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Diagnosis And Treatment For Isthmocele
Published on: September 27, 2024
diagnosis and treatment for isthmocele
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Masudah Fahimah

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Darius Obeng Essah

Pharm D, Kwame Nkrumah University of Science and Techology

This article explores isthmocele, a common complication arising from cesarean sections. It discusses risk factors, diagnosis, and treatment options, providing insights into the comprehensive management of this condition for improved patient care.

What is isthmocele?

The most prevalent surgical procedure performed worldwide is cesarean section.1,2 In the past decades, the percentage of cesarean section deliveries has significantly increased in developed countries.3,4 Data from 150 countries shows that cesarean section rates are 6 to 27.2%.4,5 Additionally, a greater likelihood of cesarean section has been linked to higher maternal socioeconomic status.6 According to the World Health Organization, the optimal cesarean section rate is approximately 15%.7 Generally, the incision from a cesarean section surgery heals without complications. However, there are a risks of complications.8 Isthmocele, also known as pouch, diverticulum, or niche, is a cesarean scar defect first described in 1961 by Poidevin.9 Poidevin described an isthmocele as a defect in the uterine wall that is shaped like a wedge. Currently, an isthmocele is described as a hypoechoic region found within the myometrium (the middle layer of the uterine wall) of the lower portion of the uterus, indicating a break in the continuity of the myometrium where the uterine scar from a prior cesarean section is located. A hyperechoic region is a term that is used to define an area of the body shown to be darker on an ultrasound scan.7,8,10 It is unclear how or why isthmocele develops but researchers have studied possible risk factors related to patient factors and surgical technique.3,7,11 It should be noted that the current literature has very limited data due to a lack of evidence.

Risk factors

Patient factors

Patient factors refer to a variety of conditions or characteristics which are related to the individual who is seeking medical care. These factors may significantly influence the development of isthmocele and the healing process after a cesarean section.7 Some studies have found that these factors may include, multiple cesarean sections, hypertension, body mass index or BMI, and a retroflexed uterus( a uterus that tilts backwards rather than forwards).3,7,12,13 To fully elucidate why some patients develop cesarean scars whilst others do not, further research is required.

Surgical technique

A risk factor that has been associated with the development of isthmocele is a very low incision in the uterus.14 Additionally, a higher prevalence of cesarean section defects has been associated with patients who have sectioned during active labor with cervical effacement(the thinning of the cervix before and during labor).15,16 It has also been found that there is increased development of isthmocele when labor is more than 5 hours and cervical dilation (the opening of the cervix) is more than 5 cm.17 Another possible factor may be the technique used to close the incision- a single-layer or double-layer closure.3,7,8 The closure techniques used have evolvedover the years and vary from country to country. For example in the United Kingdom, the recommended technique is the double-layer closure whereas, in the Netherlands and Belgium, the most performed technique is a single-layer closure.7,18 Clinical trials assessed maternal outcomes in patients who underwent cesarean section 6 weeks after receiving a single-layer or double-layer closure.19,20 It was found that there were no significant differences between a single-layer or double-layer closure technique in terms of maternal outcome. However, another study found a statistically significant larger defect area when comparing a continuous single-layer technique vs an interrupted single-layer technique.21 Continuous techniques use absorbable or non-absorbable sutures underneath the surface of the skin whilst, interrupted techniques use non-absorbable sutures and full skin thickness.22 Furthermore, another factor may include the surgery itself, it is known that surgeries may cause bands of scar tissue which could be due to lack of oxygen to the tissue, inflammation, or manipulation of the tissue.7,23

Diagnosis

Since 1990, cesarean scar defects have been evaluated using ultrasound scans particularly transvaginal ultrasounds which is now the most common technique used.11 Six classifications of isthmocele have been proposed depending on the shape: circle, triangle, rectangle, droplet, semicircle, and inclusion cysts. When scanning for isthmocele using transvaginal ultrasound exams the following are examined: width, length, depth, position, and residual myometrium thickness. The most useful measurement for evaluation of isthmocele is residual myometrium thickness.24 Notably, it has been found that the residual myometrium thickness is thicker in patients who received double-layer closures compared to those who received single-layer closures.8 Additionally, the scar is thinner in cesarean-section patients that have previously undergone two or more cesarean-section surgeries. Furthermore, the scar is thicker in patients who have undergone previous surgeries more than 2 years apart.25 Another valuable diagnostic tool could be magnetic resonance imaging or MRI, which could be useful to evaluate the depth of the isthmocele, the lower uterine segment thickness, and the content of the cavity of the defects. The use of MRI may allow for faster diagnosis and clear definition of the defect particularly, especially for patients with unexplained abnormal uterine bleeding.11,26

Treatment

Treatment of isthmocele is focussed on symptomatic relief, thus cases that do not have any symptoms do not require treatment. Common symptoms include abnormal uterine bleeding, pelvic pain, painful period cramps, prolonged menstruation, and infertility.1,3,11 Treatment can be divided into medical treatment and surgical treatment, usually, surgical treatment is used. Surgical treatment includes vaginal repair, hysteroscopy, laparotomy, laparoscopy, and combined techniques.27,28

Medical treatment

It has been found that oral contraceptives are effective in reducing bleeding disorders which are linked to isthmocele, this could be due to their effect on the innermost lining of the uterus. Research has shown a hysteroscopy is more effective in reducing postmenstrual abnormal uterine bleeding and pelvic pain when compared to oral contraceptives.29 Thus, medical treatment could be a favorable option for patients who seek conservative therapy and do not want to conceive.

Vaginal repair

Chen et al, performed surgery to remove the isthmocele and repair the area by trimming the edges of the incisions. This procedure takes approximately 34 minutes and has been shown to improve prolonged menstruation in 85.9% to 92.9% of patients.31 Vaginal repair and laparoscopic repair are comparable in terms of effectiveness. However, the vaginal repair is quicker with lower hospitalization costs.30

Hysteroscopy

A hysteroscopy utilizes a thin tube with a camera to test inside the uterus. For cervical exploration and investigating abnormal uterine bleeding hysteroscopy is the gold standard.32 Isthmocele can be diagnosed using a hysteroscopy and then treated using a surgical technique known as isthmosplasty which involves removing scar tissue. This procedure takes 8 to 25 minutes with a success rate of 59.6% to 100%. Additionally, for those experiencing infertility, 12 to 24 months after an isthmosplasty those who wanted to conceive were able to spontaneously concieve. When comparing vaginal repair, hysteroscopy, intrauterine device, medical treatment, and laparoscopy research shows that hysteroscopy is more advantageous due to the shorter surgical duration, lower hospital fee, decreased hospital stays, and decreased blood loss. Nonetheless, a major disadvantage is that the sutures may lead to the enlargement of the defects.33,34

Laparotomy

A laparotomy uses an incision in the wall of the stomach to gain access to the inner organs. Laparotomy has been shown to be successful in the relief of abdominal pain and postmenstrual spotting.35 Additionally, following a laparotomy, there is a 71% rate of pregnancy.36

Laparoscopy

Laparoscopy is a type of keyhole surgery that allows the use of small cuts and a camera. Once identified the isthmocele and surrounding scar tissue can be cut out. This procedure ranges from 42 to 240 minutes depending on the complexity.35 It has been shown that this treatment can reduce post-menstrual bleeding, painful period cramps, spotting and pregnancy rates post-surgery is 44%.24,37

Summary

The article covers isthmocele, a uterine wall defect from prior cesarean sections, discussing risk factors, diagnosis, and treatments. Diagnosis involves ultrasound or MRI scans, while treatments range from medical management to surgical interventions like vaginal repair, hysteroscopy, or laparoscopy. Treatment choice depends on symptoms and fertility desires, emphasizing personalized care.

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Masudah Fahimah

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