{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T21:11:14Z","timestamp":1793394674125,"version":"4.5.0"},"reference-count":44,"publisher":"FapUNIFESP (SciELO)","issue":"5","license":[{"start":{"date-parts":[[2019,5,1]],"date-time":"2019-05-01T00:00:00Z","timestamp":1556668800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2019,5,1]],"date-time":"2019-05-01T00:00:00Z","timestamp":1556668800000},"content-version":"am","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2019,5,1]],"date-time":"2019-05-01T00:00:00Z","timestamp":1556668800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Rev. Assoc. Med. Bras."],"abstract":"<jats:p>SUMMARY 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.<\/jats:p>","DOI":"10.1590\/1806-9282.65.5.714","type":"journal-article","created":{"date-parts":[[2019,6,1]],"date-time":"2019-06-01T15:44:57Z","timestamp":1559403897000},"page":"714-721","source":"Crossref","is-referenced-by-count":89,"title":["Isthmocele: an overview of diagnosis and treatment"],"prefix":"10.1590","volume":"65","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3254-3507","authenticated-orcid":false,"given":"Thaysa Guglieri","family":"Kremer","sequence":"first","affiliation":[{"name":"Federal University of Rio Grande do Sul,  Brasil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5526-0630","authenticated-orcid":false,"given":"Isadora Bueloni","family":"Ghiorzi","sequence":"additional","affiliation":[{"name":"Federal University of Health Sciences of Porto Alegre,  Brasil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6825-773X","authenticated-orcid":false,"given":"Raquel Papandreus","family":"Dibi","sequence":"additional","affiliation":[{"name":"Federal University of Health Sciences of Porto Alegre,  Brasil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"530","published-online":{"date-parts":[[2019,5]]},"reference":[{"issue":"45","key":"ref1","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1016\/j.rhm.2015.07.007","article-title":"WHO statement on caesarean section rates","volume":"23","year":"2015","journal-title":"Reprod Health Matters"},{"issue":"2","key":"ref2","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0148343","article-title":"The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014","volume":"11","author":"Betr\u00e1n AP","year":"2016","journal-title":"PLoS One"},{"issue":"4","key":"ref3","doi-asserted-by":"crossref","first-page":"372","DOI":"10.1002\/uog.13199","article-title":"Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following cesarean section: systematic review","volume":"43","author":"Bij de Vaate AJ","year":"2014","journal-title":"Ultrasound Obstet Gynecol"},{"issue":"6","key":"ref4","doi-asserted-by":"crossref","first-page":"893","DOI":"10.1016\/j.jmig.2016.06.020","article-title":"Emerging manifestations of cesarean scar defect in reproductive-aged women","volume":"23","author":"Tulandi T","year":"2016","journal-title":"J Minim Invasive Gynecol"},{"issue":"2","key":"ref5","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1016\/j.jmig.2007.10.004","article-title":"Resectoscopic correction of the \u201cisthmocele\u201d in women with postmenstrual abnormal uterine bleeding and secondary infertility","volume":"15","author":"Gubbini G","year":"2008","journal-title":"J Minim Invasive Gynecol"},{"issue":"3","key":"ref6","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1097\/GCO.0b013e3283521202","article-title":"Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility","volume":"24","author":"Florio P","year":"2012","journal-title":"Curr Opin Obstet Gynecol"},{"issue":"1","key":"ref7","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1097\/00004347-199501000-00004","article-title":"Surgical pathology of the lower uterine segment caesarean section scar: is the scar a source of clinical symptoms?","volume":"14","author":"Morris H","year":"1995","journal-title":"Int J Gynecol Pathol"},{"issue":"5","key":"ref8","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1016\/j.jmig.2013.03.008","article-title":"Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications","volume":"20","author":"Tower AM","year":"2013","journal-title":"J Minim Invasive Gynecol"},{"issue":"2","key":"ref9","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1016\/j.advms.2017.01.004","article-title":"Hysteroscopy in the treatment of uterine cesarean section scar diverticulum: a systematic review","volume":"62","author":"Abacjew-Chmylko A","year":"2017","journal-title":"Adv Med Sci"},{"key":"ref10","first-page":"1765624","article-title":"Efficacy of combined laparoscopic and hysteroscopic repair of post-cesarean section uterine diverticulum: a retrospective analysis","volume":"2016","author":"Li C","year":"2016","journal-title":"Biomed Res Int"},{"issue":"12","key":"ref11","first-page":"2695","article-title":"Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development","volume":"30","author":"Vervoort AJ","year":"2015","journal-title":"Hum Reprod"},{"issue":"2","key":"ref12","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1111\/1471-0528.12542","article-title":"Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding","volume":"121","author":"Van der Voet LF","year":"2014","journal-title":"BJOG"},{"issue":"1","key":"ref13","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1002\/uog.8864","article-title":"Ultrasound evaluation of the cesarean scar: relation between a niche and postmenstrual spotting","volume":"37","author":"Bij de Vaate AJ","year":"2011","journal-title":"Ultrasound Obstet Gynecol"},{"issue":"1","key":"ref14","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1002\/uog.5200","article-title":"Deficient lower-segment cesarean section scars: prevalence and risk factors","volume":"31","author":"Ofili-Yebovi D","year":"2008","journal-title":"Ultrasound Obstet Gynecol"},{"issue":"6","key":"ref15","doi-asserted-by":"crossref","first-page":"434","DOI":"10.3109\/09513590.2010.495431","article-title":"A retrospective case\u2013control study comparing hysteroscopic resection versus hormonal modulation in treating menstrual disorders due to isthmocele","volume":"27","author":"Florio P","year":"2011","journal-title":"Gynecol Endocrinol"},{"issue":"3","key":"ref16","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1002\/uog.999","article-title":"Cesarean section scar evaluation by saline contrast sonohysterography","volume":"23","author":"Regnard C","year":"2004","journal-title":"Ultrasound Obstet Gynecol"},{"issue":"1","key":"ref17","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1002\/uog.6395","article-title":"High prevalence of defects in cesarean section scars at transvaginal ultrasound examination","volume":"34","author":"Osser OV","year":"2009","journal-title":"Ultrasound Obstet Gynecol"},{"issue":"3","key":"ref18","doi-asserted-by":"crossref","first-page":"386","DOI":"10.1016\/j.jmig.2012.12.006","article-title":"Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women","volume":"20","author":"Marotta ML","year":"2013","journal-title":"J Minim Invasive Gynecol"},{"issue":"2","key":"ref19","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1016\/j.jmig.2014.09.011","article-title":"Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study","volume":"22","author":"Raimondo G","year":"2015","journal-title":"J Minim Invasive Gynecol"},{"issue":"1","key":"ref20","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1002\/uog.6405","article-title":"Cesarean scar defect: correlation between cesarean section number, defect size, clinical symptoms and uterine position","volume":"34","author":"Wang CB","year":"2009","journal-title":"Ultrasound Obstet Gynecol"},{"issue":"4","key":"ref21","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1080\/00016340500430436","article-title":"Methods for myometrium closure and other factors impacting effects on cesarean section scars of the uterine segment detected by the ultrasonography","volume":"85","author":"Hayakawa H","year":"2006","journal-title":"Acta Obstet Gynecol Scand"},{"issue":"7","key":"ref22","doi-asserted-by":"crossref","first-page":"695","DOI":"10.7863\/jum.2003.22.7.695","article-title":"The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy","volume":"22","author":"Fabres C","year":"2003","journal-title":"J Ultrasound Med"},{"issue":"4","key":"ref23","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1097\/GCO.0000000000000380","article-title":"The minimally invasive approach to the symptomatic isthmocele \u2013 what does the literature say? A step-by-step primer on laparoscopic isthmocele \u2013 excision and repair","volume":"29","author":"Sipahi S","year":"2017","journal-title":"Curr Opin Obstet Gynecol"},{"issue":"9","key":"ref24","doi-asserted-by":"crossref","first-page":"664","DOI":"10.5603\/GP.2016.0063","article-title":"When and how should we treat cesarean scar defect \u2014 isthmocoele?","volume":"87","author":"Futyma K","year":"2016","journal-title":"Ginekol Pol"},{"issue":"10","key":"ref25","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.7863\/jum.2001.20.10.1105","article-title":"Saline Infusion sonohysterography in nonpregnant women with previous cesarean delivery: the \u201cniche\u201d in the scar","volume":"20","author":"Monteagudo A","year":"2001","journal-title":"J Ultrasound Med"},{"issue":"1","key":"ref26","doi-asserted-by":"crossref","first-page":"13","DOI":"10.7863\/jum.1999.18.1.13","article-title":"Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography","volume":"18","author":"Thurmond AS","year":"1999","journal-title":"J Ultrasound Med"},{"issue":"1","key":"ref27","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/j.jmig.2004.12.023","article-title":"Surgical treatment and follow-up of women with intermenstrual bleeding due to cesarean section scar defect","volume":"12","author":"Fabres C","year":"2005","journal-title":"J Minim Invasive Gynecol"},{"issue":"2","key":"ref28","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1016\/j.jmig.2010.10.011","article-title":"Surgical hysteroscopic treatment of cesarean-induced isthmocele in restoring fertility: prospective study","volume":"18","author":"Gubbini G","year":"2011","journal-title":"J Minim Invasive Gynecol"},{"issue":"3","key":"ref29","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1111\/j.1471-0528.2006.01237.x","article-title":"Caesarean scar pregnancy","volume":"114","author":"Ash A","year":"2007","journal-title":"BJOG"},{"issue":"12","key":"ref30","doi-asserted-by":"crossref","first-page":"1719","DOI":"10.1111\/jog.13146","article-title":"Laparoscopic repair with hysteroscopy of cesarean scar diverticulum","volume":"42","author":"Liu SJ","year":"2016","journal-title":"J Obstet Gynaecol Res"},{"issue":"6","key":"ref31","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1055\/s-0032-1304829","article-title":"Systematic review of cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect","volume":"29","author":"Roberge S","year":"2012","journal-title":"Am J Perinatol"},{"issue":"1","key":"ref32","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1002\/uog.7496","article-title":"Cesarean section scar defects: agreement between transvaginal sonographic findings with and without saline contrast enhancement","volume":"35","author":"Osser OV","year":"2010","journal-title":"Ultrasound Obstet Gynecol"},{"issue":"1","key":"ref33","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1016\/j.fertnstert.2016.09.033","article-title":"Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women","volume":"107","author":"Donnez O","year":"2017","journal-title":"Fertil Steril"},{"key":"ref34","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1186\/s12905-015-0260-8","article-title":"The HysNiche trial: hysteroscopic resection of uterine caesarean scar defect (niche) in patients with abnormal bleeding, a randomised controlled trial","volume":"15","author":"Vervoort AJ","year":"2015","journal-title":"BMC Women's Health"},{"issue":"3","key":"ref35","doi-asserted-by":"crossref","first-page":"326","DOI":"10.1111\/1471-0528.14733","article-title":"Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trial","volume":"125","author":"Vervoort A","year":"2018","journal-title":"BJOG"},{"issue":"2","key":"ref36","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1016\/j.fertnstert.2006.01.020","article-title":"Preliminary report of treatment with oral contraceptive pills for intermenstrual vaginal bleeding secondary to a cesarean section scar","volume":"86","author":"Tahara M","year":"2006","journal-title":"Fertil Steril"},{"issue":"3","key":"ref37","doi-asserted-by":"crossref","first-page":"317","DOI":"10.1111\/1471-0528.14822","article-title":"The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study","volume":"125","author":"Vervoort A","year":"2018","journal-title":"BJOG"},{"issue":"4","key":"ref38","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1016\/j.jmig.2012.03.012","article-title":"Vaginal repair of cesarean section scar diverticula","volume":"19","author":"Luo L","year":"2012","journal-title":"J Minim Invasive Gynecol"},{"key":"ref39","doi-asserted-by":"crossref","first-page":"1395","DOI":"10.12659\/MSM.890642","article-title":"Transvaginal management of cesarean scar section diverticulum: a novel surgical treatment","volume":"20","author":"Chen Y","year":"2014","journal-title":"Med Sci Monit"},{"issue":"4","key":"ref40","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1016\/j.jmig.2016.01.007","article-title":"A comparative study of transvaginal repair and laparoscopic repair in the management of patients with previous cesarean scar defect","volume":"23","author":"Zhang Y","year":"2016","journal-title":"J Minim Invasive Gynecol"},{"key":"ref41","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1186\/s12884-014-0365-3","article-title":"Prediction of uterine dehiscence using ultrasonographic parameters of cesarean section scar in the nonpregnant uterus: a prospective observational study","volume":"14","author":"Pomorski M","year":"2014","journal-title":"BMC Pregnancy and Childbirth"},{"issue":"1","key":"ref42","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1620\/tjem.183.55","article-title":"Ultrasonographic evaluation of lower uterine segment to predict the integrity and quality of cesarean scar during pregnancy: a prospective study","volume":"183","author":"Qureshi B","year":"1997","journal-title":"Tohoku J Exp Med"},{"issue":"2","key":"ref43","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1002\/uog.12479","article-title":"Sonographic measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor in women with previous Cesarean section: a meta-analysis","volume":"42","author":"Kok N","year":"2013","journal-title":"Ultrasound Obstet Gynecol"},{"issue":"4","key":"ref44","doi-asserted-by":"crossref","first-page":"410","DOI":"10.1002\/uog.15786","article-title":"Can third-trimester assessment of uterine scar in women with prior Cesarean section predict uterine rupture?","volume":"47","author":"Jastrow N","year":"2016","journal-title":"Ultrasound Obstet Gynecol"}],"container-title":["Revista da Associa\u00e7\u00e3o M\u00e9dica Brasileira"],"original-title":[],"link":[{"URL":"http:\/\/www.scielo.br\/pdf\/ramb\/v65n5\/1806-9282-ramb-65-05-0714.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,2,11]],"date-time":"2020-02-11T13:19:11Z","timestamp":1581427151000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.scielo.br\/scielo.php?script=sci_arttext&pid=S0104-42302019000500714&tlng=en"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,5]]},"references-count":44,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2019,5]]}},"alternative-id":["S0104-42302019000500714"],"URL":"https:\/\/doi.org\/10.1590\/1806-9282.65.5.714","relation":{},"ISSN":["1806-9282","0104-4230"],"issn-type":[{"value":"1806-9282","type":"electronic"},{"value":"0104-4230","type":"print"}],"subject":[],"published":{"date-parts":[[2019,5]]}}}