Definition and Criteria for Diagnosing Cesarean Scar Disorder

Importance

Approximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms.

Objective

To achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition.

Design, Setting, and Participants

A consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022.

Main Outcomes and Measures

Definition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche.

Results

In total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis.

Conclusions and Relevance

In this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.

P–299 Efficacy and safety of linzagolix for the treatment of severe adenomyosis: Initial results from a pilot study

Study question

Is a once daily regimen of the GnRH antagonist, linzagolix, high-dose (200mg) for 12 weeks then low-dose (100mg) for 12 weeks, effective in severe adenomyosis?

Summary answer

After 12 weeks, there was marked shrinkage of uterine volume, regression of adenomyotic lesions and symptom improvement (pain, anemia), 24 weeks data is pending.

What is known already

Suppression of estradiol using GnRH antagonists has been shown to be an effective treatment for endometriosis and uterine fibroids. Linzagolix is an investigational, oral GnRH receptor antagonist, which dose-dependently reduces E2 levels, providing full suppression (serum E2 < 20 pg/mL) and partial suppression with once daily oral dosing of 200 mg and 100 mg, respectively. We hypothesized that a regimen of full suppression for 12 weeks followed by partial suppression maintenance therapy for 12 weeks could be effective for the treatment of severe adenomyosis.

Study design, size, duration

This was a single-center, open-label exploratory study in women with symptomatic adenomyosis confirmed by Magnetic Resonance Imaging (MRI) (EudraCT number: 2017–004–042–14). Patients were recruited from a single private clinic and infertility research unit between March 2019 to June 2020.

Participants/materials, setting, methods

Eligible patients were premenopausal women 18 to 48 years old with symptomatic uterine adenomyosis confirmed by MRI, moderate-to-severe pain and abnormal uterine bleeding. The primary measure of efficacy was the reduction in uterine volume assessed by MRI. Other endpoints included adenomyosis lesion volume, pelvic pain, haemoglobin, uterine bleeding and quality of life (EHP–30 domains: pain, control and powerlessness, emotional well-being, social support and self-image).

Main results and the role of chance

Eight (3 black and 5 white) enrolled subjects had mean±SD age 42±3 years and weight 75±19 kg. At baseline (day 2 of the cycle) all patients presented with pelvic pain, severe dysmenorrhea and heavy menstrual bleeding. In all cases, MRI showed an enlarged uterus (mean±SD volume 343±253 cm3) with severe adenomyosis characterized by heterogenous myometrium with multiple myometrial cysts. The mean±SD junctional zone was 29.0±14.2 mm. Median serum estradiol was suppressed to 12 pg/mL by 4 weeks and this was maintained up to 12 weeks. After 12 weeks, mean±SD uterine volume was 162±117 cm3, a 57±16% reduction from baseline, with marked regression of adenomyotic lesions and the junctional zone was 21.0±13.4 mm. Mean±SD overall pelvic pain score (0–10 NRS) was reduced from 8.4±1.1 at baseline to 2.4±3.4 (p = 0.0035) and there were also improvements in dysmenorrhea, dyspareunia, non-menstrual pelvic pain and dyschezia scores. No subjects reported uterine bleeding between Weeks 4 to 12. Mean±SD haemoglobin was 12.1±2.0 at baseline and 12.8±1.1 at 12 weeks. Anemia at baseline (≤10g/dL) was resolved by 12 weeks. Substantial improvements were observed on each of the EHP–30 domains.

The most common side effect was the expected hypoestrogenic side effects of hot flushes, which were reported by 6/8 subjects.

Limitations, reasons for caution

This was a single-centre, open-label pilot study in 8 patients with symptomatic adenomyosis. We report the results after the first 12 weeks treatment of a high full suppression dose of linzagolix. Results after 24 weeks will further inform on the potential for a low partial suppression dose to maintain efficacy.

Wider implications of the findings: The initial results of this open-label pilot study in women with severe adenomyosis indicate that a high full suppression dose of linzagolix 200 mg is effective in reducing uterine and adenomyosis lesion size, reducing abnormal uterine bleeding and pelvic pain and improving quality of life.

Trial registration number

EudraCT number: 2017–004–042–14

Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure

OBJECTIVE

To generate guidance for detailed uterine niche evaluation by ultrasonography in the non-pregnant woman, using a modified Delphi procedure amongst European experts.

METHODS

Twenty gynecological experts were approached through their membership of the European Niche Taskforce. All experts were physicians with extensive experience in niche evaluation in clinical practice and/or authors of niche publications. By means of a modified Delphi procedure, relevant items for niche measurement were determined based on the results of a literature search and recommendations of a focus group of six Dutch experts. It was predetermined that at least three Delphi rounds would be performed (two online questionnaires completed by the expert panel and one group meeting). For it to be declared that consensus had been reached, a consensus rate for each item of at least 70% was predefined.

RESULTS

Fifteen experts participated in the Delphi procedure. Consensus was reached for all 42 items on niche evaluation, including definitions, relevance, method of measurement and tips for visualization of the niche. A niche was defined as an indentation at the site of a Cesarean section with a depth of at least 2 mm. Basic measurements, including niche length and depth, residual and adjacent myometrial thickness in the sagittal plane, and niche width in the transverse plane, were considered to be essential. If present, branches should be reported and additional measurements should be made. The use of gel or saline contrast sonography was preferred over standard transvaginal sonography but was not considered mandatory if intrauterine fluid was present. Variation in pressure generated by the transvaginal probe can facilitate imaging, and Doppler imaging can be used to differentiate between a niche and other uterine abnormalities, but neither was considered mandatory.

CONCLUSION

Consensus between niche experts was achieved regarding ultrasonographic niche evaluation. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures

OBJECTIVE

The aim of this study was to evaluate the complication rate after laparoscopic total hysterectomy and laparoscopic subtotal hysterectomy (LASH) in case of benign disease.

DESIGN

All complications were prospectively recorded at the time of surgery and analysed retrospectively.

SETTING

University hospital.

POPULATION

Among 4505 hysterectomies performed by the same team using the same techniques between 1990 and 2006, 3190 were performed by laparoscopy, 906 by the vaginal route and 409 by laparotomy.

METHODS

Laparoscopic hysterectomies, defined as laparoscopic subtotal hysterectomy (LASH) and total laparoscopic hysterectomy [laparoscopy-assisted vaginal hysterectomy (LAVH) switched to total laparoscopic hysterectomy (TLH) in 2000], were compared with vaginal and abdominal hysterectomies.

MAIN OUTCOME MEASURES AND RESULTS

Since the early 1990s, the number of laparoscopic procedures has continued to grow, while the number of abdominal and vaginal procedures has decreased. Both minor complications (fever >38.5 degrees C after 2 days, bladder incision of <2 cm and iatrogenic adenomyosis) and major complications (haemorrhage, vesicoperitoneal fistula, ureteral injury, rectal perforation or fistula) have been observed during the surgical procedure itself and postoperatively. In the LASH group (n = 1613), the minor complication rate was 0.99% (n = 16) and the major complication rate 0.37% (n = 6). In the total laparoscopic hysterectomy (LAVH/TLH) group (n = 1577), the minor complication rate was 1.14% (n = 18) and the major complication rate 0.51% (n = 8). In the vaginal hysterectomy group (n = 906), minor and major complication rates were 0.77% (n = 7) and 0.33% (n = 3), respectively. In the abdominal hysterectomy group (n = 409), minor and major complication rates were 0.73% (n = 3) and 0.49% (n = 2), respectively.

CONCLUSION

The results from our series of 4505 women clearly show that, in experienced hands, laparoscopic hysterectomy is not associated with any increase in major complication rates.

Cadmium, lead and endometriosis

OBJECTIVES

Cadmium (Cd) and lead (Pb) have been demonstrated to exert endocrine disrupting activities. Their possible role in endometriosis, an oestrogen-dependent disease, is unknown.

METHODS

We compared cadmium urinary excretion (CdU) and blood concentration of cadmium (CdB) and lead (PbB) in 119 patients with peritoneal endometriosis and/or deep endometriotic (adenomyotic) nodules of the rectovaginal septum and 25 controls.

RESULTS

The mean levels of cadmium in urine and blood did not differ among the groups. Women suffering from endometriotic diseases showed lower levels of PbB than controls.

CONCLUSIONS

These data do not support a role for cadmium in the onset or the growth of endometriotic diseases but suggest a possible relationship with lead.