Giant postcesarean niche (isthmocele) with secondary amenorrhea in Mosul city: A rare case report

Post-cesarean isthmocele is a rare but serious complication characterized by a defect in the uterine scar, which can result in gynecological and urological issues. This case report highlights a unique presentation in a patient with multiple cesarean sections. A 45-year-old woman, with a history of five cesarean sections, the last performed in 2014, was referred for secondary amenorrhea and recurrent ovarian cysts noted since early 2024. She was also having some difficulty passing urine and was admitted to Al-Batool Teaching Hospital on November 7, 2024, where she complained of intense pain in the lower abdomen, which had an index of loins and back pain, with development of fever and rigors. The patient, gravida 5, para 5 with 5 previous repeat cesarean deliveries, was referred to our hospital with her imaging studies demonstrating a large collection in the right adnexa (trans vaginal ultrasound), with a clear connection between the endometrial cavity and the collection, wherein hemorrhagic particles were noted., on MRI there is bulky uterus, the endometrium is filled with fluid collection which is hyper intense in T1 and T2 image. Laparotomy showed dense adhesions between the uterus and urinary bladder, collection between uterus and urinary bladder, and a sizeable defect on the previous cesarean scar. Surgical management consisted of total hysterectomy and resection of the right ovary and fallopian tube. Postoperative course was unremarkable with stable vital signs, normal urinary output, and minimal drain output. This case emphasizes the complexities of post-cesarean isthmocele, its potential complications and there are lot of risk factors can be avoided to prevent its occurrence.

The following core competencies are addressed in this article:

Medical knowledge, Patient care and procedural skills, Systems-based practice.