The isthmocele, also called the “caesarean scar defect”, can be described as a complication that can occur after a caesarean birth. This health problem, whose frequency has increased with the rise in caesarean birth rates worldwide, is associated with many different gynaecological and obstetric problems.
What Is an Isthmocele (Caesarean Scar Disease)?
When performed for the right indications (labour not progressing, the baby lying in a breech or transverse position, the baby being very large, a narrow pelvis, the incision made during a previous caesarean not being suitable for a vaginal birth, the baby becoming distressed in the womb, etc.), the caesarean is surgery that can save the life of both the mother and the baby. Indeed, this statement is also confirmed by the data announced by the World Health Organization. However, however many benefits it may have, there are also complications specific to caesarean birth. One of the most prominent of these complications is the isthmocele, that is, the caesarean scar defect. The isthmocele, or caesarean scar disease, can be defined as the situation in which, after a previous caesarean birth, poor healing at the place that was cut to deliver the baby and then stitched leads to a separation at the edges of the suture and the formation of a small pouch. For the pouch or pocket that forms in the area to be accepted as an isthmocele, it must measure at least 2 mm. The isthmocele usually forms on the anterior wall of the uterus, in the upper part of the cervical canal.
The isthmocele can be likened to a small pocket forming towards the outer part of the uterus because the incision at the site of the caesarean cut has not healed completely; it can have different shapes such as a droplet, a triangle or a rectangle. Blood or fluid can collect in this space. As a result of menstrual blood collecting in the space, the implantation of the embryo (the baby) in the uterus can be disturbed. In other words, in women who have given birth for the first time, an isthmocele can prevent the next pregnancy, that is, it can be a cause of infertility originating from the woman.
What Are the Signs of an Isthmocele?
If there is spotting bleeding that lasts a very long time and does not stop, together with a history of caesarean, it must certainly come to mind!
The signs of an isthmocele and their severity can vary from person to person. Among the most common signs are long-lasting spotting bleeding, pain in the pelvic area, vaginal discharge, pain during menstruation, ectopic pregnancy as a result of the embryo implanting in this pocket, pain during sexual intercourse and infertility originating from the woman. The isthmocele can cause women to experience vaginal discharge that is mostly foul-smelling and altered in consistency and colour, to suffer groin pain and to notice brown discharge that continues for a while after the period has ended. Especially in spotting bleeding that covers almost the greater part of the month, if the patient has a previous history of caesarean, it must certainly come to mind. Women who experience these signs and who have difficulty becoming pregnant after giving birth by caesarean should consult specialists in obstetrics and gynaecology.
How Does an Isthmocele Arise?
Although there is no definite cause regarding how the isthmocele arises, there are various views on the subject. We can mention two important causes; the first is inadequate healing of the caesarean suture site, and the second is related to the surgical technique. The view is that there is a mechanical problem at the point of outflow in this pouch that can form as a result of wound healing in the area where the caesarean incision was made. The mechanical problem occurring in the outflow causes blood or fluid to collect in the area, and as a result of the inflammation that occurs when blood collects, thin and delicate blood vessels form. As a result of all these changes, the isthmocele develops.
How Is an Isthmocele Diagnosed?
It is recommended that women with a history of caesarean birth who experience signs of a caesarean scar defect be examined. Along with listening to the history of the disease, various investigations may need to be carried out in this context. In general, it is possible to diagnose this complication that can occur after a caesarean thanks to imaging methods.
Transvaginal ultrasound: During the examination the ultrasound probe is placed inside the vagina. In this way images of the uterus and the ovaries can be transferred to the monitor by the ultrasound device. The isthmocele pouch can be seen even more easily during menstruation in particular.
Saline infusion sonography (SIS): SIS, which can also be called sonohysterography, is carried out by giving sterile saline solution inside the uterus with the help of a catheter that can be passed through the vagina and the cervix into the uterus. To use this imaging method, the end of the menstrual period is usually awaited. It can safely be carried out in the days after menstrual bleeding has ended. This method is used very rarely.
Hysterosalpingography: Also known as the contrast uterine X-ray, an examination is carried out by radiographic methods after contrast material is given into the uterus and the tubes. Like SIS, this method is used very rarely.
Magnetic resonance imaging (MRI): It is rarely used in the diagnosis of the isthmocele. But when it is used, it offers a very good chance of making the diagnosis.
Diagnostic hysteroscopy: This is an imaging method based on the principle of assessing the inner part of the uterus and the parts of the tubes that open into the uterus with the help of a camera, entering through the cervix.
Today, thanks to highly advanced ultrasonography devices, the diagnosis can easily be made with ultrasound alone.
Does an Isthmocele Cause Infertility?
The caesarean scar, which can form a short time or a long time after a caesarean birth, can cause infertility. Just like hydrosalpinx (inflamed tubes), it is accepted that in some women diagnosed with an isthmocele (the exact proportion is not certain at present) these pouches can harm sperm and can disturb the process of the embryo implanting in the uterus.
Treatment of the Isthmocele
In all women who develop an isthmocele after a caesarean birth, the signs of the isthmocele are not seen in every patient. This complication, which can lead to troublesome symptoms in some women, does not cause any problem in others. When the signs of an isthmocele are noticed and this complication is diagnosed, we present the treatment options to our patients.
In the treatment of the isthmocele, isthmocele surgery stands out as the most definitive method. Thanks to advancing technology, isthmocele surgery can be performed laparoscopically, that is with the closed method, or with robotic surgery. In the process of deciding on the treatment method, as much as the symptoms the patients experience and that lower their quality of life, whether they want to have children in the future also has a determining effect.
With the effect of advancing technology, robotic surgery is coming more to the fore in the treatment of the isthmocele. By the nature of robotic surgery, it becomes possible to carry out very delicate work on the patient. In robotic surgery, which allows the images to be magnified enough to observe even the finest detail, the occurrence of hand tremor can be completely prevented while suturing also becomes easier, and these ensure that the operation goes more comfortably. Because the suturing of the damaged tissue is carried out very successfully, the success of the results obtained can also increase. After robotic surgery, patients can be discharged the following day and can return to their daily lives in a short time.
In patients in whom a smaller pouch has formed, if there is no wish for pregnancy, hysteroscopic surgery can also be offered to the patient as an alternative treatment method.