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      Ultrasonographic Evaluation of Uterine Scar Niche before and after Laparoscopic Surgical Repair: A Case Report

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          Abstract

          Context Uterine scar defects or scar niche are relatively common after cesarean delivery. An association has been observed between the severity of scar defect, also known as isthmocele, some gynecologic symptoms, and the risk of uterine scar dehiscence at the next delivery. It has been suggested that surgical repair of scar defect could improve the gynecological symptoms, but it remains unclear whether such surgery mends the uterine scar itself.

          Case Report We report the case of a woman with uterine scar defect in whom laparoscopic repair significantly improved the gynecological symptoms without affecting the uterine scar, evaluated by hysterosonography.

          Conclusion This case highlights the significant dearth of knowledge surrounding the diagnosis, consequences, and benefits of surgical repair of uterine scar defect after cesarean.

          Most cited references15

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          Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position.

          To determine the prevalence of clinical symptoms associated with Cesarean scar defects, and to determine the association between the size of these defects, clinical complaints, uterine position, and a history of multiple Cesarean sections. In this cross-sectional study, Cesarean scar defects in women with a history of transverse lower-segment Cesarean section were measured by transvaginal ultrasound while being assessed for other gynecological conditions. The relationships between the size of the Cesarean scar defect and the clinical symptoms, uterine position and number of previous Cesarean sections were evaluated. Patients with other uterine pathologies, including endometrial hyperplasia, polyps, malignancy and submucosal myomas, were excluded from the study. During a 3-year period, 4250 women were assessed by transvaginal sonography, of whom 293 (6.9%) were diagnosed with Cesarean scar defects. Eighty-six patients were excluded due to other uterine pathologies. Altogether, 207 patients with Cesarean scar defects were included in this study. Women who had undergone multiple Cesarean sections tended to have larger scar defects (in width and depth) than did those who had undergone a single Cesarean section. Women with retroflexed uteri also tended to have wider defects than those with anteflexed uteri. Defect width was significantly greater in women with postmenstrual spotting, dysmenorrhea and chronic pelvic pain. Multiple Cesarean sections and retroflexed uteri are risk factors for larger Cesarean scar defects. The size of the Cesarean scar defect is associated with clinical symptoms such as postmenstrual spotting, dysmenorrhea and chronic pelvic pain. (c) 2009 ISUOG.
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            Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications.

            The gynecologic sequelae due to deficient uterine scar healing after cesarean section are only recently being identified and described. These include conditions such as abnormal bleeding, pelvic pain, infertility, and cesarean scar ectopic pregnancy, as well as a potentially higher risk of complications and difficulties during gynecologic procedures such as uterine evacuation, hysterectomy, endometrial ablation, and insertion of an intrauterine device. The proposed mechanism of abnormal uterine bleeding is a pouch or "isthmocele" in the lower uterine segment that causes delayed menstrual bleeding. The prevalence of symptomatic or clinically relevant cesarean scar defects (CSDs) ranges from 19.4% to 88%. Possible risk factors for CSD include number of cesarean sections, uterine position, labor before cesarean section, and surgical technique used to close the uterine incision. There are no accepted guidelines for the diagnostic criteria of CSD. We propose that a CSD be defined on transvaginal ultrasound or saline infusion sonohysterography as a triangular hypoechoic defect in the myometrium at the site of the previous hysterotomy. We also propose a classification system to aid in standardized classification for future research. Surgical techniques for repair of CSD include laparoscopic excision, resectoscopic treatment, vaginal revision, and endometrial ablation.
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              Surgical treatment and follow-up of women with intermenstrual bleeding due to cesarean section scar defect.

              Previous cesarean delivery scar (PCDS) defect has been described as a cause of intermenstrual bleeding in women with no other uterine pathology except for a pouch on the anterior uterine segment at the site of the cesarean scar. The objective of this study was to assess the effectiveness of hysteroscopic surgery to correct this anatomic defect and eliminate the bleeding disturbance in a group of women with this symptom. Retrospective study (Canadian Task Force classification XX). Private hospital, department of obstetrics and gynecology. Twenty-four women, age 29-41 years, who reported intermenstrual bleeding, especially postmenstrual spotting, with no other gynecologic pathology except for the presence of a PCDS defect. Diagnosis was established with transvaginal ultrasound, when a fluid-filled, triangular defect was seen in the anterior uterine isthmus, in relation to the cesarean section scar. Hysteroscopic resection of fibrotic tissue that overhangs underneath the triangular pouch, facilitating blood drainage through the cervix and fulguration of endometrial glands and/or dilated blood vessels. The mean number of previous cesarean-section deliveries was 2.75. Postoperative follow-up was 24 months in 21 patients and at least 14 months in the other 3 patients. Eleven of these patients with the desire to become pregnant were unable to conceive after trying for a period of at least 2 years before hysteroscopy. Infertility work-up in the 11 patients revealed 9 with unknown infertility, 1 with male infertility, and 1 with failed tubal reversal surgery. Nine of them became pregnant between 14- and 24-months of follow-up. Eighty-four percent of patients (20/24) remained asymptomatic (without bleeding disturbances) after surgery. Previous cesarean delivery scar defect may be the cause of intermenstrual bleeding, and it is possible that it also may impair fertility, but it can be successfully treated by hysteroscopic surgery.
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                Author and article information

                Journal
                AJP Rep
                AJP Rep
                10.1055/s-00000169
                AJP Reports
                Thieme Medical Publishers (333 Seventh Avenue, New York, NY 10001, USA. )
                2157-6998
                2157-7005
                28 May 2014
                November 2014
                : 4
                : 2
                : e65-e68
                Affiliations
                [1 ]Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec, Canada
                [2 ]Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec, Canada
                Author notes
                Address for correspondence Emmanuel Bujold, MD, MSc, FRCSC Department of Obstetrics and Gynecology, Faculty of Medicine Université Laval, 2705 Boulevard Laurier, Québec, Canada G1V 4G2 emmanuel.bujold@ 123456crchul.ulaval.ca
                Article
                140012
                10.1055/s-0034-1376187
                4239137
                3f604c43-a2a1-4c25-93c5-537eb831a8f4
                © Thieme Medical Publishers
                History
                : 07 March 2014
                : 24 March 2014
                Categories
                Article

                cesarean,laparoscopic repair,scar defect,hysterosonography

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