Follow-Up
Postoperative follow-ups were completed in March 2020. All participants
were called after delivery and invited to complete sixth-month
evaluations. However, participants who experienced post-CD pregnancies,
or uterine surgeries were excluded. All remaining participants were
examined at six to nine months period after CD for niche presence in the
scar region, niche measurements, scar shape, distance between niche and
the external cervical os and residual myometrium thickness (RMT), and
adjacent myometrium thicknesses (AMT). The distance between the niche
and external os should be measured parallel to the top of the main
niche, from the most distal niche point to external os. These
examinations were conducted by two experienced sonographers who were
blinded to clinical information regarding the closure technique.
Procedures were specifically completed using a 4-10 MHz transducer
(E8C-RS micro convex endocavity probe, Voluson S6, GE, Milwaukee, US),
ultrasonography, and through the saline infusion sonohysterography (SIS)
method. The cervix was first cleaned with povidone iodine while the
patient was on the gynecological examination table prior to
ultrasonography. The SIS process then progressed toward the inside of
the endometrial cavity by passing from the cervical os with an
intrauterine insemination cannula (intrauterine insemination catheter,
Wallace Artificial Insemination Catheter, Smiths Medical International
Ltd., Ashford, Kent, UK). A sterile saline solution was the applied to
sufficiently distend the cavity, while ultrasonography was conducted via
transvaginal probe. At this time, the presence of a hypoechogenic area
with a depth of 2mm or deeper in the CD scar region within the
endometrial cavity was accepted as a niche. Niche dimensions were then
determined via 3-axis measurements for depth, length, and width. Niche
shape, distance to the external cervical os, RMT, and AMT were then
evaluated. Figure 2 and 3 Figure 2 demonstrated saline infusion
sonohysterography evaluation of patient’s cesarean scar defects (length
of niche, depth of niche, RMT, AMT, distance between niche and external
os and width of niche).
During these follow-ups, patients were also asked about their
menstruation processes and any experiences of cervical pain,
menstruation pain, postmenstrual bleeding (PMB) in the form of spotting,
and other abnormal bleeding patterns. Those who experienced bleeding for
two days or more in the form of spotting after menstruation were defined
as PMB. Participants who used intrauterine devices after CD and/or those
who could not tolerate speculum application were examined via
transvaginal ultrasonography (TV USG).