Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy.

OBJECTIVE: To evaluate Cesarean scar defects using saline contrast sonohysterography (SCSH) in women with a history of Cesarean scar pregnancy (CSP). METHODS: A cohort of 38 non-pregnant women with a history of CSP treated with combined local and systemic methotrexate was investigated prospectively by SCSH. For the purpose of analysis, they were classified, according to the modified Delphi consensus criteria for CSP in early gestation, into three subgroups based on the depth of the gestational sac herniation in the midsagittal plane. Subgroup A included eight (21.1%) cases, in which the largest part of the gestational sac protruded towards the uterine cavity; Subgroup B included 20 (52.6%) cases, in which the largest part of the gestational sac was embedded in the myometrium; and Subgroup C included 10 (26.3%) cases, in which the gestational sac was located partially outside the outer contour of the cervix or uterus. RESULTS: SCSH revealed that all women in Subgroup C had a uterine niche. The median niche length (P = 0.006) and depth (P = 0.015) were significantly greater in Subgroup C than in Subgroups A or B. The median residual myometrial thickness (RMT) was significantly lower in Subgroup C than in Subgroups A or B (P = 0.006). CONCLUSIONS: Women with prior CSP who had a gestational sac protruding beyond the serosal line had a significantly greater niche length and depth, and lower RMT. This knowledge may guide individualized risk counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries.

OBJECTIVES: To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). METHODS: Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. RESULTS: A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. CONCLUSIONS: While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.

Ultrasound diagnostic of intrauterine adhesions: Systematic review and meta-analysis.

PURPOSE: To summarize and compare the accuracy of transvaginal ultrasound (TVS), 3D-TVS, and sonohysterography (SHG) for the diagnosis of intrauterine adhesions (IUA). METHODS: The computer searches databases such as web of science, Medline, EMBASE, and PubMed collecting diagnostic studies of IUA via ultrasound. The retrieval time was included from inception to January 1, 2023. Two researchers independently screened the literature, extracted information, and used RevMan 5.3 to complete an assessment of the risk of bias in the included literature. Meta-analysis of included studies using Stata 16.0 and Meta Disc 1.4 software. RESULTS: Thirteen studies were included. The analysis results of 2D-TVS are The sensitivity (SEN): 0.54 (95% CI [0.28078]), specificity (SPE): 0.96 (95% CI [0.78, 0.99]), and the area (AUC) under the operating characteristic curve (SROC): 0.83 (95% CI [0.80, 0.86]); the SEN, SPE, and AUC of 3D-TVS are: 0.96 (95% CI [0.90, 0.98]), 0.84 (95% CI [0.68, 0.93]), 0.97 (95% CI [0.95, 0.98]); and the SEN, SPE, and AUC of SHG are: 0.74 (95% CI [0.53, 0.88]), 0.97 (95% CI [0.94, 0.99]), 0.95 (95% CI [0.93, 0.97]). CONCLUSION: The current results show that the diagnostic value of 3D-TVS for IUA is better than SHG and significantly higher than that of 2D-TVS. However, the analysis of subgroups is still limited by the number of included studies. In order to better explore the application of ultrasound in intrauterine adhesion, more high-quality studies are needed in the future.

The effects of Saline Infusion Sonography on the histological quality of endometrial sampling in women with postmenopausal bleeding.

BACKGROUND: The aim of this study is to analyze the histopathological features of endometrial samples obtained by aspiration when performed before or after the saline contrast sonohysterography in women with postmenopausal bleeding and a thickened endometrium. Hypothetically, the saline infusion could disrupt the tissue and therefore affect the quality of the sample. Furthermore, we want to determine which histological features have impact on the quality of the endometrial sample. METHODS: We performed a randomized controlled trial (ESPRESSO trial) in which we analyzed the aspiration samples in two groups. Women were allocated either to saline contrast sonohysterography and subsequent endometrial sampling (SCSH-Sampling group) or to the opposite order (Sampling-SCSH group). Dedicated gyneco-pathologists retrospectively assessed the specimens and recorded the type (blood, mucus, epithelium, intact glands, stroma and tissue context) and quantity (on a scale of 0-3) of material that was found in the specimens. RESULTS: This analysis consisted of 197 samples, with 101 women in the SCSH-Sampling group and 96 women in the Sampling-SCSH group. No significant differences were found in the histological features between the two groups. All significant histological features differed significantly in the sufficient samples compared to the insufficient samples: higher amounts of blood, more endometrial epithelium, presence of intact endometrial glands, better stroma and tissue context. Oppositely, a significantly higher amount of mucus was found in the insufficient samples. CONCLUSION: This study shows that the histological features of the endometrial sample were not affected by the saline contrast sonohysterography, when performed prior to the tissue sampling. Trial registration ESPRESSO TRIAL, NTR5690, registered 16 February 2016, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR5690 .

Differences between proximal and distal endometrial monolayer thickness in women aged over 50 years undergoing saline infusion sonohysterography.

BACKGROUND: Saline infusion sonohysterography (SIS) is a procedure performed to evaluate the endometrium in women with postmenopausal bleeding. PURPOSE: To investigate differences in endometrial monolayer measurements in women aged >50 years undergoing SIS. MATERIAL AND METHODS: Retrospective study of women aged >50 undergoing SIS. Endometrial echo (EE) was measured according to the International Endometrial Tumor Analysis (IETA) guidelines. Monolayer thickness was compared between anterior and posterior uterine walls and between the monolayer that was proximal or distal to the ultrasound probe. Presence and location of focal thickening and polyps on each of the monolayers were assessed. RESULTS: SIS was performed in 608 patients. Of them, 485 (79.8%) had anteverted, 85 (14%) retroverted, and 38 (6.2%) a midposition uterus. The mean posterior monolayer was thicker than the anterior monolayer (2.14 mm vs. 1.88 mm; P = 0.002). The distal monolayer was thicker than the proximal layer in both anteverted and retroverted uteri (2.18 mm vs. 1.84 mm; P < 0.0001). In 16% of women, the difference between distal and proximal monolayers was ≥1 mm. Focal thickening was seen 3.3 times more frequently in the distal endometrium. Among women with a double layer EE >4 mm, 18.8% had a proximal layer of <2 mm while only 4.6% had a distal EE <2 mm. CONCLUSION: Distal endometrium measures thicker than the proximal endometrium in most SIS cases and in one out of six women, the difference is >1 mm. The distal layer is three times more likely to contain focal thickening. Sonologists should be conscious of possible enhancement artifact when measuring the EE during SIS.

Identification of Endometrial Cancer-Specific microRNA Biomarkers in Endometrial Fluid.

Abnormal uterine bleeding is a common benign gynecological complaint and is also the most common symptom of endometrial cancer (EC). Although many microRNAs have been reported in endometrial carcinoma, most of them were identified from tumor tissues obtained at surgery or from cell lines cultured in laboratories. The objective of this study was to develop a method to detect EC-specific microRNA biomarkers from liquid biopsy samples to improve the early diagnosis of EC in women. Endometrial fluid samples were collected during patient-scheduled in-office visits or in the operating room prior to surgery using the same technique performed for saline infusion sonohysterography (SIS). The total RNA was extracted from the endometrial fluid specimens, followed by quantification, reverse transcription, and real-time PCR arrays. The study was conducted in two phases: exploratory phase I and validation phase II. In total, endometrial fluid samples from 82 patients were collected and processed, with 60 matched non-cancer versus endometrial carcinoma patients used in phase I and 22 in phase II. The 14 microRNA biomarkers, out of 84 miRNA candidates, with the greatest variation in expression from phase I, were selected to enter phase II validation and statistical analysis. Among them, three microRNAs had a consistent and substantial fold-change in upregulation (miR-429, miR-183-5p, and miR-146a-5p). Furthermore, four miRNAs (miR-378c, miR-4705, miR-1321, and miR-362-3p) were uniquely detected. This research elucidated the feasibility of the collection, quantification, and detection of miRNA from endometrial fluid with a minimally invasive procedure performed during a patient in-office visit. The screening of a larger set of clinical samples was necessary to validate these early detection biomarkers for endometrial cancer.

Endometrial Abnormalities: Correlation Between Different Diagnostic Modalities.

OBJECTIVES: We sought to evaluate the diagnostic accuracy of transvaginal ultrasound (TVUS) saline infusion sonohysterogram (SIS), and hysteroscopy for diagnosing endometrial abnormalities and their correlation with histological findings. In addition, we sought to validate the subsistence of a more subtle abnormality called "redundant endometrium" (RE). METHODS: Retrospective cohort study of patients presenting with infertility and diagnosed with endometrial abnormalities who underwent hysteroscopy and pathology evaluation. Each patient underwent TVUS at the first visit regardless of the cycle phase, followed by SIS during proliferative phase, and then hysteroscopy, which was performed when abnormal SIS findings were diagnosed. Endometrial abnormalities were categorized as polyps (EP), RE, or normal. Frequencies of the abnormalities were recorded for the 3 imaging modalities and their sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each. RESULTS: A total of 105 TVUS and 73 SIS were performed. Because of the frequent association of EP with RE, when all endometrial pathologies were combined, the three diagnostic modalities showed high sensitivity (TVUS 88.9%, SIS 100%, hysteroscopy 82.9%, respectively), but they also showed low specificity (TVUS 56.7%, SIS 56.1%, hysteroscopy 58.2%, respectively). Pathological evaluation showed isolated RE (26 cases), to harbor polyps (19.2%), disordered endometrium (19.2%), and complex atypical hyperplasia (3.8%). CONCLUSIONS: The three diagnostic modalities showed high sensitivity in diagnosing endometrial abnormalities. We identified RE as an independent endometrial abnormality. Benign endometrium is the predominant histology in RE, however, a small proportion harbors endometrial hyperplasia. Based on these results, we advocate further evaluation when this condition is diagnosed with TVUS, or SIS.

The Impact of Uterine Incision Closure Techniques on Post-cesarean Delivery Niche Formation and Size: Sonohysterographic Examination of Nonpregnant Women.

OBJECTIVE: To compare the prevalence and size of residual niche in the nongravid uterus following Cesarean delivery (CD) with different hysterotomy closure techniques (HCTs). METHODS: Saline infusion sonohysterogram (SIS) was performed in women after one prior CD, documenting the presence or absence of a postoperative niche and measuring its depth, width, length, and residual myometrial thickness. Women were grouped by HCT: Technique A (endometrium-free) and Technique B (routine non-endometrium-free). The primary outcome was the prevalence of a clinically significant niche, defined as a depth of >2 mm. HCT groups were compared using χ2 , T-test (ANOVA), and analyzed using logistic regression and two-sided test (P < .05). RESULTS: Forty-five women had SIS performed, 25 and 20 via Technique A and B, respectively. Technique groups varied by average interval time from CD to SIS (13.6 versus 74.5 months, P = 0.006) but were otherwise similar. Twenty niches were diagnosed, 85% of which were clinically significant, including five following Technique A, nine following Technique B with double-layer closure, and three following Technique B with single-layer (P = .018). The average niche depth was 2.4 mm and 4.9 mm among the two-layer subgroups following Techniques A and B, respectively (P = .005). A clinically significant niche development was six times higher with Technique B when compared to Technique A (OR 6.0, 95% CI 1.6-22.6, P = .008); this significance persisted after controlling for SIS interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3, P = .04). The average niche depth was 5.7 ± 2.9 mm following Technique B with single-layer. CONCLUSION: Hysterotomy closure techniques determine the prevalence of post-Cesarean delivery niche formation and size. Exclusion of the endometrium at uterine closure reduces the development of significant scar defects.

Typical ultrasound features of various endometrial pathologies described using International Endometrial Tumor Analysis (IETA) terminology in women with abnormal uterine bleeding.

OBJECTIVE: To describe the ultrasound features of different endometrial and other intracavitary pathologies inpre- and postmenopausal women presenting with abnormal uterine bleeding, using the International Endometrial Tumor Analysis (IETA) terminology. METHODS: This was a prospective observational multicenter study of consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler and fluid-instillation sonography were performed. Endometrial sampling was performed according to each center's local protocol. The histological endpoints were cancer, atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (EIN), endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma and other. For fluid-instillation sonography, the histological endpoints were endometrial polyp, intracavitary leiomyoma and cancer. For each histological endpoint, we report typical ultrasound features using the IETA terminology. RESULTS: The database consisted of 2856 consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler was performed in all cases and fluid-instillation sonography in 1857. In 2216 women, endometrial histology was available, and these comprised the study population. Median age was 49 years (range, 19-92 years), median parity was 2 (range, 0-10) and median body mass index was 24.9 kg/m2 (range, 16.0-72.1 kg/m2 ). Of the study population, 843 (38.0%) women were postmenopausal. Endometrial polyps were diagnosed in 751 (33.9%) women, intracavitary leiomyomas in 223 (10.1%) and endometrial cancer in 137 (6.2%). None (0% (95% CI, 0.0-5.5%)) of the 66 women with endometrial thickness < 3 mm had endometrial cancer or atypical hyperplasia/EIN. Endometrial cancer or atypical hyperplasia/EIN was found in three of 283 (1.1% (95% CI, 0.4-3.1%)) endometria with a three-layer pattern, in three of 459 (0.7% (95% CI, 0.2-1.9%)) endometria with a linear endometrial midline and in five of 337 (1.5% (95% CI, 0.6-3.4%)) cases with a single vessel without branching on unenhanced ultrasound. CONCLUSIONS: The typical ultrasound features of endometrial cancer, polyps, hyperplasia and atrophy and intracavitary leiomyomas, are described using the IETA terminology. The detection of some easy-to-assess IETA features (i.e. endometrial thickness < 3 mm, three-layer pattern, linear midline and single vessel without branching) makes endometrial cancer unlikely. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Endometrial sampling before or after saline contrast sonohysterography in women with postmenopausal bleeding (ESPRESSO trial): A multicenter randomized controlled trial.

INTRODUCTION: The aim of this study is to evaluate the quality of the endometrial sample obtained by office endometrial aspiration when performed before or after saline contrast sonohysterography (SCSH) in women with postmenopausal bleeding and a thickened endometrium. To conduct a complete, minimally invasive and cost-effective diagnostic workup in women with postmenopausal bleeding and a thickened endometrium, ideally both the office endometrial sampling and SCSH are performed. However, it is not known whether both tests affect each other when performed one after another. MATERIAL AND METHODS: Women with postmenopausal bleeding and an endometrial thickness >4 mm were eligible. Women were randomized into two groups: one group received endometrial aspiration before SCSH, the other group received SCSH before endometrial aspiration. The primary outcome was the proportion of sufficient endometrial samples. Reliability of the SCSH images and pain during procedures were secondary outcomes. RESULTS: During the inclusion period, 513 eligible women with postmenopausal bleeding visited the participating hospitals, 293 of whom received information about the study. Of these women, 232 (79%) agreed to participate. In the SCSH-aspiration group, 65 women (59%) had a sufficient endometrial sample compared with 70 (67%) in the aspiration-SCSH group (odds ratio 1.46, 95% CI 0.83-2.54, P = .19). The proportion of reliable sonographic images was significantly higher in the SCSH-aspiration group (n = 88, 87%) compared with the aspiration-SCSH group (n = 71, 74%) (OR 2.38, 95% CI 1.38-4.99, P = .02) in the per protocol analysis. CONCLUSIONS: This study shows that the quality of an endometrial sample in women with postmenopausal bleeding is not affected by SCSH. Both procedures can be performed in one outpatient visit to perform an optimal diagnostic workup.

Removal of uterine polyps: clinical management and surgical approach.

Endometrial polyps have a reported prevalence from 7.8% up to 30% and are one of the most cost-consuming gynecological conditions for our specialty. There are strong practitioner beliefs that surgical removal of endometrial polyps is highly beneficial, particularly for those with abnormal uterine bleeding and infertility. Additionally, polypectomy is indicated to reduce the risk of malignancy. Transvaginal ultrasound is the first-line diagnostic option for detection of endometrial polyps, while sonohysterography has similar accuracy as hysteroscopy in the diagnostic confirmation. Blind dilatation and curettage is not recommended for polyp removal; rather, hysteroscopy in the operating room and office setting using small-diameter hysteroscopic equipment is the standard approach. This can be performed without anesthesia in most women. While hysteroscopy is an effective method for polypectomy with a low complication rate, it is unknown whether this is truly beneficial for reproductive-age women with infertility and prior assisted reproduction therapy. The risk of malignancy in women with postmenopausal bleeding justifies the necessity of polypectomy with histologic tissue examination. In asymptomatic women, the risk of malignancy is low, and there are no known benefits of polyp removal in the prevention of malignant transformation. Cost-effective studies remain to be done to provide us with the optimal approach to endometrial polyps including the management of asymptomatic and/or infertile women, ideal location including office-based or the operating room setting, complication prevention including intrauterine adhesions, and recurrence issues.

Pain Perception and Side Effects During Saline Infusion Sonohysterography With a Balloon Catheter: A Randomized Comparative Study of Cervical Versus Intrauterine Catheter Placement.

OBJECTIVES: This study aimed to evaluate whether the site of the balloon placement into either the uterine cavity or cervical canal can affect the intensity of pain during sonohysterography. METHODS: In this randomized clinical trial, women who underwent saline infusion sonohysterography (SIS) were randomized to intracervical or intrauterine balloon placement between May 2012 and May 2014. The examination was scheduled at the early follicular phase of the menstrual cycle. The primary outcome measures included the degree of pain after inflation and then after deflation of the balloon catheter. Data were analyzed on the basis of the intention-to-treat principle for each woman who underwent SIS. RESULTS: A total of 300 infertile women were assigned to the treatment groups. There were no significant differences in inflation and deflation pain and the total procedure time between the 2 groups. The total volume of required saline for adequate distention of the cavity was significantly lower in the cervical group than the intrauterine group (p = .015). Nulliparous women had insignificantly more pain after the initial inflation of the balloon compared with multiparous women (p = .069). The pain score was not associated with patients' age, the volume of the saline infused, the presence of intrauterine abnormality, and the procedure time. CONCLUSIONS: Intracervical catheter placement did not reduce pain during or after SIS. However, intracervical balloon insertion requires a less-significant volume of saline compared with intrauterine placement, leading to a reduced risk of intrauterine infection and the spread of malignant endometrial cells into the peritoneal cavity at the time of the procedure.

Intrauterine Fluid Instillation and Transtubal Flow: A Randomized Controlled In vitro Trial Comparing Gel and Water.

BACKGROUND: Possible transtubal spillage of malignant cells is a major concern in fluid instillation sonography, as it is in hysteroscopy. This study aims to compare the transtubal flow of gel and saline and validate the clinical hypothesis that application of fluids with higher viscosity causes less spillage. METHODS: Randomized controlled in vitro trial comparing gel and saline infusion on 15 tissue specimens after hysterectomy with bilateral salpingectomy. Instillations are performed with saline and gel dyed with a 1% ink solution. Qualitative assessment of tubal spill is investigated as primary outcome. Secondary outcomes are instillation-volume and -pressure, assessed by measuring endometrial cavity dilation at in vitro ultrasound examination and subjective numeric 10-point scoring of the instillation pressure by a dedicated examiner. RESULTS: Tubal flow was more often observed during saline instillation (odds ratio 4.88, P = 0.008). Median subjectively assessed instillation pressures were nine arbitrary units for gel and three for saline (P < 0.001). Tubal flow occurred from 2 cc onward in the saline group versus five cc in the gel instillation group. Cavitary dilation did not differ between both groups. CONCLUSION: Gel instillation sonography is in vitro associated with less tubal flow and therefore could be a safer diagnostic test compared to saline infusion sonography or hysteroscopy. In vivo studies are necessary to confirm these results.

Advanced Imaging in Female Infertility.

PURPOSE OF REVIEW: This review highlights the role of imaging in the diagnosis and management of reproductive disorders. The additional information that imaging studies can contribute to reproductive medicine is emphasized, including the role of pelvic ultrasonography (US, including sonohysterography and contrast-enhanced hysterosalpingosonography), hysterosalpingography (HSG), and magnetic resonance imaging (MRI) of the female reproductive tract. In addition, the implications of congenital causes of infertility on the urinary tract in females are reviewed. While the evaluation of infertility in women is initially focused on the assessment of ovulation via serum hormone levels, imaging plays a role in evaluating other causes of infertility. Recent research in this field focuses on the establishment of a comprehensive single imaging study for the assessment of female reproductive disorders. Two proposed methods are MR hysterosalpingography and Fertiliscan, a combination of high-quality 3D ultrasound and assessment of tubal patency with hysterosalpingo-foam-sonography, though more research is needed to determine the risks and benefits of each method, as well as their reliability.

The effect of alpha lipoic acid on uterine wound healing after primary cesarean section: a triple-blind placebo-controlled parallel-group randomized clinical trial.

PURPOSE: To investigate the effect of alpha lipoic acid (ALA) on uterine wound healing after primary cesarean section (CS). METHODS: A parallel-group, triple-blind, placebo-controlled randomized clinical trial was conducted in Ain Shams University Maternity Hospital, Cairo, Egypt, involving 102 women undergoing pre-labor primary CS. The participants were randomly assigned using a computer-generated list of random numbers to receive oral ALA or a placebo twice daily for 6 weeks after CS. Allocation to either group was in a 1:1 ratio by an independent statistician (not involved in the treatment or data collection). The primary outcome was the presence of CS defect and measuring its depth and width. Secondary outcomes were measurements of the anterior myometrial and residual myometrium thicknesses, healing ratio and the presence of intrauterine adhesions. Assessment was done using saline contrast sonohysterography. RESULTS: Twenty (39.2%) women in the treatment group and ten (19.6%) controls had no niche (P value = 0.03, 95% CI - 0.388, - 0.0037). The absolute and relative risk reduction of forming a niche was 19.61% and 24.39%, respectively. The number of women needed to treat was five to avoid one niche formation. ALA use was associated with gastrointestinal upset in only three participants; however, none of the women withdrew during the study. CONCLUSION: In women undergoing primary CS, the administration of ALA for 6 weeks postpartum improved uterine healing and decreased the incidence of scar niche.

Cesarean scar defect: a prospective study on risk factors.

BACKGROUND: Cesarean scar defect (isthmocele) is a known complication after cesarean delivery. It has become more common due to a rising cesarean delivery rate. Isthmocele has been associated with various gynecological and obstetric problems such as uterine rupture, cesarean scar pregnancy, and bleeding disorders. OBJECTIVE: We sought to prospectively investigate factors associated with the risk for isthmocele assessed by sonohysterography. STUDY DESIGN: A prospective observational cohort study was conducted in 401 nonpregnant women who were recruited within 3 days of cesarean delivery. Women were evaluated with sonohysterography 6 months after cesarean delivery to detect a possible isthmocele. The ultrasonographer was blinded to any clinical information. The main outcome measure was the presence of isthmocele. Type of surgery (elective vs emergency), maternal background variables, and factors related to pregnancy, labor, and postoperative recovery were analyzed in relation to isthmocele. A logistic regression model was used to assess independent risk factors from univariate analysis. RESULTS: In all, 371 women were examined with sonohysterography resulting in a follow-up rate of 92.5%. The prevalence of isthmocele was 45.6%. Independent risk factors for isthmocele development were a history of gestational diabetes (odds ratio, 1.73; 95% confidence interval, 1.02-2.92; P = .042), previous cesarean delivery (odds ratio, 3.14; 95% confidence interval, 1.90-5.17; P < .001), and advanced maternal body mass index (odds ratio, 1.06; 95% confidence interval, 1.01-1.11; P = .012). Every additional unit of body mass index increased the risk of isthmocele by 6%. In the subgroup of emergency cesarean delivery, longer duration of active labor increased the risk for isthmocele (odds ratio, 1.06; 95% confidence interval, 1.01-1.11; P = .032). There was no statistically significant difference in prevalence between the groups of elective and emergency cesarean delivery (P = .898). CONCLUSION: Based on sonohysterographic examination, maternal body mass index, gestational diabetes, and previous cesarean deliveries are associated with an increased risk for incomplete healing of the uterine incision.

Comparison of transvaginal ultrasound and saline contrast sonohysterography in evaluation of cesarean scar defect: a prospective cohort study.

INTRODUCTION: The aim of this study was to investigate the prevalence of post-cesarean isthmocele and to measure agreement between transvaginal ultrasonography and saline contrast sonohysterography in assessment of isthmocele. MATERIAL AND METHODS: A prospective observational cohort study was carried out at Tampere University Hospital, Finland. Non-pregnant women delivered by cesarean section (n = 371) were examined with transvaginal ultrasonography (TVUS) and sonohysterography (SHG) six months after cesarean section. The main outcome measure was the prevalence of isthmocele using TVUS and SHG. Secondary outcome measures were characteristics of isthmocele. RESULTS: In all, 371 women were included. The prevalence of isthmocele was 22.4% based on TVUS and 45.6% based on SHG. Sensitivity and specificity for TVUS was 49.1 and 100%, respectively, when compared with SHG. Therefore, half of the defects (50.9%) diagnosed with SHG remained undiagnosed with TVUS. Bland-Altman analysis showed an underestimation of 1.1 mm (range 0.00-7.90) for TVUS compared with SHG, with 95% limits of agreement from -1.9 to 4.1 mm. CONCLUSIONS: This methodological study provides confirmatory data that TVUS and SHG are not in good agreement in the isthmocele diagnostics and the use of only TVUS may lead to an underestimation of the prevalence of isthmocele. Thus, SHG should be considered as a method of choice in diagnostics of isthmocele.

Changes in the Uterine Scar during the First Year after a Caesarean Section: A Prospective Longitudinal Study.

AIM: To study changes in a ceasarean section (CS) scar during the first year after a CS using gel installation sonography (GIS). METHODS: Proof-of-concept study, prospective cohort study. Twenty women who delivered by their first CS were evaluated by both transvaginal sonography and GIS 2 months and 1 year after CS. A niche was defined as an anechogenic space at the uterine caesarean scar with a depth >2 mm. The primary outcome was any change in the thickness of the residual myometrium (RMT) as evaluated by GIS. RESULTS: Mean RMT changed in time from 11.9 mm at 2 months to 6.5 mm at 12 months after the CS (p < 0.001). Niche prevalence did not change. The adjacent myometrium (AM) reduced from 15 to 12.4 mm (p = 0.04). The ratio between RMT and AM with GIS decreased from 0.80 at 2 months to 0.54 at 12 months (p = 0.002). CONCLUSION: RMT thickness, the adjacent myometium and the ratio between the RMT and AM reduces from 2 to 12 months after a CS. The prevalence did not change. This needs to be taken into account when deciding on the timing of niche measurement and the interpretation of the RMT.

Comparison of sonohysterography to hysterosalpingogram for tubal patency assessment in a multicenter fertility treatment trial among women with polycystic ovary syndrome.

PURPOSE: To compare saline infusion sonohysterography (SIS) versus hysterosalpingogram (HSG) for confirmation of tubal patency. METHODS: Secondary analysis of a randomized controlled trial, Pregnancy in Polycystic Ovary Syndrome II (PPCOS II). Seven hundred fifty infertile women (18-40 years old) with polycystic ovary syndrome (PCOS) were randomized to up to 5 cycles of letrozole or clomiphene citrate. Prior to enrollment, tubal patency was determined by HSG, the presence of free fluid in the pelvis on SIS, laparoscopy, or recent intrauterine pregnancy. Logistic regression was conducted in patients who ovulated with clinical pregnancy as the outcome and HSG or SIS as the key independent variable. RESULTS: Among women who ovulated, 414 (66.9%) had tubal patency confirmed by SIS and 187 (30.2%) had at least one tube patent on HSG. Multivariable analysis indicated that choice of HSG versus SIS did not have a significant relationship on likelihood of clinical pregnancy, after adjustment for treatment arm, BMI, duration of infertility, smoking, and education (OR 1.14, 95% CI 0.77, 1.67, P = 0.52). Ectopic pregnancy occurred more often in women who had tubal patency confirmed by HSG compared to SIS (2.8% versus 0.6%, P = 0.02). CONCLUSIONS: In this large cohort of women with PCOS, there was no significant difference in clinical pregnancy rate between women who had tubal patency confirmed by HSG versus SIS. SIS is an acceptable imaging modality for assessment of tubal patency in this population.