子宫瘢痕憩室病理学变化与并发症的关系

doi:10.12280/gjfckx.20220210

摘要/Abstract

摘要：

子宫瘢痕憩室（caesarean scar defect，CSD）是指剖宫产术后子宫瘢痕的肌层缺损，使子宫内膜层向肌层突起，形成凹陷。由于瘢痕处愈合不良形成了异常的解剖学结构，并随着时间的推移而发生了一系列的病理学变化，如纤维组织的增生、迂曲血管的形成、激素受体的分布不均、炎症环境的出现及其他合并症等。CSD的病理学变化往往引起异常阴道出血、继发性不孕、痛经及慢性盆腔痛等并发症，影响女性的生活质量，给有生育要求的患者造成了极大的困扰。因此，CSD的诊治在临床工作中是不容忽视的。分析CSD形成的临床相关因素，探讨发生CSD病理学改变的危险因素，从而进一步明确CSD病理学变化与不同并发症的关系，更好地预防与诊治CSD及其并发症。

关键词: 子宫, 瘢痕, 憩室, 剖宫产术, 子宫出血, 不孕, 痛经, 子宫内膜异位症

Abstract:

Caesarean scar defect (CSD) refers to the myometrial defect of the uterine scar after cesarean section, which causes the endometrial layer protrude to the myometrium and form a depression. Abnormal anatomical structures are formed due to poor healing of the scar, and a series of pathological changes have occurred over time, such as proliferation of fibrous tissue, formation of tortuous blood vessels, uneven distribution of hormone receptors, and inflammatory environment and other comorbidities. The pathological changes of CSD often cause complications such as abnormal vaginal bleeding, secondary infertility, dysmenorrhea and chronic pelvic pain, which affect the quality of life of women and cause great distress to patients with fertility requirements. Therefore, the diagnosis and treatment of CSD cannot be ignored in clinical work. The clinical related factors of CSD formation were analyzed, and the risk factors of CSD pathological changes were explored, so as to further study the relationship between CSD pathological changes and different complications, and better prevent, diagnose and treat CSD and its complications.

Key words: Uterus, Scar, Diverticulum, Cesarean section, Uterine hemorrhage, Infertility, Dysmenorrhea, Endometriosis

王亚楠, 王琳, 陈亚慧, 董燕, 周燕, 孙琳. 子宫瘢痕憩室病理学变化与并发症的关系[J]. 国际妇产科学杂志, 2022, 49(6): 699-703.

WANG Ya-nan, WANG Lin, CHEN Ya-hui, DONG Yan, ZHOU Yan, SUN Lin. The Relationship between Pathological Changes and Complications of Caesarean Scar Defect[J]. Journal of International Obstetrics and Gynecology, 2022, 49(6): 699-703.

参考文献 31

[1]	Stupak A, Kondracka A, Fronczek A, et al. Scar Tissue after a Cesarean Section-The Management of Different Complications in Pregnant Women[J]. Int J Environ Res Public Health, 2021, 18(22):11998. doi: 10.3390/ijerph182211998. doi: 10.3390/ijerph182211998
[2]	Vikhareva Osser O, Valentin L. Risk factors for incomplete healing of the uterine incision after caesarean section[J]. BJOG, 2010, 117(9):1119-1126. doi: 10.1111/j.1471-0528.2010.02631.x. doi: 10.1111/j.1471-0528.2010.02631.x
[3]	Ben-Nagi J, Walker A, Jurkovic D, et al. Effect of cesarean delivery on the endometrium[J]. Int J Gynaecol Obstet, 2009, 106(1):30-34. doi: 10.1016/j.ijgo.2009.02.019. doi: 10.1016/j.ijgo.2009.02.019 pmid: 19356756
[4]	Tang X, Wang J, Du Y, et al. Caesarean scar defect: Risk factors and comparison of evaluation efficacy between transvaginal sonography and magnetic resonance imaging[J]. Eur J Obstet Gynecol Reprod Biol, 2019, 242:1-6. doi: 10.1016/j.ejogrb.2019.09.001. doi: S0301-2115(19)30403-8 pmid: 31520876
[5]	Liu S, Chen L, Zhu G, et al. Analysis of risk factors for cesarean scar diverticulum: A STROBE-compliant case-control study[J]. Medicine(Baltimore), 2021, 100(17):e25757. doi: 10.1097/MD.0000000000025757. doi: 10.1097/MD.0000000000025757
[6]	Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, et al. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development[J]. Hum Reprod, 2015, 30(12):2695-2702. doi: 10.1093/humrep/dev240. doi: 10.1093/humrep/dev240
[7]	Ofili-Yebovi D, Ben-Nagi J, Sawyer E, et al. Deficient lower-segment Cesarean section scars: prevalence and risk factors[J]. Ultrasound Obstet Gynecol, 2008, 31(1):72-77. doi: 10.1002/uog.5200. doi: 10.1002/uog.5200
[8]	Di Spiezio Sardo A, Saccone G, McCurdy R, et al. Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials[J]. Ultrasound Obstet Gynecol, 2017, 50(5):578-583. doi: 10.1002/uog.17401. doi: 10.1002/uog.17401 pmid: 28070914
[9]	Pomorski M, Fuchs T, Rosner-Tenerowicz A, et al. Morphology of the cesarean section scar in the non-pregnant uterus after one elective cesarean section[J]. Ginekol Pol, 2017, 88(4):174-179. doi: 10.5603/GP.a2017.0034. doi: 10.5603/GP.a2017.0034 pmid: 28509317
[10]	Antila-Långsjö RM, Mäenpää JU, Huhtala HS, et al. Cesarean scar defect: a prospective study on risk factors[J]. Am J Obstet Gynecol, 2018, 219(5):458.e1-458.e8. doi: 10.1016/j.ajog.2018.09.004. doi: 10.1016/j.ajog.2018.09.004
[11]	Abdull Gaffar B, Almulla A. A Histopathologic Approach to Uterine Niche: What to Expect and to Report in Hysteroscopy-Resected Isthmocele Specimens[J]. Int J Surg Pathol, 2022, 30(3):240-250. doi: 10.1177/10668969211039415. doi: 10.1177/10668969211039415
[12]	Chen YY, Tsai CC, Kung FT, et al. Association between hysteroscopic findings of previous cesarean delivery scar defects and abnormal uterine bleeding[J]. Taiwan J Obstet Gynecol, 2019, 58(4):541-544. doi: 10.1016/j.tjog.2019.05.020. doi: 10.1016/j.tjog.2019.05.020
[13]	Fan Y, Sun J, Zhang Q, et al. Transplantation of human amniotic epithelial cells promotes morphological and functional regeneration in a rat uterine scar model[J]. Stem Cell Res Ther, 2021, 12(1):207. doi: 10.1186/s13287-021-02260-6. doi: 10.1186/s13287-021-02260-6 pmid: 33762002
[14]	Donnez O. Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased[J]. Fertil Steril, 2020, 113(4):704-716. doi: 10.1016/j.fertnstert.2020.01.037. doi: S0015-0282(20)30083-2 pmid: 32228874
[15]	Al Naimi A, Wolnicki B, Mouzakiti N, et al. Anatomy of the sonographic post-cesarean uterus[J]. Arch Gynecol Obstet, 2021, 304(6):1485-1491. doi: 10.1007/s00404-021-06074-y. doi: 10.1007/s00404-021-06074-y pmid: 33891206
[16]	El-Toukhy T. Treatment of post-caesarean niche: the accumulation of evidence[J]. BJOG, 2018, 125(3):335. doi: 10.1111/1471-0528.14733. doi: 10.1111/1471-0528.14733
[17]	毛萌, 郭瑞霞. 基于病理变化创新治疗剖宫产切口瘢痕缺损的新术式[J]. 中国实用妇科与产科杂志, 2021, 37(7):707-710. doi: 10.19538/j.fk2021070105. doi: 10.19538/j.fk2021070105
[18]	宋晓珊, 杨炳. 子宫切口瘢痕憩室所致异常子宫出血的临床研究[J]. 贵州医药, 2021, 45(2):180-182. doi: 10.3969/j.issn.1000-744X.2021.02.004. doi: 10.3969/j.issn.1000-744X.2021.02.004
[19]	Xin L, Lin X, Pan Y, et al. A collagen scaffold loaded with human umbilical cord-derived mesenchymal stem cells facilitates endometrial regeneration and restores fertility[J]. Acta Biomater, 2019, 92:160-171. doi: 10.1016/j.actbio.2019.05.012. doi: S1742-7061(19)30327-7 pmid: 31075515
[20]	He X, YAN L, HE C, et al. The effect of a hysteroscopic niche resection compared with Levonorgestrel-releasing intrauterine device on postmenstrual spotting in patients with a symptomatic niche in the uterine cesarean scar: A prospective cohort study[J]. Eur J Obstet Gynecol Reprod Biol, 2021, 265:66-73. doi:10.1016/j.ejogrb.2021.08.014. doi: 10.1016/j.ejogrb.2021.08.014 pmid: 34461384
[21]	Karpathiou G, Chauleur C, Dridi M, et al. Histologic Findings of Uterine Niches[J]. Am J Clin Pathol, 2020, 154(5):645-655. doi: 10.1093/ajcp/aqaa080. doi: 10.1093/ajcp/aqaa080 pmid: 32561918
[22]	Shapira M, Mashiach R, Meller N, et al. Clinical Success Rate of Extensive Hysteroscopic Cesarean Scar Defect Excision and Correlation to Histologic Findings[J]. J Minim Invasive Gynecol, 2020, 27(1):129-134. doi: 10.1016/j.jmig.2019.03.001. doi: 10.1016/j.jmig.2019.03.001
[23]	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[J]. Ultrasound Obstet Gynecol, 2014, 43(4):372-382. doi: 10.1002/uog.13199. doi: 10.1002/uog.13199 pmid: 23996650
[24]	Bi B, Gao S, Ruan F, et al. Analysis on clinical association of uterine scar diverticulum with subsequent infertility in patients underwent cesarean section[J]. Medicine(Baltimore), 2021, 100(41):e27531. doi: 10.1097/MD.0000000000027531. doi: 10.1097/MD.0000000000027531
[25]	Hsu I, Hsu L, Dorjee S, et al. Bacterial colonization at caesarean section defects in women of secondary infertility: an observational study[J]. BMC Pregnancy Childbirth, 2022, 22(1):135. doi: 10.1186/ s12884-022-04471-y. doi: 10.1186/ s12884-022-04471-y
[26]	Li Z, Bian X, Ma Y, et al. Uterine Scarring Leads to Adverse Pregnant Consequences by Impairing the Endometrium Response to Steroids[J]. Endocrinology, 2020, 161(11):bqaa174. doi: 10.1210/endocr/bqaa174. doi: 10.1210/endocr/bqaa174
[27]	Lu X, Ma Y, Wang Y. Cesarean scar epithelial defect: an underrecognized defect associated with abnormal uterine bleeding[J]. Am J Obstet Gynecol, 2020, 223(6):923-924. doi: 10.1016/j.ajog.2020.04.018. doi: 10.1016/j.ajog.2020.04.018 pmid: 32335052
[28]	Gulz M, Imboden S, Nirgianakis K, et al. Endometriosis and Isthmocele: Common or Rare?[J]. J Clin Med, 2022, 11(5):1158. doi: 10.3390/ jcm11051158. doi: 10.3390/ jcm11051158
[29]	Donnez J. An update on uterine cervix pathologies related to infertility[J]. Fertil Steril, 2020, 113(4):683-684. doi: 10.1016/j.fertnstert.2020.02.107. doi: S0015-0282(20)30237-5 pmid: 32228872
[30]	García-Solares J, Donnez J, Donnez O, et al. Pathogenesis of uterine adenomyosis: invagination or metaplasia?[J]. Fertil Steril, 2018, 109(3):371-379. doi: 10.1016/j.fertnstert.2017.12.030. doi: S0015-0282(17)32177-5 pmid: 29566849
[31]	Dosedla E, Gál P, Calda P. Association between deficient cesarean delivery scar and cesarean scar syndrome[J]. J Clin Ultrasound, 2020, 48(9):538-543. doi: 10.1002/jcu.22911. doi: 10.1002/jcu.22911