Arch Gynecol Obstet DOI 10.1007/s00404-014-3582-0
GYNECOLOGIC ENDOCRINOLOGY AND REPRODUCTIVE MEDICINE
Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women Neele Schepker • Guillermo-Jose´ Garcia-Rocha • Frauke von Versen-Ho¨ynck • Peter Hillemanns • Cordula Schippert
Received: 22 May 2014 / Accepted: 5 December 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Caesarean delivery (c-section) scar dehiscences may cause bleeding abnormalities, e.g. postmenstrual spotting, dysmenorrhea and abdominal pain, secondary sterility and at worst peripartum uterine rupture. The purpose of this study was firstly to identify the correlation of women’s complaints after c-section with scar-related clinical symptoms. Secondly, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic. Methods We present data of a retrospective study of 13 premenopausal, non-pregnant women with symptomatic c-section scars. In 9 out of 13 patients, a microsurgical uterus reconstruction was performed by mini-laparotomy. The postoperative changes of scar-associated symptoms were assessed by a questionnaire as earliest as 4 months after surgery (N = 5). Results The c-section scar was visualised by transvaginal sonography in 12 out of 13 women by a typical U- or V-shaped hypoechoic or anechoic fluid accumulation in the region of former uterotomy and in all 13 patients by hysteroscopy. Bleeding disorders were often accompanied by dysmenorrhea/abdominal pain (38.5 %, N = 5) and secondary sterility (46.2 %, N = 6). Blood residues in the scar pouch and bleeding disorders/postmenstrual spotting were found in 30.8 % of patients (N = 4) and combined with secondary sterility in 38.5 % of patients (N = 5). Reconstructive surgeries resulted in discontinuation of bleeding
N. Schepker G.-J. Garcia-Rocha F. von Versen-Ho¨ynck P. Hillemanns C. Schippert (&) Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany e-mail: [email protected]
disorders in all women and a pregnancy in three out of five patients (60 %) with secondary sterility. Conclusion Clinical symptoms, e.g. ‘‘bleeding disorders’’ like postmenstrual spotting, ‘‘pain/dysmenorrhea’’ and ‘‘secondary sterility’’ could be specific indicators for the diagnosis of uterine dehiscence after c-section. Scar dehiscences can be diagnosed by obtaining the patients medical history and asking for typical symptoms followed by vaginal sonography and diagnostic hysteroscopy. If a c-section scar defect is confirmed, microsurgical uterus reconstruction can stop postmenstrual spotting, reduce abdominal pain/dysmenorrhea and improve fertility. Keywords Uterine scar dehiscence Scar pouch Postmenstrual spotting Secondary sterility Caesarean section
Introduction Pre- or peripartum uterine rupture is a serious obstetric complication that occurs almost exclusively in the uterine scar region after surgical interventions such as myoma enucleation or caesarean section (c-section) [1]. Prior c-section has been identified as the main risk factor for uterine rupture in subsequent pregnancies [2]. The success rate of trial of labour in states post c-section varies between 50 and 90 % (mean 73 %) [3, 4]. The risk of rupture is reported as 0.3–17 % [2, 5–11] depending on spontaneous or induced labour, while for planned primary repeat c-section the incidence is \0.1 % [12]. The rate of c-section is constantly increasing, reaching 1.6–50 % depending on region and federal state. In the USA, the rate of c-section increased from 23–30 % between 1989 and 2005 [13]. A rising c-section rate is presenting gynaecologists with
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new challenges. Firstly, number of scar dehiscences and thus the potential risk of uterine ruptures is increased [14], secondly there is a wide range of dehiscence-associated complaints such as menstrual disorders, dysmenorrhea, abdominal pain and impairment of fertility [5, 6, 15]. The primary purpose of this study was to identify typical, diagnostically indicative symptoms of uterine scar dehiscence following c-section. In addition, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic.
Materials and methods In this retrospective study, data of patients were analysed who presented at the Department of Gynaecology and Obstetrics at Hanover Medical School (MHH) with bleeding abnormalities, pain or secondary sterility after at least one prior c-section between 1996 and 2011. The use of patient’s data was approved by the local Clinical Ethics Committee (Ethics Committee Approval No. 473). Secondary sterility was defined according to the WHO definition (‘‘Scientific Group on the Epidemiology of Infertility’’) as the inability to become pregnant, following the birth of one or more biological children during a period of 2 years. Bleeding abnormalities included postmenstrual spotting, renewed bleeding after end of normal menstruation or menorrhagia. The study sample comprised 13 premenopausal women between 24 and 43 years (mean value = 33 years, standard deviation (SD) ± 5.8 years). Women with other causes for their symptoms (e.g. myomas, endometriosis, tubal pathologies) than uterine scar dehiscence after c-section were excluded from the study. Only symptomatic patients in whom dehiscence was detected by hysteroscopy and who subsequently underwent corrective surgical procedures received a questionnaire and were included in the final data evaluation. A flow chart of diagnostic and therapeutic steps is shown in Fig. 1. Diagnosis of uterine scar dehiscence All women underwent vaginal sonography and hysteroscopy. The main focus of sonography was on visualisation of the dehiscence and measurement of remaining myometrial thickness. Hysteroscopy recorded substance losses at the ventral cervico-corporal junction and accumulations of blood in the dehiscence. Ten patients underwent laparoscopy to diagnose intra-abdominal pathologies and to observe the dehiscence from an intra-abdominal perspective. Chromopertubation with methylene blue was
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additionally performed to detect accumulations of dye in the scar pouch and to exclude tubal sterility in seven out of ten patients. Therapy of uterine scar defects In nine patients, dehiscence correction was performed by laparotomy: the dehiscent myometrium was resected completely and a two-layered suture was performed with 2-0 to 4-0 Vicryl interrupted sutures. Attention was paid to ensuring layered adaptation of the myometrial wound margins (‘‘edge-to-edge’’) and subtle haemostasis for adhesion prophylaxis. Three patients denied surgical correction, one patient wanted a hysterectomy. Patients follow-up Women’s symptoms were monitored for at least 4 months postoperatively, an adequate period to assess post-reconstruction scar healing. Patients were advised to use contraception during this time. Outcomes were recorded by sending the patients a questionnaire to monitor persistent menstrual abnormalities, pain and renewed pregnancies. One patient was lost to follow-up, one patient did not return the questionnaire. Two women had not yet completed the follow-up period. Finally, postoperative outcome data of five women were available for analysis.
Results Typical symptoms of dehiscence Of the 13 non-pregnant, symptomatic patients 11 previously underwent one c-section, while two patients had two c-sections. Numerous of the patients had multiple complaints (Table 1). A majority (61.5 %, 8/13) complained of bleeding abnormalities (‘‘bleeding disorders’’/‘‘spotting’’) such as postmenstrual spotting, renewed bleeding after the end of normal menstruation or menorrhagia. About half of the patients (53.9 %, 7/13) suffered from pain since the previous c-section. The term ‘‘pain’’ includes classical dysmenorrhea, pain during intermenstrual bleeding and cycle-independent lower abdominal complaints. Secondary sterility was diagnosed in 69.2 % (9/13) of women at their first attendance. Diagnosis of dehiscence Uterine scar dehiscence was demonstrated sonographically in 12 of the 13 examined patients; findings and one sketch are shown in Fig. 2a–c. Hypoechoic or anechoic fluid
Arch Gynecol Obstet Fig. 1 Patient flow chart
Total patients with symptoms (N=13)
diagnosis
Sonography, hysteroscopy, laparoscopy (N=10), chromopertubation (7/10)
therapy
No correction (N=3)
Scar correction by laparotomy (N=9)
Lost of follow up, no questionaire return, other easons N=4
Table 1 Clinical symptoms and diagnostic findings of c-section scar dehiscence
Sonography, hysteroscopy (N=3)
Hysterectomy (N=1)
Final postoperative analysis (N=5)
Findings
Number (N)
Rate (%)
Total (N/N)
8/13
Clinical diagnostics of caesarean section scar pouch Bleeding disorders/postmenstrual spotting
8
61.5
Dysmenorrhoea/lower abdominal pain
7
53.9
8/13
Secondary sterility
9
69.2
8/13
12
Sonographical presentability of scar pouch Sonographical thickness of remaining myometrium Hysteroscopical presentability of scar pouch
92.3
12/13
6
50
6/12 13/13
13
100
Hysteroscopical detection of blood residues in scar pouch
6
46.2
6/13
Transclucency of hysteroscopy light through scar pouch during laparoscopy (‘positive diaphanoscopy’)
6
60.0
6/10
Accumulation of methylene blue in scar pouch during chromopertubation
3
42.9
3/7
accumulation was observed in the region of former uterotomy with interruption of the contour of the cervico-corporal myometrium (Fig. 2a, b), the tissue appeared ‘‘punched-out’’. In one patient, sonographic findings were not clear. Measurement of remaining residual myometrium yielded a mean value of d = 4.2 mm (1.7–8 mm, SD ± 1.94 mm). Hysteroscopy confirmed the dehiscence in all cases, in some cases complete endometrial loss was observed in the region of former uterotomy (Fig. 2c). In 46.1 % (6/13), blood residues were detected in the dehiscence despite cessation of menstrual bleeding. In six out of ten women (60 %) who underwent laparoscopy, the hysteroscopy light was shining through the scar pouch (‘‘positive diaphanoscopy’’). In four out of seven patients (57.1 %) in whom chromopertubation was performed an accumulation of dye was observed in the dehiscence cavity, and in one patient methylene blue spurted out in a manner consistent with a fistula formation.
Correlations with symptoms A high proportion of women complained about a combination of symptoms. From both bleeding abnormalities and pain suffered 38.5 % (5/13) of patients and six patients (46.2 %) showed both bleeding disorders and secondary sterility. In the presence of postmenstrual bleeding abnormalities, women were frequently affected by secondary sterility (46.2 %, 6/13). Overall there was no age dependency (\35 and C35 years) of secondary sterility. In 12 women, the uterine scar dehiscence was detected sonographically. An equal distribution of the remaining myometrial wall thicknesses was determined when differentiation was made between a minimum thickness of ‘‘\3.5 mm’’ and ‘‘C3.5 mm’’ (N = 6 in each case). Division into these subgroups appears useful because a value \3.5 mm in a pregnant uterus is considered critical in terms of impending uterine rupture [10].
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Fig. 2 Transvaginal sonography illustrating scar pouch (ventral on left side of sonogram, dorsal on right side; anteflected uterus, hypoechoic fluid accumulation in the scar pouch of 0.73 cm 9 0.39 cm and a second rounded fluid accumulation close to urinary bladder corresponding to myometrial defect) (a), sketch to
present relationship between uterus, urinary bladder and scar pouch (black, correlates to fluid accumulation) (b) and hysteroscopy (at the top ventral abdominal side, below dorsal side: view on complete loss of myometrium substance in scar pouch, ‘‘endometrium bald head’’, entry to cavum uteri is visible as dark area in depth) (c)
In 46.2 %, blood residues in the dehiscent cavity were detected by hysteroscopy. In 50 % of women with bleeding abnormalities, remaining blood constituents were detected in the dehiscence cavity. In five sterile women, hysteroscopy showed blood residues in the scar pouch, representing 38.5 % of the total patient sample. Of the six patients in whom blood was detected in the scar cavity, five (80 %) had secondary sterility.
included in the analysis had secondary sterility. Postoperatively, three patients (60 %) became pregnant naturally, one no longer wished to become pregnant, and another patient planned to become pregnant by assisted reproductive therapy. Two of the three pregnancies/births proceeded without complications. One child was delivered vaginally in the 37th week of pregnancy (3,040 g, 1-min APGAR 8), the second child in the 35th week of pregnancy (2,380 g, 1-min AGPAR 9). The third patient underwent secondary c-section in an external hospital due to premature labour, vaginal bleeding and retroplacental haematoma (35th week of pregnancy, 3,750 g, 1-min APGAR 9). No uterine rupture occurred.
Postoperative outcome Data for the outcome after dehiscence correction/reconstruction showed the following results. Preoperatively, three out of five operated women (60 %) complained of bleeding abnormalities/postmenstrual spotting. Postoperatively, all patients were free of these complaints. Preoperatively, three women suffered from pain (60 %), while postoperatively two patients continued to complain of lower abdominal pain. Preoperatively, all five women
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Comments In our retrospective, observational study of 13 women with clinical symptoms after c-section, we observed typical uterine scar dehiscence-associated symptoms and in most
Arch Gynecol Obstet
cases a combination of symptoms, e.g. bleeding disorders, abdominal pain and secondary sterility. The diagnosis was confirmed by transvaginal sonography and hysteroscopy and in the majority of cases an additional assessment using laparoscopy was performed. Reconstructive surgeries resulted in a discontinuation of bleeding disorders in all women and a pregnancy in three out of five patients (60 %) with secondary sterility. With a rising prevalence of c-sections worldwide postoperative complications and risks increase, one of them being uterine scar defects. The exact reasons for scar defects after c-section remain obscure [16–18]. Our study supports the assumption that women can already develop a dehiscence in the region of the past uterotomy after a single c-section. Our results concerning the clinical symptoms reflect those obtained in other studies [19, 20]. The majority of previous reports focused on abnormal uterine bleeding [5, 18, 20–22] as the primary symptom, while a few others considered chronic pelvic pain [23] and dysmenorrhea in addition to abnormal uterine bleeding, as the main presenting symptoms. The issue of sterility [23] is seldom mentioned, but we believe it is critical to consider it as an additional factor and we were able to show that our patient cohort with bleeding disorders suffers more frequently from secondary sterility. We assume as the causal factor that menstrual blood in the dehiscence behaves in a similar manner to hydrosalpinx fluid. Various fertility impairing reactions can occur, e.g. changes in intracavitary pH as well as toxic effects on sperm ascension and embryo nidation [18, 24–27], changes in endometrial activity [25, 28], impaired quality of cervical mucus or ‘‘washout’’ of the blastocysts ready for implantation [29]. Therefore, the occurrence of postmenstrual spotting or intermenstrual bleeding after c-section appears to be a possible risk factor for secondary sterility as supported by other authors [23, 30, 31]. More than half of the women investigated in our study reported pain and women with postmenstrual bleeding also suffered frequently from pain. Some studies show that development of pain is promoted by retained menstrual blood in the uterine cavity [18]. Studies on hysterectomy preparations showed chronic inflammatory processes in the region of scar dehiscences to be a possible precipitating factor for dysmenorrhea [14]. A recent systematic review investigating different techniques to detect uterine scar defects found a median prevalence of 37–59 % depending on the diagnostic technique used [32]. Sonographic analysis described triangular accumulations of fluid in dehiscence, as well as a concave retraction towards the urinary bladder [33–35]. In our study, the presumed dehiscence was visualised by transvaginal sonography in 12 out of 13 patients. The dehiscence shows itself in form of hypoechoic to anechoic zones
(stored menstrual blood) in the region of former c-section scars (Fig. 2a). In most cases, size, extent and remaining myometrial thickness can be determined exactly [36, 38]. The measurement of remaining myometrial diameter, however, is probably of little clinical relevance outside pregnancy. Cutoff of the remaining residual myometrial thickness in which there is not yet any increased risk of later uterine rupture is unknown outside pregnancy and most studies on the determination of risk of impending uterine rupture were performed on pregnant uteri in third trimester. The diagnosis of a dehiscence with a consecutively increased risk of rupture is achieved here with a mean thickness at the thinnest site of d \ 2.5 mm to d = 3.5 mm [6, 7, 10, 19, 38]. These findings, however, are not necessarily applicable to a non-pregnant uterus. For therapy planning, especially for women desiring to have more children, diagnostic hysteroscopy after cessation of menstrual bleeding is valuable. In our study population, as also in other studies [20, 39], a high correlation was apparent between intraoperative and previously sonographically recorded findings. Diagnosis of myometrial scar dehiscence is confirmed by demonstrating a loss of myometrial substance in the region of caesarean scar defect (Fig. 2c). In some cases, cavity formation or fistulation is evident or residues of blood are detectable in the dehiscence. The diagnosis of dehiscence and their extent can be additionally assessed by laparoscopy and chromopertubation showing positive diaphanoscopy and dye accumulation in the scar pouch. In our population, bleeding abnormalities ceased after surgical dehiscence correction, an outcome consistent with results of other investigators [15, 30, 40]. We and others assume that menstrual blood in the dehiscence collects as if in a reservoir and flows out in the form of postmenstrual spotting [4, 5, 14, 40]. There are various therapeutic options taking into account dehiscence-associated symptoms [5, 15, 30, 31, 37, 40]. The technique of defect excision and layered wound adaptation through a combined hysteroscopic-abdominal access route used in our clinic results in control of intermenstrual bleeding, pain control and improvement of fertility. Other studies also show that pain states improve after surgical intervention [15, 27, 30, 40]. In postmenstrual bleeding disorders, when family planning is not yet concluded, surgical correction should rather be the first-line option [27, 30, 31, 41–44]. The outflow of menstrual blood can be relieved and the bleeding problem thereby treated by only hysteroscopic resection of the dehiscence margins [5, 45, 46]. Data on postoperative pregnancies and uterine ruptures, however, are not presented in these publications. In solely hysteroscopic therapy, there is the continued risk of pre- and intrapartum uterine rupture due to thinning of the myometrium. For women wishing to have children, we,
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therefore, recommend complete abdominal resection of the dehiscent tissue and reconstruction of the uterus by exact adaptation of wound margins to minimise risk of subsequent uterine rupture. Naturally, peripartal rupture cannot be prevented completely despite reconstruction. There are several limitations to our study. First, due to a small number of cases a sufficient statistical analysis and interpretation of results can not be performed and our findings should be recognised as clinical observations. Second, we do not have a control group available to compare the clinical outcomes, e.g. pregnancy rate with or without intervention. Additionally a selection bias regarding the complaints reported by our patients might exist. Also, the follow-up time of about four month after corrective surgery might be to short and a second time point, e.g. 1 year after surgery, might be useful for future studies and gives additional, valuable insights into the long-term development of clinical symptoms. Our data confirm that the symptoms ‘‘bleeding disorders/ postmenstrual spotting’’, ‘‘pain/dysmenorrhea’’ and ‘‘secondary sterility’’ can be used as indicators for uterine scar dehiscence after c-section and corrective surgery is a useful tool to improve these symptoms and possibly fertility rate. With increasing c-section rates worldwide and accompanied risks, e.g. uterine scar defects, greater emphasis should be placed in the preoperative patient briefing on the development of scar dehiscences after c-sections. This applies especially for ‘‘elective c-sections’’, particularly when a couple wishes to have several children. Ideally, the early identification of scar dehiscence in non-pregnant women and appropriate treatment can contribute to the prevention of uterine ruptures and improvement pregnancy outcomes. Therefore, it is essential for health care professionals to be aware of typical symptoms, diagnostic and therapeutic strategies and associated risks. Acknowledgments We thank Mrs Rieck of the Institute for Biometrics of MHH for the biometric and statistical analysis.
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Conflict of interest The authors have no conflict of interest, have had full control of all primary data and agree to allow the Journal to review their data if requested. 18.
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GYNECOLOGIC ENDOCRINOLOGY AND REPRODUCTIVE MEDICINE
Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women Neele Schepker • Guillermo-Jose´ Garcia-Rocha • Frauke von Versen-Ho¨ynck • Peter Hillemanns • Cordula Schippert
Received: 22 May 2014 / Accepted: 5 December 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Caesarean delivery (c-section) scar dehiscences may cause bleeding abnormalities, e.g. postmenstrual spotting, dysmenorrhea and abdominal pain, secondary sterility and at worst peripartum uterine rupture. The purpose of this study was firstly to identify the correlation of women’s complaints after c-section with scar-related clinical symptoms. Secondly, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic. Methods We present data of a retrospective study of 13 premenopausal, non-pregnant women with symptomatic c-section scars. In 9 out of 13 patients, a microsurgical uterus reconstruction was performed by mini-laparotomy. The postoperative changes of scar-associated symptoms were assessed by a questionnaire as earliest as 4 months after surgery (N = 5). Results The c-section scar was visualised by transvaginal sonography in 12 out of 13 women by a typical U- or V-shaped hypoechoic or anechoic fluid accumulation in the region of former uterotomy and in all 13 patients by hysteroscopy. Bleeding disorders were often accompanied by dysmenorrhea/abdominal pain (38.5 %, N = 5) and secondary sterility (46.2 %, N = 6). Blood residues in the scar pouch and bleeding disorders/postmenstrual spotting were found in 30.8 % of patients (N = 4) and combined with secondary sterility in 38.5 % of patients (N = 5). Reconstructive surgeries resulted in discontinuation of bleeding
N. Schepker G.-J. Garcia-Rocha F. von Versen-Ho¨ynck P. Hillemanns C. Schippert (&) Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany e-mail: [email protected]
disorders in all women and a pregnancy in three out of five patients (60 %) with secondary sterility. Conclusion Clinical symptoms, e.g. ‘‘bleeding disorders’’ like postmenstrual spotting, ‘‘pain/dysmenorrhea’’ and ‘‘secondary sterility’’ could be specific indicators for the diagnosis of uterine dehiscence after c-section. Scar dehiscences can be diagnosed by obtaining the patients medical history and asking for typical symptoms followed by vaginal sonography and diagnostic hysteroscopy. If a c-section scar defect is confirmed, microsurgical uterus reconstruction can stop postmenstrual spotting, reduce abdominal pain/dysmenorrhea and improve fertility. Keywords Uterine scar dehiscence Scar pouch Postmenstrual spotting Secondary sterility Caesarean section
Introduction Pre- or peripartum uterine rupture is a serious obstetric complication that occurs almost exclusively in the uterine scar region after surgical interventions such as myoma enucleation or caesarean section (c-section) [1]. Prior c-section has been identified as the main risk factor for uterine rupture in subsequent pregnancies [2]. The success rate of trial of labour in states post c-section varies between 50 and 90 % (mean 73 %) [3, 4]. The risk of rupture is reported as 0.3–17 % [2, 5–11] depending on spontaneous or induced labour, while for planned primary repeat c-section the incidence is \0.1 % [12]. The rate of c-section is constantly increasing, reaching 1.6–50 % depending on region and federal state. In the USA, the rate of c-section increased from 23–30 % between 1989 and 2005 [13]. A rising c-section rate is presenting gynaecologists with
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new challenges. Firstly, number of scar dehiscences and thus the potential risk of uterine ruptures is increased [14], secondly there is a wide range of dehiscence-associated complaints such as menstrual disorders, dysmenorrhea, abdominal pain and impairment of fertility [5, 6, 15]. The primary purpose of this study was to identify typical, diagnostically indicative symptoms of uterine scar dehiscence following c-section. In addition, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic.
Materials and methods In this retrospective study, data of patients were analysed who presented at the Department of Gynaecology and Obstetrics at Hanover Medical School (MHH) with bleeding abnormalities, pain or secondary sterility after at least one prior c-section between 1996 and 2011. The use of patient’s data was approved by the local Clinical Ethics Committee (Ethics Committee Approval No. 473). Secondary sterility was defined according to the WHO definition (‘‘Scientific Group on the Epidemiology of Infertility’’) as the inability to become pregnant, following the birth of one or more biological children during a period of 2 years. Bleeding abnormalities included postmenstrual spotting, renewed bleeding after end of normal menstruation or menorrhagia. The study sample comprised 13 premenopausal women between 24 and 43 years (mean value = 33 years, standard deviation (SD) ± 5.8 years). Women with other causes for their symptoms (e.g. myomas, endometriosis, tubal pathologies) than uterine scar dehiscence after c-section were excluded from the study. Only symptomatic patients in whom dehiscence was detected by hysteroscopy and who subsequently underwent corrective surgical procedures received a questionnaire and were included in the final data evaluation. A flow chart of diagnostic and therapeutic steps is shown in Fig. 1. Diagnosis of uterine scar dehiscence All women underwent vaginal sonography and hysteroscopy. The main focus of sonography was on visualisation of the dehiscence and measurement of remaining myometrial thickness. Hysteroscopy recorded substance losses at the ventral cervico-corporal junction and accumulations of blood in the dehiscence. Ten patients underwent laparoscopy to diagnose intra-abdominal pathologies and to observe the dehiscence from an intra-abdominal perspective. Chromopertubation with methylene blue was
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additionally performed to detect accumulations of dye in the scar pouch and to exclude tubal sterility in seven out of ten patients. Therapy of uterine scar defects In nine patients, dehiscence correction was performed by laparotomy: the dehiscent myometrium was resected completely and a two-layered suture was performed with 2-0 to 4-0 Vicryl interrupted sutures. Attention was paid to ensuring layered adaptation of the myometrial wound margins (‘‘edge-to-edge’’) and subtle haemostasis for adhesion prophylaxis. Three patients denied surgical correction, one patient wanted a hysterectomy. Patients follow-up Women’s symptoms were monitored for at least 4 months postoperatively, an adequate period to assess post-reconstruction scar healing. Patients were advised to use contraception during this time. Outcomes were recorded by sending the patients a questionnaire to monitor persistent menstrual abnormalities, pain and renewed pregnancies. One patient was lost to follow-up, one patient did not return the questionnaire. Two women had not yet completed the follow-up period. Finally, postoperative outcome data of five women were available for analysis.
Results Typical symptoms of dehiscence Of the 13 non-pregnant, symptomatic patients 11 previously underwent one c-section, while two patients had two c-sections. Numerous of the patients had multiple complaints (Table 1). A majority (61.5 %, 8/13) complained of bleeding abnormalities (‘‘bleeding disorders’’/‘‘spotting’’) such as postmenstrual spotting, renewed bleeding after the end of normal menstruation or menorrhagia. About half of the patients (53.9 %, 7/13) suffered from pain since the previous c-section. The term ‘‘pain’’ includes classical dysmenorrhea, pain during intermenstrual bleeding and cycle-independent lower abdominal complaints. Secondary sterility was diagnosed in 69.2 % (9/13) of women at their first attendance. Diagnosis of dehiscence Uterine scar dehiscence was demonstrated sonographically in 12 of the 13 examined patients; findings and one sketch are shown in Fig. 2a–c. Hypoechoic or anechoic fluid
Arch Gynecol Obstet Fig. 1 Patient flow chart
Total patients with symptoms (N=13)
diagnosis
Sonography, hysteroscopy, laparoscopy (N=10), chromopertubation (7/10)
therapy
No correction (N=3)
Scar correction by laparotomy (N=9)
Lost of follow up, no questionaire return, other easons N=4
Table 1 Clinical symptoms and diagnostic findings of c-section scar dehiscence
Sonography, hysteroscopy (N=3)
Hysterectomy (N=1)
Final postoperative analysis (N=5)
Findings
Number (N)
Rate (%)
Total (N/N)
8/13
Clinical diagnostics of caesarean section scar pouch Bleeding disorders/postmenstrual spotting
8
61.5
Dysmenorrhoea/lower abdominal pain
7
53.9
8/13
Secondary sterility
9
69.2
8/13
12
Sonographical presentability of scar pouch Sonographical thickness of remaining myometrium Hysteroscopical presentability of scar pouch
92.3
12/13
6
50
6/12 13/13
13
100
Hysteroscopical detection of blood residues in scar pouch
6
46.2
6/13
Transclucency of hysteroscopy light through scar pouch during laparoscopy (‘positive diaphanoscopy’)
6
60.0
6/10
Accumulation of methylene blue in scar pouch during chromopertubation
3
42.9
3/7
accumulation was observed in the region of former uterotomy with interruption of the contour of the cervico-corporal myometrium (Fig. 2a, b), the tissue appeared ‘‘punched-out’’. In one patient, sonographic findings were not clear. Measurement of remaining residual myometrium yielded a mean value of d = 4.2 mm (1.7–8 mm, SD ± 1.94 mm). Hysteroscopy confirmed the dehiscence in all cases, in some cases complete endometrial loss was observed in the region of former uterotomy (Fig. 2c). In 46.1 % (6/13), blood residues were detected in the dehiscence despite cessation of menstrual bleeding. In six out of ten women (60 %) who underwent laparoscopy, the hysteroscopy light was shining through the scar pouch (‘‘positive diaphanoscopy’’). In four out of seven patients (57.1 %) in whom chromopertubation was performed an accumulation of dye was observed in the dehiscence cavity, and in one patient methylene blue spurted out in a manner consistent with a fistula formation.
Correlations with symptoms A high proportion of women complained about a combination of symptoms. From both bleeding abnormalities and pain suffered 38.5 % (5/13) of patients and six patients (46.2 %) showed both bleeding disorders and secondary sterility. In the presence of postmenstrual bleeding abnormalities, women were frequently affected by secondary sterility (46.2 %, 6/13). Overall there was no age dependency (\35 and C35 years) of secondary sterility. In 12 women, the uterine scar dehiscence was detected sonographically. An equal distribution of the remaining myometrial wall thicknesses was determined when differentiation was made between a minimum thickness of ‘‘\3.5 mm’’ and ‘‘C3.5 mm’’ (N = 6 in each case). Division into these subgroups appears useful because a value \3.5 mm in a pregnant uterus is considered critical in terms of impending uterine rupture [10].
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Fig. 2 Transvaginal sonography illustrating scar pouch (ventral on left side of sonogram, dorsal on right side; anteflected uterus, hypoechoic fluid accumulation in the scar pouch of 0.73 cm 9 0.39 cm and a second rounded fluid accumulation close to urinary bladder corresponding to myometrial defect) (a), sketch to
present relationship between uterus, urinary bladder and scar pouch (black, correlates to fluid accumulation) (b) and hysteroscopy (at the top ventral abdominal side, below dorsal side: view on complete loss of myometrium substance in scar pouch, ‘‘endometrium bald head’’, entry to cavum uteri is visible as dark area in depth) (c)
In 46.2 %, blood residues in the dehiscent cavity were detected by hysteroscopy. In 50 % of women with bleeding abnormalities, remaining blood constituents were detected in the dehiscence cavity. In five sterile women, hysteroscopy showed blood residues in the scar pouch, representing 38.5 % of the total patient sample. Of the six patients in whom blood was detected in the scar cavity, five (80 %) had secondary sterility.
included in the analysis had secondary sterility. Postoperatively, three patients (60 %) became pregnant naturally, one no longer wished to become pregnant, and another patient planned to become pregnant by assisted reproductive therapy. Two of the three pregnancies/births proceeded without complications. One child was delivered vaginally in the 37th week of pregnancy (3,040 g, 1-min APGAR 8), the second child in the 35th week of pregnancy (2,380 g, 1-min AGPAR 9). The third patient underwent secondary c-section in an external hospital due to premature labour, vaginal bleeding and retroplacental haematoma (35th week of pregnancy, 3,750 g, 1-min APGAR 9). No uterine rupture occurred.
Postoperative outcome Data for the outcome after dehiscence correction/reconstruction showed the following results. Preoperatively, three out of five operated women (60 %) complained of bleeding abnormalities/postmenstrual spotting. Postoperatively, all patients were free of these complaints. Preoperatively, three women suffered from pain (60 %), while postoperatively two patients continued to complain of lower abdominal pain. Preoperatively, all five women
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Comments In our retrospective, observational study of 13 women with clinical symptoms after c-section, we observed typical uterine scar dehiscence-associated symptoms and in most
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cases a combination of symptoms, e.g. bleeding disorders, abdominal pain and secondary sterility. The diagnosis was confirmed by transvaginal sonography and hysteroscopy and in the majority of cases an additional assessment using laparoscopy was performed. Reconstructive surgeries resulted in a discontinuation of bleeding disorders in all women and a pregnancy in three out of five patients (60 %) with secondary sterility. With a rising prevalence of c-sections worldwide postoperative complications and risks increase, one of them being uterine scar defects. The exact reasons for scar defects after c-section remain obscure [16–18]. Our study supports the assumption that women can already develop a dehiscence in the region of the past uterotomy after a single c-section. Our results concerning the clinical symptoms reflect those obtained in other studies [19, 20]. The majority of previous reports focused on abnormal uterine bleeding [5, 18, 20–22] as the primary symptom, while a few others considered chronic pelvic pain [23] and dysmenorrhea in addition to abnormal uterine bleeding, as the main presenting symptoms. The issue of sterility [23] is seldom mentioned, but we believe it is critical to consider it as an additional factor and we were able to show that our patient cohort with bleeding disorders suffers more frequently from secondary sterility. We assume as the causal factor that menstrual blood in the dehiscence behaves in a similar manner to hydrosalpinx fluid. Various fertility impairing reactions can occur, e.g. changes in intracavitary pH as well as toxic effects on sperm ascension and embryo nidation [18, 24–27], changes in endometrial activity [25, 28], impaired quality of cervical mucus or ‘‘washout’’ of the blastocysts ready for implantation [29]. Therefore, the occurrence of postmenstrual spotting or intermenstrual bleeding after c-section appears to be a possible risk factor for secondary sterility as supported by other authors [23, 30, 31]. More than half of the women investigated in our study reported pain and women with postmenstrual bleeding also suffered frequently from pain. Some studies show that development of pain is promoted by retained menstrual blood in the uterine cavity [18]. Studies on hysterectomy preparations showed chronic inflammatory processes in the region of scar dehiscences to be a possible precipitating factor for dysmenorrhea [14]. A recent systematic review investigating different techniques to detect uterine scar defects found a median prevalence of 37–59 % depending on the diagnostic technique used [32]. Sonographic analysis described triangular accumulations of fluid in dehiscence, as well as a concave retraction towards the urinary bladder [33–35]. In our study, the presumed dehiscence was visualised by transvaginal sonography in 12 out of 13 patients. The dehiscence shows itself in form of hypoechoic to anechoic zones
(stored menstrual blood) in the region of former c-section scars (Fig. 2a). In most cases, size, extent and remaining myometrial thickness can be determined exactly [36, 38]. The measurement of remaining myometrial diameter, however, is probably of little clinical relevance outside pregnancy. Cutoff of the remaining residual myometrial thickness in which there is not yet any increased risk of later uterine rupture is unknown outside pregnancy and most studies on the determination of risk of impending uterine rupture were performed on pregnant uteri in third trimester. The diagnosis of a dehiscence with a consecutively increased risk of rupture is achieved here with a mean thickness at the thinnest site of d \ 2.5 mm to d = 3.5 mm [6, 7, 10, 19, 38]. These findings, however, are not necessarily applicable to a non-pregnant uterus. For therapy planning, especially for women desiring to have more children, diagnostic hysteroscopy after cessation of menstrual bleeding is valuable. In our study population, as also in other studies [20, 39], a high correlation was apparent between intraoperative and previously sonographically recorded findings. Diagnosis of myometrial scar dehiscence is confirmed by demonstrating a loss of myometrial substance in the region of caesarean scar defect (Fig. 2c). In some cases, cavity formation or fistulation is evident or residues of blood are detectable in the dehiscence. The diagnosis of dehiscence and their extent can be additionally assessed by laparoscopy and chromopertubation showing positive diaphanoscopy and dye accumulation in the scar pouch. In our population, bleeding abnormalities ceased after surgical dehiscence correction, an outcome consistent with results of other investigators [15, 30, 40]. We and others assume that menstrual blood in the dehiscence collects as if in a reservoir and flows out in the form of postmenstrual spotting [4, 5, 14, 40]. There are various therapeutic options taking into account dehiscence-associated symptoms [5, 15, 30, 31, 37, 40]. The technique of defect excision and layered wound adaptation through a combined hysteroscopic-abdominal access route used in our clinic results in control of intermenstrual bleeding, pain control and improvement of fertility. Other studies also show that pain states improve after surgical intervention [15, 27, 30, 40]. In postmenstrual bleeding disorders, when family planning is not yet concluded, surgical correction should rather be the first-line option [27, 30, 31, 41–44]. The outflow of menstrual blood can be relieved and the bleeding problem thereby treated by only hysteroscopic resection of the dehiscence margins [5, 45, 46]. Data on postoperative pregnancies and uterine ruptures, however, are not presented in these publications. In solely hysteroscopic therapy, there is the continued risk of pre- and intrapartum uterine rupture due to thinning of the myometrium. For women wishing to have children, we,
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therefore, recommend complete abdominal resection of the dehiscent tissue and reconstruction of the uterus by exact adaptation of wound margins to minimise risk of subsequent uterine rupture. Naturally, peripartal rupture cannot be prevented completely despite reconstruction. There are several limitations to our study. First, due to a small number of cases a sufficient statistical analysis and interpretation of results can not be performed and our findings should be recognised as clinical observations. Second, we do not have a control group available to compare the clinical outcomes, e.g. pregnancy rate with or without intervention. Additionally a selection bias regarding the complaints reported by our patients might exist. Also, the follow-up time of about four month after corrective surgery might be to short and a second time point, e.g. 1 year after surgery, might be useful for future studies and gives additional, valuable insights into the long-term development of clinical symptoms. Our data confirm that the symptoms ‘‘bleeding disorders/ postmenstrual spotting’’, ‘‘pain/dysmenorrhea’’ and ‘‘secondary sterility’’ can be used as indicators for uterine scar dehiscence after c-section and corrective surgery is a useful tool to improve these symptoms and possibly fertility rate. With increasing c-section rates worldwide and accompanied risks, e.g. uterine scar defects, greater emphasis should be placed in the preoperative patient briefing on the development of scar dehiscences after c-sections. This applies especially for ‘‘elective c-sections’’, particularly when a couple wishes to have several children. Ideally, the early identification of scar dehiscence in non-pregnant women and appropriate treatment can contribute to the prevention of uterine ruptures and improvement pregnancy outcomes. Therefore, it is essential for health care professionals to be aware of typical symptoms, diagnostic and therapeutic strategies and associated risks. Acknowledgments We thank Mrs Rieck of the Institute for Biometrics of MHH for the biometric and statistical analysis.
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Conflict of interest The authors have no conflict of interest, have had full control of all primary data and agree to allow the Journal to review their data if requested. 18.
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