Abstract
Background: Cesarean section is one of the most common surgical procedures in young women. Cesarean scar defects may occur postoperatively and may cause symptoms such as chronic pain, postmenstrual bleeding as well as secondary infertility. Case presentation: We report the case of a 35-year-old woman who was referred to our center for the management of a large cesarean scar defect. She had history of two cesarean sections and presented with abnormal uterine bleeding, chronic pain and dyspareunia. Hysteroscopic examination showed the presence of a little isthmocele on the anterior uterine wall. Hysteroscopic resection with electrocoagulation was performed. The patient remained symptomatic and, unfortunately, five years later, magnetic resonance imaging (MRI) revealed a large anterior isthmocele (50x80 mm). A complete repair of the large defect was achieved by laparotomy.Postoperative MRI as well as hysteroscopic examination showed no signs of residual isthmocele. Conclusion: There are three main surgical options for isthmocele repair: vaginal approach, hysteroscopic resection or laparoscopic resection and repair of the uterine wall. While there is no clear consensus about general management of isthmocele, there are very few cases the medical literature of large isthmoceles, such as the one we describe. This case is interesting since no case of worsening of isthmocele following hysteroscopic treatment has been described so far.
Highlights
Cesarean section is one of the most common surgical procedures in young women
A complete repair of the large defect was achieved by laparotomy.Postoperative magnetic resonance imaging (MRI) as well as hysteroscopic examination showed no signs of residual isthmocele
We describe a large isthmocele, the size of which dramatically increased after hysteroscopic resection
Summary
Cesarean section is one of the most frequent surgical procedures in women and its incidence is constantly rising in most developed countries [1]. A 35-year-old woman was referred to our center for the management of a large cesarean scar defect Her medical history showed a laparoscopic ovarian cystectomy for an endometrioma. Hysteroscopic examination showed a small cesarean scar defect on the anterior wall of the uterine isthmus. MRI showed complete repair of the scar defect, with a normal anterior uterine wall (Figure 1B). Common risk factors for the development of cesarean scar defect include cesarean section with cervical dilatation ≥ 5 cm or labor duration ≥ 5 h, low (cervical) hysterotomy, single-layer uterine wall closure, use of locking sutures, closure of hysterotomy with endometrial-sparing technique, multiple cesarean deliveries, uterine retroflexion as well as patient-related factors that may impact wound healing, such as diabetes and smoking [3, 4]. Laparotomy is not often described as an option for isthmocele treatment, but in difficult cases with lots of adherences and extremely large defects it appears to be a reasonable and effective solution
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