All posts by : Kunal Walia

Estimated reading time: 4 minutes

C-section scar defects, or isthmoceles, are increasingly recognised as an important yet often overlooked cause of abnormal bleeding, pelvic pain, and infertility in women with previous caesarean deliveries. In this detailed session, Dr. Aarti Chitkara breaks down everything—from what an isthmocele truly is to how it develops, how we diagnose it, and the best management approaches. This blog captures her complete explanation, imaging demonstrations, and key clinical insights exactly as discussed.

What Is an Isthmocele?

So let us see what thymosyl truly is. It’s a caesarean scar defect or uterine niche. It can come with different names, honestly, so you do not get confused if it’s asked by different names in the exam.
It is any indentation representing a myomaterial discontinuity. It is not only the endometrial discontinuity, it is also a myometrial discontinuity or a Triangular and echoic defect in the uterine wall, mostly present anteriorly, with the base communicating to the uterine cavity. At the site of a previous caesarean section scar, with no universally accepted definition. So this is actually not a definition. It only explains what thymosyl is.

It is a descriptive definition, but not truly a universal definition of thymosyl.

Prevalence & Best Imaging Modality

The largest Systematic review in thymosyl was proposed by Tulandi and Cohen.
They found the prevalence of thymosyl:

• On TVS: 24–70%
  
• On SHG: 56–84%

Hence SHG (sonohysterography) becomes the better investigation of choice in cases of thymosyl.
This is in women who had one or more previous caesarean sections.

How Does Isthmocele Develop?

It causes two pathological changes that may predispose to symptoms like:

• Menorrhagia
• Abnormal uterine bleeding
• Pelvic pain
• Dysmenorrhea
• Caesarean scar pregnancy
• Secondary infertility

A very specific symptom of caesarean scar niche or a thymosyl is post-menstrual spotting, and any woman presenting with this should undergo imaging to rule out the defect.

Ultrasound & SHG Findings

The transcript walks through detailed ultrasound and SHG demonstrations:

• Transvaginal needle insertion
• Aspiration of the collected altered blood
• SHG fluid delineating the scar
• Transabdominal confirmation
• Intraoperative surgical repair visuals
• MR images showing triangular defects

These videos were referenced during the lecture.

Management Options

Treatment ranges from:

• Expectant/clinical management
• Pharmacological treatment
• Surgical treatment
• Hysterectomy
• Uterine-sparing techniques like:
  
  • Hysteroscopy
  • Laparoscopy
    Laparotomy
  • Transvaginal procedures

Hysteroscopic resection is used when residual myometrial thickness is more than 3 mm. A combined hysteroscopic + laparoscopic repair is also described.

Conclusion Presented at the Conference

• Obstetric complications of caesarean section are well established
• It is necessary to identify and manage this new gynecological entity
• Isthmocele is currently classified as AUB-N
• May require reclassification into AUB-I (iatrogenic)
• A new terminology, “cervicoseal” may better explain etiopathogenesis

Ultrasound Appearance & Types

Isthmocele can take various shapes:

• Triangular
• Semi-lunar
• Circular
• Rectangular
• Droplet
• Inclusion cysts

It is a spectrum; inclusion cysts at the caesarean scar behave like adenomyosis.

Definition & Etiology

It refers to an iatrogenic uterine defect of a previous caesarean section or other isthmic tract surgery.
The term “isthmic tract surgery” was added because defects can occur after:

• Cervical fibroid removal
• Hysteroscopic myomectomy

Epidemiology

• 70% of women with a previous C-section may develop isthmocele
• One-third are symptomatic
• Symptoms: menstrual spotting, AUB, pain syndromes, infertility

Risk Factors & Pathophysiology

1. Lower Uterine Segment Factors

• Cervical dilatation > 5 cm during C-section
• Prolonged active labor
• Advanced fetal station
• Thin, stretched, poorly vascularized LUS
• Second stage C-section increases risk

2. Level of Uterine Incision

• Incisions too close to cervix heal poorly due to cervical mucus interference
• Advanced labor + cervical effacement → cervicoseal formation

3. Uterine Closure Technique

• Single-layer decidua-sparing closure predisposes to defects
• Full-thickness single-layer is better
• Two-layer closure preferred
• Avoid locking sutures
• Avoid tissue strangulation
• Ensure good myometrial approximation

4. Adhesions

• Excessive mopping increases peritoneal trauma → adhesions
• Adhesions pull the scar toward the abdominal wall
• Counteracting forces prevent proper healing → niches

5. Uterine Retroflexion

• A retroflexed uterus creates larger defects

6. Patient-Related Factors

• Genetic predisposition
• Poor wound healing
• Hemostatic disorders
• Post-operative infections
• GDM
• Previous CS
• High BMI

Clinical Features

1. Post-Menstrual Spotting

Defined as:

• ≥ 2 days of inter-menstrual spotting
• Brownish discharge
• Persisting > 7 days after menses

Very characteristic of isthmocele.

2. Prolonged Bleeding

Due to impaired menstrual drainage.

3. Intermittent Spotting

Poorly formed niche endometrium sheds irregularly.

4. Dysmenorrhea & Pelvic Pain

Due to abnormal contractions around the fibrosed myometrium.

5. Mid-Cycle Fluid Collection

A key cause of secondary infertility. Retained blood → excess mucus formation → interferes with implantation, similar to hydrosalpinx.

Additional Symptoms Discussed

The lecture proceeds into:

• Caesarean scar ectopic
• And further symptoms (the transcript ends in this segment)

Conclusion

Isthmocele is no longer just an incidental finding—it is a significant gynecological entity that can affect bleeding patterns, fertility, and overall quality of life in women with previous caesarean deliveries.

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Estimated reading time: 4 minutes

Heart diseases in pregnancy are among the most important and challenging topics for both doctors and students preparing for exams. Let’s understand two important parts — the MWHO classification of heart disease in pregnancy and Peripartum Cardiomyopathy (PPCM) — simply.

1. MWHO Classification – What It Means

The first question discussed was:
Which maternal conditions are classified as MWHO Class 4 (pregnancy contraindicated)?

To answer this, we should know what the MWHO classification is.

Earlier, the WHO classification of heart disease in pregnancy was based only on the type of heart disease, not on how severe the symptoms were. But this was not very helpful because two women with the same disease could have very different risk levels.

So, doctors started using a system that combines:

• The type of disease (WHO classification)
  
• The severity of symptoms (NYHA classification)

Later, a modified version called MWHO 2.0 came, which also includes the CARPREG 2.0 score — this helps predict how risky the pregnancy might be for a woman with heart disease.

In short, MWHO 2.0 = WHO classification + CARPREG 2.0 risk score.

Click Here to Watch: Ace Your Exams: MCQ Discussion on Heart Disease Explained

MWHO Class 4 – When Pregnancy Should Be Avoided

You don’t have to remember all the classes. The most important one is Class 4, which means pregnancy is contraindicated — it is too risky for the mother.

If a woman with Class 4 heart disease becomes pregnant, doctors usually advise termination because continuing pregnancy can lead to severe complications or even death.

Conditions under MWHO Class 4:

• Severe aortic stenosis (valve area <1 cm²)
  
• Eisenmenger syndrome (reversal of blood flow causing cyanosis)
  
• Marfan syndrome with an aortic root >5 cm
  
• Aortic root dilatation >4.5 cm (even without Marfan’s)
  
• Ejection fraction <30% (due to any cause like PPCM or old MI)
  
• Severe hypertrophic cardiomyopathy (HOCM)

These are high-risk conditions because the heart cannot handle the extra load of pregnancy.

Example question:
“Which of the following is MWHO Class 4?”
→ Answer: Pulmonary hypertension (PA pressure >70 mmHg)

2. Peripartum Cardiomyopathy (PPCM) – What It Is

PPCM is another important topic. It means heart failure that happens near the end of pregnancy or soon after delivery, without any other known cause. The ejection fraction is usually below 45%.

It is a diagnosis of exclusion, meaning other causes of heart failure must first be ruled out.

Why PPCM Happens?

It is explained by the two-hit theory:

1. Some women have a genetic predisposition.
   
2. During pregnancy, the hormone prolactin increases. In certain women, prolactin breaks down into a harmful fragment (16 kDa) that damages heart muscle and blood vessels.

This toxic fragment causes endothelial damage, reduces blood supply to the heart, and leads to weak heart pumping.

If the woman also has preeclampsia, which releases more harmful anti-angiogenic factors, the risk increases even more.

What Happens in PPCM?

• The heart muscle becomes weak and enlarged
• The pumping function reduces (EF <45%)
• Blood starts backing up into the lungs → breathlessness and swelling
• Both the left and right sides of the heart may fail in severe cases

Common Symptoms and Complications

• Shortness of breath
  
• Fatigue and swelling in the feet
  
• Cough due to fluid in the lungs
  
• Low oxygen levels
  
• In severe cases, cardiac arrest or death

Can the Patient Recover?

Recovery depends on how early it is diagnosed and treated.
With timely treatment — diuretics, beta-blockers, and sometimes bromocriptine (which stops prolactin release) — many women recover well. But in severe cases, the heart may remain weak permanently.

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In simple terms
Understanding heart disease in pregnancy isn’t just about remembering lists. It’s about knowing why these diseases are risky, how they affect the mother, and what can be done to prevent complications.

Estimated reading time: 5 minutes

When things get tense in the labour room, clear anatomy and calm technique matter more than anything else. This blog is focusing on episiotomy — the why, the how, and the bits of anatomy that decide whether a patient walks out better or worse. No big textbook lecture here — just practical, clinically useful points I always stress on rounds.

The superficial perineal compartment — what’s really there

If you picture the perineum, think of two compartments: superficial and deep. For episiotomy, we mostly care about the superficial layer. It contains:

• An erectile body that continues into the clitoris (homologue of the penis),
  
• A few important muscles, and
  
• The Bartholin (vestibular) glands.

The key muscles you’ll notice on the surface are:

• Ischiocavernosus (runs along the ischium) — not that relevant for episiotomy,
  
• Bulbocavernosus — very important, and
  
• Superficial transverse perineal — also important.

Deeper down, you’ll find fibres of the pubococcygeus. All these muscles meet at a common point—the perineal body—and that little structure is hugely important.

Click Here to Watch: Labor Room Emergency! 👶 Shoulder Dystocia & Episiotomy Explained

Why the perineal body matters?

The perineal body is the anchor for all those muscles. With repeated stretching during vaginal births or poorly healed tears, the body becomes lax. The consequence? Early pelvic organ prolapse and pelvic floor dysfunction.

I always ask postpartum patients if they’ve been taught pelvic floor (Kegel) exercises. Too often, the answer is no. If the perineal body is thin on exam (you can check the posterior fourchette), reconstruction should be considered.

So, what is an episiotomy?

Simply put, an episiotomy is an intentional perineal incision made to enlarge the vaginal outlet during delivery. It’s iatrogenic — we do it for a reason. Usually it’s performed with episiotomy scissors, but in an emergency, a stout Mayo scissor will do.

Technically, an episiotomy corresponds to around a grade 1–2 tear (Sultan’s classification), but incorrect angle or timing can create extensions and worse grades.

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When should you cut?

The right time is during crowning — when the fetal head has thinned the perineum and is visible between the labia. If you cut too early, the tissue is thick, and you risk deeper muscle injury. If you wait until crowning, you can often make a neat, thin incision and avoid uncontrolled tearing.

Angle matters — and here’s the simple math

This is the practical bit I drill into trainees:

• If you cut at about 40° from the midline while the perineum is stretched, that angle shortens as tissue recoils after delivery and becomes dangerously close to the anal sphincter, making extension into the anal mucosa possible.
  
• Aim for 60° from the midline. After recoil, this generally becomes about 45°, which safely bypasses the anal canal.

Measure the angle from the midline (a line joining the posterior fourchette to the anal opening), not from a horizontal line. Specially designed episiotomy scissors help maintain this angle.

Types of episiotomy — and when to use which

There are several kinds; keep it simple:

1. Median (midline)
   
   • Cut along the midline (±25°). Once popular, now less favoured because extensions can track straight to the anal mucosa → grade 3–4 tears.
     
2. Modified median
   
   • Midline start, slight lateral extension (~2.5 cm each side). Gives room but can injure deeper muscles and cause more bleeding and sitting pain.
     
3. J-shaped
   
   • Starts midline, then curves laterally. Useful if you want to avoid a straight midline extension.
     
4. Mediolateral (my preferred in most obstetric practice)
   
   • Taken at ~60° to the midline, either side (commonly maternal left if you’re right-handed). Safer from sphincter injury and the most commonly used.
     
5. Radical lateral / Schuchardt’s incision
   
   • Rare in obstetrics — used mainly in gynecologic surgery (e.g., to increase vaginal access in postmenopausal vagina).

Which muscles get cut?

With a proper mediolateral episiotom,y you’ll usually transect:

1. Superficial transverse perineal (most consistently),
   
2. Bulbocavernosus, and
   
3. Sometimes, a bit of pubococcygeus if the incision is deep or poorly placed.

If you follow the angle and timing recommendations, you minimise deeper damage.

A practical note on technique

• Hold the scissors so the blade points away from your body and aim for the 60° line.
  
• Prefer to cut during crowning so the incision is as small and controlled as needed.
  
• If you’re called for a repair, identify which muscles were cut and reapproximate them anatomically — it makes a huge difference in recovery.

A quick clinical aside — Dührssen’s incision

In rare scenarios where the cervix is obstructing delivery (e.g., entrapped cervix) a Dührssen’s incision at 2 or 10 o’clock is taught. The reason for those positions is to avoid the descending cervical branches (around 3 and 9 o’clock). Knowing vascular anatomy prevents uncontrolled bleeding.

Conclusion:

Episiotomy isn’t a “routine” reflex — it’s a surgical decision. If done at the right time, at the correct angle, and with careful repair, it prevents worse tears and promotes better pelvic floor outcomes. Sound anatomy + careful technique = fewer complications.

Want more practical, hands-on tips on perineal repair and pelvic floor preservation? I cover step-by-step repair techniques in my procedural sessions — they make the real difference at the bedside.