Isthmocele is a growing pathology due to the increase in the number of cesarean deliveries. Pelvic pain and abnormal uterine bleeding are common complaints in our clinical practice, and isthmocele should be included in the differential diagnosis, especially in women who underwent previous cesarean sections.info:eu-repo/semantics/publishedVersio

Brandão, A

de Vasconcelos Gaspar, A

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Clin Case Rep. 2022;10:e05727.	 	 		 |	 1 of 3https://doi.org/10.1002/ccr3.5727wileyonlinelibrary.com/journal/ccr3An	 isthmocele	 corresponds	 to	 a	 myometrial	 disconti-nuity	 at	 the	 hysterotomy	 site.	 Although	 its	 exact	 preva-lence	is	unknown,	it	is	an	emerging	pathology	due	to	the	increasing	 number	 of	 cesarean	 sections.	 Its	 prevalence	ranges	 from	24%	 to	70%	on	 transvaginal	ultrasound	and	between	 56%	 and	 84%	 on	 sonohysterography	 in	 women	Received:	15	July	2021	 |	 Revised:	12	March	2022	 |	 Accepted:	27	March	2022DOI:	10.1002/ccr3.5727		C L I N I C A L  I M A G EIsthmocele, a rising pathologyAndreia de Vasconcelos Gaspar1  |   Ana Brandão2This	is	an	open	access	article	under	the	terms	of	the	Creative	Commons	Attribution-	NonCommercial-	NoDerivs	License,	which	permits	use	and	distribution	in	any	medium,	provided	the	original	work	is	properly	cited,	the	use	is	non-	commercial	and	no	modifications	or	adaptations	are	made.©	2022	The	Authors.	Clinical Case Reports	published	by	John	Wiley	&	Sons	Ltd.1Serviço	de	Ginecologia	e	Obstetrícia	B,	Centro	Hospitalar	e	Universitário	de	Coimbra,	Coimbra,	Portugal2Serviço	de	Ginecologia	e	Obstetrícia,	Hospital	de	Cascais,	Alcabideche,	PortugalCorrespondenceAndreia	de	Vasconcelos	Gaspar,	Serviço	de	Ginecologia,	Centro	Hospitalar	e	Universitário	de	Coimbra,	Rua	Prof.	Mota	Pinto,	3004-	561	Coimbra,	Portugal.Email:	andreiadevasconcelosgaspar@gmail.comFunding informationThe	authors	declare	that	there	are	no	sources	of	financingAbstractIsthmocele	is	a	growing	pathology	due	to	the	increase	in	the	number	of	cesarean	deliveries.	Pelvic	pain	and	abnormal	uterine	bleeding	are	common	complaints	in	our	clinical	practice,	and	isthmocele	should	be	included	in	the	differential	diag-nosis,	especially	in	women	who	underwent	previous	cesarean	sections.K E Y W O R D Scesarean	scar	defect,	isthmocele,	niche,	uterine	sacculation,	uterine	scar	defectF I G U R E  1  Transvaginal	ultrasound	revealing	uterus	in	sagittal	section,	in	retroversion,	with	a	defect	in	the	isthmus,	at	the	site	of	an	anterior	scar2 of 3 |   de VASCONCELOS GASPAR and BRANDÃOwho	underwent	one	or	more	previous	cesarean	sections.1	It	is	often	associated	with	abnormal	uterine	bleeding	and	chronic	pelvic	pain.2A	32-	year-	old	woman,	melanodermic,	with	a	history	of	two	previous	cesarean	sections,	was	referred	due	to	pelvic	pain	with	several	months	of	evolution.	She	was	under	con-traception	 with	 a	 subcutaneous	 implant.	 She	 performed	a	transvaginal	ultrasound,	which	revealed	a	retroversion	uterus	measuring	79 × 33 × 43 mm,	with	regular	contours	and	a	myometrium	with	a	diffusely	heterogeneous	echo-structure;	with	the	endometrial	echo	measuring	2.4 mm.	At	the	level	of	the	hysterorrhaphy	zone,	a	23 × 8 × 37 mm	isthmocele	was	observed,	presenting	an	anechogenic	con-tent	with	suspended	echoes,	suggestive	of	collected	blood	(Figures 1	and	2).	Due	to	the	associated	symptomatology	and	volume	of	the	defect,	surgical	correction	was	decided.Isthmocele	 is	 an	 emerging	 pathology	 with	 associated	morbidity.2	 Ultrasound	 is	 a	 good	 method	 for	 diagnosing	this	 condition.	 Treatment	 depends	 on	 associated	 symp-toms,	 defect	 size,	 and	 reproductive	 desire.3	 Although	there	are	no	studies	on	the	prevention	of	this	pathology,	the	surgical	technique	seems	to	be	paramount,	since	there	is	a	correlation	between	cesarean	section	defects	and	low	hysterotomy,	 close	 to	 the	 cervical	 portion	 of	 the	 uterus.	Incomplete,	 unintentional	 closure	 of	 the	 myometrium's	deeper	muscular	layer	of	the	myometrium	can	also	lead	to	this	type	of	defects.4This	condition	should	be	considered	in	women	with	a	history	of	previous	cesarean	section,	with	complaints	of	pelvic	pain,	abnormal	uterine	bleeding,	or	infertility.CONFLICT OF INTERESTThe	authors	declare	that	they	have	no	conflicts	of	interest	related	to	this	work.AUTHOR CONTRIBUTIONSAndreia	 de	 Vasconcelos	 Gaspar	 involved	 in	 concep-tualization;	 methodology;	 software;	 investigation;	resources;	 writing—	original	 draft	 preparation;	 and	writing—	review	and	editing.	Ana	Brandão	 involved	 in	conceptualization;	validation;	writing—	review	and	edit-ing;	and	supervision.ETHICAL APPROVALThe	authors	declare	that	the	procedures	were	followed	ac-cording	to	the	regulations	established	by	the	2013	Helsinki	Declaration	 of	 the	 World	 Medical	 Association.	 The	 au-thors	declare	having	followed	the	protocols	in	use	at	their	working	center	regarding	patients'	data	publication.CONSENTWritten	informed	consent	was	obtained	from	the	patient	to	publish	this	report	in	accordance	with	the	journal's	pa-tient	consent	policy.DATA AVAILABILITY STATEMENTData	sharing	is	not	applicable—	no	new	data	are	generated.ORCIDAndreia de Vasconcelos Gaspar  	https://orcid.org/0000-0003-3071-1236	REFERENCES	 1.	 Tulandi	T,	Cohen	A.	Emerging	manifestations	of	cesarean	scar	defect	in	reproductive-	aged	women.	J Minim Invasive Gynecol.	2016;23(6):893-	902.	 2.	 Donnez	O.	Cesarean	scar	defects:	management	of	an	iatrogenic	pathology	whose	prevalence	has	dramatically	increased.	Fertil Steril.	2020;113(4):704-	716.F I G U R E  2  Isthmocele	in	axial	section,	with	the	largest	dimension	of	37 mm   | 3 of 3de VASCONCELOS GASPAR and BRANDÃO	 3.	 El-	Gharib	MN.	Uterine	 isthmocele	 (Niche	after	 cesarean	 sec-tion).	Gynecol Obstet Open Access Open J.	2019;I(1):13-	16.	 4.	 Vervoort	 AJ,	 Uittenbogaard	 LB,	 Hehenkamp	 WJ,	 Brölmann	HA,	Mol	BW,	Huirne	JA.	Why	do	niches	develop	in	caesarean	uterine	 scars?	 Hypotheses	 on	 the	 aetiology	 of	 niche	 develop-ment.	Hum Reprod.	2015;30(12):2695-	2702.How to cite this article:	de	Vasconcelos	Gaspar	A,	Brandão	A.	Isthmocele,	a	rising	pathology.	Clin Case Rep.	2022;10:e05727.	doi:10.1002/ccr3.5727

Isthmocele, a rising pathology

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Isthmocele, a rising pathology

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