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İSTMOSEL Prof.Dr.Ahmet Zeki IŞIK İzmir Üniversitesi ÜYTE Merkezi
TJOD İzmir-2015
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İSTMOSEL
İstmik sezaryen skar patolojisi İhmal edilmiş bir konu
Diagnostik yöntemler:
-Klinik tanı
-Ultrason ile
-Histeroskopi ile
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İSTMOSEL TAM OLARAK NEDİR?
Sezaryen skarı nedeniyle oluşan, uterin istmusun
veya servikal kanalın ön duvarına yerleşen kese
şeklinde divertiküldür.
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İSTMOSEL TAM OLARAK NEDİR?
•Servikal pasajda bir kesinti gibi gözükmektedir. Tüysüz mukoza ile kaplı bir çeşit kesedir. Altındaki doku iyi kanlanmaktadır. • Menstruel kanın geri kalanı ve mukoza için rezervuar görevi görmektedir. İçeriği koyu kan ve yapışkan materyalden oluşmaktadır. •Biriken kan kronik inflamasyon oluşturabilmektedir.
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İSTMOSEL NEREDE BULUNMAKTADIR?
•Servikal kanaldaki tam lokalizasyonu sezeryan kesisi esnasında etkilenen alana uymaktadır. •Fizyolojik uterin involusyon sonucunda genellikle ön sol tarafta (saat 2 yönünde) bulunmaktadır.
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İSTMOSEL KLASİFİKASYONU
• 1° derece: <15 mm2 • 2° derece : =16 - 25 mm2 • 3° derece : > 25 mm2
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İSTMOSEL: TOPOGRAFİ
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İSTMOSEL LOKALİZASYONU
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• Birçok araştırmacı niş şeklini TVS ile üçgen olarak tanımlamıştır
• %83’ünü üçgen, %2’nin yuvarlak, %4’nün oval ve %10’unda myometriyum dokusu kalmamıştır
• SHG kullanarak nişlerin %50’inin semisirküler, %32’nin üçgen, %10’nun damla şeklinde, %7’sinde inklüzyon kisti şeklinde görülmüştür
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: 93–99.
Fabres C, Aviles G, De La Jara C, Escalona J, Mun˜ oz JF, Mackenna A, Fern´andez C, Zegers-Hochschild F, Fern´andez E. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J Ultrasound Med 2003; 22: 695–700.
Osser OV, Jokubkiene L, Valentin L. High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination. Ultrasound Obstet Gynecol 2009; 34: 90–97.
Chen HY, Chen SJ, Hsieh FJ. Observation of cesarean section scar by transvaginal ultrasonography. Ultrasound Med Biol 1990; 16: 443–447.
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• Uterin sütur tekniği • İsterotomik insizyonun üst ve alt sınırı arasındaki uyumsuzluk • Menstruel kan akımını engelleyen sezaryen skar alanındaki uterin kasların kötü kontraktilitesi —> Menstruel kanın istenmeyen birikimi • Multipl sezaryen skarı • Uterin retroversiyon-retrofleksiyon • Yanlış kullanılan sütur materyali • İnflamasyon
İSTMOSEL ETYOPATOGENEZİ
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SONUÇ:Histerografi, sonohisterografi ve transvajinal ultrasonografi sezaryanlı olguların % 40-60 ında uterin skar defektleri saptayabilmektedir.
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İstmosel, sezaryen geçirmiş kadınlarda %6.2 ve %36 oranları arasında görülmektedir (ortalama %21.1).
Daha sonraki gebeliklerde uterin rüptür ve plasenta yerleşim anomalileri gibi iyi tanımlanmış komplikasyonları vardır. Sezaryen skar defekti, divertikül, poş ve niş olarak da tanımlanabilir .
Transvaginal ultrasonografi ( TVS ) ve sonohisterografi ( SHG ) istmoselin değerlendirilmesi için en fazla kullanılan yöntemlerdir. Niş özellikle bir ultrasonografi bulgusudur ve sezeryan insizyon hattında üçgen şeklinde anekoik alan olarak görülür.
Histeroskopi ve histerosalpingografi ise tanıda daha az kullanılan yöntemlerdir .
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• En sık semptom postmenstruel damlama şeklinde kanama ve infertilite
• TVS kullanıldığında geçmişinde bir ya da daha fazla C/S doğum olan kadınlarda yapılan dört ayrı çalışmada istmosel prevalansı %24 ile %70
• SHG kullanıldığında prevalans %56 ve %84
• Bir kez sezaryen doğum yapanlarda %14,
• İki kez sezaryen doğum yapanlarda %23,
• Üç kez sezaryen ile doğum yapanlarda %45 oranında görülmektedir
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İSTMOSEL: Semptomları ve Komplikasyonları
Asemptomatik olabilir. Postmenstruel anormal uterin kanama Menstruasyon boyunca aşırı kanama Suprapubik pelvik ağrı Sekonder infertilite Uygun yerleşimi olmayan embryonel transfer Ektopik gebelik Vezikouterin fistül nedeni olabilir.
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Menstruasyon
Menstruel kanın birikimi ve istmosel distansiyonu
Postmenstruel lekelenme
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İSTMOSEL: SEKONDER İNFERTİLİTE NEDENİ
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İstmoplasti ve İnfertilite
41 hasta 37 ( % 90.2)- C/S doğum 4 ( % 9.8) - ilk trimester spontan abortus .
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İstmoplasti ve İnfertilite
Table 1. Synthesis of data reported in literature regarding the number of patients affected by isthmocele and secondary infertility
Author Type of study Potients Follow up [months) Control group Pregnancy Outcome
Gubbini et al.[l] Prospective 9 12-24 None 7 7 ECS
Fabres el al. [5] Retrospective 32 Not applicable Not applicable Not known Not applicable
Van Horenbeeck el al. [6] Case-report 1 Not known Not applicable 1 1 preterm delivery
Fabres et al. [7] Prospective 11 12-24 None 9 5 ECS; unknown in 4
Gubbini et al. [1 ] **] Prospective 41 12-24 None 41 37 ECS; 4 abortions
Donnez et al [29) Prospective 3 Not indicated None 1 1 ECS
Fernandez et al. [30] Prospective 4 12-24 None 2 Not known
Kavakami et al. [31] Retrospective 13 Not applicable Not applicable Not known Not applicable
Xu et al. [32] Prospective 1 12 None 0 Not known
ECS. elective cesarean section.
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Medikal/ ilaç histeroskopi laparoskopik kombinasyon vaginal cerrahi
1. Tedavi semptomatik hastalara yapılmalıdır.
2. Tedavi , olası komplikasyonları göz önünde bulundurularak seçilmelidir.
İSTMOSEL: NE TÜR TEDAVİ?
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İSTMOSEL: HİSTEROSKOPİK TEDAVİ
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İSTMOPLASTİ
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Rezeke edilen materyalin histolojik analizi: ■inflame doku (79.5%) ■adenomyozis (7.7%) ■skar dokusu (16.7%)
Histolojik analiz
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İstmoplasti ve Ağrı
Tedavi edilen hastaların % 91 inin semptomlarında azalma görülmektedir.
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Komplikasyon: Semptomların
persistansı
•Rezektoskopik istmoplastinin tekrarlanması •Ara kanama olması durumunda : Mirena kullanılarak lokal progestin tedavisi
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Ş.İ.
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Ü.Ç. • 34 y.
• G1P1Y1 ( C/S) 5 yıl önce
• 7 yıllık evli, 2 yıllık sekonder infertil
• Semptomatik istmosel
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Ü.Ç.
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N.G.
• 37 y.
• G7P1Y1A6 (C/S) 2.5 yıl önce
• Abortus öyküsü: 2-2.5 aylık ve 3 spontan -3 IVF
• Hipotroidi( Euthyrox kullanıyor.)
• Semptomatik istmosel
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N.G.
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TEŞEKKÜRLER