Sezaryen doğum sırasında uterin defektin cerrahi olarak tek veya çift kat kapatılmasının istmosel gelişimi üzerine etkisinin değerlendirilmesi
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Dosyalar
Tarih
2018
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
GİRİŞ: Gelişmiş ve gelişmekte olan ülkelerde olduğu gibi ülkemizde de sezaryen doğum sıklığının arttığı görülmektedir. Doğumların %6.2-%36 (ortalama %21) sının sezaryen şeklinde olduğu kayıtlarda rapor edilmiştir. Sezaryen doğum sayısı ile birlikte sonraki gebeliklerde görülen uterin rüptür, plasenta invazyon anomalisi gibi iyi bilinen komplikasyonların da arttığı görülmektedir. Bunların dışında son zamanlarda dikkat çeken istmosel olarak adlandırılan uterus kesi hattında patolojik iyileşme/iyileşmenin yetersizliği olarak da değerlendirebileceğimiz uterin skar defektinin görülme sıklığının arttığı açıktır. İstmosel ile jinekolojik problemler, obstetrik komplikasyonlar ve potansiyel subfertilite arasındaki ilişki düşünüldüğünde, sezaryen sonrası istmosel gelişme nedenlerini araştırmak ve mümkünse önleyici stratejiler geliştirmek önemlidir ve bu konuda araştırmalar giderek artmaktadır. AMAÇ: Çalışmamızda uterin skar defekti nedenlerini araştırmak özellikle uterus kapatma tekniğinin istmosel oluşumuna etkisini değerlendirmek amaçlanmıştır. MATERYAL VE METOD: Çalışmaya Ege Üniversitesi Hastanesi Kadın Hastalıkları ve Doğum Kliniği'ne Aralık 2016- Aralık 2017 tarihleri arasında başvuran, acil ya da elektif sezaryen endikasyonu konulan 86 hasta dahil edildi. Daha önce geçirilmiş gebeliği olan hastalar, uterin cerrahi öyküsü olanlar, preeklampsi, eklampsi, HELLP, insülin kullanımı olan GDM/DM olan gebeler, çoğul gebelikler, 37 gebelik haftasından önceki preterm gebelikler, plasental yerleşim ve invazyon anomalisi olan gebeler (plasenta previa, plasenta akreata, plasenta inkreata, plasenta perkreata), çalışmaya dahil edilmedi. Kriterlere uygun 86 hasta üç gruba randomize edildi. Randomizasyon için permütasyon yöntemi kullanılarak hastalar ikişer ikişer sırayla üç gruba dağıtıldı. Her üç gruba da modifiye Misgav Ladach tekniği ile sezaryen cerrahi protokolu uygulandı; grup 1'e dahil edilen hastalarda uterus defekti tek kat kilitsiz sütürasyon ile, grup 2'ye dahil edilen hastalarda tek kat kilitli sütürasyon ile, grup 3'e dahil edilen hastalarda çift kat sütürasyon ile onarıldı. Operasyon sonrası hastalar 6. hafta ve 6. ay'da kontrole çağrılarak sezaryen skarı ve defekt (istmosel) varlığı transvaginal USG ile değerlendirildi. Hastalardan 1 tanesi kontroller sırasında gebelik görülmesi nedeniyle, 39 tanesi kontrollere gelmemesi nedeniyle çalışmadan çıkarıldı. Kalan 46 hastada üç grup istmosel gelişimi açısından birbiri ile kıyaslandı. SONUÇLAR: Gruplar arasında yaş, BMI, gebelik haftası, sigara içimi, ek hastalıklar (diyabet, hipertansiyon) açısından anlamlı fark izlenmedi. Çift kat grubunda, tek kat kilitli grubuna göre 3 kat fazla istmosel görüldü ancak istatistiksel olarak anlamlı bulunmadı. Tek kat kilitsiz grubunda ise tek kat kilitli grubuna göre 12 kat fazla istmosel görüldü ve istatistiksel olarak anlamlı bulundu. Hiçbir hastada istmosele bağlı şikayet izlenmedi. Servikal dilatasyon ve efasmanın olduğu durumların her üç grupta da sayısal olarak istmosel gelişiminin arttırdığı görülse de istatistiksel olarak anlamlı saptanmadı. İstmosel görülenlerde sağ ve sol uterin arterlerin PI değerleri ile istmosel alanı arasında ilişki saptanmadı. TARTIŞMA: Çalışmamızın sonucunda uterusun tek kat kilitleyerek kapatılmasının istmosel görülme riskini azalttığı saptandı ve istatistiksel olarak anlamlı bulundu. Sezaryen sırasında uterusun tamirinde bu tekniğin tercih edilmesi avantajlı görünmektedir. Bu zamana kadar yapılan çalışmalarda en uygun kapatma tekniğinin kesin olarak belirlenemediği görülmektedir. Bunun nedeni istmosel oluşumuna uterus kapatma tekniği dışında birçok faktörün etken olması olabilir. Daha geniş hasta sayısıyla diğer faktörlerin dışlandığı çalışmalar yapılırsa en uygun tekniğin belirlenmesinde yardımcı olabilir. Çalışmamızın bu yönde yapılacak diğer çalışmalara ışık tutacağını düşünmekteyiz.
INTRODUCTION: Similar to developed and developing countries there is an increase in cesarean birth rate in our country. In the records %6-%36(%21 average) of births were reported to be delivered via ceaserean. Along with the increase in ceaserean birth rate there is also an increase in uterin rupture, placental invasion anomalies and other known complications with the following pregnancies. Other than these lately there was an apparent increase in incidences of uterine scar defects named isthmocele which can be evaluated as a pathologic recovery/insufficient recovery on the uterine incision line. Considering the connections that isthmocele has with gynecological problems, obstetric complications and potential subfertility it is important to search the causes of post ceaserean isthmocele and if possible develop preventive strategies. OBJECTIVE: In our study we aimed to evaluated the causes of uterine scar decefts and the effects of uterin closure technique on the isthmocele development. MATERIAL AND METHOD: In our study we included 86 patients who were admitted to the Department of Obstetrics and Gynecology, Ege University Hospital between December 2016 and December 2017 and required urgent or elective cesarean section. Patients with previous pregnancies, uterine surgical history, preeclampsia, eclampsia, HELLP, GDM/DM pregnant patients who use insulin, multiple pregnancies, preterm pregnancies before 37th week and placental invasion anomalies (plasenta previa, plasenta akreata, plasenta inkreata, plasenta perkreata) were not included in the study. We randomised the 86 patients within the criterias into three groups. With the permutation method patients were distributed two by two into the groups. In all three groups cesarean surgical protocol Modified Misgav Ladach technique was performed. Uterus defects were repaired with single-layer unlocked suturation in group 1, single-layer locked suturation in group 2, and double-layer suturation in group 3. After the operation patients were called back for postop follow up in 6th week and 6th month and the presence of cesarean scars and defects (isthmocele) were evaluated by transvaginal USG. Out of the 86 patients 1 of them was removed due to new pregnancy and 39 of them were removed because they did not attend the follow up. Remanining 46 patients were compared to each other in terms of istmosel development according to the three groups of uterin closure they were grouped into in the begining. RESULTS: There were no substantial differences of age, BMI, pregnancy week, smoking or other diseases (diabetes, hypertension) between the three groups. Double-layer group had 3 times more isthmocele compared to single-layer locked group but it was not statistically significant. Single-layer unlocked group had 12 times more isthmocele than the single-layer locked group and it was statistically significant. There were no complaints from any patient due to isthmocele. Although the cases with cervical dilatation and effacement had increased isthmocele development in all three groups but it was not statistically significant. There was no correlation between PI values of left and right uterine arteries and isthmocele area. CONCLUSION: Our study showed that single-layer locked suturation reduced the istmosel development rate and was statistically significant. Although during the cesarean section uterus repair with this technique appears to be advantageous over the others, it cannot be determined exactly which technique is the most appropriate, most likely due to many factors involved other than the suturing technique. Further studies including larger sample size with elimination of the other factors would greatly help to determine the most appropriate technique. Our aim is to be a leading study for the future studies.
INTRODUCTION: Similar to developed and developing countries there is an increase in cesarean birth rate in our country. In the records %6-%36(%21 average) of births were reported to be delivered via ceaserean. Along with the increase in ceaserean birth rate there is also an increase in uterin rupture, placental invasion anomalies and other known complications with the following pregnancies. Other than these lately there was an apparent increase in incidences of uterine scar defects named isthmocele which can be evaluated as a pathologic recovery/insufficient recovery on the uterine incision line. Considering the connections that isthmocele has with gynecological problems, obstetric complications and potential subfertility it is important to search the causes of post ceaserean isthmocele and if possible develop preventive strategies. OBJECTIVE: In our study we aimed to evaluated the causes of uterine scar decefts and the effects of uterin closure technique on the isthmocele development. MATERIAL AND METHOD: In our study we included 86 patients who were admitted to the Department of Obstetrics and Gynecology, Ege University Hospital between December 2016 and December 2017 and required urgent or elective cesarean section. Patients with previous pregnancies, uterine surgical history, preeclampsia, eclampsia, HELLP, GDM/DM pregnant patients who use insulin, multiple pregnancies, preterm pregnancies before 37th week and placental invasion anomalies (plasenta previa, plasenta akreata, plasenta inkreata, plasenta perkreata) were not included in the study. We randomised the 86 patients within the criterias into three groups. With the permutation method patients were distributed two by two into the groups. In all three groups cesarean surgical protocol Modified Misgav Ladach technique was performed. Uterus defects were repaired with single-layer unlocked suturation in group 1, single-layer locked suturation in group 2, and double-layer suturation in group 3. After the operation patients were called back for postop follow up in 6th week and 6th month and the presence of cesarean scars and defects (isthmocele) were evaluated by transvaginal USG. Out of the 86 patients 1 of them was removed due to new pregnancy and 39 of them were removed because they did not attend the follow up. Remanining 46 patients were compared to each other in terms of istmosel development according to the three groups of uterin closure they were grouped into in the begining. RESULTS: There were no substantial differences of age, BMI, pregnancy week, smoking or other diseases (diabetes, hypertension) between the three groups. Double-layer group had 3 times more isthmocele compared to single-layer locked group but it was not statistically significant. Single-layer unlocked group had 12 times more isthmocele than the single-layer locked group and it was statistically significant. There were no complaints from any patient due to isthmocele. Although the cases with cervical dilatation and effacement had increased isthmocele development in all three groups but it was not statistically significant. There was no correlation between PI values of left and right uterine arteries and isthmocele area. CONCLUSION: Our study showed that single-layer locked suturation reduced the istmosel development rate and was statistically significant. Although during the cesarean section uterus repair with this technique appears to be advantageous over the others, it cannot be determined exactly which technique is the most appropriate, most likely due to many factors involved other than the suturing technique. Further studies including larger sample size with elimination of the other factors would greatly help to determine the most appropriate technique. Our aim is to be a leading study for the future studies.
Açıklama
Anahtar Kelimeler
Sezaryen Doğum, Uterus Kapatma Yöntemi, Istmosel, Cesarean Birth, Uterus Closure Method, Isthmocele
