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).