<h2><span style="font-size: 14pt; color: #ff0000;"><strong>Cesarean Scar Defect Formation :<\/strong><\/span><\/h2>\r\n- It forms after cesarean delivery, at the site of hysterotomy, on the anterior wall of the\u00a0 uterine isthmus.\r\n- Improper healing of the cesarean incision leads to thinning of the anterior uterine wall,\u00a0which creates an indentation & a fluid-filled pouch at the cesarean scar site.\r\n<h2><span style="font-size: 14pt; color: #ff0000;"><strong>Cesarean Scar Defect Risk Factors :<\/strong><\/span><\/h2>\r\n- The exact reason why a niche develops has not yet been determined; however, Surgical\u00a0 techniques that may increase the chance of niche development include low (cervical)\u00a0 hysterotomy, single-layer uterine wall closure, use of locking sutures, closure of\u00a0 hysterotomy with endometrial-sparing technique & multiple cesarean deliveries. Patients\u00a0 with medical conditions that may impact wound healing (such as DM & smoking) may be\u00a0 at increased risk for niche formation.\r\n<h2><span style="font-size: 14pt; color: #ff0000;"><strong>Cesarean Scar Defect Complications :<\/strong><\/span><\/h2>\r\n- The presence of fibrotic tissue in the niche acts like a valve, leading to the accumulation\u00a0 of blood in this reservoir-like area. A niche thus can cause delayed menstruation,\u00a0 resulting in abnormal bleeding, pelvic pain, vaginal discharge, dysmenorrhea,\u00a0 dyspareunia & infertility. Accumulated blood in this area can ultimately degrade cervical\u00a0 mucus & sperm quality, as well as inhibit sperm transport, a proposed mechanism of\u00a0 infertility. Women with a niche who conceive are at potential risk for cesarean scar\u00a0 ectopic pregnancy, with the embryo implanting in the pouch & subsequently growing &\u00a0 developing improperly.\r\n<h2><span style="font-size: 14pt; color: #ff0000;"><strong>Cesarean Scar Defect Evaluation :<\/strong><\/span><\/h2>\r\n- The best time to assess for the abnormality is after the patient\u2019s menstrual cycle, when\u00a0 the endometrial lining is at its thinnest & recently menstruated blood has collected in the\u00a0 defect (this can highlight the niche on imaging).\r\n- Transvaginal U\/S or saline-infusion sonohysterogram serve as a first-line test for in\ufffeoffice diagnosis.\r\n<h2><span style="font-size: 14pt; color: #ff0000;"><strong>Cesarean Scar Defect Treatment :<\/strong><\/span><\/h2>\r\n- Treatments for cesarean scar defect vary dramatically & include hormonal therapy,hysteroscopic resection, laparoscopic repair & hysterectomy.\r\n- To promote fertility, the fibrotic tissue must be removed as the cesarean scar defect in a\u00a0 gravid uterus represents a risk for uterine rupture. The laparoscopic approach allows the\u00a0 defect to be repaired & restore the integrity of the myometrium.\r\n\r\n[caption id="attachment_2040" align="alignnone" width="800"]<img class="wp-image-2040 size-full" src="https:\/\/www.meduweb.com\/wp-content\/uploads\/2018\/03\/1522435685627-800x400.jpg" alt="Cesarean Scar Defect" width="800" height="400" \/> Cesarean Scar Defect[\/caption]\r\n<h2>\u00a0<span style="font-size: 14pt; color: #ff0000;"><strong>Technique of uterine closure (Uptodate) :<\/strong><\/span><\/h2>\r\n- Routine manual\/instrumental cervical dilatation before closing the uterus is unnecessary in both laboring and non-laboring women.\r\n- Do not irrigate the uterus with antibiotic solution before closure.\r\n- Choice of suture is largely based on personal preference.\r\n- 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.\r\n- We do not use locking sutures unless arterial bleeding is evident.\r\n- The endometrial layer should probably be included in the full thickness myometrial closure.\r\n- 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.\r\n- Do not close the visceral or parietal peritoneum because it saves time and there is no convincing evidence of harm (increased adhesion formation).