Double-layer unlocked sutures are preferable to single-layer locked sutures regarding RMT, healing ratio and dysmenorrhoea. Excluding the decidua seems to result in higher niche prevalence. As thin residual myometrium or niches may serve as intermediates for gynaecological and reproductive outcomes, future studies should focus on these outcomes. TWEETABLE ABSTRACT: #Uterineclosuretechniques after #caesarean affect #longtermoutcomes.

ObjectiveTo compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect.DesignMulticentre randomised controlled trial.SettingEleven hospitals collaborating in a consortium for women's health research in the Netherlands.PopulationWomen reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography.MethodsWomen were randomly allocated to hysteroscopic niche resection or expectant management for 6 months.Main outcome measuresThe primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation.ResultsWe randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2–7 days) in the intervention group and 7 days (IQR 3–10 days) in the control group (P = 0.04); on a scale of 0–10, discomfort as a result of spotting had a median score of 2 (IQR 0–7) in the intervention group, compared with 7 (IQR 0–8) in the control group (P = 0.02).ConclusionsIn women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting‐related discomfort.Tweetable abstractA hysteroscopic niche resection is an effective treatment to reduce niche‐related spotting.

This randomised controlled trial (RCT) by Kroese et al. tackles an interesting, common gynaecological condition of significant clinical importance. It is original work as the previous RCTs (Ander-sen et al. Acta Obstet Gynecol Scand 1992;71:59-62; Gennis et al. Am J Emerg Med 2005;23:414-15) were small, and not as well designed. When appropriately designed, conducted and reported, RCTs represent the reference standard in evaluating healthcare interventions. This RCT demonstrated that in women with an abscess or cyst of the Bartholin gland, treatment with Word catheter or marsu-pialisation resulted in comparable recurrence rates. Median time from ran-domisation to treatment was 3 hours shorter for Word catheter than for mar-supialisation. Maximal and average pain experienced during treatment were both higher in the Word catheter group compared with marsupialisation. However, pain scores after treatment were comparable , although those women undergoing marsupialisation required more analgesia during the first postoperative day. There are obviously other confounding factors affecting the recurrence rate, such as diabetes. How did the authors address that issue and was there any trend difference in the diabetic group? In other words, in a woman with diabetes how can the authors reliably make inferences that the recurrence is method/technique-related and not attributed to her dia-betes? This RCT is well designed, conducted and adequately implemented the Consolidated Standards of Reporting Trials recommendations (CONSORT) (Schulz, et al. BMJ 2010;340:c332). One of these recommendations is that the trial's results be discussed in light of the totality of the available evidence. There is explicit reference in the discussion to the results of the systematically conducted , published review of previously reported studies, explaining why the current study was justified. I agree with the authors' statements that the strengths of this RCT are the following. 1. The multicentre design within 19 hospitals reflects daily practice, and allows generalisation of the results. 2. A robust follow up, exclusion criteria and follow-up strategy have been conducted. However, I am not sure why women under 18 years were excluded, not under 16 years for instance. I wonder whether the latter would have expedited the recruitment and shortened the duration of the study (2010-14)? 3. The sample size calculation meant that the RCT is adequately powered to result in meaningful conclusions. 4. Statistical analysis was performed according to the intention-to-treat principle. This RCT also adapts the proposal by Docherty et al. (BMJ 1999; 318:1224-5) stating the main results, the strengths and limitations, interpretation/ comparison with the previous reviews/ RCTs and literature, but could have elaborated further on implication on clinical practice. The authors stated that 'In our opinion, our data therefore favour treatment of a Bartholin cyst or abscess with a Word catheter since this is the fastest procedure, relieving pain sooner after diagnosis,...

12 June 2012.

Objectives: While the Caesarean section (CS) rate is increasing in most Western countries, the gynaecological side effects of this procedure are poorly studied. Recently, some attention has been given to the presence of a niche at the site of a Caesarean scar. A niche is defined as a triangular, anechoic area at the presumed site of incision. The main purpose of the SECURE-study (Scar Evaluation after Caesarean by Ultrasound REgistry) was to assess the prevalence and appearance of a niche, and to evaluate the relation with abnormal uterine bleeding. Methods: An observational prospective cohort study was performed between October 2007 and May 2009. All 225 women were consecutively included and examined with two-dimensional (2D) and three-dimensional (3D) gel instillation sonohysterography (GIS) 6 to 12 months after CS to detect a niche. A questionnaire about the menstrual cycle was completed and women were asked to keep record of their bleeding pattern for a period of 2 cycles. As part of the follow up, the questionnaire will be repeated every year for the next 5 years. Results: The presence of a niche could be demonstrated with GIS in 117 (56%) out of 209 women. In 16 women distension was insufficient for accurate assessment. Most niches had a semicircular (50%) or a triangular shape (32%). Examples of different types of niches (2D/3D) will be shown. The prevalence of postmenstrual spotting was 34% in the group of women with a niche compared to 15% in the group without a niche (P = 0.002). Conclusions: A niche can be seen in 56% of women with a Caesarean scar, and mostly has a semicircular or triangular shape. Postmenstrual spotting is significantly associated with the presence of a niche. OC01.02The effect of metformin on the uteroplacental circulation in comparison with aspirin in pregnant women with polycystic ovary syndrome Objectives:To compare the effect of metformin with aspirin on the uteroplacental circulation in pregnant women with polycystic ovary syndrome (PCOS). Methods: This was a randomized, observer-blind, controlled trial in pregnant women with PCOS. Of the 105 pregnant women, 35 were randomly assigned to metformin (2000 mg/day), 35 to aspirin (80 mg/day) and 35 as control. Doppler studies of the uterine arteries were performed at 12 and 20 gestational weeks. Pregnancy adverse outcomes, such as pre-eclampsia, PTD, IUGR and GDM were compared in three groups. Results: Baseline characteristics of the three groups were similar (Table 1). All three groups had significant reduction in mean bilateral uterine artery pulsatility index (PI) from 12 to 20 weeks (P < 0.05), but this reduction was more pronounced in aspirin and metformin groups than control group (0.46 and 0.38 vs. 0.16 respectively, P = 0.003). There was a statistically significant difference in mean PI at 20 weeks of gestation among the groups (P = 0.031); and aspirin group found significantly lower mean PI compared to control group (P = 0.023). The chance of occurrence of adverse pregnancy outcomes were 8.6% in metformin, 17.1% in aspiri...