Caeserean Scar Isthamocele with Recurrent Failure of Mirena Coil Insertion and Uterine Ablation: Challenges Overcome By the Usage of Modified Techniques

Abstract A 40-year-old woman who underwent 2 previous caesarean sections suffered from abnormal uterine bleeding of idiopathic cause and visited a general practitioner (GP). The GP inserted a Mirena coil, but due to recurrent failure of Mirena coil insertion, and multiple Mirena coil insertions can be a risk, the patient was referred to an outpatient Gynecologic clinic with the provision of outpatient hysteroscopy or hysterectomy. In the Gynecologic clinic, all options were discussed with the patient for the management of abnormal uterine bleeding, and the patient chose to have Novasure Endometrial ablation. During the intraoperative procedure, it was noticed that the patient had an acutely retroverted uterus, and the uterine cavity also measured <4 cm, which is the contraindication for Novasure ablation, hence the procedure was stopped. Thereafter, for further management options the patient was referred, after thorough discussion, it was decided by the patient, medical professionals, and surgeons to use a modified technique such as; the patient under an anaesthetic condition instead of traditional techniques (non-anesthetic condition) while operating hysteroscopy for complete cooperation of the patient and Mirena coil insertion. During hysteroscopy, upon entering the internal os, brownish fluid was observed collecting predominantly on the anterior wall of the uterus. For better visibility of the uterine cavity, and to evacuate the collected blood, another modified technique was used like; an outer hysteroscopic sheath was introduced while increasing the pressure of the fluid. After the evacuation of blood, a pouch was identified in the anterior wall of the uterus diagnosing the patient with isthamocele. As the patient also had acute retroflexion and retroversion uterus, emptying the bladder and traction applied on the anterior lip of the cervix allowed for the straightening of the uterus and improved visualization through hysteroscopy. By applying modified techniques, finally, the uterine cavity was visualised, utero-cervical length measured 10 cm, and a pipelle endometrial biopsy was performed. Mirena coil was successfully inserted into the uterine cavity and by ultrasound, the site of the Mirena coil was confirmed to be inside the uterine cavity. After an observation at a daycare, the patient was discharged without complications. In conclusion, by modified techniques, and continuous training, we overcame the challenges of caeserean Scar Isthamocele with recurrent failure of Mirena coil insertion and uterine ablation.