ISTHMOCELE DURING PREGNANCY - TREAT IT OR LEAVE IT?

Problem statement

An isthmocele is a defect of the caesarean scar characterised by myometrial discontinuity, similar to a diverticulum located at the level of the anterior isthmus of the uterus. It is an iatrogenic entity created due to the worldwide increase rate of cesarean delivery. The presence of an isthmocele has been associated with increased obstetrical complication such as cesarean scar ectopic pregnancy, uterine rupture, placenta accreta. The incidental discovery of an isthmocele during a first trimester ultrasound scan render difficult the management decision between surgical treatment and continuation of pregnancy, expectative management or termination of pregnancy and subsequent isthmocele surgical repair.

Methods

We present the case of a 28 Years old, G2P1 pacient, diagnosed with an isthmocele on the first trimester ultrasound scan performed at 7 Weeks. We discussed the available treatment options, and the pacient chose surgical treatment and continuation of pregnancy.

Results

We performed a laparoscopic repair of the caesarean scar defect on a 8 weeks ongoing pregnancy. Ultrasound guidance allowed the correct identification of the niche during laparoscopy. The defect margins were excised into healthy tissue, then sutured in a double-layer. The pregnancy evolved uneventfully and was terminated by C-section at 38 weeks of gestation.

Conclusion

Data regarding the management of an isthmocele during pregnancy is scarce. Surgical management by minimally invasive surgery seems to be a feasible option in selected case.