Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis

Extragenital endometriosis associated with uterine scar defects

Introduction

Uterine scar defects result from poor healing of the hysterotomy after cesarean sections (CS), in multiple cases leading to retroflexio uteri and retrograde menstruation. Endometriosis is the probable consequence. Patients often experience overlapping symptoms such as dysmenorrhea, dyspareunia, and infertility.

Material and methods

This study analysed cases of sonographically detected uterine scar defects, subsequently undergoing laparoscopy at the University Clinic St. Hedwig, in Regensburg, between 2020 and 2024. Herefore, surgery reports were reviewed, focusing on extragenital endometriosis, symptoms of Cesarean Scar Disorder (CSD), niche morphology, uterine position, and endometriosis localisation using the #Enzian classification.

Results

Extragenital endometriosis was histologically confirmed in 45 of 94 patients (47.9 %) with symptomatic or large uterine niches. A significant association was found between endometriosis and heavy menstrual bleeding (HMB) (p < 0.001) as well as retroflexio uteri (p = 0.036). Symptoms related to CSD did not differ in patients with or without Endometriosis. Endometriotic implants were primarily located in the peritoneum behind the uterus and sacrouterine ligaments, supporting the hypothesis of retrograde menstruation.

Conclusion

There is significant overlap between the symptoms of endometriosis and CSD. Almost half of the patients with a symptomatic niche were found to have endometriosis, whereby the location of endometriosis supports the hypothesis of retrograde menstruation. However, the patient´s history of complaints is not indicative of the diagnosis of endometriosis. Therefore, all patients with CSD should be offered a laparoscopy and endometriosis surgery. All patients with a previous caesarean section presenting with symptoms of endometriosis should be offered standardised and high-quality niche diagnosis and treatment.

Comparison of long-term clinical effect and re-pregnant outcomes between hysteroscopic resection and laparoscopic defect repair in patients with non-severe cesarean scar defect: a retrospective study

OBJECTIVE

To evaluate and compare the long-term therapeutic effect and the re-pregnant outcomes of hysteroscopic resection and laparoscopic defect repair in the treatment of non-severe cesarean scar defect (CSD).

METHODS

The clinical data of 154 CSD patients whose residual myometrium thickness (RMT) ≥ 3 mm that treated at Maternal and Child Health Hospital of Hubei Province from January 2019 to May 2022 were retrospectively analyzed (74 accepted hysteroscopic resection and 80 received laparoscopic defect repair). We compared the general clinical data, laboratory tests, surgical related indicators and perioperative complications of two groups of patients, followed up and recorded the menstrual days at the 3rd, 6th, and 12th months after surgery, as well as the obstetric outcomes of re-pregnant patients.

RESULTS

The surgical duration, intraoperative bleeding, postoperative vaginal bleeding days, hospital stay, and total treatment cost in hysteroscopic group were all obviously lower than those in laparoscopic group. More importantly, the incidence of postoperative complications such as fever and pelvic pain was also significantly lower in patients undergoing hysteroscopic surgery than those undergoing laparoscopic surgery. In terms of menstrual improvement, at the postoperative 3rd,6th and 12th month, the patients of hysteroscopic group had shorter menstrual days than laparoscopic group. Additionally, the postoperative re-pregnancy rate of hysteroscopic group (61.29%) was higher than that of laparoscopic group (55%). No serious obstetric complications such as placenta implantation and uterine rupture occurred in the re-pregnant patients of both groups.

CONCLUSIONS

Although both hysteroscopic resection and laparoscopic defect repair have good clinical effects on improving the symptoms of non-severe CSD patients. But in contrast, the hysteroscopic resection displays the advantages of minimal trauma, shorter surgical time, less intraoperative bleeding, shorter hospital stay, lower treatment costs, faster postoperative recovery, lower incidence of postoperative complications, and higher re-pregnancy rate. Hence, hysteroscopic resection is safe and effective, and could be the first choice for the treatment of no-severe CSD patients.

Combined hysteroscopic and laparoscopic management of an isthmocele: about a case report

BACKGROUND

Isthmocele, a cesarean scar defect, is a common complication of cesarean delivery that can cause postmenstrual spotting, pelvic pain, and infertility. Its management requires accurate diagnosis and tailored surgical approaches, especially in women desiring future fertility.

CASE PRESENTATION

A 29-year-old woman with a history of cesarean section presented with pelvic pain, metrorrhagia, and secondary infertility. Ultrasound and hysteroscopy confirmed an isthmocele with a residual myometrial thickness of 2.2 mm. She underwent a combined laparoscopic and hysteroscopic repair. The defect was excised and reconstructed using two layers of size 0 absorbable sutures. Postoperative recovery was uneventful, and follow-up hysteroscopy at 8 weeks showed complete resolution of the defect.

DISCUSSION

Isthmocele symptoms arise from menstrual blood retention in the defect. Deeper defects benefit from laparoscopic repair, which restores uterine wall integrity, particularly for fertility preservation. The combined approach enhances defect localization and repair precision, as demonstrated in this case.

CONCLUSION

This case underscores the effectiveness of a combined laparoscopic and hysteroscopic approach in managing isthmocele, achieving symptom resolution and uterine integrity restoration. Individualized management and long-term follow-up are essential for optimizing outcomes.

Hysteroscopic Management of Symptomatic Cesarean Scar Diverticulum in Patients Undergoing Frozen-Thawed Embryo Transfer: Impact on Clinical Pregnancy Rates and Pregnancy Complications

This retrospective cohort study aimed to compare the clinical outcomes of patients with cesarean scar defect (CSD) undergoing frozen embryo transfer (FET) with or without hysteroscopic repair surgery. The study included 82 patients, with 48 patients in surgical group A (undergoing CSD repair) and 34 patients in surgical group B (undergoing hysteroscopic treatment for other uterine lesions). The results showed that patients in group A had a larger CSD volume and a different shape compared to group B. However, there was no significant difference in clinical pregnancy rates between the two groups. Additionally, there were no differences in miscarriage, live birth, or preterm birth rates, and no complications such as scar pregnancy or placental abnormalities were observed in either group. These findings suggest that hysteroscopic treatment of CSD in symptomatic patients undergoing FET does not increase the risk of pregnancy complications and can lead to comparable clinical pregnancy rates with asymptomatic patients. Further studies with larger sample sizes are needed to confirm these results and evaluate long-term reproductive outcomes following CSD repair.

Improving Precision and Safety in Uterine Isthmocele Repair by Utilizing the KOH Cup and Firefly Guidance

Multiple surgical modalities are currently used for uterine isthmocele repair. Identifying defects intraoperatively remains challenging, and guidelines for optimal repair techniques are still evolving. Here, we present a case of safe and precise uterine isthmocele repair using the KOH Cup (Cooper Surgical Inc., Trumbull, USA) in combination with the Firefly technology of the Da Vinci Xi robotic system (Intuitive Surgical Inc., Sunnyvale, USA). A 30-year-old woman, para 1 living 1, with a history of previous cesarean section, presented with secondary infertility for the past seven years. A suspicion of a uterine isthmocele was revealed by ultrasonography. Magnetic resonance imaging (MRI) confirmed the diagnosis of a bulky uterus with a thinned-out anterior wall myometrium at the utero-cervical junction and an isthmocele of collection measuring 7.6 x 3.0 mm. The KOH Cup was used alongside Firefly-guided complete isthmocele repair and bladder adhesiolysis, with the patient being discharged within 24 hours. By using the KOH Cup with the Firefly imaging system, surgical accuracy can be improved through real-time feedback, making it a safe approach for uterine isthmocele repair. While the KOH Cup and Firefly combination appear to be a novel and promising approach, a direct comparison with traditional laparoscopic methods (without robotic guidance) is necessary to establish its clear advantages. Without supporting data or references, the claim of superiority remains speculative.

Incidence of chronic pelvic pain after childbirth and its causal association with C-section

ABSTRACT

This study aimed to report the incidence of chronic pelvic pain in women 12 to 24 months postpartum, to identify the independently associated factors, and to conduct a causal inference with C-section as the exposure. This was a cross-sectional study nested within 2 distinct prospective cohorts from 2 Brazilian cities. Chronic pelvic pain was the dependent variable. Independent variables were collected. Fisher exact test or Pearson χ2 test and t test or Wilcoxon rank-sum test were performed as appropriate, with P-values adjusted. Data were assumed to be missing at random, and multivariate imputation by chained equations was performed. Sensitivity analysis was conducted using complete cases. Multicollinearity was assessed by computing the variance inflation factor. Binomial logistic regression was used to obtain an interpretable model. Odds ratios and 95% confidence intervals were used as measurements. A directed acyclic graph was used for causal inference. A total of 2160 women were included. The incidence of chronic pelvic pain was 12.7%. C-sections doubled the odds of developing chronic pelvic pain (CPP). Additional factors associated with increased odds included city of birth, feelings of discrimination, severe symptoms of anxiety, dissatisfaction with the care received during childbirth, and mental suffering. Women who underwent C-sections had a 6.1% higher incidence of CPP compared to those who did not undergo the procedure. The incidence of CPP postpartum is high, and there is a potential causal effect of C-sections. City of birth, discrimination, anxiety, dissatisfaction with the care, and mental suffering were also associated with an increased odds.

Current surgical treatment of uterine isthmocele: an update of existing literature

The prevalence of uterine isthmocele, also known as a uterine niche, has risen in parallel with increasing cesarean section (CS) rates, affecting approximately 60% of women depending on their history of cesarean deliveries. This condition, now categorized as cesarean scar disorder (CSD) by the "Delphi consensus," is characterized by one primary or two secondary symptoms. Diagnosis can be made through transvaginal ultrasound, sonohysterography, hysteroscopy, or magnetic resonance imaging (MRI). Management of isthmocele may involve pharmacological or surgical interventions. This review aims to provide a thorough analysis of the surgical management options, focusing on postoperative symptom relief, intraoperative and postoperative complications, length of hospital stay, and impact on secondary infertility. PubMed was comprehensively searched for observational studies from inception to 07.08.2024. Surgical treatments include hysteroscopic resection, laparoscopic procedures, and vaginal approaches, all of which offer comparable symptom relief. However, the vaginal approach is associated with a longer hospital stay. The robotic-assisted approach shows promising results but lacks extensive data. Among surgical options, hysteroscopic treatment has the fewest complications but is generally avoided when residual myometrial thickness (RMT) is less than 3 mm. While many CSDs remain asymptomatic, and some women with uterine isthmocele may not wish to conceive, symptomatic patients or those desiring to conceive may benefit from surgical intervention. The choice of procedure should be based on individual patient characteristics, particularly RMT, to define the most appropriate surgical approach.

Sonographic Assessment of Isthmocele and Its Obstetric Complications in Subsequent Pregnancies: A Pictorial Review

Cesarean scar defect represents a significant pathology attributed to the rising prevalence of cesarean deliveries. While not commonplace, these lesions can give rise to severe obstetric consequences during subsequent pregnancies. Given the potential complications, it is advisable to screen for uterine niches using transvaginal ultrasound (TVUS) or contrast-enhanced TVUS for individuals planning to conceive. Surgical repair and correction of these lesions can be crucial in averting obstetric and perinatal complications in future pregnancies. Furthermore, timely sonographic evaluation and reporting of isthmocele-related obstetric complications can help avoid serious issues.

Impact of caesarean scar defects on the success of assisted human reproduction: the NICHE-ART prospective French cohort study protocol

BACKGROUND

The global increase in caesarean sections (CS), currently at 21.1% of all deliveries, has led to a rise in uterine scar defects, or 'niches', at the hysterotomy site. These niches, detectable in 13%-84% of cases via transvaginal ultrasound (TVS) and 42%-84% through sonohysterography (SHG), may contribute to gynaecological complications, including abnormal uterine bleeding, chronic pain and secondary infertility. Niche-associated risks for in vitro fertilisation (IVF) outcomes remain underexplored, and this study aims to evaluate their impact on clinical pregnancy rates.

METHODS AND ANALYSIS

This multicentre, prospective, non-interventional study will involve 250 women with a history of CS and secondary infertility undergoing IVF in 14 reproductive units of French Hospital. Participants will be assessed using SHG and TVS to determine niche presence (measurements of the length, depth and width of the niche, and residual myometrial thickness (RMT)). A niche is diagnosed by an indentation of at least 2 mm at the site of the caesarean scar, with a large niche defined as RMT <3 mm. The primary outcome is clinical pregnancy rate, with secondary outcomes including live birth rates, biochemical pregnancies and obstetric complications. Multivariate logistic regression will control for confounders. The duration of the inclusion period is estimated to be 42 months.

ETHICS AND DISSEMINATION

The study protocol was approved by the relevant French medical review board, 'Comité de Protection des Personnes Sud Méditerranée IV', on 10 November 2020 and recorded prospectively (before the inscription of the first participant) under the number ID-RCB: 2020-A02068-31. The study will be conducted according to the guidelines of the Declaration of Helsinki. Informed consent will be obtained from all participants. The findings will be published in peer-reviewed journals and presented at relevant meetings.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, ID: NCT04869007. Registered on 16 August 2020.

Investigating the impact of isthmocele and its surgical repair on fertility: results from a systematic review and meta-analysis

The aim of this systematic review was to quantify the impact of isthmocele and its treatment on fertility. The review was conducted according to the PRISMA guidelines, and the meta-analysis according to the MOOSE guidelines. The meta-analysis of data from 29 studies showed that 43% (rate 0.43, 95% CI 0.33-0.54; n = 2038) of women with a symptomatic isthmocele reported secondary infertility as a presenting symptom (quality of evidence [QOE)]: very low). In the IVF setting, women with an isthmocele were shown to have a lower live birth rate (LBR) than women with a previous Caesarean section without an isthmocele (odds ratio [OR] 0.57, 95% CI 0.49-0.66; n = 7719, eight studies) (QOE: high). Ten studies reported the LBR after isthmocele hysteroscopic repair in a cohort of infertile women (LBR 0.63, 95% CI 0.49-0.77; QOE: very low). Seven studies reported the LBR after isthmocele laparoscopic repair (LBR 0.51, 95% CI 0.40-0.63; QOE: very low). The combination of these findings suggests that isthmoceles play a role in the pathophysiology of infertility. Hysteroscopic and laparoscopic surgical repair emerged as promising options for the treatment of infertility in women with an isthmocele. To provide comprehensive counselling, these findings must be communicated to patients, together with the weaknesses of the underlying evidence.

Advanced repair of recurrent and low-large hysterotomy defects using a myometrial glide flap

BACKGROUND

The resolution of factors linked to the recurrence of cesarean section defects can be accomplished through a comprehensive technique that effectively addresses the dehiscent area, eliminates associated intraluminal fibrosis, and establishes a vascularized anterior wall by creating a sliding myometrial flap.

OBJECTIVE

Propose a comprehensive surgical repair for recurrent and large low hysterotomy defects in women seeking pregnancy or recurrent spotting.

STUDY DESIGN

A retrospective cohort analysis included 54 patients aged 25-41 with recurrent large cesarean scar defects treated at Otamendi, CEMIC, and Valle de Lili hospitals. Comprehensive surgical repair was performed by suprapubic laparotomy, involving a wide opening of the vesicouterine space, removal of the dehiscent cesarean scar and all intrauterine abnormal fibrous tissues, using a glide myometrial flap, and intramyometrial injection of autologous platelet-rich plasma. Qualitative variables were determined, and descriptive statistics were employed to analyze the data in absolute frequencies or percentages. The data obtained were processed using the InfostatTM statistic program.

RESULTS

Following the repair, all women experienced normal menstrual cycles and demonstrated an adequate lower uterine segment thickness, with no evidence of healing defects. All patients experienced early ambulation and were discharged within 24 h. Uterine hemostasis was achieved at specific points, minimizing the use of electrocautery. The standard duration of the procedure was 60 min (skin-to-skin), and the average bleeding was 80-100 ml. No perioperative complications were recorded. A control T2-weighted MRI was performed six months after surgery. All patients displayed a clean, unobstructed endometrial cavity with a thick anterior wall (Median: 14.98 mm, IQR 13-17). Twelve patients became pregnant again, all delivered by cesarean between 36.1 and 38.0 weeks, with a mean of 37.17 weeks. The thickness of the uterine segment before cesarean ranged between 3 and 7 mm, with a mean of 3.91 mm. No cases of placenta previa, dehiscence, placenta accreta spectrum (PAS), or postpartum hemorrhage were reported.

CONCLUSIONS

The comprehensive repair of recurrent low-large defects offers a holistic solution for addressing recurrent hysterotomy defects. Innovative repair concepts effectively address the wound defect and associated fibrosis, ensuring an appropriate myometrial thickness through a gliding myometrial flap.

Targeting nuclear factor erythroid 2-related factor 2-regulated ferroptosis to treat nervous system diseases

By critically examining the work, we conducted a comprehensive bibliometric analysis on the role of nuclear factor erythroid 2-related factor 2 (NRF2) in nervous system diseases. We also proposed suggestions for future bibliometric studies, including the integration of multiple websites, analytical tools, and analytical approaches, The findings presented provide compelling evidence that ferroptosis is closely associated with the therapeutic challenges of nervous system diseases. Targeted modulation of NRF2 to regulate ferroptosis holds substantial potential for effectively treating these diseases. Future NRF2-related research should not only focus on discovering new drugs but also on designing rational drug delivery systems. In particular, nanocarriers offer substantial potential for facilitating the clinical translation of NRF2 research and addressing existing issues related to NRF2-related drugs.

Prevalence and Clinical Features of Uterine Isthmocele Following Cesarean Sections: An Observational Study at Rabia Balkhi Hospital in Afghanistan

Background Uterine isthmocele, a defect in the uterine wall at the cesarean scar, is increasingly recognized due to the rising rate of cesarean deliveries. Often asymptomatic, it may lead to complications such as abnormal bleeding, chronic pelvic pain, secondary infertility, or uterine rupture during subsequent pregnancies. Objective This study aimed to assess the prevalence, clinical features, and associated risk factors of uterine isthmocele among women with previous cesarean scars over four years (2019-2023) at Rabia Balkhi Hospital, Afghanistan. Methods This observational study analyzed 9,207 women with prior cesarean sections, including 4,540 cases retrospectively (2019-2021) and 4,667 cases prospectively (2021-2023). The diagnosis was based on clinical evaluations and transvaginal ultrasonography. Data were analyzed using MS Excel (Microsoft Corporation, Redmond, USA), with statistical significance assessed for symptom associations and risk factors. Results Uterine isthmocele was identified in 58 women (0.63%). The most common symptom was abnormal uterine bleeding (78%, p < 0.001), followed by dysmenorrhea (48%, p = 0.793), chronic pelvic pain (31%, p = 0.004), secondary infertility (22%, p < 0.001), and hypovolemic shock (8.6%, p < 0.001). Women with three cesarean scars had the highest prevalence of isthmocele (46.5%, p < 0.001). Ultrasonography was effective in detecting isthmocele and evaluating post-surgical outcomes. Conclusion The study highlights the need for improved cesarean techniques, early ultrasonographic diagnosis, and standardized management protocols for uterine isthmocele. These findings provide a foundation for optimizing care in women with multiple cesarean scars and underscore the importance of early intervention to prevent complications.

Emerging data on diagnosis and management of uterine isthmoceles: a rapid review

PURPOSE OF REVIEW

With a rising number of cesarean sections, the prevalence of uterine isthmoceles is increasing. We performed a rapid review to assess the most recent data on the diagnosis and management of uterine isthmoceles over the past 18 months to identify current trends and directions for continued research.

RECENT FINDINGS

A comprehensive search was conducted in PubMed (NLM), Embase (Ovid), CINAHL (EBSCOhost) to find English written articles discussing the diagnosis or management of uterine isthmoceles published in the previous 18 months. Data extraction was performed on one hundred articles that met inclusion criteria.

SUMMARY

This rapid review highlights agreement regarding diagnostic methods, symptoms, and recommended treatment paths for patients with symptomatic uterine niches. However, the diversity in definitions hampers the capacity to formulate detailed conclusions regarding the features of uterine niches and their impact on women's health.

Surgical treatment and reproductive outcomes in caesarean scar pregnancy at a single center

BACKGROUND

To investigate factors associated with different reproductive outcomes in patients with Caesarean scar pregnancies (CSPs).

METHODS

Between May 2017 and July 2022, 549 patients underwent ultrasound-guided uterine aspiration and laparoscopic scar repair at the Gynaecology Department of Hubei Maternal and Child Health Hospital. Ultrasound-guided uterine aspiration was performed in patients with type I and II CSPs, and laparoscopic scar repair was performed in patients with type III CSP. The reproductive outcomes of 100 patients with fertility needs were followed up and compared between the groups.

RESULTS

Of 100 patients, 43% had live births (43/100), 19% had abortions (19/100), 38% had secondary infertility (38/100), 15% had recurrent CSPs (RCSPs) (15/100). The reproductive outcomes of patients with CSPs after surgical treatment were not correlated with age, body mass index, time of gestation, yields, abortions, Caesarean sections, length of hospital stay, weeks of menopause during treatment, maximum diameter of the gestational sac, thickness of the remaining muscle layer of the uterine scar, type of CSP, surgical method, uterine artery embolisation during treatment, major bleeding, or presence of uterine adhesions after surgery. Abortion after treatment was the only risk factor affecting RCSPs (odds ratio 11.25, 95% confidence interval, 3.302-38.325; P < 0.01) and it had a certain predictive value for RCSP occurrence (area under the curve, 0.741).

CONCLUSIONS

The recurrence probability of CSPs was low, and women with childbearing intentions after CSPs should be encouraged to become pregnant again. Abortion after CSP is a risk factor for RCSP. No significant difference in reproductive outcomes was observed between the patients who underwent ultrasound-guided uterine aspiration and those who underwent laparoscopic scar repair for CSP.

Isthmocele and Infertility

Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman's quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5-3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted.

Reproductive outcomes after in vitro fertilization in women with cesarean section scar diverticulum: A retrospective study

PURPOSE

Some studies have suggested that cesarean section diverticulum may affect the pregnancy outcomes of assisted reproductive technology through a variety of mechanisms. This study aims to explore whether previous cesarean section and uterine scar diverticulum affect pregnancy outcomes after in vitro fertilization.

METHODS

This retrospective study included 954 infertile women with only one previous delivery who had in vitro fertilization treatment and underwent fresh embryo transplantation for the first time at our center between 2015 and 2019. We first divided the women into two groups by previous vaginal delivery (n = 557) or cesarean section delivery (n = 397), and the latter group included 88 women with cesarean diverticulum and 309 women without cesarean diverticulum. Baseline characteristics were compared and analyzed, and logistic regression analyses were performed to explore the different pregnancy outcomes among the above groups.

RESULTS

Although the live birth rate, clinical pregnancy rate, and mean embryo implantation rate after in vitro fertilization were significantly reduced in patients with previous cesarean section (live birth rate: 26.45% vs. 43.99%, adjusted OR: 0.602, CI: 0.447-0.810; clinical pregnancy rate: 35.26% vs. 49.91%, adjusted OR: 0.724, CI: 0.544-0.962; mean embryo implantation rate: 0.227 ± 0.378 vs. 0.243 ± 0.397, adjusted OR: 0.860, CI: 0.514-1.439), there were no significant differences in pregnancy outcomes between the women with cesarean diverticulum and without cesarean diverticulum (p > 0.05) or between the two groups at different ages. The live birth and clinical pregnancy rates in the women with residual muscle thickness ≤2.2 mm or prolonged menstruation were reduced, but the difference was not statistically significant (p > 0.05).

CONCLUSION

This study showed reduced pregnancy and live birth rates after in vitro fertilization in patients with previous cesarean section, while uterine scarring did not adversely affect pregnancy and delivery outcomes after in vitro fertiliazation.

Impact of cesarean scar defect on reproductive outcomes after assisted reproductive technology

In the last twenty years, the cesarean section rate has been rising in China, leading to an increased prevalence of cesarean scar defect (CSD) and secondary infertility. CSD decreases receptivity of endometrium, induces adenomyosis and endometriosis, disrupts uterine micro-environment and causes difficulties in embryo transplant operation as well as has further pregnancy complications. For women undergoing assisted reproductive technology (ART), CSD significantly reduces live birth rate, clinical pregnancy rate and embryo implantation rate. CSD can be effectively treated by hysteroscopic surgery, laparoscopic surgery and transvaginal surgery to increase the pregnancy rate. This article reviews the research progress on the impact of CSD on the reproductive outcomes of ART, the potential factors and related treatments, and provides a reference for the management of CSD patients undergoing ART.

Isthmocele abscess: A rare case report

A rare case report of an isthmocele abscess—its presentation, diagnosis and clinical management is discussed.

Application of Failure Mode and Effects Analysis to Improve the Quality of the Front Page of Electronic Medical Records in China: Cross-Sectional Data Mapping Analysis

BACKGROUND

The completeness and accuracy of the front pages of electronic medical records (EMRs) are crucial for evaluating hospital performance and for health insurance payments to inpatients. However, the quality of the first page of EMRs in China's medical system is not satisfactory, which can be partly attributed to deficiencies in the EMR system. Failure mode and effects analysis (FMEA) is a proactive risk management tool that can be used to investigate the potential failure modes in an EMR system and analyze the possible consequences.

OBJECTIVE

The purpose of this study was to preemptively identify the potential failures of the EMR system in China and their causes and effects in order to prevent such failures from recurring. Further, we aimed to implement corresponding improvements to minimize system failure modes.

METHODS

From January 1, 2020, to May 31, 2022, 10 experts, including clinicians, engineers, administrators, and medical record coders, in Zhejiang People's Hospital conducted FMEA to improve the quality of the front page of the EMR. The completeness and accuracy of the front page and the risk priority numbers were compared before and after the implementation of specific improvement measures.

RESULTS

We identified 2 main processes and 6 subprocesses for improving the EMR system. We found that there were 13 potential failure modes, including data messaging errors, data completion errors, incomplete quality control, and coding errors. A questionnaire survey administered to random physicians and coders showed 7 major causes for these failure modes. Therefore, we established quality control rules for medical records and embedded them in the system. We also integrated the medical insurance system and the front page of the EMR on the same interface and established a set of intelligent front pages in the EMR management system. Further, we revamped the quality management systems such as communicating with physicians regularly and conducting special training seminars. The overall accuracy and integrity rate of the front page (P<.001) of the EMR increased significantly after implementation of the improvement measures, while the risk priority number decreased.

CONCLUSIONS

In this study, we were able to identify the potential failure modes in the front page of the EMR system by using the FMEA method and implement corresponding improvement measures in order to minimize recurring errors in the health care services in China.

Assessment of the clinical outcomes and complications of hysteroscopic and laparoscopic approaches in the treatment of symptomatic isthmocele: An observational study

OBJECTIVES

To investigate the outcomes of patients undergoing laparoscopic or hysteroscopic approaches for isthmoplasty.

METHODS

A total of 99 isthmocele patients with an average age of 38.45 ± 4.72 years were included in the 2 years of this retrospective cohort study. Forty-five underwent laparoscopic and 54 underwent hysteroscopic isthmocele excision and myometrial repair.

RESULTS

Pain scores were significantly higher in the hysteroscopy group before the procedure, but there were no significant pain score differences after the surgery. In 1 year of follow up, dysmenorrhea and dyspareunia were higher among hysteroscopy patients. Furthermore, hysteroscopy significantly improved postmenstrual spotting after surgery better than laparoscopy, but in the follow up, there was no significant difference between the two groups in this regard (mean rank for hysteroscopy vs. laparoscopy: 32.30 vs. 37.48, U = 418, P = 0.29).

CONCLUSION

In patients with a history of infertility, ectopic pregnancy, lower gravidity, lower parity, and a lower number of cesarean sections, laparoscopic isthmoplasty is preferred over the hysteroscopic approach. Both methods have similar effects on midcycle vaginal bleeding, duration of postmenstrual spotting, and pain. However, a higher rate of dyspareunia and dysmenorrhea could be associated with hysteroscopy.