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Chen H, Yao M, Gao Z, Yang X, Wang Y, Wang X. Outcomes of Vaginal Repair and Vaginal Repair Combined With GnRHa Administration in the Treatment of Cesarean Section Scar Defects: A Randomized Clinical Trial. J Minim Invasive Gynecol 2024; 31:787-794.e1. [PMID: 38810836 DOI: 10.1016/j.jmig.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
STUDY OBJECTIVE To prospectively investigate whether the application of vaginal repair (VR) of cesarean section scar defect (CSD) combined with a gonadotropin-releasing hormone agonist (GnRHa) achieve better clinical outcomes than VR alone. DESIGN A randomized clinical trial. SETTING University Hospital. PATIENTS A total of 124 women with CSD were undergoing expectant management from December 2016 to September 2021. 61 were randomized to VR+ GnRHa and 63 to VR alone. INTERVENTION Vaginal repair combined with GnRHa and vaginal repair alone. MEASURES AND MAIN RESULTS The primary outcome was the duration of menstruation and thickness of the remaining muscular layer (TRM) at 6 months after surgery. Secondary outcomes included the length, width, and depth of the CSD; operation time; estimated blood loss; hospitalization time; and operative complications. Women were treated with either VR (n = 63) or VR + GnRHa (n = 61). Menstruation and TRM in patients pre vs post comparisons either with VR or VR + GnRHa are significantly improved (p <.05). Significant differences in menstruation duration and TRM occurred in patients treated with VR + GnRHa compared with those treated with VR (p <.05). Moreover, the rate of CSD after surgery in the VR group was significantly higher than that in the VR + GnRHa group (p = .033), and CSD patients in the VR + GnRHa group achieved better therapeutic effects than those in the VR group (p = .017). Patients who received VR + GnRHa had a shorter menstruation duration and a greater increment of TRM postoperatively than patients treated with VR alone (p = .021; p = .002, respectively). CONCLUSION VR + GnRHa therapy has a greater potential to improve scar healing and reduce the number of menstruation days than VR alone for symptomatic women with CSD.
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Affiliation(s)
- Huihui Chen
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine (Chen, Yao, Gao, Wang and Wang), Shanghai, China
| | - Min Yao
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine (Chen, Yao, Gao, Wang and Wang), Shanghai, China
| | - Zhenyan Gao
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine (Chen, Yao, Gao, Wang and Wang), Shanghai, China
| | - Xiaoqian Yang
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine (Yang and Wang), Shanghai, China
| | - Yizhi Wang
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine (Chen, Yao, Gao, Wang and Wang), Shanghai, China; Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine (Yang and Wang), Shanghai, China
| | - Xipeng Wang
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine (Chen, Yao, Gao, Wang and Wang), Shanghai, China.
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Xu XJ, Jia JX, Sang ZQ, Li L. Association of caesarean scar defect with risk of abnormal uterine bleeding: results from meta-analysis. BMC Womens Health 2024; 24:432. [PMID: 39075427 PMCID: PMC11285571 DOI: 10.1186/s12905-024-03198-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 06/10/2024] [Indexed: 07/31/2024] Open
Abstract
OBJECTIVE To investigate the association between caesarean scar defects and abnormal uterine bleeding through systematic literature review. METHODS PubMed, Web of Science, Cochrane Library and Embase databases were searched based on PRISMA 2020 to include studies exploring abnormal uterine bleeding in women with caesarean scar defects. The combined relative risk (RR) of uterine bleeding, combined prevalence of abnormal uterine bleeding and combined RR of intermenstrual uterine bleeding were calculated using a fixed- or random-effects model. RESULTS Ten studies involving 1,183 women with caesarean scar defects met the inclusion criteria for this study. Compared with women without caesarean scar defects, those with caesarean scar defects had a higher risk of abnormal uterine bleeding (RR: 3.22, 95% CI: 1.83-5.66) and intermenstrual bleeding (RR: 2.93, 95% CI: 1.91-4.50). The prevalence of abnormal uterine bleeding was approximately 0.46 (95% CI: 0.27-0.64), and across populations, women with a previous caesarean section who had undergone imaging specifically for gynaecological disease had a significantly higher prevalence of abnormal uterine bleeding (0.77, 95% CI: 0.65-0.89) than those with at least one caesarean Sect. (0.25, 95% CI: 0.10-0.39). CONCLUSION A significant association was observed between caesarean scar defects and abnormal uterine bleeding, with the former being a risk factor for the latter. However, previous studies have differed in the definition of caesarean scar defects and abnormal uterine bleeding, and more high-quality studies are needed to further investigate the relevant definitions and study results in the future.
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Affiliation(s)
- Xiao-Jing Xu
- Hubei Minzu University, Enshi, Hubei, 445000, China
| | - Jing-Xing Jia
- Department of Obstetrics, Minda Hospital of Hubei Minzu University, No.2 of Wufengshan Road, Tuqiao Road, Enshi, Hubei, 445000, China
| | - Zi-Qiong Sang
- Department of Obstetrics, Minda Hospital of Hubei Minzu University, No.2 of Wufengshan Road, Tuqiao Road, Enshi, Hubei, 445000, China
| | - Li Li
- Department of Obstetrics, Minda Hospital of Hubei Minzu University, No.2 of Wufengshan Road, Tuqiao Road, Enshi, Hubei, 445000, China.
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Maki J, Mitoma T, Ooba H, Nakato H, Mishima S, Tani K, Eto E, Yamamoto D, Yamamoto R, Kai K, Tamada T, Akamatsu K, Kawanishi K, Masuyama H. Barbed vs conventional sutures for cesarean uterine scar defects: a randomized clinical trial. Am J Obstet Gynecol MFM 2024; 6:101431. [PMID: 39019212 DOI: 10.1016/j.ajogmf.2024.101431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/08/2024] [Accepted: 06/15/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND The role of barbed sutures in preventing myometrial defects and enhancing postpartum outcomes after cesarean section (C-section) is uncertain. OBJECTIVE This study compared clinical and ultrasonographic outcomes of uterine scar defects after C-section with barbed and conventional smooth thread sutures. STUDY DESIGN This was a multicenter, parallel-group, randomized, controlled clinical trial. Four obstetrics and gynecology departments across three Japanese healthcare regions were included. The participants were women requiring their first cesarean delivery between May 2020 and March 2023. Of the 1211 participants enrolled, 298 underwent C-section and 253 were followed up until July 2023. Participants with singleton pregnancies were randomly assigned (1:1 ratio) to receive either conventional or spiral thread sutures with a double-layer continuous suture. The study period comprised the time of consent to the 6- to 7-month examination. The primary endpoint was the rate of scar niches >2 mm evaluated using transvaginal ultrasonography at 6 to 7 months after surgery. Additional metrics included the total operative time, suture application time, operative blood loss, number of additional sutures required for hemostasis, maternal surgical complications, postoperative infections, surgeon's years of experience, and individual subscale scores. RESULTS All data of the 220 participants (barbed suture group: 110; conventional suture group: 110) were available, thus enabling a full analysis set. A comparison of the barbed and conventional suture groups, respectively, revealed the following: niche length, 2.45±1.65 mm (range: 1.0-6.7) vs 3.79±1.84 mm (range: 1.0-11.0) (P<.001); niche depth, 1.78±1.07 mm (range: 1.0-5.7) vs 2.70±1.34 mm (range: 1.0-7.3) (P<.001); residual myometrial thickness (RMT), 8.46±1.74 mm (range: 4.8-13.0) vs 7.07±2.186 mm (range: 2.2-16.2) (P<.001); and niche width, 1.58±2.73 mm (range: 0.0-14.0) vs 2.88±2.36 mm (range: 0.0-11.0) (P<.001), respectively. The barbed suture group exhibited no defects and an RMT <3 mm. Furthermore, the barbed suture group had a lower rate of uterine niches (29.1%; n=32/110) than the conventional suture group (68.2%; n=75/110). Secondary outcomes showed no significant differences in operative times, maternal surgical complications, or postoperative complications. CONCLUSION Double-layer barbed sutures during cesarean delivery may prevent C-section scar defects and postoperative complications.
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Affiliation(s)
- Jota Maki
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (Maki, Mitoma, Ooba, Nakato, Mishima, Tani, Eto, and Masuyama), Kita-ku, Okayama, Japan.
| | - Tomohiro Mitoma
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (Maki, Mitoma, Ooba, Nakato, Mishima, Tani, Eto, and Masuyama), Kita-ku, Okayama, Japan
| | - Hikaru Ooba
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (Maki, Mitoma, Ooba, Nakato, Mishima, Tani, Eto, and Masuyama), Kita-ku, Okayama, Japan
| | - Hikari Nakato
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (Maki, Mitoma, Ooba, Nakato, Mishima, Tani, Eto, and Masuyama), Kita-ku, Okayama, Japan
| | - Sakurako Mishima
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (Maki, Mitoma, Ooba, Nakato, Mishima, Tani, Eto, and Masuyama), Kita-ku, Okayama, Japan
| | - Kazumasa Tani
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (Maki, Mitoma, Ooba, Nakato, Mishima, Tani, Eto, and Masuyama), Kita-ku, Okayama, Japan
| | - Eriko Eto
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (Maki, Mitoma, Ooba, Nakato, Mishima, Tani, Eto, and Masuyama), Kita-ku, Okayama, Japan
| | - Dan Yamamoto
- Department of Obstetrics and Gynecology, National Hospital Organization Fukuyama Medical Center (Yamamoto, Yamamoto, and Kai), Fukuyama City, Hiroshima, Japan
| | - Risa Yamamoto
- Department of Obstetrics and Gynecology, National Hospital Organization Fukuyama Medical Center (Yamamoto, Yamamoto, and Kai), Fukuyama City, Hiroshima, Japan
| | - Kenji Kai
- Department of Obstetrics and Gynecology, National Hospital Organization Fukuyama Medical Center (Yamamoto, Yamamoto, and Kai), Fukuyama City, Hiroshima, Japan
| | - Takashi Tamada
- Department of Obstetrics and Gynecology, Iguchi Perinatal and Obstetrics and Gynecology Hospital (Tamada and Akamatsu), Fukuyama City, Hiroshima, Japan
| | - Kazuyo Akamatsu
- Department of Obstetrics and Gynecology, Iguchi Perinatal and Obstetrics and Gynecology Hospital (Tamada and Akamatsu), Fukuyama City, Hiroshima, Japan
| | - Kunihiro Kawanishi
- Department of Obstetrics and Gynecology, Yashima General Hospital (Kawanishi), Takamatsu City, Kagawa, Japan
| | - Hisashi Masuyama
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (Maki, Mitoma, Ooba, Nakato, Mishima, Tani, Eto, and Masuyama), Kita-ku, Okayama, Japan
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Kellner H, Horky A, Louwen F, Bahlmann F, Al Naimi A. The association between gynecological complaints and the uterine sonographic features in women with a history of cesarean section. Arch Gynecol Obstet 2024; 310:485-491. [PMID: 38695973 PMCID: PMC11169038 DOI: 10.1007/s00404-024-07526-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 04/19/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE The aim of this study is to investigate the association between post-cesarean sonographic uterine measures, dysmenorrhea, and bleeding disorders. METHODS This is a cross-sectional study where 500 women with a history of only one cesarean section (CS) were recruited. A transvaginal transducer, GE RIC6-12-D was used for the acquisition of volumetric datasets 18 ± 7 months postpartum. Uterine length (UL), cervical length (CL), niche length (L), niche depth (D), niche width (W), fibrosis length (FL), fibrosis depth (FD), residual myometrial thickness (RMT), endometrial thickness (EM), scar to internal os distance (SO), anterior myometrial thickness superior (sAMT) and inferior (iAMT) to the scar, and the posterior myometrial thickness opposite the scar (PMT), superior (sPMT), and inferior to it (iPMT) were measured. Logistic regression with odds ratios (OR), 95% confidence intervals (CI) and ROC curves were utilized. RESULTS The proportion of patients with incident post-cesarean bleeding disorders and dysmenorrhoea was 36% (CI 32%, 40%) and 17% (CI 14%, 21%) respectively. Univariate logistic regression showed that only UL was associated with bleeding disorders [OR 1.04 (CI 1.01,10.7) p value 0.005], whereas dysmenorrhea was associated with RMT [OR 0.82 (CI 0.71,0.95) p value 0.008], SO [OR 0.91 (CI 0.86,0.98) p value 0.01], and RMT ratio [OR 0.98 (CI 0.97,0.99) p value 0.03]. Multivariate logistic regression for dysmenorrhoea including SO and RMT remains statistically significant with p values <0.05 and area under the curve of 0.66. CONCLUSION There is an association between sonographic appearance of CS scars and dysmenorrhoea. Nevertheless, the association is weak and other biological post-cesarean characteristics should be explored as potential causes.
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Affiliation(s)
- Helen Kellner
- Department of Obstetrics and Prenatal Medicine, University Hospital of the Goethe University of Frankfurt, Hessen, Germany
| | - Alex Horky
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenberg Foundation, Nibelungenallee 37-41, D-60318, Frankfurt Am Main, Hessen, Germany
| | - Frank Louwen
- Department of Obstetrics and Prenatal Medicine, University Hospital of the Goethe University of Frankfurt, Hessen, Germany
| | - Franz Bahlmann
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenberg Foundation, Nibelungenallee 37-41, D-60318, Frankfurt Am Main, Hessen, Germany
| | - Ammar Al Naimi
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenberg Foundation, Nibelungenallee 37-41, D-60318, Frankfurt Am Main, Hessen, Germany.
- Department of Obstetrics and Prenatal Medicine, University Hospital of the Goethe University of Frankfurt, Hessen, Germany.
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Zhou X, Gao Z, Chen H, Wang Y, Yin Y, Zhang J, Wang X. A Prediction Model for the Efficacy of Transvaginal Repair in Patients With Cesarean Scar Defect: An Evidence-Based Proposal for Patient Selection. J Minim Invasive Gynecol 2024; 31:213-220. [PMID: 38135001 DOI: 10.1016/j.jmig.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 11/24/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
STUDY OBJECTIVE To establish a prediction model to help doctors determine which patients with cesarean scar defect are more suitable for transvaginal repair. DESIGN Retrospective analysis. SETTING Xinhua Hospital and Shanghai First Maternity & Infant Hospital between June 2014 and May 2021. PATIENTS 1015 women who underwent transvaginal repair of cesarean scar defect (CSD). INTERVENTIONS All enrolled patients underwent CSD repair performed by the same gynecologist and his team. And followed up a clinic visit at 6 months to record their menstruation and measure multiple parameters of the CSD by Magnetic Resonance Imaging. MAIN OUTCOMES AND MEASURES CSD patients are categorized as optimal healing group when the menstruation duration is no more than 7 days, meanwhile the thickness of residual myometrium is no less than 5.39 mm after vaginal repair. The final nomogram is constructed to predict surgical outcomes based on preoperative variables. RESULTS The key factors that determine optimal healing are the timing of cesarean section (elective or emergency), menstrual cycle, CSD length, width, depth, and the thickness of the lower uterine segment. With the prediction model, scores are given to each parameter according to the statistics. Total scores range from 0 to 25 points, with a cutoff point of 16.5. When a score is greater than 16.5, the transvaginal repair can achieve optimal healing. Uterine position (anteflexion or retroflexion) and preoperative thickness of residual myometrium are the key factors affecting postoperative thickness of residual myometrium. The width of the CSD and the thickness of the lower uterine segment are the key factors affecting abnormal uterine bleeding symptoms (p < 0.01). CONCLUSIONS For the first time, we established a prediction model system that may predict the repair effect of CSD and can potentially be useful in future clinical trials to determine which patients are more suitable for surgery or other treatment options.
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Affiliation(s)
- Xingchen Zhou
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Zhenyan Gao
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Huihui Chen
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Yizhi Wang
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Yujia Yin
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang)
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health (Dr. Zhang), Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xipeng Wang
- Department of gynecology and obstetrics, (Drs. Zhou, Gao, Chen, Wang, Yin, and Wang).
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Allameh Z, Rouholamin S, Rasti S, Adibi A, Foroughi Z, Goharian M, Rad MR, Dabaghi GG. A transvaginal ultrasound-based diagnostic calculator for uterus post-cesarean scar defect. BMC Womens Health 2023; 23:558. [PMID: 37891612 PMCID: PMC10612219 DOI: 10.1186/s12905-023-02715-3] [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: 08/12/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND A cesarean scar defect (CSD) is incomplete healing of the myometrium at the site of a prior cesarean section (CS), complicating more than half of all cesarean sections. While transvaginal ultrasound (TVU) is the most common modality for diagnosing this defect, hysteroscopy remains the gold standard. We aimed to develop an efficient diagnostic tool for CSD among women with abnormal uterine bleeding (AUB) by integrating TVU findings and participants' demographic features. METHODS A single-center cross-sectional study was conducted on 100 premenopausal and non-pregnant women with a history of CS complaining of AUB without a known systemic or structural etiology. Each participant underwent a hysteroscopy followed by a TVU the next day. The defect dimensions in TVU, patients' age, and the number of previous CSs were integrated into a binary logistic regression model to evaluate their predictive ability for a hysteroscopy-confirmed CSD. RESULTS Hysteroscopy identified 74 (74%) participants with CSD. The variables age, the number of CSs, defect length, and defect width significantly contributed to the logistic regression model to diagnose CSD with odds ratios of 9.7, 0.7, 2.6, and 1.7, respectively. The developed model exhibited accuracy, sensitivity, and specificity of 88.00%, 91.89%, and 76.92%, respectively. The area under the receiver operating curve was 0.955 (P-value < 0.001). CONCLUSION Among non-pregnant women suspected of CSD due to AUB, looking at age, the number of previous CSs, and TVU-based defect width and length can efficiently rule CSD out.
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Affiliation(s)
- Zahra Allameh
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Ostad Motahari St., Felezi Bridge, Isfahan, Iran
| | - Safoura Rouholamin
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Ostad Motahari St., Felezi Bridge, Isfahan, Iran
| | - Sina Rasti
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atoosa Adibi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Foroughi
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Ostad Motahari St., Felezi Bridge, Isfahan, Iran
| | - Maryam Goharian
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Ostad Motahari St., Felezi Bridge, Isfahan, Iran.
| | - Mehrdad Rabiee Rad
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Klein Meuleman SJM, Min N, Hehenkamp WJK, Post Uiterweer ED, Huirne JAF, de Leeuw RA. The definition, diagnosis, and symptoms of the uterine niche - A systematic review. Best Pract Res Clin Obstet Gynaecol 2023; 90:102390. [PMID: 37506497 DOI: 10.1016/j.bpobgyn.2023.102390] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023]
Abstract
Of all neonates, 21% are delivered by cesarean section (CS). A long-term maternal complication of an SC is a uterine niche. The aim of this review is to provide an overview of the current literature on imaging techniques and niche-related symptomatology. We performed systematic searches on imaging and niche symptoms. For both searches, 87 new studies were included. Niche evaluation by transvaginal sonography (TVS) or contrast sonohysterography (SHG) proved superior over hysteroscopy or magnetic resonance imaging. Studies that used SHG in a random population identified a niche prevalence of 42%-84%. Niche prevalence differed based on niche definition, symptomatology, and imaging technique. Most studies reported an association with gynecological symptoms, poor reproductive outcomes, obstetrical complications, and reduced quality of life. In conclusion, non-invasive TVS and SHG are the superior imaging modalities to diagnose a niche. Niches are prevalent and strongly associated with gynecological symptoms and poor reproductive outcomes.
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Affiliation(s)
- S J M Klein Meuleman
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - N Min
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - W J K Hehenkamp
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - E D Post Uiterweer
- Amsterdam University Medical Center, Location Amsterdam Medical Center, Uterine Repair Center, Department of Obstetrics & Gynaecology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - J A F Huirne
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - R A de Leeuw
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
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Murji A, Sanders AP, Monteiro I, Haiderbhai S, Matelski J, Walsh C, Abbott JA, Munro MG, Maheux-Lacroix S. Cesarean scar defects and abnormal uterine bleeding: a systematic review and meta-analysis. Fertil Steril 2022; 118:758-766. [PMID: 35985862 DOI: 10.1016/j.fertnstert.2022.06.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To synthesize the published literature to better understand the association between cesarean scar defects (CSDs) and abnormal uterine bleeding (AUB). In particular, we aimed to evaluate the risk and pattern(s) of CSD-associated AUB in addition to exploring the relationship between defect morphology with bleeding symptoms. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENTS Patients with CSD and reports of uterine bleeding as an outcome were identified in 60 studies from database searches. INTERVENTIONS Studies that investigated CSD (as defined by investigators) and reported uterine bleeding, menstrual bleeding, or AUB as an outcome were included. MAIN OUTCOME MEASURES The prevalence and risk of AUB (intermenstrual, postmenstrual, and unscheduled bleeding) in patients with confirmed CSD. RESULTS Nine studies reported on the prevalence of AUB in patients with a confirmed CSD. Patients with CSD were more likely to experience AUB, compared with those without CSD (relative risk, 3.47; 95% confidence interval [CI], 2.02-5.97; 6 studies, 1,385 patients; I2 = 67%). In a population of patients with at least 1 cesarean delivery, the prevalence of AUB in those with CSD was 25.5% (95% CI, 14.7-40.5; 6 studies, 667 patients, I2 = 93%). However, symptom prevalence was much higher in patients presenting for imaging for a gynecologic indication where the prevalence of AUB in the presence of a CSD was 76.4% (95% CI, 67.8-83.3; 5 studies, 505 patients; I2 = 71%). The mean menstrual duration in symptomatic patients with CSD was 13.4 days (95% CI, 12.6-14.2; 19 studies, 2,095 patients; I2 = 96%), and the mean duration of early-cycle intermenstrual bleeding was 6.8 days (95% CI, 5.7-7.8 days; 9 studies, 759 patients; I2 = 93%). The most common descriptor of CSD-associated AUB was "brown discharge". Patients with larger CSD experienced more bleeding symptoms. CONCLUSION There is a strong and consistent association between patients with CSD and AUB. These patients experience a unique bleeding pattern, namely prolonged menstruation and early-cycle intermenstrual bleeding. These data should provide impetus for including CSD as a distinct entity in AUB classification systems. High heterogeneity in our results calls for standardization of nomenclature and outcome reporting for this condition.
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Affiliation(s)
- Ally Murji
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | - Ari P Sanders
- Department of Obstetrics and Gynecology, University of Calgary, Peter Lougheed Centre, Calgary, Alberta, Canada
| | - Ilza Monteiro
- Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences (UNICAMP), Campinas, SP, Brazil
| | - Shabbir Haiderbhai
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Chris Walsh
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada; Sidney Liswood Library, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jason A Abbott
- School of Women's and Children's Health University of New South Wales (UNSW), Sydney, Australia
| | - Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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