Search Results (15)

Background: Cesarean section (CS) is one of the most frequently performed surgical procedures worldwide, with postoperative wound complications and suboptimal scarring contributing to maternal morbidity. Platelet-rich plasma (PRP) has been proposed as a regenerative adjunct; however, existing evidence remains heterogeneous and incompletely synthesized. Objectives: The purpose of this review was to evaluate the efficacy and safety of PRP for wound healing and scar outcomes after cesarean section, including uterine scar healing outcome Methods: This systematic review and meta-analysis was conducted according to PRISMA 2020 guidelines and prospectively registered in PROSPERO (CRD420261383413). Major databases were searched from inception to April 2026 for randomized controlled trials (RCTs) evaluating PRP versus standard care in women undergoing CS. Primary outcomes included scar quality (POSAS) and early wound healing (REEDA), while secondary outcomes included pain (VAS), Vancouver Scar Scale (VSS), and uterine scar parameters. Random-effects models were used, and risk of bias and certainty of evidence were assessed using established tools. Results: Five RCTs (n = 366) were included in the quantitative synthesis. PRP was associated with improved patient-reported scar quality (POSAS-patient: SMD −0.50, 95% CI −0.83 to −0.17) and clinician-assessed scar quality (POSAS-observer: SMD −0.42, 95% CI −0.75 to −0.10), as well as reduced early wound inflammation (REEDA: SMD −0.52, 95% CI −0.84 to −0.20), with low statistical heterogeneity. No significant reduction in early postoperative pain was observed (VAS: SMD −0.22, 95% CI −0.50 to 0.06). Evidence regarding uterine scar outcomes was limited and imprecise. No PRP-related adverse events were reported. Conclusions: Intraoperative PRP may improve scar quality and early wound healing following cesarean section while not significantly affecting early postoperative pain. Given the limited number of RCTs and variability in PRP protocols, these findings should be interpreted with caution. Further well-designed, adequately powered trials with standardized methodologies are required to confirm clinical effectiveness and long-term outcomes. Full article

Background/Objectives: Post-cesarean section scar niche pregnancy is one of the rarest forms. It is characterized by implantation of the gestation sac within the scar niche and is often associated with chorionic villi adhesion into the thinned cesarean section scar. The increasing incidence of this condition is associated with the increasing frequency of cesarean sections and the widespread use of ultrasound in early pregnancy. The most significant clinical findings are the detection of chorionic villus invasion and uterine wall insufficiency, which may be detected using magnetic resonance imaging, including contrast, and are crucial for determining patient management. This pathology may be considered life-threatening due to complications such as early uterine rupture with bleeding, which, if not diagnosed promptly, can lead to hysterectomy and loss of the woman’s reproductive health. Early diagnosis allows for the use of conservative treatment methods, preserving the uterus. The aim of the study is to clarify the clinical practices to follow in cases where an MRI examination with contrast agent is indicated to be performed on a pregnant patient. Methods: Ultrasound and MRI examination with counter-rotation, as well as histological and immunohistochemical examination of the remnants of the gestational sac were performed. Results: A 36-year-old pregnant woman was hospitalized in her eighth week of pregnancy with complaints of vaginal bleeding and persistent abdominal pain. An ultrasound scan revealed a pregnancy of 8 weeks and 5 days, and a low-lying chorion in the isthmus of the uterus, along with thinning of the cesarean scar and the formation of a scar niche resembling a hernia. Early signs of chorionic invasion were not treated. An MRI revealed signs of superficial chorionic adhesion to the cesarean scar, both to the isthmus and the internal os. Given that the woman did not wish to continue the pregnancy, uterine artery embolization was performed to reduce potential blood loss. Subsequently, laparoscopy, adhesiolysis, vacuum aspiration of the gestational sac, uterine curettage, hysteroresectoscopy, and coagulation of the fetal bed were performed. Histological and immunohistochemical examination revealed signs of inflammation in the area of the suspected lesion. Conclusions: This case report shows the potential value of MRI in complex cases of ultrasound detection of a gestational sac within scar tissue. MRI was used to assess the location of the gestational sac and evaluate the thickness of the cesarean scar to detect its dysfunction. Furthermore, contrast enhancement of the MRI may be useful in the most complex cases but requires an informed consent discussion with the patient. However, the latter issue requires discussion and proof of its safety for the fetus. Full article

Background and Clinical Significance: Cesarean scar pregnancy (CSP) is a rare complication that can occur after cesarean delivery, potentially exposing the patient to severe and life-threatening complications. This case report aimed to illustrate the evolution of CSP cases following initial conservative surgical treatment. Case Presentation: We present two cases involving pregnant women aged 29 and 36 years, both diagnosed with type 2 CSP based on ultrasound findings between 6 and 8 weeks of gestation. In these cases, we initially performed an aspirative curettage after administering systemic Methotrexate (MTX) or Mifepristone. Unfortunately, both patients experienced severe bleeding during the aspirative curettage, which necessitated emergency abdominal hysterectomy along with bilateral salpingectomy. Additionally, we provide an updated review of the related literature. Conclusions: For optimal outcomes, treatment must be tailored to various factors, including gestational age at diagnosis, gestational sac size, anterior myometrial thickness, and the presence of embryonic cardiac activity. Full article

Background/Objective: Cesarean scar pregnancy (CSP) represents a challenging and potentially life-threatening form of ectopic pregnancy. This study aims to assess the feasibility, safety, and clinical efficacy of employing the hysteroscopic mechanical tissue removal system as a primary treatment modality for CSP. Methods: This retrospective cohort study included 53 patients diagnosed with CSP who underwent primary hysteroscopic resection at a tertiary care center. The surgical procedure was performed by prioritizing the “no-touch” vaginoscopic approach, which avoids instrumentation. Success rates, operation time, time to negative serum β-hCG, complications, and differences between the anatomical types of CSP (Type 1 vs. Type 2) were analyzed. Results: Primary hysteroscopic treatment was successful in 51 of 53 patients (96.2%). For the entire cohort, the median operative time was 7 min (range: 2–30), and the median interval to β-hCG negativization was 11 days (range: 6–45). The overall major complication rate was 3.8% (n = 2). One case was deemed unsuccessful due to conversion to laparotomy following uterine perforation during cervical dilation. Another patient, diagnosed with persistent trophoblastic disease requiring methotrexate (MTX) therapy, was also considered a treatment failure. Operative time was significantly longer in patients with Type II CSP compared with Type I (median 9 min vs. 5 min; p = 0.0004). Conclusions: Hysteroscopic mechanical tissue removal as a primary treatment for cesarean scar pregnancy represents an effective and safe “one-step” approach, characterized by a high success rate, rapid β-hCG resolution, and a low incidence of complications. This fertility-preserving, minimally invasive technique may be considered a primary treatment option for hemodynamically stable patients with CSP, provided that appropriate patient selection is undertaken and sufficient surgical expertise is available. Full article

Background and Objectives: A cesarean scar defect (CSD), also referred to as a niche or isthmocele, is often detected incidentally during transvaginal sonography (TVS) and is typically asymptomatic. However, the exact prevalence of symptomatic niches remains unclear. This study aimed to evaluate the incidence of cesarean scar niches and identify potential risk factors in a prospectively gathered cohort of Egyptian women. Materials and Methods: The primary endpoint was to determine the incidence of isthmoceles after six months following a cesarean section (CS) and to investigate any associated symptoms and risk factors. The study included 420 women, divided into three groups: Group A included 140 women who had undergone their first CS, Group B included 140 women with a history of two CSs, and Group C consisted of 140 women with more than two prior CSs. Results: Niches were identified in 23.8% of the participants via TVS. The highest incidence was observed in women with more than two previous CSs (31.2%, 39/125), followed by those with two prior CSs (24.4%, 30/123), and the lowest was among women with one previous CS (16.3%, 22/135). Of the 91 women diagnosed with a CS niche, only 23 (25.27%) reported symptoms—most commonly postmenstrual spotting (7.7%) and dyspareunia (8.8%). Conclusions: The findings indicate that multiple cesarean deliveries, the uterine positioning (as assessed via TVS), a postpartum fever, breastfeeding, low post-cesarean platelet counts, and maternal anemia are contributing factors to the development of cesarean scar niches. Full article

Background/Objectives: To assess the effectiveness of the levonorgestrel-releasing intrauterine device (LNG-IUD) compared to hysteroscopic resection for managing women with symptomatic cesarean scar defects (CSDs). Methods: This systematic review and meta-analysis followed PRISMA guidelines. A comprehensive search of four electronic databases was conducted to identify studies comparing LNG-IUD with hysteroscopic management for symptomatic CSDs. Studies reporting outcomes of bleeding and spotting days and effectiveness rates were included. Quality assessment was performed using the ROBINS-I and RoB-2 tools. Results: Three studies involving 344 patients met the inclusion criteria. At 6 months, LNG-IUD use significantly reduced total bleeding days (MD −4.13; 95% CI: −5.17 to −3.09; p < 0.00001) and spotting days (MD 1.90; 95% CI: 0.43 to 3.37; p = 0.01) compared to hysteroscopic treatment. By 12 months, LNG-IUD demonstrated superior effectiveness (OR 3.46; 95% CI: 1.53 to 7.80; p = 0.003), with fewer total bleeding days (MD −5.69; 95% CI: −6.55 to −4.83; p < 0.00001) and spotting days (MD 3.09; 95% CI: 1.49 to 4.69; p = 0.0002). Approximately 50% of LNG-IUD users experienced amenorrhea within 1 year. Conclusions: LNG-IUD offers a minimally invasive and effective alternative to hysteroscopic resection for women with symptomatic CSD and no desire for future pregnancies. Its role should be considered in clinical practice, but further research is needed to validate these findings and define its long-term benefits and limitations. Full article

Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman’s quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5–3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted. Full article

Cesarean scar defect, also known as niche, isthmocele, uteroperitoneal fistula and uterine diverticulum, is a known complication after cesarean delivery. Due to the rising cesarean delivery rates, niche has become more common and can present as irregular bleeding, pelvic pain, infertility, cesarean scar pregnancy and uterine rupture. Treatments for symptomatic cesarean scar defect vary and include hormonal therapy, hysteroscopic resection, vaginal or laparoscopic repair, and hysterectomy. We report on the safety and efficacy of our method of repairing cesarean scar defects in 27 patients without adverse outcomes: two-layer repair where the suture does not enter the uterine cavity. Our method of laparoscopic niche repair improves symptoms in nearly 77% of patients, restores fertility in 73% of patients, and decreases the time to conception. Full article

(1) Background: Uterine niche is a frequent condition in patients with a history of cesarean section. Although the relation to uterotomy seems to be clear, the exact pathogenesis is not fully understood. Uterine niche can easily be diagnosed by transvaginal ultrasound. It can be related to symptoms like dysmenorrhea, bleeding disorders, dysuria and dyspareunia. Uterine niche can be the cause of scar pregnancy, a rare form of ectopic pregnancy which can be related to severe complications; (2) Methods: We present a series of nine cases with different uterine niche related findings and discuss the diagnostic and therapeutic options reviewing the current literature and introduce a novel intrauterine ICG use for laparoscopic niche detection in one case; (3) Results: Most of uterine niche related symptoms and complications can be treated by a minimally invasive approach. Laparoscopic fluorescence guided niche detection is feasible; (4) Conclusions: Hysteroscopic and laparoscopic techniques allow the treatment of uterine niche related symptoms and complications. Intrauterine ICG application during fluorescence guided laparoscopy may allow easy niche detection. Full article

Background and Objectives: The aim of this study is to evaluate changes in uterine scar thickness after previous cesarean delivery longitudinally during pregnancy, and to correlate cesarean section (CS) scar myometrial thickness in the first trimester in two participants groups (CS scar with a niche and CS scar without a niche) with the low uterine segment (LUS) myometrial thickness changes between the second and third trimesters. Materials and Methods: In this prospective longitudinal study, pregnant women aged 18–41 years after at least one previous CS were included. Transvaginal sonography (TVS) was used to examine uterine scars after CS at 11–14 weeks. The CS scar niche (“defect”) was defined as an indentation at the site of the CS scar with a depth of at least 2 mm in the sagittal plane. Scar myometrial thickness was measured, and scars were classified subjectively as a scar with a niche (niche group) or without a niche (non-niche group). In the CS scar niche group, RMT (distance from the serosal surface of the uterus to the apex of the niche) was measured and presented as CS scar myometrial thickness in the first trimester. The myometrial thickness at the internal cervical os was measured in the non-niche group. The full LUS and myometrial LUS thickness at 18–20 and 32–35 weeks of gestation were measured in the thinnest part of the scar area using TVS. Friedman’s ANOVA test was used to analyse scar thickness during pregnancy and Mann–Whitney test to compare scar changes between CS scar niche and non-niche women groups. For a pairwise comparison in CS scar thickness measurements in the second and third trimesters, we used Wilcoxon Signed Ranks test. Results: A total of 122 eligible participants were recruited to the study during the first trimester of pregnancy. The scar niche was visible in 40.2% of cases. Uterine scar myometrial thickness decreases during pregnancy from 9.9 (IQR, 5.0–12.9) at the first trimester to 2.1 (IQR, 1.7–2.7) at the third trimester of pregnancy in the study population (p = 0.001). The myometrial CS scar thickness in the first trimester (over the niche) was thinner in the women’s group with CS scar niche compared with the non-niche group (at internal cervical os) (p < 0.001). The median difference between measurements in the CS scar niche group and non-niche group between the second and third trimester was 2.4 (IQR, 0.8–3.4) and 1.1 (IQR, 0.2–2.6) (p = 0.019), respectively. Myometrial LUS thickness as percentage decreases significantly between the second and third trimester in the CS scar niche group compared to the non-niche group (U = 1225; z = −2.438; p = 0.015). Conclusions: CS scar myometrial thickness changes throughout pregnancy and the appearance of the CS scar niche was associated with a more significant decrease in LUS myometrial thickness between the second and third trimesters. Full article

Objective: The aim of this study is to propose a standardized management of care for patients diagnosed with cesarean scar pregnancy (CSP). There are two types of CSP: Type 1 (on the scar) vs. type 2 (in the niche). To date there is no international standard to predict the extent of invasion or the optimal management of CSP. Materials and methods: We used intramuscular methotrexate injection followed by uterine artery embolization combined with suction evacuation as a conservative approach for the treatment of seven patients diagnosed with CSP. Our inclusion criteria, to be satisfied simultaneously, were established as follows: (1) patients with CSP; (2) early gestational age ≤ 9 weeks, and (3) written consent of the proposed treatment of the patient. Results: This course of treatment produced a positive outcome in all cases. We did not have any complications (e.g., emergency hysterectomy, perforation of the uterine cavity, severe hemorrhage, or endometritis) during the procedures or in the follow-up. The most important predictors of successful management are early diagnosis of CSP and orientation of the invasive trophoblast opposite to the scar. Conclusions: The main finding from this series of cases is that associating systemic methotrexate and uterine artery embolization provides efficient and low-risk management of CSP. This treatment regime is adequate for both types of CSPs. We consider that early localization diagnosis of pregnancy following a cesarean delivery is mandatory for CSP morbidity prevention. Full article

Objective: To evaluate the effect of laparoscopic isthmocele repair on isthmocele-related symptoms and/or fertility-related problems. The residual myometrial thickness before and after subsequent cesarean section was also evaluated. Design: Retrospective, case series. Setting: Public university hospital. Population: Women with isthmocele (residual myometrium < 5 mm) complaining of abnormal uterine bleeding, chronic pelvic pain or secondary infertility not otherwise specified. Methods: Women’s complaints and the residual myometrium were assessed pre-operatively and at three to six months post-operatively. In patients who conceived after surgery, the latter was measured at least six months after delivery by cesarean section. Main Outcome Measures: Resolution of the main symptom three to six months after surgery and persistence of laparoscopic repair benefits after subsequent cesarean section were considered as primary outcome measures. Results: Overall, 31 women underwent laparoscopic isthmocele repair. The success rates of the surgery as improvement of abnormal uterine bleeding, chronic pelvic pain and secondary infertility were 71.4% (10 of 14), 83.3% (10 of 12) and 83.3% (10 of 12), respectively. Mean residual myometrial thickness increased significantly from 1.77 mm pre-operatively to 6.67 mm, three to six months post-operatively. Mean myometrial thickness in patients who underwent subsequent cesarean section (N = 7) was 4.49 mm. In this sub-group, there was no significant difference between the mean myometrial thickness measured after the laparoscopic isthmocele repair and that measured after the subsequent cesarean section. None of these patients reported recurrence of their symptoms after delivery. Conclusion: Our findings suggest that the laparoscopic isthmocele excision and repair is an appropriate approach for the treatment of isthmocele-related symptoms when done by skilled laparoscopic surgeons. The benefit of this new surgical approach seems to persist even after a subsequent cesarean section. Further investigations and prospective studies are required to confirm this finding. Full article

The definition of a cesarean scar pregnancy (CSP) is the localization of the gestational sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous cesarean section (CS). The worldwide prevalence of CSP has been growing rapidly. However, there are no general recommendations regarding prophylaxis and treatment of the abnormalities of the anterior wall of the uterus discovered in a non-pregnant myometrium, or how to deal with existing cases of CSP. We present the latest knowledge, a holistic approach to the biology, histology, imaging, and management concerning post-CS scars based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy in the Medical University of Lublin, Poland. In our study, we present images of tissue samples of areas with a cicatrix in the uterus, and ultrasound and MRI images of CSP. We discuss the advances in the biology of the post-CS scar tissue, the prevention techniques used to repair the scar defect (niche) before the pregnancy, and the treatment of different complications of CSP, such as the rupture of the gravid uterus or the dehiscence of the myometrium. Full article

Background and Objectives: To investigate the prevalence of a Cesarean section (CS) scar niche during pregnancy, assessed by transvaginal ultrasound imaging, and to relate scar measurements, demographic and obstetric variables to the niche evolution and final pregnancy outcome. Materials and Methods: In this prospective observational study, we used transvaginal sonography to examine the uterine scars of 122 women at 11⁺⁰–13⁺⁶, 18⁺⁰–20⁺⁶ and 32⁺⁰–35⁺⁶ weeks of gestation. A scar was defined as visible on pregnant status when the area of hypoechogenic myometrial discontinuity of the lower uterine segment was identified. The CS scar niche (“defect”) was defined as an indentation at the site of the CS scar with a depth of at least 2 mm in the sagittal plane. We measured the hypoechogenic part of the CS niche in two dimensions, as myometrial thickness adjacent to the niche and the residual myometrial thickness (RMT). In the second and third trimesters of pregnancy, the full lower uterine segment (LUS) thickness and the myometrial layer thickness were measured at the thinnest part of the scar area. Two independent examiners measured CS scars in a non-selected subset of patients (n = 24). Descriptive analysis was used to assess scar visibility, and the intraclass correlation coefficient (ICC) was calculated to show the strength of absolute agreement between two examiners for scar measurements. Factors associated with the CS scar niche, including maternal age, BMI, smoking status, previous vaginal delivery, obstetrics complications and a history of previous uterine curettage, were investigated. Clinical information about pregnancy outcomes and complications was obtained from the hospital’s electronic medical database. Results: The scar was visible in 77.9% of the women. Among those with a visible CS scar, the incidence of a CS scar niche was 51.6%. The intra- and interobserver agreement for CS scar niche measurements was excellent (ICC 0.98 and 0.89, respectively). Comparing subgroups of women in terms of CS scar niche (n = 49) and non-niche (n = 73), there was no statistically significant correlation between maternal age (p = 0.486), BMI (p = 0.529), gestational diabetes (p = 1.000), smoking status (p = 0.662), previous vaginal delivery after CS (p = 1.000) and niche development. Uterine scar niches were seen in 56.3% (18/48) of the women who had undergone uterine curettage, compared with 34.4% (31/74) without uterine curettage (p = 0.045). We observed an absence of correlation between the uterine scar niche at the first trimester of pregnancy and mode of delivery (p = 0.337). Two cases (4.7%) of uterine scar dehiscence were confirmed following a trial of vaginal delivery. Conclusions: Based on ultrasonography examination, the CS scar niche remained visible in half of the cases with a visible CS scar at the first trimester of pregnancy and could be reproducibly measured by a transvaginal scan. Previous uterine curettage was associated with an increased risk for uterine niche formation in a subsequent pregnancy. Uterine scar dehiscence might be potentially related to the CS scar niche. Full article

Due to an increasing number of cesarean section deliveries, the common consequences of that surgery are observed more often in the population. One of them is the uterine cesarean scar defect known as niche or isthmocele. Most patients with that aliment are asymptomatic, but some of them can report abnormal uterine bleeding, pelvic pain, subfertility which can be the reason for reduced quality of life (QoL) of the patients. In our study, we analyzed the subjective feelings of changes in the severity of symptoms and quality of life of women with niche after diagnostic and operative hysteroscopy. The patients n = 85 included in the study group completed a follow up questionnaire six months after the procedure. Patients after operative hysteroscopy in comparison to patients after diagnostic procedure reported statistically significant reduction in post-menstruation bleeding/spotting and improvement in the quality of sexual activity. We have also noticed a higher pregnancy rate in the operative group, however, the difference was not statistically significant. According to our study, most women reported a positive effect of hysteroscopy on their QoL in social, psychological, environmental, and health domains. Full article