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Uterine scar dehiscence – a demanding defect
European Journal of Obstetrics & Gynecology and Reproductive Biology 188 (2015) 138
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTER TO THE EDITOR—BRIEF COMMUNICATION Uterine scar dehiscence – a demanding defect Dear Editors, A 30-year-old Para 1 woman presented to our hospital at 14 weeks gestation for her booking visit. In 2011 she had an emergency lower segment caesarean section at term for failure to progress in her native Poland. During her booking consultation she reported that a pelvic ultrasound scan in 2012 for pelvic pain had demonstrated a post caesarean section scar defect. There was no uterine defect seen on her 20-week anatomy scan. She attended for a routine antenatal visit at 25 weeks and she reported some mild discomfort at the site of her caesarean section scar. Subsequently a large defect in the lower uterine segment with bulging membranes was identified sonographically. She was admitted to hospital for inpatient management and MRI confirmed uterine scar dehiscence. Her operative notes from her previous caesarean delivery obtained from Poland documented an uneventful procedure with single layer closure of the uterus. She remained an inpatient for the rest of the pregnancy, reporting ongoing suprapubic discomfort. Following a course of corticosteroids for lung maturity, at 34 weeks gestation she had an elective caesarean section. The open lower segment with bulging membranes did not require a uterine incision. The uterus was closed in two layers. Mother and baby did well postnatally, and were discharged on day 4 and day 10 respectively. Uterine scar dehiscence denotes the disruption and opening of a pre-existing uterine scar. It does not disrupt the overlying visceral peritoneum. It can lead to uterine rupture with catastrophic maternal and fetal consequences [1]. Due to the rising incidence of caesarean deliveries uterine defects are becoming an increasing complication seen in our obstetric population. They can prove a challenge both preconceptually and antenally, especially as there is no general consensus regarding their management. There is no reliable way of predicting uterine rupture in women with a prior caesarean delivery; however techniques have been used to image uterine scar defects in an attempt to assess for risk. The most common method is ultrasound imaging to measure the myometrial thickness of the lower uterine segment and the size of the hypoechoic uterine defect at the scar site [2]. Normal scar thickness may be encouraging, while a thinning or dehisced scar concerning for a possible future rupture [3]. However a direct correlation between risk of rupture and the size of the defect has not been determined [4].
http://dx.doi.org/10.1016/j.ejogrb.2015.02.012 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Outside of pregnancy scar defects have been found to be associated with symptoms such as menstrual spotting, dysmenorrhoea and chronic pelvic pain. Successful preconception repairs have been described to both alleviate clinical symptoms and potentially to prevent scar dehiscence in future pregnancies [5]. Our patient had an ultrasound diagnosis of a scar defect made while investigating pelvic pain. Given the subsequent dehiscence in this pregnancy, perhaps preconception repair could have been considered. The challenges posed by such a large defect at this gestation are vast. They include inpatient management for a significant length of the pregnancy, the uncertainty of the clinical course, timing of delivery and the potential catastrophic outcome while the pregnancy is allowed to advance. However, at present, despite these difficulties clinicians face there are no guidelines for managing uterine scar defects either prior to or during pregnancy. References [1] Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed. Eur J Obstet Gynecol Reprod Biol 1994;56(August (2)):107–10. [2] Naji O, Abdallah Y, Bij De Vaate AJ, et al. Standardized approach for imaging and measuring Cesarean section scars using ultrasonography. Ultrasound Obstet Gynecol 2012;39:252. [3] Kok N, Wiersma IC, Opmeer BC, de Graaf IM, Mol BW, Pajkrt E. Sonographic measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor in women with previous Cesarean section: a metaanalysis. Ultrasound Obstet Gynecol 2013;42(August (2)):132–9. [4] Cheung VY. Sonographic measurement of the lower uterine segment thickness: is it truly predictive of uterine rupture? J Obstet Gynaecol Can 2008;30:148. [5] Tower A, Frishman G. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol 2013;20(September–October (5)):562–72.
T. Rigney* K. Flood M. Eogan Obstetric Department, Rotunda Hospital, Dublin 1, Ireland *Corresponding
author. Tel.: +353 858389057; fax: +353 01 872 6523 E-mail address: [email protected] (T. Rigney). 9 January 2015
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTER TO THE EDITOR—BRIEF COMMUNICATION Uterine scar dehiscence – a demanding defect Dear Editors, A 30-year-old Para 1 woman presented to our hospital at 14 weeks gestation for her booking visit. In 2011 she had an emergency lower segment caesarean section at term for failure to progress in her native Poland. During her booking consultation she reported that a pelvic ultrasound scan in 2012 for pelvic pain had demonstrated a post caesarean section scar defect. There was no uterine defect seen on her 20-week anatomy scan. She attended for a routine antenatal visit at 25 weeks and she reported some mild discomfort at the site of her caesarean section scar. Subsequently a large defect in the lower uterine segment with bulging membranes was identified sonographically. She was admitted to hospital for inpatient management and MRI confirmed uterine scar dehiscence. Her operative notes from her previous caesarean delivery obtained from Poland documented an uneventful procedure with single layer closure of the uterus. She remained an inpatient for the rest of the pregnancy, reporting ongoing suprapubic discomfort. Following a course of corticosteroids for lung maturity, at 34 weeks gestation she had an elective caesarean section. The open lower segment with bulging membranes did not require a uterine incision. The uterus was closed in two layers. Mother and baby did well postnatally, and were discharged on day 4 and day 10 respectively. Uterine scar dehiscence denotes the disruption and opening of a pre-existing uterine scar. It does not disrupt the overlying visceral peritoneum. It can lead to uterine rupture with catastrophic maternal and fetal consequences [1]. Due to the rising incidence of caesarean deliveries uterine defects are becoming an increasing complication seen in our obstetric population. They can prove a challenge both preconceptually and antenally, especially as there is no general consensus regarding their management. There is no reliable way of predicting uterine rupture in women with a prior caesarean delivery; however techniques have been used to image uterine scar defects in an attempt to assess for risk. The most common method is ultrasound imaging to measure the myometrial thickness of the lower uterine segment and the size of the hypoechoic uterine defect at the scar site [2]. Normal scar thickness may be encouraging, while a thinning or dehisced scar concerning for a possible future rupture [3]. However a direct correlation between risk of rupture and the size of the defect has not been determined [4].
http://dx.doi.org/10.1016/j.ejogrb.2015.02.012 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Outside of pregnancy scar defects have been found to be associated with symptoms such as menstrual spotting, dysmenorrhoea and chronic pelvic pain. Successful preconception repairs have been described to both alleviate clinical symptoms and potentially to prevent scar dehiscence in future pregnancies [5]. Our patient had an ultrasound diagnosis of a scar defect made while investigating pelvic pain. Given the subsequent dehiscence in this pregnancy, perhaps preconception repair could have been considered. The challenges posed by such a large defect at this gestation are vast. They include inpatient management for a significant length of the pregnancy, the uncertainty of the clinical course, timing of delivery and the potential catastrophic outcome while the pregnancy is allowed to advance. However, at present, despite these difficulties clinicians face there are no guidelines for managing uterine scar defects either prior to or during pregnancy. References [1] Gardeil F, Daly S, Turner MJ. Uterine rupture in pregnancy reviewed. Eur J Obstet Gynecol Reprod Biol 1994;56(August (2)):107–10. [2] Naji O, Abdallah Y, Bij De Vaate AJ, et al. Standardized approach for imaging and measuring Cesarean section scars using ultrasonography. Ultrasound Obstet Gynecol 2012;39:252. [3] Kok N, Wiersma IC, Opmeer BC, de Graaf IM, Mol BW, Pajkrt E. Sonographic measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor in women with previous Cesarean section: a metaanalysis. Ultrasound Obstet Gynecol 2013;42(August (2)):132–9. [4] Cheung VY. Sonographic measurement of the lower uterine segment thickness: is it truly predictive of uterine rupture? J Obstet Gynaecol Can 2008;30:148. [5] Tower A, Frishman G. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol 2013;20(September–October (5)):562–72.
T. Rigney* K. Flood M. Eogan Obstetric Department, Rotunda Hospital, Dublin 1, Ireland *Corresponding
author. Tel.: +353 858389057; fax: +353 01 872 6523 E-mail address: [email protected] (T. Rigney). 9 January 2015