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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Reclosure of scar
A two-layered, running, nonlocking suture is performed with 2–0 and 3–0 Vicryl
®
suture (Ethicon, Inc., Somerville, NJ).
Careful attention should be made to reapproximate the endometrial edges.
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Reapproximation of bladder flap
The bladder flap should be reapproximated, but not advanced upward onto the lower uterine segment of the uterus.
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Hysteroscopic visuali zati on of repaired defect
If a hysteroscope was used to identify the defect, visualization of the repaired defect can be performed. Absence of fluid
leaking through the repair assures adequate approximation of the hysterotomy incision.
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PEARLS AND PITFALLS
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POSTOPERATIVE CARE
We advise the patient to delay conception for 3 months following the repair. A postoperative saline infusion
hysterosonography can be performed to ensure the completeness of the repair.
When future pregnancy is achieved, we recommend liberal use of ultrasound to rule out an ectopic gestation at the site of
the repair and/or abnormal placentation.
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OUTCOMES
Repair of the scar defect can ameliorate pain and bleeding symptoms and restore fertility.
Paucity of data.
Small cohort studies reported.
9
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COMPLICATIONS
Residual defect
Intrauterine scarring
Perform saline infusion sonography after repair of a PCSD to assess both any residual defect and/or intrauterine scarring.
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KEY REFERENCES
1. Schepker N, Garcia-Rocha G-J, von Versen-Hoynck F, et al. Clinical diagnosis and therapy of uterine scar defects after
caesarean section in non-pregnant women. Arch Gynecol Obstet. 2015;291:1417–1423.
2. Api M, Boza A, Gorgen H, et al. Should cesarean scar defect be treated laparoscopically? A case report and review of
the literature. J Minim Invasive Gynecol. 2015;22(7):1145–1152.
3. Li C, Guo Y, Liu Y, et al. Hysteroscopic and laparoscopic management of uterine defects on previous cesarean delivery
scars. J Perinat Med. 2014;42(3):363–370.
4. Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, et al. Why do niches develop in Caesarean uterine scars? Hypotheses
on the aetiology of niche development. Hum Reprod. 2015;30(12):2695–2702.
5. Bij de Vaate AJ, van der Voet LF, Naji O, et al. Prevalence, potential risk factors for development and symptoms related
to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet Gynecol.
2014;43(4):372–382.
6. Allornuvor GF, Xue M, Zhu X, et al. The definition, aetiology, presentation, diagnosis and management of previous
caesarean scar defects. J Obstet Gynaecol. 2013;33(8):759–763.
7. Jacobson MT, Osias J, Velasco A, et al. Laparoscopic repair of a uteroperitoneal fistula. JSLS. 2003;7:367–369.
8. Nezhat C, Grace L, Soliemannjad R, et al. Cesarean scar defect: What is it and how should it be treated? OBG Manag.
2016;28:32–53.
9. Florio P, Filippeschi M, Moncini I, et al. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring fertility.
Curr Opin Obstet Gynecol. 2012;24(3):180–186.
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Chapter 3.3
Excision of Uterine Septum
Travis W. M cCoy, Steve n T. Nak ajima
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GENERAL PRINCIPLES
Definition
Uterine anomalies occur in up to 5% of women, with approximately one-third of these being septated uteri.
1
,
2
A septate uterus
is typically defined as having a fundal indentation of the uterine cavity >1.5 cm. Uterine septa are associated with miscarriage
and preterm birth, with insufficient data linking to infertility. Even small septa of between 1 and 1.5 cm are associated with a
significant increase in preterm birth.
3
While randomized controlled trials are lacking, there is evidence that suggests that
treatment of a septum improves live birth rates, lowers miscarriage rates and preterm birth rates in women with infertility, and
prior miscarriage.
3,4
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