الفهرس 
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Abstract
The Caesarean section (CS) is a surgical procedure that is considered life-saving in cases of high-risk pregnancies. In the five-year period leading up to the 2014 Egypt Demographic and Health Survey, the proportion of live births attributed to cesarean section (CS) in Egypt was 51.8%. In 2014, the cesarean section (CS) rate had risen to 67% of deliveries that took place in hospitals during that year. The prevalence of deliveries in certain areas can be as high as 70.4%. (Cunarro-Lopez et al., 2021).
The prevalence of CS is increasing, leading to a growing concern regarding the occurrence of incompletely healed scars. These scars are associated with a range of complications, including nonlife-threatening but distressing conditions such as postmenstrual bleeding, dysmenorrhea, pelvic pain, and fertility issues. Additionally, there are life-threatening conditions such as scar pregnancy, placenta accrete spectrum, and uterine rupture. (Miller et al., 2022).
A prospective observational study was undertaken in the department of Obstetrics and Gynecology, Minia Maternity and Children University Hospital, involving a sample of 150 women who had undergone a previous cesarean section or had more than one cesarean section. The study was done from March 2021 to March 2023.
The study participants consisted of non-pregnant females between the ages of 18 and 40 who had undergone a previous cesarean section or more. These individuals were selected based on their presence of abnormal uterine bleeding, foul vaginal discharge, pelvic pain, and secondary infertility.Patients underwent postmenstrual assessment.
The study excludes individuals who have focal lesions such as fibroids, adenomyosis, or endometrial hyperplasia, as well as those with cervical pathology such as tumors. Additionally, patients with concomitant disease in their ovaries, recognized anomalies of the uterus, or a history of past myomectomy are also excluded.
A sample of women was questioned in order to administer a pre-designed questionnaire that aimed to gather demographic information as well as comprehensive obstetric history and examination details. Subsequently, the patients undergo Transvaginal ultrasonography 2D to identify the presence of any scar defects. However, 25 cases are removed due to insufficient data regarding their last caesarian section. An initial session involves the use of transvaginal ultrasound 2D saline sonohysterography, followed by transvaginal ultrasonography 3D saline sonohysterography. This is followed by hysteroscopy, which is considered the most reliable method for detecting scars.
The findings of the study indicate that the age distribution of the population under investigation spanned from 19 to 39 years, with an average age of 28.49 years. The majority of participants fell within the age range of 30-39 years 47.3%, followed by 46.7% in the age group of 20-29 years, and 6% in the age group of less than 20 years. The participants’ average weight was 75.68 ±13.96 kg, their average height was 167.49 ±7.21 cm, and their average BMI was 26.57 ±3.74.
Concerning the symptoms of the cases included, 19.4% of patients reported experiencing painful intercourse, while 24.6% reported painful micturition. Furthermore, 53.3% of patients exhibited vaginal infection, while 22% experienced subfertility. Additionally, 26% of patients complained pelvic pain, and irregular uterine bleeding was observed in 60% of patients.
Within our examined population, 46.7% of individuals with 2DSHG exhibit scars that are likely to be clinically irrelevant, while 53.3% have a total score greater than 2(according to VTS score system), indicating potentially clinically relevant features of the uterine niche. Similarly, among individuals with 3DSHG, 37.3% have scars that are likely to be clinically irrelevant, and 62.7% have a total score greater than 2, indicating potentially clinically relevant features of the uterine niche. It is recommended that future pregnancies should be closely monitored however by hysteroscopy 64% possess a niche, while 36% don’t have niche . The majority of cases (28.1%) exhibited triangular defects, while 22.9% displayed semicircular defects, 18.8% had irregular defects, 15.6% had linear defects, and 14.6% had quadrangular defects. Additionally, our study revealed hysteroscopic findings in the cases, with 64% displaying scar ballooning, 64% displaying scar discontinuity, 40% displaying scar vascularity, 18% exhibiting intrauterine adhesions related to the scar, and only 1.3% presenting with endometriotic nodules at the scar site.
The study found that 2DSHG has a sensitivity of 57.3% and a specificity of 53.7%, with an accuracy of 56%, for detecting niche. On the other hand, 3DSHG has a sensitivity of 95.8% and a specificity of 96.3%, with an accuracy of 96%, for detecting niche. These results are compared to hysteroscopy, which is considered the gold standard for diagnosing niche.