Истмоцеле: дискуссионные вопросы терминологии, диагностики и лечения

Подзолкова Н.М., Демидов А.В., Осадчев В.Б., Бабков К.В., Денисова Ю.В. Истмоцеле: дискуссионные вопросы терминологии, диагностики и лечения. Гинекология. 2024;26(2):119–127.
DOI: 10.26442/20795696.2024.2.202716

© ООО «КОНСИЛИУМ МЕДИКУМ», 2024 г.

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Podzolkova NМ, Demidov AV, Osadchev VB, Babkov KV, Denisova YuV. Isthmocele: controversial issues of terminology, diagnosis and treatment. A review. Gynecology. 2024;26(2):119–127.
DOI: 10.26442/20795696.2024.2.202716

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Аннотация

Частота абдоминального родоразрешения в мире неуклонно растет. Поскольку последнее сопряжено с большим, в сравнении с вагинальными родами, количеством осложнений, увеличение доли родов у женщин с рубцом на матке через естественные родовые пути служит важной стратегической задачей акушерско-гинекологического сообщества. Помимо этого установлено, что у каждой второй пациентки после кесарева сечения формируется дефект области рубца, который часто сопровождается различными нарушениями менструального цикла (в 25,5% случаев – аномальными маточными кровотечениями) и может служить причиной вторичного бесплодия. Как оценка риска развития несостоятельности рубца на этапе прегравидарной подготовки, так и своевременное выявление и лечение симптомов истмоцеле являются серьезными задачами специалистов акушерско-гинекологического профиля. Клинические рекомендации, посвященные проблеме дефекта рубца на матке после кесарева сечения, на данный момент не разработаны. С целью стандартизации подходов к диагностике и лечению данного патологического состояния в обзоре собрана квинтэссенция современных данных о возможных факторах риска, клинических проявлениях с подробным рассмотрением патофизиологических механизмов их развития, диагностических инструментах и методах коррекции с подробным описанием показаний и сравнительной оценкой эффективности существующих методик.

Ключевые слова: истмоцеле, рубец на матке, кесарево сечение, гистероскопия, метропластика

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The frequency of abdominal delivery in the world is steadily rising. Since the latter is associated with a lot of complications compared with vaginal delivery, the increase in the proportion of deliveries in women with a uterine scar through the natural birth canal is an important strategic goal of the obstetrics and gynecology community. In addition, it is established that every second patient after a cesarean section develops a defect in the scar area, which is often accompanied by various disorders of the menstrual cycle (in 25,5% of cases – abnormal uterine bleeding) and can cause secondary infertility. Both assessment of the risk of scar failure at the stage of preconceptional preparation and timely detection and treatment of isthmocele symptoms are still serious challenges facing obstetricians and gynecologists. Clinical guidelines devoted to the cesarean scar defect problem have not yet been developed. This review presents the quintessence of modern data on possible risk factors, clinical manifestations with a detailed consideration of pathophysiological mechanisms, diagnostic tools and correction methods of symptomatic isthmocele and uterine scar defect with a detailed description of indications and a comparative assessment of their effectiveness in order to standardize approaches to the diagnosis and treatment of these pathological conditions.

Keywords: isthmocele, uterine scar, cesarean section, hysteroscopy, metroplasty

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Список литературы

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41. Ludwin A, Martins WP, Ludwin I. Evaluation of uterine niche by three-dimensional sonohysterography and volumetric quantification: techniques and scoring classification system. Ultrasound Obstet Gynecol. 2019;53(1):139-43.
42. Alalfy M, Osman OM, Salama S, et al. Evaluation of the Cesarean Scar Niche In Women With Secondary Infertility Undergoing ICSI Using 2D Sonohysterography Versus 3D Sonohysterography and Setting a Standard Criteria; Alalfy Simple Rules for Scar Assessment by Ultrasound To Prevent Health Problems for Women. Int J Women’s Health.
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43. Roberge S, Boutin A, Chaillet N, et al. Systematic review of cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect. Am J Perinatol. 2012;29(6):465-71.
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1. Krasnopolskii VI, Buianova SN, Shchukina NA, Logutova LS. Uterine suture (scar) incompetence after cesarean section: Problems and solutions (an editorial). Russian Bulletin of Obstetrician-Gynecologist. 2015;15(3):4‑8 (in Russian).
2. Robson SJ, de Costa CM. Thirty years of the World Health Organization`s target caesarean section rate: time to move on. Med J Aust. 2017;206:181-5.
3. Birth After Previous Caesarean Birth RCOG Green-top Guideline No. 45 October 2015. Available at: http://www.rcog.org.uk. Accessed: 08.01.2024.
4. Shmakov RG, Baev OR, Pekarev OG, et al. Khirurgicheskaia taktika operatsii kesareva secheniia. Uchtbnoe posobie. Moscow: Binom, 2019 (in Russian).
5. Poidevin LO. The value of hysterography in the prediction of cesarean section wound defects. Am J Obstet Gynecol. 1961;81:67-71.
6. Burger NF, Darazs B, Boes EG. An echographic evaluation during the early puerperium of the uterine wound after caesarean section. J Clin Ultrasound. 1982;10:271-4.
7. Chen HY, Chen SJ, Hsieh FJ. Observation of cesarean section scar by transvaginal ultrasonography. Ultrasound Med Biol. 1990;16:443-7.
8. Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the «niche» in the scar. J Ultrasound Med. 2001;20:1105-15.
9. Ofili-Yebovi D, Ben-Nagi J, Sawyer E, et al. Deficient lower segment cesarean section scars: Prevalence and risk factors. Ultrasound Obstet Gynecol. 2008;31:72-7.
10. Gubbini G, Casadio P, Marra E. Resectoscopic Correction of the «Isthmocele» in Women With Postmenstrual Abnormal Uterine Bleeding and Secondary Infertility. J Min Invas Gynecol. 2008;15(2):172-5.
11. Martynov SA, Adamyan LV. Cesarean scar defect: terminological aspects. Gynecology. 2020;22(5):70-5 (in Russian).
12. Vikhareva Osser O, Valentin L. Clinical importance of appearance of Cesarean hysterotomy scar at transvaginal ultrasonography in non-pregnant women. Obstet Gynecol. 2011;117:525-32.
13. Gozzi P, Hees KA, Berg C, et al. Frequency and associated symptoms of isthmoceles in women 6 months after caesarean section: a prospective cohort study. Arch Gynecol Obstet. 2023;307(03):841-8.
14. Jordans IPM, de Leeuw R, Stegwee SI, et al. A practical guideline for examining a uterine niche using ultrasonography in non-pregnant women: a modified Delphi method amongst European experts. Ultrasound Obstet Gynecol. 2018;53(1).
15. Bij de Vaate AJ, Van der Voet LF, Naji O, et al. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following cesarean section: systematic review. Ultrasound Obstet Gynecol. 2014;43(4):372-82.
16. Hanacek J, Vojtech J, Urbankova I, et al. Ultrasound cesarean scar assessment one year postpartum in relation to one- or two-layer uterine suture closure. Acta Obstet Gynecol Scand. 2020;99:69-78.
17. Ceci O, Cantatore C, Scioscia M, et al. Ultrasonographic and hysteroscopic outcomes of uterine scar healing after cesarean section: comparison of two types of single-layer suture. J Obstet Gynaecol Res. 2012;38:1302-7.
18. Yazicioglu F, Gökdogan A, Kelekci S, et al. Incomplete healing of the uterine incision after caesarean section: is it preventable? Eur J Obstet Gynecol Reprod Biol. 2006;124(01):32-6.
19. Vikhareva Osser O, Valentin L. Risk factors for incomplete healing of the uterine incision after caesarean section. BJOG. 2010;117:1119-26.
20. Hayakawa H, Itakura A, Mitsui T, et al. Methods for myometrium closure and other factors impacting effects on cesarean section scars of the uterine segment detected by the ultrasonography. Acta Obstet Gynecol Scand. 2006;85(4):429-34.
21. Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, et al. Why do niches develop in caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod. 2015;30:2695-702.
22. Antila-Långsjö RM, Mäenpää JU, Huhtala HS, et al. Cesarean scar defect: A prospective study on risk factors. Am J Obstet Gynecol. 2018;219(5):458.e1-8.
23. Dosedla E, Gal P, Calda P. Association between deficient cesarean delivery scar and cesarean scar syndrome. J Clin Ultrasound. 2020;48:538-43.
24. Van der Voet LF, Bij de Vaate AM, Veersema S, et al. Long-term 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;121(2):236-44.
25. 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(1):16-20.
26. Wang CB, Chiu WW, Lee CY, et al. Cesarean scar defect: correlation between cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet Gynecol. 2009;34(1):85-9.
27. O’Neill SM, Kearney PM, Kenny LC, et al. Caesarean delivery and subsequent pregnancy interval: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13(1):1-12.
28. Gurol-Urganci I, Bou-Antoun S, Lim C, et al. Impact of caesarean section on subsequent fertility: a systematic review and meta-analysis. Hum Reprod. 2013;28(7):1943-52.
29. Hsu I, Hsu L, Dorjee S, Hsu CC. Bacterial colonization at caesarean section defects in women of secondary infertility: an observational study. BMC Pregnancy Childbirth. 2022;22:135.
30. Vissers J, Sluckin T, van Driel-Delprat CR, et al. Reduced pregnancy and live birth rates after in vitro fertilization in women with previous caesarean section: a retrospective cohort study. Hum Reprod. 2020;35(3):595-604.
31. Florio P, Filippeschi M, Moncini I, et al. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol. 2012;24:180-6.
32. Dehkordi FS, Tavakoli-Far B, Jafariaskari S, et al. Uropathogenic Escherichia coli in the high vaginal swab samples of fertile and infertile women: virulence factors, O-serogroups, and phenotyping and genotyping characterization of antibiotic resistance. N Microbes N Infect. 2020;38:100824.
33. Clegg S, Murphy CN. Epidemiology and virulence of Klebsiella pneumoniae. Microbiol Spectr. 2016;4(1).
34. Defrère S, Lousse J-C, Gonzalez-Ramos R, et al. Potential involvement of iron in the pathogenesis of peritoneal endometriosis. Mol Hum Reprod. 2008;14(7):377-85.
35. Nobuta Y, Tsuji S, Kitazawa J, et al. Decreased Fertility in Women with Cesarean Scar Syndrome Is Associated with Chronic Inflammation in the Uterine Cavity. Tohoku J ExperimMed. 2022;258(3):237.
36. Buianova SN, Shchukina NA, Babunashvili EL, et al. Scar endometriosis after laparotomy: Ultrasound diagnosis, surgical treatment, a post-mortem rationale. Russian Bulletin of Obstetrician-Gynecologist. 2017;17(4):49‑53 (in Russian).
37. Defrere S, Lousse JC, Gonzalez-Ramos R, et al. Potential involvement of iron in the pathogenesis of peritoneal endometriosis. Molecular Human Reproduction. 2008;14(7):377-85.
38. Vervoort A, Vissers J, Hehenkamp W, et al. The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study. BJOG. 2018;125(3):317-25.
39. Kulshrestha V, Agarwal N, Kachhawa G. Post-caesarean Niche (Isthmocele) in Uterine Scar: An Upd ate. J Obstet Gynecol India. 2020;70(6):440-6.
40. Reed BG, Carr BR. The Normal Menstrual Cycle and the Control of Ovulation.. In: De Groot LJ, Chrousos G, Dungan K, et al, editors. Endotext. South Dartmouth (MA): MDText.com, Inc.; 2000–2015. Available at: https://www.ncbi.nlm.nih.gov/books/NBK279054/. Accessed: 09.01.2024.
41. Ludwin A, Martins WP, Ludwin I. Evaluation of uterine niche by three-dimensional sonohysterography and volumetric quantification: techniques and scoring classification system. Ultrasound Obstet Gynecol. 2019;53(1):139-43.
42. Alalfy M, Osman OM, Salama S, et al. Evaluation of the Cesarean Scar Niche In Women With Secondary Infertility Undergoing ICSI Using 2D Sonohysterography Versus 3D Sonohysterography and Setting a Standard Criteria; Alalfy Simple Rules for Scar Assessment by Ultrasound To Prevent Health Problems for Women. Int J Women’s Health.
2020;12:965-74.
43. Roberge S, Boutin A, Chaillet N, et al. Systematic review of cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect. Am J Perinatol. 2012;29(6):465-71.
44. Tahara M, Shimizu T, Shimoura H. Preliminary report of treatment with oral contraceptive pills for intermenstrual vaginal bleeding secondary to a cesarean section scar. Fertil Steril. 2006;86(2):477-9.
45. Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. Revista Da Associação Médica Brasileira. 2019;65(5):714-21.
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Авторы

Н.М. Подзолкова^1,2, А.В. Демидов³, В.Б. Осадчев^1,3, К.В. Бабков^1,3, Ю.В. Денисова*^1,3

¹ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России, Москва, Россия;
²ГБУЗ «Городская клиническая больница им С.П. Боткина» Департамента здравоохранения г. Москвы, Москва, Россия;
³ГБУЗ «Городская клиническая больница им. Д.Д. Плетнева» Департамента здравоохранения г. Москвы, Москва, Россия
*yuliya.sheveleva.97@mail.ru

________________________________________________

Natalia М. Podzolkova^1,2, Anton V. Demidov³, Vasilii B. Osadchev^1,3, Kirill V. Babkov^1,3, Yulia V. Denisova*^1,3

¹Russian Medical Academy of Continuous Professional Education, Moscow, Russia;
²Botkin City Clinical Hospital, Moscow, Russia;
³Pletnev City Clinical Hospital, Moscow, Russia
*yuliya.sheveleva.97@mail.ru

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