Clinical outcomes of hysteroscopy-assisted transvaginal repair of cesarean scar defect

A Prediction Model for the Efficacy of Transvaginal Repair in Patients With Cesarean Scar Defect: An Evidence-Based Proposal for Patient Selection

STUDY OBJECTIVE

To establish a prediction model to help doctors determine which patients with cesarean scar defect are more suitable for transvaginal repair.

DESIGN

Retrospective analysis.

SETTING

Xinhua Hospital and Shanghai First Maternity & Infant Hospital between June 2014 and May 2021.

PATIENTS

1015 women who underwent transvaginal repair of cesarean scar defect (CSD).

INTERVENTIONS

All enrolled patients underwent CSD repair performed by the same gynecologist and his team. And followed up a clinic visit at 6 months to record their menstruation and measure multiple parameters of the CSD by Magnetic Resonance Imaging.

MAIN OUTCOMES AND MEASURES

CSD patients are categorized as optimal healing group when the menstruation duration is no more than 7 days, meanwhile the thickness of residual myometrium is no less than 5.39 mm after vaginal repair. The final nomogram is constructed to predict surgical outcomes based on preoperative variables.

RESULTS

The key factors that determine optimal healing are the timing of cesarean section (elective or emergency), menstrual cycle, CSD length, width, depth, and the thickness of the lower uterine segment. With the prediction model, scores are given to each parameter according to the statistics. Total scores range from 0 to 25 points, with a cutoff point of 16.5. When a score is greater than 16.5, the transvaginal repair can achieve optimal healing. Uterine position (anteflexion or retroflexion) and preoperative thickness of residual myometrium are the key factors affecting postoperative thickness of residual myometrium. The width of the CSD and the thickness of the lower uterine segment are the key factors affecting abnormal uterine bleeding symptoms (p < 0.01).

CONCLUSIONS

For the first time, we established a prediction model system that may predict the repair effect of CSD and can potentially be useful in future clinical trials to determine which patients are more suitable for surgery or other treatment options.

Cesarean scar niche, fertility and uterine rupture during labor - A retrospective study

OBJECTIVES

To determine how does a uterine niche diagnosed prior to conception, affects future fertility and obstetrical outcomes, in a group of patients with secondary infertility undergoing fertility treatments.

STUDY DESIGN

A retrospective case-control study was performed, recruiting patients after cesarean delivery, before fertility treatment. Using stored ultrasound photos and video loops, we determined niche's sonographic parameters during the preconception period and retrieved the fertility and obstetrical outcomes thereafter.

RESULTS

104 patients met the inclusion criteria, and 86 were available for analysis. 56 (65%) had uterine niches larger than 2 mm in depth, and 30 (34%) had a uterine scar of 2 mm or less. Demographic characteristics were not different between groups. No statistically significant differences were observed regarding rates of implantation and clinical pregnancy between the groups. There were four cases of cesarean scar rupture during failed trial of labor (TOLAC), all of which were in the group with larger than 2 mm niche (33% of all TOLAC cases in the respected group).

CONCLUSIONS

While it appears that pre-conception presence of uterine niches larger than 2 mm in depth does not adversely affect future fertility, these niches might serve as a risk factor for future uterine rupture during TOLAC.

Comparative effectiveness of transvaginal repair vs. hysteroscopic resection in patients with symptomatic uterine niche

Objective

To compare the efficacy of transvaginal repair and hysteroscopic resection in improving niche associated postmenstrual spotting.

Methods

The improvement rate of postmenstrual spotting in women who underwent transvaginal repair or hysteroscopic resection treatment was assessed retrospectively in patients accepted at the Niche Sub-Specialty Clinic in International Peace Maternity and Child Health Hospital between June 2017 and June 2019. Postoperative spotting symptom within one year after surgery, pre- and postoperative anatomical indicators, women' satisfaction with menstruation and other perioperative parameters were compared between the two groups.

Results

68 patients in the transvaginal group and 70 patients in the hysteroscopic group were included for analysis. The improvement rate of postmenstrual spotting in the transvaginal group at the 3rd, 6th, 9th, and 12th months after surgery was 87%, 88%, 84%, and 85%, significantly higher than 61%, 68%, 66%, and 68% in the hysteroscopic group, respectively (P < 0.05). The total days of spotting improved significantly at the 3rd month after surgery but did not change over time within one year in each group (P > 0.05). After surgery, the disappearance rates of the niche are 68% in transvaginal group and 38% in hysteroscopic group, however, hysteroscopic resection had shorter operative time and hospitalization duration, less complications, and lower hospitalization costs.

Conclusion

Both treatments can improve the spotting symptom and anatomical structures of uterine lower segments with niches. Transvaginal repair is better in thickening the residual myometrium than hysteroscopic resection, however, hysteroscopic resection has shorter operative time and hospitalization duration, less complications, and lower hospitalization costs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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