EP25.08: Ultrasound diagnosis and combined: laparoscopic‐hysteroscopic repair of a large silent uterine scar defect after VBAC: a case report

The prevalence of elective and acute Caesarean sections (CS) is increasing, which leads to dilemmas of the safe management of the trial of labour after CS (TOLAC) and the vaginal birth after CS (VBAC) in practice. Guidelines for the management of TOLAC exist, and to minimise the risk VBAC score calculators based on Grobman's research can be used. However, the recommendations for postnatal imaging of the uterine scar and the management of the incidental finding of the uterine scar defects after VBAC are not uniform. Here we present the complete pre-, intra- and postoperative imaging documentation of a case of a 35 years old women, who had a CS in 2020 and an uneventful VBAC in 2023. At six-weeks postpartum routine control examination she was almost complaintless, except light vaginal spotting. On transvaginal sonography (TVS) a large 18mm long discontinuation of the lower segment anterior myometrium and a 18x36mm hematoma elevating the bladder were detected. With the clinical diagnosis of a large silent uterine dehiscence affecting the entire scar of the previous CS an elective isthmoplastic surgery was performed with a combined laparoscopic (LSC) and hysteroscopic approach HSC). Briefly, after identifying the myometrial borders with HSC, during LSC we dissected the urine bladder from the isthmic part of the uterus below to the dehiscence with lateral approach. After removing all the scar tissue and the uterine wall was reconstruction was done in 2 layers with barbed (V-loc) suture. The patients was discharged on the 2nd postop day. Six weeks after the surgery the uterine scar was intact with a 6.8mm thickness at TVS, the vaginal spotting was stopped. With this case we illustrate the rationale of the routine sonographic control of the uterine scar in the postpartum period after VBAC. If silent scar dehiscence is documented, the combined hysteroscopic and laparoscopic approach offers a quick and effective surgical reconstruction in order to minimise long-term risks.