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Clinical Observations |
1 Department of Radiology, Long Island College Hospital, Brooklyn, NY.
2 Department of Radiology, St. Luke's-Roosevelt Hospital Center, 1000 Tenth
Ave., 4th Floor, New York, NY 10019.
Received July 22, 2007;
accepted after revision November 5, 2007.
Address correspondence to J. E. Silberzweig
(jsilberz{at}chpnet.org).
Abstract
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MATERIALS AND METHODS. We reviewed the hysterosalpingograms of 150 women with a history of cesarean section. The incidence, location, and appearance of defects at the expected location of a hysterotomy scar were evaluated.
RESULTS. Of the 148 patients with history of cesarean section and technically adequate hysterosalpingograms, 89 (60%) had defects that were in the expected location of a hysterotomy incision. Fifty-eight (65%) of the diverticula were focal outpouchings, and 31 (35%) were thin linear defects. Forty-eight (54%) of the diverticula were located at the lower uterine cavity, 32 (36%) at the uterine isthmus, and nine (10%) at the upper endocervical canal.
CONCLUSION. A diverticulum at the lower uterine cavity, uterine isthmus, or upper endocervical canal is a common finding on hysterosalpingography in patients with a history of cesarean section.
Keywords: cesarean section • hysterosalpingography
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A urine pregnancy test (QuickVue One-Step hCG Urine Test, Quidel) was performed immediately before hysterosalpingography. Hysterosalpingography was performed in a standard fashion using sterile technique. The patient was placed in a lithotomy position and a vaginal speculum was inserted. After cleansing the external os with povidone-iodine solution, the cervical os was cannulated with a hystero salpingography balloon catheter (H/S Catheter, CooperSurgical; Silicone Balloon HSG Catheter, Cook; HSG & HyCoSy Catheter, Rocket Medical). A cervical tenaculum was not used. The balloon catheter was inflated within the endocervical canal or lower uterine cavity and contrast material injection was performed with C-arm fluoroscopic control (OEC 9800, GE Healthcare). Standard hystero salpingography was performed using iopromide (Ultravist-300 [300 mg I/mL], Bayer HealthCare). The balloon catheter was not routinely placed in the uterine cavity because it may prevent or obscure opacification of underlying pathology in the lower uterine segment.
A combination of pulse fluoroscopy (eight frames per second) and continuous fluoroscopy was used with automated exposure control. Static image capture was achieved by use of the fluoroscopic last-image-hold feature. Images of early and maximal opacification of the uterine cavity, fallopian tubes, and peritoneal contrast spillage were obtained. Oblique and craniocaudal C-arm angulations were used to obtain an en face view of the uterine cavity and fallopian tubes and for detailed evaluation of any abnormal findings. Fluoroscopy was performed using a 33-cm field of view.
Selective salpingography was performed in patients with proximal fallopian tube occlusion. A completion image was obtained after removal of the balloon catheter to assess for abnormalities in the lower uterine cavity and endocervical canal that may have been obscured by the presence of the balloon catheter. Selected static images were transferred to a PACS for review.
Of the 150 patients with a history of cesarean section, two patients had inadequate contrast opacification of the isthmus–endocervical canal during hysterosalpingography and were therefore excluded. The defects were categorized by location (lower uterine segment, uterine isthmus, upper endocervical canal), side (right, left, bilateral, small midline), and size. Defect size was categorized by the craniocaudal dimension of the defect: thin linear, small (< 5 mm), medium (5–9 mm), or large (> 9 mm). Measurements were made by using the electronic calipers on the PACS, with the hystero salpingo graphy catheter shaft width serving as a reference distance.
This retrospective HIPAA-compliant study was performed after the institutional review board deemed the study exempt from review and not to require patient informed consent.
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The diverticula appeared as focal outpouchings (n = 58, 65%) (Figs. 1, 2, and 3) and as thin linear defects (n = 31, 35%) (Fig. 4). The diverticula were located at the lower uterine segment (n = 48, 54%), at the uterine isthmus (n = 32, 36%), and at the upper endocervical canal (n = 9, 10%). The defects were unilateral (n = 41, 46%), bilateral (n = 41, 46%), and midline (n = 7, 8%). One patient with a small triangular-shaped outpouching defect had an associated prominence of the superior aspect of the defect resulting in narrowing at the uterine isthmus (Fig. 5). The appearance of the lower uterine cavity and endocervical canal in the six patients who had undergone multiple hysterosalpingography examinations did not change from initial to subsequent examinations.
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Cesarean section is the most commonly performed surgical procedure involving the uterus in the fertile women [1], with the low transverse incision being the most common type of uterine hysterotomy. In the interpretation of a hysterosalpingogram, awareness of the appearance of the cesarean scar defect is important in avoiding misdiagnosing the scar for underlying pathology or normal variants such as prominent cervical glands, postmyomectomy diverticulum, synechiae, and focal adenomyosis [2, 3].
Prominent cervical glands may appear as tubular symmetric structures that arise from both walls of the endocervical canal. The walls of the endocervical canal can either be smooth or corrugated in appearance, which represent the mucosal furrows known as plicae palmatae. Cervical glands may vary in appearance according to the individual patient and the phase of the menstrual cycle. The characteristic appearance of cervical glands as small tubular structures arising from both cervical walls helps in differentiating them from cesarean section scars.
Postmyomectomy diverticula will generally appear as small unilateral outpouching at the site of resection. Correlation with surgical history and location of the diverticula are differentiating factors that help distinguish this from a cesarean section scar defect.
Gartner's duct cysts are remnants of the wolffian duct that fail to normally resorb in women. These ducts can be unilateral or bilateral and are generally only seen if they communicate with the uterine cavity. They appear as long tubular structures that run parallel to the uterine cavity and occasionally can have a focal segment of saccular or cystic dilatation [3]. Visualization of a long contrast-filled tubular duct parallel to the uterus and possibly extending from a region of cystic dilatation is more characteristic of a Gartner's duct cyst and allows differentiation from a cesarean scar diverticulum.
Adenomyosis is a pathologic condition associated with ectopic endometrial extension into the myometrium. If the ectopic endometrial tissue communicates with the uterine cavity, adenomyosis can have the appearance of contrast-filled diverticula extending into the myometrium. Women with adenomyosis most often will present with pelvic pain, and generally these patients are diagnosed via sonography or MRI. Asymptomatic women evaluated for infertility may be incidentally diagnosed with adenomyosis on hysterosalpingography. Differentiating asymptomatic adenomyosis from a cesarean section scar will depend on location of the defect because the latter are confined to the lower uterine cavity–endocervical canal, whereas adenomyosis can occur anywhere along the uterine cavity.
Sixty percent of patients in our study with a history of cesarean section were found to have anatomic defects readily apparent on hysterosalpingography. Ninety percent of these cesarean section scar defects were located in the lower uterine cavity or uterine isthmus. The most common appearance of the defect was as a linear defect or small outpouching. Among patients with a small defect, one patient had an associated prominence of the superior aspect of the defect resulting in narrowing at the uterine isthmus that projected into the contrast-filled lumen (Fig. 5). This type of defect has been described as an "overhang" of congested endometrium above the scar recess, which has been seen on histopathologic evaluation of the cesarean scar [4]. A steep oblique or lateral view may be helpful in better defining this particular cesarean section scar because certain defects can be obscured on a frontal view.
In comparison with hysterosalpingographic diagnosis of cesarean scar defects, Regnard et al. [5] detected a similar rate of cesarean section scars (57.5%) via saline contrast sonohysterography. One clear limitation of hysterosalpingography is the inability to precisely measure myometrial thickness and the size of the scar, both of which can be readily characterized via sonohysterography. Regnard et al. measured the residual myometrium within the defect and quantified the extent of thinning and classified the most severe defects (those in which the depth was at least 80% of the anterior myometrium) as scar dehiscence [5]. In their series of 33 patients, they found a 6% rate of dehiscence, which is significantly higher than the reported rate of uterine rupture (0.4%) [5]. Coupled with the relatively common finding of a scar defect in patients with prior cesarean section (57.5%), it can be inferred that the mere presence of a defect is likely of little clinical significance unless myometrial thickness is quantified and "dehiscence" as defined by Regnard et al. [5] is identified. Further studies examining the relationship between myometrial thickness and long-term follow-up of these defects are warranted to assess the risks associated with severe myometrial thinning.
The reason certain patients have anatomic defects after cesarean section while other patients do not is unclear. Fabres et al. [6] suggested that the defect may be related to the suture material used, the suturing technique itself, or a combination of both. It is presumed that the most ischemic technique and slowest reabsorbable suture would be the worst combination and thus likely to produce a cesarean scar defect. Accumulation of blood or mucous in the scar may potentially obscure the defect on hysterosalpingography.
The clinical significance of a cesarean section scar defect is most often benign, although several authors have reported complications associated with the defect with respect to the very rare ectopic scar pregnancy and as a potential cause of intermenstrual bleeding [6–12]. Pregnancy after prior cesarean delivery requires attention during follow-up and subsequent pregnancy because of the potential risk of developing an ectopic pregnancy in the cesarean scar tissue and potential uterine rupture during labor [7–9].
The presence of a cesarean section scar has been implicated as an underrecognized cause of abnormal uterine bleeding in premenopausal women. Abnormal uterine bleeding is often associated with functional disorders of the menstrual cycle or intrauterine abnormalities such as polyps, submucous myomas, and endometrial hyperplasia. In many instances, these abnormalities cannot be identified, and some authors have suggested that the presence of a cesarean section scar is responsible [4]. Thurmond et al. [10] identified nine patients by sonohysterography with abnormal uterine bleeding secondary to a cesarean section scar.
Fabres et al. [6] examined 92 premenopausal patients with abnormal bleeding and found a high correlation on transvaginal sonography (with hysteroscopic correlation) between bleeding disturbances and the presence of a cesarean section scar. In addition, they found that larger scars corresponded to heavier and longer bleeding episodes. Menada Valenzano et al. [11] examined 217 women in a case-control study and found a significantly higher rate of abnormal uterine bleeding in patients who had a cesarean section versus vaginal delivery. In addition, they found a stronger correlation between abnormal intermenstrual bleeding and women who had cesarean sections 5–10 years prior than those whose surgeries were more recent. Thus, awareness of the presence of a cesarean section scar may help referring clinicians with diagnostic information that can elucidate the cause of abnormal uterine bleeding in premenopausal women.
One limitation of this study is the lack of follow-up of patients who were found to have cesarean section scar defects. The retrospective nature of this study limited evaluation of prospective potential symptoms experienced by patients such as abnormal uterine bleeding and problems associated with subsequent pregnancies. In the intake questionnaire administered to all patients before hysterosalpingography, the patient was not asked to list current clinical symptoms, if present. In addition, the patient was not asked for the precise number of prior cesarean sections. Without knowing the number of prior cesarean sections a patient had undergone, we were unable to evaluate the relationship between the size of the defect and the number of prior cesarean sections. Waniorek [12] has shown that the severity of the scar is directly proportional to the number of cesarean sections. Another limitation of this study was the lack of correlation between a cesarean scar defect detected on hysterosalpingography with evidence for quantifiable myometrial thinning. Further investigation correlating the hysterosalpingogram scar defect with follow-up sonohysterography, MRI, or histopathologic measurement of myometrial thickness is warranted.
Hysterosalpingography is an important component in the evaluation of the infertile patient. To the best of our knowledge, this is the first large-scale characterization in the English-language literature of the incidence, location, and appearance of uterine scar defects secondary to prior cesarean section on hysterosalpingography. Patients who have had a cesarean section will exhibit anatomic abnormalities in the lower uterine segment [9]. The presence and location of a cesarean section scar may rarely impact patient care with respect to potential uterine perforation during instrumentation and the rare occurrence of a cesarean scar ectopic pregnancy after in vitro fertilization. In addition, the presence of a cesarean section scar may represent a cause of abnormal uterine bleeding, a common gynecologic complaint. The clinical significance of the scar in asymptomatic women is most likely benign, although further investigation is needed to establish this. Thus, the presence of an anatomic uterine defect in patients with a history of cesarean section is a common, expected finding with a relatively typical appearance and location.
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