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It's like "leaking and raining"
Ms. Wang, 32, is pregnant for the second time.
She had her first birth by caesarean section, which had been miscarried once before. It was difficult to get pregnant again, Ms. Wang was immersed in the joy of becoming a mother soon, and was suddenly told that it was a scarring diverticulum pregnancy during the obstetric examination, and it was recommended to terminate the pregnancy.
Ms. Wang froze, the doctor could not bear it, but still told her to operate as soon as possible, there was once a scar pregnant woman did not heed the doctor's advice, wait until 5 months, suddenly a large amount of bleeding, when the family sent her to the hospital, has almost coma.
In the end, more than a dozen people rescued most of the night, and the uterus was removed to rescue them...
Suddenly, there was a heavy bleeding, which turned out to be a pit left by a cesarean section
Post-caesarean scar diverticulum (CSD) refers to poor healing of the incision after caesarean section, and the muscle layer at the scar of the uterus becomes thinner, forming a depression or space that communicates with the uterine cavity, with an incidence of about 6% to 84%.
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Abnormal vaginal bleeding is the most common symptom of CSD and can also lead to secondary infertility, dysmenorrhea, and chronic pelvic pain.
More seriously, CSD not only causes the above clinical symptoms to plague women's daily lives, but also affects women's re-pregnancy, and to a certain extent, threatens women's life safety. Diverticular or scar pregnancies can lead to dangerous placental implantation, uterine rupture, haemorrhage and even endanger the lives of mothers and children, resulting in adverse maternal and infant outcomes.
When IUD ectopia occurs in patients with CSD, it is also possible to cause uterine perforation[1].
What factors does CSD relate to?
In recent years, due to the high rate of caesarean section, the pathogenesis of CSD has also attracted attention.
These include:
1. Number of caesarean sections
The more frequent caesarean sections, the higher the incidence of scar diverticula from the incision.
2. Surgical factors
The location and suture method of the uterine incision chosen, most researchers believe that bilateral suture is superior to monolayer suture.
3. Uterine characteristics
The lower uterine incision of the posterior uterus has a large tension, affecting the healing of the uterine incision. The duration of preoperative labour and the degree of uterine opening also affect the healing of the uterine incision.
4. General condition of the patient
Factors such as the age of the surgeon, infection, nutritional status, metabolic disorders, and complications during pregnancy all affect the degree of healing of the incision [2].
Reducing caesarean section rates and improving uterine suture techniques are key to reducing caesarean section diverticula.
How can CSD be diagnosed?
At present, the commonly used inspection methods are:
1. Three-dimensional transvaginal ultrasound (TVUS)
Images may show a continuous serous layer at the uterine incision and discontinuous muscle layer, with one or more wedge-shaped or cystic fluid dark areas visible at the anterior wall scar of the uterus.
2. Hysterine ultrasound (SHG)
Ultrasound contrast agent is injected into the uterine cavity, and by transvulsive ultrasonography, a typical wedge-shaped or cystic fluid dark area of the lower uterus is seen.
3. Magnetic resonance imaging (MRI)
Examination shows discontinuity of the uterine muscle layer in the diverticulum and the absence of all or part of the myometrium layer in the diverticulum.
4. Hysteroscopy
The structure of the diverticulum formed by the depression at the lower uterine incision can be clearly observed under the microscope, and the old hematosis can be seen in the depression, and the local vascular hyperplasia and tortuous dilation in the diverticulum can be seen.
What are the treatments for CSD?
Patients with CSD may be clinically asymptomatic, observable when they are not required to have children, and are not treated. For patients with fertility requirements and affecting the quality of daily life, the treatment method is mainly based on the patient's age, symptoms and whether there are fertility requirements for comprehensive consideration, mainly conservative treatment and surgical treatment.
1. Conservative treatment
Oral medications: such as traditional Chinese medicine treatment, oral contraceptive treatment.
Placement of an IUD: levonorgestrel intrauterine sustained-release system.
2. Surgical treatment
Indications for surgery: those diagnosed with CSD and corresponding clinical symptoms, affecting the patient's quality of life, and have a need for treatment.
Hysteroscopic surgery: symptoms are improved by incising the inferior diverticular tissue that obstructs the outflow of menstrual blood and the lining of the electrocoagulation diverticulum, and is suitable for CSD with a thickness of ≥3 mm in the inferior muscle layer of the anterior wall of the uterus.
Laparoscopic surgery: suitable for patients with a thickness of <3 mm of muscle thickness in the anterior and inferior wall of the uterus and with reproductive requirements. The hysteroscopic guided downward transmission test locates the CSD diverticulum site, fully excises the diverticulum and repairs the uterine defect.
Negative surgery: during the operation, attention should be paid to avoiding damage to the bladder, which requires the operator to have skilled skills in negative surgery.
Open surgery: suitable for patients with heavy pelvic adhesions and large cSD diverticulum, not preferred.
Contraception is recommended for 2 years in patients with CSD who are recircumcised after surgery when they are recircumcised after caesarean section [3].
When a person with CSD becomes pregnant again, an ultrasound is required to rule out scarring pregnancy. For normal pregnancies, it is necessary to strengthen the monitoring of mother and child during pregnancy, and if there is a precursor to uterine rupture, seek medical attention in time.
Therefore, CSD is not so terrible, early detection, early treatment is the key.
Resources:
Ma Yulan. Pathogenesis factors of scar diverticulum in caesarean section[D].Ningxia Medical University, 2020.
Dai Qiaohong. Prognosis of cervical laparoscopy combined with caesarean section scar diverticulum[D].Ningbo University, 2020.
Family Planning Branch of Chinese Medical Association. Expert consensus on the diagnosis and treatment of cervical scar diverticulum after caesarean section[J] . Chin J Obstetrics & Gynecology,2019,54( 3 ): 145-148.
This article was first published: Medical Sciences Obstetrics and Gynecology Channel
This article is written by Liu Wenxin
Editor-in-Charge: Ichikawa