Backer Sean, Khanna Deepesh, Sadr Sonia, Khatibi Ali
Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Tampa, USA.
Foundational Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA.
Cureus. 2023 Sep 1;15(9):e44521. doi: 10.7759/cureus.44521. eCollection 2023 Sep.
Formation of a uterine niche following a C-section can predispose the patient to future obstetric complications such as dehiscence, uterine rupture, ectopic pregnancy, and placenta accreta. The significant morbidity and mortality of these complications along with increasing C-section rates emphasizes the importance of prevention. However, there are no clear guidelines on intra-operative protocol to prevent postpartum niche formation. Besides surgical technique, the novel use of platelet-rich plasma (PRP) and mesenchymal stem cell (MSC) injections has demonstrated promising potential and may have applications in hysterotomy closures. The objective is to examine current research on optimal C-section procedures to prevent uterine niche formation and subsequent obstetric complications. A systematic review was conducted using PubMed and Google Scholar. Initial searches yielded 827 results. Inclusion criteria were human, animal, and in-vitro studies, peer-reviewed sources, and outcomes pertinent to the uterine niche. Exclusion criteria applied to articles with outcomes unrelated to myometrium and interventions outside of the intra-operative and immediate pre-/post-operative period. Based on the criteria, 41 articles were cited. Pathophysiology of uterine niche formation was associated with incisions through cervical tissue, adhesion formation, and poor approximation. Significant risk factors were low uterine incisions, advanced cervical dilatation, low station, non-closure of the peritoneum, and creation of a bladder flap. There was no consensus on uterine closure as it likely depends on surgical proficiency with the given technique, but a double-layered non-locking suture appears reliable to reduce niche severity. Recent trials indicate that intra-operative PRP/MSC injections may decrease niche incidence and severity, but more research is needed. If prevention or minimization of uterine niche is desired, the optimal C-section protocol should avoid low uterine incisions, choose uterine closure technique based on the surgeon's proficiency (double-layered non-locking is reliable), and close the peritoneum, and myometrial injection of PRP/MSC may be a useful adjunct intervention pending further clinical evidence.
剖宫产术后子宫切口憩室的形成会使患者易发生未来的产科并发症，如子宫切口裂开、子宫破裂、异位妊娠和胎盘植入。这些并发症的高发病率和死亡率以及剖宫产率的上升凸显了预防的重要性。然而，目前尚无关于预防产后憩室形成的术中操作规范的明确指南。除了手术技术外，富血小板血浆（PRP）和间充质干细胞（MSC）注射的新应用已显示出有前景的潜力，可能在子宫切开术缝合中得到应用。目的是研究当前关于预防子宫切口憩室形成及后续产科并发症的最佳剖宫产手术的研究。使用PubMed和谷歌学术进行了系统综述。初步检索得到827条结果。纳入标准为人、动物和体外研究、同行评审来源以及与子宫切口憩室相关的结果。排除标准适用于与子宫肌层无关的结果以及术中及术前/术后即刻以外的干预措施的文章。根据标准，引用了41篇文章。子宫切口憩室形成的病理生理学与通过宫颈组织的切口、粘连形成和对合不良有关。重要的危险因素是低位子宫切口、宫颈扩张进展、胎头低、腹膜未关闭和膀胱瓣的形成。对于子宫缝合尚无共识，因为这可能取决于对特定技术的手术熟练程度，但双层非锁定缝合似乎在降低憩室严重程度方面是可靠的。最近的试验表明，术中PRP/MSC注射可能会降低憩室的发生率和严重程度，但还需要更多的研究。如果希望预防或最小化子宫切口憩室，最佳的剖宫产方案应避免低位子宫切口，根据外科医生的熟练程度选择子宫缝合技术（双层非锁定是可靠的），关闭腹膜，并且在有更多临床证据之前，子宫肌层注射PRP/MSC可能是一种有用的辅助干预措施。
