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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 versus conventional sutures for cesarean uterine scar defects: A randomized clinical trial. Am J Obstet Gynecol MFM 2024:101431. [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 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 cesarean 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) versus 3.79±1.84 mm (range: 1.0-11.0) (P<0.001); niche depth, 1.78±1.07 mm (range: 1.0-5.7) versus 2.70±1.34 mm (range: 1.0-7.3) (P<0.001); residual myometrial thickness, 8.46±1.74 mm (range: 4.8-13.0) versus 7.07±2.186 mm (range: 2.2-16.2) (P<0.001); and niche width, 1.58±2.73 mm (range: 0.0-14.0) versus 2.88±2.36 mm (range: 0.0-11.0) (P<0.001), respectively. The barbed suture group exhibited no defects and a residual myometrial thickness <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. CONCLUSIONS Double-layer barbed sutures during cesarean delivery may prevent cesarean 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, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan.
| | - Tomohiro Mitoma
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Hikaru Ooba
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Hikari Nakato
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Sakurako Mishima
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Kazumasa Tani
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Eriko Eto
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Dan Yamamoto
- Department of Obstetrics and Gynecology, National Hospital Organization Fukuyama Medical Center, 4-14-17, Okino-kamicho, Fukuyama City, Hiroshima 720-8520, Japan
| | - Risa Yamamoto
- Department of Obstetrics and Gynecology, National Hospital Organization Fukuyama Medical Center, 4-14-17, Okino-kamicho, Fukuyama City, Hiroshima 720-8520, Japan
| | - Kenji Kai
- Department of Obstetrics and Gynecology, National Hospital Organization Fukuyama Medical Center, 4-14-17, Okino-kamicho, Fukuyama City, Hiroshima 720-8520, Japan
| | - Takashi Tamada
- Department of Obstetrics and Gynecology, Iguchi Perinatal and Obstetrics and Gynecology Hospital, 71-4 Kambe-cho, Fukuyama City, Hiroshima 720-2122, Japan
| | - Kazuyo Akamatsu
- Department of Obstetrics and Gynecology, Iguchi Perinatal and Obstetrics and Gynecology Hospital, 71-4 Kambe-cho, Fukuyama City, Hiroshima 720-2122, Japan
| | - Kunihiro Kawanishi
- Department of Obstetrics and Gynecology, Yashima General Hospital, 2105-17 Yashima-Nishi-machi, Takamatsu City, Kagawa 761-0113, Japan
| | - Hisashi Masuyama
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
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Mohr-Sasson A, Castel E, Dadon T, Brandt A, Etinger R, Cohen A, Zajicek M, Haas J, Mashiach R. The association of endometrial closure during cesarean section to the risk of developing uterine scar defect: a randomized control trial. Arch Gynecol Obstet 2024; 309:2063-2070. [PMID: 38498161 DOI: 10.1007/s00404-024-07417-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/04/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms. METHODS A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range. RESULTS 130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0-7.7) vs. 4.6 (3.0-6.5) mm for the endometrial closure and non-closure groups, respectively (p = 0.38). Substantially low RMT (< 2.5 mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group (p = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups. CONCLUSION Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6 months follow-up.
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Affiliation(s)
- Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel.
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Elias Castel
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tal Dadon
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
| | - Ariel Brandt
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
| | - Roie Etinger
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
| | - Adiel Cohen
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
| | - Michal Zajicek
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Mashiach
- Department of Obstetrics and Gynecology, Sheba Medical Center, 5265601, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Fakhr MS, Mozafari M, Rezvanfar K, Amini Z, Amiri K, Hosseini RS, Sarnaz H, Gholami P, Lavasani Z. Investigating the risk factors for isthmocele development after cesarean delivery. AJOG GLOBAL REPORTS 2024; 4:100299. [PMID: 38725541 PMCID: PMC11078695 DOI: 10.1016/j.xagr.2023.100299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Cesarean delivery rates are increasing globally, raising concerns about associated complications such as isthmocele. Isthmoceles are pouch-like defects in the anterior uterine wall at the site of a prior cesarean delivery scar. OBJECTIVE This study aimed to determine isthmocele prevalence, associated symptoms, and risk factors among women with a history of cesarean delivery. STUDY DESIGN This cross-sectional study evaluated 297 women with prior cesarean delivery using transvaginal ultrasound to screen for isthmocele. Data on demographics, pregnancy details, comorbidities, and indications for cesarean delivery were collected. Isthmocele was defined sonographically as any niche or defect at the hysterotomy site. Descriptive and comparative analyses identified factors associated with isthmocele. RESULTS Isthmocele prevalence was 65.3% (n=194). Abnormal vaginal bleeding was reported in 21.1% of participants, pelvic pain by 4.1% of participants, and both by 4.1% of participants. Compared to women without isthmocele, those with isthmocele were older (35.9 vs 31.6 years), had higher body mass index (26.8 vs 25.5 kg/m2), gravidity (1.8 vs 1.3), and parity (1.7 vs 1.2). Repeat cesarean delivery was more common (30.4% vs 12.6%) and elective cesarean delivery less common (33.5% vs 67.9%) among those with isthmocele. CONCLUSION Over half of the women with history of cesarean delivery had an isthmocele. Abnormal bleeding was common. Advanced maternal age, obesity, repeat procedures, and certain comorbidities appear to increase risk. Further research on prevention and treatment is warranted given the high prevalence.
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Affiliation(s)
- Masoud Saadat Fakhr
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran (Drs Fakhr, Mozafari, Rezvanfar, Amini, Amiri, Sarnaz, and Gholami)
| | - Mahya Mozafari
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran (Drs Fakhr, Mozafari, Rezvanfar, Amini, Amiri, Sarnaz, and Gholami)
| | - Kiana Rezvanfar
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran (Drs Fakhr, Mozafari, Rezvanfar, Amini, Amiri, Sarnaz, and Gholami)
| | - Zahra Amini
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran (Drs Fakhr, Mozafari, Rezvanfar, Amini, Amiri, Sarnaz, and Gholami)
| | - Koosha Amiri
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran (Drs Fakhr, Mozafari, Rezvanfar, Amini, Amiri, Sarnaz, and Gholami)
| | - Reza Shah Hosseini
- Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey (Mr Hosseini)
| | - Hengame Sarnaz
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran (Drs Fakhr, Mozafari, Rezvanfar, Amini, Amiri, Sarnaz, and Gholami)
| | - Poorya Gholami
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran (Drs Fakhr, Mozafari, Rezvanfar, Amini, Amiri, Sarnaz, and Gholami)
| | - Zohreh Lavasani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran (Dr Lavasani)
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Baldini GM, Lot D, Malvasi A, Di Nanni D, Laganà AS, Angelucci C, Tinelli A, Baldini D, Trojano G. Isthmocele and Infertility. J Clin Med 2024; 13:2192. [PMID: 38673465 PMCID: PMC11050579 DOI: 10.3390/jcm13082192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman's quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5-3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted.
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Affiliation(s)
- Giorgio Maria Baldini
- MOMO’ FertiLIFE, IVF Clinic, 76011 Bisceglie, Italy
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy;
| | - Dario Lot
- MOMO’ FertiLIFE, IVF Clinic, 76011 Bisceglie, Italy
| | - Antonio Malvasi
- Obstetrics and Gynecology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy;
| | - Doriana Di Nanni
- Pathology Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70125 Bari, Italy
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Department of Health Promotion, Mother and Childcare, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Cecilia Angelucci
- Gynecology and Obstetrics Clinic, University of Sassari, 07100 Sassari, Italy;
| | - Andrea Tinelli
- Department of Gynaecology and Obstetrics, “Veris Delli Ponti” Hospital, and CERICSAL (Centro di RIcerca Clinico SALentino), “Veris delli Ponti Hospital”, 73020 Lecce, Italy;
| | | | - Giuseppe Trojano
- Department of Maternal and Child, Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Madonna Delle Grazie Hospital ASM, 75100 Matera, Italy
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Yang H, Zhao Y, Tu J, Chang Y, Xiao C. Clinical analysis of incomplete rupture of the uterus secondary to previous cesarean section. Open Med (Wars) 2024; 19:20240927. [PMID: 38584842 PMCID: PMC10998671 DOI: 10.1515/med-2024-0927] [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: 09/06/2022] [Revised: 08/28/2023] [Accepted: 02/28/2024] [Indexed: 04/09/2024] Open
Abstract
Uterine rupture is a rupture of the body or lower part of the uterus during pregnancy or delivery. Total of 98 cases with incomplete uterine rupture were classified as the incomplete uterine rupture group, 100 cases with a history of cesarean delivery without uterine rupture were classified as the non-ruptured uterus group, and controls were selected using a systematic sampling method. The maternal age ≥35 years were associated with 2.18 times higher odds of having an incomplete uterine rupture. The odd of having an incomplete uterine rupture was 3.744 times higher for a woman with delivery interval ≤36 months. Having pregnancy complication was associated with 3.961 times higher odds of having an incomplete uterine rupture. The neonatal weight was lighter in the incomplete uterine rupture group (P = 0.007). The number of preterm birth and transfer to the NICU were higher in the incomplete uterine rupture group (P < 0.01). The operation time and the length of time in hospital were longer in the group with incomplete uterine rupture (P < 0.01). Age ≥35 years, delivery interval ≤36 month, and pregnancy with complication were independent risk factors of incomplete rupture of the uterus secondary to previous cesarean section.
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Affiliation(s)
- Hong Yang
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Wuhan City, Hubei Province, 430070, P. R. China
| | - Yun Zhao
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Wuhan City, Hubei Province, 430070, P. R. China
| | - Jiahui Tu
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Wuhan City, Hubei Province, 430070, P. R. China
| | - Yanan Chang
- Women's Health Unit, Maternal and Child Health Hospital of Hubei Province, Wuhan City, Hubei Province, 430070, P. R. China
| | - Chanyun Xiao
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, No. 745 Wuluo Road, Hongshan District, Wuhan City, Hubei Province, 430070, P. R. China
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Shakki Katouli F, Zebardast J, Tavoli Z, Bayani L, Azizinik F, Moradpour M, Mardani R, Meimani N, Fathi S. Evaluation of Association Between Adenomyosis and Cesarean Scar Defect. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:553-560. [PMID: 38088498 DOI: 10.1002/jum.16388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/04/2023] [Accepted: 11/25/2023] [Indexed: 02/08/2024]
Abstract
PURPOSE This study aims to investigate and compare quantitative factors of the cesarean scar defect (CSD) in symptomatic patients with and without uterine adenomyosis. METHOD This study was conducted as a case-control study. Patients who met the inclusion criteria were divided into two groups: with adenomyosis (case) and without adenomyosis (control). The demographic data, medical history, and sonohysterography findings were extracted from the patient's documents and archived images. RESULT During 2 years, 310 symptomatic women with a history of previous cesarean section underwent sonohysterography. Among them, 204 patients met the inclusion criteria. The most common chief complaints were post-menstrual bleeding (34.3%) and prolonged bleeding (27%). Cesarean scar depth and width significantly differed between these two groups, and patients with underlying adenomyosis had significantly larger defects (P-value of .009 and .005, respectively). Mean RMT/AMT ratio was 31.83% in the case group and 42.88% in the control group. In our study, RMT/AMT ratios were significantly lower in the case group (P-value of .001). In addition, we performed analysis on a subgroup of patients with one prior cesarean section. Similar results were achieved with a lower RMT/AMT ratio in case group (mean of 31.20% in case group and 46.47% in control group; P-value of .000). CONCLUSION Our study showed a strong association between the presence of adenomyosis and larger clinically more significant CSDs. To establish a causative relationship, we suggest a prospective cohort study to follow up the patients and compare the evolution of CSD in patients with and without adenomyosis.
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Affiliation(s)
- Fatemeh Shakki Katouli
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Radiology, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Jayran Zebardast
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Cognitive Linguistics, Institute for Cognitive Science Studies (ICSS), Tehran, Iran
| | - Zahra Tavoli
- Department of Obstetrics and Gynecology, Ziaeeian Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Bayani
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Radiology, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahimeh Azizinik
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Radiology, Yas and Amir-Alam Hospitals, Tehran University of Medical Sciences, Tehran, Iran
| | - Moein Moradpour
- Department of Radiology, Taleghani Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Reza Mardani
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Radiology, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Najme Meimani
- Research Center of Biomedical Technology and Robotics (RCBTR), Advanced Medical and Technologies and Equipment Institute (AMTEI), Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Fathi
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
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Warrier H, Warrier AR. Isthmocele abscess: A rare case report. Int J Gynaecol Obstet 2024; 164:1224-1226. [PMID: 37947245 DOI: 10.1002/ijgo.15238] [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: 04/25/2023] [Revised: 09/14/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
SynopsisA rare case report of an isthmocele abscess—its presentation, diagnosis and clinical management is discussed.
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Affiliation(s)
- Hema Warrier
- Department of Obstetrics and Gynecology, The Palakkad District Cooperative Hospital and Research Centre, Palakkad, India
| | - Anjana R Warrier
- Department of Obstetrics and Gynecology, The Palakkad District Cooperative Hospital and Research Centre, Palakkad, India
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Salem Wehbe G, Amara IA, Nisolle M, Badr DA, Timmermans M, Karampelas S. Efficacy, Safety and Outcomes of the Laparoscopic Management of Cesarean Scar Ectopic Pregnancy as a Single Therapeutic Approach: A Case Series. J Clin Med 2023; 12:7673. [PMID: 38137743 PMCID: PMC10743864 DOI: 10.3390/jcm12247673] [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: 10/13/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
A standardized consensus for the management of cesarean scar pregnancy (CSP) is lacking. The study objective is to evaluate the efficacy, safety and outcomes of the laparoscopic management of CSP as a single therapeutic surgical approach without being preceded by vascular pretreatment or vasoconstrictors injection. This is a retrospective bi-centric study, a case series. Eight patients with a future desire to conceive underwent the laparoscopic treatment of unruptured CSPs. Surgery consisted of "en bloc" excision of the deficient uterine scar with the adherent tissue of conception, followed by immediate uterine repair. The data collected for each patient was age, gestity, parity, number of previous c-sections, pre-pregnancy isthmocele-related symptoms, gestational age, fetal cardiac activity, initial β-human chorionic gonadotropin levels, intra-operative blood loss, blood transfusion, operative time and the postoperative complications, evaluated according to Clavien-Dindo classification. The CSP was successfully removed in all patients by laparoscopy. The surgical outcomes were favorable. All patients with histories of isthmocele-related symptoms reported postoperative resolution of symptoms. The median residual myometrium thickness increased significantly from 1.2 mm pre-operatively to 8 mm 3 to 6 months after surgery. The laparoscopic management seems to be an appropriate treatment of CSP when performed by skilled laparoscopic surgeons. It can be safely proposed as a single surgical therapeutic approach. Larger series and further prospective studies are needed to confirm this observation and to affirm the long-term gynecological and obstetrical outcomes of this management.
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Affiliation(s)
- Georges Salem Wehbe
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Free University of Brussels, 1020 Brussels, Belgium; (G.S.W.); (I.A.A.); (D.A.B.)
| | - Inesse Ait Amara
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Free University of Brussels, 1020 Brussels, Belgium; (G.S.W.); (I.A.A.); (D.A.B.)
| | - Michelle Nisolle
- Department of Obstetrics and Gynecology, Hospital the Citadelle, University of Liege, 4000 Liege, Belgium; (M.N.); (M.T.)
| | - Dominique A. Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Free University of Brussels, 1020 Brussels, Belgium; (G.S.W.); (I.A.A.); (D.A.B.)
| | - Marie Timmermans
- Department of Obstetrics and Gynecology, Hospital the Citadelle, University of Liege, 4000 Liege, Belgium; (M.N.); (M.T.)
| | - Stavros Karampelas
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Free University of Brussels, 1020 Brussels, Belgium; (G.S.W.); (I.A.A.); (D.A.B.)
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Hill S, Shetty MK. Abnormal Uterine Bleeding in Reproductive Age Women: Role of Imaging in the Diagnosis and Management. Semin Ultrasound CT MR 2023; 44:511-518. [PMID: 37832698 DOI: 10.1053/j.sult.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Abnormal uterine bleeding (AUB) is defined by the International Federation of Gynecology and Obstetrics as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy. AUB is a common condition that affects about a third of women in their lifetime. Abnormal bleeding in duration, quantity, or timing consists of 2 categories, predictable cyclical heavy menstrual bleeding (HMB) and irregular non-cyclical intermenstrual bleeding (IMB). The most common causes of HMB include fibroids and adenomyosis and IMB is commonly caused by ovulatory dysfunction such as in polycystic ovaries, endometrial polyp, or an IUD. A pelvic ultrasound is the initial and often only imaging modality needed in the imaging evaluation of abnormal uterine bleeding and can accurately identify the common causes of abnormal uterine bleeding in the reproductive age group.
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Fatehnejad M, Hadizadeh A, Tayebi A, Ayati A, Marjani N, Gheshlaghi P, Asgari Z, Hosseini R. Assessment of the clinical outcomes and complications of hysteroscopic and laparoscopic approaches in the treatment of symptomatic isthmocele: An observational study. Int J Gynaecol Obstet 2023; 163:965-971. [PMID: 37350282 DOI: 10.1002/ijgo.14926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/23/2023] [Accepted: 05/28/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES To investigate the outcomes of patients undergoing laparoscopic or hysteroscopic approaches for isthmoplasty. METHODS A total of 99 isthmocele patients with an average age of 38.45 ± 4.72 years were included in the 2 years of this retrospective cohort study. Forty-five underwent laparoscopic and 54 underwent hysteroscopic isthmocele excision and myometrial repair. RESULTS Pain scores were significantly higher in the hysteroscopy group before the procedure, but there were no significant pain score differences after the surgery. In 1 year of follow up, dysmenorrhea and dyspareunia were higher among hysteroscopy patients. Furthermore, hysteroscopy significantly improved postmenstrual spotting after surgery better than laparoscopy, but in the follow up, there was no significant difference between the two groups in this regard (mean rank for hysteroscopy vs. laparoscopy: 32.30 vs. 37.48, U = 418, P = 0.29). CONCLUSION In patients with a history of infertility, ectopic pregnancy, lower gravidity, lower parity, and a lower number of cesarean sections, laparoscopic isthmoplasty is preferred over the hysteroscopic approach. Both methods have similar effects on midcycle vaginal bleeding, duration of postmenstrual spotting, and pain. However, a higher rate of dyspareunia and dysmenorrhea could be associated with hysteroscopy.
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Affiliation(s)
- Mina Fatehnejad
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Hadizadeh
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Tayebi
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Aryan Ayati
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Narjes Marjani
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parand Gheshlaghi
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Asgari
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reihaneh Hosseini
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Mercier M, Meneu A, Tesson C, Lassel L, Le Lous M, Enderle I. Retrospective evaluation of labor induction with scar uterus at the university hospital of Rennes. J Gynecol Obstet Hum Reprod 2023; 52:102641. [PMID: 37595753 DOI: 10.1016/j.jogoh.2023.102641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE The aim of the study was a retrospective evaluation of labor induction in women with one previous cesarean section. The primary outcome was the mode of delivery. We also studied the severe maternal and neonatal morbidity and identify some prediction factors of vaginal delivery after labor induction after one previous cesarean section. STUDY DESIGN This was a retrospective observational monocentric study performed over the period from January 1st, 2016 to April 30th, 2020 at the university hospital of Rennes. Were included women with scar uterus because of one previous cesarean section with a viable singleton fetus in cephalic presentation and an induction of labor for medical reason, at term. Multivariate logistic regression analysis was used to analyze prediction of vaginal delivery after labor induction after one previous cesarean section. We also studied maternal (included uterine rupture, loss of blood, obstetrical injury of anus sphincter) and neonatal (APGAR score, arterial umbilical pH after 1 minute of life and eventual admission to neonatal unit) morbidity. We used a stepwise multivariate logistic regression model to select variables for multivariate analysis. The model with the lowest Akaike Index Criteria was chosen. RESULTS The study enrolled 353 women with scar uterus: 121 women were induced by balloon catheter, 57 by osmotic cervical dilatators, 91 by oxytocin alone, 84 by amniotomy. Vaginal delivery rate was 47,9%. There was 45% of vaginal delivery in the group with Bishop < 6 before induction of labor versus 62% in the group with Bishop ≥ 6. There was no statistically significative difference in neonatal and maternal severe morbidities between vaginal delivery and cesarean section: 4,5% of severe maternal morbidities (n = 16). Among their, we highlighted 7 uterine ruptures (3,8%). We observed also 3% of postpartum severe hemorrhage in vaginal delivery group (n = 5) against 1,6% in cesarian section group (n = 3) with no statistical significant difference (p = 0,632). Regarding to the obstetric perineal tears and lacerations we noticed 1,2% of OASIS 3 (n = 2) and 0,6% of OASIS 4 (n = 1). Severe neonatal morbidities were comparable by mode of delivery without significant difference: APGAR score at 5 min was similar (p = 1), as well as arterial umbilical pH after 1 min. (p = 0.719) and admissions to a neonatal unit (p = 1). Two variables were statistically associated with vaginal delivery after labor induction in women with scar uterus: Bishop score ≥ 6 (OR = 0,44; 95%CI: 0,25-0,81) and/or previous vaginal delivery after cesarean section (OR = 0,17; 95%CI: 0,08-0,35). CONCLUSION With 47,9% of vaginal delivery after labor induction in women with scar uterus, only 3.8% (n = 7/353) of uterine ruptures, less than 1% APGAR < 7 at 5 min (n = 3/353), induction on scar uterus should be consider in obstetrical practice. Bishop score ≥ 6 and/or previous vaginal delivery after cesarean section are associated to vaginal delivery after labor induction.
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Affiliation(s)
- Marion Mercier
- Department of Obstetrics and Gynecology and Reproductive Medicine, Anne de Bretagne University Hospital, Rennes, France.
| | - Alisée Meneu
- Department of Obstetrics and Gynecology and Reproductive Medicine, Anne de Bretagne University Hospital, Rennes, France
| | - Caroline Tesson
- Department of Obstetrics and Gynecology and Reproductive Medicine, Anne de Bretagne University Hospital, Rennes, France
| | - Linda Lassel
- Department of Obstetrics and Gynecology and Reproductive Medicine, Anne de Bretagne University Hospital, Rennes, France
| | - Maela Le Lous
- Department of Obstetrics and Gynecology and Reproductive Medicine, Anne de Bretagne University Hospital, Rennes, France
| | - Isabelle Enderle
- Department of Obstetrics and Gynecology and Reproductive Medicine, Anne de Bretagne University Hospital, Rennes, France
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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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Backer S, Khanna D, Sadr S, Khatibi A. Intra-operative Guidelines for the Prevention of Uterine Niche Formation in Cesarean Sections: A Review. Cureus 2023; 15:e44521. [PMID: 37790067 PMCID: PMC10544643 DOI: 10.7759/cureus.44521] [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: 07/21/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Formation of a uterine niche following a C-section can predispose the patient to future obstetric complications such as dehiscence, uterine rupture, ectopic pregnancy, and placenta accreta. The significant morbidity and mortality of these complications along with increasing C-section rates emphasizes the importance of prevention. However, there are no clear guidelines on intra-operative protocol to prevent postpartum niche formation. Besides surgical technique, the novel use of platelet-rich plasma (PRP) and mesenchymal stem cell (MSC) injections has demonstrated promising potential and may have applications in hysterotomy closures. The objective is to examine current research on optimal C-section procedures to prevent uterine niche formation and subsequent obstetric complications. A systematic review was conducted using PubMed and Google Scholar. Initial searches yielded 827 results. Inclusion criteria were human, animal, and in-vitro studies, peer-reviewed sources, and outcomes pertinent to the uterine niche. Exclusion criteria applied to articles with outcomes unrelated to myometrium and interventions outside of the intra-operative and immediate pre-/post-operative period. Based on the criteria, 41 articles were cited. Pathophysiology of uterine niche formation was associated with incisions through cervical tissue, adhesion formation, and poor approximation. Significant risk factors were low uterine incisions, advanced cervical dilatation, low station, non-closure of the peritoneum, and creation of a bladder flap. There was no consensus on uterine closure as it likely depends on surgical proficiency with the given technique, but a double-layered non-locking suture appears reliable to reduce niche severity. Recent trials indicate that intra-operative PRP/MSC injections may decrease niche incidence and severity, but more research is needed. If prevention or minimization of uterine niche is desired, the optimal C-section protocol should avoid low uterine incisions, choose uterine closure technique based on the surgeon's proficiency (double-layered non-locking is reliable), and close the peritoneum, and myometrial injection of PRP/MSC may be a useful adjunct intervention pending further clinical evidence.
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Affiliation(s)
- Sean Backer
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Tampa, USA
| | - Deepesh Khanna
- Foundational Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Sonia Sadr
- Foundational Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Ali Khatibi
- Obstetrics and Gynaecology, Sahlgrenska University Hospital, Gothenburg, SWE
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Dominguez JA, Pacheco LA, Moratalla E, Carugno JA, Carrera M, Perez-Milan F, Caballero M, Alcázar JL. Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:336-344. [PMID: 36730180 DOI: 10.1002/uog.26171] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/28/2022] [Accepted: 01/17/2023] [Indexed: 06/18/2023]
Abstract
The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J A Dominguez
- IERA (Instituto Extremeño de Reproducción Asistida), Badajoz, Spain
| | | | - E Moratalla
- Department of Obstetrics and Gynecology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J A Carugno
- Minimally Invasive Gynecology Division, University of Miami, Miami, FL, USA
| | - M Carrera
- Department Obstetrics and Gynecology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - F Perez-Milan
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M Caballero
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J L Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
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Al-Ghotani B, Martini N, Alabdallah E, Alawad I, Hussien K. A large post-caesarean Niche (Isthmocele) with amenorrhea, a symptom that was not reported in the medical literature: A rare case report. Int J Surg Case Rep 2023; 109:108528. [PMID: 37499350 PMCID: PMC10413087 DOI: 10.1016/j.ijscr.2023.108528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Isthmocele is identified as an iatrogenic defect in the myometrium of the anterior uterine wall at the site of a previous cesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding (AUB) and pelvic pain. Herein, we report a rare case of a large isthmocele that manifested with secondary amenorrhea; which was not reported in the medical literature previously. CASE PRESENTATION A 30-year-old Syrian woman, G5P5, came to our clinic with a complaint of secondary amenorrhea that began two years ago. She was treated symptomatically with progesterone with no response. She has had five cesarean sections. Ultrasonography findings suggested a large uterine niche. Trans-Abdominal niche repair was the obtained technique, depending on the drainage of the isthmocele, excising the fibrotic tissue from the edges and re-approximating them. On follow-up, menstruation returned to normal. CLINICAL DISCUSSION Isthmocele can be, radiologically, defined as a hypoechoic or anechoic, triangular area at the scar site. Its pathophysiology is still unknown. Although, an isthmocele can be diagnosed using a variety of imaging techniques like ultrasonography (US), magnetic resonance imaging (MRI), sonohysterography, and hysteroscopy; transvaginal ultrasound (TVUS) is the first method described for assessing it. The goal of isthmocele treatment is to alleviate symptoms. CONCLUSION We recommend that health awareness campaigns alert people to the need to see a specialist doctor in the context of a serious complaint. For the uterine niche, many risk factors can be avoided to reduce its probability.
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Affiliation(s)
- Basel Al-Ghotani
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic.
| | - Nafiza Martini
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Ebaa Alabdallah
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Ieman Alawad
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic; Alassad Medical Complex, Hama, Syrian Arab Republic
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Mohr-Sasson A, Dadon T, Brandt A, Shats M, Axcelrod M, Meyer R, Zajicek M, Haas J, Mashiach R. The association between uterine scar defect (niche) and the presence of symptoms. Reprod Biomed Online 2023; 47:103221. [PMID: 37277298 DOI: 10.1016/j.rbmo.2023.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 06/07/2023]
Abstract
RESEARCH QUESTION Is there association between the presence of a uterine niche and the presence of symptoms? DESIGN This cross-sectional study was conducted at a single tertiary medical centre. All women who underwent Caesarean section from January 2017 to June 2020 were invited to the gynaecological clinics, and requested to complete a questionnaire regarding symptoms related to the presence of a niche (heavy menstrual bleeding, intermenstrual spotting, pelvic pain, infertility). Transvaginal two-dimensional ultrasonography was performed to assess the uterus and uterine scar characteristics. The primary outcome was defined as the presence of a uterine niche, evaluated by length, depth, residual myometrial thickness (RMT) and ratio between the residual myometrial thickness (RMT) and adjacent myometrial thickness (AMT). RESULTS Of 524 women who were eligible and scheduled for evaluation, 282 (54%) completed the follow-up; 173 (61.3%) were symptomatic and 109 (38.6%) asymptomatic. Niche measurements, including RMT/AMT ratio, were comparable between the groups. In a sub-analysis of each symptom, heavy menstrual bleeding and intermenstrual spotting were associated with reduced RMT (P = 0.02 and P = 0.04, respectively) compared with women with normal menstrual bleeding. An RMT less than 2.5 mm was significantly more prevalent in women reporting heavy menstrual bleeding (11 [25.6%] versus 27 [11.3%]; P = 0.01] and new infertility (7 [16.3%] versus 6 [2.5%]; P = 0.001]. In logistic regression analysis, infertility was the only symptom associated with an RMT less than 2.5 mm (B = 1.9; P = 0.002). CONCLUSIONS A reduced RMT was found to be associated with heavy menstrual bleeding and intermenstrual spotting, while values below 2.5 mm were also associated with infertility.
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Affiliation(s)
- Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel..
| | - Tal Dadon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Ariel Brandt
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Maya Shats
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Axcelrod
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Zajicek
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Mashiach
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Timmermans M, Nisolle M, Brichant G, Henry L, Gillet E, Kellner B, Karampelas S. Impact of Adenomyosis and Endometriosis on Chronic Pelvic Pain after Niche Repair. J Clin Med 2023; 12:jcm12103484. [PMID: 37240590 DOI: 10.3390/jcm12103484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Chronic pelvic pain (CPP) is one of the main isthmocele symptoms, together with abnormal uterine bleeding and secondary infertility. When patients undergo a laparoscopic niche repair surgery, it is important to determine if they present associated pathologies, such as adenomyosis and/or endometriosis, which are also a cause of CPP. A retrospective study was performed on 31 patients with CPP undergoing a laparoscopic niche repair. The pre-operative ultrasound was analyzed to determine the presence of adenomyosis. Endometriosis was histologically diagnosed. CPP outcome was evaluated at early (3-6 months) and late (12 months) post-operative follow ups. In our population of 31 women presenting CPP, only six of them (19.4%) did not have any associated pathology. In the group of 25 patients with associated pathology, 10 (40%) had no benefit from the reconstructive surgery in terms of CPP at early follow-up (3-6 months) and 8 (32%) in the post-operative period at 12 months. Patients with CPP who undergo niche repair should be carefully selected as CPP does not seem to be a good indication for uterine scar repair in patients with concomitant adenomyosis and endometriosis.
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Affiliation(s)
- Marie Timmermans
- Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, 4000 Liège, Belgium
| | - Michelle Nisolle
- Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, 4000 Liège, Belgium
| | - Géraldine Brichant
- Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, 4000 Liège, Belgium
| | - Laurie Henry
- Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, 4000 Liège, Belgium
| | - Evy Gillet
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium
| | - Betty Kellner
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium
| | - Stavros Karampelas
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium
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Huang CC, Chiu SC, Pan CM, Huang CC, Chang CYY, Chao SC, Cho DY, Lin WC. New Efficient Method for Hysteroscopic Isthmoplasty: Four Simple Steps Lead to a Significant Improvement in Bleeding Status. J Clin Med 2022; 11:jcm11216541. [PMID: 36362769 PMCID: PMC9655228 DOI: 10.3390/jcm11216541] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
We demonstrate an effective reduction in postmenstrual spotting after our novel hysteroscopic isthmoplasty. This study included 66 patients with isthmocele-related postmenstrual spotting confirmed by sonography and diagnostic hysteroscopy between 2000 and 2017. Our new interventions included the following four steps: (1) make a resection gradient of the distal edge of the isthmocele from the ape of the isthmocele down to the cervical outer orifice; (2) resect the distal and proximal niches of the isthmocele; (3) electrocauterize the distal and proximal sides (not only the niche bottom) of the small cave on the scar side of the isthmocele; (4) manage the isthmocele until it is largely connected to the cavity. In our results, all patients underwent extensive hysteroscopic repair of newly hysteroscopic isthmoplasty without any intra- or postoperative complications. After final hysteroscopic repair modification, prolonged menstrual spotting was significantly decreased in 98.2% (53/54) of the patients, and the total number of bleeding days per menstrual cycle significantly decreased from a mean of 15.38 ± 3.3 days to 6.4 ± 1.9 days postoperatively (p < 0.001). Our four-step hysteroscopic technique successfully resolved prolonged menstrual spotting in over 90% of the patients, exceeding the resolution rates of 60−85% achieved with other hysteroscopic techniques used to treat symptomatic isthmocele. No patients experience recurrence after long-term follow up. Four simple steps led to a significant improvement in bleeding status.
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Affiliation(s)
- Chien-Chu Huang
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung 404327, Taiwan
| | - Shao-Chih Chiu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
- Translational Cell Therapy Center, China Medical University Hospital, Taichung 404327, Taiwan
| | - Chih-Ming Pan
- Translational Cell Therapy Center, China Medical University Hospital, Taichung 404327, Taiwan
| | - Chun-Chung Huang
- Institute of Oral Sciences, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Cherry Yin-Yi Chang
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung 404327, Taiwan
- School of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Shih-Chi Chao
- Institute of Oral Sciences, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Medical Research and Education, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 265501, Taiwan
| | - Der-Yang Cho
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
- Translational Cell Therapy Center, China Medical University Hospital, Taichung 404327, Taiwan
- Correspondence: (D.-Y.C.); (W.-C.L.)
| | - Wu-Chou Lin
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung 404327, Taiwan
- School of Chinese Medicine, China Medical University, Taichung 40402, Taiwan
- Correspondence: (D.-Y.C.); (W.-C.L.)
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19
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Antoine C, Alexander JS, Yaghoubian YC, Harary JM. Variations in uterine closure technique: an institutional survey of obstetricians and implications for patient counseling and prevention of adverse sequelae. J Perinat Med 2022; 50:1045-1052. [PMID: 35538677 DOI: 10.1515/jpm-2021-0485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 04/07/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the diversity of uterine closure techniques (UCTs) among providers in one institution and evaluate concurrent consideration of adverse outcomes for patient counseling, provisional care, and prevention. METHODS Forty-four obstetricians at NYU Langone Health were emailed a survey of their uterine closure technique, patient counseling, and practice experience. Results were stratified by years of practice: ≤5, 5-20, and 20-40 years. RESULTS Thirty-nine obstetricians (88.6%) completed the survey. Among those, a blunt uterine opening was preferred by 29 (74.4%), and a mid-lower segment location was favored by 34 (87.2%). At uterine closure, the endometrium was included by 20 (51.3%), with half a centimeter or more incorporated in the myometrial closure, whereas 15 (38.5%) did not factor in the endometrium's presence. Closure duration varied from 1 to 20 min, with 21 (53.9%) lasting 1-5 min and 12 (30.8%) lasting 5-10 min. All physicians were familiar with the potential post-cesarean complications and counseled their patients accordingly; 25 (64.1%) at the first post-op visit while 14 (35.9%) did so before the next conception. Practitioners with fewer years in practice endorsed the safety of up to five consecutive cesarean births, while those with more experience approved up to ten. Thirty-two obstetricians (82.1%) stated that the risk of abnormal placentation is exclusively associated with the number of cesarean sections, whereas five (12.8%) senior obstetricians asserted that individual surgical techniques are most impactful. CONCLUSIONS The survey illustrates that various UCTs are performed irrespective of potential adverse sequelae and without consideration for subsequent patient counseling and care. Ongoing research must study the impact of UCT on scar healing to formulate preventive strategies for post-cesarean complications.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | | | - Yasaman C Yaghoubian
- Department of Obstetrics and Gynecology, North Shore University Hospital/Long Island Jewish Medical, New York, NY, USA
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20
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Aslan K, Aslan EK, Mesut C, Orhan A, Uncu G. Laparoscopic Management for Complications of Cesarean-Scar Pregnancy. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Affiliation(s)
- Kiper Aslan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bursa Uludag University, Görükle/Bursa, Turkey
| | - Elif Külahci Aslan
- Department of Obstetrics and Gynecology, Bursa Jimer Hospital, Bursa, Turkey
| | - Cagatay Mesut
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bursa Uludag University, Görükle/Bursa, Turkey
| | - Adnan Orhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bursa Uludag University, Görükle/Bursa, Turkey
| | - Gürkan Uncu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bursa Uludag University, Görükle/Bursa, Turkey
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21
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Chen H, Wang Y, Zhang H, Wang X. Vaginal repair of cesarean section scar defects: Preoperative hysteroscopic evaluation. Acta Obstet Gynecol Scand 2022; 101:1308-1314. [PMID: 35996831 PMCID: PMC9851086 DOI: 10.1111/aogs.14429] [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: 02/16/2022] [Revised: 07/01/2022] [Accepted: 07/11/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Cesarean section scar defects (CSDs) are one of the long-term complications following cesarean section. They can be detected by transvaginal sonography, hysterosalpingography, sonohysterography and magnetic resonance imaging (MRI). Hysteroscopy is frequently used in evaluating endometrial disease. However, the description of CSDs by hysteroscopy is very limited. Only a few papers about hysteroscopy evaluation have been published. This is an exploratory study to compare hysteroscopic findings with myometrial thickness and post-surgical outcomes. MATERIAL AND METHODS From February 2019 to December 2020, 143 women with CSDs were enrolled in the observational study. All women suffered from abnormal uterine bleeding and were evaluated in a standardized way with hysteroscopy before vaginal surgery. Dome-shaped CSDs could be clearly observed in all patients under hysteroscopy. We recorded the pictures of each patient under hysteroscopy and classified them. All patients underwent outpatient review at 3 and 6 months after surgery to obtain menstrual information and CSD scar size by MRI or transvaginal sonography. RESULTS Pale mucosae in the defect were meager endometrial lining covering the surface of muscle layer, cyst lesions were some cyst lesions in the defect, increased local vascularization was a vascular tree with branching and irregular vascular distribution in defect, polypoid lesions were polypoid lesions in the defect, and serrated niches were two niches at the anterior uterine isthmus. The features of the CSDs observed under hysteroscopy were identified as five phenotypes: pale mucosae (90/143, 62.9%), cyst lesions (23/143, 16.1%), polypoid lesions (19/143, 13.3%), increased local vascularization (27/143, 18.9%) and serrated niches (7/143, 4.9%). The most common finding in scar defects under hysteroscopy was pale mucosae in the CSD. The results suggest that patients with increased local vascularization and serrated niches have a high risk of thinner residual myometrium before vaginal repair (p < 0.05). However, there was no significant difference in menstrual duration or in the outcome of vaginal repair for CSDs between these five phenotypes (p > 0.05). CONCLUSIONS Patients with the abnormal blood vessel or serration phenotypes of defects under hysteroscopy may have a thinner residual myometrium. The phenotypes of hysteroscopic findings of CSDs have no correlation with the outcome of repair.
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Affiliation(s)
- Huihui Chen
- Department of Obstetrics and GynecologyXin Hua Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yizhi Wang
- Department of Obstetrics and GynecologyXin Hua Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Hui Zhang
- Department of Obstetrics and GynecologyXin Hua Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xipeng Wang
- Department of Obstetrics and GynecologyXin Hua Hospital Affiliated to Shanghai Jiao Tong University School of MedicineShanghaiChina
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22
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Mutlu AE. Assessment of in vitro fertilization outcomes after hysteroscopic isthmoplasty in recurrent implantation failure. J Obstet Gynaecol Res 2022; 48:1829-1835. [PMID: 35623894 DOI: 10.1111/jog.15317] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/28/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to assess the in vitro fertilization (IVF) treatments outcomes of women with recurrent implantation failure (RIF) after hysteroscopic isthmoplasty for isthmocele. METHODS This retrospective, observational study included 61 patients with RIF and isthmocele who presented to IVF Unit of Hüma Obstetrics and Gynecology Hospital between January, 2018 and December, 2020. Thirty-one patient who underwent hysteroscopic isthmoplasty-before IVF procedure-were included. Remaining 30 patients underwent IVF without hysteroscopic isthmoplasty were included as controls. The fertility outcome were compared between groups. RESULTS After 3 months, spontaneous pregnancy was achieved in 18.4% (7/38) of patients with isthmocele who underwent hysteroscopic isthmoplasty. In the isthmoplasty group, implantation rate, clinical pregnancy rate, biochemical pregnancy rate, and the miscarriage rate were 41.9% (13/31), 35.5% (11/31), 6.5% (2/31), and 9.7% (3/31), respectively. The live birth rate after in vitro fertilization was 25.8% (8/31) in the isthmoplasty group and 3.3% (1/30) in the control group (p < 0.05). There were no significant differences in the IVF outcomes such as the biochemical pregnancy rate and miscarriage rate between the isthmoplasty and control groups. CONCLUSION This study demonstrated that hysteroscopic isthmoplasty improves pregnancy and live birth rates for women with a history of RIF and isthmocele. Reproductive results of the IVF cycles after hysteroscopic correction of isthmocele were comparable to those of the patients without any uterine abnormalities and those with diagnosis of unexplained infertility.
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Affiliation(s)
- Ahmet Emin Mutlu
- Department of Obstetrics and Gynecology, Hüma Obstetrics and Gynecology Hospital, IVF Center, Kayseri, Turkey
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23
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Gencer FK, Dincgez B, Yuksel S. Levonorgestrel-Releasing Intrauterine Device Use Can Be a Treatment Option in Symptomatic Patients with Isthmocele. Reprod Sci 2022; 29:2977-2982. [PMID: 35610461 DOI: 10.1007/s43032-022-00976-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022]
Abstract
Levonorgestrel-releasing intrauterine devices have been used for contraception and treatment of heavy menstrual bleeding. There is only limited data about the effect of this on isthmocele. Here, we aimed to evaluate the effect of levonorgestrel-releasing intrauterine devices in a larger study population with a longer follow-up as compared to the literature on symptomatic patients with isthmocele. A total of 29 patients with symptomatic isthmocele and inserted levonorgestrel-releasing device were included in this prospective study. All patients were included at January 2020 and followed for 18 months. Sociodemographic findings, laboratory parameters, premenstrual spotting, postmenstrual spotting, menorrhagia, dysmenorrhea, and pelvic pain related to isthmocele were recorded. In sonography, width, length, area of isthmocele, and residual myometrial thickness were determined. The frequency of symptoms during follow-up was compared between visits and also compared between groups according to residual myometrial thickness. Premenstrual spotting and pelvic pain were significantly reduced at 6th months (48.3 to 10.3%, p = 0.007 and 34.5 to 10.3%, p = 0.039, respectively) and no significant change was detected until the end of follow-up period. Postmenstrual spotting reduced at 6th months (96.6 to 34.5%, p < 0.001) and also significant change was detected between 6 and 12th months (34.5% vs 13.8%, p = 0.031). Menorrhagia and dysmenorrhea disappeared at 12th months. No association was found between residual myometrial thickness and the frequency of symptoms for each follow-up. Levonorgestrel-releasing intrauterine devices are useful and reliable therapeutic tools for symptomatic isthmocele patients who do not desire fertility, regardless of residual myometrial thickness.
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Affiliation(s)
- Fatma Ketenci Gencer
- Department of Obstetrics and Gynecology, Istanbul Gaziosmanpasa Training and Research Hospital, University of Health Sciences, Hizirefendi Street, Gaziosmanpasa, 34255, Istanbul, Turkey.
| | - Burcu Dincgez
- Department of Obstetrics and Gynecology, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Semra Yuksel
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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24
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Hosseini E, Aghajanpour S, Zameni N, Hafezi M. Isthmocele—a neglected cause of secondary infertility and implantation failure: A case report. Clin Case Rep 2022; 10:e05853. [PMID: 35600035 PMCID: PMC9107921 DOI: 10.1002/ccr3.5853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 12/02/2022] Open
Abstract
Isthmocele is myometrial scar tissue that develops after cesarean section delivery. In this case, other more prevalent pathologies delayed isthmocele diagnosis as the main cause of the patient's symptoms. Considering isthmocele is a fluid‐filled pouch‐like defect associated with infection caused by stagnant menstrual blood, its immunological aspects lead to implantation failure.
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Affiliation(s)
- Elham Hosseini
- Department of Obstetrics and Gynecology Mousavi Hospital School of Medicine Zanjan University of Medical Sciences Zanjan Iran
| | - Samaneh Aghajanpour
- Department of Endocrinology and Female Infertility Reproductive Biomedicine Research Center Royan Institute for Reproductive Biomedicine ACECR Tehran Iran
| | - Nadia Zameni
- School of Medicine Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Maryam Hafezi
- Department of Endocrinology and Female Infertility Reproductive Biomedicine Research Center Royan Institute for Reproductive Biomedicine ACECR Tehran Iran
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25
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Vrijdaghs V, Dewilde K, Froyman W, Van den Bosch T. Hysteroscopic management of caesarean scar defects. J OBSTET GYNAECOL 2022; 42:816-822. [PMID: 35014923 DOI: 10.1080/01443615.2021.2003310] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A caesarean section may lead to a defect of the myometrium at the site of the uterine scar. The association with abnormal uterine bleeding or impaired fertility has been demonstrated. Hysteroscopic remodelling reportedly reduces the symptoms. To review the available literature reporting on hysteroscopic treatment of these defects in symptomatic women with abnormal uterine bleeding or impaired fertility. A systematic search of PubMed and Cochrane databases has been performed until January 2021, including 27 articles. Hysteroscopic remodelling relieved symptoms of abnormal uterine bleeding in 60-100% and 25-100% of women with impaired fertility conceived within the follow up period. No major complications were reported. Hysteroscopic remodelling seems a treatment option in the management of symptomatic caesarean scar defects. Long-term follow-up and larger studies are needed to evaluate the effect on abnormal uterine bleeding as well as on reproductive outcomes.
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Affiliation(s)
- V Vrijdaghs
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - K Dewilde
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - W Froyman
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - T Van den Bosch
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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26
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Nobuta Y, Tsuji S, Kitazawa J, Hanada T, Nakamura A, Zen R, Amano T, Murakami T. Decreased Fertility in Women with Cesarean Scar Syndrome Is Associated with Chronic Inflammation in the Uterine Cavity. TOHOKU J EXP MED 2022; 258:237-242. [DOI: 10.1620/tjem.2022.j082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yuri Nobuta
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Jun Kitazawa
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Tetsuro Hanada
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Akiko Nakamura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Rika Zen
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
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27
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Nguyen AD, Nguyen HTT, Duong GTT, Phan TTH, Do DT, Tran DA, Nguyen TK, Nguyen TB, Ville Y. Improvement of symptoms after hysteroscopic isthmoplasty in women with abnormal uterine bleeding and expected pregnancy: A prospective study. J Gynecol Obstet Hum Reprod 2022; 51:102326. [DOI: 10.1016/j.jogoh.2022.102326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/11/2022] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
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28
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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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29
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Zhang Q, Lei L, Zhang A, Zou L, Xu D. Comparative effectiveness of laparoscopic versus hysteroscopic approach in patients with previous cesarean scar defect: a retrospective cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1529. [PMID: 34790735 PMCID: PMC8576701 DOI: 10.21037/atm-21-4339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
Background The aim of this study was to evaluate the clinical effectiveness and obstetric outcomes of laparoscopic and hysteroscopic surgery in patients with previous cesarean scar defect (PCSD). Methods A retrospective cohort analysis was performed on women who underwent laparoscopic or hysteroscopic surgery for PCSD from 2016 to 2019 at the Third Xiangya Hospital of Central South University. Among these participants, 13 underwent laparoscopic surgery and 33 received hysteroscopic surgery. Results Significant differences were displayed in the operative times (156.9±42.3 vs. 40.7±38.9 min, P<0.05), intra-operative blood loss (80.0±61.0 vs. 17.9±51.2 mL, P<0.05), hospital stay (7.1±1.6 vs. 4.1±2.1 days, P<0.05), postoperative hospital stay (4.3±0.8 vs. 1.5±1.1 days, P<0.05), and hospitalization expenses (22,240.3±249.9 vs. 9,547.1±4,747.2 yuan, P<0.05) between the laparoscopic surgery and hysteroscopic group. No significant difference was observed in the incidence of clinical efficacy between the laparoscopic and hysteroscopic surgery group. A total of 2 of the 4 patients in the laparoscopic surgery group, and 9 of 11 patients in the hysteroscopic surgery group delivered successfully. All 2 participants in the laparoscopic surgery group and 2 participants in the hysteroscopic surgery group were diagnosed with placenta previa. No uterine rupture was reported in our study. Conclusions Both laparoscopic and hysteroscopic surgery are safe and effective treatments for PCSD patients, and hysteroscopic surgery is more efficient for PCSD patients.
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Affiliation(s)
- Qi Zhang
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Lei Lei
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China.,Medical Center of Hysteroscopy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Aiqian Zhang
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Lingxiao Zou
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Dabao Xu
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
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30
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Gupta T, Singal K, Gupta N, Kohli S, Kanyal M. Comparative Study of USG and MRI in Evaluation of Isthmocele. J Obstet Gynaecol India 2021; 71:292-296. [PMID: 34408349 DOI: 10.1007/s13224-021-01433-w] [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: 09/19/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022] Open
Abstract
Objective To study the presence of isthmocele in post-cesarean women using USG and MRI and its correlation with risk factors. Method This was a prospective observational study. A total of 90 patients were enrolled at the time of discharge of cesarean delivery and were advised to come for follow-up at 3-4 months for detection of isthmocele. A total of 82 patients reported for follow-up, and TVS and MRI Pelvis were done for visualization of isthmocele. If isthmocele was diagnosed, its correlation with risk factors was studied. Results On TVS isthmocele was present in 11 patients and on MRI in 16 patients. Detection rate was 77.07% in comparison with previous studies. Compared to MRI, sensitivity of USG was 68.75%; however, the specificity and positive predictive value for both were 100%. The negative predictive value for USG compared to MRI was 92.96%. Shape of the isthmocele was triangular in most women. Obesity, prior history of cesarean delivery, elective cesarean, gestational diabetes, preeclampsia and prolonged active labor were associated with development of isthmocele. Conclusion The study concluded that yield of diagnosis of isthmocele by MRI was better than TVS but not statistically significant. Further study with large sample size is needed to identify the best tool for diagnosis of isthmocele. Obesity, gestational diabetes, preeclampsia, prior history of cesarean, elective cesarean and prolonged active labor were associated with development of isthmocele.
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Affiliation(s)
- Taru Gupta
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Khushbu Singal
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Nupur Gupta
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Supreeti Kohli
- Department of Radiology, ESI PGIMSR Basaidarapur, New Delhi, India
| | - Monica Kanyal
- Department of Obstetrics & Gynaecology, ESI PGIMSR Basaidarapur, New Delhi, India
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32
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Symptoms and Quality of Life Changes after Hysteroscopic Treatment in Patients with Symptomatic Isthmocele-Preliminary Results. J Clin Med 2021; 10:jcm10132928. [PMID: 34208804 PMCID: PMC8269349 DOI: 10.3390/jcm10132928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 11/17/2022] Open
Abstract
Due to an increasing number of cesarean section deliveries, the common consequences of that surgery are observed more often in the population. One of them is the uterine cesarean scar defect known as niche or isthmocele. Most patients with that aliment are asymptomatic, but some of them can report abnormal uterine bleeding, pelvic pain, subfertility which can be the reason for reduced quality of life (QoL) of the patients. In our study, we analyzed the subjective feelings of changes in the severity of symptoms and quality of life of women with niche after diagnostic and operative hysteroscopy. The patients n = 85 included in the study group completed a follow up questionnaire six months after the procedure. Patients after operative hysteroscopy in comparison to patients after diagnostic procedure reported statistically significant reduction in post-menstruation bleeding/spotting and improvement in the quality of sexual activity. We have also noticed a higher pregnancy rate in the operative group, however, the difference was not statistically significant. According to our study, most women reported a positive effect of hysteroscopy on their QoL in social, psychological, environmental, and health domains.
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33
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Fishbone double-layer barbed suture in cesarean section: a help in preventing long-term obstetric sequelae? Arch Gynecol Obstet 2021; 304:573-576. [PMID: 34146146 DOI: 10.1007/s00404-021-06121-8] [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: 11/27/2022]
Abstract
Due to the high number of cesarean sections over the last two decades, there has been a growing awareness of the post-surgical obstetric long-term sequelae (i.e., uterine scar defects and abnormal placentation) following this surgical procedure. Knotless barbed suture is an absorbable bidirectional and unidirectional monofilament, characterized by the presence of "barbs" along its length. After being introduced in gynecology, the favorable features of the knotless barbed suture, such as the uniform distribution of tensile force, provide the rationale for studying its benefits in obstetric surgery. Recently, our research group has investigated a double-layer barbed suture ("fishbone" suture) for closing the uterine wall during cesarean section by a case-control study, reporting a low incidence of uterine scar defects and a reduced size of defects in women who had developed them (NCT04825821). In the near future, large prospective studies are strongly awaited to investigate reproductive outcomes and long-term sequelae after cesarean section performed with knotless barbed suture.
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Black KA, Simone K, Hirt-Walsh C, Sabourin J. Epithelioid trophoblastic tumor presenting as a Caesarean scar defect: A case report. Gynecol Oncol Rep 2021; 36:100715. [PMID: 33604444 PMCID: PMC7873655 DOI: 10.1016/j.gore.2021.100715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/16/2021] [Accepted: 01/24/2021] [Indexed: 02/07/2023] Open
Abstract
Malignancy should be considered as a possible cause of a Caesarean scar defect. Gestational trophoblastic neoplasia can be present despite negative hCG. Limited evidence on fertility-sparing treatment of epithelioid trophoblastic tumor.
Background Epithelioid trophoblastic tumor is a rare form of gestational trophoblastic neoplasia. We present the first known case of this rare malignancy presenting as a Caesarean scar defect. Case A patient with 3 prior Caesarean sections presented with vaginal bleeding 2 months following management of retained products of conception. Her hCG was negative. She underwent surgical repair of a Caesarean scar defect, and pathology was consistent with epithelioid trophoblastic tumor. Conclusion This case highlights the possibility of malignancy presenting to the general gynecologist as a Caesarean scar defect. The diagnosis of gestational trophoblastic neoplasia should always be considered in the differential diagnosis of a patient with postpartum vaginal bleeding. Limited evidence on fertility conserving treatment of epithelioid trophoblastic tumors does not seem favorable.
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Affiliation(s)
- Kristin A Black
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kristen Simone
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Cassandra Hirt-Walsh
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Grey Nuns Community Hospital, Edmonton, Alberta, Canada
| | - Jeanelle Sabourin
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Division of Gynecologic Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
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Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update. J Obstet Gynaecol India 2021; 70:440-446. [PMID: 33417629 DOI: 10.1007/s13224-020-01370-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022] Open
Abstract
Uterine niche is one of the emerging complications of caesarean section. With rising caesarean rates, the caesarean-related iatrogenic complications are also on the rise. These include placenta accreta, scar ectopic pregnancy and uterine niche which is a newer entity being described in the recent literature. Uterine niche, also described as uterine isthmocele, caesarean scar defect and diverticulum, is an iatrogenic defect in the myometrium at the site of previous caesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding, post-menstrual spotting and infertility, though many women may be asymptomatic and diagnosed incidentally. Diagnosis is made radiologically by transvaginal sonography, saline instillation sonohysterography or magnetic resonance imaging. Occurrence of niche may be prevented by using correct surgical technique during caesarean. Patients may be managed medically; however, subfertility and persistent symptoms may require surgical correction either by hysteroscopic resection or transabdominal or transvaginal repair. This mini-review comprehensively covers the potential risk factors, clinical presentation, diagnosis and management of this increasingly encountered condition due to rising caesarean rates.
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Tsuji S, Takahashi A, Higuchi A, Yamanaka A, Amano T, Kimura F, Seko-Nitta A, Murakami T. Pregnancy outcomes after hysteroscopic surgery in women with cesarean scar syndrome. PLoS One 2020; 15:e0243421. [PMID: 33270754 PMCID: PMC7714235 DOI: 10.1371/journal.pone.0243421] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022] Open
Abstract
Cesarean scar defect often causes postmenstrual abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, and infertility, which are collectively known as cesarean scar syndrome (CSS). Several studies have reported that hysteroscopic surgery can restore fertility in women with CSS. The study aimed to identify factors that influence subsequent pregnancy following hysteroscopic surgery. Therefore, we studied 38 women with secondary infertility due to CSS who underwent hysteroscopic surgery at Shiga University of Medical Hospital between July 2014 and July 2019. Our hysteroscopic procedure included inferior edge resection and superficial cauterization of the cesarean scar defect under laparoscopic guidance. Patients were followed up for 3 to 40 months after surgery. Surgery was successful in all cases and no complications were observed. Twenty-seven patients (71%) became pregnant (pregnant group), while 11 (29%) did not (non-pregnant group). Baseline characteristics of age, body mass index, gravidity, parity, previous cesarean section, presence of endometriosis, retroflex uterus, and preoperative residual myometrial thickness were not significantly different between the groups. However, the median residual myometrium thickness was significantly higher after surgery than before surgery in the pregnant group (1.9 [1.1-3.6] vs 4.9 [3.4-6.6] mm, P<0.0001), whereas this difference was not significant in the non-pregnant group. Of those who became pregnant, 85% conceived within 2 years of surgery. Although three pregnancies resulted in abortion and one is ongoing at the time of writing, 23 pregnancies resulted in healthy babies at 35-38 gestational weeks by scheduled cesarean sections with no obstetrical complications due to hysteroscopic surgery. The average birth weight was 3,076 g. Our findings support that hysteroscopic surgery is a safe and effective treatment for secondary infertility due to CSS. The thickness of the residual myometrium may be a key factor that influences subsequent pregnancy in women with CSS.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
- * E-mail:
| | - Akimasa Takahashi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Asuka Higuchi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Akiyoshi Yamanaka
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Ayumi Seko-Nitta
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
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Zeller A, Villette C, Fernandez H, Capmas P. Is Hysteroscopy a Good Option to Manage Severe Cesarean Scar Defect? J Minim Invasive Gynecol 2020; 28:1397-1402. [PMID: 33197611 DOI: 10.1016/j.jmig.2020.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/28/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To compare the outcomes of hysteroscopic management in women with a severe or nonsevere symptomatic cesarean scar defect (residual myometrium ≤3-mm vs >3-mm, respectively). DESIGN Retrospective cohort study. SETTING Gynecology department of a teaching hospital. PATIENTS Seventy-one women with an operative hysteroscopy for a symptomatic defect (49 with severe defects and 22 with nonsevere ones). INTERVENTIONS Operative hysteroscopy for cesarean scar defect in women with a severe defect (residual myometrium ≤3-mm) and with nonsevere defect (residual myometrium >3-mm). MEASUREMENTS The main objective was to compare success rates between the 2 groups. The secondary objectives were the comparisons of (1) the number of women who required more than 1 procedure, (2) the rate of complications, (3) the number of subsequent pregnancies, and (4) the evolution of residual myometrium thickness between the groups. MAIN RESULTS The success rates were not significantly different between the groups (73.5% in the severe group and 63.6% in the nonsevere group [p = .40]). The number of women requiring more than 1 procedure was also similar, as were the rate of complications and the mean increase of myometrium thickness. The rate of subsequent pregnancies in women who were infertile was significantly higher in women with a severe defect (p = .04). CONCLUSION The hysteroscopic approach seems to be a good way to manage cesarean scar defects even when the residual myometrium is thin. A prospective study is, however, necessary to confirm these findings.
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Affiliation(s)
- Amélie Zeller
- Department of Gynecology and Obstetrics, AP-HP, GHU-Sud, Hospital Bicêtre (Drs. Zeller, Villette, Fernandez, and Capmas); Faculty of Medicine, University Paris-Sud Saclay (Drs. Fernandez and Capmas), Le Kremlin-Bicêtre; INSERM, centre de research in Epidemiology and Population Health, U1018 (Drs. Fernandez and Capmas), Villejuif, France
| | - Claire Villette
- Department of Gynecology and Obstetrics, AP-HP, GHU-Sud, Hospital Bicêtre (Drs. Zeller, Villette, Fernandez, and Capmas); Faculty of Medicine, University Paris-Sud Saclay (Drs. Fernandez and Capmas), Le Kremlin-Bicêtre; INSERM, centre de research in Epidemiology and Population Health, U1018 (Drs. Fernandez and Capmas), Villejuif, France
| | - Hervé Fernandez
- Department of Gynecology and Obstetrics, AP-HP, GHU-Sud, Hospital Bicêtre (Drs. Zeller, Villette, Fernandez, and Capmas); Faculty of Medicine, University Paris-Sud Saclay (Drs. Fernandez and Capmas), Le Kremlin-Bicêtre; INSERM, centre de research in Epidemiology and Population Health, U1018 (Drs. Fernandez and Capmas), Villejuif, France
| | - Perrine Capmas
- Department of Gynecology and Obstetrics, AP-HP, GHU-Sud, Hospital Bicêtre (Drs. Zeller, Villette, Fernandez, and Capmas); Faculty of Medicine, University Paris-Sud Saclay (Drs. Fernandez and Capmas), Le Kremlin-Bicêtre; INSERM, centre de research in Epidemiology and Population Health, U1018 (Drs. Fernandez and Capmas), Villejuif, France.
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Yılmaz Baran Ş, Kalaycı H, Doğan Durdağ G, Yetkinel S, Alemdaroğlu S, Çok T, Bulgan Kılıçdağ E. Single- or double-layer uterine closure techniques following cesarean: A randomized trial. Acta Obstet Gynecol Scand 2020; 100:531-537. [PMID: 33029804 DOI: 10.1111/aogs.14018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Cesarean deliveries are commonly performed throughout the world. Although the uterine closure technique following this procedure may influence how the uterine scar heals, there is insufficient evidence for choosing the appropriate technique and so preventing long-term negative consequences. This prospective, randomized study examined the effects of single- and double-layer uterine closure techniques on uterine scar healing following cesarean delivery. MATERIAL AND METHODS This study assessed a total of 282 women aged 18-45 years who were in gestational weeks 24-41 of singleton pregnancies. None had previously undergone uterine surgeries. These participants completed their first cesarean deliveries at the time of study and were randomized into the following two treatment groups: single-layer closure with locking and double-layer closure with locking in the first layer, but not in the second layer (NCT03629028). However, the decidua was not included for treatment in either group. Participants were evaluated at 6-9 months after cesarean section by saline infusion sonohysterography to assess cesarean delivery scar defects. These procedures were conducted by experienced sonographers who were not aware of the uterine closure technique. RESULTS Of the 225 final participants, 109 received the single-layer closure technique, whereas 116 received the double-layer technique. The niche rates were 37% (n = 40) for the single-layer group and 45.7% (n = 53) for the double-layer group (P = .22, relative risk 1.4, 95% CI = 0.8-4.4). CONCLUSIONS The single- and double-layer closure techniques did not produce different impacts on uterine scar niche development.
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Affiliation(s)
- Şafak Yılmaz Baran
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Hakan Kalaycı
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Gülşen Doğan Durdağ
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Selçuk Yetkinel
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Songül Alemdaroğlu
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Tayfun Çok
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine, Adana, Turkey
| | - Esra Bulgan Kılıçdağ
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine, Adana, Turkey
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Chin HMS, Ng ZY, Yang L. Postmenopausal bleeding in a woman with caesarean scar defect: A case report. Case Rep Womens Health 2020; 27:e00235. [PMID: 32637326 PMCID: PMC7327884 DOI: 10.1016/j.crwh.2020.e00235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022] Open
Abstract
Background Caesarean scar defect (CSD) is a complication of caesarean section with implications for abnormal uterine bleeding. Most cases of CSD are discovered incidentally or with the development of menstrual changes. However, CSD may rarely have a longer latency period, resulting in postmenopausal presentation of bleeding and abdominal pain. Case A 52-year-old postmenopausal woman presented with acute suprapubic pain and postmenopausal bleeding. Pelvic ultrasonography and magnetic resonance imaging suggested bleeding from a CSD. Her symptoms resolved with expectant management. She subsequently underwent elective hysterectomy and bilateral salpingo-oophorectomy, which provided histological confirmation of a CSD. Conclusion Caesarean scar defect should be considered in patients who present with acute abnormal uterine bleeding or pelvic pain with a history of caesarean section, even after menopause. Caesarean scar defect may present as acute postmenopausal bleeding or pelvic pain. Endometrial biopsy should be carefully considered due to the risk of perforation. Hysterectomy may be offered for postmenopausal bleeding from a caesarean scar defect.
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Insights on Hysteroscopic Procedures and Their Place in Romanian Gynecologic Practice—The Experience of Two Medical Units. Diagnostics (Basel) 2020; 10:diagnostics10050281. [PMID: 32384648 PMCID: PMC7278013 DOI: 10.3390/diagnostics10050281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022] Open
Abstract
Hysteroscopy has known an increasing use in Romania over the last decade, succeeding to mark an impact on lowering the costs of medical services. The strategy of this study was to present the experience of two Romanian medical units with different experiences using inpatient regimen hysteroscopy, and to further compare it with current worldwide tendencies. Strong points in our practice were sought, as well as components that require improvement. Overall, abnormal uterine bleeding stands for most hospital case presentations in our study group; hysteroscopy had the highest accuracy and positive predictive value in identifying uterine myomas: 91.03% and 100%, respectively; for endometrial polyps, statistical analysis showed the highest sensitivity: 100%, with 83.89% specificity and a 77.64% positive predictive value. The applicability of hysteroscopy was further described for infertility cases and isthmocele repair.
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Vigueras Smith A, Cabrera R, Zomer MT, Ribeiro R, Talledo R, Kondo W. Combined Laparoscopic-Hysteroscopic Isthmoplasty Using the Rendez-vous Technique Guided Step by Step. J Minim Invasive Gynecol 2020; 27:1469-1470. [PMID: 31917331 DOI: 10.1016/j.jmig.2019.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/16/2019] [Accepted: 12/30/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To demonstrate the surgical technique of Rendez-vous isthmoplasty for the treatment of symptomatic cesarean scar defect. In this video, the authors show the complete procedure in a step-by-step manner to standardize and facilitate the comprehension and performance of the procedure in a simple and safe way. DESIGN Step-by-step video demonstration of the surgical technique. SETTING Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS The patient is a 36-year-old woman without any comorbidities, G3 C3, and with radiologic transvaginal ultrasound diagnosis of isthmocele grade 3 (over 25 mm) identified in the superior third of the cervical canal. The main steps of combined laparoscopic-hysteroscopic isthmoplasty using the Rendez-vous technique are described in detail. A combined laparoscopic-hysteroscopic approach was performed. Under general anesthesia, the patient was placed in 0° supine decubitus, with her arms alongside her body. Operative setup included 15 mm Hg pneumoperitoneum, created using the closed Veress technique, and 4 trocars: a 10-mm trocar at the umbilicus for a 0° laparoscope, a 5-mm trocar in the right iliac fossa, a 5-mm trocar in the left iliac fossa, and a 5-mm trocar in the suprapubic area. The procedure begins after a systematic exploration of the pelvic and abdominal cavities. Step 1: Identification of key anatomic landmarks and exposure of the operation field. Step 2: By carrying out blunt and sharp dissection with cold scissors or a harmonic scalpel, the visceral peritoneal layer over the isthmus area is opened, a vesicouterine space is developed, and the bladder is pushed down at least 2 cm from the lower edge of the isthmocele. Step 3: Final Phrase: By hysteroscopic exploration of the cervical canal using the vaginoscopic approach, identification and delimitation of the isthmocele its performed by recognizing the diverticular mucosal hyperplasia, and then the hysteroscopic light is pointed directly toward the cephalic limit of the scar defect. Step 4: Laparoscopic lights are decreased in intensity and the "Halloween sign" is identified (hysteroscopic transillumination). The light of the hysteroscope is pointed to the top of the cesarean scar defect allowing the laparoscopist to identify the upper and lower edges of the scar. Step 5: Laparoscopic resection of all scar tissue, excision of all the edges of the pseudo cavity. Step 6: Adequate intracorporeal suturing technique, with a 2-layer myometrial repair using intracorporeal running and interrupted stitches of polydioxanone 2-0, is done, while ensuring preservation of the cavity by not including the endometrial tissue in the myometrial suture [1-3]. Step 7: Installation of the methylene blue dye to locate any leakage. The surgery ended without any intraoperative complications and within 60 minutes. The patient was discharged on the first day postoperatively and became pregnant 6 months after surgery, with a final C-section delivery of a healthy term newborn at 39-weeks gestational age. CONCLUSION Combined Rendez-vous isthmoplasty is feasible, safe, and effective in experienced hands, giving the surgeon a comprehensive evaluation of the anatomy of the isthmocele, and increasing the odds of a complete resection and restoration of the anatomy [4-7]. In this patient, the procedure was uneventful, without any intra- or postoperative complications, and the symptoms were completely controlled.
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Affiliation(s)
- Andres Vigueras Smith
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil.
| | - Ramiro Cabrera
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
| | - Monica Tessmann Zomer
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
| | - Reitan Ribeiro
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
| | - Renzo Talledo
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
| | - William Kondo
- Department of Gynecological Surgery, Vita Batel Hospital (Drs. Vigueras Smith, Cabrera, Tessmann Zomer, Talledo, and Kondo); Department of Gynecological Surgery, Minimal Invasive Surgery and Oncology Unit, Erasto Gardner Hospital (Dr. Reitan), Curitiba, Brazil
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