A scar on the uterus in a woman after a cesarean section
In the world, caesarean section is carried out in 20% of all deliveries, in Russia their number also increases and amounts to 16%. Uterine fibroids are getting younger, it is increasingly common in women of fertile age. This leads to an increase in the number of myomectomy, as well as various plastic operations on the uterus. Therefore, doctors increasingly have to observe birth with a scar on the uterus. This is a condition that threatens the development of complications during gestation and delivery.
What is dangerous scarring for pregnancy
During the second pregnancy, women after cesarean and other operations on the uterus are at risk of developing the following complications:
- preterm labor,
- rupture gap
- fetal hypoxia (chronic)
- trauma of the child during childbirth,
- the threat of spontaneous miscarriage,
- fetal death,
- placental insufficiency
- risk of trauma to the mother,
- high frequency of maternal and perinatal mortality.
After surgery, the blood supply to certain parts of the organ is deteriorating. Implantation of the embryo and the development of the chorion can occur in areas with good blood flow, for example, over the internal throat. At the stage of formation of the placenta, it can migrate in search of a better place. This leads to placenta previa, low attachment.
A similar mechanism underlies the growth of the placenta into the uterine scar. There is a deep invasion of the wall, which during childbirth is manifested by lengthening of the third period and bleeding. The condition requires emergency care - trying to separate the placenta manually, and with inefficiency and diagnosed true increment, the only possible way out is extirpation.
In the first trimester more often than the others, there is a threat of spontaneous miscarriage. The causes of the condition and the mechanism of its development are often associated not with the healed wound itself, but with a lack of progesterone, hyperandrogenism, or antiphospholipid syndrome. Appointed preserving therapy (we have already talked about its methods), depending on the underlying condition that caused the threat of miscarriage.
Often there is a combination with isthmic-cervical insufficiency. Pregnant women are prescribed complete rest, infusion of magnesium sulfate and antispasmodics to reduce the tone of the uterus, it is possible to use an unloading obstetric pessary. Surgical correction of the ICN is not applicable. The failure of the uterine scar in combination with a threatening spontaneous miscarriage can lead to rupture.
Uterine rupture is possible both during the childbearing period and during childbirth. In the first case, the main reason is dystrophic processes that lead to the gradual thinning of tissues. When ruptured during active labor, mechanisms are associated with dystrophy and active contractions.
Causes and mechanism of formation of scar tissue
A scar on the uterus is the area where surgery was previously performed. It is formed due to the proliferation of myocytes and connective tissue, contains hyaline and collagen fibers.
In most cases, the defect occurs as a result of the first birth by cesarean section. The incision is performed in several ways:
- In the lower uterine segment - above the transition to the neck, used for planned operations.
- Corporeal scar - along the body of the uterus, a vertical incision, often used for fibroids in the lower segment, the transverse position of the fetus, varicose veins and placenta previa.
- Istmic-corporal - combines the two previous methods, is rarely used.
The scar can be the result of not only cesarean section, but also other operations on the uterus. Removal of myoma node at reproductive age entails the formation of cicatricial changes. Their severity and possible failure depends on the type of operation, the size and location of the fibroids. With the interstitial node, the uterine cavity may be opened or not. In a subserous-interstitial node, the size of the damage depends on the depth of its ingrowth into the body. After removal of the fibula, cicatricial changes may be minimal.
Also a triggering factor is wall injury during abortion, curettage or other invasive manipulation. An ectopic pregnancy that developed in the interstitial part of the tube, at the junction of the rudimentary horn or in the neck, after the operation also leads to the formation of connective tissue. Cicatricial changes are formed after plastic operations on the uterus to remove the rudimentary horn, plastics with an intrauterine septum (for pathology, read the link).
Cicatrization of injuries is a biological mechanism for restoring an organ’s integrity. The wound after an incision with a surgical instrument, while observing the rules of asepsis, remains sterile. The exception is postoperative infectious complications - endometritis, parametritis.
Healing can occur in two ways:
- Restitution - a full-fledged scar tissue is formed, which is represented by smooth muscle fibers.
- Substitution - defective regeneration, dominated by connective tissues, which are represented by coarse fibers, deposition of hyaline.
Inadequate regeneration leads to the formation of an insolvent scar. It has a loose structure, inelastic and unable to withstand stretching, in this area the uterus can not fully contract.
The predominance of one of the mechanisms of scar tissue formation depends on the presence of infectious complications, as well as the individual characteristics of the organism. Some women may have a predisposition for the development of connective tissue formations in places of injury.
Examination of women at risk
For women who are planning to re-become pregnant after surgery on the uterus, it is best to be examined several months before conception in order to eliminate or minimize the risk of rupture and other complications. But even after conception, regular monitoring and compliance with the recommendations of the doctor is necessary.
Determining the viability before pregnancy
Patients with previous operations on the uterus or childbirth by cesarean section in history, must be at the dispensary account with your gynecologist. This will allow to diagnose the development of complications in a timely manner or to treat them. They are recommended high-quality contraception for at least a year after delivery. Preference is given to hormonal methods. Lactating mothers are prescribed Linestrenol, Lactinet, as less dangerous for the fetus. In the absence of lactation, you can switch to combined oral contraceptives.
The condition of the wound is assessed using several diagnostic methods:
- Hysterography - pictures are taken for 7-8 days of the menstrual cycle after 6 months or more after surgery. On them niches, shift of a normal position of a wound are noticeable. The contours of the uterus in this area may be jagged, with filling defects.
- Hysteroscopy is a more informative way to diagnose. It is carried out on the 4-5 day cycle. In this period, the functional layer completely departed, and under the basal the former wound shines through. An insolvent scar has a flattened shape, and retractions may be noticeable. Color speaks about the type of tissue: white is observed in connective tissue formation, there are few vessels in it, and after a while, the appearance of niches and confluences is observed. This may be an indicator of scar thinning. Good fabrics have a pinkish tint, rich in blood vessels.
- Ultrasonography before pregnancy is characterized by the following features: a smooth contour, myometrium thickness more than 3 mm, a small number of hyperechoic zones indicates the formation of muscle fibers.
Ultrasound has less information than hysteroscopy, but with the help of Doppler it is possible to assess the state of blood flow in the vessels and organ cavity.
The most accurate results are given by MRI. The method allows to determine the ratio of connective and muscle tissue, which indicates its viability along with other signs.
All examination results are stored in the patient's outpatient card. This is necessary to decide whether it is possible to plan a subsequent pregnancy and whether childbirth is possible naturally.
Examination of a pregnant
To prevent the development of complications during gestation, it is necessary to inform the doctor about a cesarean section or other operations on the uterus. The time elapsed between the intervention and the planned or actual pregnancy is taken into account. The recommended range is 2 years.
When registering it is necessary to determine the size of the pelvis. In the later period, the location of the incision, the presence of pain in the rumen are determined by palpation. By 38-39 weeks, the estimated mass of the fetus is calculated in order to exclude the presence of a large child as the risk of a break in labor.
Laboratory diagnostics is the same in any gestational age and includes:
- general clinical blood and urine tests,
- biochemistry with determination of urea, total protein, glucose, residual nitrogen, enzymes, bilirubin and electrolytes,
To assess the placental complex hormones are investigated:
- placental lactogen,
- alpha fetoprotein.
To monitor the condition of the fetus conduct regular CTG. He is appointed at each appearance in the antenatal clinic after 27 weeks. It is possible to clarify the condition of the child with the help of an ultrasound scan with Doppler of the vessels of the umbilical cord, aorta, middle cerebral artery and placenta. The study is recommended from the end of the 2nd trimester.
A scar on the uterus in the ultrasound image
Ultrasound is the main way to monitor and diagnose deterioration in time. It is recommended to spend every 10 days. During pregnancy, the scar changes thickness depending on the period of gestation. At the beginning it may be 5 mm thick, but by the time of birth it is gradually thinning. The optimum for independent births consider the thickness of 3-4 mm.
Using ultrasound to determine signs of the viability of the scar:
- typical position
- the absence of niches and cavities
- the absence of hematomas, inclusions of connective tissue, fluid in its area,
- good blood flow.
Tactics of pregnancy and childbirth
Features of pregnancy planning consist in careful pregravid preparation and determination of the viability of the scar. Scar thickness is normal - 5 mm and more. In the first trimester, waiting tactics, if there is no progression of the condition, are limited to regular ultrasounds.
If the fertilized egg is attached in the rumen, then it is recommended to terminate the pregnancy in a medical way (as is the medical abortion, you can read in a separate article), so as not to injure the tissue. If this is not done, the proteolytic enzymes that the embryo secretes will dissolve the connective tissues and make them unsuitable.
When deciding to preserve the fetus, tactics are selected depending on the risk of complications. At 22 weeks, the state of the feto-placental complex is assessed. In case of placental insufficiency, treatment is prescribed to support the growth of the fetus and eliminate the manifestations of complications. Optimal conditions for treatment are the wards of pregnancy pathology in the maternity hospital.
Second birth after cesarean section
Most doctors first birth caesarean section associated with re-operation when planning the next pregnancy. But such an approach in the civilized world is not used. The correct tactic is a survey to determine the state of the scar and the pregnant woman in order to decide whether the woman can give birth independently. In Western countries, such genera have been proven to be physiological and have a lower risk of complications than reoperation.
Normal delivery is possible when the following conditions are met:
- The only cesarean section, the incision is made in the lower segment,
- no extragenital diseases and other indications for a planned operation,
- wealthy, not thin scar,
- placenta is attached normally, does not affect the scar,
- the head of the fetus is set,
- normal size of the pelvis of the mother, correspond to the head of the fetus.
If the choice is made in favor of natural childbirth, then there should be all the conditions for carrying out an emergency operation, if the indications arise during childbirth.
Births are in accordance with generally accepted standards. Anesthesia can be carried out both by intravenous administration of antispasmodics during the opening period, and by means of epidural anesthesia.
Stimulation of birth with a scar on the uterus is not contraindicated, but it is used very carefully to prevent discordination, hypertonia and rupture. With a prolonged period of 2, episiotomy can be performed, vacuum extraction of the fetus.
After childbirth, it is necessary to perform an ultrasound scan in the delivery room in order to timely diagnose a possible rupture. If the device is unavailable, then manual inspection is necessary.
In the delivery plan include a cesarean section in the presence of the following indications:
- According to the results of the diagnosis, the scar is unsound,
- the previous operation was performed corporally
- two or more cesareans in history,
- the pelvic end of the child is set
- placenta previa
- rejection of women from childbirth in a natural way.
Consequences of myomectomy, plastic surgery and perforation
Patients with myomectomy history, the method of delivery is chosen depending on the location and nature of the fibroids. The deeper in the thickness of the uterus the knot was located, the greater the risk of a break. Births lead through natural paths, except for some indications for surgery:
- myoma was removed during pregnancy,
- the posterior wall after the interstitial or subserous-interstitial node is damaged,
- the intraligamentary node was removed,
- operation for multiple fibroids.
If there is no evidence from other diseases or the condition of the child, the birth is carried out through natural ways.
The decision on the tactics of labor after perforation depends on the location of the hole. Bad prognosis at the location on the back wall or in the area of the isthmus. In women with this pathology is often observed:
- hypotonic bleeding,
- pathology of the placenta,
- rupture of the uterus.
If the perforated hole was located on the front wall, high-quality suturing was carried out, then labor is carried out through natural paths. After the birth of the afterbirth, a manual examination of the uterus is necessary.
Plastic surgery is most often carried out with congenital anomalies of the uterus. If the operation was about the removal of a rudimentary horn, penetration into the cavity was not required, natural childbirth is possible. After metroplasty, preference is given to caesarean section.
Symptoms of rupture during childbirth
A serious complication during pregnancy is rupture. Symptoms of discrepancy of the scar associated with reflex irritation of the walls of the body, which is accompanied by:
Pain syndrome occurs in the epigastric region, then the sensation moves to the lower abdomen. Sometimes the pain is felt more to the right, imitating an attack of acute appendicitis. Less commonly, pain occurs in the lumbar region and resembles renal colic.
When palpating the area of the postoperative scar, there is a local pain, fingers can detect a depression in the uterus.
The progression of the condition leads to the appearance of a hematoma due to the tearing of the uterus vessels, the hypertonus joins, and blood appears from the vagina.
The gap is characterized by signs of acute blood loss and internal bleeding:
- drop in blood pressure
- cold sweat,
- weakness, dizziness,
- pallor of the skin.
Abdominal pain increases dramatically. The fetus has symptoms of acute hypoxia. After a sudden increase in mobility comes a period of silence.
With a poor supply of connective tissue of the rumen with vessels, the rupture can occur without pronounced bleeding, so the main symptoms are pain and symptoms of acute hypoxia of the fetus.
Symptoms of rupture during active labor
The risk group includes women with a formed suture, in which there are dystrophic changes, as well as those with multiple walls.
The first signs of a threatening gap are:
- epigastric pain,
- nausea and vomiting,
- violation of uterine contractions.
After the use of amniotic fluid, there is a weakness of labor activity or discoordination. The mother complains of extremely painful contractions, which does not correspond to their strength when recording CTG. Against the background of the complete opening of the neck, the fetus may stop progressing.
The beginning of the gap is manifested by a constant tension of the uterus, hypertonia associated with the appearance of a hematoma in its wall. At attempt to palpate the lower segment sharp soreness comes to light. Signs of acute fetal hypoxia appear on the CTG tape. From the genital tract appear bloody discharge.
From the appearance of the first signs of a threatening gap to its beginning, a few minutes can pass. The condition of the woman in labor is rapidly deteriorating. Свершившийся разрыв характеризуется симптомами геморрагического шока, наступает антенатальная гибель плода.During the vaginal examination is determined by the displaced head of the fetus, which was previously tightly pressed against the entrance to the small pelvis.
The gap during the expulsion of the fetus is more difficult to diagnose:
- the attempts become weaker
- contractions may stop
- there is pain in the abdomen, extending to the sacrum,
- from the birth canal observed bloody discharge
- the fetus dies against the background of acute hypoxia.
Rarely, a break occurs at the height of the last attempt. This is the most favorable option for the child, he manages to be born without signs of asphyxia. The third period of labor proceeds unchanged, but then symptoms of acute blood loss, weakness, a sharp decrease in pressure, pain in the center of the abdomen appear. Diagnose a condition during manual inspection.
How to distinguish a gap from other states
If there are indications of a caesarean section in history, the woman is subject to better observation, she is recommended to transfer to a specialized hospital.
The differential diagnosis in the initial stages is carried out with acute appendicitis, renal colic. A surgeon may be invited to make a decision.
If ultrasound and other signs of a thin scar, the risk of insolvency, the woman is in the hospital until the moment of delivery. If symptoms increase, then an emergency caesarean section is performed.
Distinguish the threat of interruption from insolvent scar. In the first case, there is no bleeding, pain is observed over the entire surface of the abdomen. With a threatening miscarriage appear bloody discharge. For a rupture bleeding is characteristic only in the remote period. With the threat of interruption during vaginal examination, the cervix is determined, smoothed or already with the opening.
Ultrasound confirms the failure of the scar during thinning, the presence of various inclusions, niches, reducing vascularization.
Tactics in the development of complications in childbirth
What is dangerous niche in the rumen on the uterus? The development of a gradual spread of tissue. Tactics in the development of complications in childbirth depends on their period. But it is recommended to give preference to overdiagnosis: it is better to behave cautiously, and at the first signs to change the natural birth to an emergency cesarean, than to expect the beginning of uterine rupture through scar tissue.
Treatment of uterine scar after rupture may be in the form of tissue excision and re-suturing. Conditions for such an approach will be timely fetal extraction, the size of the injury. The most favorable prognosis for an incomplete rupture within the limits of an existing wound.
If signs of thinning tissue, pain in the lower segment, signs of fetal hypoxia appear in the first stage of labor, then they end up with an operation. In the second stage of labor, the operation is practically impossible: the fetus is in the pelvic cavity, so obstetric techniques are chosen to speed up the birth of the child.
In the third period, a diagnosis of a possible accomplished injury and the choice of a way to eliminate the consequences is necessary.
Prevention of rupture
To reduce the risk of rupture of the scar and other complications, prevention begins at the stage of pregravid preparation. In some cases, a woman may be offered a plastic scar on the uterus. This is a surgical operation that aims to restore the integrity of the tissue and the formation of a full-fledged scar. As a suture material, it is preferable to use absorbable synthetic threads, to suture the incision with separate sutures.
After any operation, it is necessary to avoid infectious complications that can cause unsuccessful formation of connective tissue.
Treatment of uterine scars by folk methods, medication methods is ineffective.
To reduce the likelihood of rupture of the scar for a woman during pregnancy and at birth, careful monitoring, regular CTG and ultrasound scans are necessary. At birth, monitoring fetal heartbeat and uterine contractions are also required.
What is a scar on the uterus
The area of dense connective tissue in the uterus, which in the past was damaged during surgery, is called the scar. This is a special formation, which consists of myometrial fibers, which regenerate after injury. The human body is poorly adapted to recovery, so the gaps are closed not by the original tissue, but by the connective tissue. It does not replace the muscle layer fully, but only restores the integrity of the uterus after the incision.
Postoperative scar has no characteristic symptoms. He does not bother the patient until there is a rupture of the uterus along the scar. This is a very serious pathology, manifested by such symptoms:
- bleeding from the vagina,
- pain in the lower and middle abdomen,
- irregular and strong contractions of the uterus,
- lowering blood pressure
- rare pulse
- paleness of the skin,
- nausea, vomiting.
More often there is a scar on the cervix after childbirth. Today, the frequency of cesarean section in maternity hospitals reaches 25%. In addition, cicatricial defects on the female organ result from:
- perforation of the uterus during intrauterine examination or artificial termination of pregnancy,
- gynecological surgery to treat adenomyosis or removal of fibroids,
- ectopic pregnancy
- plastic surgery to remove the intrauterine septum or correct the two-horned or saddle-shaped uterus.
A woman with a suture on the uterus when planning a child must be examined before conception. Outside of pregnancy, it is necessary to evaluate the viability of the scar in patients who have undergone surgery with the opening of the uterine cavity: caesarean section, suturing of the perforation, myomectomy and others. First, the doctor palpatorically probes the contours of the walls of the uterus, evaluates the suture, determines its size.
Further examination is carried out using hysterography (inspection using a high-precision optical device), hysterosalpingography (x-ray with a contrast agent) and ultrasound. Also conducted laboratory tests:
- general urine and blood tests
- blood chemistry,
- hemostasiogram, coagulogram,
- hormonal status of FPK.
If the woman is pregnant, then the uterus cavity is examined on the viability of the scar only by ultrasound. Ultrasound helps to know the exact dimensions of the suture, the thickness of the uterine wall in this area, the presence of niches, ligatures, non-conglomerations and the shape of the lower uterine segment. The results will help doctors predict the likelihood of complications during pregnancy. If an ultrasound of the uterine scar is performed after caesarean or at the planning stage of conception, then 10-14 days of the menstrual cycle are more suitable for this.
The rate of thickness of the myometrium in the area of the scar
The failure of the suture on the uterus after cesarean can be found by comparing the figures with the norm. According to the rules, the thickness of the scar after artificial delivery should be from 5 mm. If there is a thinning of up to 1 mm, this indicates its inconsistency. During pregnancy, the norms are different. Since the scar becomes thinner due to an enlarged uterus, at the end of the term even a thickness of 3 mm will be considered normal.
Pregnancy and scar
To form a wealthy suture in the uterus, it takes about two years. This time, doctors advise the woman to wait and not plan a pregnancy. However, a too long break is not the best option, because four years after the scar heals, it begins to lose elasticity. For this reason, the planning and course of pregnancy with a stitch on the neck or another part of the female organ should be under the special supervision of a physician.
Possible complications of pregnancy
Thinning of the uterine scar during pregnancy is normal. However, its presence may affect the condition of the fetus. Due to the atrophied area, partial, marginal or complete presentation sometimes occurs. There may be an increment of the placenta at any level of the uterine wall. If the implantation of the ovum occurred at the site of the connective scar, then this is also a bad sign - in this case there is a very high risk of premature birth or termination of pregnancy.
The most dangerous complication of pregnancy is rupture of the uterus due to severe thinning of the atrophied tissue. This is preceded by certain symptoms:
- hypertonus of the uterus,
- soreness when touching the abdomen,
- arrhythmia in the fetus,
- bleeding from the vagina,
- arrhythmic uterine spasms.
After a rupture of the uterus, more serious symptoms are observed: sharp pain in the abdominal cavity, nausea and vomiting, a drop in hemodynamics, an arrest of labor activity. For a woman and a fetus, these consequences are deplorable. As a rule, the child has hypoxia, which leads him to death. A woman suffers from hemorrhagic shock. If time does not take action, the probability of a fatal outcome of the woman in labor is high. In order to save a woman, emergency hospitalization, surgical opening of the cavity with a transverse incision and curettage of the uterus are required.
Births with a scar on the uterus
The uterine cavity is opened in two types: transverse, which is done in the lower segment during full-term pregnancy in a planned manner and with a corporal incision performed during bleeding, during emergency surgery, hypoxia or premature delivery (up to 28 weeks). During pregnancy with a scar in the uterine cavity, the woman is usually subjected to repeated cesarean. However, medicine is not in place and in recent years more and more women with a scar on the female organ after prenatal planned hospitalization are poisoning for childbirth through natural ways.
When natural delivery is permitted in the presence of a scar
In the absence of contraindications after a comprehensive examination and prenatal hospitalization at 37-38 weeks of gestation, the woman is allowed natural childbirth with a suture on the uterus. However, the following conditions must be met for this:
- the presence of one wealthy scar,
- the first operation was carried out exclusively according to relative indications (a fetus of more than 4 kg, weak labor, intrauterine hypoxia, transverse or pelvic presentation, infectious diseases, aggravated shortly before birth)
- the first operation was performed by a cross-section and was without complications,
- the first child has no pathologies,
- This pregnancy proceeded safely,
- signs of insolvent scar are absent from the results of ultrasound,
- estimated fruit weight does not exceed 3.8 kg
- the fetus is not observed pathologies.
The scar after the operation of artificial delivery heals in several stages. In the first week, the primary seam is bright red with clear edges. Movement causes great pain. The second stage is characterized by scar compaction. It changes color to less bright, still hurts, but less than in the first week. This stage lasts a month after the operation, by the end of which the pains during movement cease. About a year last phase lasts. The scar changes color to pale pink, looks almost imperceptible, becomes elastic. Healing occurs through the production of collagen.
The failure of the uterine scar after cesarean section
A scar after opening the uterine cavity does not always heal safely. A complication is the failure of the scar, which is an improperly formed tissue at the incision site. The pathology is characterized by non-cohesive cavities, insufficient thickness and the presence of a large amount of scar tissue, which prevents the female organ from stretching normally during the next pregnancy. Pathology is a threat to full-fledged childbearing, since there is a strong displacement and change in the shape of the uterus, a violation of its contractile activity.
If pregnancy and childbirth proceed normally, then the uterine scar does not require treatment. In the case of an insolvent scar, women are advised not to plan future pregnancies in order to avoid obstetric complications. Laparoscopic metroplasty is considered the only effective treatment for this pathology. Drug or any other schemes to eliminate a failed scar in the uterine cavity are ineffective. Due to the fact that the uterus is in the abdominal cavity for internal organs, it is impossible to resort to a more benign method.
Metroplasty after cesarean section
The indication for this operation is the thinning of the walls of the myometrium up to 3 mm and the deformation of the suture in the area of the postoperative scar. Its formation is mainly a complication of cesarean section. The essence of laparotomic metroplasty is the excision of a thin scar, followed by the imposition of new stitches. Open surgery due to the need to ensure access to the defect, which is located under the bladder in the area of strong blood supply. This is due to the risk of pronounced bleeding during surgery.
Accompanied by metroplasty with the release of large vessels and the imposition of (temporary) soft clamps on them in order to stop blood flow. After excision of the failed scar, the plastic is held and the clips are removed. The advantage of the laparoscopic method is the low degree of invasiveness of the surgical intervention and the low risk of adhesions forming in the abdominal cavity. The method provides short rehabilitation time and a good cosmetic effect.
To prevent complications from occurring during pregnancy or childbirth in women with a scar in the uterine cavity, prevention is needed, which includes:
- assessment of the state of the scar at the planning stage of pregnancy,
- determination of the location of the placenta during pregnancy,
- formation of normal conditions for scar healing after cesarean section,
- timely treatment and prevention of complications of the pathology,
- fetal monitoring during labor,
- CTG and ultrasound control during childbirth,
- balanced approach to the decision of natural childbirth with a scar in the uterine cavity.
The effect of the scar on the course of pregnancy and the upcoming delivery
The degree of scar healing is of great importance, and depending on this circumstance, certain predictions can be made:
- Wealthy (or full) scar - This is the one in which the complete recovery of muscle fibers after surgery. Such a scar is elastic, able to stretch with an increase in the duration of pregnancy and the growth of the uterus, it is capable of contractions during contractions.
- Insolvent (or defective) scar - This is one in which connective tissue prevails, and it is unable to stretch and contract like muscle tissue.
What operation did a uterine scar appear on?
Another aspect that should be considered is the type of surgery, as a result of which operation, a scar on the uterus appeared:
1. A scar after a cesarean section can be of 2 types:
- transverse make in the lower uterine segment, in a planned manner with full-term pregnancy, and it is able to withstand both pregnancy and childbirth, since the muscle fibers are transversely, and therefore grow together and heal after surgery,
- longitudinal - performed during emergency surgery, with bleeding, hypoxia (lack of oxygen) of the fetus or for up to 28 weeks of pregnancy.
2. If the scar has appeared due to conservative myomectomy (removal of nodes of a benign tumor - myoma with preservation of the uterus), then the degree of its recovery depends on the nature of the location of the removed nodes, access of surgical intervention (scar size), the fact of opening the uterus.
Most often, small fibroids are located on the outer side of the reproductive organ and are removed without opening the uterus, so the scar after such an operation will be more prosperous than when opening the organ cavity when intermuscular nodes located between the myometrium fibers or intermuscularly are removed.
3. A scar caused by perforation of the uterus after induced abortion it is also considered taking into account whether the operation was limited only to the closure of the perforation hole (puncture), or the uterine dissection was still present.
The postoperative period and the occurrence of possible complications
The course of the postoperative period, the presence of possible postoperative complications, will affect how the process of uterine tissue repair will proceed.
For example, after a cesarean section may occur:
- subinvaluation of the uterus - insufficient contraction of the organ after childbirth,
- the delay of the parts of the afterbirth in the uterus, which will require scraping,
- postpartum endometritis - inflammation of the inner lining of the uterus.
Complications after conservative myomectomy can be:
- hematoma formation (blood accumulation),
Abortion and curettage of the uterus, performed after surgery, injure the uterus and do not contribute to the normal formation of the scar. Moreover, they increase the risk of an inferior scar formation.
All these complications will complicate the scar healing process.
The term of pregnancy after surgery
Any tissue, including the wall of the uterus, after surgery, needs time to recover. От этого зависит степень заживления рубца.For the uterus, in order to restore the proper functioning of the muscular layer, it takes 1-2 years, so the optimal timing for the onset of pregnancy after surgery is not earlier than 1.5 years, but not later than after 4 years. This is due to the fact that the more time passes between the genera, the more the connective tissue grows in the area of the scar, and this reduces its elasticity.
That is why women who have undergone surgery on the uterus (whether it is myomectomy or cesarean section) are recommended to protect themselves for 1-2 years from becoming pregnant. And even before the planned conception it is necessary to be examined for the viability of the scar: on the basis of the results, it will be possible to predict the course of the pregnancy and the birth itself.
Examination of the uterine scar
It is possible to examine the uterus scar after the transferred operations with the help of:
- Ultrasound research. With the onset of pregnancy, this is the only possible type of research. Signs indicating the inferiority of the scar - its roughness, discontinuity of the outer contour, scar thickness less than 3-3.5 mm.
- Hysterosalpingography - X-ray examination of the uterus and fallopian tubes after the injection of a contrast agent into the uterus. For this procedure, a special substance is injected into the uterine cavity, and then a series of X-ray images is taken to judge the state of the inner surface of the postoperative scar, its position, the shape of the uterus and its deviation (aside) from the midline. Using this method, it is possible to detect the inferiority of the scar, manifested in a sharp displacement of the uterus, its deformation, fixation to the front wall, as well as unevenness of the contours and niche of the scar. However, this study does not provide enough information, and therefore today is used rarely and more often as a method of additional examination.
- Hysteroscopy - carried out using a hyperfine optical device of a hysteroscope, which is introduced into the uterine cavity through the vagina (the procedure is performed on an outpatient basis under local anesthesia). This is the most informative method for studying the condition of the uterine scar, which is performed 8-12 months after the operation, on the 4-5 day of the menstrual cycle. On the usefulness of the scar indicates its pink color, indicating muscle tissue. Deformations and whitish inclusions in the area of the scar indicate its inferiority.
Symptoms of discrepancies during pregnancy
Deliveries with the presence of a scar on the uterus during the second pregnancy are carried out without complications, but a certain percentage of seam divergence is present. An important moment in the second pregnancy is the age of the woman in labor, a small break between conceptions. Moms who have given birth to an insolvent scar on the uterus, undergo a second operation.
When recurring, caesarean is performed for some women, even with a standard organ incision. Statistics of rupture of the uterus along the scar says that the vertical and horizontal lower incisions are broken in 5-7% of cases. The risk of rupture is affected by its shape. The seams on the organ resemble the letters J and T, even the shape of an inverted T is. In 5-8%, T-like scars diverge.
When a child breaks while carrying a child, there is a complex condition that contributes to the death of both. The main cause of the manifestations of complications is called the failure of the uterine scar after childbirth. The main difficulty is the impossibility of predicting the seam divergence. After all, the body is torn, both during delivery and during pregnancy, even after childbearing after a few days. The midwife immediately determines the discrepancy already during contractions.
Can a uterus scar? Yes, there is discomfort when stretching. An unsuitable seam always hurts a lot, the discrepancy is accompanied by nausea and vomiting.
- threatening rupture of the uterus along the scar,
Note factors affecting the beginning or already occurred seam rupture. A mother in labor feels bad, she has severe pain, bleeding develops.
- between contractions there are strong pain,
- contractions are weak and not intense,
- hurts the scar on the uterus during pregnancy,
- the baby is moving in a different direction,
- the head of the fetus is beyond the boundaries of the gap.
When a non-standard heartbeat of a child is observed, the heart rhythm slows down, the pulse decreases, these are symptoms of divergence. There are cases that after a break, labor continues, contractions also remain intense. The suture broke, and signs of rupture of the uterine scar during pregnancy are not even observed.
Threat of rupture
Situations of discrepancy are systematically studied. If you monitor this type of labor, diagnose a suture gap in time and perform an emergency operation, you can avoid serious complications or minimize them. When organizing an unplanned cesarean, the risk of a child dying due to a spike gap during childbirth is reduced. There is a gap in the posterior commissure after childbirth, damage to the walls of the vagina, the skin of the perineum and muscles, as well as violations of the rectum and its walls.
When a woman is observed during the entire period of gestation, experienced obstetricians of the hospital with the necessary equipment are involved in the delivery. Under the control of childbirth pass without complications for the mother and child.
There are women who wish to give birth at home. They should know that there may be a divergence of the seam, so it is not recommended to give birth at home. If a woman gives birth naturally in a non-state institution, then it is necessary to clarify whether there is equipment in this hospital for performing an emergency operation.
There are signs that increase the risk of scarring:
- oxytocin and medicines that stimulate uterine contraction are used at birth,
- in the previous operation, a single layer suture was imposed, instead of a reliable double,
- re-pregnancy occurred earlier than 24 months after the previous one,
- a woman over 30 years old
- Vertical dissection
- the woman experienced two or more cesareans.
There are techniques that diagnose gap seam. Electronic device monitors the status of the child. There are obstetricians who use fetoscopy or Doppler research, but have not proven that these methods are effective. The institutions advised to use electronic devices that allow to monitor the status of the fetus.
Treatment and Prevention
Treatment of scarring in the uterus involves repeated surgical intervention, but there are also few invasive methods for the removal of the abnormality. In no case should not refuse therapy.
If you refuse treatment, complications arise:
- gap during gestation or childbirth,
- increased body tone,
- bleeding scar on the uterus,
- severe pain, it is impossible to even lie on your stomach,
- increases the risk of ingrowth of the placenta,
- lack of oxygen for the fetus.
It is easy to diagnose a complication. When an organ is torn, the stomach changes shape, the uterus is like an hourglass. Mom is worried, faints, the pulse is almost not palpable, bleeding opens, the vagina swells. It is impossible to listen to the fetal heartbeat, as there is hypoxia and, as a result, the death of the child.
A woman is registered at the hospital, examined and underwent surgery. First, exclude the patient's blood loss. During surgery, the uterus is removed and blood loss is restored. After the procedure, prevention of the occurrence of blood clots and low hemoglobin is carried out. If the newborn has survived, then it is sent to intensive care and nursed under the apparatus.
How to treat uterine scar:
- laparoscopy - excision of the existing unsuitable suture and stitching of the walls of the organ,
- metroplasty - the destruction of the septum inside the body in the presence of many niches.
In order to prevent uterine tears, conception should be planned in advance and examined. If a woman has had an abortion or surgery before, then the body should recover. At the onset of conception with uterine scar, it is recommended to be urgently registered with a doctor.
When the patient is responsible for the long-awaited labor activity, chooses a suitable doctor, closely monitors the health during the second pregnancy, then the appearance of the child will be really joyful. There are mothers who have two cicatrices on the uterus and the third pregnancy is common for them. Women are ready to take such a responsible step. Discuss the seam and how the birth will take place with an obstetrician in advance.
What is a scar?
Scar is called tissue damage, which was subsequently eliminated. Often used for this surgical method of suturing. Rarely dissected places are glued with special plasters and so-called glue. In simple cases, with non-serious damage, the gap grows together independently, forming a scar.
Such education can be anywhere: on the body or organs of a person. In women, a scar on the uterus is of particular importance. Photos of this education will be presented to you in the article. Damage can be diagnosed using ultrasound, palpation, on different types of tomography. In addition, each method has its advantages. So, during the ultrasound, the doctor can assess the position of the scar, its size and thickness. Tomography helps to determine the reliefs of education.
Why do some women form scars on the uterus? Such injuries become a consequence of medical interventions. This is usually a caesarean section. At the same time plays a big role type of operation. It can be planned and emergency. With planned delivery, the uterus is dissected in the lower abdominal segment. After extraction of the fetus, layer-by-layer closure is performed. Such a scar is called transverse. For emergency caesarean section, a longitudinal incision is often made. In this case, the scar has the same name.
Accrete damage can be the result of perforation of the uterine wall during gynecological procedures: curettage, hysteroscopy, introduction of the IUD. Also, scars always remain after removal of fibroids surgically. In these cases, the position of the scar does not depend on the specialists. It is formed where the operation was performed.
Conducting pregnancy and childbirth with a scar on the uterus
If you have a scar on the reproductive organ, then this should be reported to the specialist who will lead your pregnancy. In this case, it is necessary to tell about the existing fact immediately, at the first visit, and not just before the birth. Conducting pregnancy in women with uterine lesions in history is somewhat different. They get more attention. Also this category of expectant mothers regularly have to visit the office of ultrasound diagnostics. Especially frequent such visits in the third trimester. Before giving birth, an ultrasound of the uterine scar is performed almost every two weeks. It should be noted that other methods of diagnosis during childbirth are unacceptable. X-ray and tomography are contraindicated. The exception is only special difficult situations, when it comes to not only health, but also the life of a woman.
Delivery can be carried out by two methods: natural and operational. Most often women themselves choose the second option. However, with the wealth of the scar and the normal well-being of the expectant mother, natural childbirth is quite acceptable. To make the right choice, you need to consult with an experienced specialist. Also during labor activity and the increase in contractions, periodic ultrasound monitoring of the condition of the scar and uterus is worth conducting. Doctors control the fetal heartbeat.
Practice shows that some women who give birth on their own have a scar on the cervix. It occurs due to tissue rupture. In the process of delivery, the woman feels painful contractions. Behind them begin the attempts. If the cervix is not fully open at the moment, they can lead to its rupture. For a child, it does not threaten anything. However, the woman subsequently has a scar on the cervix. Of course, after delivery, all tissues are sutured. But in the future this may become a problem in the following genera.
Such a scar on the mouth of the cervical canal may appear after other gynecological procedures: cauterization of erosion, removal of a polyp, and so on. In all cases, the resulting scar is a connective tissue. With subsequent delivery, it simply does not stretch, leaving an area of the cervix undisclosed. Otherwise, the damage does not have any danger to the mother and her unborn child. Let's try to figure out what can be dangerous scars, located on the genital organ.
Attachment of the ovum and its growth
If there are scars on the uterus, then after fertilization, a set of cells can be fixed on them. So, it happens in about two cases out of ten. In this case, the forecasts are very pitiable. On the surface of the scar is the mass of damaged vessels and capillaries. It is on them that the feeding of the ovum occurs. Most often, this pregnancy is terminated independently during the first trimester. The consequence can be called not only unpleasant, but also dangerous. After all, a woman needs emergency medical care. Decomposing embryonic tissues can lead to sepsis.
Incorrect placenta attachment
A cicatrix on a uterus after a cesarean section is dangerous in that during the next pregnancy it can cause an incorrect attachment of a child’s seat. Often women are confronted with the fact that the placenta is fixed close to the birth canal. In this case, with the course of pregnancy, it migrates higher. A scar can prevent such a movement.
The presence of a scar after injury to the reproductive organ often leads to placenta invasion. The baby seat is located at the same time on the area of the scar. Doctors secrete basal, muscular and complete ingrowth of the placenta. In the first case, the forecasts can be good. However, natural childbirth is no longer possible. At full increment of the placenta may require removal of the uterus.
A scar on the uterus can lead to impaired blood circulation in the reproductive organ. In this case, the future child loses oxygen and all the substances it needs. With the timely detection of such pathology, treatment and support with appropriate preparations can be made. Otherwise, there is hypoxia, which is fraught with intrauterine growth retardation. In particularly difficult situations, the child may remain disabled or even die.
In the usual non-pregnant state, the thickness of the walls of the reproductive organ is about 3 centimeters. By the end of pregnancy, they stretch to 2 millimeters. In this case, the scar also becomes thinner. As is known, accrete damage is replaced by connective tissue. However, normally, a large area of the scar is represented by the muscular layer. In this case, the scar is recognized wealthy. If the damage becomes thinner to 1 millimeter, this is not a very good sign. In most cases, specialists prescribe to the expectant mother bed rest and supporting drugs. Depending on the gestational age and the thickness of the scar on the uterus, a decision on premature delivery can be made. This condition is dangerous consequences for the baby.
Scars on the uterus after childbirth can also be dangerous. Despite the fact that the baby has already been born, the consequences may arise for his mother. Scars are damages to the mucous membrane. As you know, after giving birth, every woman has bleeding. There is a process of separation of mucus and residual membranes. These secretions are called lochia. In some situations, mucus may linger on the scar area. This leads to an inflammatory process. A woman needs curettage, her body temperature rises, her condition worsens. In the absence of timely treatment, blood infection begins.
Often the presence of a scar on the uterus is the reason for cesarean section. Many women are concerned about their subsequent appearance. An ugly scar remains on the stomach. However, much depends on the technique of the surgeon. The opportunities of cosmetology also do not stand still. If desired, you can make plastic and hide the ugly seam.
You have learned about what is a scar on the uterus, in what situations it appears and what is dangerous. Note that if you properly prepare for pregnancy and listen to the advice of an experienced doctor in its management, then the outcome in most cases is good. Newly-born mom and baby are discharged from the maternity ward about a week later. Do not be very upset if you have a scar on the uterus. Before planning, be sure to contact your doctor, go through a routine research, take all tests. After that you can get pregnant.
Experts do not advise starting pregnancy planning earlier than two years after receiving such a trauma. Also do not delay with this. Doctors say that in 4-5 years it will be almost impossible to stretch the scar. It is then that problems can begin during pregnancy and childbirth. All the best to you!
Causes of uterine scar
Scarring of the uterine wall occurs after various traumatic effects. Наиболее распространенными причинами замещения мышечных волокон миометрия рубцовой тканью являются:
- Кесарево сечение. Плановое или экстренное родоразрешение хирургическим путем завершается ушиванием разреза.Today it is the most common cause of scarring in the uterus.
- Gynecological surgery. Scar tissue in the wall of the uterus is formed after myomectomy, tubectomy in ectopic pregnancy, reconstructive plasty with the removal of the rudimentary horn of the two-horned uterus.
- Uterine rupture in labor. Often, when a rupture of the body or cervix with the transition to the inner pharynx, the decision is made to preserve the organ. In this case, the wound is sutured, and after its healing a scar is formed.
- Damage due to invasive procedures.. Perforation of the uterine wall can complete a surgical abortion, diagnostic curettage, and much less often endoscopic procedures. After such damage, the scar is usually small.
- Abdominal trauma. In exceptional cases, the integrity of the uterine wall is broken with penetrating wounds of the abdominal cavity and small pelvis during accidents, accidents at work, etc.
The formation of the uterine scar is a natural biological process of its recovery after mechanical damage. Depending on the level of overall reactivity and the size of the incision, rupture or puncture, the healing of the uterine wall can occur in two ways - by restitution (full regeneration) or substitution (incomplete recovery). In the first case, the damaged area is replaced by smooth muscle fibers of the myometrium, in the second case - by gross bundles of connective tissue with hyalinization foci. The probability of formation of a connective tissue scar increases in patients with inflammatory processes in the endometrium (postpartum, chronic specific or nonspecific endometritis, etc.). For full maturation of scar tissue usually takes at least 2 years. The functional viability of the uterus directly depends on the type of healing.
The clinical classification of uterine scars is based on the type of tissue with which the damaged area was replaced. Specialists in the field of obstetrics and gynecology distinguish between:
- Rich scars - elastic sections, which are formed by myometrial fibers. Able to shrink at the moment of contraction, resistant to stretching and significant loads.
- Insolvent Scars - maloelasticheskih areas formed by connective tissue and underdeveloped muscle fibers. Can not shrink during contractions, unstable to rupture.
In determining the survey design and obstetric tactics, it is important to consider the localization of scars. Scar-modified may be the lower segment, body, neck with the area adjacent to the inner throat.
Symptoms of uterine scar
Outside of pregnancy and childbirth, cicatricial changes of the uterine wall do not manifest clinically. In the late gestational period and childbirth, the inconsistent scar may diverge. In contrast to the primary gap, the clinical manifestations in these cases are less acute, and in some pregnant women, symptoms may be absent at the initial stage. With the threat of re-rupture in the prenatal period, the woman notes pain of varying intensity in the epigastrium, lower abdomen and lower back. A recess may be felt on the wall of the uterus. As the pathology deepens, the uterine wall tone rises, bloody discharge from the vagina appears. Touching the belly of a pregnant woman is extremely painful. A sharp deterioration in well-being with weakness, pallor, dizziness, or even loss of consciousness indicates a rupture caused by the scar.
The rupture of the old scar during childbirth has almost the same clinical signs as in pregnancy, however, some of the symptoms are due to labor. With the onset of scar tissue damage, contractions and attempts are intensified or weakened, become frequent, irregular, and cease after rupture. The pain felt by the woman in labor during contractions does not match their strength. Fetal movement along the birth canal is delayed. If the uterus ruptures along the old scar with the last attempt, there are no signs of violation of the integrity of its wall at first. After separation of the placenta and afterbirth, the typical symptoms of internal bleeding increase.
Cicatricial change of the uterine wall causes anomalies in the location and attachment of the placenta - its low location, previa, tight attachment, increment, ingrowth and germination. Such pregnant women are more likely to have signs of placental insufficiency and hypoxia. With a significant size of the scar and its localization in the istmico-corporal department, the threat of placental abruption, spontaneous abortion and premature birth increases. The most serious threat to pregnant women with cicatricial changes of the uterine wall is uterine rupture during childbirth. Such a pathological condition is often accompanied by massive internal hemorrhage, DIC, hypovolemic shock and, in most cases, antenatal fetal death.
Uterine scar treatment
Currently, there are no specific treatments for cicatricial changes in the uterus. Obstetric tactics and the preferred mode of delivery are determined by the state of the scar area, the characteristics of the gestational period and childbirth. If during echography, it was determined that the fertilized egg attached to the wall of the uterus in the postoperative scar, the woman is recommended to terminate the pregnancy with a vacuum aspirator. When the patient refuses abortion, regular monitoring of the condition of the uterus and the developing fetus is provided.
Independent labor for a uterine scar is recommended for women with one previously transferred cesarean section, made through a cross-section. The prerequisites for choosing a natural delivery are uncomplicated pregnancy, the viability of scar tissue, the normal functioning of the placenta and its attachment outside the zone of scar changes, the head presentation of the fetus, its conformity to the size of the mother's pelvis. In such cases, the pregnant woman is hospitalized at 37-38 weeks of pregnancy for a comprehensive examination. To improve the prognosis with the onset of labor, prescription of antispasmodics, antihypoxic and sedative drugs, and means for improving the placental blood flow is shown.
Patients with a high risk of re-rupture recommended prompt delivery. Direct indications are:
- Longitudinal scar. The probability of divergence of scar tissue after dissection of the uterine wall in the longitudinal direction is several times higher than with transverse incisions.
- Having more than one scar. If a woman has suffered more than one cesarean section, the pregnancy is completed surgically.
- Some gynecological interventions. Conservative myectomy of the node on the back wall of the uterus, reconstructive plastics for uterine abnormalities and surgery for cervical pregnancy are contraindications to natural childbirth.
- Previously transferred uterine rupture. If past labor is complicated by rupture of the uterine wall, the next pregnancy is completed with a cesarean section.
- Scar failure. If diagnostic signs of prevalence of coarse-fibrous connective tissue are detected in the scar area, the operation is performed.
- Pathology of the placenta. Surgical delivery is indicated with placenta previa or its location in the scarring area.
- Clinically narrow pelvis. The load that occurs during the passage of the fetus, the size of which does not correspond to the pelvis of the woman, as a rule, provokes a repeated break.
If during the spontaneous birth of a woman with a scar on the uterus, there is a threat of rupture, the cesarean section is performed on an emergency basis. After surgery, the defect of the uterine wall is sutured. Extirpation of the uterus is carried out only with extensive injuries with the impossibility of suturing or the occurrence of massive intraligamentary hematomas.
Prognosis and prevention
Choosing the right obstetric tactics and dynamic observation of a pregnant woman minimizes the likelihood of complications during pregnancy and during childbirth. It is important for a woman who has undergone a cesarean section or gynecologic surgical intervention to plan a pregnancy no earlier than 2 years after the surgical intervention, and when she does it, regularly visit the obstetrician-gynecologist and follow its recommendations. To prevent re-rupture, it is necessary to ensure proper examination of the patient and constant monitoring of the scar, choose the optimal method of delivery, taking into account possible indications and contraindications.