الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
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Abstract
T
here is no universal definition of isthmocele or standard characterization that clearly indicates its location and size. Several authors have proposed definitions in an attempt of establishing a universal concept. Overall, most studies refer to isthmocele, cesarean scar defect, niche or diverticulum as a myometrial discontinuity or a hypoechoic triangle in the myometrium of the anterior uterine wall at the site of hysterotomy presented in transvaginal ultrasound (TVUS) or sonohysterography (SHG) examination in non-pregnant women.
Some authors classified the niche according to the size of the defect a large defect is described as a myometrial reduction of >50% of the wall thickness or even >80% by some authors..
The radiologic findings can be found incidentally in the absence of symptoms or be associated with clinical symptoms. Therefore, they can also be classified as asymptomatic or symptomatic when presenting AUB, pelvic pain, and infertility, for example.
Several risk factors have been related to the development of the isthmocele;, multiple CS is the principal risk factor for its development.also duration of labor, stage of the presenting part, and a lower position of the CS hysterotomy may be potential predisposing factors for the development of a niche. A CS conducted in active labor and cervical dilatation >5cm is related to larger isthmoceles.
In general, most isthmoceles are asymptomatic, being found incidentally on ultrasound. However, over the last decades, with the rising rates of CS, there has been an increase of sequelae reported after this procedure. Symptoms including abnormal uterine bleeding, postmenstrual spotting, dysmenorrhea, pelvic pain, and infertility;) have now been associated with isthmocele. Obstetric complications of isthmocele were described in the literature, such as placenta accrete, placenta praevia, scar dehiscence, uterine rupture, and ectopic pregnancy in cesarean scar defects.
Various imaging methods including ultrasonography, sonohysterography, hysterography, hysteroscopy, and magnetic resonance imaging can be used to assess the anterior uterine wall and diagnose isthmocele. Transvaginal ultrasound (TVUS) is the initial and most usual method described to assess the integrity of the uterus wall in non-pregnant patients. Because the principal symptom is postmenstrual bleeding, the early proliferative phase best shows the deposit of blood within the isthmocele, allowing its identification even without the necessity of saline or gel infusion.
The aim of this study is to investigate the prevalence of cesarean scar defect in women with secondary infertility with history of previous cesarean delivery and also to measure agreement between diagnostic tools like three- dimensional ultrasound, hysterography, hysteroscopy and laparoscopy (when indicated) in assessment of isthmocele.
A prospective observational study conducted on 113 women with secondary infertility with history of previous cesarean delivery at Ain Shams University Maternity hospital. They were recruited at infertility clinic during period from January 2021 to December 2021. Detailed history including postmenstrual spotting, dysparonia, menometrorrhgia and pelvic pain were obtained. Also history was obtained about circumstances around cesarean section and factors affecting healing of cesarean scar like emergency (1st stage or 2nd stage) versus elective CS and post operative fever and blood transfusion, Roboson calassification was used to classify type of last casarean section of each patient.Each one was examined by three dimensional US, hysterography and hysteroscopy, laparoscopy if indicated.
Our study showed that the prevalence of CSD among cases of secondary infertility is 37.2%. Postmenstrual spots (18.6%) were the most common presentation among the studied infertile cases. We found that Cases with niche based on Hysteroscopy had significantly higher Parity and higher Previous cesarean sections as well as more frequent indications 1& 5 Robson classification, Emergency cesarean sections at 2nd stage of labour and blood transfusion in last cesarean delivery. So all these factors are significant independent factors that increase the likehood of having niche.
Niche was detected by 3D US, Hysterosalpingography, Laparoscopy and Hysteroscopy in 23.9%, 20.5%, 0.0% and 37.2% respectively. A total number of 51(45.1%) cases of niches were detected by all diagnostic tools among 113 (100%) cases of our study, 42 cases (82.4%) by hysteroscopy, 23(45.1%) cases by hysterosalpingography and 27 (52.9%) by 3D US. So our study showed that hysteroscopy is the most sensitive diagnostic tool among our study diagnostic tools.
The greement regarding niche diagnosis was significant moderate between Hysteroscopy and 3D US, also was significant low between Hystroslpingography and each of Hysteroscopy and 3D US. No significant agreement between laparaoscopy and other techniques regarding niche diagnosis.
Conclusion
The study showed that prevalence of CSD is 37.2% in infertile patients. CSD prevalence higher in patients with multiple previous cesarean sections and in patients with history of CS at labour. CSD associated with various of symptoms, postmenstrual spotting is the most common among all infertile patients of the study, also nonspecific pain and dyspareunia. Hysteroscopy is considered the golden standard tool for the diagnosis of CSD compared to 3D transvaginal ultrasound and hysterosalpingography.
Recommendations
It is worthy to use more than one modality of diagnostic tools to give more information about the niche and for better diagnosis and management of CSD. Further studies are needed for better evaluation of CSD using other diagnostic tools like sonohysterography and MRI, they would be worthy in diagnosis if compared to hysteroscopy and transvaginal US.
Further studies are needed for assessment of different risk factors of scar niche and its relationship to different gynecological symptoms. The relation between subfertility and a scar niche still needs to be fully proved.
Decreasing CSD by avoiding risk factors like encourage vaginal delivery and good uterine closure during cesarean section will decrease future obstetric and gynecological complication of CSD.