Kremer Thaysa Guglieri, Ghiorzi Isadora Bueloni, Dibi Raquel Papandreus
Department of Medicine at the Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil.
Department of Medicine at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil.
Rev Assoc Med Bras (1992). 2019 Jun 3;65(5):714-721. doi: 10.1590/1806-9282.65.5.714.
An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.
剖宫产瘢痕憩室，又称剖宫产瘢痕缺损或子宫切口憩室，是指在前次剖宫产瘢痕部位，子宫前壁出现的任何代表肌层连续性中断的凹陷或三角形无回声缺损，其底部与子宫腔相通。根据肌层缺损的壁厚情况，可将其分为小缺损或大缺损。虽然通常无症状，但其主要症状是异常出血或经后出血，也可能出现慢性盆腔疼痛。不孕、胎盘植入或前置、瘢痕裂开、子宫破裂以及剖宫产瘢痕部位异位妊娠也可能是这种情况的并发症。迄今为止已证实的剖宫产瘢痕憩室的危险因素包括子宫后倾和多次剖宫产。然而，诸如剖宫产位置较低、子宫切口闭合不全、子宫壁早期粘连以及遗传易感性等因素也可能促使憩室形成。由于目前尚无诊断剖宫产瘢痕憩室的明确标准，可采用几种影像学方法来评估子宫壁的完整性，从而诊断剖宫产瘢痕憩室。然而，经阴道超声和盐水灌注子宫声学造影已成为诊断剖宫产瘢痕憩室的特异性、敏感性和性价比高的方法。治疗方法包括临床治疗或手术治疗，具体取决于缺损大小、症状的有无、继发性不孕的情况以及生育计划。手术治疗包括根据缺损大小采用保留技术的微创方法，如宫腔镜、腹腔镜或经阴道手术。
