Kremer, T. G., Ghiorzi, I. B., & Dibi, R. P. (2019). Isthmocele: an overview of diagnosis and treatment. Revista Da Associacao Medica Brasileira (1992), 65(5), 714-721. https://doi.org/10.1590/1806-9282.65.5.714
Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. Rev Assoc Med Bras (1992). 2019;65(5):714-721. doi:10.1590/1806-9282.65.5.714
Kremer, Thaysa Guglieri, et al. "Isthmocele: an overview of diagnosis and treatment." Revista Da Associacao Medica Brasileira (1992), vol. 65, no. 5, 2019, pp. 714-721.
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RRM Academy Synopsis
Isthmocele, a cesarean scar defect, is linked to spotting
An isthmocele is usually silent, and its main symptom is spotting after periods, says a 2019 narrative review of cesarean scar defects. The defect is also linked to pelvic pain, secondary infertility and pregnancy problems. The review presents resection of the defect as the first-choice treatment for symptomatic cases.
Key Findings
In women with one or more previous cesarean sections, prevalence ranged from 24% to 70% on transvaginal ultrasound and from 56% to 84% on sonohysterography (ultrasound with fluid in the womb).
Abnormal uterine bleeding, mostly postmenstrual, was present in 28.9% to 82% of women with an isthmocele.
The overall rate of uterine rupture in a later pregnancy does not exceed 2%, and in larger defects the risk increases to 5%.
A systematic review reported favorable outcomes after hysteroscopic resection in 85.5% of cases (range 59.6% to 100%), with abnormal bleeding completely resolved in 72.4%.
In a series of 38 symptomatic women with a large defect, laparoscopic repair left 93% symptom-free, and 44% of women with infertility achieved pregnancy and delivered healthy full-term babies.
Interpretation
This is a narrative review summarizing published research on cesarean scar defects. The authors identify multiple cesarean sections and a retroflexed (backward-tilted) uterus as established risk factors for isthmocele. The authors note that no consensus yet exists on how to define or classify these defects. Treatment selection depends on defect size, symptoms, infertility and pregnancy plans. The findings support further study to standardize isthmocele diagnosis and treatment.
RRM Context
Restorative reproductive medicine treats bleeding, pelvic pain and secondary infertility as symptoms with a cause to find. A cesarean scar defect is one such cause. The review reports spotting after periods as the main symptom. It notes that combined hysteroscopy and laparoscopy can also check for other causes of pain or infertility, such as endometriosis. Couple-centered evaluation includes both partners.
Our editorial summary of this paper, not the article's abstract.
Abstract
An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.
