Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update
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MINI REVIEW ARTICLE
Post‑caesarean Niche (Isthmocele) in Uterine Scar: An Update Vidushi Kulshrestha1 · Nutan Agarwal1,2 · Garima Kachhawa1 Received: 7 April 2020 / Accepted: 1 August 2020 © Federation of Obstetric & Gynecological Societies of India 2020
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. Keywords Uterine niche · Isthmocele · Caesarean scar defect
Introduction Uterine niche is an iatrogenic pouch-like defect at the site of previous caesarean scar due to defective tissue healing. Other terms used are uterine isthmocele, caesarean scar defect, uterine dehiscence and diverticulum. The niche is defined radiologically as a triangular, hypoechoic or anechoic area at scar site [1, 2]. It has also been described as Vidushi Kulshrestha is a Associate Professor, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India; Nutan Agarwal is a Consultant Gynaecologist, Head- Fetal Medicine, Department of Obstetrics and Gynaecology, Artemis Hospital, Gurugram, Haryana, India; Ex-Professor, Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India; Garima Kachhawa is a Additional Professor, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India. * Vidushi Kulshrestha [email protected] 1
Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, 3082 A, 3rd Floor, Teaching Block, Ansari Nagar, New Delhi 110029, India
Department of Obstetrics and Gynaecology, Artemis Hospital, Gurugram, Haryana, India
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indentations at least 2 mm deep in the myometrium [1, 3]. There is recent surge in the literature including reviews addressing various aspects of niche [4, 5].
Prevalence Uterine niche occurs in up to 70% women with previous caesarean of whom 30% are s
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