الفهرس 
Cesarean Section
Reconstructive vaginal surgeryOnly 14 pages are availabe for public view
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Abstract
Cesarean section delivery is becoming more frequent. The progressive increase in the incidence of cesarean birth has been a notable feature of contemporary obstetric practice and cesarean delivery is now the most frequent major surgical procedure performed in obstetrics and gynaecology (Martin et al., 2002). The surgical techniques for performing cesarean delivery has changed from time to time, from surgeon to surgeon and these changes were involved both, of the uterine and skin incisions. Only a small number of these techniques have been evaluated in randomized controlled trials (Tully et al., 2002).
In the last decades we became aware of gynecological symptoms after a CS, such as postmenstrual spotting, dysmenorrhea, chronic pelvic pain and dyspareunia (Wang et al., 2009; Bij de Vaate et al., 2011; van der Voet et al., 2014a). Already in 1999 it was postulated that these symptoms could be related to an incompletely healed uterine scar, also called a niche. Thurmond et al. postulated the hypothesis that a niche in the Cesarean scar could be a cause of abnormal bleeding due to the collection of menstrual blood in a uterine scar defect causing postmenstrual spotting (Thurmond et al., 1999).The objective of the currant study was to identify the prevalence of CS scar niche in women 6 weeks to 6 months after a single previous CS, and to evaluate its association with abnormal uterine bleeding, dysmenorrhea and urinary symptoms.
After application of Inclusion criteria:
1. Maternal age (20-35) years old.
2. Fetal weight (2500-3500) grams.
3. Level of performing surgeon (experience at least 2years residence).
4. Women who underwent Cesarean section through a transverse lower-segment incision.
5. Women who underwent Cesarean section at gestations ≥ 37 weeks.
6. Singleton not multi-fetal pregnancy.
And Exclusion criteria:
1. Premature rupture of membrane or emergency C.S like (rupture uterus, placenta previa or abruption, chorioamnitis).
2. Women who had previously scarred uterus (previous Cesarean section or previous uterine surgery e.g. myomectomy).
3. Women with medical disorders like (D.M, HTN, anemia, low platelets, and infection) during pregnancy.
4. Intra operative complication (uterine extension, sever blood loss).
5. Post-operative complication (hemorrhage, pyrexia, wound infection).All 300 women under the study were asked about the following:
Detalied history including:
- Personal history (including lactation), past history (medical and surgical), obstetric history, contracetive method (IUD, hormonal (POP, COC), Local).
- All amenorrohic women were asked to do pregnancy test (serum BHCG) before the ultrasound in order to exclude pregnancy.
- Then a detailed questionnaire was filled in order to detect abnormal uterine bleeding (premenstrual, intermenstural, postmestural spotting), dysmenrehea (VAS), urinary symptoms.
A. Menstrual symptoms:
Women were asked for the regularity and duration of their menstrual cycle, number of days of blood loss (including the number of days of brownish discharge just before and after the cycle), and the number of days of inter-menstrual bleeding.
In addition, they were asked to keep:
Modified pictorial blood loss assessment chart (PBAC) (Higham et al., 1990) to assess the amount of blood loss during their period.B. Dysmenorrhea:
In the same questionnaire women were asked about
Significant pain during menstruation.
Onset and offset of pain in relation to menstrual flow.
Pain was assessed by asking the patient using the 10- Visual scale (with 0 denoting no pain and 10 denoting the worst pain).
C. Urinary symptoms:
Women were asked in the same questionnaire about the symptoms of urinary incontinence.
Then all included women were subjected to trans-vaginal ultra-sound scan in maternity hospital of Ain Shams university for detection of a CS scar niche after giving informed oral consent
TVS was performed during the first postmenstrual week and the cycle day was recorded, or if the woman is amenorrheic or on irregular menstruation TVUS done after negative serum human chorionic gonadotropin.
The best time to assess for the abnormality is after the patient‘s menstrual cycle, when the endometrial lining is at its thinnest and recently menstruated blood has collected in the defect (this can highlight the niche on imaging).Patients needed to have their bladder completely empty during the test. TVS was performed first and the following details of the uterus were recorded: Position, length, width, endometrial thickness and presence of intra-cavitary fluid.
The uterus was examined for presence of a niche, defined as an anechoic area at the site of the Cesarean scar with a depth of at least 1 mm. If a niche could be detected, the depth of the niche (The vertical distance between the base and apex of the defect) and residual myometrium (from the serosal surface of the uterus to the apex of the niche) were measured.
The niche shape was assessed according to a specified classification in the figure below.
Schematic diagram demonstrating classification used to assess niche shape: triangle, semicircle, rectangle, circle, droplet and inclusion cysts.
The uterine cavity was examined for the presence of other intrauterine abnormalities, such as sub-mucosal fibroids or polyps.Subsequently, saline infusion sonohysterography was performed for women who had niche except women with intra-cavitery fluid to confirm the presence of niche and its shape and depth after TVUS.
The study had revealed that:
- Cesarean section scar niche was found by trans-vaginal ultrasonography in 21.7% of the studied women.
- The most frequent SC scar niche shape found by trans-vaginal ultrasonography in the studied women is triangular shape.
- In women who did both trans-vaginal and sono-hysterography; the shape of the niche was the same by trans-vaginal and sonohysterography, while depth was significantly higher, and residual myometrium was thinner in sonohysterography.
- No significant difference was found between women with and without niche regarding demographic characteristics.
- Women with RVF uterus mostly had more niche occurance than women who had AVF uterus (more prone to develop niche), and also the niche has greater depth in women with RVF uterus than in women with AVF uterus.Women with CS scar niche had significantly, higher uterine length, longer menstrual duration, higher PBAC score, more postmenstrual spotting days, more inter-menstrual spotting days and more dysmenorrhea.
- In the currant study, there was a positive correlation between presence of the niche and post menstrual spotting, heaviness of menstrual flow, inter-menstrual spotting and dysmenorrhea but there was no relation between presence of the niche and premenstrual spotting in women under the study.
- There were significant positive correlations between niche depth and uterine length, menstrual duration, PBAC score, postmenstrual spotting days and dysmenorrhea. Women with intra-cavitary fluid had significantly higher niche depth.
- Women with and without niche had same uterine width.