Brochure colorectale chirurgie - vakgroep Chirurgie, Ziekenhuis Rivierenland ...Chirurgen Tiel
De chirurgen van de afdeling colorectale chirurgie zijn gespecialiseerd in behandelingen van aandoeningen van het colon, rectum en de anus. In deze brochure vertellen wij u over onze expertise en de technieken die wij hanteren.
This document discusses Cesarean Section Scar Defects (CSDs). It provides information on:
- The definition and types of CSDs including thin linear defects, focal outpouching, and diverticula.
- Risk factors for incomplete healing including advanced labor, multiple C-sections, and surgical technique.
- Long term complications such as abnormal bleeding, pain, and difficulties with future procedures.
- Diagnostic tools like transvaginal ultrasound, saline sonohysterography, and hysterosalpingography.
- Surgical repair techniques including laparoscopic excision, resectoscopic treatment, and combined approaches.
Morbidly Adherent Placenta and Peripartum HysterectomyAnkur Shah
This document describes a case of a 25-year-old woman who was 38 weeks pregnant with her second child. She had a previous cesarean delivery and was diagnosed with placenta praevia and placenta increta for her current pregnancy. She underwent a planned cesarean section and peripartum hysterectomy due to life-threatening bleeding from the morbidly adherent placenta that could not be removed manually. The surgery was successful and she recovered well after receiving multiple blood transfusions.
Brochure colorectale chirurgie - vakgroep Chirurgie, Ziekenhuis Rivierenland ...Chirurgen Tiel
De chirurgen van de afdeling colorectale chirurgie zijn gespecialiseerd in behandelingen van aandoeningen van het colon, rectum en de anus. In deze brochure vertellen wij u over onze expertise en de technieken die wij hanteren.
This document discusses Cesarean Section Scar Defects (CSDs). It provides information on:
- The definition and types of CSDs including thin linear defects, focal outpouching, and diverticula.
- Risk factors for incomplete healing including advanced labor, multiple C-sections, and surgical technique.
- Long term complications such as abnormal bleeding, pain, and difficulties with future procedures.
- Diagnostic tools like transvaginal ultrasound, saline sonohysterography, and hysterosalpingography.
- Surgical repair techniques including laparoscopic excision, resectoscopic treatment, and combined approaches.
Morbidly Adherent Placenta and Peripartum HysterectomyAnkur Shah
This document describes a case of a 25-year-old woman who was 38 weeks pregnant with her second child. She had a previous cesarean delivery and was diagnosed with placenta praevia and placenta increta for her current pregnancy. She underwent a planned cesarean section and peripartum hysterectomy due to life-threatening bleeding from the morbidly adherent placenta that could not be removed manually. The surgery was successful and she recovered well after receiving multiple blood transfusions.
Fairmonte 2014 treatment of niche asogicMohamad Saad
This document discusses cesarean scar defects and various treatment methods. It describes three studies conducted on this topic. The first study found that 22% of women with a previous cesarean section had a scar defect, which were associated with symptoms like abnormal bleeding and pain. Defects higher in the uterus were more symptomatic. The second study evaluated vaginal ligation of the uterine artery to treat bleeding from scar defects, finding it effective with few complications. The third study assessed transvaginal repair of scar defects in 22 infertile women, finding it addressed symptoms and improved scar dimensions.
This document outlines a study protocol to evaluate a novel transvaginal surgical approach for repairing caesarean section scar defects. The study will recruit 60 symptomatic women to undergo transvaginal repair involving endometrial curettage of the scar defect cavity and suturing of the defect. Patients will be followed for 6 months with clinical and ultrasound evaluations at regular intervals to assess outcomes. The goal is to evaluate if this approach can effectively repair scar defects while avoiding complete excision of healthy myometrium.
This document outlines 10 ways for pregnant women to avoid an unnecessary cesarean delivery. It discusses the rising cesarean rate in the US and some of the contributing factors, such as fear of lawsuits and physician convenience. It provides tips for women before and during labor to reduce the chances of a cesarean, such as educating themselves, carefully selecting providers, avoiding inductions when possible, and asking questions during labor about alternatives to surgery. The document concludes that open communication between patients and providers is key to avoiding unnecessary cesareans.
This document provides information on performing a Cesarean section (C-section). It begins by defining a C-section and explaining the different types based on gestational age. It then discusses techniques to reduce operating time and costs. Common causes of C-sections are listed, along with reasons for increasing C-section rates. Preoperative testing, positioning, catheterization, skin preparation, draping, and abdominal entry techniques are outlined. Regional versus general anesthesia options are presented. The document concludes by describing uterine incision techniques and addressing central placenta praevia.
This document discusses ureteric injuries that can occur during gynecological surgeries. It notes that the most common site of injury is near the pelvic brim at the infundibulopelvic ligament. The most common type of injury is obstruction and the most common cause is attempts to obtain hemostasis. It provides details on the anatomy of the ureter and risk factors for injury. Preventive strategies discussed include preoperative imaging, adequate exposure during surgery, and avoiding blind clamping of vessels near the ureter. Treatment depends on the severity, location, and timing of diagnosis of the injury. Options include conservative management, delayed repair, or immediate reoperation.
This document discusses ureteric injury as a complication of gynecologic surgery. It covers the incidence, risk factors, applied anatomy of the pelvic ureter, common sites of injury, prevention strategies, and management approaches. Ureteric injury can occur in 0.03-6% of hysterectomies, with laparoscopic hysterectomy having the highest risk. The pelvic ureter has variable anatomy and is susceptible to injury at sites like the pelvic brim. Prevention focuses on proper identification and dissection of the ureter during surgery. Management depends on the severity and timing of injury but may involve stenting, urinary diversion, or ureteral reimplantation
This presentation aims to explain the anatomical features and clinical implications of the lower uterine segment (LUS). The LUS is the part of the uterus between the attachment of the peritoneum superiorly and the internal cervical os inferiorly. It contains less muscle fibers and blood vessels than the upper segment. During pregnancy, the LUS stretches to form the lower part of the uterine cavity in the third trimester. Placental attachment to the LUS can lead to bleeding risks as the area thins in preparation for labor. The LUS is the site of incision for caesarean sections due to its weaker muscles and blood supply.
This document discusses vaginal birth after cesarean (VBAC) and elective repeat cesarean delivery (ERCD). It begins by outlining the history of the "once a cesarean, always a cesarean" dictum and subsequent research challenging this view. It then compares the risks and benefits of VBAC versus ERCD. Key points include a VBAC success rate of 60-80% and increased risks of uterine rupture and emergency cesarean with VBAC. Factors affecting VBAC likelihood of success and failure are also reviewed. The document provides guidance on candidate selection and counseling for VBAC.
This case report describes a caesarean scar ectopic pregnancy in a 28-year old woman with two previous caesarean deliveries. Ultrasound found the gestational sac located in the lower uterine segment within the region of the previous caesarean scar. 3D imaging confirmed these findings. The differential diagnosis considered cervical ectopic pregnancy and missed abortion but color Doppler showed peripheral flow around the sac, confirming a caesarean scar ectopic pregnancy. Early detection of caesarean scar ectopic pregnancies by ultrasound is important to reduce risks of complications like hemorrhage which can require emergency hysterectomy.
The document discusses the pelvic ureter and prevention of ureteric injuries during pelvic surgery. It provides details on the anatomy of the pelvic ureter and sites where it is vulnerable to injury. Ureteric injuries can occur during abdominal or vaginal hysterectomy or other pelvic operations, with an incidence ranging from 0.4-2.5% for benign conditions and up to 30% for malignancies. Preventive measures include adequate exposure of the ureter during surgery, identification of its location using surrounding structures as guides, and avoidance of blind clamping or coagulation near the ureter. Early diagnosis and management of any ureteric injuries is important to reduce morbidity.
The human placenta is discoid, haemochorial, deciduate, and larynthine. It attaches to the uterine wall and connects the mother and fetus through the umbilical cord. The placenta undergoes development from implantation through the third trimester, forming the chorionic and basal plates separated by the intervillous space containing branching villi. The placenta acts as the site of nutrient, waste, and gas exchange between mother and fetus as well as producing important hormones. Various abnormalities can occur in placental shape, implantation, circulation or development that impact clinical outcomes.
This document discusses the interpretation of various types of Doppler ultrasound during pregnancy. It describes:
1. Umbilical artery Doppler which can detect placental hypoxia and increased resistance, predicting abnormal outcomes. Abnormal readings include increased resistance index and absent/reversed end diastolic flow.
2. Middle cerebral artery Doppler which can detect fetal anemia by increased blood flow to the brain. It is also used to time delivery of growth restricted infants.
3. Ductus venosus Doppler which has moderate predictive value for growth restriction in preterm infants.
4. Uterine artery Doppler has limited use in predicting fetal growth restriction but can identify maternal causes by abnormal readings.
Vacuum extraction is a method to assist in childbirth using suction from a cup placed on the baby's head to help with traction during contractions. There are different types of cups including metal, soft, and bird's cups. Vacuum extraction is indicated when forceps cannot be used and has advantages over forceps like less need for anesthesia and less compression force applied. Complications can include maternal lacerations and cervical injuries or fetal issues like cephalhematomas and scalp lacerations.
This document discusses umbilical and uterine artery Doppler ultrasound. It notes that umbilical artery Doppler is useful for predicting abnormal fetal outcomes, with a resistance index above 0.72 outside normal limits after 26 weeks. Absent or reversed end diastolic flow in the umbilical artery indicates fetal distress and need for monitoring or delivery. Uterine artery Doppler has limited use in predicting fetal growth restriction but can suggest maternal versus fetal causes. An abnormal uterine Doppler with decreased diastolic flow or persistence of a diastolic notch after 24 weeks can help predict preeclampsia. Fortnightly umbilical artery Doppler scans are recommended when growth is not maintained or abdominal circumference is below the third percentile.
1. Cesarean scar pregnancy (CSP) is an uncommon but potentially life-threatening complication where a gestational sac is implanted at the site of a previous cesarean section scar.
2. The incidence of CSP is rising due to increases in both cesarean section rates and use of transvaginal ultrasound.
3. Early diagnosis of CSP is important to avoid complications like morbidly adherent placenta. Diagnosis involves transvaginal ultrasound identifying the gestational sac within the lower uterine segment.
1. The document discusses various operative obstetric procedures including vaginal operations like forceps delivery, breech extraction, and vacuum extraction as well as abdominal operations like cesarean section and postpartum hysterectomy.
2. Forceps delivery classifications include outlet, low, mid, and high forceps. Indications, techniques, and complications are described.
3. Breech delivery techniques include the Pinard maneuver and total breech extraction. Risks to the mother and fetus are outlined.
4. Vacuum extraction provides an alternative to forceps delivery using suction to assist delivery. Placement of the suction cup is critical for success.
Caesarean section is the delivery of a fetus through an incision made in the mother's abdomen and uterus. It was originally a fatal operation but is now commonly performed worldwide. The WHO recommends an ideal c-section rate of 15-20% though rates have increased due to factors like previous c-sections and increased fetal distress diagnosis. C-sections are performed under spinal or epidural anesthesia with various abdominal incision types closed afterwards. Complications can include hemorrhage, infection, and injury to internal organs during the operation or issues like ileus, DVT and wound separation after.
The document summarizes the development and anatomy of the human placenta. It begins by defining the placenta and outlining its objectives. It then describes the development of the placenta from the chorion and decidua, the structures of the mature placenta including the chorionic plate, basal plate, intervillous space and villi, and the maternal and fetal circulations that occur through it. Finally, it discusses placental aging and the degenerative changes that occur over the course of a pregnancy.
Organisatie van zinnige zorg Breast Clinic Albert Schweitzer ziekenhuisMarc Kock
Door Imaging First met beeldvormende triage door borstfoto's (mammografie) heeft de patiënt snellere diagnose bij lagere kosten. Deze werkwijze vind al jaren plaats op de Breast Clinic van het ASz.
Fairmonte 2014 treatment of niche asogicMohamad Saad
This document discusses cesarean scar defects and various treatment methods. It describes three studies conducted on this topic. The first study found that 22% of women with a previous cesarean section had a scar defect, which were associated with symptoms like abnormal bleeding and pain. Defects higher in the uterus were more symptomatic. The second study evaluated vaginal ligation of the uterine artery to treat bleeding from scar defects, finding it effective with few complications. The third study assessed transvaginal repair of scar defects in 22 infertile women, finding it addressed symptoms and improved scar dimensions.
This document outlines a study protocol to evaluate a novel transvaginal surgical approach for repairing caesarean section scar defects. The study will recruit 60 symptomatic women to undergo transvaginal repair involving endometrial curettage of the scar defect cavity and suturing of the defect. Patients will be followed for 6 months with clinical and ultrasound evaluations at regular intervals to assess outcomes. The goal is to evaluate if this approach can effectively repair scar defects while avoiding complete excision of healthy myometrium.
This document outlines 10 ways for pregnant women to avoid an unnecessary cesarean delivery. It discusses the rising cesarean rate in the US and some of the contributing factors, such as fear of lawsuits and physician convenience. It provides tips for women before and during labor to reduce the chances of a cesarean, such as educating themselves, carefully selecting providers, avoiding inductions when possible, and asking questions during labor about alternatives to surgery. The document concludes that open communication between patients and providers is key to avoiding unnecessary cesareans.
This document provides information on performing a Cesarean section (C-section). It begins by defining a C-section and explaining the different types based on gestational age. It then discusses techniques to reduce operating time and costs. Common causes of C-sections are listed, along with reasons for increasing C-section rates. Preoperative testing, positioning, catheterization, skin preparation, draping, and abdominal entry techniques are outlined. Regional versus general anesthesia options are presented. The document concludes by describing uterine incision techniques and addressing central placenta praevia.
This document discusses ureteric injuries that can occur during gynecological surgeries. It notes that the most common site of injury is near the pelvic brim at the infundibulopelvic ligament. The most common type of injury is obstruction and the most common cause is attempts to obtain hemostasis. It provides details on the anatomy of the ureter and risk factors for injury. Preventive strategies discussed include preoperative imaging, adequate exposure during surgery, and avoiding blind clamping of vessels near the ureter. Treatment depends on the severity, location, and timing of diagnosis of the injury. Options include conservative management, delayed repair, or immediate reoperation.
This document discusses ureteric injury as a complication of gynecologic surgery. It covers the incidence, risk factors, applied anatomy of the pelvic ureter, common sites of injury, prevention strategies, and management approaches. Ureteric injury can occur in 0.03-6% of hysterectomies, with laparoscopic hysterectomy having the highest risk. The pelvic ureter has variable anatomy and is susceptible to injury at sites like the pelvic brim. Prevention focuses on proper identification and dissection of the ureter during surgery. Management depends on the severity and timing of injury but may involve stenting, urinary diversion, or ureteral reimplantation
This presentation aims to explain the anatomical features and clinical implications of the lower uterine segment (LUS). The LUS is the part of the uterus between the attachment of the peritoneum superiorly and the internal cervical os inferiorly. It contains less muscle fibers and blood vessels than the upper segment. During pregnancy, the LUS stretches to form the lower part of the uterine cavity in the third trimester. Placental attachment to the LUS can lead to bleeding risks as the area thins in preparation for labor. The LUS is the site of incision for caesarean sections due to its weaker muscles and blood supply.
This document discusses vaginal birth after cesarean (VBAC) and elective repeat cesarean delivery (ERCD). It begins by outlining the history of the "once a cesarean, always a cesarean" dictum and subsequent research challenging this view. It then compares the risks and benefits of VBAC versus ERCD. Key points include a VBAC success rate of 60-80% and increased risks of uterine rupture and emergency cesarean with VBAC. Factors affecting VBAC likelihood of success and failure are also reviewed. The document provides guidance on candidate selection and counseling for VBAC.
This case report describes a caesarean scar ectopic pregnancy in a 28-year old woman with two previous caesarean deliveries. Ultrasound found the gestational sac located in the lower uterine segment within the region of the previous caesarean scar. 3D imaging confirmed these findings. The differential diagnosis considered cervical ectopic pregnancy and missed abortion but color Doppler showed peripheral flow around the sac, confirming a caesarean scar ectopic pregnancy. Early detection of caesarean scar ectopic pregnancies by ultrasound is important to reduce risks of complications like hemorrhage which can require emergency hysterectomy.
The document discusses the pelvic ureter and prevention of ureteric injuries during pelvic surgery. It provides details on the anatomy of the pelvic ureter and sites where it is vulnerable to injury. Ureteric injuries can occur during abdominal or vaginal hysterectomy or other pelvic operations, with an incidence ranging from 0.4-2.5% for benign conditions and up to 30% for malignancies. Preventive measures include adequate exposure of the ureter during surgery, identification of its location using surrounding structures as guides, and avoidance of blind clamping or coagulation near the ureter. Early diagnosis and management of any ureteric injuries is important to reduce morbidity.
The human placenta is discoid, haemochorial, deciduate, and larynthine. It attaches to the uterine wall and connects the mother and fetus through the umbilical cord. The placenta undergoes development from implantation through the third trimester, forming the chorionic and basal plates separated by the intervillous space containing branching villi. The placenta acts as the site of nutrient, waste, and gas exchange between mother and fetus as well as producing important hormones. Various abnormalities can occur in placental shape, implantation, circulation or development that impact clinical outcomes.
This document discusses the interpretation of various types of Doppler ultrasound during pregnancy. It describes:
1. Umbilical artery Doppler which can detect placental hypoxia and increased resistance, predicting abnormal outcomes. Abnormal readings include increased resistance index and absent/reversed end diastolic flow.
2. Middle cerebral artery Doppler which can detect fetal anemia by increased blood flow to the brain. It is also used to time delivery of growth restricted infants.
3. Ductus venosus Doppler which has moderate predictive value for growth restriction in preterm infants.
4. Uterine artery Doppler has limited use in predicting fetal growth restriction but can identify maternal causes by abnormal readings.
Vacuum extraction is a method to assist in childbirth using suction from a cup placed on the baby's head to help with traction during contractions. There are different types of cups including metal, soft, and bird's cups. Vacuum extraction is indicated when forceps cannot be used and has advantages over forceps like less need for anesthesia and less compression force applied. Complications can include maternal lacerations and cervical injuries or fetal issues like cephalhematomas and scalp lacerations.
This document discusses umbilical and uterine artery Doppler ultrasound. It notes that umbilical artery Doppler is useful for predicting abnormal fetal outcomes, with a resistance index above 0.72 outside normal limits after 26 weeks. Absent or reversed end diastolic flow in the umbilical artery indicates fetal distress and need for monitoring or delivery. Uterine artery Doppler has limited use in predicting fetal growth restriction but can suggest maternal versus fetal causes. An abnormal uterine Doppler with decreased diastolic flow or persistence of a diastolic notch after 24 weeks can help predict preeclampsia. Fortnightly umbilical artery Doppler scans are recommended when growth is not maintained or abdominal circumference is below the third percentile.
1. Cesarean scar pregnancy (CSP) is an uncommon but potentially life-threatening complication where a gestational sac is implanted at the site of a previous cesarean section scar.
2. The incidence of CSP is rising due to increases in both cesarean section rates and use of transvaginal ultrasound.
3. Early diagnosis of CSP is important to avoid complications like morbidly adherent placenta. Diagnosis involves transvaginal ultrasound identifying the gestational sac within the lower uterine segment.
1. The document discusses various operative obstetric procedures including vaginal operations like forceps delivery, breech extraction, and vacuum extraction as well as abdominal operations like cesarean section and postpartum hysterectomy.
2. Forceps delivery classifications include outlet, low, mid, and high forceps. Indications, techniques, and complications are described.
3. Breech delivery techniques include the Pinard maneuver and total breech extraction. Risks to the mother and fetus are outlined.
4. Vacuum extraction provides an alternative to forceps delivery using suction to assist delivery. Placement of the suction cup is critical for success.
Caesarean section is the delivery of a fetus through an incision made in the mother's abdomen and uterus. It was originally a fatal operation but is now commonly performed worldwide. The WHO recommends an ideal c-section rate of 15-20% though rates have increased due to factors like previous c-sections and increased fetal distress diagnosis. C-sections are performed under spinal or epidural anesthesia with various abdominal incision types closed afterwards. Complications can include hemorrhage, infection, and injury to internal organs during the operation or issues like ileus, DVT and wound separation after.
The document summarizes the development and anatomy of the human placenta. It begins by defining the placenta and outlining its objectives. It then describes the development of the placenta from the chorion and decidua, the structures of the mature placenta including the chorionic plate, basal plate, intervillous space and villi, and the maternal and fetal circulations that occur through it. Finally, it discusses placental aging and the degenerative changes that occur over the course of a pregnancy.
Organisatie van zinnige zorg Breast Clinic Albert Schweitzer ziekenhuisMarc Kock
Door Imaging First met beeldvormende triage door borstfoto's (mammografie) heeft de patiënt snellere diagnose bij lagere kosten. Deze werkwijze vind al jaren plaats op de Breast Clinic van het ASz.
Fvd berkmortel geriotto_geriatric navigator in atrium mc250502011Ger3er
Franchette van den Berkmortel (internist-medisch oncoloog in het Atrium MC) presenteert de ervaringen met de uitrol en het gebruik van de Geriatric Navigator.
2. Onderwerp
Prof. Dr. Hans Brölmann, Dr. Judith Huirne: ‘benigne’
gynaecologie
VUmc
3 Onderzoeken: prevalentie en risicofactoren,
complicaties niche, minimale invasieve therapie
Snowballing process
Pubmed: ‘niche’ AND ‘cesarean’
2
3. Inleiding
Sectio’s prevalentie stijgt, dus ook de complicaties (0)
Na sectio meer kans op: placenta praevia, increta,
percreta, EUG, uterus ruptuur, gynaecologische
problemen (AUB) niche vorming (1)
13. Risicofactoren niche
Closure technique:
-’Split thickness suturing’ (endometrium niet meegehecht) vaker niche dan
‘full thickness suturing’ (including endometrial layer) (6)
-1 Laag hechtingen om myometrium te sluiten na sectio vaker niche dan dubbele laag
-Vaker grote niches na one-layer uterine closure dan two-layer closure (deze niet statistisch
significant) (5)
-Locked uterine closure technique. Het ‘percentage of thinning of the scar region’
significant minder met unlocked uterine closure technique (11)
Development LUS: van invloed op ontwikkeling niche
-Duration of labor voor aanvang sectio > 5h
-Cervical Dilatation > 5cm
-Meer kans op grote niche als tijdens CS deel van de foetus onder apertura pelvis superior (5)
-PPROM (7)
Wound healing
-Retroflexie uterus: large niche potential negative effect on wound healing
-Pre-eclampsie
-Multipele CS’s (5)
13
14. Theorie…
Dunner myometrium = minder goed gevasculariseerd
insufficiënte wondgenezing + nichevorming (5)
! Bevestiging door andere studie Van der Voet, L.F. Bij de
Vaate, A.M. et al. (8) <50% residuaal myometrium
aangrenzend aan sectio-litteken toegenomen
prevalentie nichevorming.
1 Andere studie: juist meer kans op niche bij minder
cervical dilatation (Yazicioglu et al 2006 n = 70)(9)
14
15. Schematic presentation of niche measurement.
(1) niche depth (in the sagittal plane);
(2) residual myometrium (RM), from the serosal surface of the uterus
(without the white lining of the serosa) to the apex of the niche,
perpendicular to the endometrium (in sagittal plane);
(3) adjacent myometrial thickness (AMT).
Adapted from Bij de Vaate et al. (2)
15
19. Diagnostiek
Transvaginale US: donkere (echoarm/anechoic) ruimte -
met of zonder vloeistof- van ten minste 2mm op de plek
vh sectio-litteken. Niet te verwarren met sectio-litteken.
Sonohysterografie (SIS): driehoekige/semicirculaire
echoarme regio.
Hysteroscopie
Hysterosalpingografie
MRI
19
20. Preoperative (left) and postoperative (right) magnetic resonance imaging
Sagittal views of uterus A, following medical treatment of cesarean ectopic (arrow indicates resultant defect or “niche”) and B, after removal of
retained products and hysterotomy repair (arrow indicates reconstructed cesarean hysterotomy scar).Siedhoff. Robotic cesarean scar
revision. Am J Obstet Gynecol 2015. (2)
20
22. Therapie
Systemic review en Meta-analyse
van der Voet LF, Vervoort AJ et al. Minimally invasive
therapy for gynaecological symptoms related to a niche in
the ceasarean scar: a systematic review BJOG 2014 jan;
121(2):145-56 PMID 24373589
Effect verschillende therapien op AUB, pain relief, sexual
function, quality of life, surgical, anatomic, fertility, or
pregnancy outcome
12 studies, (MOOSE-guidelines gebruikt)
-8 studies hysteroscopic niche resection (n=384)
-1 studie laparoscopic repair (n=13)
-2 studies (laparoscopic assisted) vaginal repair (n=47)
-1 studie OCs (n=11)
22
23. Therapie: AUB n=455
Laparoscopic repair: bij 100% verbetering (22)
Vaginal repair: 93% (23)
Orale anticonceptiva: Pranoval 3 tot 6 cycli (estrogen,
progesterone, nl. 0,05mg ethynyl estradiol en 0,5mg
norgestrel
91% geen klachten meer (12)
Hysteroscopische resectie: bij 87% verbetering (1, 13 t/m 21)
23
24. 3 Studies reported bleeding parameters both at baseline and after surgery
Luo et al. (23) Vaginal repair
Chang et al. (16) Hysteroscopische niche resectie
Wang et al. (17) Hysteroscopische niche resectie
24
26. Hysteroscopische resectie
9-mm resectoscoop (Karl Storz), met unipolaire
elektrische stroom
Sorbitol-mannitol-oplossing voor uitzetting uterus/cervix
Resection edges and bottom of the defect – complete
removal fibrotic scar tissue until muscular tissue below
evident. Met cutting loop, using ‘pure cutting current’
Electrocoagulation bottom of pouch with roller-ball to
avoid in situ production of blood (14)
N.b. Niet uitvoeren als RM < 3mm (22)
26
28. A) Isthtmocele superior third
cervical canal
B) Treatment by use of
resectoscopic loop
C) 3-mm roller-ball
28
29. Laparascopic repair
Bladder dissection laser
Sectio litteken openen (A)
Verwijderen fibrotic tissue from the edges of the defect.
Zodat gezond myometrium zichtbaar (B)
Probe inserted into cervix to preserve continuity of the
cervical canal with the uterine cavity.
Closing scar: 3 aparte hechtingen, two layers.
Closing peritoneum: using running sutures (22)
29
32. Discussie review
Gevonden literatuur voldeed niet aan al hun eisen.
-Clear definition and standardised measurements of
outcomes were lacking in most articles.
-No report of how they evaluated bleeding
symptoms or niche measurements
Current evidence not sufficient to draw solid conclusions
Evidence on the most optimal therapy is lacking least
invasive therapy (OAC) daarom eerste keus voor
gynaecologische symptomen.
Lack of sufficient evidence on the outcome of repair on
fertility and pregnancy outcome
32
33. Conclusie
Nichevorming na sectio is geassocieerd met o.a.
tussentijds VBV en pijn. Interventies laten een reductie
hiervan zien.
Low complication rate
Maar: kleine onderzoeken, slechte kwaliteit en geen
long-term follow-up
33
35. Toekomst
Long-term follow-up waarbij effect verschillende
therapiën (hysteroscopic, laparoscopic, vaginal repair en
OAC’s)op alle symptomen (m.n. fertility and pregnancy
outcome)
Randomised trial waarin wordt vergeleken:
-surgical interventions vs.
-expectant management vs.
-medical therapies
35
36. Literatuur
(0) PMID 23743391: La Rosa MF, McCarthy S et al. 2013
(1) PMID 24373589: van der Voet LF, Vervoort AJ et al. 2014
(2) PMID 25173662: Moshiri M, Osman S et al. 2014
(3) PMID 25499261: Siedhoff MT, Schiff LD etal. 2014
(4) PMID 21031351: Bij de Vaate AJ, Brölmann HA et al. 2011
(5) PMID 23996650: Bij de Vaate AJ, Brölmann HA et al. 2014
(6) PMID 16023780: Yazicioglu F, Gökdogan A et al. 2006
(7) PMID 16612704: Hayakawa H, Itakura A et al. 2006
(8) PMID 24373597: van der Voet LF. Bij de Vaate Am et al. 2014
(9) PMID 16023780: Yazicioglu F, Gökdogan A et al. 2006
(10) PMID 25452883: Drouin O, Bergeron T et al. 2014
(11) PMID 24948973: Turan GA, Gur EB et al. 2014
36
37. 12) PMID 16769058: Tahara M, Shimizu T et al. 2006
13) PMID 15904593: Fabres C, Arriagada P et al. 2005
14) PMID 18312986: Gubbini G, Casadio et al. 2008
15) PMID 10912399: Erickson SS, van Voorhis BJ 1999
16) PMID19318145: Chang Y, Tsai EM et al. 2009
17) PMID 21074310: Wang CJ, Huang HJ et al. 2011
18) PMID 21354070: Gubbini G, Centini G et al. 2011
19) PMID 21204608: Florio P, Gubbini G et al. 2011
20) PMID 22621994: Feng YL, Li MX et al. 2012
21) PMID 21204608: Florio P, Gubbini G et al. 2011
22) PMID 23357466: Marotta ML, Donnez J et al. 2013
23) PMID 22748951: Luo L, Niu G et al. 2012
37
-Ectopic mass pregnancy = EUG -Na sectio littekens in uterus, dus gevolgen te beredeneren. -Increta: chorionic vilii in myometrium -percreta: chorionic vilii door myometrium heen
-Case: Residuaal trofoblastweefsel (3) (trofoblast wordt placenta) dat achterblijft in de niche. Dit komt na 1% van de zwangerschappen voor. Meestal komt het voor na terminatie van een zs, maar het kan ook na een spontane vaginale bevalling of een keizersnede. Symptomen van residuaal trofoblastweefsel; koorts, vaginaal bloeden, abdominale/pelvic pijn. Gevolg: Asherman’s syndroom (adhesies). Achiron et al 1993; Zalel et al 2001; Romero et al 1990. -Buidel.
-Theorie: een dikkere Residuale Myometrium is misschien gerelateerd aan betere functionaliteit van het lower uterine segment. -Uterine dehiscence: disruprion of the myometrium: -Wound dehiscence = surgical complication in which a wound ruptures along surgical suture. (Uitscheurt)
-Ongeveer 60% kans op niche na sectio gemiddeld. Internationaal. -SIS saline infusion hysterografie (zoutoplossing/fysiol zout) -Watercontrastechoscopie = sonohysterografie = SIS: is ook transvaginaal, maar dan eerst water via catheter ingebracht. Zo zie je beter vormafwijkingen. -Prospectief onderzoek: steekproef van bepaalde onderzoekspersonen waarop metingen of waarnemingen worden gedaan. Deze worden gevolgd en aan de hand daarvan worden conclusies getrokken. Bij retrospectief wordt de steekproef achteraf samengesteld (en is het dus niet meer echt random). -Dysmenorrie van tevoren niet dan? -Hadden ze het zonder niche ook gehad, die spotting? -Chronic pelvic pain is pain in your pelvic region — the area below your bellybutton and between your hips — that lasts six months or longer.
-Deze indeling komt van Bij de Vaate, van der Voet et al. 2 april 2014 Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. -Apertura pelvis superior. -Locked wordt vaker gebruikt omdat dan bloeden beter wordt tegen gegaan. Hechtingen zitten dan aan elkaar vast
-Het gaat helemaal over niche hier, behalve waar spotting bij staat. -Retrospectief vastgesteld, geen etiologisch hoogstandje -Er blijft meer over van het residuaal myometrium als je unlocked gebruikt -LUS: the inferior portion or isthmus of the uterus, the lower extremity of which joins with the cervical canal and, during pregnancy, expands to become the lower part of the uterine cavity. This is not the active contracting portion of the uterus. -Meer kans op grote niche als ttv section het kind al is ingedaald -PPROM prematuur breken van de vliezen.
Onderste (passieve) uterus segment contraheert niet maar rekt alleen uit.
Uit 2
5/10=0,5 10/10=1
-Raar, want bij vorige onderzoek (bron 5) juist meer niche bij excluding myometrium
-SIS: watercontrast (saline infusion sonohysterography = zoutoplossing zodat uterus uitzet) -Hysterosalpingografie: Rontgenfoto van de met contrastvloeistof gevulde uterus en salpinges (tubae)
-2 mm: http://www.zonmw.nl/nl/projecten/project-detail/hysteroscopic-resection-of-uterine-cesarean-scar-defect-niche-in-patients-with-abnormal-bleeding/voortgang/ DR. JAF HUIRNE
Meta-analysis of Observational Studies in Epidemiology. Ik kijk alleen naar AUB en pain relief. Rest erg weinig literatuur. --Stematische review = vraagstelling in zoveel mogelijk goede artikelen proberen te beantwoorden (in- en exclusiecriteria) -Meta-analyse: samenvatting van de resultaten van afzonderlijke onderzoeken. Zo ontstaat 1 overall schatting van het bestudeerde effect. Dit is vaak een onderdeel van een systematische review, maar alleen als de studies van goede kwaliteit zijn! -VBV vaginaal bloedverlies
Grote meta-analyse (1) is een meta-analyse: een opsomming van 13 t/m 21 (dus bv studie 21 liet zien dat hysteroscopisch beter werkt dan vaginal repair)
-3 studies, totaal 121 vrouwen, hebben vergeleken aantal dagen bloeden voor en na operatie. Hysteroscopische resectie 2-4 minder; vaginal repair 4-7 dagen. Gemiddelde verschil in dagen was -4,48 (dus met zoveel dagen is bloeden afgenomen). Betrouwbaarheidsinterval hiervoor had een lower en een upper limit (85% CI): -6,59 - -2,37 -Vaginal repair: lithotomy position
-Unipolair: 1 pool, geleiding door ofwel negatieve ofwel positieve deeltjes. -Pure cut electrocautery current: je gebruikt een hoge, gerichte stroom die weinig warmte afgeeft aan omgeving zodat minder weefselschade. Wel eerder bloeding. -Ivm kans op perforatie
-Vanuit trocqrd komt laser. -Lig latum
Stokje door ostium als probe, maar voelen eigenlijk naast de vagina (in de vesicocervicale ruimte). A) nterior portio vastgepakt B) Adrenaline oplossing erbij om de boel wat op te blazen C) Incisie in voorwand vd vagina, waardoor je toegang krijgt tot de vesicocervicale ruimte D) Voelen waar niche zit E) Littekenweefsel opengesneden en litteken en omgevend weefsel weggesneden F) Sluiten met 3 – 4 aparte hechtingen. 2 Lagen is beter voor de stevigheid.
-Evaluated bleeding symptoms: hoe ze het geregistreerd hebben (vragenlijst ed?)
