Cesarean Scar Defect Formation :
– It forms after cesarean delivery, at the site of hysterotomy, on the anterior wall of the uterine isthmus.
– Improper healing of the cesarean incision leads to thinning of the anterior uterine wall, which creates an indentation and a fluid-filled pouch at the cesarean scar site.
Cesarean Scar Defect Risk Factors :
– The exact reason why a niche develops has not yet been determined; however, Surgical techniques that may increase the chance of niche development include low (cervical) hysterotomy, single-layer uterine wall closure, use of locking sutures, closure of hysterotomy with endometrial-sparing technique and multiple cesarean deliveries. Patients with medical conditions that may impact wound healing (such as DM and smoking) may be at increased risk for niche formation.
Cesarean Scar Defect Complications :
– The presence of fibrotic tissue in the niche acts like a valve, leading to the accumulation of blood in this reservoir-like area. A niche thus can cause delayed menstruation, resulting in abnormal bleeding, pelvic pain, vaginal discharge, dysmenorrhea, dyspareunia and infertility. Accumulated blood in this area can ultimately degrade cervical mucus and sperm quality, as well as inhibit sperm transport, a proposed mechanism of infertility. Women with a niche who conceive are at potential risk for cesarean scar ectopic pregnancy, with the embryo implanting in the pouch, subsequently growing and developing improperly.
Cesarean Scar Defect Evaluation :
– The best time to assess for the abnormality is after the patient’s menstrual cycle, when the endometrial lining is at its thinnest and recently menstruated blood has collected in the defect (this can highlight the niche on imaging).
– Transvaginal U/S or saline-infusion sonohysterogram serve as a first-line test for in-office diagnosis.
Cesarean Scar Defect Treatment :
– Treatments for cesarean scar defect vary dramatically and include hormonal therapy, hysteroscopic resection, laparoscopic repair and hysterectomy.
– To promote fertility, the fibrotic tissue must be removed as the cesarean scar defect in a gravid uterus represents a risk for uterine rupture. The laparoscopic approach allows the defect to be repaired and restore the integrity of the myometrium.
Technique of uterine closure (Uptodate) :
– Routine manual/instrumental cervical dilatation before closing the uterus is unnecessary in both laboring and non-laboring women.
– Do not irrigate the uterus with antibiotic solution before closure.
– Choice of suture is largely based on personal preference.
– Myometrial closure: perform a 2-layer, continuous closure with delayed absorbable synthetic suture incorporating all of the muscle to avoid bleeding from the incision edges.
– We do not use locking sutures unless arterial bleeding is evident.
– The endometrial layer should probably be included in the full thickness myometrial closure.
– Perform a 2-layer rather than a single-layer uterine closure, but use a single-layer closure when a tubal ligation is performed concurrently. If a single-layer closure is performed to save time, we suggest an unlocked technique. A double (or even triple)- layer closure may be necessary when the myometrium is thick, such as with a classical incisions.
– Do not close the visceral or parietal peritoneum because it saves time and there is no convincing evidence of harm (increased adhesion formation).
Cesarean Scar Defect PPT(power point presentations):