Hysteroscopic management of symptomatic fibrosed cervical stenosis associated with Caesarean scar defect (CSD)
Megan Ruien Ling1, Dr Hui Min Angela Ho2, Dr Shahul Hameed Mohamed Siraj2, Associate Professor Bernard Chern Su Min2
1Yong Loo Lin School of Medicine, National University of Singapore, Department of Minimally Invasive Surgery, Division of Obstetrics and Gynaecology, K. K. Women’s and Children’s Hospital, Singapore
Introduction
•Uterine cervical stenosis is difficult to diagnose as patients present heterogeneously. [1]
•CSDs are often overlooked as a potential cause despite rising rates of lower segment Caesarean Section (LSCS) globally. [2]
•In this series, we present three cases of symptomatic cervical stenosis secondary to CSD to provide useful insights into the risk factors, presentation and novel hysteroscopic treatment of uterine cervical stenosis secondary to CSD fibrosis.
Case Presentations
(tables)
Discussion
1.Revising risk factors for Cervical Stenosis – Individuals receiving exclusive LSCS deliveries are more prone to cervical stenosis
•Traditionally, the lower uterine segment scar post-LSCS is limited to the uterine cervical isthmus. [3] However, thinning and fibrosis of the posterior and lateral uterine muscle layers have also been observed during caesarean scar repairs and in Case 1. [4]
•Proposed mechanism of fibrosis: uterine stretch and expansion during pregnancy
•Tissue microtrauma à superficial translocation of basal endometrial fragments àinvagination into the myometrium through microdehiscences in the endometrial-myometrial junctional zone à fibrosis and scar formation. [5]
•This invagination also causes adenomyosis, and may explain the association between adenomyosis and larger Caesarean Scar defects. [5, 6]
•Most significant at cervix: Quick rate and extent of cervical effacement, and will be clinically significant as the narrowest portion of the uterus
•Risk factors for presenting with symptomatic cervical stenosis: Exclusive LSCS Deliveries
•With normal vaginal delivery: significant cervical dilation by infant through the birth canal during labour
•With LSCS: Cervical distension equivalent to nulliparous women, but confounded by cervical fibrosis secondary to microdehiscence in pregnancy
•Similar case by Thomas et al: Cervical stenosis and haematometra post-LSCS in a 36-year-old lady with exclusive LSCS deliveries [7]
2. Unique sonographic presentation of Cervical Stenosis
•All patients presented with haematotracheolos, distal to the area of stenosis in the internal os.
•Proposed explanation: Haematotracheolos is a milder phenotype of cervical stenosis
•In post-exclusive LSCS patients, the fibrosed internal os and stenosed external os create a pathological sealed compartment within the endocervical canal, causing poor drainage of cervical secretions and menstrual blood.
•While this also occurs in the endometrial cavity, the sealed endocervical canal is a smaller compartment that is more easily distensible.
•Case 2, who reported a longer history of menstrual abnormalities (more advanced cervical stenosis), presented with haematometra and haematotracheolos.
3. Novel hysteroscopic approach to treatment to minimize complications
•While hysteroscopy is the gold standard treatment for cervical stenosis, it paradoxically increases the risk of post-instrumentation cervical stenosis. [1,8]
•In case 1, we employed temporary stenting with a Foley catheter for 7 days after hysteroscopy and limited scar resection to prevent complications
•Well tolerated by patient – mild abdominal cramping, which abated following removal during post-operative review
•Witt et al: Successful temporary stenting with nasopharyngeal airway
•However, an indwelling Foley catheter is more secure (longer, balloon component), cheaper and more accessible within the gynaecological operating theatre
•Optimal duration of stenting remains elusive, and requires further investigation
Conclusion
•With the rise of LSCS, the incidence of uterine cervical stenosis will follow. [3]
•Our study proposes more specific risk factors, early clinical manifestations and a novel treatment method, which are not widely available in literature.
References
1. Vitale SG, De Angelis MC, Della Corte L, Saponara S, Carugno J, Laganà AS, Török P, Tinelli R, Pérez-Medina T, Ertas S et al: Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity. Arch Gynecol Obstet 2024, 309(3):755-764.
2. Angolile CM, Max BL, Mushemba J, Mashauri HL: Global increased cesarean section rates and public health implications: A call to action. Health Sci Rep 2023, 6(5):e1274.
3. Sholapurkar SL: Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate. J Clin Med Res 2018, 10(3):166-173.
4. Siraj SHM, Lional KM, Tan KH, Wright A: Repair of the myometrial scar defect at repeat caesarean section: a modified surgical technique. BMC Pregnancy Childbirth 2021, 21(1):559.
5. Kobayashi H, Kishi Y, Matsubara S: Mechanisms Underlying Adenomyosis-Related Fibrogenesis. Gynecol Obstet Invest 2020, 85(1):1-12.
6. ShakkiKatouli F, Zebardast J, Tavoli Z, Bayani L, Azizinik F, Moradpour M, Mardani R, Meimani N, Fathi S: Evaluation of Association Between Adenomyosis and Cesarean Scar Defect. J Ultrasound Med 2024, 43(3):553-560.
7. Thomas S, Roy P, Biswas B, Jose R: Complete Cervical Stenosis Following Cesarean Section & VVF Repair. J Obstet Gynaecol India 2012, 62(Suppl 1):49-51.
8. Di Spiezio Sardo A, Taylor A, Tsirkas P, Mastrogamvrakis G, Sharma M, Magos A: Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies. Fertil Steril 2008, 89(2):438-443.
