ISSN: 2148-8274 / E-ISSN: 2587-0084
, Türk Üreme Tıbbı ve Cerrahisi
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Turkish Journal of Reproductive Medicine and Surgery

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ORİJİNAL ARAŞTIRMALAR

İsthmosel; Anormal Uterus Kanamalarının Ve Diğer Jinekolojik Komplikasyonların Gözden Kaçan Nedeni
Isthmocele; An Overlooked Cause Of Abnormal Uterine Bleeding And Other Gynecological Complications
Received Date : 01 Jun 2023
Accepted Date : 20 Nov 2023
Available Online : 01 Dec 2023
Doi: 10.24074/tjrms.2023-98274 - Makale Dili: EN
Turkish Journal of Reproductive Medicine and Surgery. 2024;8(1):1-6.
ÖZET
Amaç: Sezaryen skar defektleri(istmosel); sezaryen sonrasında yetersiz uterin skar oluşumu veya skarın ayrılması ile karakterizedir. İstmosel tanısı sıklıkla adet sonrası lekelenme, dismenore, disparoni, kronik pelvik ağrı gibi klinik semptomlarla başvuran hastalarda tesadüfen saptanır. Bu çalışmanın amacı, sezeryan skar defekti olan hastalarda çeşitli klinik semptomların prevalansını tanımlamak ve sezeryan skar defektinin boyutu, uterus pozisyonu ve önceki sezaryen sayısı ile klinik şikayetler arasındaki ilişkiyi belirlemektir. Gereç ve Yöntemler: Mart 2019-Mayıs 2022 tarihleri arasında Sezeryan skar defekti tanısı alan 97 hasta dahil edilmiştir. Üç farklı parametre: Skar derinliği (defektin tabanı ile zirvesi arasındaki dikey mesafe), skar genişliği (servikoistmik kanaldaki en büyük yarığın uzunluğu) ve kalan miyometriyumun kalınlığı incelendi. Uterusun pozisyonu ek olarak değerlendirildi. Dismenore, postmenstrüel lekelenme, disparoni gibi klinik semptomlar, hastaların tıbbi geçmişleri incelendikten sonra veri tabanından kontrol edildi. Bulgular: Katılımcıların postmenstrüel kanama geçirip geçirmemesine göre sezaryen sayısı (C/S) ve defekt genişliği açısından istatistiksel olarak anlamlı farklılık bulundu (p:0.039, p:0.000). Katılımcıların postmenstrüel kanama geçirip geçirmemesine göre rezidüel miyometriyal kalınlık açısından istatistiksel olarak anlamlı farklılık bulundu (p:0.001). Sezaryen sayısı ile defektin genişliği arasında istatistiksel olarak anlamlı, pozitif ve orta düzeyde bir ilişki vardı(p:0.005, r=.454).Katılımcıların dismenore olup olmamasına göre sezaryen sayısı ve defekt genişlikleri istatistiksel olarak anlamlı bir farklılık saptanmıştır (p: 0.044, p:0.000). Katılımcıların kronik pelvik ağrısı olup olmamasına göre sezaryen sayısı ve defekt genişlikleri istatistiksel olarak anlamlı bir farklılık saptanmıştır(p: 0.036, p:0.000). Sonuç: İstmosel insidansı ve prevalansı çoğu jinekoloğun düşündüğünden daha yüksektir. Kadınlarda sezaryen sonrası istmosel gelişebilir ve bunun sonucunda kadınlar hayatlarının geri kalanını morbid olarak etkileyen uzun vadeli komplikasyonlar yaşayabilirler. İstmosel prevalansını azaltmanın en etkili yolu sezaryen ameliyatlarının sayısını azaltmaktır. Hekimlerin, dismenore ve kronik pelvik ağrıdan şikayet eden kadınlarda İstmosel'i akılda tutması önemlidir.
ABSTRACT
Objective: Cesarean scar defects (isthmocele); are characterized by insufficient uterine scar formation or scar separation after cesarean section. The diagnosis of isthmocele is often found incidentally in patients presenting with clinical symptoms such as postmenstrual spotting, dysmenorrhea, dyspareunia, and chronic pelvic pain. The aim of this study was to describe the prevalence of various clinical symptoms in patients with cesarean scar defect and to determine the relationship between the size of the cesarean scar defect, uterine position, previous cesarean section number, and clinical complaints. Material and Methods: Between March 2019 and May 2022, 97 patients diagnosed with cesarean scar defects were included in the study. Three different parameters were examined: Scar depth (the distance vertically between the defect's base and its peak), scar breadth (the length of the biggest breach in the cervicoistmic canal), and the thickness of the remaining myometrium. The position of the uterus was also noted. Results: A statistically significant difference was found in terms of the number of cesarean sections (C/S) and defect width depending on whether the participants had postmenstrual bleeding or not (p:0.039, p:0.000). A statistically significant difference was found in terms of residual myometrial thickness depending on whether the participants had postmenstrual bleeding or not (p:0.001). There was a statistically significant, positive, and moderate relationship between the number of cesarean sections and the width of the defect(p:0.005, r=.454). A statistically significant difference was found in the number of cesarean sections and defect widths depending on whether the participants had dysmenorrhea (p: 0.044, p: 0.000). The number of cesarean sections and the width of the defect show a statistically significant difference according to whether the participants have chronic pelvic pain or not (p: 0.036, p:0.000). Conclusion: The incidence and prevalence of isthmocele are higher than most gynecologists realize. Isthmocele can develop after cesarean section in women, and as a result, women may experience long-term complications that morbidly affect the rest of their lives. The most effective way to reduce the prevalence of isthmocele is to reduce the number of cesarean section operations. It is important for physicians to keep the isthmocele in mind when examining the complaints of dysmenorrhea and chronic pelvic pain in women.
REFERANSLAR
  1. Erickson SS, Van Voorhis BJ. Intermenstrual bleeding secondary to cesarean scar diverticuli: report of three cases. Obstet Gynecol. 1999;93(5 Pt 2):802-5. [Crossref]  [PubMed] 
  2. Thurmond AS, Harvey WJ, Smith SA. Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography. J Ultrasound Med. 1999;18(1):13-6; quiz 17-8. [Crossref]  [PubMed] 
  3. Bromley B, Pitcher BL, Klapholz H, Lichter E, Benacerraf BR. Sonographic appearance of uterine scar dehiscence. Int J Gynaecol Obstet. 1995;51(1):53-6. [Crossref]  [PubMed] 
  4. Fabres C, Aviles G, De La Jara C, Escalona J, Muñoz JF, Mackenna A, Fet al. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J Ultrasound Med. 2003;22(7):695-700; quiz 701-2. [Crossref]  [PubMed] 
  5. World Health Organization Human Reproduction Programme, 10 April 2015. WHO Statement on caesarean section rates. Reprod Health Matters. 2015;23(45):149-50. [Crossref]  [PubMed] 
  6. Poidevin LO. The value of hysterography in the prediction of cesarean section wound defects. Am J Obstet Gynecol. 1961;81:67-71. [Crossref]  [PubMed] 
  7. Diaz SD, Jones JE, Seryakov M, Mann WJ. Uterine rupture and dehiscence: ten-year review and case-control study. South Med J. 2002;95(4):431-5. [Crossref]  [PubMed] 
  8. van der Voet LLF, Limperg T, Veersema S, Timmermans A, Bij de Vaate AMJ, Brölmann HAM, et al. Niches after cesarean section in a population seeking hysteroscopic sterilization. Eur J Obstet Gynecol Reprod Biol. 2017;214:104-8. [Crossref]  [PubMed] 
  9. Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH. Detection of cesarean scars by transvaginal ultrasound. Obstet Gynecol. 2003;101(1):61-5. [Crossref]  [PubMed] 
  10. Ofili-Yebovi D, Ben-Nagi J, Sawyer E, Yazbek J, Lee C, Gonzalez J, et al. Deficient lower-segment Cesarean section scars: prevalence and risk factors. Ultrasound Obstet Gynecol. 2008;31(1):72-7. [Crossref]  [PubMed] 
  11. Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013;20(5):562-72. [Crossref]  [PubMed] 
  12. van der Voet LF, Vervoort AJ, Veersema S, BijdeVaate AJ, Brölmann HA, Huirne JA. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review. BJOG. 2014; 121(2):145-56. [Crossref]  [PubMed] 
  13. Chen HY, Chen SJ, Hsieh FJ. Observation of cesarean section scar by transvaginal ultrasonography. Ultrasound Med Biol. 1990;16(5):443-7. [Crossref]  [PubMed] 
  14. Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, Brölmann HA, Mol BW, Huirne JA. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod. 2015;30(12):2695-702. [Crossref]  [PubMed]  [PMC] 
  15. van der Voet LF, Bij de Vaate AM, Veersema S, Brölmann HA, Huirne JA. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014;121(2):236-44. [Crossref]  [PubMed] 
  16. Setubal A, Alves J, Osório F, Guerra A, Fernandes R, Albornoz J, et al. Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar. J Minim Invasive Gynecol. 2018;25(1):38-46. [Crossref]  [PubMed] 
  17. Osser OV, Jokubkiene L, Valentin L. High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination. Ultrasound Obstet Gynecol. 2009;34(1):90-7. [Crossref]  [PubMed] 
  18. Bij de Vaate AJ, Brölmann HA, van der Voet LF, van der Slikke JW, Veersema S, Huirne JA. Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting. Ultrasound Obstet Gynecol. 2011;37(1): 93-9. [Crossref]  [PubMed] 
  19. Vikhareva Osser O, Valentin L. Risk factors for incomplete healing of the uterine incision after caesarean section. BJOG. 2010;117(9):1119-26. [Crossref]  [PubMed] 
  20. Stegwee SI, Jordans IPM, van der Voet LF, Bongers MY, de Groot CJM, Lambalk CB, et al. Single- versus double-layer closure of the caesarean (uterine) scar in the prevention of gynaecological symptoms in relation to niche development - the 2Close study: a multicentre randomised controlled trial. BMC Pregnancy Childbirth. 2019;19(1):85. [Crossref]  [PubMed]  [PMC] 
  21. Hayakawa H, Itakura A, Mitsui T, Okada M, Suzuki M, Tamakoshi K, et al. Methods for myometrium closure and other factors impacting effects on cesarean section scars of the uterine segment detected by the ultrasonography. Acta Obstet Gynecol Scand. 2006;85(4):429-34. [Crossref]  [PubMed] 
  22. Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the "niche" in the scar. J Ultrasound Med. 2001;20(10):1105-15. [Crossref]  [PubMed] 
  23. Wang CB, Chiu WW, Lee CY, Sun YL, Lin YH, Tseng CJ. Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet Gynecol. 2009;34(1):85-9. [Crossref]  [PubMed] 
  24. Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. Laparoscopic and vaginal repair of uterine scar dehiscence following cesarean section as detected by ultrasound. J Perinat Med. 2005;33(4):324-31. [Crossref]  [PubMed] 
  25. Tahara M, Shimizu T, Shimoura H. Preliminary report of treatment with oral contraceptive pills for intermenstrual vaginal bleeding secondary to a cesarean section scar. Fertil Steril. 2006;86(2):477-9. [Crossref]  [PubMed] 
  26. Burger NF, Darazs B, Boes EG. An echographic evaluation during the early puerperium of the uterine wound after caesarean section. J Clin Ultrasound. 1982;10(6):271-4. [Crossref]  [PubMed] 
  27. Regnard C, Nosbusch M, Fellemans C, Benali N, van Rysselberghe M, Barlow P, et al. Cesarean section scar evaluation by saline contrast sonohysterography. Ultrasound Obstet Gynecol. 2004;23(3):289-92. [Crossref]  [PubMed] 
  28. Bujold E, Goyet M, Marcoux S, Brassard N, Cormier B, Hamilton E, et al. The role of uterine closure in the risk of uterine rupture. Obstet Gynecol. 2010;116 (1):43-50. [Crossref]  [PubMed] 
  29. Roberge S, Chaillet N, Boutin A, Moore L, Jastrow N, Brassard N, et al. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. Int J Gynaecol Obstet. 2011;115(1):5-10. [Crossref]  [PubMed] 
  30. Chen Y, Han P, Wang YJ, Li YX. Risk factors for incomplete healing of the uterine incision after cesarean section. Arch Gynecol Obstet. 2017;296(2): 355-61. [Crossref]  [PubMed] 
  31. Jarvela IY, Sladkevicius P, Kelly S, Ojha K, Campell S, Nargund G. Cesarean delivery scar. Ultrasound Obstet Gynecol. 2002;19:632-3. [Crossref]  [PubMed] 
  32. Wang CB, Tseng CJ. Primary evacuation therapy for Cesarean scar pregnancy: three new cases and review. Ultrasound Obstet Gynecol. 2006;27 (2):222-6. [Crossref]  [PubMed]