Objective
To study the prevalence of niches in the caesarean scar in a random population, and the relationship with postmenstrual spotting and urinary incontinence.
Design
A prospective cohort study.
...Setting
A teaching hospital in the Netherlands.
Population
Non‐pregnant women delivered by caesarean section.
Methods
Transvaginal ultrasound (TVU) and gel instillation sonohysterography (GIS) were performed 6–12 weeks after caesarean section. Women were followed by questionnaire and menstruation score chart at 6–12 weeks, 6 months, and 12 months after caesarean section.
Main outcome measures
Prevalence of a niche 6–12 weeks after caesarean section, using TVU and GIS. Secondary outcomes: relation to postmenstrual spotting and urinary incontinence 6 and 12 months after caesarean section; and niche characteristics, evaluated by TVU and GIS.
Results
Two hundred and sixty‐three women were included. Niche prevalence was 49.6% on evaluation with TVU and 64.5% with GIS. Women with a niche measured by GIS reported more postmenstrual spotting than women without a niche (OR 5.48, 95% CI 1.14–26.48). Women with residual myometrium at the site of the uterine scar measuring <50% of the adjacent myometrial thickness had postmenstrual spotting more often than women with a residual myometrial thickness of >50% of the adjacent myometrial thickness (OR 6.13, 95% CI 1.74–21.63). Urinary incontinence was not related to the presence of a niche.
Conclusions
A niche is present in 64.5% of women 6–12 weeks after caesarean section, when examined by GIS. Postmenstrual spotting is more prevalent in women with a niche and in women with a residual myometrial thickness of <50% of the adjacent myometrium.
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Background
Caesarean section (CS) rates are rising globally. Long‐term adverse outcomes after CS might be reduced when the optimal uterine closure technique becomes evident.
Objective
To determine ...the effect of uterine closure techniques after CS on maternal and ultrasound outcomes.
Search strategy
Literature search in electronic databases.
Selection criteria
Randomised controlled trials (RCTs) or prospective cohort studies that evaluated uterine closure techniques and reported on ultrasound findings, perioperative or long‐term outcomes.
Data collection and analysis
Twenty studies (15 053 women) were included in our meta‐analyses for various outcomes. We calculated pooled risk ratios (RR) and weighted mean differences (WMD) with 95% CI through random‐effect analysis.
Main results
Residual myometrium thickness (RMT), reported in eight studies (508 women), decreased by 1.26 mm after single‐ compared with double‐layer closure (95% CI −1.93 to −0.58), particularly when locked sutures were used. Healing ratio RMT/adjacent myometrium thickness (AMT) decreased after single‐layer closure (WMD −7.74%, 95% CI −13.31 to −2.17), particularly in the case of locked sutures. Niche prevalence increased (RR 1.71, 95% CI 1.11–2.62) when the decidua was excluded. Dysmenorrhea occurred more often in the single‐layer group (RR 1.23, 95% CI 1.01–1.48), whereas incidence of uterine rupture was similar (RR 1.91, 95% CI 0.63–5.74).
Conclusion
Double‐layer unlocked sutures are preferable to single‐layer locked sutures regarding RMT, healing ratio and dysmenorrhoea. Excluding the decidua seems to result in higher niche prevalence. As thin residual myometrium or niches may serve as intermediates for gynaecological and reproductive outcomes, future studies should focus on these outcomes.
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#Uterineclosuretechniques after #caesarean affect #longtermoutcomes.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Objective
To compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect.
Design
Multicentre randomised ...controlled trial.
Setting
Eleven hospitals collaborating in a consortium for women's health research in the Netherlands.
Population
Women reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography.
Methods
Women were randomly allocated to hysteroscopic niche resection or expectant management for 6 months.
Main outcome measures
The primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation.
Results
We randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2–7 days) in the intervention group and 7 days (IQR 3–10 days) in the control group (P = 0.04); on a scale of 0–10, discomfort as a result of spotting had a median score of 2 (IQR 0–7) in the intervention group, compared with 7 (IQR 0–8) in the control group (P = 0.02).
Conclusions
In women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting‐related discomfort.
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A hysteroscopic niche resection is an effective treatment to reduce niche‐related spotting.
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A hysteroscopic niche resection is an effective treatment to reduce niche‐related spotting.
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Background
Various therapies are currently used to treat symptoms related to the niche (an anechoic area) in the caesarean scar, in particular to treat abnormal uterine bleeding (AUB).
Objective
To ...systematically review the available literature reporting on the effect of various therapies on niche‐related symptoms.
Search strategy
A systematic search of MEDLINE, Embase, Cochrane, trial registers and congress s from AAGL and ESGE was performed.
Selection criteria
Articles reporting on the effectiveness of therapies other than hysterectomy in women with niche‐related symptoms were included. Studies were included if they reported one of the following outcomes: effect on AUB, pain relief, sexual function, quality of life (QOL), and surgical, anatomic, fertility, or pregnancy outcome.
Data collection and analysis
Two authors independently selected the articles to be included. The Meta‐analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed. A standardised checklist was used to score the methodological quality of the included studies.
Main results
Twelve studies were included, reporting on hysteroscopic niche resection (eight studies, 384 patients), laparoscopic repair (one study, 13 patients), (laparoscopic assisted) vaginal repair (two studies, 47 patients), and oral contraceptives (OCs) (one study, 11 patients). Reported AUB improved in the vast majority of the patients after these interventions, ranging from 87 to 100%. The rate of complications was low. Pregnancies were reported after therapy; however, sample sizes and follow‐up were insufficient to study fertility or pregnancy outcome. The methodological quality of the selected papers was considered to be moderate to poor, and was therefore insufficient to make solid conclusions.
Author's conclusions
More evidence is needed before (surgical) niche interventions are implemented in daily practice.
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Objective
To evaluate the effectiveness of hysteroscopy for the detection and treatment of endometrial polyps versus expectant management in women with postmenopausal bleeding (PMB), a thickened ...endometrium and benign endometrial sampling.
Design
Multicentre, randomised controlled trial.
Setting
Three academic hospitals and nine non‐academic teaching hospitals in the Netherlands.
Population
Women with PMB, an endometrial thickness >4 mm and benign result from endometrial sampling.
Methods
Women were randomised to either further diagnostic workup by hysteroscopy (preceded by saline infusion sonography) or expectant management.
Main outcomes
The primary outcome measure was recurrence of PMB within a year after randomisation. Secondary outcome measures were time to recurrent bleeding and recurrent bleeding after more than 1 year. In the hysteroscopy group, the presence of polyps and the results of their histology were registered.
Results
Between January 2010 and October 2013, 200 women were randomised; 98 to hysteroscopy and 102 to expectant management. Within 1 year a total of 15 women (15.3%) in the hysteroscopy group experienced recurrent bleeding, versus 18 (18.0%) in the expectant management group (relative risk 0.85 (95% CI 0.46–1.59). In the hysteroscopy group, 50/98 (51%) polyps were diagnosed of which 6/98 (6%) showed evidence of endometrial (pre)malignancy; final pathology results after hysterectomy showed three women with hyperplasia with atypia and three women with endometrial cancer.
Conclusion
In women with PMB, a thickened endometrium and benign endometrial sampling, operative hysteroscopy does not reduce recurrent bleeding. Hysteroscopy detected focal endometrial (pre)malignancy in 6% of women who had benign endometrial sampling. This finding indicates that in these women, further diagnostic workup is warranted to detect focal (pre)malignancies, missed by blind endometrial sampling.
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In women with PMB, hysteroscopy does not reduce recurrent bleeding but is warranted to detect focal malignancy.
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In women with PMB, hysteroscopy does not reduce recurrent bleeding but is warranted to detect focal malignancy.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Objective
To compare recurrence of a cyst or abscess of the Bartholin gland after surgical treatment using a Word catheter or marsupialisation.
Design
Multicentre, open‐label, randomised controlled ...trial.
Setting
Eighteen hospitals in the Netherlands and one hospital in England.
Population
Women with a symptomatic cyst or abscess of the Bartholin gland.
Methods
Women were randomised to treatment with Word catheter or marsupialisation.
Main outcome measures
The primary outcome was recurrence of the cyst or abscess within 1 year of treatment. The secondary outcomes included pain during and after treatment (measured on a 10‐point scale), use of analgesics, and time from diagnosis to treatment. Analysis was by intention‐to‐treat. To assess whether marsupialisation would reduce the recurrence rate by 5% (from 20 to 15%) we needed to include 160 women (alpha error 0.05, beta error 0.2).
Results
One hundred and sixty‐one women were randomly allocated to treatment by Word catheter (n = 82) or marsupialisation (n = 79) between August 2010 and May 2014. Baseline characteristics were comparable. Recurrence occurred in 10 women (12%) allocated to Word catheter versus eight women (10%) allocated to marsupialisation: relative risk (RR) 1.1, 95% confidence interval (CI) 0.64–1.91; P = 0.70. Pain scores after treatment were also comparable. In the first 24 hours after treatment, 33% used analgesics in the Word catheter group versus 74% in the marsupialisation group (P < 0.001). Time from diagnosis to treatment was 1 hour for placement of Word catheter versus 4 hours for marsupialisation (P = 0.001).
Conclusions
In women with an abscess or cyst of the Bartholin gland, treatment with Word catheter and marsupialisation results in comparable recurrence rates.
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Comparable recurrence rates for treatment of Bartholinic abscess/cyst with Word catheter and marsupialisation.
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Comparable recurrence rates for treatment of Bartholinic abscess/cyst with Word catheter and marsupialisation.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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8.
Reply: Niche risk factor for uterine rupture? Bij de Vaate, A.J.M.; van der Voet, L.F.; Naji, O. ...
Ultrasound in obstetrics & gynecology,
September 2014, Volume:
44, Issue:
3
Journal Article
Peer reviewed
Open access
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
We describe the design of a randomised controlled trial to evaluate the efficacy of endometrial polyp removal in women with postmenopausal bleeding. We designed a trial in which patients with ...postmenopausal bleeding and endometrial thickness >4 mm undergo hysteroscopy. If during hysteroscopy an endometrial polyp was diagnosed, patients were asked to participate in this trial and after informed consent allocated to immediate removal of the polyp or expectant management. This trial suffered from lack of recruitment related both to doctors seeking for informed consent as well as to patients’ unwillingness to participate in this trial. However, a randomised controlled trial on this subject is still necessary to evaluate the efficacy of uterine cavity evaluation in the diagnostic work‐up of women with postmenopausal bleeding, focussing on benign pathology. Therefore, we propose an alternative design, which might be more feasible.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Objective
To evaluate whether double‐layer uterine closure after a first caesarean section (CS) is superior compared with single‐layer uterine closure in terms of postmenstrual spotting and niche ...development in the uterine caesarean scar.
Design
Multicentre, double‐blind, randomised controlled superiority trial.
Setting
Thirty‐two hospitals in the Netherlands.
Population
A total of 2292 women aged ≥18 years undergoing a first CS were randomly assigned to each procedure (1:1): 1144 women were assigned to single‐layer uterine closure and 1148 women were assigned to double‐layer uterine closure.
Methods
Single‐layer unlocked closure and double‐layer unlocked closure, with the second layer imbricating the first.
Main outcome measures
Number of days with postmenstrual spotting during one menstrual cycle 9 months after CS. Secondary outcomes: perioperative and menstrual characteristics; transvaginal ultrasound measurements.
Results
A total of 774 (67.7%) women from the single‐layer group and 770 (67.1%) women from the double‐layer group were evaluable for the primary outcome, as a result of drop‐out and amenorrhoea. The mean number of postmenstrual spotting days was 1.33 (bootstrapped 95% CI 1.12–1.54) after single‐layer closure and 1.26 (bootstrapped 95% CI 1.07–1.45) after double‐layer closure (adjusted mean difference −0.07, 95% CI −0.37 to 0.22, P = 0.810). The operative time was 3.9 minutes longer (95% CI 3.0–4.9 minutes, P < 0.001) and niche prevalence was 4.7% higher (95% CI 0.7–8.7%, P = 0.022) after double‐layer closure.
Conclusions
The superiority of double‐layer closure compared with single‐layer closure in terms of postmenstrual spotting after a first CS was not shown. Long‐term obstetric follow‐up of our trial is needed to assess whether uterine caesarean closure guidelines should be adapted.
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Double‐layer uterine closure is not superior for postmenstrual spotting after a first caesarean; single‐layer closure performs slightly better on other outcomes.
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Double‐layer uterine closure is not superior for postmenstrual spotting after a first caesarean; single‐layer closure performs slightly better on other outcomes.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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