Kulshrestha, V., Agarwal, N., & Kachhawa, G. (2020). Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update. Journal of Obstetrics and Gynaecology of India, 70(6), 440-446. https://doi.org/10.1007/s13224-020-01370-0
Kulshrestha V, Agarwal N, Kachhawa G. Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update. J Obstet Gynaecol India. 2020;70(6):440-446. doi:10.1007/s13224-020-01370-0
Kulshrestha, Vidushi, et al. "Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update." Journal of Obstetrics and Gynaecology of India, vol. 70, no. 6, 2020, pp. 440-446.
Post-Caesarean Uterine Niche Can Cause Bleeding and Infertility
About 30% of women with a post-caesarean uterine niche, also called an isthmocele, get bleeding, pain, or trouble getting pregnant. This 2020 mini-review describes the scar defect, which forms in up to 70% of women who have had a caesarean.
Key Findings
Niche prevalence varies by imaging method: 24-70% by transvaginal ultrasound versus 56-84% by saline-instillation sonohysterography, which detects more and larger defects than ultrasound alone.
Independent risk factors included gestational diabetes (odds ratio 1.73), a prior caesarean (odds ratio 3.14), and higher body mass index (odds ratio 1.06 per unit increase).
In one prospective study, postmenstrual spotting one year post-caesarean occurred in 20% of women with a niche versus 8.3% without, odds ratio 3.34 for large defects.
Hysteroscopic resection resolved abnormal bleeding in 72.4% of cases, and one laparoscopic repair series reported symptom relief in 79% of 101 women with large defects.
Pregnancy rates after surgical repair ranged from 22% to 71% across studies; one retrospective series found isthmocele was the primary infertility cause in 45.7% of patients (16 of 35).
Interpretation
This narrative mini-review pulls findings from cohort studies, case series, and a few trials on the caesarean scar niche. Surgical repair resolved bleeding in most treated patients and restored pregnancy in many of those who had struggled to conceive. The authors note that no single surgical repair method has been shown to work better than the others. Larger, standardized studies could clarify which repair approach works best.
RRM Context
A caesarean scar niche can cause spotting between periods and may contribute to trouble getting pregnant. A cycle chart can flag this spotting as a pattern worth a closer look. In the studies cited here, surgical repair helped most treated women, and in several series, a pregnancy followed. Caesarean rates keep rising, so RRM clinicians will see more women whose bleeding or infertility traces back to a scar niche from a prior caesarean.
Our editorial summary of this paper, not the article's abstract.
Abstract
Uterine niche is one of the emerging complications of caesarean section. With rising caesarean rates, the caesarean-related iatrogenic complications are also on the rise. These include placenta accreta, scar ectopic pregnancy and uterine niche which is a newer entity being described in the recent literature. Uterine niche, also described as uterine isthmocele, caesarean scar defect and diverticulum, is an iatrogenic defect in the myometrium at the site of previous caesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding, post-menstrual spotting and infertility, though many women may be asymptomatic and diagnosed incidentally. Diagnosis is made radiologically by transvaginal sonography, saline instillation sonohysterography or magnetic resonance imaging. Occurrence of niche may be prevented by using correct surgical technique during caesarean. Patients may be managed medically; however, subfertility and persistent symptoms may require surgical correction either by hysteroscopic resection or transabdominal or transvaginal repair. This mini-review comprehensively covers the potential risk factors, clinical presentation, diagnosis and management of this increasingly encountered condition due to rising caesarean rates.
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