Objectives: This study focused on evaluating the value of transvaginal 3D ultrasound for the diagnosis and prognostic assessment of post-cesarean section uterine diverticulum. Materials and Methods: We retrospectively analyzed the data from 32 patients with post-cesarean section uterine diverticulum over three recent years. In all patients, transvaginal 3D ultrasound was used to measure the size of the uterine diverticulum and the thickness of the lower uterine segment (LUS) and myometrium. Patients with a LUS with a myometrial thickness under 4 mm underwent resection and repair surgery; those with a LUS with a myometrial thickness over 4 mm underwent hysteroscopic resection. The postoperative sonograms were compared with preoperative images to evaluate the efficacy of various treatments. Results: The mean length, width and depth of the uterine diverticula were 18.30 ± 2.80 mm, 9.14 ± 3.20 mm and 11.49 ± 2.71 mm, respectively. The average LUS myometrial thickness was 3.40 ± 0.80 mm (with a range of 1.6 mm - 6.3 mm). After surgery, two patients’ sonograms still showed diverticula at the post-cesarean section scar, measuring 6 mm × 7 mm × 6 mm and 6 mm × 8 mm × 4 mm. There were significant differences in the size of uterine diverticula between preoperative and postoperative sonograms (P < 0.05) and the effective rate of surgery was 93.75% (30/32). Conclusions: Transvaginal 3D ultrasound is an accurate method for detecting post-cesarean section uterine diverticulum and is helpful for assessing surgical options and prognosis. The LUS myometrial thickness, which is considered as an optional index of post-cesarean section uterine diverticulum, should be measured routinely.
Concern is growing over the association between delivery by cesarean section and long-term maternal morbidity, as the use of cesarean section delivery has increased markedly worldwide over the last several decades [
Post-cesarean section uterine diverticulum is defined as a triangular anechoic structure at the site of the scar or a gap in the myometrium of the anterior lower uterine segment (LUS) at the site of a previous cesarean section [
This study was conducted at the Guangzhou Institute of Obstetrics and Gynecology, the Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China. Thirty-two patients with post-cesarean section uterine diverticulum were referred to the institute from January 2012 to June 2015. The study protocol was approved by the Ethical Committee of the Guangzhou Medical University, Guangzhou, China, and all patients provided written informed consent before beginning management.
All transvaginal 3D sonographic examination procedures were performed and evaluated by sonologists (both board certified and with more than 15 years of obstetric and gynecologic sonography experience). Transvaginal 3D ultrasound was performed using a 7.5-MHz transducer (Voluson S8, GE Healthcare, Milwaukee, WI, USA). Patients were examined after emptying their bladders. The uterus, uterine scar, and uterine diverticulum, if present, were examined in a standardized way. The position, length, and width of the uterus and double thickness of the endometrium were registered in the midsagittal plane. A diverticulum was defined as an anechoic space with or without fluid at the presumed site of the previous cesarean section scar. When a diverticulum was identified, its length, width, and depth, as well as those of the residual myometrium at the site of the scar and the LUS myometrium, were measured in real time. In cases when more than one cesarean section scar was present the largest niche was measured.
All patients had a history of cesarean section delivery and were diagnosed with a post-cesarean section uterine diverticulum with non-specific clinical symptoms by transvaginal 3D ultrasound. The LUS myometrial thickness and size of the uterine diverticulum, which are considered to be indices of surgical options, were routinely measured. The preoperative and postoperative menstrual periods were compared and postoperative sonograms were reviewed to monitor the disappearance of the sonolucent zone in the LUS scar, as a determinant of treatment success.
The Student’s t-test was used to compare the size of the uterine diverticulum before and after surgical treatment. Statistical analysis was performed using SPSS software version 18.0 (IBM, Chicago, IL, USA).
Thirty-two women aged 25 - 49 years who were diagnosed with post-cesarean section uterine diverticulum were included in the study. Twenty-four patients had undergone one cesarean section delivery and eight patients had had two cesarean section deliveries. The time interval from the present post-cesarean section uterine diverticulum to the previous cesarean delivery ranged from nine months to 14 years. All the patients presented with postmenstrual spotting, and four had accompanying lower abdominal pain. The duration of their menstrual periods was 13 ± 4.29 days.
The transvaginal 3D ultrasounds showed a uterine diverticulum or anechoic space in the anterior part of the LUS or in the previous cesarean section scar with a thin myometrium. The mean length, width, and depth of the uterine diverticula were 18.30 ± 2.80 mm, 9.14 ± 3.20 mm, and 11.49 ± 2.71 mm, respectively. The average LUS myometrial thickness was 3.40 ± 0.80 mm (with a range from 1.6 mm to 6.3 mm). Patients with an LUS myometrial thickness under 4 mm underwent resection and repair surgery (including transvaginal resection, resection and repair treatment with laparotomy, and laparoscopy combined with hysteroscopy) while hysteroscopic resections were performed for patients with an LUS myometrial thickness over 4 mm.
After surgical treatment, two patients’ sonograms still showed diverticula at the post-cesarean section scar, measuring 6 mm × 7 mm × 6 mm and 6 mm × 8 mm × 4 mm. All the patients had a menstrual period lasting 6.42 ± 1.24 days. There were significant differences in the size of uterine diverticulum and the duration of the menstrual period after surgical treatment (P < 0.05). The effective rate of surgery was 93.75% (30/32) (
Menstrual period (d) | Disappearance of sonolucent zone in the lower uterine segment scar (effective rate, %) | |||
---|---|---|---|---|
Laparotomy | Hysteroscopy and laparoscopy | Transvaginal | ||
Pre operation | 13.00tionK- | - | - | |
Post operation (3 days) | - | 100% (8/8) | 100% (16/16) | 100% (8/8) |
Post operation (1 month) | (6.67nth)K* | 100% (8/8) | 100% (16/16) | 100% (8/8) |
Post operation (3 months) | (6.42nthn)K* | 100% (8/8) | 87.5% (14/16) | 100% (8/8) |
Note: - means the index was too insignificant to be measured; *P < 0.01, with remarkable difference in statistics.
Iatrogenic diverticulum of the uterus after cesarean section is becoming increasingly common and the current rate of cesarean delivery in China is 40% to 50% [
Interestingly, the incidence of scar diverticulum was higher in women who were older at the time of cesarean section, and it correlated positively with the number of previous cesarean sections [
Although there have been various treatments for CSP in recent years, no standardized diagnostic or management guidelines have been established. A scar diverticulum is easily identified using transvaginal ultrasound, and its size, shape and location can be accurately determined [
Surgical approaches to treating cesarean section scar abnormalities include hysteroscopic techniques, laparotomy and defect repair, and hysterectomy. Complete hysterectomy is curative in patients who do not wish to have more children [
In our study, all 32 patients were diagnosed with post-cesarean section uterine diverticulum by transvaginal 3D ultrasound. Resection and repair surgery was recommended for patients with an LUS myometrial thickness under 4 mm to prevent surgical complications such as hemorrhage and uterine rupture. Hysteroscopic resection was recommended for patients with an LUS myometrial thickness over 4 mm as it is minimally invasive and there is less blood loss. Transvaginal 3D ultrasound was used to monitor the disappearance of sonolucent zone in the lower uterine segment scar three days, one month and three months after surgery.
In conclusion, transvaginal 3D ultrasound is an accurate method for detecting post-cesarean section uterine diverticulum and is helpful for assessing surgical options and prognosis. The LUS myometrial thickness, which is considered as an optional index of post-cesarean section uterine diverticulum, should be measured routinely. However, comparative studies of different therapies with sufficient methodological quality are lacking. Future studies involving sufficient sample size, long-term follow-up, and validated instruments are needed.
The authors thank Oxford Language Editing for helping us to edit and proofread this manuscript.
Support for this research was provided by the Clinical research about Cesarean scar pregnancy from precious cesarean delivery of Science and Technology Innovation Project from Guangzhou Medical University (2014); to explore the application of Early clinical training and early research training education mode in lower grade MBBS student of Guangzhou Medical University, the research on practical teaching of the “Twelfth Five Year Plan” for education science (Key Funding 2014); The practice and Research of the implementation of Double Early Education, Early Clinical Training & Early Research Training, for medical undergraduates, Research on the teaching reform of clinical teaching base in Guangdong Province in 2014, key Funding in Teaching Research, Funding number 2014JDA028; the Prevention and Control of Major Obstetric Disease major collaborative innovation project of the Educational Bureau of Guangzhou City (medical and health grant no. 13xt04, 2013), and the Collaborative Innovation Centre for Prevention and Control of Major Obstetric Disease collaborative innovation platform of the educational and financial departments of Guangdong Province (regional development grant, 2014).
The authors have no conflicts of interest to declare in relation to this article.
Cui-LanLi,Xue-TangMo,Kai-XuanDeng,Dun-JinChen,Xing-ChengGao,Jin-GuoZhai,Yi-MingLiao,Hui-RuDai,XiangCai, (2015) Transvaginal 3D Ultrasound Evaluation of Post-Cesarean Section Uterine Diverticulum. Open Journal of Obstetrics and Gynecology,05,698-702. doi: 10.4236/ojog.2015.512098