Futyma, K., Gałczyński, K., Romanek, K., Filipczak, A., & Rechberger, T. (2016). When and how should we treat cesarean scar defect - isthmocoele? Ginekologia polska. https://doi.org/10.5603/gp.2016.0063
Futyma K, Gałczyński K, Romanek K, Filipczak A, Rechberger T. When and how should we treat cesarean scar defect - isthmocoele? Ginekologia polska. 2016. doi:10.5603/gp.2016.0063
Futyma, Konrad, et al. "When and how should we treat cesarean scar defect - isthmocoele?" Ginekologia polska, 2016.
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Faculty of Medical Sciences and Health Sciences, Siedlce University of Natural Sciences and Humanities , Siedlce, Poland
Linked to ROR, the Research Organization Registry
RRM Academy Synopsis
Some cesarean scar defects may cause bleeding, pain and infertility
Most cesarean scar defects cause no symptoms, but some may cause bleeding, pain or infertility, says this 2016 review from Polish gynecologists. The review describes how defects are found and reports small studies of three surgical routes.
About 5 in 10 women examined after cesarean section showed a niche on ultrasound alone. Source: Futyma K et al., 2016, PMID 27723075.Study at a glance, review article of 263 women: Some cesarean scar defects may cause bleeding, pain and infertility. Source: Futyma K et al., 2016, PMID 27723075.
Key Findings
Among 263 women examined after cesarean section, a niche appeared in 49.6% with ultrasound alone and in 64.5% with ultrasound with gel instillation.
Women whose scar was thinner than 50% of the surrounding myometrium had a 6 times higher risk of abnormal uterine bleeding (odds ratio 6.13, 95% CI 1.74 to 21.63).
Hysterosalpingography in 148 women with secondary infertility after cesarean section found a scar defect in 60% (n = 89): 58 focal outpouchings and 31 thin linear defects.
Ultrasound shows a defect in almost 50% of patients. Rupture risk in the next pregnancy is up to 2%, rising to 5% when the scar is under 50% of surrounding myometrium.
Studies reported symptom resolution in 93% of 42 women after vaginal repair and 80% of 120 after hysteroscopy. In one series, 8 of 9 women with secondary infertility became pregnant.
Interpretation
This is a review article that summarizes individual case series and reports of cesarean scar defect repair. The authors advise that an asymptomatic defect should not be an indication for surgery: only bothersome symptoms justify the risk of an operation. The authors note that their explanations for how the defect forms remain hypotheses. The findings support larger studies of these surgical repairs.
RRM Context
Restorative reproductive medicine looks for the physical cause of symptoms such as spotting after menstruation and secondary infertility. A scar from a past cesarean is one such cause. The review ties bleeding after menstruation to lower fertility through mucus quality, sperm motility and implantation. Cycle charting records when bleeding occurs. Evaluation comes before treatment, since most defects cause no symptoms.
Our editorial summary of this paper, not the article's abstract.
Abstract
The reported number of cesarean sections in Poland is approximately 30% and is associated with increasing number of early and late complications. The myometrial discontinuity at the site of previous cesarean section is known in the literature as "isthmocoele", "niche", "pouch" or cesarean scar defect. In most cases presence of isthmocoele has no clinical significance, but in some patients it may cause abnormal uterine bleeding, dysmenorrhea, dyspareunia, pelvic pain or be associated with secondary infertility. This defect may be treated by laparoscopy, hysteroscopy or vaginal surgery.
A uterine isthmocele is a pouch-like defect at the cesarean scar that causes postmenstrual spotting, pelvic pain, and secondary infertility. Diagnosis, repair options, and the restorative approach.
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