRM and duration of menstruation 3 and 6 months after surgery were significantly improved in both groups (p < 0.05). There were more patients with optimal healing in the non-adenomyosis group than in the adenomyosis group (44.7% vs. 30.0%; p < 0.05). Furthermore, 59.3% (32/54) of the women tried to conceive after vaginal repair. The pregnancy rates of women with and without adenomyosis were 66.7% (8/12) and 61.9% (26/42), respectively. The duration of menstruation decreased significantly from 13.4 ± 3.3 days before vaginal repair to 7.6 ± 2.3 days after vaginal repair in 25 patients (p < 0.001). The TRM increased significantly from 2.3 ± 0.8 mm before vaginal repair to 7.6 ± 2.9 mm after vaginal repair (p < 0.001). Conclusions Vaginal repair reduced postmenstrual spotting and may have improved fertility in patients with CSDs. Patients with adenomyosis are more likely to have suboptimal menstruation and suboptimal healing of CSDs. Adenomyosis might be an adverse factor in the repair of uterine incisions.
Collapse
Affiliation(s)
- Huihui Chen
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Yangpu District, Shanghai, 200092, China
| | - Wenjing Wang
- Department of Radiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China
| | - Husheng Wang
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Yangpu District, Shanghai, 200092, China.
| | - Xipeng Wang
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Yangpu District, Shanghai, 200092, China.
| |
Collapse
|
41
|
Endometriosis and Isthmocele: Common or Rare? J Clin Med 2022; 11:jcm11051158. [PMID: 35268248 PMCID: PMC8911021 DOI: 10.3390/jcm11051158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/13/2022] [Accepted: 02/19/2022] [Indexed: 01/27/2023] Open
Abstract
Higher cesarean section rates and better ultrasound diagnostics have led to a more frequent diagnosis of isthmocele, a cesarean scar defect. Sometimes, endometriosis is found in the isthmocele, but simultaneous extrauterine endometriosis and endometriosis in the isthmocele have not yet been reported. Additionally, the surgical technique to repair the isthmocele is the subject of ongoing controversy. The aim of this study is to analyze a possible correlation between uterine scar (isthmocele) endometriosis and extrauterine endometriosis and to investigate the outcome of laparoscopic isthmocele resection in the rendezvous technique. In this single-center retrospective study, we included 83 women of reproductive age with symptomatic isthmocele undergoing laparoscopic isthmocele repair in rendezvous technique from 2004 to 2020 at the University of Bern. We collected data on patient and surgical characteristics as well as on postoperative outcomes (symptoms, further pregnancy, and pregnancy outcomes) retrospectively. We analyzed and compared these data for patients with and without endometriosis. Endometriosis was diagnosed during surgery in 22 out of 83 operated patients (26.5%). Diagnosis of isthmocele endometriosis (n = 9, 11%) was significantly higher in patients with extrauterine endometriosis (n = 6, p = 0.004). While the duration of surgery was significantly longer for patients with endometriosis (p = 0.006), the groups did not differ with regard to blood loss or complications. In addition, both groups showed similar indications for isthmocele repair (infertility, abnormal uterine bleeding, or dysmenorrhea). Surgery significantly improved abnormal uterine bleeding (χ2 p < 0.001), dysmenorrhea (χ2, p = 0.03), and infertility (χ2, p < 0.001). Regardless of the presence of endometriosis, 25 of 40 (63%) infertile patients became pregnant after surgery. In one out of eight pregnancies, however, we observed scar complications during pregnancy such as uterine scar pregnancy (n = 3), uterine scar dehiscence (n = 3), and placenta previa (n = 1). Endometriosis is a non-negligible intraoperative finding in patients with symptomatic isthmocele. The laparoscopic approach in the rendezvous technique is safe and effective. Therefore, this method should be recommended, especially in women with secondary infertility, and preoperatively simultaneous endometriosis resection should be discussed with the patient. In follow-up, postoperative pregnancies have to be monitored with care.
Collapse
|
42
|
Reduced live birth rates after embryo transfer in patients with prior cesarean delivery: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2022; 271:250-254. [DOI: 10.1016/j.ejogrb.2022.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/03/2022] [Accepted: 02/13/2022] [Indexed: 11/18/2022]
|
43
|
Santos LBD, Barbosa IR, Dantas THDM, Araujo CM, Dantas JH, Ferreira CWS, Câmara SMAD, Dantas D. Prevalence of primary dysmenorrhea and associated factors in adult women. REVISTA DA ASSOCIAÇÃO MÉDICA BRASILEIRA 2022; 68:31-36. [DOI: 10.1590/1806-9282.20210341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/01/2021] [Indexed: 11/22/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Diego Dantas
- Universidade Federal do Rio Grande do Norte, Brazil; Universidade Federal de Pernambuco, Brazil
| |
Collapse
|
44
|
Blagoveshchensky RE. FEATURES OF CLINICAL PRESENTATION OF ABNORMAL UTERINE BLEEDING IN WOMEN OF REPRODUCTIVE AGE. BULLETIN OF PROBLEMS BIOLOGY AND MEDICINE 2022. [DOI: 10.29254/2077-4214-2022-3-166-12-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
45
|
Karampelas S, Salem Wehbe G, de Landsheere L, Badr DA, Tebache L, Nisolle M. Laparoscopic Isthmocele Repair: Efficacy and Benefits before and after Subsequent Cesarean Section. J Clin Med 2021; 10:jcm10245785. [PMID: 34945080 PMCID: PMC8708618 DOI: 10.3390/jcm10245785] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate the effect of laparoscopic isthmocele repair on isthmocele-related symptoms and/or fertility-related problems. The residual myometrial thickness before and after subsequent cesarean section was also evaluated. DESIGN Retrospective, case series. SETTING Public university hospital. POPULATION Women with isthmocele (residual myometrium < 5 mm) complaining of abnormal uterine bleeding, chronic pelvic pain or secondary infertility not otherwise specified. METHODS Women's complaints and the residual myometrium were assessed pre-operatively and at three to six months post-operatively. In patients who conceived after surgery, the latter was measured at least six months after delivery by cesarean section. MAIN OUTCOME MEASURES Resolution of the main symptom three to six months after surgery and persistence of laparoscopic repair benefits after subsequent cesarean section were considered as primary outcome measures. RESULTS Overall, 31 women underwent laparoscopic isthmocele repair. The success rates of the surgery as improvement of abnormal uterine bleeding, chronic pelvic pain and secondary infertility were 71.4% (10 of 14), 83.3% (10 of 12) and 83.3% (10 of 12), respectively. Mean residual myometrial thickness increased significantly from 1.77 mm pre-operatively to 6.67 mm, three to six months post-operatively. Mean myometrial thickness in patients who underwent subsequent cesarean section (N = 7) was 4.49 mm. In this sub-group, there was no significant difference between the mean myometrial thickness measured after the laparoscopic isthmocele repair and that measured after the subsequent cesarean section. None of these patients reported recurrence of their symptoms after delivery. CONCLUSION Our findings suggest that the laparoscopic isthmocele excision and repair is an appropriate approach for the treatment of isthmocele-related symptoms when done by skilled laparoscopic surgeons. The benefit of this new surgical approach seems to persist even after a subsequent cesarean section. Further investigations and prospective studies are required to confirm this finding.
Collapse
Affiliation(s)
- Stavros Karampelas
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (G.S.W.); (D.A.B.)
- Correspondence:
| | - Georges Salem Wehbe
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (G.S.W.); (D.A.B.)
| | - Laurent de Landsheere
- Department of Obstetrics and Gynecology, CHR de La Citadelle, University of Liège, 4000 Liège, Belgium; (L.d.L.); (L.T.); (M.N.)
| | - Dominique A. Badr
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (G.S.W.); (D.A.B.)
| | - Linda Tebache
- Department of Obstetrics and Gynecology, CHR de La Citadelle, University of Liège, 4000 Liège, Belgium; (L.d.L.); (L.T.); (M.N.)
| | - Michelle Nisolle
- Department of Obstetrics and Gynecology, CHR de La Citadelle, University of Liège, 4000 Liège, Belgium; (L.d.L.); (L.T.); (M.N.)
| |
Collapse
|
46
|
Novel laparoscopic surgery for the repair of cesarean scar defect without processing scar resection. BMC Pregnancy Childbirth 2021; 21:815. [PMID: 34879840 PMCID: PMC8653604 DOI: 10.1186/s12884-021-04281-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean scar defect (CSD), especially CSD with residual myometrium less than 3 mm is reported to be the highest risk agent associated with uterine rupture for subsequent pregnancy. Currently, laparoscopic resection and suture was the mainstay therapy method for CSD with a residual myometrium less than 3 mm in women with a desire to conceive. Besides, the women have CSD related symptoms, especially postmenstrual bleeding, should be recommended for CSD treatment. This study is to investigate the efficiency of this novel laparoscopic surgery for the repair of cesarean scar defect (CSD) without scar resection for residual myometrium thickening. METHOD This retrospective clinical study enrolled 76 women diagnosed with CSD who had a residual myometrium thickness less than 3 mm and also had a desire to conceive, had undergone laparoscopic surgery for the repair of CSD in the time period March 2016 to March 2018. Two study cohorts were created among the 76 patients: 40 patients had undergone the novel laparoscopic repair of CSD without processing scar resection (Group A), whereas 36 patients had undergone the traditional laparoscopic resection and suture of CSD (Group B). RESULTS Residual myometrium thickening occurred among all the 76 patients and the average residual myometrium thickness was increased to almost 6 mm, presenting no between-group difference. In Group A, all the CSD-related postmenstrual bleeding was resolved or improved, but one patient in Group B has no obvious change to postmenstrual bleeding. After CSD repair, 20 patients got pregnant naturally in Group A, and there was no cesarean scar pregnancy and uterine rupture. While, there were 9 cases of natural pregnancy in Group B. No uterine rupture occurred among these 9 pregnant women of Group B, but 1 case of pregnancy was terminated due to cesarean scar pregnancy. CONCLUSION Laparoscopic repair without processing scar resection seems to be a feasible, safe and simple operative approach for CSD treatment, which can thicken residual myometrium and improve postmenstrual bleeding.
Collapse
|
47
|
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.
Collapse
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
| |
Collapse
|
48
|
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.
Collapse
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
| |
Collapse
|
49
|
Bi B, Gao S, Ruan F, Shi Y, Jiang Y, Liu S, Lv W. Analysis on clinical association of uterine scar diverticulum with subsequent infertility in patients underwent cesarean section. Medicine (Baltimore) 2021; 100:e27531. [PMID: 34731147 PMCID: PMC8519233 DOI: 10.1097/md.0000000000027531] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/28/2021] [Indexed: 01/05/2023] Open
Abstract
To evaluate the relationship between uterine cesarean scar diverticulum (CSD) and subsequent infertility in patients who underwent cesarean section, and determine the effects of pelvic fluid-releasing inflammations on infertility.A retrospective analysis was designed among patients with CSD who were admitted to our hospital from January 1, 2018 to December 31, 2019. A total of 60 patients with CSD and uterine fibroids or benign ovarian tumors who underwent cesarean section were included, and divided into the CSD group and control group. Baseline characteristics of all patients were collected, and the pelvic adhesion scores and the percents of tubal patency were evaluated. Furthermore, the postoperative clinical outcomes were followed up. The levels of inflammatory factors in pelvic fluid were tested using Elisa kits.Preoperative data indicated that the size of the uterine scar diverticulum was (1.68 ± 0.52) cm, the pelvic adhesion scores were higher in CSD group than control group (4.67 ± 0.90 vs 0.47 ± 0.90, P < .05), and 21 of 30 patients with unobstructed fallopian tubes. The levels of tumor necrosis factor-α, interleukin-1β, and interleukin-6 in patients with CSD were obviously higher than control group (P < .05). After the follow-up, the data displayed that no CSD was found in all patients, the time of menstrual period in patients with CSD was shortened to 7.80 ± 1.27 days, and the myometrial thickness at uterine scar was significantly increased (P < .05). Additionally, the pregnancy rate was increased, and 12 of 30 patients were repregnant. Correlation analysis showed that the levels of inflammatory factors (tumor necrosis factor-α, interleukin-1β, interleukin-6), the size of uterine scar diverticulum, and the myometrial thickness at uterine scar were significantly correlated with subsequent infertility (r = 0.307, 0.083, 0.147, 0.405, 0.291, P < .05).Uterine scar diverticulum repair could improve menstrual prolongation, increased the thickness of myometrium and repregnant rate. Subsequent infertility was positively correlated with uterine scar diverticulum and the levels of inflammatory factors.
Collapse
|
50
|
Robotic or laparoscopic treatment of cesarean scar defects or cesarean scar pregnancies with a uterine sound guidance. Taiwan J Obstet Gynecol 2021; 60:821-826. [PMID: 34507655 DOI: 10.1016/j.tjog.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility and effectiveness of robotic/laparoscopic repair of cesarean scar defects or cesarean scar pregnancies with a uterine sound. MATERIALS AND METHODS All consecutive women with cesarean scar defects or cesarean scar pregnancies who underwent robotic/laparoscopic repair with a bent uterine sound guidance were reviewed. Subjective changes in symptoms and objective changes in the depth and width of cesarean scar defects after surgery were reviewed. RESULTS A total of 20 women underwent robotic (n = 3) or conventional laparoscopic (n = 17) repair of cesarean scar defects, which included postmenstrual vaginal bleeding associated with cesarean scar defects (n = 15), cesarean scar pregnancies (n = 3), accumulated pus in the cesarean scar defect (n = 1) and an incomplete abortion incarcerated in the cesarean scar defect (n = 1). Bladder perforation occurred in one woman during robotic adhesiolysis. All women with cesarean scar defects (n = 15) reported an improvement in postmenstrual vaginal bleeding after surgery. Follow-up sonography showed a decrease in the depth and width of the cesarean scar defect and an increase in the residual myometrial thickness. CONCLUSION Robotic or laparoscopic repair with a uterine sound guidance seems to be a feasible and effective method in the treatment of cesarean scar defect or cesarean scar pregnancy.
Collapse
|