الفهرس 
Cesarean Scar Defect “Niche or IsthmoceleOnly 14 pages are availabe for public view
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Abstract
I
n past decades the Cesarean section rate has increased markedly. At a rate of 52 percent Egypt stands out among countries with the highest CS delivery rates in the world, following Dominican Republic (56.4 percent) and Brazil (55.6 percent). Within the Arab region, rates of CS are far higher in Egypt than any other Arab country.
Cesarean section is associated with complications in subsequent pregnancies, such as scar pregnancy with life-threatening bleeding, placenta previa, placenta accreta, increta or percreta, dehiscence or uterine rupture.
Cesarean scar defect (isthmocele) (CSD) is a known complication after cesarean delivery. It has become more common due to a rising cesarean delivery rate.
Cesarean scar defect (isthmocele) is the formation of a pouch at the site of an old caesarean incision at the anterior lower uterine segment, uterine isthmus or in the upper segment of the cervical canal.
Isthmocele has been associated with various gynecological and obstetric problems such as uterine rupture, cesarean scar pregnancy, and bleeding disorders.
There are several imaging techniques to detect the CSD as 2D transvaginal ultrasound (TVUS) but there is no universal consensus about which is the gold standard. Moreover, there are no standardized diagnostic criteria. Also, many methods have been suggested, including hysterography, sonohysterography, hysteroscopy and magnetic resonance imaging.
2D TVUS is a first level and widely used imaging technique. It is not known whether defects in Cesarean section scars that are visible at transvaginal ultrasound examination of non-pregnant women are associated with a higher risk of these complications than apparently intact scars, or whether large defects are associated with a higher risk of complications than small defects.
The role of ultrasound in visualization and detection of CS scar defects in non-pregnant females has been investigated. The 2D transvaginal ultrasound was found to be an accurate method for measurement of scar thickness. Also colored Doppler was found to be useful in detecting the vascularity of the scar.
Diagnostic hysteroscopy was considered the ‘‘gold standard’’ for the diagnosis of intrauterine abnormalities; it has been shown to be a sensitive tool for direct visualization of uterine scar and intrauterine adhesions.
Consequently, this study was conducted and aimed to compare between the accuracy of Two Dimensional Transvaginal ultrasound and hysteroscopy in visualization of the site of Cesarean section scar in non-pregnant females and also to determine and comment on thickness, continuity and ballooning of the scar.
This prospective diagnostic test accuracy controlled clinical trial was conducted at Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University Maternity Hospitals from August 2022 until February 2023.
During this study, 41 women with any indication of hysteroscopy were enrolled. Those who accepted the invitation were booked for an ultrasound examination for assessment of cesarean scar defect after hysteroscopic procedure.
To the best of our knowledge, there is a paucity of studies in literature assessing our study outcomes and most of studies that disagreed with our results were due to several causes as different study methodology, outcomes, sample size and different medical conditions of studied cases at time of enrollment.
Our study revealed that 2D TVUS could detect 13 (31.7%) out of 41 women having CSD, on the other hand, 16 women (39.0%) were diagnosed using hysteroscopy. There is a statistically significant correlation between the use of 2DTVUS and hysteroscopy in determination of occurrence of scar defect after previous Cesarean sections with (kappa agreement “=0.629” & p-value “p<0.001”).
As regard validity of TVUS and hysteroscopy in detection of cesarean scar defect, 2DTVUS had sensitivity 68.8%, specificity 92%, positive predictive value 84.6% and negative predictive value 82.1% and accuracy 82.9%.
Two Dimensional Transvaginal ultrasound is advised to be used in evaluating cesarean scar thickness and detection of scar defect with a significant validity. It is less invasive, cheaper, safe, without any complications compared with diagnostic hysteroscopy. The present study can burden the knowledge and shed some light on future prospective studies with larger sample sizes to reevaluate our study outcomes and results and confirm our conclusion.