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Uterine and Pelvic Conditions · Acquired Uterine Conditions

Isthmocele: From Risk Factors to Management

Iannone P, Nencini G, Bonaccorsi G, Martinello R, Pontrelli G, Scioscia M, Nappi L, Greco P, Scutiero G

Published January 16, 2019 Revista Brasileira De Ginecologia E Obstetricia : Revista Da Federacao Brasileira Das Sociedades De Ginecologia E Obstetricia, 41(1), 44-52
DOI 10.1055/s-0038-1676109 PMID 30646424 PMC PMC10416161

RRM Academy Synopsis

Isthmocele after cesarean is common and linked to abnormal bleeding

A 2019 literature review found isthmocele prevalence of 24 to 70% on transvaginal ultrasound, in studies through October 2017. Isthmocele is a scar defect from a prior cesarean. Abnormal bleeding, most often postmenstrual spotting, was present in 28.9 to 82% of cases studied.

Key Findings

  • Prevalence ranged from 24 to 70% on transvaginal ultrasound and from 56 to 84% on sonohysterography, an ultrasound exam with saline infused into the uterus.
  • Abnormal uterine bleeding, in particular postmenstrual spotting, was present in between 28.9 and 82% of the studied cases.
  • Hysteroscopic isthmoplasty had successful outcomes in 85.5% overall (59.6 to 100%). In cited studies, most patients who wanted pregnancy conceived spontaneously between 12 and 24 months afterward.
  • Clinical improvement after vaginal repair was observed in between 85.9 and 92.9% of patients, with prolonged menstrual symptoms improved.
  • Single cited studies report a pregnancy rate of 71% after laparotomy repair and an estimated 44% after laparoscopic repair.

Interpretation

Hysteroscopic isthmoplasty worked well overall, with success in 85.5% of patients. Most of those patients who wanted pregnancy conceived on their own within 12 to 24 months. Vaginal repair also brought clinical improvement in most patients, including relief from prolonged menstrual symptoms. The authors advise surgery for women who have symptoms. The authors note that the evidence does not yet show which surgical approach works best. The findings support larger studies that compare these approaches directly.

RRM Context

Restorative reproductive medicine looks for the cause of bleeding and infertility. Ultrasound can show a scar defect. A daily cycle chart records the spotting that follows the period. The review's medical option, oral contraceptives, is a suppressive medication. Its surgical options repair the defect instead. A prior cesarean belongs in the history when both partners are evaluated.

Our editorial summary of this paper, not the article's abstract.

Abstract

Objective

The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition.

Methods

A comprehensive review of the literature was performed to identify the most relevant studies about this topic.

Results

Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data.

Conclusion

Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.

Topics

By this author

Related research

Uterine and Pelvic Conditions › Acquired Uterine Conditions › Cesarean Scar Defect · Diagnostics › Tubal and Uterine Imaging › Sonohysterography · Reproductive Surgery › Uterine Surgery › Cesarean Scar Repair
Piergiorgio Iannone, Giulia Nencini, Gloria Bonaccorsi, Ruby Martinello, Giovanni Pontrelli, Marco Scioscia, Luigi Nappi, Pantaleo Greco, Gennaro Scutiero
P Iannone, G Nencini, G Bonaccorsi, R Martinello, G Pontrelli, M Scioscia, L Nappi, P Greco, G Scutiero
PMID 30646424 30646424 DOI 10.1055/s-0038-1676109 10.1055/s-0038-1676109 Iannone et al. 2019, Iannone 2019

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