It is also called as isthmocele or diverticula, caesarian scar niche is an evolving concern in clinical practice CS niche is an indentation at the site of CS with a depth of at least 2mm the cause of niche appears to be multifactorial technical and anatomical factors like one Incision low down in the lower uterine segment as a cervical mucus hinders healing in proper suturing and use of locking sutures the good procedure involves suturing first layer deep and near to the wound margin second layer superficial far from the wound margin and non-locking this helps to eliminate the decidua as far as possible since inclusion of more decidua’s leads to large canaliculi formation in the healed scar in which embryo is likely to be embedded and prevention of uterine retroversion post-partum, retroversion of uterus leads to increased stress factors on the wound healing of CS non-locking sutures [3,4].

CASE REPORT

Patient 26 years gravida 2 para 1 with eight weeks pregnancy came with history of pain abdomen and bleeding PV, patent was anemic vitals pulse 100, BP 100/70, per abdomen tenderness in the lower abdomen PV severe bleeding seen, uterus eight week size, investigation-pregnancy test positive USG showed query missed abortion in view of severe vaginal bleeding emergency Foley’s catheter introduced into lower uterine segment and inflated with 00ml saline and the bleeding was stopped then patient was taken for laparotomy which reveled products of conception protruding through ruptured lower uterine segment caesarian scar no evidence of bladder involvement the products of conception removed and the uterine scar sutured in two layers, blood transfusion was given and patient was put on higher antibiotics and the patient was discharged on the sixth day [5,6] (Figures 1-5).

DISCUSSION

The clinical outcome of caesarian scar niche pregnancy was studied, in one study the gestational age was lower at delivery in those with niche, 80 % patients with pregnancy in the scar underwent caesarian 10% CS hysterectomy in patients with pregnancy in the niche 90% underwent caesarian hysterectomy for placenta accrete 10% underwent gravid hysterectomy for vaginal bleeding at 20 weeks the prevalence of decondition is 25 to 70% in women after caesarian delivery Sono Hystography can detect 56 to 86% cases, the development of caesarian scar niche is multi factorial which includes a low uterine incision, use of locking sutures the proper technique is the first layer suturing should be deep and near to the wound margin non-locking the second layer should be far to the wound and non-locking and preventing postpartum of retro version of the uterus [7,8].

CONCLUSION

The most common gynecological symptom of CS niche is post menstrual spotting during pregnancy rupture of the uterus can occur by 10 to 12 weeks causing severe bleeding the various management options for pregnancy in the niche include

1. Methotrexate in locally under ultra sound guidance
2. Double balloon Foley’s catheter tamponed
3. Surgical laparotomy and excision of the defect and repair by two-layer sutures
4. High intensity focusses ultra sound (HIFU)

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