Readers React

Scar or niche?

I enjoyed reading [“Cesarean scar pregnancy management and diagnosis” December 2015] and have a couple of comments regarding its content. I realize the focus of the article was about managing a CSP (ie, the “cat out of the bag”) and undoubtedly the length of the article was restricted. However, the omission of the inclusion of the topic of isthmoceles following C-section as a precursor to CSP was disappointing.

At a recent ASRM meeting, there was a presentation about this topic and it was amazing to me that the majority of REIs were unfamiliar with the term and with its management. In our own practice, we’ve seen several patients with isthmoceles discovered during either a saline infusion transvaginal ultrasound examination, or stimulation cycles with accumulation of mucus in the endometrial cavity as a result of reverse flow of cervical mucus diverted in a retrograde fashion, presumably as a result of the isthmocele (cesarean scar defect). I have never seen anything written about the incidence of CSP with isthmoceles and that information could be very useful in counseling patients prior to pregnancy.

Perhaps one could devise an interesting study in patients with prior C-sections, contemplating another pregnancy, with an SIS prior to conception to identify isthmoceles. In this fashion, one could get an estimate of the prevalence of isthmoceles and also be in a position to advise those patients with regard to repair of the defect. One other related topic might be a brief discussion about the closure of C-section incisions and the importance of a full thickness closure and possibly a double layer closure to avoid the formation of an isthmocele and the potentially devastating consequences of a CSP.

John L Gililland, MD

Salt Lake City, Utah

NEXT: The authors reply >>

IN REPLY:

Your comment on the general awareness about the “isthmocele” and its clinical importance is greatly appreciated.

Searching the literature with the term “isthmocele” revealed 20 articles from 2008 to 2015. Doing the same for “niche” revealed 25 articles from 2011 until 2015.^1,2 There are even some articles that use both terms.^3-6 Fiaschetti et al. in 2015 defined the term “isthmocele” as a niche of the anterior wall of the uterine isthmus at the site of a previous cesarean section scar.⁷ So, we believe that both terms refer to the same diagnosis and can be used interchangeably.

A cesarean scar pregnancy is defined as a pregnancy implanted in the area of the cesarean section scar; either “on the scar” or “in the niche/ isthmocele.”^8,9 In the above article we included images of the difference between the 2 kinds of implantation.

At the last ASRM meeting in Baltimore, during my lecture I also elaborated on the cesarean scar pregnancies and included a discussion about the “niche” at the cesarean section scar. Perhaps the most important message is that providers should consider an early (5 –6 weeks’ gestation) transvaginal ultrasound in every patient with history of cesarean delivery (CD).

In your comment you mentioned the importance of the correct diagnosis and management of patients with a niche/isthmocele. A systematic review of Bij de Vaate et al. in 2014 addressed that topic and found a prevalence of between 56% and 84% in a random population of women with a history of CD, using saline infusion sonohysterography.⁵ Probable risk factors were single-layer myometrium closure, multiple CDs, and retroflexion of the uterus. The most probable niche-related symptom is abnormal uterine bleeding,¹⁰ which can be improved by surgical repair.¹¹ Impact of surgical repair on fertility and pregnancy outcome is not yet clear, because of the lack of reliable data.¹¹

As to the suggested study addressing patients desiring pregnancy after a prior CD, this could be a rather simple and important one. It would be completed in a relatively short amount of time given the large number of CDs.

Ilan E Timor-Tritsch, MD

Ana Monteagudo, MD

Andrea Kaelin Agten, MD

References

1. Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the “niche” in the scar. J Ultrasound Med. 2001;20(10):1105-1115.

2. van der Voet LF, Bij de Vaate AM, Veersema S, Brolmann HA, Huirne JA. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014;121(2):236-244.

3. Gubbini G, Casadio P, Marra E. Resectoscopic correction of the “isthmocele” in women with postmenstrual abnormal uterine bleeding and secondary infertility. J Minim Invasive Gynecol. 2008;15(2):172-175.

4. Florio P, Filippeschi M, Moncini I, Marra E, Franchini M, Gubbini G. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol. 2012;24(3):180-186.

5. 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. Ultrasound Obstet Gynecol. 2014;43(4):372-82.

6. Drouin O, Bergeron T, Beaudry A, Demers S, Roberge S, Bujold E. Ultrasonographic evaluation of uterine scar niche before and after laparoscopic surgical repair: a case report. AJP Rep. 2014;4(2):e65-68.

7. Fiaschetti V, Massaccesi M, Fornari M, et al. Isthmocele in a retroflexed uterus: a report of an unrecognized case. Clin Exp Obstet Gynecol. 2015;42(5):705-707.

8. Comstock CH, Bronsteen RA. The antenatal diagnosis of placenta accreta. BJOG. 2014;121(2):171-181; discussion 181-182.

9. Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol. 2012;207(1):44.e1-13.

10. Bij de Vaate AJ, Brolmann HA, van der Voet LF, van der Slikke JW, Veersema S, Huirne JA. Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting. Ultrasound Obstet Gynecol. 2011;37(1):93-99.

11. van der Voet LF, Vervoort AJ, Veersema S, BijdeVaate AJ, Brolmann HA, Huirne JA. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review. BJOG. 2014;121(2):145-156.

NEXT: Zika and glucose >>

Zika and glucose levels

Thank you for your excellent information on Zika [“Zika virus and microcephaly” February 2016].

I am a nutrition scientist, not a medical doctor, but wanted to present the following observations.

Little is known about the etiology of microcephaly with Zika as an initiating event. However, it is known that microcephaly can result when there is a deficiency of GLUT1, a transporter of glucose across membranes-including the blood-brain barrier and the placenta. This can result in lower levels of glucose in the cerebrospinal fluid of the developing fetus even when there is more than adequate glucose available elsewhere.

Add to this a report that the flaviviral-related Dengue fever has been reported to reduce GLUT1 on the neutrophil cell membrane. Is there some commonality by which Zika affects glucose transport across the blood-brain barrier? Could this be the event that gives rise to microcephaly? If so it might be a transient effect-albeit at critical period of cephalic development-that is no longer detectable once the immune system denigrates Zika.

Given these theoretical possibilities, it would be particularly informative to follow CSF glucose levels in at risk-individuals to see if and how transport is indeed affected. (Having an experimental model would be very helpful.)

But if it turns out that GLUT1 is affected, it may be prudent to consider energy sources for cephalic development that do not rely on GLUT1, such as fructose, or medium chain triglycerides, or even an external source of a ketone body such as beta-hydroxy butyrate or triheptanoin. It will be vital to consider the risk/benefit of any therapy considered for use during pregnancy.

Microcephaly can also be brought about by specific nutrient deficiencies. The question is whether there is some aspect to Zika viral expression that affects utilization of nutrients involved at key periods of cephalic development.

Edward R Blonz, PhD

Kensington, CA

IN REPLY:

These are all terrific ideas, and they lay out a strategy for mitigating Zika-mediated fetal CNS pathology if confirmed. Thank you for sharing this with our readers.

Charles J Lockwood, MD, MHCM

NEXT: Letters on the Labor Force Survey >>

Labor Force Survey

I enjoyed your recent article “Your life, your work.” [January 2016]. Almost all of the concerns of the physicians-stress, work-life balance, liability, night work, lack of experience of new residents, really almost anything-can be helped by having ob/gyn hospitalists work in your hospital.

Rob Olson, MD, FACOG

Bellingham, WA

In 1978, I returned to my city of birth, recruited my sister as total staff and opened the door in the practice of ob/gyn. I was told then that the best years of medicine had passed. I hoped not.

There has been more than a little water under the bridge. In some ways everything that was taught as gospel then has become heresy and now back to gospel again … the Kieland forceps? Even so, over these 38 1/2 years it has been an honor and a privilege to practice medicine.

Now have there been challenges? Yes. Sleepless nights? Many. Regrets about judgments made? Of course. But there is still hope. The opportunity for true service remains. The window to match your wits against the worst nature can manage is open. Receiving, earned or not, the true, complete, and enduring adulation of appreciative patients is assured.

Who could ask for anything more in a life well lived?

David Giammittorio, MD

Alexandria, VA

I am writing regarding the Labor Force survey published in the January issue of Contemporary OB/GYN.

It would have been helpful to have a demographic breakdown (age, gender, location, urban vs rural practice environment, etc) of the respondents to help with perspective on the answers and the comments.

On that note, there were several comments that I found interesting in that they were chosen to be published, especially under “Concerns about the future of the specialty” the comment “I don’t see the women seeing the number of patients that men used to and I don’t see them practicing in underserved rural areas.”

I grant that this is someone’s opinion, but as it was published as part of a labor force survey which is supposed to represent the specialty, I found it rather biased and a very generalized negative statement about the capabilities of “the women” versus “ the men,” and what type of practice model a female physician might choose.

Furthermore, the comments on how ob/gyn is becoming sexist toward men was also interesting. While the specialty is becoming more female-dominated, I’ll point to the AAMC Reporter’s article from June 2015. (https://www.aamc.org/newsroom/reporter/june2015/434740/ob-gyn.html)

“One workforce area that remains a concern, however, is that women are underrepresented in the top levels of OB/GYN leadership. While women continue to enter this traditionally male-dominated field, they aren’t being promoted as much as you’d expect,” said Lisa Hofler, MD, MPH, of Emory University School of Medicine. She conducted a study (Obstetrics & Gynecology, 2015) that showed women comprise only 20% of department chairs, 29.6% of division directors, 31.9% of fellowship directors, and 47.3% of residency directors.

With this in mind, I think it would have been helpful to have these comments framed in a less biased way. In the current publication, regarding males in ob/gyn, it sounds as if men somehow lack opportunities in the field.

Finally, in terms of concerns regarding training, this is the ongoing dialogue in surgical specialties about lack of surgical exposure vs following work hour guidelines. I will comment that this is an opportunity to look into (as the AAMC reporter article above also mentions) how surgical training can be the focus of residency (along with obstetrics and other skills), while decreasing the amount of “scut work” residents perform that mid-level providers or nurses could easily do instead. Many studies show that increasing duty hours does not lead to better quality of training, patient care, or resident well-being (enough for a whole separate article). I think this is a generational bias that once again isn’t framed well in the survey.

Ob/gyn is my specialty too. I may be still in training, but this is the world I will enter in a couple of years. I am sad to say I read this survey and not only did I not feel represented by the comments, but also was very disappointed about my own future. One of the comments that rang true was “Abysmal failure of physicians and our professional organizations to take control of US healthcare.” Perhaps ob/gyns at large should look into how we can make the specialty a more attractive and rewarding one for ourselves and our patients.

Aliye Runyan, MD

Detroit, MI

NEXT: An editor's response >>

IN REPLY:

Thank you for your comments. This was not intended to be a scientific survey but rather a sampling of the attitudes and opinions of those readers who chose to take the time to respond. We were pleased that 943 people did respond and that so many of them wrote lengthy comments about the state of the specialty and their state of mind.

In selecting quotations to feature, we were very careful to select representative comments and to not feature only the most sensational or controversial statements. We were surprised by the number of comments regarding men in the field (especially considering that we did not pose a question relating to this issue), and this is why we chose to highlight some of them in a sidebar.

We appreciate your interest in the demographics of the respondents.  Fifty-seven percent of the respondents were male. Respondents had been in practice an average of 17.5 years. Forty-five percent reported practicing in suburban settings, 41% in urban locations, and 14% in rural areas.

We are eager to refine and repeat this survey next year and we welcome your response and those of your colleagues. It’s fascinating to us to hear what’s on the minds of our nation’s ob/gyns.

Susan C Olmstead

Content Channel Director