Pouch of sorrow: Undiagnosed isthmocele – presenting as secondary infertility of 11 years in a middle age female

In the past decade, the rate of cesarean sections has doubled leading to the more frequent occurrence of cesarean-related complications. Cesarean scar site diverticulum or isthmocele is one such complication that is defined as an outpouching of the anterior uterine wall at the cesarean scar site in continuity with the endometrial cavity, creating a wedge-shaped defect of variable depth. We report a case of a middle-aged female with secondary infertility for the last 11 years with one live issue 12 years back through a cesarean section at term. She had undergone an array of investigations for infertility for the past 5 years. She was diagnosed as having an isthmocele and managed with surgical repair of the defect at our hospital with subsequent assisted conception 8-month post-surgical repair. The importance of diagnosing a cesarean scar diverticulum cannot be understated not only because it is a surgically treatable cause of infertility but also because if such patients conceive, they may land in uterine rupture, placenta accreta, or scar ectopic pregnancy which can complicate into life-threatening situations.

Associação entre a técnica de fechamento uterino na cesárea e a istmocele: uma visão global / Association between uterine closure technique after cesarean and isthmocele: an overview

A istmocele (ou "defeito cicatricial de cesariana") é uma alteração anatômica na parede uterina responsável por formar um "nicho", que é visualizado como uma área hipoecoica por histerografia ou por outros métodos de imagem, devido a uma cicatrização inapropriada de uma cesárea anterior. Essa modificação leva a complicações ginecológicas e obstétricas. Este estudo pretendeu analisar, entre os fatores de risco, a relação da istmocele com a técnica de fechamento uterino, comparando a sutura em camada simples com a dupla. Foi realizada uma revisão de literatura por meio de pesquisa bibliográfica em diferentes bases de dados eletrônicos. Foram encontrados 31 artigos, todavia apenas 13 estudos foram incluídos no presente estudo após avaliação criteriosa. A técnica de fechamento uterino é um dos fatores de risco possível de prevenir, sendo que a sutura em camada simples é associada a maior chance de se desenvolver a istmocele. A sutura de camada simples (ancorada) incluindo o endométrio está relacionada a menor espessura miometrial residual, associada a probabilidade de ruptura uterina e a istmocele, que a camada dupla não ancorada com a exclusão do endométrio.(AU)

The isthmocele is an anatomical alteration in the uterine wall responsible for forming a "niche", which is visualized as a hypoechoic area by hysterography or other imaging methods, due to inappropriate healing of a previous cesarean section. This modification leads to gynecological and obstetric complications. This study aimed to analyze among the risk factors the relation of isthmocele and the uterine closure technique comparing the single- and double-layer suture. It was conducted an electronic based search in different electronic databases. The research led to the retrieval of 31 articles; however only 13 studies were included in the present research after careful reading. The uterine closure technique is one of the possible risk factors to be modified; the single-layer suture is associated with a greater chance of developing isthmocele. The locked single-layer suture including the decidua is related to the decreased residual myometrial thickness, associated with the likelihood of uterine rupture and the isthmocele, than the double-layer unlocked excluding the decidua.(AU)

Research progress of epidemiological characteristics and influencing factors of cesarean scar defect after cesarean section / 复旦学报（医学版）

With the rising rate of cesarean section (CS),the presence of a niche at the site of a CS scar,one of the potential long-term morbidity of CS,has also been increasingly observed.Currently,there are no standard diagnostic methods for evaluating cesarean scar defect (CSD).The incidence and prevalence of CSD are also not well established.Risk factors of CSD occurrence include history of CS,factors affecting labor,uterine position,closure technique,and factors related to immunity and inflammation.It is important to further study the epidemiology of CSD in order to prevent,treat and improve prognosis of CSD.

The Clinical Experience of Professor Zhang Qin in Treating Menostaxis Caused by Previous Cesarean Scar Defect / 浙江中医药大学学报

Objective] To sum up the clinical experience of professor Zhang Qin in treating menostaxis caused by PCSD. [Methods] From the TCM theory , therapy and successful case,it analyses the professor Zhang Qin's unique feature of PCSD.[Results] Professor Zhang considers that the disease is induced by the blades,which leads to blood stagnation-heat and Qi-deficiency,and puts forward the two-step traditional Chinese medicine: step one is to expel blood stasis using modified Jiawei Shixiaosan in the menstrual cycle from the first day to the fifth day ,step two is to stanch bleeding using modified Guchongtang in the menstrual cycle from the sixth day to the twelfth day. A case in point proves that two-step traditional Chinese medicine can recover the menstrual period normally. [Conclusion] Professor Zhang Qin's clinical experience in treating menostaxis caused by PCSD obtains the good curative effect,having enlightenment meaning to clinical practice,with promotion value.

The diagnosis value of transvaginal ultrasound combined with hysterosalpinography on previous cesarean scar defect / 中国医师进修杂志

Objective To investigate the clinical practice value of transvaginal ultrasound (TVU) combined with hysterosalpinography (HSG) in diagnosis of previous cesarean scar defect (PCSD).Methods Forty-two patients with colporrhagia,algomenorrhea or infertility after cesarean section were examined by TVU,HSG and hysteroscope.The results were compared among TVU,HSG and TVU combined with HSG.Results Among the 42 patients,21 patients were diagnosed PCSD by hysteroscope.The sensitivity of TVU was 66.7％ (14/21),specificity was 95.2％ (20/21),positive predictive value was 14/15,negative predictive value was 74.1％ (20/27).The sensitivity of HSG was 95.2％ (20/21),specificity was 100.0％ (21/21),positive predictive value was 100.0％(20/20),negative predictive value was 95.5％(21/22).The sensitivity of TVU combined with HSG was 95.2％(20/21),the sensitivity of TVU combined with HSG was significantly higher than TVU,there was statistical difference (P ＜0.05).Conclusions Compared with TVU,the sensitivity of TVU combined with HSG is increased markedly.TVU combined with HSG is a feasible clinical diagnostic method.