Protocol

• 1. Assessment ofTransvaginal Repairof Caesarean SectionScar Defects

2. Protocol of thesisSubmitted For Partial Fulfillment of the PhDDegreeIn Obstetrics and GynecologyByMohamad Saad Bedeir HamedMaster Degree ofObstetrics & Gynecology, Al Azhar University(2014) 3. Supervised ByProf. Reffat AlsheemyProfessor of Obstetrics and GynecologyAl Azhar faculty of medicine DamiettaDr. Ibrahim Ramadan AlsawyLecturer in Obstetrics and GynecologyAl Azhar faculty of medicine Damietta 4. Introduction:Over the past decade, with the increase in cesareansection rate and improvement in diagnosticmodalities, the incidence of previous cesarean scardefect (PCSD) is increasing, and in randompopulations it was present in 2469% of womenevaluated with transvaginal sonography (Van der etal., 2014). 5. Introduction:Definition and symptoms:Previous cesarean section scar defect (PCSD), alsoknown as previous cesarean scar diverticulum, isdefined as deficient uterine scars or scar dehiscencefollowing a cesarean section, which involves themyometrial discontinuity at the cesarean scar(Borges et al., 2010).PCSD is a serious complication of cesareansection. PCSD has been reported to be associatedwith prolonged postmenstrual bleeding,dysmenorrhea, abnormal uterine bleedingthroughout menstrual cycle, infertility and deepdyspareunia (Tower and Frishman, 2013). 6. Introduction:Diagnosis:Caesarean section scar defects can be detected attransvaginal unenhanced ultrasound examinationand the best time to visualize the cesarean sectionscar defect is mid-cyclic as the cervical mucus acts asa good contrast media (Al sheimy et al., 2014). 7. Introduction:Diagnosis:Saline contrast sonohysterography (SCSH) has beenshown to be useful for assessing the uterine cavity, inparticular for detecting and evaluating thePCSD (Monteagudo et al., 2001).Hysterosalpingography (HSG) evaluates the frequencyand appearance of uterine cavity anatomic defects inpatients with a history of cesarean section(Krishna et al., 2008). 8. Introduction:Diagnosis:Hysteroscopic assessment of PCSD is alsodocumented to be a good way for detection andevaluation (Fabres et al., 2003). 9. Introduction:Treatment:Due to the unclear pathogenesis of PCSD, its treatmenthas yet been elucidated.Although oral contraceptives (OC) may result in thetemporary improvement in symptoms but manypatients cannot their adverse effects (Tahara et al.,2006).An abdominal approach (laparoscopic) to repair theuterine defect can completely correct the defect butits invasiveness and complications significantlyrestrain its wide application in clinical practice(Demers et al., 2013) 10. Introduction:Treatment:Hysteroscopic treatment has been introduced inrecent years depends on electro cautery of dilatedblood vessels, endometrial like tissues, with removalof fibrotic scar and debris in the roof of the pouch(Feng et al., 2012) and (Li et al., 2013)However, the clinical improvement rate is just59.6% after hysteroscopic treatment and the cause offailure is still unknown (Wang et al., 2011). 11. Introduction:Treatment:To the best of our knowledge, there are only twowide studies have been reported in China toinvestigate the transvaginal management of PCSD(Luo et al., 2012) and (Yuqing et al., 2014).Both studies revealed that transvaginal repair ofPCSD is a safe method but both have a leaking thepostoperative follow up and both reported removal ofthe total edge of the PCSD by excision of the fibrotictissue during repair, A 22% failure rate was reportedin both studies. 12. Introduction:Treatment:In this study we will try a novel approach thatavoiding complete excision of the residual healthymyometrium and only remove the necrotic tissues inthe cavity of the PCSD creating a row area that mayfacilitate the healing process after stitching thedefect. 13. Aim of the work:To evaluate the repair of caesarean section scardefect in symptomatic patients throughtransvaginal novel surgical approachdepending on creating a row area byendometrial curettage to the roof of the PCSDand follow up of the cases as regard outcome. 14. Patients and Methods:This prospective clinical observational study willbe conducted in obstetrics and gynecologydepartment, Al Azhar University hospital (NewDamietta), at the period from November 2014. 15. Patients and Methods: 16. Patients and Methods:Inclusion criteriaAll women who have at least one of the followingsymptoms (dysmenorrhea, pelvic pain, deepdyspareunia, unexplained infertility for more thantwo years, prolonged postmenstrual bleeding orpostmenstrual intermittent bleeding) provided thatpresence of all of the following conditions: At least one previous caesarean section for more than oneyear. Caesarean section scar defect measures more than 4mmbase length and 6mm depth. 17. Patients and Methods: 18. Patients and Methods:Exclusion criteriaAll women with any of the following must be excluded All pregnant women. Asymptomatic patients with PCSD. Irregular menstrual cycle before Caesarian section. Caesarian section less than one year. PCSD equal or less than 4mm base length and 6mm depth. Presence of other organic uterine pathology responsible forabnormal uterine bleeding, such as endometrialhyperplasia, polyps, malignancy, cervical atypia or submucosal myomas. 19. Patients and Methods: 60 women will be recruited in this study from theoutpatient gynecological clinic at Al Azhar universityhospital in New Damietta City. The study will be conducted after agreement of thescientific medical and ethics committee at ourdepartment Careful history taking to check for inclusion andexclusion criteria according to a standardizedresearch protocol. 20. Patients and Methods: The diagnosis will be confirmed on the basis ofmedical history, clinical symptoms (postmenstrualspotting), transvaginal ultrasonography (TVU) andhysteroscopy or MRI in selected cases. The purpose of the study will be explained to allpatients and written consent will be taken. Proper preparation of the patients for operation(Basic preoperative investigation, misoprostol takingand Pap smear if not done in the past year). 21. Patients and Methods:Operative ProceduresOperative procedures All procedures will be done under general anesthesia. All patients will place in a dorsal lithotomy position Evacuation of the bladder. Measuring the length of the cervix by sound will bedone Endometrial curettage with special stress on thecavity of the PCSD which usually identified and feltduring curettage will be done firstly for making a rawarea at the caesarian section scar defect which willhelp in the process of healing. 22. Patients and Methods:Operative Procedures Pair of vaginal retractors will be placed to the vaginalwall to expose the cervix. A Vulsellum will be used to grasp and retract thecervix. 23. Patients and Methods:Operative Procedures An incision will be made at the anterior cervico-vaginaljunction, and the bladder will be dissected away two cm abovethe level of internal os. 24. Patients and Methods:Operative Procedures The anterior drawing retractor will be inserted to thevaginal incision to retract the bladder upwards. Thedefect will locate in the previous cesarean incision,where the residual myometrium was thin. 25. Patients and Methods:Operative Procedures With the guidance of a dilator or sound in the uterus, asmall hollow or depression will be identified in theanterior wall of the lower uterus above the internal orificeof the cervix. 26. Patients and Methods:Operative Procedures Then repair of the defect will be easily by suturing ininterrupted manner by absorbable sutures. 27. Patients and Methods:Follow up Clinically improvement will be observed for threemonth by Telephoning the patient and transvaginalultrasonography twice weekly. Three months later hysteroscopic assessment toevaluate the defect will be done. After six month post operatively all patients will beevaluated clinically and ultrasonographicaly toestimate the degree of women satisfaction. 28. Patients and Methods: The collected data will be organizing, tabulating andstatistically analyzing using Statistical Package for SocialScience (SPSS) version 16 (SPSS Inc, USA).