Download Cesarean section uterine scar dehiscence

Uterus & Ovary 2015; 2: e751. doi: 10.14800/uo.751; © 2015 by Kaundinya Kiran Bharatam
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REVIEW
Cesarean section uterine scar dehiscence - A review
Kaundinya Kiran Bharatam
General, endoscopic and laparoscopic surgeon, Assistant professor in General Surgery, Sri Ramachandra medical college and
hospital, Chennai.
Correspondence: Kaundinya Kiran Bharatam
E-mail: [email protected]
Received: March 25, 2015
Published online: April 07, 2015
Cesarean section uterine scar dehiscence is a rare but important complication of LSCS; one of the commonest
performed operations. The presentation of the patient can be subtle with abnormalities in menstruation or
with features of dyspareunia and secondary infertility. Sometimes the dehiscence can present with features of
peritonitis (generalized/localized) and even sepsis. In any circumstance a high index of suspicion should be
present to identify this condition with modalities like the transvaginal ultrasonography or the MRI scan. Once
confirmed treatment can be done conservatively by antibiotic cover and repair using open or laparoscopic
techniques. If extensive infection, endomyometritis or intrabdominal abscess exist then hysterectomy is the best
form of treatment especially in women who are not planning further pregnancies. This review article highlights
all the aspects of uterine scar dehiscence based on evidences collected from studies and case reports.
Keywords: cesarean section; uterine scar dehiscence; transvaginal ultrasonography; conservative treatment;
hysterectomy
To cite this article: Kaundinya Kiran Bharatam. Cesarean section uterine scar dehiscence - A review. Uterus Ovary 2015; 2:
e751. doi: 10.14800/uo.751.
0.6% and 3.8% [6, 7]. Incidence of Uterine scar dehiscence
irrespective of cause is around 0.6 % worldwide [9].
Introduction
Cesarean section uterine scar dehiscence (CSD) is a rare
but notable complication of Lower segment cesarean section
(LSCS) surgery. Underlying defects in the uterus like a
cesarean scar are implicated in most circumstances. The
incidence of cesarean section scar defect reportedly ranges
between 6.6 % to 69 % with variations mainly due to absence
of criteria for the CSD [1-4]. Meta-analysis reports have
shown the incidence of cesarean scar dehiscence to be around
1.9 %. [8]
Ofili-Yebovi et al found uterine scars in 99.1% of patients
who had undergone cesarean section surgery, but 19.4% had
a defect in their scars; 9.9% of the CSDs were severe,
defined as the loss of >50% of myometrial mantle at the scar
level. [5] Other studies have reported rates of CSD between
Cause
The cause for a uterine scar dehiscence is based on the
etiology behind the uterine scar defect or any event that
would predispose the cesarean scar to dehisce. Underlying
anatomical defects in the uterus which would have been
corrected prior to pregnancy like uterine septum or fibroid
uterus may weaken the uterus and the resultant scar of the
cesarean section.
In cesarean sections, risk of rupture in classical (vertical)
incision in subsequent pregnancies is greater with the vertical
incision as compared to the transverse incision. Risk factors
for uterine rupture include myomectomy, septoplasty,
metroplasty, trauma, congenital uterine anomalies (especially
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ectopic pregnancy in the rudimentary horn), inadequate
treatment of endometriosis, placental abruption, and
mid-forceps delivery. Sometimes postpartum ruptures occur
in patients giving birth by vaginal delivery following
previous cesarean sections [11].
concurrent postpartum uterine and abdominal wall
dehiscence, site of implantation for ectopic pregnancy, etc.
Infections with Streptococcus anginosus and Staphylococcus
aureus have been reported also indicating the wide spectrum
of infection possible in such a circumstance.
Typical important causes would be previous lower
segment cesarean section, classical cesarean section,
previous uterine trauma, congenital anomaly, abnormal
placenta implantation and inappropriate oxytocin
administration [9,10]. Reported risk factors applicable to many
patients would be nulliparity, diabetes, emergency surgery,
infection, and incision placed too low in the uterine segment.
Following table shows the incidence of CSD in various
studies/ case reports:
STUDY
NO OF CASES
YEAR
r s dhar et al
1
2012
la rosa et al
1
2013
taner a usta et al
1
2013
radka filipcikova et al
4
2013
melo-cerda et al
25
2014
fox n s et al
42
2014
baron j et al
180
2014
schepker n et al
13
2014
k k bharatam et al
1
2015
[12]
Types
Uterine dehiscence is of 2 types - complete and
incomplete dehiscence. In incomplete uterine dehiscence, the
myometrium is disrupted but the serosa is intact. Full
thickness tears of uterine wall result in complete uterine
ruptures. These ruptures mostly occur at the level of previous
cesarean section scars. Compared to complete uterine
rupture, uterine dehiscence has much lower maternal and
neonatal morbidity. [12]
Presentation
Cesarean scar dehiscence can present in multiple ways.
The presentation may be silent in many, but may cause
symptoms like dysmenorrhea, inter menstrual bleeding,
irregular genital bleeding, chronic pelvic pain, dyspareunia
and secondary infertility. [14,15] In a 3-year study, Wang et al
found that among the 293 patients diagnosed with CSD by
transvaginal sonography, the most common symptom was
intermenstrual spotting (64%), followed by dysmenorrhea
(53%), chronic pelvic pain (40%), and dyspareunia (18%)
[13,16]
.
During labor symptoms of eminent uterine rupture would
include vaginal bleeding, sharp pain between contractions,
abdominal pain or tenderness, recession of the fetal head,
bulging under the pubic bone and onset of sharp pain at the
site of previous scar [17,18].
Uterine scar dehiscence can thence occur either
immediately after childbirth or some may have presentation
after about 2-4 weeks of delivery. Presentation can be with
post partum hemorrhage, endomyometritis and peritonitis
(generalized/localized). Once peritonitis occurs as a result,
sepsis may ensue risking the life of the patient [19].
Rare and unusual presentations have been reported in
associations with wound infections, secondary PPH,
Investigations and Diagnosis
Among the methods for detecting CSD, TVUS
(transvaginal ultrasonography) and SIS (saline infusion
hysterography) are the simplest and most useful.[21,22] In the
TVUS, the CSD can be detected as a defect appearing as a
triangular or dome-shaped echo-free space, which has been
referred to by Monteagudo et al. as a “niche”. In addition,
Gubbini et al [20]. named it “isthmocele,” whereas for
Regnard et al., a niche with a depth accounting for 80% or
more of the muscle layer in the anterior wall of the uterus
was referred to as “dehiscence” [23]. Performing SIS allows
the TVUS results to be clearer and facilitates an accurate
diagnosis. Hence patients with CSD symptoms, such as
prolonged menstruations, should undergo SIS, in addition to
TVUS [24].
MRI has been shown to be the most definitive modality to
evaluate uterine incision healing after cesarean deliveries [25,
26]
. It has the advantage of superior contrast resolution,
enabling detailed visualization of tissue planes. Furthermore,
MRI is not impeded by body habitus or bowel gas. The size
of the defect can be better estimated by using MRI. In a case
of posterior wall dehiscence from laparoscopic
myomectomy, MRI was able to clearly depict the defect,
whereas the initial ultrasonography evaluation did not [27].
Hemorrhage or hematomas have a characteristic signal on
MRI and therefore can be readily distinguished from other
fluid collections or masses. In expectant management of
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uterine dehiscence during pregnancy, MRI can be used to
confirm the diagnosis, and then the lesion can be followed by
ultrasonography if it is adequately visualized by the latter
modality. [28]
incision, closure of the deep subcutaneous layer in patients
with subcutaneous tissue thickness greater than 2 cm and
appropriate deep vein thrombosis prophylaxis formed the
checklist [39].
Treatment
Identification of the condition requires a high index of
clinical suspicion and dependence on radiological signs seen
on ultrasonography (transvaginal/3D) or the CT/MRI scan.
The identification of such condition can guide the doctor
towards
decreasing
maternal
and
neonatal
morbidity/mortality.
Exploratory laparotomy should be considered as the most
important tool for diagnosis and treatment for uterine scar
dehiscence and repair. Conservative resuturing after
debridement can be chosen, but in presence of marked
wound infection, endomyometritis and/or intra-abdominal
abscess, hysterectomy should be considered [29,30,31,32].
There are still, reports of conservative treatment even in
the presence of infection [32,33].
The consequences of this complication for a future
pregnancy are unknown. It has been recommended that all
women who do not undergo a hysterectomy after a
significant PPH following CS should undergo evaluation for
any defect of scar. Laparoscopic and vaginal repair of scar
dehiscence has been diagnosed and repaired after many years
after caesarean section. The future pregnancies in such
patients heralds risk of scar rupture again and needs prior
assessment and a high index of suspicion [34,35].
The treatment of CSD in patients who desire to bear
children requires the use of surgical repair. In the past,
surgical repair required a laparotomy; recently,
microsurgical, laparoscopic and robotic surgical repair /
uterus reconstruction has also been reported. [36] In women
who do not desire to bear children, the treatment choices
have involved either low doses of monophasic contraceptives
or total hysterectomies. A total hysterectomy is a radical
surgical treatment that many patients may be reluctant to
undergo. There have also been recent reports of symptom
improvement after resectoscopic surgery for removal of the
flap-shaped fibrous tissue at the site of the scar [37,38].
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