Emerging Manifestations of Cesarean Scar Defect in the Reproductive-Age Group

Cesarean scar defect (CSD), also referred to as isthmocele or niche, has emerged as a significant gynecological issue among reproductive-age women, attributed to rising cesarean delivery rates and improved imaging modalities. It often manifests as abnormal uterine bleeding (AUB), pelvic pain, and infertility. This study aimed to assess the clinical profile, imaging characteristics, and reproductive associations of CSD in women of reproductive age.

This cross-sectional study was conducted in the Department of Obstetrics and Gynecology from July 2022 to December 2023. Women aged 20-45 years with a history of cesarean delivery presenting with menstrual irregularities, pelvic pain, or infertility were evaluated using transvaginal sonography (TVS; GE Voluson E8, GE Healthcare, Chicago, IL, USA). Cases suspected of CSD underwent confirmation with saline infusion sonohysterography (GE Healthcare, Chicago, IL, USA) or hysteroscopy (Karl Storz GmbH & Co. KG, Tuttlingen, Germany). Clinical features, imaging findings, and reproductive outcomes were analyzed using SPSS Statistics version 24.0 (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.), with p ≤ 0.05 considered statistically significant.

A total of 100 women were included, with a mean age of 31.6 ± 4.2 years. AUB was the most common symptom, 78 (78%), followed by pelvic pain, 46 (46%), and secondary infertility, 39 (39%). TVS identified CSD in 89 (89%) of cases; it was confirmed hysteroscopically in 81 (81%). Women with ≥2 previous cesarean sections had significantly deeper defects (p = 0.02). A niche depth >3 mm, as defined in prior literature, was significantly associated with secondary infertility (p = 0.01). Emergency cesarean delivery correlated with irregular niche formation (p = 0.03).

CSD is an underdiagnosed but clinically important condition contributing to gynecological morbidity and infertility. Early recognition through imaging and heightened clinical awareness can improve reproductive outcomes and prevent complications in subsequent pregnancies.