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Transvaginal ultrasound image (a) and schematic diagram (b) showing measurement of width (blue line) of uterine niche in the transverse plane.
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... Sonographically, the uterine niche can be classified as simple, simple with one branch, or complex (main niche with more than one branch). A branch is a smaller part at the serosal side with a width less than that of the main niche ( Fig. 1) [22]. For surgical planning, it is crucial to estimate distances between the niche and the external os, as well as between the niche and the vesicovaginal fold, although not essential for basic evaluation. ...
... Measurements in the sagittal plane include length, depth, RMT, and AMT (Figs. 2 and 3) [22]. In the transverse plane, main niche width and branch identification are essential, without repeating RMT and depth measurements ( Fig. 4) [22]. ...
... Measurements in the sagittal plane include length, depth, RMT, and AMT (Figs. 2 and 3) [22]. In the transverse plane, main niche width and branch identification are essential, without repeating RMT and depth measurements ( Fig. 4) [22]. ...
Background
The increasing prevalence of cesarean section (CS) deliveries globally has sparked apprehension regarding potential long-term complications, notably the emergence of uterine niches. CS results in a scar that in certain patients, inadequate healing of that scar results in the development of a uterine niche. While most small niches show no symptoms, large cesarean scar niches in nonpregnant women can give rise to cesarean scar disorder syndrome. This syndrome is characterized by abnormal uterine bleeding, dysmenorrhea, and secondary infertility. In pregnant women, the presence of substantial niches may be linked to potentially life-threatening complications, including cesarean scar dehiscence, uterine rupture, placenta accreta spectrum disorders, placenta previa, and cesarean scar ectopic pregnancy.
Main body
Given the potential dangers associated with uterine niche occurrence, numerous studies in recent years have delved into the concept of cesarean scar niche, exploring its risk factors, diagnostic approaches, and treatment options. Various diagnostic modalities, such as two- or three-dimensional transvaginal ultrasonography, two- and three-dimensional sono-hysterography, hysterosalpingography, hysteroscopy, or magnetic resonance imaging, can be employed to detect uterine niches. However, none of these diagnostic methods is universally accepted as the “gold standard,” and there remains a lack of unequivocal guidelines on certain aspects related to the diagnosis of cesarean scar niche. These niches, characterized by hypoechoic regions within the myometrium at the site of a previous CS scar, pose diagnostic complexities and provoke inquiries into their prevalence, factors influencing their development, clinical presentations, and appropriate therapeutic approaches.
Conclusion
As CS rates rise, this review aims to understand and address uterine niches and mitigate their impact on maternal health and reproductive outcomes.
... In general, transvaginal ultrasonography (TVS) is the first suggested method for PCSD evaluation due to its effectiveness and affordability (20,29). A TVS standardized guideline (a modified Delphi procedure) could be applied for detailed PCSD evaluation in non-pregnant women (30,31). However, MRI is able to scan larger areas of the pelvis for further scrutiny, so one of its advantages is a more accurate and clear view in the pre-operation evaluation. ...
Background
As the cesarean delivery rate continues to rise globally, the treatment of previous cesarean scar defects (PCSD) remains challenging. This study aimed to analyze the variables that may influence the clinical cure rate of patients with PCSD-related abnormal uterine bleeding (AUB) as determined by preoperative magnetic resonance imaging (MRI) following hysteroscopic therapy.
Methods
Women who underwent hysteroscopic surgery for PCSD-related AUB at the Gynecology Department of Third Xiangya Hospital of Central South University from 2018 to 2022 were recruited to this retrospective cohort investigation. A total of 147 patients were enrolled in this study and underwent follow-up over 6 months. The significance of clinical characteristics linked to the clinical cure rate of AUB was examined by logistic regression.
Results
There were 64 clinically cured (43.5%) and 83 non-clinically cured (56.5%) patients in the study. There were no significant differences in the age, menstrual duration, gravidity, parity, number of cesarean sections, time since the previous cesarean section, uterus position, width, depth, and thickness of the remaining muscle layer of the defect by MRI T2-weighted images (T2WI) before hysteroscopic surgery between the 2 groups. MRI T2WI of the myometrial thickness adjacent to the defect [P=0.038, odds ratio (OR) =2.095, 95% confidence interval (CI): 1.047–4.261] and the distance from the defect to the external cervical os (P=0.021, OR =2.254, 95% CI: 1.136–4.540) before hysteroscopic surgery are risk factors for the clinical cure rate.
Conclusions
The myometrial thickness adjacent to the defect and the distance from the defect to the external cervical os in preoperative MRI are risk factors for clinical cure rate in patients with PCSD-related AUB after hysteroscopic treatment, which is helpful for evaluating the prognosis of disease.
... The defect width was determined as the maximum diameter of the niche base in the transverse plane. The length was measured in the sagittal plane using the same criterion [12]. The depth was quantified as the minimum distance between the apex and the base (Fig. 1). ...
Background
A cesarean scar defect (CSD) is incomplete healing of the myometrium at the site of a prior cesarean section (CS), complicating more than half of all cesarean sections. While transvaginal ultrasound (TVU) is the most common modality for diagnosing this defect, hysteroscopy remains the gold standard. We aimed to develop an efficient diagnostic tool for CSD among women with abnormal uterine bleeding (AUB) by integrating TVU findings and participants’ demographic features.
Methods
A single-center cross-sectional study was conducted on 100 premenopausal and non-pregnant women with a history of CS complaining of AUB without a known systemic or structural etiology. Each participant underwent a hysteroscopy followed by a TVU the next day. The defect dimensions in TVU, patients’ age, and the number of previous CSs were integrated into a binary logistic regression model to evaluate their predictive ability for a hysteroscopy-confirmed CSD.
Results
Hysteroscopy identified 74 (74%) participants with CSD. The variables age, the number of CSs, defect length, and defect width significantly contributed to the logistic regression model to diagnose CSD with odds ratios of 9.7, 0.7, 2.6, and 1.7, respectively. The developed model exhibited accuracy, sensitivity, and specificity of 88.00%, 91.89%, and 76.92%, respectively. The area under the receiver operating curve was 0.955 (P-value < 0.001).
Conclusion
Among non-pregnant women suspected of CSD due to AUB, looking at age, the number of previous CSs, and TVU-based defect width and length can efficiently rule CSD out.
... All sonographic examiners will undertake the online tutorial (www.nichelearning.online). 36 This learning module is be based on the results of a Delphi procedure involving an international group of niche experts. 7 ...
Introduction
A uterine niche is a defect at the site of the uterine caesarean scar that is associated with gynaecological symptoms and infertility. Promising results are reported in cohort studies after a laparoscopic niche resection concerning reduction of gynaecological symptoms in relation to baseline and concerning pregnancy outcomes. However, randomised controlled trials to study the effect of a laparoscopic niche resection on reproductive outcomes in infertile women are lacking. This study will answer the question if laparoscopic niche resection in comparison to expectant management improves reproductive outcomes in infertile women with a large uterine niche.
Methods and analysis
The LAPRES study is a randomised, non-blinded, controlled trial, including 200 infertile women with a total follow-up of 2 years. Women with the presence of a large niche in the uterine caesarean scar and unexplained infertility of at least 1 year or failed IVF will be randomly allocated to a laparoscopic niche resection within 6 weeks or to expectant management for at least 9 months. A large niche is defined as a niche with a depth of >50% of the myometrial thickness and a residual myometrium of ≤3 mm on transvaginal ultrasound. Those receiving expectant management will be allowed to receive fertility therapies, including assisted reproductive techniques, if indicated. The primary outcome is time to ongoing pregnancy, defined as a viable intrauterine pregnancy at 12 weeks’ gestation. Secondary outcome measures are time to conception leading to a live birth, other pregnancy outcomes, received fertility therapies after randomisation, menstruation characteristics, patient satisfaction, quality of life, additional interventions, and surgical and ultrasound outcomes (intervention group). Questionnaires will be filled out at baseline, 6, 12 and 24 months after randomisation. Ultrasound evaluation will be performed at baseline and at 3 months after surgery.
Ethics and dissemination
The study protocol was approved by the medical ethics committee of the Amsterdam University Medical Centre. (Ref. No. 2017.030). Participants will sign a written informed consent before participation. The results of this study will be submitted to a peer-reviewed journal for publication.
Trial registration number: Dutch Trial Register (ref. no. NL6350 http://www.trialregister.nl )
... Ultrasonography experts have already proposed a more consistent classification taking into consideration the heterogeneous shapes and branches of the USDs, which do not always happen to be wedge-shaped but at times mimicking a round, square or even a cribriform area (8,9,13). ...
... its hysteroscopic management remains unclear as there are to dates no guidelines to specify how to approach them.The presence of branches has already been acknowledged by the ultrasonographers as modifying the level at which the residual myometrium needs to be measured: rather from the top of the branch and not from the roof of the niche itself(9,13). During diagnostic hysteroscopy, attention should be given to the movement of air bubbles within the niche, as they tend to go through the branches' orifices (fig3). ...
Isthmocele is an anatomo clinical entity still lacking standardization in its diagnostic and therapeutic approaches. It is a condition where building bridges between ultrasound and hysteroscopy is particularly fruitful. The surgical management of the symptomatic forms can be conducted through hysteroscopic, laparoscopic, vaginal or laparotomic routes. In this article is provided a review of the relevant data of the literature exclusively related to its diagnostic aspects. An overview of the main hysteroscopic and sonographic findings encountered in practice is also discussed and provide new insights on the condition's pathogenesis. Although the niche has long been thought of as a static defect causing accumulation of menstrual blood, it is also likely to act as an active valve closing the internal ostium of the cervix and causing fluid dynamic changes as described by an Indian team. Additional observations during hysteroscopy allow collecting different anomalies which are likely to explain the usually encountered symptoms such as abnormal uterine bleeding, subfertility, chronic pelvic pain, dysmenorrhea and dyspareunia.
... Contrast-using saline-infusion sonohysterography (SIS) and gel-instillation sonohysterography, in two (2D) or three dimensions (3D), are very accurate diagnostic procedures to describe submucous leiomyomas (14,15,16), cesarean scar niche (17,18,19) and congenital uterine malformations (20,21). For instance, in accordance with a Cochrane systematic review and a 2017 systematic review and meta-analysis of 1398 citations and 5 studies, high-quality evidence supports that SIS is equally performant as hysteroscopy to diagnose submucous leiomyomas (6,15,22). ...
This article provides a brief and evidence-based overview of the basic principles related to the evaluation and preparation of the patients planned to undergo diagnostic hysteroscopy. Anamnestic data should be taken and analyzed, general and pelvic physical examination performed, pregnancy and genital infections excluded, and a gynecological ultrasound realized. The patients should be advised about alternative diagnostic procedures and informed in details about the benefits, expected success of diagnostic hysteroscopy, but also about possible discomfort/pain and complications. In addition to adequate patient counseling, preparation for a successful hysteroscopy includes proper timing of the procedure and cervical ripening in selected women. Analgesia is addressed in a separated review of this journal issue. There are no evidence-based indications for antibiotic prophylaxis to be given before or during hysteroscopy.
... As previously reported, 13 during the ultrasonographic exams, the sector angle was adjusted to obtain an optimal uterine resolution. ...
... 14 A uterine niche is defined as an indentation at the site of the CD scar with a depth of at least 2 mm, according to the modified Delphi criteria. 13 The presence of niche branches (a branch is defined as a thinner part of the main niche that is directed towards the serosa and has a smaller width than that of the main niche visible in the sagittal or transverse plane) was identified. Three types of niches were distinguished: (1) simple niche (no branches), (2) simple niche with one branch, and (3) complex niche (more than one branch). ...
Objective
To compare the ultrasonographic features of uterine scars and clinical symptoms after cesarean delivery (CD) using barbed and conventional smooth sutures.
Methods
This case–control study enrolled women who underwent primary CD at 37 weeks of pregnancy or later. The uterus was closed using either double‐layer unidirectional barbed suture or conventional double‐layer smooth suture. Ultrasound scans of the uterine scar and evaluations of menstrual patterns were performed at 6, 12, and 24 months after surgery.
Results
In all, 102 patients underwent uterine closure with barbed suture, while 135 patients underwent smooth suture. At 6 months, patients in the barbed group had a lower incidence of uterine niches (20.2% vs 32.6%) that were also shallower in depth (P < 0.001). Lower incidence of niches was also observed in the barbed group at 12 and 24 months (P = 0.043 and 0.048, respectively). At these two follow‐up times, the smooth group had a higher number of patients reporting postmenstrual spotting (P < 0.05) and more postmenstrual spotting days per month (P < 0.050).
Conclusion
The use of double‐layer barbed suture during CD was associated with a lower incidence of scar niches and a more favorable menstrual pattern compared with the use of smooth suture.
Purpose of review
With a rising number of cesarean sections, the prevalence of uterine isthmoceles is increasing. We performed a rapid review to assess the most recent data on the diagnosis and management of uterine isthmoceles over the past 18 months to identify current trends and directions for continued research.
Recent findings
A comprehensive search was conducted in PubMed (NLM), Embase (Ovid), CINAHL (EBSCOhost) to find English written articles discussing the diagnosis or management of uterine isthmoceles published in the previous 18 months. Data extraction was performed on one hundred articles that met inclusion criteria.
Summary
This rapid review highlights agreement regarding diagnostic methods, symptoms, and recommended treatment paths for patients with symptomatic uterine niches. However, the diversity in definitions hampers the capacity to formulate detailed conclusions regarding the features of uterine niches and their impact on women's health.
Objectives
To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs).
Methods
Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant.
Results
A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively.
Conclusions
While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.
