Акушерство и Гинекология Санкт-Петербурга. 2019; : 52-58
Диагностика и лечение локального истончения миометрия в виде «ниши»
Аннотация
Цель исследования. выявить факторы, способные приводить к формированию локального истончения маточного рубца после кесарева сечения (КС), определить значимость УЗИ и МРТ в отношении диагностики рубца на матке, обосновать необходимость метропластики.
Материал и методы. обследовано 175 небеременных женщин, которым проведено комплексное обследование, включающее трансвагинальное УЗИ. Измерена остаточная толщина миометрия (ОТМ) рубца. При ОТМ менее 5 мм выполнено МРТ. 50 пациенткам с ОТМ менее 3,1 мм проведена лапароскопия, интраоперационная гистероскопия, метропластика.
Результаты исследования. выполнение КС в родах, осложненное течение послеродового периода повышают вероятность возникновения «ниши». По данным УЗИ и МРТ ОТМ после метропластики значимо увеличилась (р <0,05). Жалобы на НМЦ уменьшились у 86,4% опрошенных. Всего произошло 9 родов.
Заключение. Визуализировать зону рубца на матке следует комплексно с помощью УЗИ и МРТ. Метропластика увеличивает толщину рубца, что уменьшает вероятность разрыва матки при последующих беременностях.
Список литературы
1. Tulandi T., Cohen A. Emerging manifestations of cesarean scar defect in reproductive women. J Minim Invasive Gynecol. 2016; 23 (06): 893–902. doi: 10.1016/j.jmig.2016.06.020.
2. Betrán A.P., Ye J., Moller A.B., Zhang J., Gülmezoglu A.M., Torloni M.R. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990–2014. PLoS One. 2016 Feb 5; 11 (2): e0148343. doi: 10.1371/journal.pone.0148343.
3. Письмо Министерства здравоохранения РФ, 2019. https://kraszdrav.ru/assets/documents/Rekomendatsii_VOZ15.03.2019%2016:31.pdf.
4. Ножницева О.Н., Беженарь В.Ф. Современный взгляд на проблему развития несостоятельных рубцов после операции кесарева сечения. Акушерство и гинекология Санкт-Петербурга. 2017; 3: 13–16.
5. Di Spiezio Sardo A., Saccone G., McCurdy R., Bujold E., Bifulco G., Berghella V. Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials. Ultrasound Obstet Gynecol. 2017; 50 (05): 578–583. doi: 10.1002/uog.17401.
6. Poidevin L.O. The value of hysterography in the prediction of cesarean section wound defects. Am J Obstet Gynecol. 1961; 81: 67–71. doi: 10.1016/S00029378(16)36308-6.
7. Bij de Vaate A.J., Brölmann H.A., van der Voet L.F., van der Slikke J.W., Veersema S., Huirne J.A. Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting. Ultrasound Obstet Gynecol. 2011; 37 (01): 93–99. doi: 10.1002/uog.8864.
8. Naji O., Abdallah Y., Bij De Vaate A.J., Smith A., Pexsters A., Stalder C. et al. Standardized approach for imaging and measuring Cesarean section scars using ultrasonography. Ultrasound Obstet Gynecol. 2012 Mar; 39 (3): 252–9. doi: 10.1002/uog.10077.
9. Li C., Tang S., Gao X., Lin W., Han D., Zhai J. et al. Efficacy of Combined Laparoscopic and Hysteroscopic Repair of Post-Cesarean Section Uterine Diverticulum: A Retrospective Analysis. BioMed Research International. Received 7 December 2015; Revised 7 February 2016; Accepted 25 February 2016.
10. van der Voet L.F., Bij de Vaate A.M., Veersema S., Brölmann H.A., Huirne J.A. Longterm 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 Jan; 121 (2): 236-44. doi: 10.1111/1471-0528.12542.
11. Wong W.S.F., Fung W.T. Magnetic Resonance Imaging in the Evaluation of Cesarean Scar Defect. Gynecol Minim Invasive Ther. 2018 Jul-Sep; 7 (3): 104–107. doi: 10.4103/GMIT.GMIT_23_18.
12. Приходько А.М., Баев О.Р., Луньков С.С. и др. Эхографическая характеристика матки в раннем и отдаленном периоде после абдоминального родоразрешения. Акушерство и гинекология. 2015; 10: 41–46.
13. Айламазян Э.К., Кузьминых Т.У., Андреева В. Ю. и др. Современная стратегия абдоминального родоразрешения. Журн. акушерства и женских болезней. 2014; 5: 4–13.
14. Zimmer E.Z., Bardin R., Tamir A., Bronshtein M. Sonographic imaging of cervical scars after Cesarean section. Ultrasound Obstet Gynecol. 2004; 23 (06): 594–598. doi: 10.1002/uog.1033.
15. Кулаков В.И., Чернуха Е.А., Комиссарова Л.М. и др. Результаты кесарева сечения в зависимости от наложения шва на матку и шовного материала. Акушерство и гинекология. 1997; 4: 18–21.
16. Awonuga A.O., Fletcher N.M., Saed G.M., Diamond M.P. Postoperative adhesion development following cesarean and open intraabdominal gynecological operations: a review. Reprod Sci. 2011; 18 (12): 1166–1185. doi: 10.1177/1933719111414206.
17. Morris H. Surgical pathology of the lower uterine segment caesarean section scar: is the scar a source of clinical symptoms? Int J Gynecol Pathol. 1995; 14 (01): 16–20. doi: 10.1097/00004347-199501000-00004.
18. Tower A.M., Frishman G.N. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013; 20 (05): 562–572. doi: 10.1016/j.jmig.2013.03.008.
19. Setubal A., Alves J., Osório F. et al. Treatment for uterine isthmocele, a pouchlike defect at the site ofcesarean section scar. J.Minim Invasive Gynecol. 2018; 25 (01): 38–46. doi: 10.1016/j.jmig.2017.09.022.20
20. Fabres C., Aviles G., De La Jara C. et al. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J Ultrasound Med. 2003; 22 (07): 695–700, quiz 701702. doi: 10.7863/jum.2003.22.7.695.
21. Ножницева О.Н., Беженарь В.Ф. Комбинированный способ коррекции локальной несостоятельности рубца на матке после кесарева сечения. Проблемы репродукции. 2018; 24 (5): 41–48. doi: 10.17116/repro20182405141.
22. Florio P., Gubbini G., Marra E. et al. A retrospective case-control study comparing hysteroscopic resection versus hormonal modulation in treating menstrual disorders due to isthmocele. Gynecol Endocrinol. 2011; 27 (06): 434–438. doi: 10.3109/09513590.2010.495431.
23. Zhang X., Yang M., Wang Q., Chen J., Ding J., Hua K. Prospective evaluation of five methods used to treat cesarean scar defects. Int J Gynaecol Obstet. 2016; 134 (03): 336–339. doi: 10.1016/j.ijgo.2016.04.011.
24. Sen S., Malik S., Salhan S. Ultrasonographic evaluation of lower uterine segment thickness in patients of previous cesarean section. Int J Gynaecol Obstet. 2004 Dec; 87 (3): 215–9.
Obstetrics and Gynaecology of Saint-Petersburg. 2019; : 52-58
Diagnostics and management of the local myometrial thining («niche»)
Abstract
Aims. To identify factors that can lead to the formation of local thinning of the uterine scar after cesarean section (CS), to determine the significance of ultrasound and MRI in relation to the diagnosis of scar on the uterus, to justify the need for metroplasty.
Material and methods. 175 non-pregnant women were examined, who underwent a comprehensive examination, including transvaginal ultrasound. The residual myometrial thickness (RMT) of the scar was measured. When RMT is less than 5 mm, an MRI is performed. Laparoscopy, intraoperative hysteroscopy, and metroplasty were performed in 50 patients with RMT less than 3,1 mm.
Results. Performing CS, complicated postpartum period increase the likelihood of a «niche» forming. According to ultrasound and MRI, RMT after metroplasty increased significantly (p<0,05). Complaints about the NMC decreased in 86,4% of respondents. A total of 9 births took place.
Conclusions. The uterine scar area should be visualized comprehensively using ultrasound and MRI. Metroplasty increases the thickness of the scar, which reduces the likelihood of rupture of the uterus in subsequent pregnancies.
References
1. Tulandi T., Cohen A. Emerging manifestations of cesarean scar defect in reproductive women. J Minim Invasive Gynecol. 2016; 23 (06): 893–902. doi: 10.1016/j.jmig.2016.06.020.
2. Betrán A.P., Ye J., Moller A.B., Zhang J., Gülmezoglu A.M., Torloni M.R. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990–2014. PLoS One. 2016 Feb 5; 11 (2): e0148343. doi: 10.1371/journal.pone.0148343.
3. Pis'mo Ministerstva zdravookhraneniya RF, 2019. https://kraszdrav.ru/assets/documents/Rekomendatsii_VOZ15.03.2019%2016:31.pdf.
4. Nozhnitseva O.N., Bezhenar' V.F. Sovremennyi vzglyad na problemu razvitiya nesostoyatel'nykh rubtsov posle operatsii kesareva secheniya. Akusherstvo i ginekologiya Sankt-Peterburga. 2017; 3: 13–16.
5. Di Spiezio Sardo A., Saccone G., McCurdy R., Bujold E., Bifulco G., Berghella V. Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials. Ultrasound Obstet Gynecol. 2017; 50 (05): 578–583. doi: 10.1002/uog.17401.
6. Poidevin L.O. The value of hysterography in the prediction of cesarean section wound defects. Am J Obstet Gynecol. 1961; 81: 67–71. doi: 10.1016/S00029378(16)36308-6.
7. Bij de Vaate A.J., Brölmann H.A., van der Voet L.F., van der Slikke J.W., Veersema S., Huirne J.A. Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting. Ultrasound Obstet Gynecol. 2011; 37 (01): 93–99. doi: 10.1002/uog.8864.
8. Naji O., Abdallah Y., Bij De Vaate A.J., Smith A., Pexsters A., Stalder C. et al. Standardized approach for imaging and measuring Cesarean section scars using ultrasonography. Ultrasound Obstet Gynecol. 2012 Mar; 39 (3): 252–9. doi: 10.1002/uog.10077.
9. Li C., Tang S., Gao X., Lin W., Han D., Zhai J. et al. Efficacy of Combined Laparoscopic and Hysteroscopic Repair of Post-Cesarean Section Uterine Diverticulum: A Retrospective Analysis. BioMed Research International. Received 7 December 2015; Revised 7 February 2016; Accepted 25 February 2016.
10. van der Voet L.F., Bij de Vaate A.M., Veersema S., Brölmann H.A., Huirne J.A. Longterm 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 Jan; 121 (2): 236-44. doi: 10.1111/1471-0528.12542.
11. Wong W.S.F., Fung W.T. Magnetic Resonance Imaging in the Evaluation of Cesarean Scar Defect. Gynecol Minim Invasive Ther. 2018 Jul-Sep; 7 (3): 104–107. doi: 10.4103/GMIT.GMIT_23_18.
12. Prikhod'ko A.M., Baev O.R., Lun'kov S.S. i dr. Ekhograficheskaya kharakteristika matki v rannem i otdalennom periode posle abdominal'nogo rodorazresheniya. Akusherstvo i ginekologiya. 2015; 10: 41–46.
13. Ailamazyan E.K., Kuz'minykh T.U., Andreeva V. Yu. i dr. Sovremennaya strategiya abdominal'nogo rodorazresheniya. Zhurn. akusherstva i zhenskikh boleznei. 2014; 5: 4–13.
14. Zimmer E.Z., Bardin R., Tamir A., Bronshtein M. Sonographic imaging of cervical scars after Cesarean section. Ultrasound Obstet Gynecol. 2004; 23 (06): 594–598. doi: 10.1002/uog.1033.
15. Kulakov V.I., Chernukha E.A., Komissarova L.M. i dr. Rezul'taty kesareva secheniya v zavisimosti ot nalozheniya shva na matku i shovnogo materiala. Akusherstvo i ginekologiya. 1997; 4: 18–21.
16. Awonuga A.O., Fletcher N.M., Saed G.M., Diamond M.P. Postoperative adhesion development following cesarean and open intraabdominal gynecological operations: a review. Reprod Sci. 2011; 18 (12): 1166–1185. doi: 10.1177/1933719111414206.
17. Morris H. Surgical pathology of the lower uterine segment caesarean section scar: is the scar a source of clinical symptoms? Int J Gynecol Pathol. 1995; 14 (01): 16–20. doi: 10.1097/00004347-199501000-00004.
18. Tower A.M., Frishman G.N. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013; 20 (05): 562–572. doi: 10.1016/j.jmig.2013.03.008.
19. Setubal A., Alves J., Osório F. et al. Treatment for uterine isthmocele, a pouchlike defect at the site ofcesarean section scar. J.Minim Invasive Gynecol. 2018; 25 (01): 38–46. doi: 10.1016/j.jmig.2017.09.022.20
20. Fabres C., Aviles G., De La Jara C. et al. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J Ultrasound Med. 2003; 22 (07): 695–700, quiz 701702. doi: 10.7863/jum.2003.22.7.695.
21. Nozhnitseva O.N., Bezhenar' V.F. Kombinirovannyi sposob korrektsii lokal'noi nesostoyatel'nosti rubtsa na matke posle kesareva secheniya. Problemy reproduktsii. 2018; 24 (5): 41–48. doi: 10.17116/repro20182405141.
22. Florio P., Gubbini G., Marra E. et al. A retrospective case-control study comparing hysteroscopic resection versus hormonal modulation in treating menstrual disorders due to isthmocele. Gynecol Endocrinol. 2011; 27 (06): 434–438. doi: 10.3109/09513590.2010.495431.
23. Zhang X., Yang M., Wang Q., Chen J., Ding J., Hua K. Prospective evaluation of five methods used to treat cesarean scar defects. Int J Gynaecol Obstet. 2016; 134 (03): 336–339. doi: 10.1016/j.ijgo.2016.04.011.
24. Sen S., Malik S., Salhan S. Ultrasonographic evaluation of lower uterine segment thickness in patients of previous cesarean section. Int J Gynaecol Obstet. 2004 Dec; 87 (3): 215–9.
