Uterine scar defect after cesarean section: diagnostic issues

DOI

https://dx.doi.org/10.18565/aig.2024.158

Danilov A.A., Martynov S.A., Adamyan L.V.
Academician V.I. Kulakov National Medical Research Centre for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, Moscow, Russia

Currently, operative abdominal delivery remains highly frequent, and this determines the relevance of the issue of uterine scar and associated complications. Uterine scar defect (USD) is associated with a large number of complications, including uterine rupture and placenta increta, infertility, and ineffectiveness of assisted reproductive technologies. The article presents a review of modern methods of scar diagnosis after cesarean section (ultrasound, MRI, sonohysterography, hysteroscopy), including techniques that can assess the qualitative characteristics of tissues (elastography, functional MRI). Despite the numerous proposed techniques, there is no gold standard for assessing the quality of the scar after cesarean section. It should be noted that the correlation between the mathematical parameters of the scar defect and adverse pregnancy outcomes explains the considerable diversity of the data obtained and cannot be considered unambiguous. The assessment of qualitative scar characteristics is of particular importance.
Conclusion: Despite the variety of techniques, to date there is no gold standard for diagnosing USD. In this regard, the development and implementation of methods that not only increase the accuracy of USD diagnosis, but can also assess the qualitative properties of the scar and adjacent myometrium are of particular importance. Therefore, the introduction of functional diagnostic methods seems to be the most promising and needs further study.

Authors’ contributions: Martynov S.A., Adamyan L.V. – concept and design of the article, editing; Danilov A.A. – collection and analysis of material, writing the text.
Conflicts of interest: Authors declare lack of the possible conflicts of interests.
Funding: The study was carried out without sponsorship.
For citation: Danilov A.A., Martynov S.A., Adamyan L.V. Uterine scar defect after cesarean section: diagnostic issues.
Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2024; (9): 22-27 (in Russian)
https://dx.doi.org/10.18565/aig.2024.158

uterine scar defect after cesarean section

niche

ultrasonography

elastography

functional magnetic resonance imaging

Full text (in Russian)

Antoine C., Young B.K. Cesarean section one hundred years 1920-2020: the Good, the Bad and the Ugly. J. Perinat. Med. 2020; 49(1): 5-16. https://dx.doi.org/10.1515/jpm-2020-0305.
Hehir M.P., Ananth C.V., Siddiq Z., Flood K., Friedman A.M., D'Alton M.E. Cesarean delivery in the United States 2005 through 2014: a population-based analysis using the Robson 10-Group Classification System. Am. J. Obstet. Gynecol. 2018; 219(1): 105.e1-105.e11. https://dx.doi.org/10.1016/j.ajog.2018.04.012.
Boerma T., Ronsmans C., Melesse D.Y., Barros A.J.D., Barros F.C., Juan L. et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018; 392(10155): 1341-8. https://dx.doi.org/10.1016/S0140-6736(18)31928-7.
Айламазян Э.К., Андреева В.Ю., Кузьминых Т.У., Соколов Д.И., Сельков С.А., Траль Т.Г., Толибова Г.Х., Яковлева А.А. Оптимизация репаративных процессов миометрия после кесарева сечения (клинико-экспериментальное исследование). Журнал акушерства и женских болезней. 2015; 64(4): 4-12. [Ailamazyan E.K., Andreeva V.Yu., Kuzminykh T.U., Sokolov D.I., Selkov S.A., Tral T.G., Tolibova G.Kh., Yakovleva A.A. The optimization of reparative processes after cesarean section (clinical-experimental research). Journal of Obstetrics and Women's Diseases. 2015; 64(4): 4-12. (in Russian)].
Donnez O. Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased. Fertil. Steril. 2020; 113(4): 704-16. https://dx.doi.org/10.1016/j.fertnstert.2020.01.037.
Подзолкова Н.М., Демидов А.В., Осадчев В.Б., Бабков К.В., Денисова Ю.В. Истмоцеле: дискуссионные вопросы терминологии, диагностики и лечения. Гинекология. 2024; 26(2):119-27. [Podzolkova N.М., Demidov A.V., Osadchev V.B., Babkov K.V., Denisova Yu.V. Isthmocele: controversial issues of terminology, diagnosis and treatment. A review. Gynecology. 2024; 26(2): 119-27. (in Russian)]. https://dx.doi.org/10.26442/20795696.2024.2.202716.
World Health Organization Human Reproduction Programme, 10 April 2015. WHO Statement on caesarean section rates. Reprod. Health Matters. 2015; 23(45): 149-50. https://dx.doi.org/10.1016/j.rhm.2015.07.007.
Armstrong F., Mulligan K., Dermott R.M., Bartels H.C., Carroll S., Robson M. et al. Cesarean scar niche: an evolving concern in clinical practice. Int. J. Gynaecol. Obstet. 2023; 161(2): 356-66. https://dx.doi.org/10.1002/ijgo.14509.
Федеральная служба государственной статистики. Здравоохранение в России: статистический сборник. 2021. 173 с. [Federal State Statistics Service. Health care in Russia: statistical collection. 2021. 173 p. (in Russian)].
Мартынов С.А., Адамян Л.В. Рубец на матке после кесарева сечения: терминологические аспекты. Гинекология. 2020; 22(5): 70-5. [Martynov S.A., Adamyan L.V. Cesarean scar defect: terminological aspects. Gynecology. 2020; 22(5): 70-5. (in Russian)]. https://dx.doi.org/10.26442/20795696.2020.5.200415.
Jordans I.P.M., de Leeuw R.A., Stegwee S.I., Amso N.N., Barri-Soldevila P.N., van den Bosch T. et al. Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure. Ultrasound Obstet. Gynecol. 2019; 53(1): 107-15. https://dx.doi.org/10.1002/uog.19049.
Мартынов С.А. Дефект рубца на матке после кесарева сечения: диагностика и лечение вне беременности. Гинекология. 2022; 22(3): 6-10. [Martynov S.A. Cesarean scar defects: diagnosis and treatment in non-pregnant women. Gynecology. 2020; 22(3): 6-10. (in Russian)]. https://dx.doi.org/10.26442/20795696.2020.3.200189.
van der Voet L.F., Bij de Vaate A.M., Veersema S., Brölmann H.A., Huirne J.A. 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. https://dx.doi.org/10.1111/1471-0528.12542.
Budny-Winska J., Zimmer-Stelmach A., Pomorski M. Two- and three-dimensional transvaginal ultrasound in assessment of the impact of selected obstetric risk factors on cesarean scar niche formation: the case-controlled study. Ginekol Pol. 2021; 92(5): 378-82. https://dx.doi.org/10.5603/GP.a2021.0024.
Kulshrestha V., Agarwal N., Kachhawa G. Post-caesarean niche (isthmocele) in uterine scar: an update. J. Obstet. Gynaecol. India. 2020; 70(6): 440-6. https://dx.doi.org/10.1007/s13224-020-01370-0.
Stegwee S.I., van der Voet L.F., Ben A.J., de Leeuw R.A., van de Ven P.M., Duijnhoven R.G. et al.; 2Close study group. Effect of single- versus double-layer uterine closure during caesarean section on postmenstrual spotting (2Close): multicentre, double-blind, randomised controlled superiority trial. BJOG. 2021; 128(5): 866-78. https://dx.doi.org/10.1111/1471-0528.16472.
Budny-Winska J., Pomorski M. Uterine niche after cesarean section: a review of diagnostic methods. Ginekol. Pol. 2021; 92(10): 726-30. https://dx.doi.org/10.5603/GP.a2021.0195.
Dominguez J.A., Pacheco L.A., Moratalla E., Carugno J.A., Carrera M., Perez-Milan F. et al. Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis. Ultrasound Obstet. Gynecol. 2023; 62(3): 336-44. https://dx.doi.org/10.1002/uog.26171.
Гус А.И., Ярыгина Т.А., Михеева А.А., Воеводина В.И., Шмаков Р.Г. Стандартизированное исследование послеоперационного рубца на матке. Акушерство и гинекология. 2022; 1: 42-7. [Gus A.I., Yarygina T.A., Mishieva N.G., Voevodina V.I., Shmakov R.G. Standardized examination of postoperative uterine scar. Obstetrics and Gynecology. 2022; (1): 42-7. (in Russian)]. https://dx.doi.org/10.18565/aig.2022.1.42-47.
Alalfy M., Osman O.M., Salama S., Lasheen Y., Soliman M., Fikry M. et al. Evaluation of the cesarean scar niche in women with secondary infertility undergoing ICSI using 2D sonohysterography versus 3D sonohysterography and setting a standard criteria; Alalfy simple rules for scar assessment by ultrasound to prevent health problems for women. Int. J. Womens Health. 2020; 12: 965-74. https://dx.doi.org/10.2147/IJWH.S267691.
Marjolein Bij de Vaate A.J., Linskens I.H., van der Voet L.F., Twisk J.W., Brölmann H.A., Huirne J.A. Reproducibility of three-dimensional ultrasound for the measurement of a niche in a caesarean scar and assessment of its shape. Eur. J. Obstet. Gynecol. Reprod. Biol. 2015; 188: 39-44. https://dx.doi.org/10.1016/j.ejogrb.2015.02.018.
Ludwin A., Martins W.P., Ludwin I. Evaluation of uterine niche by three-dimensional sonohysterography and volumetric quantification: techniques and scoring classification system. Ultrasound Obstet. Gynecol. 2019; 53(1): 139-43. https://dx.doi.org/10.1002/uog.19181.
Сухарева Т.А., Мартынов С.А., Адамян Л.В., Кулабухова Е.А., Учеваткина П.В., Летуновская А.Б., Бойкова Ю.В. Сравнение эффективности ультразвуковых методов диагностики и магнитно-резонансной томографии в оценке дефектов рубца на матке после кесарева сечения. Акушерство и гинекология. 2023; 4: 78-86. [Sukhareva T.A., Martynov S.A., Adamyan L.V., Kulabukhova E.A., Uchevatkina P.V., Letunovskaya A.B., Boykova Yu.V. Comparing the effectiveness of ultrasound and MRI in assessing cesarean uterine scar defects. Obstetrics and Gynecology. 2023; (4): 78-86. (in Russian)]. https://dx.doi.org/10.18565/aig.2022.264.
Сидорова Т.А., Мартынов С.А., Адамян Л.В., Летуновская А.Б., Бойкова Ю.В. Сравнение эффективности ультразвуковых методов диагностики в оценке дефектов рубца на матке после кесарева сечения. Акушерство и гинекология. 2022; 4: 132-40. [Sidorova T.A., Martynov S.A., Adamyan L.V., Letunovskaya A.B., Boykova Yu.V. Comparison of the effectiveness of ultrasound diagnosis in assessment of uterine scar defets after cesarean section. Obstetrics and Gynecology. 2022; (4): 132-40. (in Russian)]. https://dx.doi.org/10.18565/aig.2022.4.132-140.
Ножницева О.Н., Беженарь В.Ф. Ниша рубца на матке после кесарева сечения – новая проблема репродуктивного здоровья женщины. Журнал акушерства и женских болезней. 2020; 69(1): 53-62. [Nozhnitseva O.N., Bezhenar V.F. The niche in the uterine cesarean scar: a new problem of women’s reproductive health. Journal of Obstetrics and Women’s Diseases. 2020; 69(1): 53-62. (in Russian)]. https://dx.doi.org/10.17816/JOWD69153-62.
Satpathy G., Kumar I., Matah M., Verma A. Comparative accuracy of magnetic resonance morphometry and sonography in assessment of post-cesarean uterine scar. Indian J. Radiol. Imaging. 2018; 28(2): 169-74. https://dx.doi.org/10.4103/ijri.IJRI_325_17.
Gupta T., Singal K., Gupta N., Kohli S., Kanyal M. Comparative study of USG and MRI in evaluation of isthmocele. J. Obstet. Gynaecol. India. 2021; 71(3): 292-6. https://dx.doi.org/10.1007/s13224-021-01433-w.
Wong W.S.F., Fung W.T. Magnetic resonance imaging in the evaluation of cesarean scar defect. Gynecol. Minim. Invasive Ther. 2018; 7(3): 104-7. https://dx.doi.org/10.4103/GMIT.GMIT_23_18.
Tang X., Wang J., Du Y., Xie M., Zhang H., Xu H. et al. Caesarean scar defect: Risk factors and comparison of evaluation efficacy between transvaginal sonography and magnetic resonance imaging. Eur. J. Obstet. Gynecol. Reprod. Biol. 2019; 242: 1-6. https://dx.doi.org/10.1016/j.ejogrb.2019.09.001.
Fiocchi F., Petrella E., Nocetti L., Currà S., Ligabue G., Costi T. et al. Transvaginal ultrasound assessment of uterine scar after previous caesarean section: comparison with 3T-magnetic resonance diffusion tensor imaging. Radiol. Med. 2015; 120(2): 228-38. https://dx.doi.org/10.1007/s11547-014-0431-y.
Chen Y.Y., Tsai C.C., Kung F.T., Lan K.C., Ou Y.C. Association between hysteroscopic findings of previous cesarean delivery scar defects and abnormal uterine bleeding. Taiwan J. Obstet. Gynecol. 2019; 58(4): 541-4. https://dx.doi.org/10.1016/j.tjog.2019.05.020.
Sako Y., Hirata T., Momoeda M. Hysteroscopy-guided laparoscopic resection of a cesarean scar defect in 5 steps: the usefulness of nonperfusion hysteroscopy. Fertil. Steril. 2022; 118(6): 1196-8. https://dx.doi.org/10.1016/j.fertnstert.2022.08.861.
Chen H., Wang Y., Zhang H., Wang X. Vaginal repair of cesarean section scar defects: Preoperative hysteroscopic evaluation. Acta Obstet. Gynecol. Scand. 2022; 101(11): 1308-14. https://dx.doi.org/10.1111/aogs.14429.
van der Voet L.L.F., Limperg T., Veersema S., Timmermans A., Bij de Vaate A.M.J., Brölmann H.A.M. et al. Niches after cesarean section in a population seeking hysteroscopic sterilization. Eur. J. Obstet. Gynecol. Reprod. Biol. 2017; 214: 104-8. https://dx.doi.org/10.1016/j.ejogrb.2017.05.004.
Zhang Q., Yi S., Yang Y., Xiao S., Xu D., Wu J. et al. Clinical analysis of uterine parameters evaluated by preoperative magnetic resonance imaging in patients treated by hysteroscopic approach with previous cesarean scar defect-related abnormal uterine bleeding: a retrospective cohort study. Quant. Imaging Med. Surg. 2024; 14(3): 2334-44. https://dx.doi.org/10.21037/qims-23-1205.
Zhang Q., Lin C., Wu J., Xu D., Zhu S., Jiang B. Value and influencing factors of preoperative MRI evaluation for previous cesarean scar defect associated abnormal uterine bleeding in patients undergoing laparoscopic surgery. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2023; 48(9): 1316-24. https://dx.doi.org/10.11817/j.issn.1672-7347.2023.230123.
Millischer A.E., Salomon L.J., Santulli P., Borghese B., Dousset B., Chapron C. Fusion imaging for evaluation of deep infiltrating endometriosis: feasibility and preliminary results. Ultrasound Obstet. Gynecol. 2015; 46(1): 109-17. https://dx.doi.org/10.1002/uog.14712.
Bolten K., Fischer T., Bender Y.Y., Diederichs G., Thomas A. Pilot study of MRI/ultrasound fusion imaging in postpartum assessment of Cesarean section scar. Ultrasound Obstet. Gynecol. 2017; 50(4): 520-6. https://dx.doi.org/10.1002/uog.17349.
Wu C., Chen X., Mei Z., Zhou J., Wu L., Chiu W.H. et al. A preliminary study of uterine scar tissue following cesarean section. J. Perinat. Med. 2018; 46(4):379-86. https://dx.doi.org/10.1515/jpm-2016-0347.
Gennisson J.L., Muller M., Gabor P., Frydman R., Musset D., Tanter M. et al. Quantification of elasticity changes in the myometrium during labor using Supersonic Shear Imaging: a feasibility study. Ultrasonics. 2015; 56: 183-8. https://dx.doi.org/10.1016/j.ultras.2014.07.013.
Гурбатов С.Н., Демин И.Ю., Прончатов-Рубцов Н.В. Ультразвуковая эластография: аналитическое описание различных режимов и технологий, физическое и численное моделирование сдвиговых характеристик мягких биологических тканей. Учебно-методическое пособие. Н. Новгород; 2015. [Gurbatov S.N., Demin I.Yu., Pronchatov-Rubtsov N.V. Ultrasonic elastography: analytical description of various modes and technologies, physical and numerical modeling of shear characteristics of soft biological tissues. Educational and methodological manual. N. Novgorod; 2015. (in Russian)].
Wozniak S., Czuczwar P., Szkodziak P., Paszkowski T. Usefulness of elastography in predicting the outcome of Foley catheter labour induction. Aust. N. Z. J. Obstet. Gynaecol. 2015; 55(3): 245-50. https://dx.doi.org/10.1111/ajo.12331.
Woźniak S. The potential role of elastography in differentiating between endometrial polyps and submucosal fibroids: a preliminary study. Prz. Menopauzalny. 2015; 14(2): 130-3. https://dx.doi.org/10.5114/pm.2015.52123.
Czuczwar P., Wozniak S., Szkodziak P., Kudla M.J., Pyra K., Paszkowski T. Elastography improves the diagnostic accuracy of sonography in differentiating endometrial polyps and submucosal fibroids. J. Ultrasound. Med. 2016; 35(11): 2389-95. https://dx.doi.org/10.7863/ultra.15.12017.
di Pasquo E., Kiener A.J.O., DallAsta A., Commare A., Angeli L., Frusca T. et al. Evaluation of the uterine scar stiffness in women with previous Cesarean section by ultrasound elastography: a cohort study. Clin. Imaging. 2020; 64: 53-6. https://dx.doi.org/10.1016/j.clinimag.2020.03.006.
Seliger G., Chaoui K., Lautenschläger C., Jenderka K.V., Kunze C., Hiller G.G.R. et al. Ultrasound elastography of the lower uterine segment in women with a previous cesarean section: comparison of in-/ex-vivo elastography versus tensile-stress-strain-rupture analysis. Eur. J. Obstet. Gynecol. Reprod. Biol. 2018; 225: 172-80. https://dx.doi.org/10.1016/j.ejogrb.2018.04.013.
Мирошникова Н.А., Быченко В.Г., Адамян Л.В., Козлова А.В., Макиян З.Н. Применения функциональной магнитно-резонансной томографии в гинекологии. Акушерство и гинекология. 2017; 5: 16-22. [Miroshnikova N.A., Bychenko V.G., Adamyan L.V., Kozlova A.V., Makiyan Z.N. Functional magnetic resonance imaging in gynecology. Obstetrics and Gynecology. 2017; (5): 16-22. (in Russian)]. https://dx.doi.org/10.18565/aig.2017.5.16-22.

Received 06.07.2024

Accepted 06.09.2024

Anton A. Danilov, PhD student at Gynecological Department, Academician V.I. Kulakov NMRC for OG&P, Ministry of Health of Russia,
117997, Russia, Moscow, Ac. Oparin str., 4, +7(495)438-77-83, an_danilov@oparina4.ru, https://orcid.org/0009-0005-2461-5354
Sergey A. Martynov, Dr. Med. Sci., Leading Researcher at Gynecological Department, Academician V.I. Kulakov NMRC for OG&P, Ministry of Health of Russia,
117997, Russia, Moscow, Ac. Oparin str., 4, +7(495)438-77-83, s_martynov@oparina4.ru, https://orcid.org/0000-0002-6795-1033
Leyla V. Adamyan, Dr. Med. Sci., Professor, Academician of RAS, Deputy Director for Science, Head of the Department of Operative Gynecology, Academician V.I. Kulakov NMRC for OG&P, Ministry of Health of Russia, 117997, Russia, Moscow, Ac. Oparin str., 4, +7(495)438-77-83, l_adamyan@oparina4.ru,
https://orcid.org/0000-0002-3253-4512

Uterine scar defect after cesarean section: diagnostic issues

Danilov A.A., Martynov S.A., Adamyan L.V.

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