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Chen H, Yao M, Gao Z, Yang X, Wang Y, Wang X. Outcomes of vaginal repair and vaginal repair combined with GnRHa administration in the treatment of cesarean section scar defects: A randomized clinical trial. J Minim Invasive Gynecol 2024:S1553-4650(24)00234-6. [PMID: 38810836 DOI: 10.1016/j.jmig.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
STUDY OBJECTIVE To prospectively investigate whether the application of vaginal repair (VR) of cesarean section scar defect (CSD) combined with a gonadotropin-releasing hormone agonist (GnRHa) achieve better clinical outcomes than VR alone. DESIGN A randomized clinical trial. SETTING University hospital. PATIENTS A total of 124 women with CSD were undergoing expectant management from December 2016 to September 2021. 61 were randomised to VR+ GnRHa and 63 to VR alone. INTERVENTION Vaginal repair combined with GnRHa and vaginal repair alone. MEASURES AND MAIN RESULTS The primary outcome was the duration of menstruation and thickness of the remaining muscular layer (TRM) at 6 months after surgery. Secondary outcomes included the length, width and depth of the CSD; operation time; estimated blood loss; hospitalization time; and operative complications. Women were treated with either VR (n = 63) or VR + GnRHa (n = 61). Menstruation and TRM in patients pre. vs. post comparisons either with VR or VR + GnRHa are significant improved (P < .05). Significant differences in menstruation duration and TRM occurred in patients treated with VR + GnRHa compared with those treated with VR (P < .05). Moreover, the rate of CSD after surgery in the VR group was significantly higher than that in the VR + GnRHa group (P = .033), and CSD patients in the VR + GnRHa group achieved better therapeutic effects than those in the VR group (P = .017). Patients who received VR + GnRHa had a shorter menstruation duration and a greater increment of TRM postoperatively than did patients treated with VR alone (P = .021; P = .002, respectively). CONCLUSION VR + GnRHa therapy has a greater potential to improve scar healing and reduce the number of menstruation days than VR alone for symptomatic women with CSD. PRéCIS: Vaginal Repair Combined with GnRHa Creates Better Therapeutic Effects of CSD. TRIAL REGISTRATION Date of registration: October 13, 2016, Date of initial participant enrollment: December 20, 2016, Clinical trial identification number: NCT02932761, URL of the registration site: ClinicalTrials.gov, Figshare DOI: 10.6084/m9.figshare.24117114 LINK TO THE CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/study/NCT02932761.
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Affiliation(s)
- Huihui Chen
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Min Yao
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Zhenyan Gao
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Xiaoqian Yang
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China
| | - Yizhi Wang
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China; Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China
| | - Xipeng Wang
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
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Candiani M, Dolci C, Schimberni M, Bartiromo L, Villanacci R, Grisafi G, Tandoi I, Salvatore S, Ferrari SM. Reproductive outcomes after vaginal repair of isthmocele: A preliminary study and systematic review of the literature. Eur J Obstet Gynecol Reprod Biol 2024; 296:163-169. [PMID: 38447278 DOI: 10.1016/j.ejogrb.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/06/2024] [Accepted: 02/11/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE Although vaginal repair of isthmocele is an effective and safe surgical option, data on reproductive and obstetrical outcomes are lacking. The aim of this study is to evaluate reproductive outcomes of women undergone vaginal repair of isthmocele. We also systematically reviewed the existent literature to offer a general view of available data. STUDY DESIGN Retrospective analysis of a database prospectively collected between January 2018 and January 2022 at San Raffaele Hospital, Milan, Italy. We included secondary infertile women with ultrasound documented isthmocele who undergone vaginal repair. Post-surgical clinical, reproductive and obstetric outcomes were recorded. An advanced systematic search of the literature up to January 2023 was conducted. RESULTS 17 women were included. The mean age of the included patients was 37.2 ± 2.7 years. The median of previous caesarian sections was 1 (1-2). One intra-operative complication (5.9 %) was reported (bladder injury, repaired at the time of surgery). At follow up, bleeding was successfully treated in 8 women (8/10; 80 %). Pregnancy was obtained in 7 women (7/17; 41.2 %): the conception was spontaneous in 4 women (4/7; 57.1 %) and trough assisted reproductive technology in 3 patients (3/7; 42.9 %). The mean time from surgery to pregnancy was 10.8 (±6.7) months. One spontaneous abortion was reported (1/7; 14.3 %), while live birth was achieved in 6 pregnancies (6/7; 85.7 %). All deliveries were by caesarian section at a median gestational age of 37.5 (36-38.25) weeks. No obstetrical complications were reported. At the time of caesarean section, no defects on the lower segment were retrieved. Regarding the systematic research, among the 21 studies screened, only 4 articles were included in the review. Pregnancy rate was around 60-70 % with very few obstetrical complications (0.01 %) such as abnormal placentation or preterm birth. CONCLUSIONS Vaginal repair of isthmocele is a minimally invasive, safe and effective surgical approach in terms of postsurgical residual myometrium tichness. Systematic review to date has found low-quality evidences on the impact of vaginal surgery in the management of secondary infertility and obstetrics outcomes in women with isthmocele.
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Affiliation(s)
- Massimo Candiani
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Carolina Dolci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy.
| | - Matteo Schimberni
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Ludovica Bartiromo
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Roberta Villanacci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Giorgia Grisafi
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Iacopo Tandoi
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefano Salvatore
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefano Maria Ferrari
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
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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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Mc Gowan S, Goumalatsou C, Kent A. Fantastic niches and where to find them: the current diagnosis and management of uterine niche. Facts Views Vis Obgyn 2022; 14:37-47. [PMID: 35373546 PMCID: PMC9612856 DOI: 10.52054/fvvo.14.1.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Caesarean section (CS) scar niche is a well recognised complication of caesarean delivery and is defined as an indentation at the site of the CS scar with a depth of at least 2mm. Objectives To review systematically the medical literature regarding the current diagnosis and management of uterine niche Materials and methods We carried out a systematic review using MeSH terms ‘niche’ OR ‘sacculation’ OR ‘caesarean scar defect’ OR ‘caesarean section scar’ OR ‘uterine defect’ OR ‘isthmocele.’ Articles included were peer-reviewed and in English language. Main outcome measures Prevalence, symptoms, diagnosis, pathophysiology and management of uterine niche. Results CS scar niche is common and, in a subgroup, produces a range of symptoms including post-menstrual bleeding, dyspareunia and subfertility. It may be linked to use of locked sutures during CS closure. Niche repair can be achieved laparoscopically or hysteroscopically and appears to improve symptoms, although solid conclusions regarding fertility outcomes cannot be drawn. Conclusions CS scar niche is associated with a range of symptoms. Repair may aid subfertile patients and those with post-menstrual spotting. The presence of a niche is probably irrelevant in the absence of symptoms. What is new? LNG-IUS and surgical repair appear to improve symptoms in those with a niche.
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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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Caesarean section defects may affect pregnancy outcomes after in vitro fertilization-embryo transfer: a retrospective study. BMC Pregnancy Childbirth 2021; 21:487. [PMID: 34229640 PMCID: PMC8261987 DOI: 10.1186/s12884-021-03955-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean section rates are rising worldwide. One adverse effect of caesarean section reported in some studies is an increased risk of subfertility. Only a few studies have assessed the relationship between the previous mode of delivery and in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) reproductive outcomes. In this study, we primarily investigated the impact of a history of caesarean section with or without defects on IVF/ICSI-ET outcomes compared to a vaginal delivery history. Methods This retrospective study included 834 women who had a IVF or ICSI treatment at our centre between 2015 and 2019 with a delivery history. In total, 401 women with a previous vaginal delivery (VD) were assigned to the VD group, and 433 women with a history of delivery by caesarean section were included, among whom 359 had a caesarean scar (CS) without a defect and were assigned to the CS group and 74 had a caesarean section defect (CSD) and were assigned to the CSD group. Baseline characteristics of the three groups were compared and analysed. Binary logistic regression analyses were performed to explore the association between clinical outcomes and different delivery modes. Results There were no significant differences in the live birth rate, biochemical pregnancy rate, clinical pregnancy rate, mean implantation rate or abnormal pregnancy rate between the CS and VD groups However, the live birth rate and mean implantation rate in the CSD group were significantly lower than those in the VD group (21.6 vs 36.4%, adjusted OR 0.50 [0.27–0.9]; 0.25 ± 0.39 vs 0.35 ± 0.41, adjusted OR 0.90 [0.81–0.99]). Among women aged ≤ 35 years, the subgroup analyses showed that the live birth rate, biochemical pregnancy rate, clinical pregnancy rate, and mean implantation rate in the CSD group were all significantly lower than those in the VD group (21.4 vs 45.8%, adjusted OR 0.35[0.15 ~ 0.85]; 38.1 vs 59.8%, adjusted OR 0.52[0.24–0.82]; 31.0 vs 55.6%, adjusted OR 0.43[0.19–0.92]; 0.27 ± 0.43 vs 0.43 ± 0.43, adjusted OR 0.85[0.43 ± 0.43]). For women older than 35 years, there was no statistically significant difference in any pregnancy outcome among the three groups. Conclusions This study suggested that the existence of a CS without a defect does not decrease the live birth rate after IVF or ICSI compared with a previous VD. However, the presence of a CSD in women, especially young women (age ≤ 35 years), significantly impaired the chances of subsequent pregnancy.
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Zheng X, Yan J, Liu Z, Wang X, Xu R, Li L, Lin Z, Zheng L, Liu M, Chen Y. Safety and feasibility of trial of labor in pregnant women with cesarean scar diverticulum. J Int Med Res 2021; 48:300060520954993. [PMID: 32938285 PMCID: PMC7503006 DOI: 10.1177/0300060520954993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Literature on trial of labor after cesarean section (TOLAC) in women with isthmoceles is scarce because of complications associated with the procedure. This study investigated TOLAC's safety and feasibility in patients with isthmoceles. METHODS The study group comprised 34 pregnant women with isthmoceles who vaginally delivered. The control group comprised 102 pregnant women without isthmoceles who vaginally delivered during the same period. Scar diverticula were measured using color Doppler ultrasonography; between-group delivery outcomes were compared. RESULTS Of the study group patients, 27/34 had isthmoceles diagnosed by ultrasound before pregnancy. Nineteen (70.37%) of these patients had mild defects and eight (29.63%) had moderate defects. The scar diverticula's mean length, depth, and width were 1.05 ± 0.62, 0.54 ± 0.28, and 1.20 ± 0.70 cm, respectively. The residual muscle layer's mean thickness was 0.27 ± 0.07 cm. The mean diverticulum depth/residual muscular thickness ratio was 2.39 ± 2.58. The duration of the first stage of labor was significantly shorter and the neonatal weight was significantly lower in the study group than control group. CONCLUSION Successful vaginal delivery is possible for women with mild and moderate isthmoceles. Further large-scale studies are needed to improve TOLAC's safety in pregnant women with isthmoceles.
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Affiliation(s)
- Xiuqiong Zheng
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Jianying Yan
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Zhaozhen Liu
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Xuechun Wang
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Rongli Xu
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Liying Li
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Zhi Lin
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Lianghui Zheng
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Min Liu
- Department of Ultrasound, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Yan Chen
- Department of Ultrasound, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, P.R. China
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Harjee R, Khinda J, Bedaiwy MA. Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review. J Minim Invasive Gynecol 2021; 28:1291-1302.e2. [PMID: 33839308 DOI: 10.1016/j.jmig.2021.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/11/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility. DATA SOURCES A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English. METHODS OF STUDY SELECTION After the removal of duplicates, 3380 articles were screened for inclusion independently by 2 authors. These 2 authors assessed for studies which focused on women of reproductive age with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least 1 of the goals being fertility restoration. TABULATION, INTEGRATION, AND RESULTS A total of 13 studies, comprising of 1 randomized controlled trial, 6 prospective case series, and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodologic quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. A total of 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods. Pregnancy rates in the randomized controlled trial were 21 of 28 (75%) for those treated by hysteroscopy compared with 9 of 28 (32%) for those untreated. Among the studies reporting pregnancy outcomes, 101 of 116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including the risk of reoperation. CONCLUSION The results of this systematic review suggest that the surgical treatment of an isthmocele, particularly through hysteroscopy, in patients with residual myometrial thickness of at least 2.5 mm, may be effective in treating isthmocele-associated secondary infertility with a relatively low complication rate. Further high-quality studies are needed because of the small sample sizes and observational nature of most available data.
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Affiliation(s)
- Rahana Harjee
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaskaran Khinda
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada.
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Zhang Y, Jia Y, Wang X, Sun Q. Feasibility analysis of different surgical methods for uterine cesarean section scar diverticulum. J Obstet Gynaecol Res 2020; 46:1758-1765. [PMID: 32567071 DOI: 10.1111/jog.14351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/02/2020] [Accepted: 05/23/2020] [Indexed: 11/29/2022]
Abstract
AIM This study analyses the effects of surgical indicators and clinical efficacy of different surgical methods for uterine cesarean section scar diverticulum. METHODS This retrospective cohort study included 65 patients who underwent surgery and postoperative follow-up at Gansu Provincial Maternity and Child-care Hospital from 1 January 2013 to 31 February 2019. RESULTS All participants were treated surgically. Among them, patients in Group A underwent combined laparoscopic and hysteroscopic surgery (n = 45), Group B underwent transvaginal surgery (n = 11), Group C underwent laparotomy (n = 9). The primary outcomes were surgical indicators. The secondary outcomes were clinical efficacy. Bleeding, operation time and hospitalization expenses were significantly different among the three groups (P < 0.05). There was no difference in the hospital stay among the three groups P = 0.22). The menstrual period before and after surgery was significantly different among the groups (P < 0.05). The recurrence outcome was no significantly different (P = 0.16), but the pregnancy outcome was not (P = 0.78). CONCLUSION The three surgical methods are effective for treating cesarean section scar diverticulum with favorable effects. Laparoscopic combined with hysteroscopic surgery is minimally invasive with less bleeding compared with the other two techniques and it is easier for patients to accept. It is the most widely used surgical method.
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Affiliation(s)
- Yanhua Zhang
- Department of Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Yanfeng Jia
- Department of Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Xiaoli Wang
- Department of Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Qian Sun
- Department of Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
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He Y, Zhong J, Zhou W, Zeng S, Li H, Yang H, Shan N. Four Surgical Strategies for the Treatment of Cesarean Scar Defect: A Systematic Review and Network Meta-analysis. J Minim Invasive Gynecol 2020; 27:593-602. [DOI: 10.1016/j.jmig.2019.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 02/04/2023]
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Cai Y, Pan H, Zhang J, Cheng W, Shi Y, Zeng M, Shi L, Yu J, Shen Y, Chen S, Zhu Q, Mol BW, Huang D. Efficacy of adjunctive azithromycin versus single-dose cephalosporin prophylaxis for caesarean scar defect: study protocol for a randomised controlled trial. BMJ Open 2020; 10:e032379. [PMID: 31915163 PMCID: PMC6955559 DOI: 10.1136/bmjopen-2019-032379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Perioperative infections may be considered predictors of caesarean scar defect (CSD), and multidose antibiotics have a protective effect against CSD. However, the ability of adjunctive azithromycin combined with cephalosporin to reduce the prevalence of CSD remains unclear. The planned study aims to clarify the protective effect of antibiotics against CSD and to assess the effectiveness of adjunctive azithromycin prophylaxis for CSD. METHODS AND ANALYSIS This study is a double-blind, parallel-control randomised clinical trial that will be carried out at the International Peace Maternity and Child Health Hospital. A total of 220 eligible patients will be randomised (1:1) to receive either adjunctive azithromycin or single-dose cephalosporin 30 min before the incision. The evaluation criteria are the prevalence and characteristics of CSD as assessed by transvaginal ultrasound (TVU) and saline infusion sonohysterography (SIS) at 42 days, 6 months and 12 months after delivery. The primary outcome will be the prevalence of CSD, and the characteristics of CSD will be assessed by TVU and SIS 42 days after delivery; all other outcomes are secondary. ETHICS AND DISSEMINATION This protocol received authorisation from the Medical Research Ethics Committee of International Peace Maternity and Child Health Hospital on 25 April 2018 (approval no. GKLW2017-84). The findings will be reported in peer-reviewed publications and presentations at international scientific meetings. TRIAL REGISTRATION NUMBER ChiCTR-INR-17013272.
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Affiliation(s)
- Yanqing Cai
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Hongjie Pan
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
- Obstetrics and Gynecology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
| | - Jian Zhang
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Weiwei Cheng
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Yiru Shi
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Min Zeng
- Ultrasound, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Liye Shi
- Ultrasound, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Jin Yu
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Ying Shen
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Shan Chen
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Qian Zhu
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Ben W Mol
- Obstetrics and Gynecology, Monash University, Melbourne, Victoria, Australia
- Robinson Research Institute, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Ding Huang
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
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Wang Y, Zhu Q, Lin F, Xie L, Li J, Wang X. Development and internal validation of a Nomogram for preoperative prediction of surgical treatment effect on cesarean section diverticulum. BMC Womens Health 2019; 19:136. [PMID: 31711470 PMCID: PMC6849201 DOI: 10.1186/s12905-019-0817-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/23/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The aim of this study was to develop and validate an individualized score based on preoperative parameters to predict patient outcomes after vaginal repair of cesarean section diverticulum. METHODS This is a retrospective cohort study (Canadian Task Force classification II-2). Patients were enrolled between Jun 11, 2012, to May 27, 2016. Multivariable logistic regression analyses were used to construct the predictive model. Then, we generated a nomogram to assess the individualized risk of poor prognosis after operation. This prediction model included information from 167 eligible patients diagnosed with cesarean section diverticulum who underwent vaginal repair. Class-A healing group was defined as CSD patients who had menstruation duration of no more than 7 days and a thickness of the remaining muscular layer of no less than 5.8 mm after vaginal repair according to conferences. Others were included in the non-class-A healing group. A final nomogram was computed using a multivariable logistic regression model. RESULTS The factors contained in the individualized prediction nomogram included the depth/ the thickness of the remaining muscular layer ratio, number of menstruation days before surgery, White blood cell and fibrinogen. This model demonstrated adequate discrimination and calibration (C-index = 0.718). There was a significant difference in the number of postmenstrual spotting days (12.98 ± 3.86 VS 14.46 ± 2.86, P = 0.022) and depth/ the thickness of the remaining muscular layer ratio (2.81 ± 1.54 VS 4.00 ± 3.09, P = 0.001) between two groups. Decision curve analysis showed that this nomogram was clinically useful. CONCLUSIONS This cesarean section diverticulum score can predict the outcomes of cesarean section diverticulum and can be useful for counseling patients who are making treatment decisions.
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Affiliation(s)
- Yizhi Wang
- Department of Gynecology & Obstetrics, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092 China
| | - Qinyi Zhu
- Shanghai first maternity and infant health institute, Shanghai, China
| | - Feikai Lin
- Department of Gynecology & Obstetrics, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Xie
- Clinical Statistics Center, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jiarui Li
- Department of Gynecology & Obstetrics, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092 China
| | - Xipeng Wang
- Department of Gynecology & Obstetrics, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092 China
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Chen H, Wang H, Zhou J, Xiong Y, Wang X. Vaginal Repair of Cesarean Section Scar Diverticula Diagnosed in Non-pregnant Women. J Minim Invasive Gynecol 2019; 26:526-534. [DOI: 10.1016/j.jmig.2018.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 06/18/2018] [Accepted: 06/18/2018] [Indexed: 12/01/2022]
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Pan H, Zeng M, Xu T, Li D, Mol BWJ, Sun J, Zhang J. The prevalence and risk predictors of cesarean scar defect at 6 weeks postpartum in Shanghai, China: A prospective cohort study. Acta Obstet Gynecol Scand 2018; 98:413-422. [PMID: 30444954 DOI: 10.1111/aogs.13505] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/06/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The aim of this study was to explore the prevalence and predictors of cesarean scar defect (CSD) at 6 weeks postpartum in Shanghai, China. MATERIAL AND METHODS Women scheduled to receive a cesarean section (CS) were recruited from a university hospital. Surgery-related factors, pregnancy complications, routine examinations, perioperative medications, and physical signs were collected and transvaginal ultrasonography was performed to assess the presence of a CSD at 6 weeks postpartum. Multivariate logistic regression was applied to identify the predictors for CSD. RESULTS A CSD was detected in 223 of 514 women (43.4%, 95% CI 39.1%-47.7%) by transvaginal ultrasonography. Of women with normal temperature (T < 37.5°C, CSD prevalence 33.9%, 95% CI 28.4%-39.5%), women with postpartum fever (T ≥ 38°C, CSD 44.1%, 95% CI 31.0%-57.1%), and women who were subfebrile in the postpartum (37.5 ≤ T ≤ 38.0°C, CSD 58.3%, 95% CI 50.9%-65.7%), the latter two had significantly increased risk for CSD (adjusted odds ratio [aOR] 2.7, 95% CI 1.3-5.2 and aOR 3.3, 95% CI 2.1-5.3, respectively). In comparison to single-dose antibiotic administration (CSD 49.0%, 95% CI 43.8%-54.3%), multi-dose antibiotic administration (CSD 31.1%, 95% CI 23.8%-38.3%) had a protective effect (aOR 0.4, 95% CI 0.3-0.7). Postpartum fever, intrapartum infection, emergency CS, and cervical dilation ≥ 3 cm were found to be the main predictors of multi-dose antibiotics management. Low platelet count postpartum (defined as ≤ 150 × 109 /L) and high fibrinogen pre-CS (defined as ≥ 4.5 g/L) increased CSD risk (aOR 2.0, 95% CI 1.1-3.6 and 1.7, 95% CI 1.1-2.5, respectively). CONCLUSIONS The prevalence of CSD in the Chinese population is high enough to be a concern. Perioperative infection and hypercoagulability should be considered CSD predictors, and multi-dose antibiotics have a protective effect.
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Affiliation(s)
- Hongjie Pan
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Institute of Embryo-Fetal Original Adult Disease Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ming Zeng
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Tianyi Xu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Dong Li
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Institute of Embryo-Fetal Original Adult Disease Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ben W J Mol
- The Robinson Research Institute, School of Pediatrics and Reproductive Health, University of Adelaide and The South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Jing Sun
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, TongJi University School of Medicine, Shanghai, China
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Institute of Embryo-Fetal Original Adult Disease Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Zhao W, Liu G, Yang Q, Zhang C. A new method using a Foley Catheter to locate the diverticulum in laparoscopic repair of uterine cesarean scar defects. Eur J Obstet Gynecol Reprod Biol 2018; 223:14-17. [DOI: 10.1016/j.ejogrb.2018.01.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/27/2018] [Accepted: 01/28/2018] [Indexed: 10/18/2022]
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Wang YQ, Yin TL, Xu WM, Qi QR, Wang XC, Yang J. Reproductive outcomes in women with prior cesarean section undergoing in vitro fertilization: A retrospective case-control study. Curr Med Sci 2017; 37:922-927. [PMID: 29270754 DOI: 10.1007/s11596-017-1828-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/18/2017] [Indexed: 12/22/2022]
Abstract
The impact of prior cesarean section (CS) on the pregnancy and neonatal outcomes of in vitro fertilization and embryo transfer (IVF-ET) was investigated. A retrospective analysis was performed on 144 patients with prior CS between January 2013 and December 2015. The pregnancy, delivery, and neonatal outcomes of patients who had previous CS delivery and received IVF-ET were analyzed. The control group comprised 166 patients who had only previous vaginal delivery (VD) and received IVF-ET during the same period. The results showed that the basal follicle stimulating hormone level, estradiol level on human chorionic gonadotropin (hCG) day, gonadotrophin dosage, duration of stimulation, retrieved oocytes, fertilization rate, high-quality embryo rate, multiple birth rate, abortion rate and ectopic pregnancy rate had no significant difference between the two groups (P>0.05). The pregnancy rate (40.28% vs. 54.22%) and implantation rate (24.01% vs. 34.67%) were significantly lower (P<0.05), and the ratio of embryo difficulty transfer (9/144 vs. 0/166) was significantly higher in CS group than in VD group. The risk of pernicious placenta previa and postpartum hemorrhage in twin deliveries was significantly increased in CS group as compared with that in VD group (P<0.05), and gestational age and neonatal birth weight were significantly reduced in twin deliveries as compared with singleton deliveries in both groups (P<0.05). It was suggested that the existence of CS scar may impact embryo implantation and clinical pregnancy outcome, and increase the difficulty of ET. We should limit the number of transfer embryos to avoid multiple pregnancies and strengthen gestational supervision in patients with cesarean scar.
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Affiliation(s)
- Ya-Qin Wang
- Reproductive Medical Center, Renmin Hospital, Wuhan University, Wuhan, 430060, China.,Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, 430060, China
| | - Tai-Lang Yin
- Reproductive Medical Center, Renmin Hospital, Wuhan University, Wuhan, 430060, China.,Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, 430060, China
| | - Wang-Min Xu
- Reproductive Medical Center, Renmin Hospital, Wuhan University, Wuhan, 430060, China.,Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, 430060, China
| | - Qian-Rong Qi
- Reproductive Medical Center, Renmin Hospital, Wuhan University, Wuhan, 430060, China.,Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, 430060, China
| | - Xiao-Chen Wang
- Reproductive Medical Center, Renmin Hospital, Wuhan University, Wuhan, 430060, China.,Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, 430060, China
| | - Jing Yang
- Reproductive Medical Center, Renmin Hospital, Wuhan University, Wuhan, 430060, China. .,Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan, 430060, China.
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Xu HY, Yang MY, Zhang X, Wang Q, Yi XF, Ding JX, Hua KQ. Efficacy of caesarean scar defect repair in improving postmenstrual bleeding and factors associated with poor effect. J OBSTET GYNAECOL 2017; 37:1076-1081. [PMID: 28760055 DOI: 10.1080/01443615.2017.1324833] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Caesarean scar defect (CSD) can cause postmenstrual bleeding. Defect repair is an effective technique to improve this symptom, but there are still a few patients getting little improvement. This retrospective study evaluates the efficacy of scar repair and explores the factors associated with poor effect. In total, 123 patients were involved in the final analysis. All of them complained about menstruation period >7 days due to postmenstrual bleeding. Before surgery, 87.8% of patients had a menstruation period more than 10 days and 20.3% had a period more than 15 days. After surgery, a normal menstruation period (< =7 days) was achieved in 46.3% (95%CI 37.3%-55.6%) of patients and a menstruation period lasting no more than 10 days was achieved in 74.8% (95%CI 66.2%-82.2%). Through multivariate logistic analysis, four factors were found dependently associated with poor effect (defined as menstruation period >10 days after surgery): repeated caesarean section (OR 9.75, 95%CI 2.30-41.36, 0.002) was a risk factor, while defect volume >600 mm3 (OR 0.14, 95%CI 0.03-0.56, 0.006), interval from caesarean section to symptom emerging >3 months (OR 0.25, 95%CI 0.07-0.94, 0.041) and straight or retroflexed uterus (OR 0.19, 95%CI 0.05-0.79, 0.022) were protective factors. Impact statement What is already known on this subject? Caesarean scar defect can cause postmenstrual bleeding. Defect repair can improve this symptom, but there are still a few patients getting little improvement after surgery. What do the results of this study add? Defect volume >600 mm3, interval from caesarean section to symptom emerging >3 months and straight or retroflexed uterus are protective factors of poor effect (defined as menstruation period >10 days after surgery), and repeated caesarean section is a risk factor. What are the implications of these findings for clinical practice and/or further research? These findings may help in counselling the patients and in medical decision. Further researches are needed to explore other factors associated with surgical effect and build prediction models.
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Affiliation(s)
- He-Yang Xu
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
| | - Meng-Yi Yang
- b Department of Gynecology , Shanghai First Maternity and Infant Hospital , Shanghai , P.R. China
| | - Xuyin Zhang
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
| | - Qing Wang
- c Department of Gynecology , Pudong New District Maternal and Child Health Hospital , Shanghai , P.R. China
| | - Xiao-Fang Yi
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
| | - Jing-Xin Ding
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
| | - Ke-Qin Hua
- a Department of Gynecology , Obstetrics and Gynecology Hospital of Fudan University , Shanghai , P.R. China
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A Comparative Study of Transvaginal Repair and Laparoscopic Repair in the Management of Patients With Previous Cesarean Scar Defect. J Minim Invasive Gynecol 2016; 23:535-41. [DOI: 10.1016/j.jmig.2016.01.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 11/21/2022]
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