The incidence of isthmocele may be higher than reported

Abstract

Aim: Isthmocele, a long-term complication of Cesarean section (CS) surgery, has drawn increasing worldwide interest. However, not all women with this Cesarean scar defect (CSD) present with clinical symptoms. We studied a group of non-pregnant women with a CS history to determine the prevalence of isthmocele, the potential risk factors for its development, and the most common clinical complaints.

Methods: This study included women who had a cesarean operation more than 6 months ago, who were not pregnant between January 2017 and April 2017 and applied to the gynecology clinic for any reason. The exclusion criteria were the patients in the menopause period. Data was collected on 115 participants, including age, body mass index, duration after CS, and the number of CS surgeries that had been performed. Standardized scar parameters (residual myometrial thickness (RMT) and the depth and width of the triangular hypoechoic niche) were measured using transvaginal-ultrasonography (TVS). Isthmocele symptoms were categorized as asymptomatic, postmenstrual spotting, menometrorrhagia, chronic pelvic pain, dysmenorrhea, and infertility. Associations between isthmocele and menstrual complications were investigated. The relationship between isthmocele development and the reasons for the CS surgery were evaluated. 

Results: TVS examination diagnosed 17 women (14.78%) with isthmocele. Women who had undergone recurrent CS surgeries tended to have more visible isthmocele than those with a single CS surgery. The average isthmocele depth was 6.006 ± 0.7970 mm. Among the women with isthmoceles, elective CS surgery had been performed in six (35.3%), while 11 (64.7%) had the surgery at parturition. The presence of an isthmocele was frequently symptomatic, predominantly as postmenstrual spotting. Women with an isthmocele had significantly lower RMT values (5.57 ± 0.60 mm versus 8.78 ± 0.22 mm) than those without an isthmocele. There was no correlation between age, body mass index, and the presence of an isthmocele (p > 0.05). 

Conclusions: The incidence and prevalence of CSD is greater than most gynecologists realize. Isthmoceles can develop after just one CS surgery, leading to long-term complications that morbidly effect women for the rest of their lives. A reduction in the number of CS surgeries is the most effective way to decrease the prevalence of isthmoceles.

Keywords

• Isthmocele,Uterine niche,Postcoital bleeding,Pelvic pain

İsthmocele'in insidansı bildirilenden daha fazla olabilir

Öz

Amaç: İsthmosel, dünyada gittikçe yaygınlaşan  sezaryen  operasyonunun uzun dönem bir komplikasyonudur. Ancak sezaryen skar defektli kadınların(SSD=İsthmosel) tamamında semptom görülmez. Biz çalışmamızda isthmosel prevalansı, gelişimi için risk faktörleri ve en yaygın semptomlarını araştırmak istedik.

Yöntemler: Bu çalışmaya 6 aydan daha uzun bir süre önce sezaryen operasyonu olan, 2017  Ocak ve 2017 Nisan tarihleri arasında gebe olmayan, jinekoloji polikliniğine herhangi bir nedenle başvuran kadınlar dahil edildi. Menapoz döneminde ki hastalar çalışma dışı bırakılma kriteri olarak alındı. Sezaryen olan  115 kadının verileri  yaşı, vücut kitle indexi, sezaryen sonrası geçen süre ve geçirilmiş sezaryen sayısını içerecek şekilde kayıt altına alındı. Standardize edilen skar parametreleri (residual myometrial kalınlık (RMK), triangular hipoekoik nishe’in genişlik ve derinliği ölçümü) transvajinal ultrasonografi (TVUSG) ile yapıldı. İsthmosel semptomları asemptomatik, postmenstrual spotting tarzı kanama, menoraji, kronik pelvik ağrı, dismenore ve infertilite olarak kategorize edildi. İsthmosel ve menstruel komplikasyonlar arasındaki ilişki araştırıldı. İsthmosel gelişimi ve sezaryen sebebleri arasındaki ilişkiler değerlendirildi.

Bulgular: Hastaların TVUSG ile değerlendirmesinde 17 tanesinde (%14,78) isthmosel tespit edildi. Birden fazla sezaryen olan hastalar tek sezaryen olan hastalara göre daha fazla  isthmosel geliştirme eğilimindeydiler. Ortalama isthmosel çapı 6,006 ± 0,7970 mm’di. İsthmoselli kadınların 6 tanesi (%35,3) elektif alınan sezaryen vakalarında gelişmiş iken, 11 tanesi (%64,7) doğum eylemi başladıktan sonar yapılmıştı. İsthmosel olan hastaların çoğunluğu semptomatikti ve daha çok spotting tarzda kanama görülüyordu. İsthmosel görülen kadınların RMK değerleri isthmosel görülemyenlerden belirgin olarak düşüktü (5,57 ± 0,60 mm vs 8,78 ± 0,22 mm).

Sonuç: SSD prevalans ve insidansı kadın doğum hekimlerinin tahmin ettiğinden çok daha fazladır. İsthmosel bir sezaryen sonrası bile gelişebilir ve o kadınlarda uzun vadeli yaşamları boyunca morbidite sebebi olarak görülür. Sezaryen  oranlarının azaltılması isthmosel prevalansını azaltmada çok etkili olacaktır.

Anahtar Kelimeler

• İsthmosel,Uterin niş,Postkoital kanama,Pelvik ağrı

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