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Hafner A, Pohle MC, Rauh M, Schnabel A, Meyer S, Köninger A. Contrast Hysterosonographic Evaluation of Niche Prevalence Following a Standardized Suturing Technique for Caesarean Sections. Geburtshilfe Frauenheilkd 2024; 84:737-746. [PMID: 39114379 PMCID: PMC11303011 DOI: 10.1055/a-2341-4586] [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: 03/05/2024] [Accepted: 05/11/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction After caesarean section a uterine niche can be detected in 42-84% of all women and in 11-45% large defects with a residual myometrium < 2.2 mm occur. If the niche compromises > 50% of myometrial thickness, risk of uterine rupture during birth increases. The suturing technique might contribute substantially on pathogenesis of niches. The objective of this study is to investigate the effect of the suturing technique on niche prevalence by using a standardized two-layer surgical technique. Methods Women with one previous caesarean section were examined within 6-23 months after caesarean section using contrast medium-supported transvaginal sonography regarding the prevalence, sonomorphological aspect and clinical symptoms of a uterine niche. The surgical technique used was: dilatation of the cervix, interrupted suture of the first layer (excluding the endometrium), continuous closure of the visceral and parietal peritoneum. Results Using native vaginal sonography, no niches were visible in the whole cohort. In three cases, there was a small niche detectable with a depth between 2.3 and 3.9 mm by contrast hysterosonography. Regarding the total myometrial thickness, the niche depth compromised less than 50%. All patients were symptom-free. Conclusion In our study population, there were only three cases (9.1%) with a small uterine niche. Residual myometrium and niche percentage on myometrial thickness were excellent in all three cases. Thus, our results show that the uterotomy closure technique used in the study cohort might be superior with respect to the development of uterine niches compared with the expected prevalence.
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Affiliation(s)
- Anita Hafner
- Department of Gynecology and Obstetrics, Hedwigʼs Clinic of the order of St. John, University of Regensburg, Regensburg, Germany
| | - Marie Christine Pohle
- Department of Gynecology and Obstetrics, Hedwigʼs Clinic of the order of St. John, University of Regensburg, Regensburg, Germany
| | - Maximilian Rauh
- Department of Gynecology and Obstetrics, Hedwigʼs Clinic of the order of St. John, University of Regensburg, Regensburg, Germany
| | - Annegret Schnabel
- Department of Gynecology and Obstetrics, Hedwigʼs Clinic of the order of St. John, University of Regensburg, Regensburg, Germany
| | - Sylvia Meyer
- Department of Gynecology and Obstetrics, Hedwigʼs Clinic of the order of St. John, University of Regensburg, Regensburg, Germany
| | - Angela Köninger
- Department of Gynecology and Obstetrics, Hedwigʼs Clinic of the order of St. John, University of Regensburg, Regensburg, Germany
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Lin PL, Hou JH, Chen CH. A common problem between gynecology, obstetrics, and reproductive medicine: Cesarean section scar defect. Taiwan J Obstet Gynecol 2024; 63:459-470. [PMID: 39004471 DOI: 10.1016/j.tjog.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 07/16/2024] Open
Abstract
Approximately 60% of patients undergoing Cesarean sections may develop Cesarean Scar Defect (CSD), presenting a significant clinical challenge amidst the increasing Cesarean section rates. This condition, marked by a notch in the anterior uterine wall, has evolved as a notable topic in gynecological research. The multifactorial origins of CSD can be broadly classified into labor-related factors, patients' physical conditions, and surgical quality. However, conflicting influences of certain factors across studies make it challenging to determine effective preventive strategies. Additionally, CSD manifests with diverse symptoms, such as abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, dyspareunia, secondary infertility, and Cesarean scar pregnancy. Some symptoms are often attributed to other diagnoses, leading to delayed treatment. The quandary of when and how to manage CSD also adds to the complexity. Despite the development of various therapies, clear indications and optimal methods for specific conditions remain elusive. This longstanding challenge has troubled clinicians in both identifying and addressing this iatrogenic disease. Recent studies have yielded some compelling consensuses on various aspects of CSD. This review aims to consolidate the current literature on every facet of CSD. We hope to raise awareness among clinicians about this clinical problem, encouraging more relevant research to unveil the complete picture of CSD.
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Affiliation(s)
- Ping-Lun Lin
- Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Taipei Medical University Hospital, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan.
| | - Jung-Hsiu Hou
- Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Taipei Medical University Hospital, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan; Graduate Institute of Medical Science, College of Medicine, Taipei Medical University, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan.
| | - Chi-Huang Chen
- Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Taipei Medical University Hospital, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan; Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, No. 252, Wusing Street, Sinyi District, Taipei City 110, Taiwan.
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3
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Gagnon C, Bergeron C, Maheux-Lacroix S, Bujold E. Optimal closure of the uterus during cesarean section: beyond the two layers. J Perinat Med 2024; 52:452-453. [PMID: 38272836 DOI: 10.1515/jpm-2024-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024]
Affiliation(s)
- Caroline Gagnon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Catherine Bergeron
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Sarah Maheux-Lacroix
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Québec, QC, Canada
- Research Center of CHU de Québec-Université Laval, Québec, QC, Canada
| | - Emmanuel Bujold
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Québec, QC, Canada
- Research Center of CHU de Québec-Université Laval, Québec, QC, Canada
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Kesrouani AK, Abdelkhalek Y, Abdallah W, Chaccour C, Hatoum I, Richa F. Uterine Scar Evaluation during the Postpartum: Pleading for Extradecidual Suturing during Cesarean Section. Am J Perinatol 2024; 41:e1357-e1361. [PMID: 36720259 DOI: 10.1055/a-2022-9892] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Our objective is to evaluate ultrasound differences in uterine scar between techniques using extramucosal suturing and full thickness suturing of the uterine incision. STUDY DESIGN A retrospective observational study included cases of primary cesarean section. At 6-week postpartum, we evaluated by endovaginal ultrasound two elements in the sagittal view: the thickness of the uterine scar and the surface of defect (niche). Hysterotomy sites closed using a running full-thickness technique including the uterine mucosa (group 1) were compared to hysterotomies operated by the same surgeon but with extramucosal suturing (group 2). The operator switched from the running suture technique to extramucosal in 2013. RESULTS The study included 241 patients (115 cases in group 1 that were compared to 126 cases in group 2). There were no significant differences in age or body mass index between the two groups. Cesarean scar and niche were detectable in the entire studied population. There was a significant difference in both uterine scar thickness (5.8 vs. 6.2 mm, p = 0.02) and the presence and size of the niche (49 vs. 40 mm2, p = 0.001) in transvaginal ultrasound performed at 6-week postpartum. CONCLUSION Extramucosal suturing of the uterine scar seems to be associated with a better outcome on the postpartum ultrasound evaluation. KEY POINTS · The technique for suturing the hysterotomy can be the source of healing changes.. · An extramucosal suturing of the uterus seems to give a better aspect at the postpartum ultrasound.. · Decreasing the niche at cesarean scar may be beneficial for future pregnancies..
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Affiliation(s)
- Assaad K Kesrouani
- Obstetrics and Gynecology Department, St. Joseph University, Beirut, Lebanon
- Department of Obstetrics and Gynecology, Hotel-Dieu de France University Hospital, Prenatal Unit, Bellevue Medical Center, Lebanon
| | - Yara Abdelkhalek
- Obstetrics and Gynecology Department, St. Joseph University, Beirut, Lebanon
- Department of Obstetrics and Gynecology, Hotel-Dieu de France University Hospital, Prenatal Unit, Bellevue Medical Center, Lebanon
| | - Wael Abdallah
- Obstetrics and Gynecology Department, St. Joseph University, Beirut, Lebanon
- Department of Obstetrics and Gynecology, Hotel-Dieu de France University Hospital, Prenatal Unit, Bellevue Medical Center, Lebanon
| | - Christian Chaccour
- Obstetrics and Gynecology Department, St. Joseph University, Beirut, Lebanon
- Department of Obstetrics and Gynecology, Hotel-Dieu de France University Hospital, Prenatal Unit, Bellevue Medical Center, Lebanon
| | - Inaam Hatoum
- Obstetrics and Gynecology Department, Rafik Hariri University Hospital, Beirut, Lebanom
| | - Freda Richa
- Anesthesia Department, St. Joseph University, Hotel-Dieu de France University Hospital, Beirut, Lebanon
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5
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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.
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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
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6
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Stegwee SI, Verberkt C, Huirne JA. Letter on Genovese et al.'s "Impact of Hysterotomy Closure Technique on Subsequent Cesarean Scar Defects Formation: A Systematic Review". Gynecol Obstet Invest 2023; 88:322-324. [PMID: 37647882 PMCID: PMC10659000 DOI: 10.1159/000533688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/15/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Sanne I. Stegwee
- Department of Obstetrics and Gynaecology, Research Institute ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Carry Verberkt
- Department of Obstetrics and Gynaecology, Research Institute ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Amsterdam, The Netherlands
| | - Judith A.F. Huirne
- Department of Obstetrics and Gynaecology, Research Institute ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
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7
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Verberkt C, Lemmers M, de Vries R, Stegwee SI, de Leeuw RA, Huirne JAF. Aetiology, risk factors and preventive strategies for niche development: A review. Best Pract Res Clin Obstet Gynaecol 2023; 90:102363. [PMID: 37385157 DOI: 10.1016/j.bpobgyn.2023.102363] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 07/01/2023]
Abstract
The increase in caesarean sections (CS) has resulted in an increase in women with a uterine niche. The exact aetiology of niche development has yet to be elucidated but is likely multifactorial. This study aimed to give a systematic overview of the available literature on histopathological features, risk factors and results of preventive strategies on niche development to gain more insight into the underlying mechanisms. Based on current published data histopathological findings associated with niche development were necrosis, fibrosis, inflammation, adenomyosis and insufficient approximation. Patient-related risk factors included multiple CS, BMI and smoking. Labour-related factors were CS before onset of labour, extended cervical dilatation, premature rupture of membranes and presenting part of the fetus at CS below the pelvic inlet. Preventive strategies should focus on the optimal level of incision, training of surgeons and full-thickness closure of the myometrium (single or double-layer) using non-locking sutures. Conflicting data exist concerning the effect of endometrial inclusion. Future studies without heterogeneity in population, using standardized performance of the CS after proper training and using standardized niche evaluation with a relevant core outcome set are required to allow meta-analyses and to develop evidence-based preventive strategies. These studies are needed to reduce the prevalence of niches and prevent complications in subsequent pregnancies such as caesarean scar pregnancies.
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Affiliation(s)
- C Verberkt
- Department of Obstetrics and Gynecology, Research Institute "Amsterdam Reproduction and Development", Amsterdam UMC, Location VU Medical Center, Amsterdam, the Netherlands
| | - M Lemmers
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - R de Vries
- Medical Library, Vrije Universiteit, 1081 HV, Amsterdam, the Netherlands
| | - S I Stegwee
- Department of Obstetrics and Gynecology, Research Institute "Amsterdam Reproduction and Development", Amsterdam UMC, Location VU Medical Center, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - J A F Huirne
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands.
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8
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Katsura D, Tsuji S, Hoshiyama T, Zen R, Inatomi A, Murakami T. A Trimming Technique: A Case Report of a Novel Surgical Approach for Cesarean Scar Dehiscence During Cesarean Section. Yonago Acta Med 2023; 66:287-291. [PMID: 37229375 PMCID: PMC10203637 DOI: 10.33160/yam.2023.05.004] [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: 01/16/2023] [Accepted: 02/16/2023] [Indexed: 05/27/2023]
Abstract
Cesarean section can lead to residual myometrial thickness thinning and cesarean scar syndrome. We report a novel trimming technique for residual myometrial thickness recovery in women with cesarean scar syndrome. Case 1: A 33-year-old woman who developed cesarean scar syndrome (CSS) and abnormal uterine bleeding post-cesarean scar became pregnant following hysteroscopic treatment. The myometrium at previous scar was dehiscent; therefore, a transverse incision was made above the scar. Post-operative uterine recovery failed owing to lochia retention, and developed cesarean scar syndrome again. Case 2: A 29-year-old woman who developed cesarean scar syndrome post-cesarean section became pregnant spontaneously. The myometrium at the previous scar was dehiscent like case 1. Scar repair was performed using a trimming technique during cesarean section; there were no subsequent complications and she conceived again spontaneously. Performing this novel surgical procedure during cesarean section may contribute to residual myometrial thickness recovery in women with cesarean scar syndrome.
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Affiliation(s)
- Daisuke Katsura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Takako Hoshiyama
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Rika Zen
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Ayako Inatomi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu 520-2192, Japan
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9
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Stegwee SI, van der Voet LFL, Heymans MW, Kapiteijn K, van Laar JOEH, van Baal WMM, de Groot CJM, Huirne JAF. Prognostic model on niche development after a first caesarean section: development and internal validation. Eur J Obstet Gynecol Reprod Biol 2023; 283:59-67. [PMID: 36796129 DOI: 10.1016/j.ejogrb.2023.01.014] [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: 09/21/2022] [Revised: 01/06/2023] [Accepted: 01/15/2023] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To develop and internally validate a prognostic prediction model for development of a niche in the uterine scar after a first caesarean section (CS). STUDY DESIGN Secondary analyses on data of a randomized controlled trial, performed in 32 hospitals in the Netherlands among women undergoing a first caesarean section. We used multivariable backward logistic regression. Missing data were handled using multiple imputation. Model performance was assessed by calibration and discrimination. Internal validation using bootstrapping techniques took place. The outcome was 'development of a niche in the uterus', defined as an indentation of ≥ 2 mm in the myometrium. RESULTS We developed two models to predict niche development: in the total population and after elective CS. Patient related risk factors were: gestational age, twin pregnancy and smoking, and surgery related risk factors were double-layer closure and less surgical experience. Multiparity and Vicryl suture material were protective factors. The prediction model in women undergoing elective CS revealed similar results. After internal validation, Nagelkerke R2 ranged from 0.01 to 0.05 and was considered low; median area under the curve (AUC) ranged from 0.56 to 0.62, indicating failed to poor discriminative ability. CONCLUSIONS The model cannot be used to accurately predict the development of a niche after a first CS. However, several factors seem to influence scar healing which indicates possibilities for future prevention such as surgical experience and suture material. The search for additional risk factors that play a role in development of a niche should be continued to improve the discriminative ability.
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Affiliation(s)
- Sanne I Stegwee
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands.
| | | | - Martijn W Heymans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology & Data Science, Amsterdam, Netherlands
| | - Kitty Kapiteijn
- Reinier de Graaf Gasthuis, Department of Obstetrics and Gynecology, Delft, Netherlands
| | - Judith O E H van Laar
- Máxima Medisch Centrum, Department of Obstetrics and Gynecology, Veldhoven, Netherlands
| | | | - Christianne J M de Groot
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands; Amsterdam UMC, Universiteit van Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Judith A F Huirne
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands; Amsterdam UMC, Universiteit van Amsterdam, Department of Obstetrics and Gynecology, Research Institute Amsterdam Reproduction & Development, Amsterdam, Netherlands.
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10
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Tsuji S, Nobuta Y, Hanada T, Takebayashi A, Inatomi A, Takahashi A, Amano T, Murakami T. Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review. Reprod Med Biol 2023; 22:e12532. [PMID: 37577060 PMCID: PMC10412910 DOI: 10.1002/rmb2.12532] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/05/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Background Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi). Methods This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery. Main findings The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective. Conclusion The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and GynecologyShiga University of Medical ScienceOtsuShigaJapan
| | - Yuri Nobuta
- Department of Obstetrics and GynecologyShiga University of Medical ScienceOtsuShigaJapan
| | - Tetsuro Hanada
- Department of Obstetrics and GynecologyShiga University of Medical ScienceOtsuShigaJapan
| | - Aike Takebayashi
- Department of Obstetrics and GynecologyShiga University of Medical ScienceOtsuShigaJapan
| | - Ayako Inatomi
- Department of Obstetrics and GynecologyShiga University of Medical ScienceOtsuShigaJapan
| | - Akimasa Takahashi
- Department of Obstetrics and GynecologyShiga University of Medical ScienceOtsuShigaJapan
| | - Tsukuru Amano
- Department of Obstetrics and GynecologyShiga University of Medical ScienceOtsuShigaJapan
| | - Takashi Murakami
- Department of Obstetrics and GynecologyShiga University of Medical ScienceOtsuShigaJapan
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11
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Tandukar A, Aryal R, Khaniya B, Maskey S, Ojha N, Chataut D. Pregnancy in an isthmocele: A rare case from Nepal. Clin Case Rep 2023; 11:e6875. [PMID: 36694651 PMCID: PMC9842908 DOI: 10.1002/ccr3.6875] [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: 07/28/2022] [Revised: 10/09/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
An infrequent form of ectopic pregnancy, pregnancy in an isthmocele can be hazardous due to hemorrhage or uterine rupture. With no clear guidelines for the management of this condition, surgery is the preferred option.
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Affiliation(s)
- Alina Tandukar
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Roshan Aryal
- Maharajgunj Medical CampusInstitute of MedicineKathmanduNepal
| | - Bishal Khaniya
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Suvana Maskey
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Neebha Ojha
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Dinesh Chataut
- Department of Radiology and ImagingTribhuvan University Teaching HospitalKathmanduNepal
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12
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Mc Gowan S, Goumalatsou C, Kent A. Fantastic niches and where to find them: the current diagnosis and management of uterine niche. Facts Views Vis Obgyn 2022; 14:37-47. [PMID: 35373546 PMCID: PMC9612856 DOI: 10.52054/fvvo.14.1.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Caesarean section (CS) scar niche is a well recognised complication of caesarean delivery and is defined as an indentation at the site of the CS scar with a depth of at least 2mm. Objectives To review systematically the medical literature regarding the current diagnosis and management of uterine niche Materials and methods We carried out a systematic review using MeSH terms ‘niche’ OR ‘sacculation’ OR ‘caesarean scar defect’ OR ‘caesarean section scar’ OR ‘uterine defect’ OR ‘isthmocele.’ Articles included were peer-reviewed and in English language. Main outcome measures Prevalence, symptoms, diagnosis, pathophysiology and management of uterine niche. Results CS scar niche is common and, in a subgroup, produces a range of symptoms including post-menstrual bleeding, dyspareunia and subfertility. It may be linked to use of locked sutures during CS closure. Niche repair can be achieved laparoscopically or hysteroscopically and appears to improve symptoms, although solid conclusions regarding fertility outcomes cannot be drawn. Conclusions CS scar niche is associated with a range of symptoms. Repair may aid subfertile patients and those with post-menstrual spotting. The presence of a niche is probably irrelevant in the absence of symptoms. What is new? LNG-IUS and surgical repair appear to improve symptoms in those with a niche.
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13
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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.
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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.)
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14
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Stupak A, Kondracka A, Fronczek A, Kwaśniewska A. Scar Tissue after a Cesarean Section-The Management of Different Complications in Pregnant Women. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11998. [PMID: 34831752 PMCID: PMC8620716 DOI: 10.3390/ijerph182211998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022]
Abstract
The definition of a cesarean scar pregnancy (CSP) is the localization of the gestational sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous cesarean section (CS). The worldwide prevalence of CSP has been growing rapidly. However, there are no general recommendations regarding prophylaxis and treatment of the abnormalities of the anterior wall of the uterus discovered in a non-pregnant myometrium, or how to deal with existing cases of CSP. We present the latest knowledge, a holistic approach to the biology, histology, imaging, and management concerning post-CS scars based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy in the Medical University of Lublin, Poland. In our study, we present images of tissue samples of areas with a cicatrix in the uterus, and ultrasound and MRI images of CSP. We discuss the advances in the biology of the post-CS scar tissue, the prevention techniques used to repair the scar defect (niche) before the pregnancy, and the treatment of different complications of CSP, such as the rupture of the gravid uterus or the dehiscence of the myometrium.
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Affiliation(s)
- Aleksandra Stupak
- Department of Obstetrics and Pathology of Pregnancy, Independent Public Teaching Hospital No 1 in Lublin, Medical University of Lublin, 20-081 Lublin, Poland; (A.K.); (A.K.)
| | - Adrianna Kondracka
- Department of Obstetrics and Pathology of Pregnancy, Independent Public Teaching Hospital No 1 in Lublin, Medical University of Lublin, 20-081 Lublin, Poland; (A.K.); (A.K.)
| | - Agnieszka Fronczek
- Department of Pathomorphology, Independent Public Teaching Hospital No 1 in Lublin, Medical University of Lublin, 20-081 Lublin, Poland;
| | - Anna Kwaśniewska
- Department of Obstetrics and Pathology of Pregnancy, Independent Public Teaching Hospital No 1 in Lublin, Medical University of Lublin, 20-081 Lublin, Poland; (A.K.); (A.K.)
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15
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Friedenthal J, Alkon-Meadows T, Hernandez-Nieto C, Gounko D, Lee JA, Copperman A, Buyuk E. The association between prior cesarean delivery and subsequent in vitro fertilization outcomes in women undergoing autologous, frozen-thawed single euploid embryo transfer. Am J Obstet Gynecol 2021; 225:287.e1-287.e8. [PMID: 33798478 DOI: 10.1016/j.ajog.2021.03.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/12/2021] [Accepted: 03/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The rates of cesarean deliveries continue to increase worldwide. Previous work suggests an association between a previous cesarean delivery and reduced fertility in natural conception and in vitro fertilization treatment cycles. To our knowledge, there is no published research that explored the relationship between a previous cesarean delivery and the clinical outcomes after in vitro fertilization and the subsequent transfer of a single frozen-thawed euploid embryo. OBJECTIVE This study aimed to investigate the relationship between the previous mode of delivery and subsequent pregnancy outcomes in patients undergoing a single frozen-thawed euploid embryo transfer after in vitro fertilization. STUDY DESIGN A retrospective cohort study was performed at a single academic fertility center from January 2012 to April 2020. All women with a history of a live birth undergoing autologous, frozen-thawed single euploid embryo transfers were identified. Cases included patients with a single previous cesarean delivery; controls included patients with a single previous vaginal delivery. Only the first embryo transfer cycle was included. The primary outcome was the implantation rate. Secondary outcomes included ongoing pregnancy and live birth rates, biochemical pregnancy rate, and clinical miscarriage rate. RESULTS A total of 525 patients met the inclusion criteria and were included in the analysis. Patients with a previous cesarean delivery had a higher body mass index (24.5±4.5 vs 23.4±4.1; P=.004) than those in the vaginal delivery cohort; the rest of the demographic data were otherwise similar. In a univariate analysis, the implantation rate was significantly lower in patients with a previous cesarean delivery (111/200 [55.5%] vs 221/325 [68.0%]; P=.004). After adjusting for the relevant covariates, a previous cesarean delivery was associated with a 48% reduction in the odds of implantation (adjusted odds ratio, 0.52; 95% confidence interval, 0.34-0.78; P=.002). In addition, after adjusting for the same covariates, a previous cesarean delivery was significantly associated with a 39% reduction in the odds of an ongoing pregnancy and live birth (adjusted odds ratio, 0.61; 95% confidence interval, 0.41-0.90; P=.01). There were no differences in the biochemical pregnancy rates or clinical miscarriage rates. CONCLUSION This study demonstrated a marked reduction in implantation and ongoing pregnancy and live birth associated with a previous cesarean delivery in patients undergoing a single euploid embryo transfer. Our work stresses the importance of reducing the primary cesarean delivery rates at a national level and elucidating the mechanisms behind the substantially lower implantation rates after a cesarean delivery.
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Affiliation(s)
- Jenna Friedenthal
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY; Reproductive Medicine Associates of New York, New York, NY.
| | | | | | - Dmitry Gounko
- Reproductive Medicine Associates of New York, New York, NY
| | - Joseph A Lee
- Reproductive Medicine Associates of New York, New York, NY
| | - Alan Copperman
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY; Reproductive Medicine Associates of New York, New York, NY
| | - Erkan Buyuk
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY; Reproductive Medicine Associates of New York, New York, NY
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16
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Bayraktar R, Mulayim B, Tamburaci E, Karadag C, Karadag B. Risk of uterine niche following single-layer locked versus unlocked uterine closure: a randomized study. J Matern Fetal Neonatal Med 2021; 35:8210-8216. [PMID: 34470144 DOI: 10.1080/14767058.2021.1966763] [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: 10/20/2022]
Abstract
INTRODUCTION The primary objective of the present study is to evaluate the effect of single-layer locked versus single-layer unlocked uterine closure techniques on the development of uterine niche. The secondary objective is to evaluate the effect of the ratio of lower uterine segment (LUS) to upper uterine segment (UUS) on the development of uterine niche, which was not previously investigated in literature but which the authors consider to be a major risk factor for the development of uterine niche. METHODS Included in this randomized study were 194 patients who were admitted to the Department of Obstetrics and Gynecology at Health Sciences University Antalya Training and Research Hospital and who underwent cesarean section (CS) due to any reason between October 2017 and May 2018. Two different techniques were used in the closure of hysterotomy: Single-layer locked continuous suturing (Group 1) and single-layer unlocked continuous suturing (Group 2). During surgery, the thicknesses of the LUS and UUS were measured using a sterile scale prior to hysterotomy closure. The patients were evaluated for the development of uterine niche at postoperative six months by transvaginal ultrasound. RESULTS Control transvaginal ultrasound performed at six months after surgery revealed uterine niches in 58 out of 194 patients (29.29%; 34 patients in Group 1 [34.3%] and 24 patients in Group 2 [25.3%]). No significant difference was noted in terms of the development of uterine niche between the two groups (p = .167). The mean LUS and UUS in patients without uterine niche development were 6.81 ± 1.26 mm and 9.38 ± 1.26 mm, whereas the mean LUS and UUS in patients with uterine niche development were 4.24 ± 1.15 mm and 9.21 ± 2.15, respectively (p = .001 and p = .236). The mean UUS/LUS ratio is 1.4 ± 0.16 among patients without uterine niche and 2.21 ± 0.31 in patients with uterine niche (p < .001). CONCLUSIONS The present study found no statistically significant difference in niche size between the two groups. However, the study reports that the ratio of upper to lower uterine segment that was not previously investigated in literature is a major risk factor for the development of uterine niche.
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Affiliation(s)
- Recep Bayraktar
- Obstetrics and Gynecology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Baris Mulayim
- Obstetrics and Gynecology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Esra Tamburaci
- Obstetrics and Gynecology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ceyda Karadag
- Obstetrics and Gynecology, Akdeniz Üniversitesi Tıp Fakültesi, Antalya, Turkey
| | - Burak Karadag
- Obstetrics and Gynecology, Antalya Training and Research Hospital, Antalya, Turkey
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17
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Stegwee SI, Ben ÂJ, El Alili M, van der Voet LF, de Groot CJM, Bosmans JE, Huirne JAF. Cost-effectiveness of single-layer versus double-layer uterine closure during caesarean section on postmenstrual spotting: economic evaluation alongside a randomised controlled trial. BMJ Open 2021; 11:e044340. [PMID: 34215598 PMCID: PMC8256741 DOI: 10.1136/bmjopen-2020-044340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/09/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of double-layer compared with single-layer uterine closure after a first caesarean section (CS) from a societal and healthcare perspective. DESIGN Economic evaluation alongside a multicentre, double-blind, randomised controlled trial. SETTING 32 hospitals in the Netherlands, 2016-2018. PARTICIPANTS 2292 women ≥18 years undergoing a first CS were randomly assigned (1:1). Exclusion criteria were: inability for counselling, previous uterine surgery, known menstrual disorder, placenta increta or percreta, pregnant with three or more fetuses. 1144 women were assigned to single-layer and 1148 to double-layer closure. We included 1620 women with a menstrual cycle in the main analysis. INTERVENTIONS Single-layer unlocked uterine closure and double-layer unlocked uterine closure with the second layer imbricating the first. MAIN OUTCOME MEASURES Spotting days, quality-adjusted life-years (QALYs), and societal costs at 9 months of follow-up. Missing data were imputed using multiple imputation. RESULTS No significant differences were found between single-layer versus double-layer closure in mean spotting days (1.44 and 1.39 days; mean difference (md) -0.056, 95% CI -0.374 to 0.263), QALYs (0.663 and 0.658; md -0.005, 95% CI -0.015 to 0.005), total healthcare costs (€744 and €727; md €-17, 95% CI -273 to 143), and total societal costs (€5689 and €5927; md €238, 95% CI -624 to 1108). The probability of the intervention being cost-effective at willingness-to-pay of €0, €10 000 and €20 000/QALY gained was 0.30, 0.27 and 0.25, respectively, (societal perspective), and 0.55, 0.41 and 0.32, respectively, (healthcare perspective). CONCLUSION Double-layer uterine closure is not cost-effective compared with single-layer uterine closure from both perspectives. If this is confirmed by our long-term reproductive follow-up, we suggest to adjust uterine closure technique guidelines. TRIAL REGISTRATION NUMBER NTR5480/NL5380.
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Affiliation(s)
- Sanne I Stegwee
- Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ângela J Ben
- Health Sciences, Amsterdam Public Health, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Mohamed El Alili
- Health Sciences, Amsterdam Public Health, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Christianne J M de Groot
- Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Judith E Bosmans
- Health Sciences, Amsterdam Public Health, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Judith A F Huirne
- Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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18
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Tahermanesh K, Mirgalobayat S, Aziz-Ahari A, Maleki M, Hashemi N, Samimi M, Fazel Anvari-Yazdi A, Shahriyaripour R, Pecks U, Allahqoli L, Alkatout I. Babu and Magon uterine closure technique during cesarean section: A randomized double-blind trial. J Obstet Gynaecol Res 2021; 47:3186-3195. [PMID: 34131999 DOI: 10.1111/jog.14889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/22/2021] [Accepted: 05/29/2021] [Indexed: 11/29/2022]
Abstract
AIM We compared the effectiveness of the Babu and Magon uterine closure technique and unlocked double-layer uterine closure on the integrity and thickness of the uterine scar. METHODS A randomized double-blind trial was performed at Hazrat-e Rasoul -e-Akram Hospital, Tehran, Iran, from March 2018 to December 2019, in 72 pregnant women who were candidates for cesarean section for the first time. Women were randomly assigned to the Babu and Magon uterine closure technique (intervention group, n = 34) or double-layer closure of the uterine incision (control group, n = 38). The primary outcome of the study was the frequency of myometrial defects at the site of the scar (niche), and a large niche. Secondary outcomes, including the time taken for uterine closure and postpartum hemorrhage (early and late), were compared between groups. RESULTS Adjacent myometrium thickness (AMT) between the two groups was not statistically significant. A niche was reported in 23.5% (8/34) and 50% (19/38) of women in the intervention and controls, respectively (p = 0.02). A large niche was reported in 2.9% (1/34) and 23.7% (9/38) of women in the intervention and controls, respectively (p < 0.01). The duration of uterine closure was not statistically significant between the two groups. Hemoglobin levels did not differ significantly between groups during the first 24 h post-surgery. CONCLUSION The results of the study showed that the technique of uterine closure is one of the main potential determinants of myometrial healing. The Babu and Magon uterine closure technique seems to lead to tissue alignment during suturing and consequently cause better myometrial healing, although this issue calls for well-founded longer studies of appropriate design.
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Affiliation(s)
- Kobra Tahermanesh
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Shahla Mirgalobayat
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Alireza Aziz-Ahari
- Department of Radiology, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Maryam Maleki
- School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Neda Hashemi
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mansooreh Samimi
- Department of Gynecology and Obstetrics, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Abbas Fazel Anvari-Yazdi
- Division of Biomedical Engineering, College of Engineering, University of Saskatchewan, Saskatoon, Canada
| | - Roya Shahriyaripour
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Ulrich Pecks
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Leila Allahqoli
- School of Public Health, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Ibrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
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19
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Zhou X, Zhang T, Qiao H, Zhang Y, Wang X. Evaluation of uterine scar healing by transvaginal ultrasound in 607 nonpregnant women with a history of cesarean section. BMC WOMENS HEALTH 2021; 21:199. [PMID: 33985487 PMCID: PMC8117607 DOI: 10.1186/s12905-021-01337-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/30/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Caesarean scar defect (CSD) seriously affects female reproductive health. In this study, we aim to evaluate uterine scar healing by transvaginal ultrasound (TVS) in nonpregnant women with cesarean section (CS) history and to build a predictive model for cesarean scar defects is very necessary. METHODS A total of 607 nonpregnant women with previous CS who have transvaginal ultrasound measurements of the thickness of the lower uterine segment. The related clinical data were recorded and analyzed. RESULTS All patients were divided into two groups according to their clinical symptoms: Group A (N = 405) who had no cesarean scar symptoms, and Group B (N = 141) who had cesarean scar symptoms. The difference in frequency of CS, uterine position, detection rate of CSD and the residual muscular layer (TRM) of the CSD were statistically significant between groups; the TRM measurements of the two groups were (mm) 5.39 ± 3.34 versus 3.22 ± 2.33, P < 0.05. All patients were divided into two groups according to whether they had CSDs: Group C (N = 337) who had no CSDs, Group D (N = 209) who had CSDs on ultrasound examination. The differences in frequency of CS, uterine position, TRM between groups were statistically significant (P < 0.05). In the model predicting CSDs by TRM with TVS, the area under the ROC curve was 0.771, the cut-off value was 4.15 mm. The sensitivity and specificity were 87.8% and 71.3%, respectively. CONCLUSIONS Patients with no clinical symptoms had a mean TRM on transvaginal ultrasonography of 5.39 ± 3.34 mm, which could be used as a good reference to predict the recovery of patients with CSDs after repair surgery.
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Affiliation(s)
- Xingchen Zhou
- Department of Obstetrics and Gynecology, Xinhua Hospital, Affiliated to Shanghai Jiaotong University, No. 1665 Kong Jiang Road, Shanghai, 200092, China
| | - Tao Zhang
- Department of Gynecology, Qingdao Municipal Hospital, Shandong, 266071, China
| | - Huayuan Qiao
- Department of Ultrasound, Shanghai First Maternity and Infant Hospital, Affiliated To Tongji University, Shanghai, China
| | - Yi Zhang
- Department of Obstetrics and Gynecology, Xinhua Hospital, Affiliated to Shanghai Jiaotong University, No. 1665 Kong Jiang Road, Shanghai, 200092, China
| | - Xipeng Wang
- Department of Obstetrics and Gynecology, Xinhua Hospital, Affiliated to Shanghai Jiaotong University, No. 1665 Kong Jiang Road, Shanghai, 200092, China.
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20
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Vissers J, Hehenkamp W, Lambalk CB, Huirne JA. Post-Caesarean section niche-related impaired fertility: hypothetical mechanisms. Hum Reprod 2021; 35:1484-1494. [PMID: 32613231 PMCID: PMC7568911 DOI: 10.1093/humrep/deaa094] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 04/02/2020] [Indexed: 11/14/2022] Open
Abstract
Caesarean section can result in an indentation of the myometrium at the site of the Caesarean scar, called a niche. Niches can cause symptoms of abnormal uterine blood loss, dysmenorrhoea, chronic pelvic pain and dyspareunia and are possibly related to subfertility. Various other explanations for the cause of subfertility after Caesarean section have been proposed in the literature, such as uterine pathology, intra-abdominal adhesions and women’s reproductive choices. Not all niches cause symptoms and the relation with subfertility and a niche in the uterine scar still needs further study since direct evidence is lacking so far. Based on the limited available evidence, and in combination with observations made during sonographic hysteroscopic evaluations and laparoscopic niche repair, we propose and discuss three hypothetical mechanisms: (i) the environment for sperm penetration and implantation may be detrimental; (ii) there could be a physical barrier to embryo transfer and implantation; and (iii) psychogenic factors may reduce the likelihood of pregnancy. Several innovative surgical treatments have been developed and are being implemented for niche-related problems. Promising results are reported, but more evidence is needed before further implementation in daily practice. The additional value of niche resections should be compared to expectant management or fertility therapies, such as ART, in randomized controlled trials. Therefore, our suggested hypotheses should, for the time being, not be used for justification of any specific procedures outside clinical trials.
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Affiliation(s)
- Jolijn Vissers
- Department of Gynaecology and Obstetrics, Amsterdam UMC—Vrije Universiteit Amsterdam, Research Institute ‘Reproduction and Development’, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Wouter Hehenkamp
- Department of Gynaecology and Obstetrics, Amsterdam UMC—Vrije Universiteit Amsterdam, Research Institute ‘Reproduction and Development’, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Cornelis Bavo Lambalk
- Department of Gynaecology and Obstetrics, Amsterdam UMC—Vrije Universiteit Amsterdam, Research Institute ‘Reproduction and Development’, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Judith Anna Huirne
- Department of Gynaecology and Obstetrics, Amsterdam UMC—Vrije Universiteit Amsterdam, Research Institute ‘Reproduction and Development’, Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
- Correspondence address. Department of Gynaecology and Obstetrics, Amsterdam UMC—Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands. Tel: +31-20-566 9111; E-mail: (J.A.F. Huirne)
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21
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Abdelfattah EA, Dayem TMAE, Galal HM, Taylon SS. Gynecological outcomes of uterine niche after cesarean section: A descriptive study. JOURNAL OF REPRODUCTIVE HEALTHCARE AND MEDICINE 2021; 2:5. [DOI: 10.25259/jrhm_31_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Objectives:
Our aim was to study the prevalence of isthmocele in cases with previous cesarean section scar presented to El Shatby maternity university hospital and its association with gynecological complications.
Material and Methods:
After approval of the ethics committee of Alexandria faculty of medicine, a sample of 300 patients delivered by cesarean section since 6 months or more presented by one or more of the following symptoms: Abnormal uterine bleeding (AUB) dysmenorrhea, secondary infertility, and lower abdominal pain were selected from the gynecology clinic of El Shatby maternity university hospital. All patients were subjected to history taking, clinical, and gynecological examination. Post-menstrual 2D transvaginal ultrasonography was done. Where the niche or isthmocele was seen as triangular or dome- shaped echo-free space. Data were collected and entered to the computer using Statistical Package for the Social Science program for statistical analysis.
Results:
Niche was found in 44 cases. Most of them were symptomatic. Duration from the last (CS) was statistically significant. Symptoms were related to number of previous cesarean sections.
Conclusion:
The incidence of post-cesarean section niche in El Shatby Maternity hospital was 14.67%. Most common symptoms were AUB and dyspareunia.
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Affiliation(s)
- E. A. Abdelfattah
- Department of Obstetrics and Gynecology, Alexandria University, Alexandria, Egypt,
| | - T. M. Abd-El Dayem
- Department of Obstetrics and Gynecology, Alexandria University, Alexandria, Egypt,
| | - H. M. Galal
- Department of Obstetrics and Gynecology, Alexandria University, Alexandria, Egypt,
| | - S. S. Taylon
- Department of Obstetrics and Gynecology, Alexandria University, Alexandria, Egypt,
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22
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The higher incision at upper part of lower uterine segment in caesarean section can decrease the incidence of placenta accreta spectrum. Med Hypotheses 2020; 144:110228. [PMID: 33254537 DOI: 10.1016/j.mehy.2020.110228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/12/2020] [Accepted: 08/28/2020] [Indexed: 11/21/2022]
Abstract
Caesarean section rate and placenta accreta spectrum prevalence are in continuous increase during last years. Multiple hypotheses can explain the abnormal adherence of placenta trophoblast to the myometrium. By reviewing the surgical techniques used in caesarean section, we hypothesize that the higher uterine incision at upper part of lower segment could decrease the abnormal placentation in next pregnancies.
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23
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Török P. Surgical Therapeutic Options for Previous Cesarean Scar Defect in Women with Postmenstrual Bleeding. J INVEST SURG 2020; 34:1156-1157. [PMID: 32434449 DOI: 10.1080/08941939.2020.1770378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Péter Török
- Faculty of Medicine, Department of Obstetrics and Gynecology, University of Debrecen, Debrecen, Hungary
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Suture techniques in caesarean section. GINECOLOGIA.RO 2020. [DOI: 10.26416/gine.29.3.2020.3767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. ACTA ACUST UNITED AC 2019; 65:714-721. [PMID: 31166450 DOI: 10.1590/1806-9282.65.5.714] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/31/2018] [Indexed: 11/21/2022]
Abstract
An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.
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Affiliation(s)
- Thaysa Guglieri Kremer
- Department of Medicine at the Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Isadora Bueloni Ghiorzi
- Department of Medicine at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil
| | - Raquel Papandreus Dibi
- Department of Gynecology and Obstetrics at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil
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Tekelioğlu M, Karataş S, Güralp O, Murat Alınca C, Ender Yumru A, Tuğ N. Incomplete healing of the uterine incision after elective second cesarean section. J Matern Fetal Neonatal Med 2019; 34:943-947. [PMID: 31146610 DOI: 10.1080/14767058.2019.1622676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the possible associations between the single-layer locked- and unlocked-uterine closure technique and closure area biometry, and cesarean scar healing in recurrent cesarean section. MATERIAL AND METHODS In this randomized prospective study, elective second cesarean section of 120 singleton pregnant women were randomized into the single-layer locked- and unlocked-continuous uterus closure technique. During the operation, the upper and lower edge thickness of the uterine incision were measured. In order to evaluate the healing in the cesarean scar area, all women were examined with vaginal ultrasonography 6-8 months after the cesarean section. The possible associations between locked- and unlocked-uterine closure technique and closure area biometry and cesarean scar healing were evaluated. RESULTS After the drop-outs, a total of 86 women, 45 in the locked-continuous closure group and 41 in the unlocked-continuous closure group were evaluated. There was no statistically significant difference between the groups in terms of demographic and clinical parameters, such as perioperative uterine closure area biometry, need for additional suture, duration of operation and amount of bleeding. However, a significantly greater number of additional sutures for hemostasis was necessary in the unlocked-continuous compared to the locked-continuous closure group. The rate of cesarean scar defect (CSD) and residual myometrium thickness were comparable whereas the healing rate was significantly higher in the locked-continuous closure group compared to the unlocked-continuous closure group (0.71 ± 0.90 vs. 0.64 ± 0.10, p = .032). In women with CSD, the lower edge was 4 mm thinner than the women without CSD (10.48 ± 6.13 mm vs. 14.53 ± 7.13 mm, p = .006). Moreover, the thickness difference between the lower and upper edge was significantly greater if CSD was present compared to the absence of CSD (5.88 ± 4.04 mm vs. 3.70 ± 3.00 mm, p = .006). CONCLUSIONS There was no association between CSD and locked versus unlocked suture technique used for the closure of uterine incision in the second cesarean section. The biometric evaluation of the scar area has shown that the thin lower wound edge and unevenness between the lower and the upper wound edges may play a role in incomplete healing of the uterine incision.
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Affiliation(s)
- Meltem Tekelioğlu
- Obstetrics and Gynecology, Prof. Dr. Ilhan Varank Sancaktepe Education and Research Hospital, Istanbul, Turkey
| | - Suat Karataş
- Obstetrics and Gynecology, Memorial Bahcelievler Hospital, Istanbul, Turkey
| | - Onur Güralp
- Department of Obstetrics and Gynaecology, Klinikum Oldenburg, AöR, Carl von Ossietzky Oldenburg University, Oldenburg, Germany
| | - Cihat Murat Alınca
- Obstetrics and Gynecology, Bahcelievler State Hospital, Istanbul, Turkey
| | - Ayşe Ender Yumru
- Obstetrics and Gynecology, Sariyer Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Niyazi Tuğ
- Obstetrics and Gynecology, Prof. Dr. Ilhan Varank Sancaktepe Education and Research Hospital, Istanbul, Turkey
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Prevalence of Infertility Among Patients With Isthmocele and Fertility Outcome After Isthmocele Surgical Treatment: A Retrospective Study. Ochsner J 2019; 19:204-209. [PMID: 31528130 DOI: 10.31486/toj.18.0048] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: An isthmocele is a diverticulum on the anterior wall of the uterine isthmus at the site of a cesarean delivery scar. We evaluated the prevalence of infertility among patients with isthmocele, the resolution of symptoms, and infertility outcomes after hysteroscopic isthmoplasty. Methods: We conducted a retrospective study of 35 consecutive patients with symptomatic isthmocele between 2010 and 2015 at Hospital Piero Palagi in Florence, Italy. Patients with symptomatic isthmocele had postmenstrual abnormal uterine bleeding, sovrapubic pain, and infertility. Results: The study population was divided into Group A - Fertile Patients (n=19) and Group B - Infertile Patients (n=16) according to the prevalence of infertility after the diagnosis of isthmocele. Group B was subdivided into Group B1 (became pregnant, n=9) and B2 (did not become pregnant, n=7) according to infertility resolution after isthmocele treatment. We found statistically significant differences between Groups A and B regarding the number of cesarean sections (P=0.0205), the grade of isthmocele (P=0.0421), and body mass index (P=0.0001). In the subgroup analysis, we found statistically significant differences between Groups B1 and B2 for age (P=0.0151), grade of isthmocele (P=0.0361), and cervical dilatation (P=0.0293). Conclusion: We identified a subgroup of patients at higher risk of being infertile after the diagnosis of isthmocele and a subgroup of patients who could benefit the most in terms of fertility after minimally invasive hysteroscopic surgery.
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Stegwee SI, de Groot CJM, Lambalk CB, Huirne JAF. Authors' reply re: Uterine caesarean closure techniques affect ultrasound findings and long-term maternal outcomes: a systematic review and meta-analysis. BJOG 2019; 126:815-816. [PMID: 30788901 DOI: 10.1111/1471-0528.15601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Sanne I Stegwee
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Christianne J M de Groot
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Cornelis B Lambalk
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Judith A F Huirne
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
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Sholapurkar SL. Re: Uterine caesarean closure techniques affect ultrasound findings and long-term maternal outcomes: a systematic review and meta-analysis: Uterine caesarean closure techniques: more studies and critical thinking required during this simple operation. BJOG 2019; 126:814-815. [PMID: 30786136 DOI: 10.1111/1471-0528.15603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2018] [Indexed: 11/29/2022]
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Levin G, Rottenstreich A. Cesarean scar defect—A rising concern or a physiological healing process? Acta Obstet Gynecol Scand 2019; 98:1077. [DOI: 10.1111/aogs.13516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 12/04/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology Hadassah‐Hebrew University Medical Center Jerusalem Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology Hadassah‐Hebrew University Medical Center Jerusalem Israel
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Antila-Långsjö RM, Mäenpää JU, Huhtala HS, Tomás EI, Staff SM. Cesarean scar defect: a prospective study on risk factors. Am J Obstet Gynecol 2018; 219:458.e1-458.e8. [PMID: 30240650 DOI: 10.1016/j.ajog.2018.09.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/15/2018] [Accepted: 09/10/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cesarean scar defect (isthmocele) is a known complication after cesarean delivery. It has become more common due to a rising cesarean delivery rate. Isthmocele has been associated with various gynecological and obstetric problems such as uterine rupture, cesarean scar pregnancy, and bleeding disorders. OBJECTIVE We sought to prospectively investigate factors associated with the risk for isthmocele assessed by sonohysterography. STUDY DESIGN A prospective observational cohort study was conducted in 401 nonpregnant women who were recruited within 3 days of cesarean delivery. Women were evaluated with sonohysterography 6 months after cesarean delivery to detect a possible isthmocele. The ultrasonographer was blinded to any clinical information. The main outcome measure was the presence of isthmocele. Type of surgery (elective vs emergency), maternal background variables, and factors related to pregnancy, labor, and postoperative recovery were analyzed in relation to isthmocele. A logistic regression model was used to assess independent risk factors from univariate analysis. RESULTS In all, 371 women were examined with sonohysterography resulting in a follow-up rate of 92.5%. The prevalence of isthmocele was 45.6%. Independent risk factors for isthmocele development were a history of gestational diabetes (odds ratio, 1.73; 95% confidence interval, 1.02-2.92; P = .042), previous cesarean delivery (odds ratio, 3.14; 95% confidence interval, 1.90-5.17; P < .001), and advanced maternal body mass index (odds ratio, 1.06; 95% confidence interval, 1.01-1.11; P = .012). Every additional unit of body mass index increased the risk of isthmocele by 6%. In the subgroup of emergency cesarean delivery, longer duration of active labor increased the risk for isthmocele (odds ratio, 1.06; 95% confidence interval, 1.01-1.11; P = .032). There was no statistically significant difference in prevalence between the groups of elective and emergency cesarean delivery (P = .898). CONCLUSION Based on sonohysterographic examination, maternal body mass index, gestational diabetes, and previous cesarean deliveries are associated with an increased risk for incomplete healing of the uterine incision.
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Affiliation(s)
| | - Johanna U Mäenpää
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Heini S Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | | | - Synnöve M Staff
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland; BioMediTech, University of Tampere, Tampere, Finland
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Park IY, Kim MR, Lee HN, Gen Y, Kim MJ. Risk factors for Korean women to develop an isthmocele after a cesarean section. BMC Pregnancy Childbirth 2018; 18:162. [PMID: 29764452 PMCID: PMC5952596 DOI: 10.1186/s12884-018-1821-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The increase in number of cesarean section (CS) operations has resulted in an increase in cases of isthmocele development. The objective of this study is to determine the risk factors for isthmocele development after CS. METHODS Isthmocele measurements were taken for 404 women with a history of at least one low transverse CS. The following potential risk factors were investigated: patient's age at CS, cause of CS, weeks of gestation at CS, premature rupture of membrane (PROM), phase of labor, type suture (single/double layer), operation time, uterine flexion (anteversion/retroversion), and blood transfusion during operation. A transvaginal ultrasound was carried out to examine the isthmocele in the uterus after CS, including the shape of the isthmocele, residual myometrial thickness, depth and width of isthmocele, cervical thickness, location of the isthmocele, and clinical characteristics. RESULTS In our study population, the isthmocele had a prevalence of 73.8%. Most isthmocele had a triangular (65.4%) or semicircular shape (10.4%). The presence of an isthmocele was significantly associated with repeat CS, premature rupture of membrane (PROM), short operation time, and extent of cervix dilatation at CS. The risk of isthmocele was low in women who had placenta previa totalis (PPT), twin, a long operation time, or a transfusion during the operation. CONCLUSIONS In our study, isthmocele development was significantly associated with repeat CS, PROM, a short operation time, and the extent of cervix dilatation at CS. Therefore, PROM prevention and a more careful uterine closure are needed to reduce the risk of developing an isthmocele after CS.
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Affiliation(s)
- I Y Park
- Department of Obstetrics and Gynecology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - M R Kim
- Department of Obstetrics and Gynecology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - H N Lee
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea
| | - Y Gen
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea
| | - M J Kim
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea.
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Başbuğ A, Doğan O, Ellibeş Kaya A, Pulatoğlu Ç, Çağlar M. Does Suture Material Affect Uterine Scar Healing After Cesarean Section? Results from a Randomized Controlled Trial. J INVEST SURG 2018; 32:763-769. [DOI: 10.1080/08941939.2018.1458926] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Alper Başbuğ
- Department of Obstetrics and Gynecology, Duzce University Hospital, Duzce, Turkey
| | - Ozan Doğan
- Department of Obstetrics and Gynecology, Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey
| | - Aşkı Ellibeş Kaya
- Department of Obstetrics and Gynecology, Duzce University Hospital, Duzce, Turkey
| | - Çiğdem Pulatoğlu
- Department of Obstetrics and Gynecology, Bayburt Government Hospital, Bayburt, Turkey
| | - Mete Çağlar
- Department of Obstetrics and Gynecology, Akdeniz University Faculty of Medicine, Antalya, Turkey
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Evaluation of cesarean scar after single- and double-layer hysterotomy closure: a prospective cross-sectional study. Arch Gynecol Obstet 2018; 297:1137-1143. [DOI: 10.1007/s00404-018-4702-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/30/2018] [Indexed: 11/26/2022]
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Stegwee SI, Jordans I, van der Voet LF, van de Ven PM, Ket J, Lambalk CB, de Groot C, Hehenkamp W, Huirne J. Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta-analysis. BJOG 2018; 125:1097-1108. [PMID: 29215795 DOI: 10.1111/1471-0528.15048] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Caesarean section (CS) rates are rising globally. Long-term adverse outcomes after CS might be reduced when the optimal uterine closure technique becomes evident. OBJECTIVE To determine the effect of uterine closure techniques after CS on maternal and ultrasound outcomes. SEARCH STRATEGY Literature search in electronic databases. SELECTION CRITERIA Randomised controlled trials (RCTs) or prospective cohort studies that evaluated uterine closure techniques and reported on ultrasound findings, perioperative or long-term outcomes. DATA COLLECTION AND ANALYSIS Twenty studies (15 053 women) were included in our meta-analyses for various outcomes. We calculated pooled risk ratios (RR) and weighted mean differences (WMD) with 95% CI through random-effect analysis. MAIN RESULTS Residual myometrium thickness (RMT), reported in eight studies (508 women), decreased by 1.26 mm after single- compared with double-layer closure (95% CI -1.93 to -0.58), particularly when locked sutures were used. Healing ratio [RMT/adjacent myometrium thickness (AMT)] decreased after single-layer closure (WMD -7.74%, 95% CI -13.31 to -2.17), particularly in the case of locked sutures. Niche prevalence increased (RR 1.71, 95% CI 1.11-2.62) when the decidua was excluded. Dysmenorrhea occurred more often in the single-layer group (RR 1.23, 95% CI 1.01-1.48), whereas incidence of uterine rupture was similar (RR 1.91, 95% CI 0.63-5.74). CONCLUSION Double-layer unlocked sutures are preferable to single-layer locked sutures regarding RMT, healing ratio and dysmenorrhoea. Excluding the decidua seems to result in higher niche prevalence. As thin residual myometrium or niches may serve as intermediates for gynaecological and reproductive outcomes, future studies should focus on these outcomes. TWEETABLE ABSTRACT: #Uterineclosuretechniques after #caesarean affect #longtermoutcomes.
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Affiliation(s)
- S I Stegwee
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Ipm Jordans
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - L F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, the Netherlands
| | - P M van de Ven
- Department of Epidemiology and Biostatistics, VU University, Amsterdam, the Netherlands
| | - Jcf Ket
- Medical Library, VU University, Amsterdam, the Netherlands
| | - C B Lambalk
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Cjm de Groot
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Wjk Hehenkamp
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Jaf Huirne
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
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Abstract
Introduction: The increase in the percentage of the Cesarean sections has got an important place in determination of modern obstetrics. The evaluation of that needs actual, modern opinion for obstetrics and transformation actual obstetric science than investigating the best situation for the mother and child in the actual moment. All medical, organizational, economic and ethical capacities with support of modern diagnostic and therapeutic procedures present a reason for the access in modern obstetrics. It takes the descriptive and analytic method at work. In our country the percentage of the Caesarean section is 15% (according to WHO data), with large variations in frequency depending on the writer and the investigated time. Aim: To investigate the prevalence of Cesarean section in Bosnia and Herzegovina until 2017. Patients and Methods: In our investigation made prospective and target analysis is investigated at 2017 as a target year. Sources are: patient charts, notes and charts of new born. Group A presents number investigated patients with made Cesarean section in time at one year (2017) in General hospital „Prim.dr A.Nakaš“. Group B presents control group with identical number of deliveries with Cesarean section in 2007 in General hospital „Prim.dr A. Nakaš“ with all variables who detected in investigation group. Results: Analysis the number of deliveries finished Cesarean section in time from 2007 to 2017 in General hospital „Prim.dr Abdulah Nakaš “Sarajevo presents augmentation frequency from 15,5 % in 2007 year to 21,7 % in 2011; smaller number in 2012 to 20,3% and finally 22.9% in 2017 for all deliveries. Conclusion: Our investigation shows an important number of Cesarean section and is still working because of clearer obstetric indication but they make a vital indication for the mother and baby. It worries percent of poorly described indications, that are something important for the comfort of doctor and any patients that wants natural delivery. It worries the public because the more important short term and long-term unwanted effects; Cesarean delivery in correlation with augmentation of this operation.
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Affiliation(s)
- Nenad Miseljic
- General Hospital "Prim. dr. Abdulah Nakas", Sarajevo, Bosnia and Herzegovina
| | - Ejub Basic
- Department Ginecology, General Hospital «Prim.dr. Abdulah Nakas», Sarajevo, Bosnia and Herzegovina
| | - Sanja Miseljic
- Department for Cardiology, Clinic for Heart, Blood Vessel and Rheumatic Diseases. Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Woźniak A, Pyra K, Tinto HR, Woźniak S. Ultrasonographic criteria of cesarean scar defect evaluation. J Ultrason 2018; 18:162-165. [PMID: 30451411 PMCID: PMC6440514 DOI: 10.15557/jou.2018.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 04/16/2018] [Indexed: 11/22/2022] Open
Abstract
Cesarean sections account for approximately 20% of all deliveries worldwide. In Poland, the percentage of women delivering by cesarean section amounts to over 43%. According to studies, the prevalence of cesarean scar defects ranges from 24-70%. Due to the overall cesarean section rate, this is a medical problem affecting a large population of women. In such cases, ultrasonographic evaluation of a cesarean scar reveals a hypoechoic space filled with postmenstrual blood, representing a myometrial tear at the wound site. Such an ultrasound appearance is referred to as a niche, and it forms after a cesarean section at the site of the hysterotomy of the anterior uterine wall, most commonly within the uterine isthmus. Currently, the exact cause of niche formation remains unexplained, yet the risk factors for its development are universally acknowledged. They include the site of hysterotomy, multiple previous cesarean section deliveries, suturing technique and maternal diabetes or smoking. Ultrasound evaluation of the cesarean section scar is an important element of obstetric and gynecologic practice, especially in the case of further pregnancies. It facilitates an early diagnosis of a cesarean scar ectopic pregnancy, and the prediction of the risk for perinatal dehiscence in the case of a vaginal birth after a cesarean section.
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Affiliation(s)
- Andrzej Woźniak
- 3 Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - Krzysztof Pyra
- Surgical Radiology and Neuroradiology Unit, Medical University of Lublin, Lublin, Poland
| | - Hugo Rio Tinto
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Sławomir Woźniak
- 3 Department of Gynecology, Medical University of Lublin, Lublin, Poland
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Huirne JAF, Stegwee SI, van der Voet LF, de Groot CJM, Hehenkamp WJK, Brölmann HAM. Re: Risk of Cesarean scar defect following single- vs double-layer uterine closure. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:664-666. [PMID: 29105218 DOI: 10.1002/uog.18901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- J A F Huirne
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
| | - S I Stegwee
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
| | - L F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, Nico Bolkesteinlaan, 75, Deventer, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology and Research Institute Amsterdam Reproduction & Development, VU University Medical Center, Amsterdam, The Netherlands
| | - W J K Hehenkamp
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | - H A M Brölmann
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
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Bamberg C, Hinkson L, Dudenhausen JW, Bujak V, Kalache KD, Henrich W. Longitudinal transvaginal ultrasound evaluation of cesarean scar niche incidence and depth in the first two years after single- or double-layer uterotomy closure: a randomized controlled trial. Acta Obstet Gynecol Scand 2017; 96:1484-1489. [DOI: 10.1111/aogs.13213] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/15/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Christian Bamberg
- Department of Obstetrics; Charité-University Medical Center; Berlin Germany
| | - Larry Hinkson
- Department of Obstetrics; Charité-University Medical Center; Berlin Germany
| | | | - Verena Bujak
- Department of Obstetrics; Charité-University Medical Center; Berlin Germany
| | - Karim D. Kalache
- Department of Obstetrics; Charité-University Medical Center; Berlin Germany
| | - Wolfgang Henrich
- Department of Obstetrics; Charité-University Medical Center; Berlin Germany
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The minimally invasive approach to the symptomatic isthmocele – what does the literature say? A step-by-step primer on laparoscopic isthmocele – excision and repair. Curr Opin Obstet Gynecol 2017; 29:257-265. [DOI: 10.1097/gco.0000000000000380] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vachon-Marceau C, Demers S, Bujold E, Roberge S, Gauthier RJ, Pasquier JC, Girard M, Chaillet N, Boulvain M, Jastrow N. Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy. Am J Obstet Gynecol 2017; 217:65.e1-65.e5. [PMID: 28263751 DOI: 10.1016/j.ajog.2017.02.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/11/2017] [Accepted: 02/24/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uterine rupture is a potential life-threatening complication during a trial of labor after cesarean delivery. Single-layer closure of the uterus at cesarean delivery has been associated with an increased risk of uterine rupture compared with double-layer closure. Lower uterine segment thickness measurement by ultrasound has been used to evaluate the quality of the uterine scar after cesarean delivery and is associated with the risk of uterine rupture. OBJECTIVE To estimate the impact of previous uterine closure on lower uterine segment thickness. STUDY DESIGN Women with a previous single low-transverse cesarean delivery were recruited at 34-38 weeks' gestation. Transabdominal and transvaginal ultrasound evaluation of the lower uterine segment thickness was performed by a sonographer blinded to clinical data. Previous operative reports were reviewed to obtain the type of previous uterine closure. Third-trimester lower uterine segment thickness at the next pregnancy was compared according to the number of layers sutured and according to the type of thread for uterine closure, using weighted mean differences and multivariate logistic regression analyses. RESULTS Of 1613 women recruited, with operative reports available, 495 (31%) had a single-layer and 1118 (69%) had a double-layer closure. The mean third-trimester lower uterine segment thickness was 3.3 ± 1.3 mm and the proportion with lower uterine segment thickness <2.0 mm was 10.5%. Double-layer closure of the uterus was associated with a thicker lower uterine segment than single-layer closure (weighted mean difference: 0.11 mm; 95% confidence interval [CI], 0.02 to 0.21 mm). In multivariate logistic regression analyses, a double-layer closure also was associated with a reduced risk of lower uterine segment thickness <2.0 mm (odd ratio [OR], 0.68; 95% CI, 0.51 to 0.90). Compared with synthetic thread, the use of catgut for uterine closure had no significant impact on third-trimester lower uterine segment thickness (WMD: -0.10 mm; 95% CI, -0.22 to 0.02 mm) or on the risk of lower uterine segment thickness <2.0 mm (OR, 0.95; 95% CI, 0.67 to 1.33). Finally, double-layer closure was associated with a reduced risk of uterine scar defect (RR, 0.32; 95% CI, 0.17 to 0.61) at birth. CONCLUSION Compared with single-layer closure, a double-layer closure of the uterus at previous cesarean delivery is associated with a thicker third-trimester lower uterine segment and a reduced risk of lower uterine segment thickness <2.0 mm in the next pregnancy. The type of thread for uterine closure has no significant impact on lower uterine segment thickness.
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Fujimoto A, Morimoto C, Hosokawa Y, Hasegawa A. Suturing method as a factor for uterine vascularity after laparoscopic myomectomy. Eur J Obstet Gynecol Reprod Biol 2017; 211:146-149. [PMID: 28260688 DOI: 10.1016/j.ejogrb.2017.02.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/25/2017] [Accepted: 02/26/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the vascularity of the myometrium after laparoscopic myomectomy sutured by two different methods using contrast-enhanced Magnetic Resonance Imaging. STUDY DESIGN Twenty-eight women who had symptomatic leiomyomas and underwent laparoscopic myomectomy between June 2013 and July 2014 were included in the present study. In the first half period, continuous sutures were used in 12 patients, and in the latter half period, single interrupted sutures were used in 16 patients. Contrast-enhanced Magnetic Resonance Imaging was used 3 or 6 months after surgery to evaluate vascularity after laparoscopic myomectomy. We defined avascularity index as the percentage of avascular area after surgery to cross sectional area of myoma before surgery. The Wilcoxon rank-sum test was applied to compare avascularity indeces in the two study groups. RESULTS At 3 months after surgery, avascularity index in continuous sutures group was significantly higher than that in single interrupted sutures group (median 5.0 vs.1.2, p<0.001), suggesting a poorer vascular recovery of the myometrium sutured continuously. CONCLUSION Simple interrupted suturing might be superior to continuous suturing in terms of vascularity evaluated using contrast enhanced Magnetic Resonance Imaging.
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Affiliation(s)
- Akihisa Fujimoto
- Department of Obstetrics and Gynecology, Sanraku Hospital, Tokyo, Japan.
| | - Chieko Morimoto
- Department of Obstetrics and Gynecology, Sanraku Hospital, Tokyo, Japan
| | - Yumi Hosokawa
- Department of Obstetrics and Gynecology, Sanraku Hospital, Tokyo, Japan
| | - Akiko Hasegawa
- Department of Obstetrics and Gynecology, Sanraku Hospital, Tokyo, Japan
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Roberge S, Demers S, Bujold E. Reply. Am J Obstet Gynecol 2017; 216:83-84. [PMID: 27521466 DOI: 10.1016/j.ajog.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
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Defect width: the prognostic index for vaginal repair of cesarean section diverticula. Arch Gynecol Obstet 2016; 295:623-630. [PMID: 27885429 DOI: 10.1007/s00404-016-4245-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the clinical parameter associated with cesarean section diverticula anatomic healing via vaginal repair management. METHODS Observational cohort study. From Jul 2014 to Dec 2015, 143 women with CSD underwent vaginal repair surgery in Shanghai First Maternity and Infant Hospital, and 137(95.80%) were diagnosed using both transvaginal ultrasound and MRI. A total of 124 patients (86.71%) who were followed-up for more than 6 months after surgery were enrolled in this study. Excision and suture of CSD was performed through the vaginal approach. The defect sizes of the width, length, depth and TRM before or after repair were evaluated. RESULTS The mean preoperative duration of menstruation was 14.47 ± 3.30 days and the thickness of the remaining muscular layer was 2.65 ± 1.13 mm before surgery. The study revealed that the healing effects of CSD repair stabilized 3 months after surgery. At the median follow-up time (11.28 months), CSD disappeared after surgery in 64.52% of patients (80/124), and 60.0% of patients (48/80) reached ≤7 days of menstruation. Meanwhile, for 35.48% of patients (44/124), CSD persisted at the median follow-up after surgery, and 31.82% (14/44) of these patients reached ≤7 days of menstruation(P < 0.05). TRM at a median follow-up time after vaginal repair >7.88 mm, 92.11% (70/76) of CSD disappeared. Moreover, when preoperative CSD width ≤18.85 mm indicates that only 18.75% (12/64) of patients will present with CSD after vaginal repair, as determined by MRI (95% CI 0.515-0.737). CONCLUSION The defect width of the preoperative CSD was the prognostic index of CSD anatomical repair effect. When the preoperative CSD width >18.85 mm, we should pay more attention to the edge of the defect during vaginal repairing.
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Kataoka S, Tanuma F, Iwaki Y, Iwaki K, Fujii T, Fujimoto T. Comparison of the primary cesarean hysterotomy scars after single- and double-layer interrupted closure. Acta Obstet Gynecol Scand 2016; 95:1352-1358. [PMID: 27617416 DOI: 10.1111/aogs.13015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 09/06/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION It is unclear whether hysterotomy closure techniques can affect niche development. Therefore, this study aimed to analyze the effect of single-layer and double-layer interrupted closures of hysterotomy incisions during primary cesarean section on the formation of uterine niches. MATERIAL AND METHODS A prospective cohort study of women undergoing primary cesarean section was performed between June 2011 and July 2014. Saline contrast sonohysterography was used to measure the niche depth and residual myometrium. The ratio of the niche depth to the sum of the niche depth and residual myometrium thickness (niche ratio) was calculated. RESULTS Niches were identified in 14/58 (24.1%) women with single-layer sutures and 55/209 (26.3%) women with double-layer sutures (p = 0.74). Single-layer closure was associated with more than a five-fold increase in the odds of a niche ratio ≥0.4 (odds ratio 5.59; 95% CI 1.71-18.28). CONCLUSION Single-layer closure may be associated with an increased risk of larger niches (niche ratio ≥0.4), although it may not increase the overall frequency of niche formation.
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Affiliation(s)
- Soromon Kataoka
- Department of Obstetrics and Gynecology, Hakodate Central General Hospital, Hakodate, Japan
| | - Fumie Tanuma
- Department of Obstetrics and Gynecology, Hakodate Central General Hospital, Hakodate, Japan
| | - Yutaka Iwaki
- Department of Obstetrics and Gynecology, Hakodate Central General Hospital, Hakodate, Japan
| | - Kurumi Iwaki
- Department of Obstetrics and Gynecology, Hakodate Central General Hospital, Hakodate, Japan
| | - Takeru Fujii
- Department of Obstetrics and Gynecology, Hakodate Central General Hospital, Hakodate, Japan
| | - Toshio Fujimoto
- Department of Obstetrics and Gynecology, Hakodate Central General Hospital, Hakodate, Japan
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Emerging Manifestations of Cesarean Scar Defect in Reproductive-aged Women. J Minim Invasive Gynecol 2016; 23:893-902. [DOI: 10.1016/j.jmig.2016.06.020] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/11/2016] [Accepted: 06/29/2016] [Indexed: 11/17/2022]
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Standardized ultrasonographic approach for the assessment of risk factors of incomplete healing of the cesarean section scar in the uterus. Eur J Obstet Gynecol Reprod Biol 2016; 205:141-5. [PMID: 27591715 DOI: 10.1016/j.ejogrb.2016.08.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/08/2016] [Accepted: 08/13/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify factors related to the healing of a Cesarean uterine incision using the standardized ultrasonographic approach of scar assessment in the non-pregnant uterus. STUDY DESIGN Measurements of the uterine scar were taken from 409 women with a history of at least one low transverse cesarean section (CS) with a single layer uterine closure. Residual myometrial thickness (RMT), width (W) and depth (D) of the triangular hypoechoic scar niche, D/RMT ratio and clinical characteristics were analyzed. For statistical analysis, the Mann-Whitney U test, chi-square test, Spearman's rank correlation coefficient, ANOVA test, and logistic regression were used. RESULTS 268 women presented with a scar defect. RMT values were significantly correlated with the number of CSs (R=-0.17) and uterus retroflection (R=-0.15). The presence of a scar defect was significantly associated with lower RMT values (R=-0.33), greater gestational age (R=0.10), and younger maternal age (R=-0.11). The mean RMT value was significantly smaller in women with CSs performed in the second stage of labor (0.62) when compared to women with CSs in the first stage of labor (0.97) or without cervical dilatation (0.91). CONCLUSION A standardized approach of CS scar assessment in the non-pregnant uterus helps to identify women at risk of long-term complications of CS.
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Roberge S, Demers S, Girard M, Vikhareva O, Markey S, Chaillet N, Moore L, Paris G, Bujold E. Impact of uterine closure on residual myometrial thickness after cesarean: a randomized controlled trial. Am J Obstet Gynecol 2016; 214:507.e1-507.e6. [PMID: 26522861 DOI: 10.1016/j.ajog.2015.10.916] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 10/21/2015] [Accepted: 10/23/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Incomplete healing of uterine scar after cesarean has been associated with adverse gynecological and obstetrical outcomes. Several studies reported that uterine closure at cesarean influences the healing of uterine scar and the risk of uterine rupture at subsequent pregnancies: the commonly used locked single-layer suture including the decidua being associated with a 4-fold increased risk of uterine rupture. However, data from randomized trials are lacking. OBJECTIVE We sought to evaluate the impact of 3 techniques of uterine closure after cesarean delivery on uterine scar healing. STUDY DESIGN This was a 3-arm 1:1:1 randomized study in women with singleton pregnancies undergoing elective primary cesarean delivery at ≥38 weeks' gestation. Closure of the uterine scar was carried out by locked single layer including the decidua, double layer with locked first layer including the decidua, or double layer with unlocked first layer excluding the decidua. Primary outcome was residual myometrial thickness (RMT) at the site of the scar, measured by transvaginal ultrasound 6 months after delivery. Secondary outcome was the RMT as a percentage of the myometrial thickness above the scar (healing ratio). Intent-to-treat analyses using Student t test were performed to compare each double-layer technique to the single-layer closure, and P < .025 was considered significant. RESULTS Complete follow-up was obtained from 73 (90%) of the 81 participants. Compared to single-layer closure, double-layer closure with unlocked first layer was associated with thicker RMT (3.8 ± 1.6 mm vs 6.1 ± 2.2 mm; P < .001) and greater healing ratio (54 ± 20% vs 73 ± 23%; P = .004). In contrast, double-layer closure with locked first layer was not significantly different than single-layer closure in either RMT (4.8 ± 1.3; P = .032) or healing ratio (60 ± 21%; P = .287). CONCLUSION Double-layer closure with unlocked first layer is associated with better uterine scar healing than locked single layer.
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Masuda H, Uchida H, Maruyama T, Sato K, Sato S, Tanaka M. Successful treatment of atypical cesarean scar defect using endoscopic surgery. BMC Pregnancy Childbirth 2015; 15:342. [PMID: 26696492 PMCID: PMC4687144 DOI: 10.1186/s12884-015-0730-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/04/2015] [Indexed: 11/23/2022] Open
Abstract
Background Cesarean scar syndrome results from a postoperative defect of the uterine isthmus, also known as an isthmocele. Patients present with gynecological symptoms, such as abnormal genital bleeding or infertility, after cesarean delivery. Although the cesarean rate is increasing worldwide, this syndrome is not widely known. Case presentation A 43-year-old G2P1 Japanese woman with atypical cesarean scar syndrome had a 3-year history of secondary infertility and postmenstrual brown discharge. Laparoscopic and hysteroscopic exploration revealed a cesarean scar defect connected to a small cavity in the myometrium: this was not an endometrial cavity or a uterine diverticulum. After endoscopic excision of the cavity, the brown discharge resolved, and the patient achieved ongoing pregnancy on her third attempt at intrauterine insemination. Conclusion Consensus is still lacking regarding the diagnosis and treatment of cesarean scar defect. However, the gynecologists should be aware that cesarean scar syndrome can have scar defects forming cavities of unusual shapes and features. Surgical correction of these defects will often improve postmenstrual bleeding and subfertility in these cases.
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Affiliation(s)
- Hirotaka Masuda
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Hiroshi Uchida
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Tetsuo Maruyama
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Kenji Sato
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Suguru Sato
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Mamoru Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
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Previous prelabor or intrapartum cesarean delivery and risk of placenta previa. Am J Obstet Gynecol 2015; 212:669.e1-6. [PMID: 25576818 DOI: 10.1016/j.ajog.2015.01.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 12/21/2014] [Accepted: 01/05/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the association between previous cesarean delivery and subsequent placenta previa while distinguishing cesarean delivery before the onset of labor from intrapartum cesarean delivery. STUDY DESIGN We conducted a retrospective cohort study of electronic medical records from 20 Utah hospitals (2002-2010) with restriction to the first 2 singleton deliveries of nulliparous women at study entry (n=26,987). First pregnancy delivery mode was classified as (1) vaginal (reference), (2) cesarean delivery before labor onset (prelabor), or (3) cesarean delivery after labor onset (intrapartum). Risk of second delivery previa was estimated by previous delivery mode with the use of logistic regression and was adjusted for maternal age, insurance, smoking, comorbidities, previous pregnancy loss, and history of previa. RESULTS Most first deliveries were vaginal (82%; n=22,142), followed by intrapartum cesarean delivery (14.6%; n=3931), or prelabor cesarean delivery (3.4%; n=914). Incidence of second delivery previa was 0.29% (n=78) and differed by previous delivery mode: vaginal, 0.24%; prelabor cesarean delivery, 0.98%; intrapartum cesarean delivery, 0.38% (P<.001). Relative to vaginal delivery, previous prelabor cesarean delivery was associated with an increased risk of second delivery previa (adjusted odds ratio, 2.62; 95% confidence interval, 1.24-5.56). There was no significant association between previous intrapartum cesarean delivery and previa (adjusted odds ratio, 1.22; 95% confidence interval, 0.68-2.19). CONCLUSION Previous prelabor cesarean delivery was associated with a >2-fold significantly increased risk of previa in the second delivery, although the approximately 20% increased risk of previa that was associated with previous intrapartum cesarean delivery was not significant. Although rare, the increased risk of placenta previa after previous prelabor cesarean delivery may be important when considering nonmedically indicated prelabor cesarean delivery.
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