Gynaecological morbidity associated with CS niche TOG 2019

Question 1

How is. CS niche identified on USS?

Answer 1

Hypoechoic area in anterior lower segment, representing a defect in the myometrium as result of poor healing of uterine scar created by hysterotomy.

Question 2

Theories of increased risk CS niche?

Answer 2

Low incision (inclusion mucus producing glands from endocervical canal)

Tight locking 1st layer - ischaemia - best double layer, non locking including inner myometrium

CS in labour >5cm

Adhesion formation

Question 3

What is the median myometrial thickness at the level of the isthmus for:
1) Vaginal birth
2) 1 CS
3) 2 CS
4) 3 CS

Answer 3

1) Vaginal birth 11.6mm
2) 1 CS 8.3mm
3) 2 CS 6.7mm
4) 3 CS 4.7mm

Question 4

How common is scar defects after:
2) 1 CS
3) 2 CS
4) 3 CS

Answer 4

2) 1 CS 61%
3) 2 CS 81%
4) 3 CS 100%

Question 5

What symptoms may be experience by women with CS niche? What the most common

Answer 5

Asymptomatic
postmenstral spotting **
Erratic or prolonged mestration **
Continous brown discharge
Chronic pelvic pain
Secondary infertility

** most common

Question 6

Gold standard image modality can be used to assess for CS niche?

Answer 6

TVUS with gel instillation sonohysterography on day 7-14 of cycle

Question 7

Diagram of Cs niche

Answer 7

Question 7

What is the niche definition?

Answer 7

Scar defect of at least 2mm in depth

Question 7

How to manage symptoms related to menstrual bleeding secondary to niche?

Answer 7

hormonal treatment - IUS or endometrial ablation

Question 8

What minimally invasive procedures can be offered to treat CS niche?

Answer 8

Distral ridge resection +/- niche ablation

Question 8

When should hysteroscopy niche resection not be offered?

Answer 8

When residual myometrial thickness is <3mm, laparoscopic approach batter