Examination of the uterine scar after cesarean section. Scar after cesarean section

A scar on a woman’s uterus during subsequent pregnancy becomes a cause for constant concern and monitoring by obstetricians and gynecologists. The muscle tissue of the uterus in the area of the incision during a cesarean section (CS) is replaced by connective tissue, which does not stretch and does not perform any functions in the body. In some cases, a new pregnancy, and indeed the patient’s life in general, after undergoing surgery is at risk due to scar failure.

Reasons for the formation of an incompetent scar on the uterus

The diagnosis of “incompetent scar” means that in some areas the scar has become thinner or modified, and if it is stretched during pregnancy, a rupture may occur in this place. Most often, the reasons for the formation of an incompetent scar after a CS are:

complications in the postpartum period associated with sutures (suppuration, dehiscence, fistula formation, inflammation);
use of low-quality suture material;
endometritis of the uterus, which occurs after CS as a result of infection inside;
2 or more surgical interventions on the uterus (this includes not only CS, but also operations to remove fibroids, polyps, and long-term surgical abortions).

Signs and diagnosis of an incompetent uterine scar

Clinically, an incompetent uterine scar does not manifest itself in any way until the moment of conception. After the fertilized egg attaches to the uterus and as it grows, the walls of the organ stretch, which contributes to the development of the clinical picture of a poor-quality scar:

cramping pain in the lower abdomen;
stabbing sensations when changing body position and sexual intercourse;
difficulty urinating;
nausea and vomiting.

When the scar diverges along the old seam, the woman feels acute pain in the abdomen. The clinical picture resembles an attack of acute appendicitis, and if the patient is not promptly treated, death may occur for both mother and baby.

The main methods for diagnosing abnormalities in the uterine scar are ultrasound and hysteroscopy (performed in the absence of pregnancy). During an ultrasound examination, doctors pay attention to indicators such as:

thickness of scar tissue;
the presence of recesses or niches in the seam area;
presence of visible suture materials;
the condition of the scar over its entire surface;
changes in the uterine mucosa in the area of the scar.

What are the dangers of an incompetent scar for women’s health?

When planning a baby after a CS, a woman needs to undergo a full examination, including an ultrasound, to assess the condition of the uterine scar. The failure of the scar during pregnancy poses a threat to a woman’s health, namely:

risk of uterine rupture during childbirth;
constantly increased tone of the uterus;
bloody vaginal discharge throughout pregnancy;
risk of miscarriage;
constant abdominal pain at the slightest touch to the anterior abdominal wall;
improper attachment of the placenta or its accretion to the wall of the uterus;
insufficient nutrition of the fetus with oxygen and other substances necessary for its growth and development.

Incompetent uterine scar and pregnancy

Pregnancy with an incompetent uterine scar is associated with increased risks:

intrauterine growth retardation;
threat of early termination;
threat of premature birth;
rupture of the scar in late pregnancy or childbirth.

To avoid such risks, pregnancy must be planned, and if a suture failure is detected after the CS, then it should be treated even before conception. Measures taken in time allow the baby to be brought to term normally.

Treatment of an incompetent uterine scar

If this pathology is detected at the stage of pregnancy planning, the patient undergoes immediate surgical treatment. The intervention consists of excision of scar tissue and application of new high-quality sutures. After such an operation, a woman is not recommended to become pregnant for 2-3 years, since the body needs time for the suture to completely heal and a wealthy scar to form.

Irina Levchenko, obstetrician-gynecologist, especially for the site

Not uncommon now. Is it possible to get pregnant again after it, carry and give birth to a child without complications? Is it possible to give birth on your own, or will I have to undergo surgery again?

Scar on the uterus - what is it?

Any damage to the uterine wall can cause scar formation. In most cases, a defect on the wall of the uterus is a consequence of a caesarean section. By the way, the rate of operative delivery averages about 20%, reaching 25% in some perinatal centers. In addition, a scar can form after various gynecological operations and perforation of the uterus during an abortion.

Essentially, a scar is a weak spot in the muscle tissue of the uterus that does not have the normal ability to stretch. The site of the surgical incision or injury to the uterine wall is healed through the replacement of elastic muscle cells with rough connective tissue. Therefore, even a well-healed wound will never become the same full-fledged uterine muscle.

How does a scar affect the ability to conceive a child?

As a rule, women with a uterine scar do not have problems with subsequent pregnancies. The only thing that must be strictly observed is the time period. After a caesarean section, the next pregnancy should be planned after 2 years. Sometimes women with a uterine scar have problems getting pregnant. This is due to the presence of chronic inflammation inside the uterus due to infectious and postoperative complications.

The course of pregnancy with a scar on the uterus

During the first half, the pregnant woman has no complaints. In the second half, when the stomach quickly increases in size, the woman may complain of nagging or aching pain in the scar area. Most often, these sensations are associated with some kind of physical activity, and at rest the pain does not bother you.

At each examination, the doctor will definitely ask the pregnant woman about the presence of pain above the womb, and will carefully palpate the lower abdomen. This is especially true after 30 weeks, when the increase in the fetal sac reaches its maximum, and the stretching in the area of the defect is most pronounced.

Corresponds to standard schemes, however, it is necessary to evaluate the condition of the scar with each ultrasound examination. A prerequisite for this diagnosis is to fill the bladder before the examination so that the doctor can evaluate the lower segment of the fetal sac.

During an ultrasound, the doctor can evaluate the following indicators:

Scar location.The usual place for a skin incision during a caesarean section is in the lower abdomen at the suprapubic fold. The wall of the uterus is dissected transversely above the pubic symphysis. It has been proven that this type of operation is optimal for preserving a woman’s ability to conceive and give birth independently. In some cases, in emergency situations, a longitudinal incision is made along the anterior wall of the uterus. With such a scar, future delivery is only possible by caesarean section.
Scar thickness. In the first half of pregnancy, the muscle wall in the area of the scar rarely changes, but subsequently, with increasing pregnancy and stretching of the uterus, the scar may become thinner. A change in thickness toward thinning, detected by ultrasound, may cause the need to deliver a baby prematurely.
Small formations and defects in the scar area. With an ultrasound of the uterus, the doctor can detect small defects in the scar area, similar to depressions, niches and small cystic formations. This will indicate failure of the scar tissue.
Blood supply to the rumen. With an ultrasound, the doctor will be able to see insufficient blood circulation in the lower parts of the uterus, in the area of scar tissue. Absent or insufficient blood flow will indicate a high risk of rupture.

Complications of pregnancy with a scar on the uterus

1. Threat of premature termination

The risk of spontaneous abortion and premature birth in a pregnant woman with a uterine scar increases, which can be explained by the following factors:

inflammatory changes on the inner surface of the uterus;
thinning of the scar with a real risk of uterine rupture;
decreased blood flow in the uterine vessels;
violation of the location and attachment of the placenta;
insufficient provision of the fetus with its intrauterine suffering.

2. Scar failure

Often, it is the weakness of the scar during pregnancy that becomes the reason for another cesarean section. If the scar fails, the pregnant woman feels stabbing or pulling pain of any intensity above the pubic joint. These pains become more pronounced when the doctor palpates the area. If these symptoms are present, an ultrasound should be done. The criteria for an incompetent scar during ultrasound examination are:

pronounced thinning of the uterine wall of 3 mm or less;
the appearance of small or large defects in the scar area (heterogeneity in the form of niches, depressions or retractions);
blood flow disorders.

In the presence of such changes, the risk of uterine rupture along the scar increases significantly. If this happens, the fetus will be the first to suffer, because its oxygen supply will almost immediately cease. For a woman, uterine rupture threatens severe intra-abdominal bleeding.

Features of the course of childbirth with a scar on the uterus

Having brought your pregnancy to term, you need to prepare for delivery. The first question that always arises is whether it is possible to give birth naturally? According to statistics, only 5-7% of pregnant women with a scar give birth naturally, and in other cases a repeat cesarean section is performed.

Indications for surgery are:

any manifestations of weakness of the uterine scar;
a large fetus in the presence of a narrow bony pelvis in a pregnant woman;
any complications from a previous operation;
placental insufficiency with the development of hypoxic or hypotrophic problems in the fetus.

It happens that the pregnant woman herself fears for the life of the child and does not want to risk demanding a caesarean section. And this fear is completely justified, because the main complication that can happen during a natural birth is uterine rupture during contractions or during the pushing period, which will lead to the death of the baby.

Is natural childbirth possible with a uterine scar?

For natural delivery, a combination of certain factors is necessary:

full-term pregnancy;
history of spontaneous childbirth;
a single cesarean section in the past with a period of 2 or more years;
the previous operation was without complications, and the incision was in the lower part of the uterus;
normal fetal size with optimal pelvic size in a pregnant woman;
modern perinatal center with highly qualified staff;
woman's consent to a normal birth.

Normal childbirth in pregnant women with a defect in the uterus is possible only in specialized obstetric centers where it is possible to perform emergency delivery. During childbirth, special equipment must be used to constantly monitor the child’s condition. Immediately after birth, a manual examination of the uterus will be required to ensure that the scar is intact. After a few days, an ultrasound should be performed to assess the condition of the scar.

Considering the significant danger to the baby and mother, normal childbirth in pregnant women with a scar defect on the uterus is rarely allowed. This is due to the high risk of uterine rupture, which can lead to catastrophic consequences for the fetus and the woman in labor. The doctor always takes an individual approach to the choice of delivery, taking into account the woman’s consent and minimizing the risk to the fetus.

A uterine scar is a special formation consisting of myometrial fibers and connective tissue and located where the integrity of the uterine wall was damaged and further restored during surgery. The planning and course of pregnancy with a uterine scar is somewhat different from a normal pregnancy.

The causes of uterine scars are not limited to cesarean sections. The integrity of the uterine walls can be disrupted during other operations: removal of fibroids, perforation of the uterine wall during curettage, uterine rupture during hyperstimulation of labor, various plastic reconstructive surgeries (removal of the uterine horn, removal of a tubal or cervical pregnancy along with a portion of the uterine cavity).

Varieties of tripe

The scar can be solvent or insolvent.

A wealthy scar is characterized by a predominance of muscle tissue, similar to the natural tissue of the uterine wall. A healthy scar is elastic, can stretch, contract and withstand significant pressure during pregnancy and childbirth.

An incompetent scar is described as inelastic, unable to contract and prone to rupture due to the fact that, for some reason, a large area of it consists of connective tissue with simultaneous underdevelopment of muscle tissue and the network of blood vessels. The gradual growth of the uterus during pregnancy leads to a thinning of this scar. Thinning of the scar on the uterus, in turn, is an uncontrollable process that is not subject to any treatment.

Severe inconsistency of the uterine scar (thickness less than 1 mm, niches, thickening or depressions in the scar, overwhelming predominance of connective tissue) may even be a contraindication to planning pregnancy.

The way the incision was made during a caesarean section is of considerable importance. A longitudinal incision, which is usually made for an emergency caesarean section, is more prone to failure than a transverse one in the lower uterus.

Planning a pregnancy with a uterine scar

Between the operation, due to which a scar on the uterus was formed, and pregnancy, doctors recommend maintaining a gap of two years - this is the time required for the formation of a good scar. At the same time, a break that is too long is undesirable - longer than four years, since even a very good scar can lose its elasticity over the years due to atrophy of muscle fibers. The transverse scar is less prone to such negative changes.

Scar assessment

The condition of the scar can be assessed before planning using ultrasound, x-ray, hysteroscopy or MRI. Each method is valuable in its own way.

Ultrasound helps to find out the size of the scar (the thickness of the uterine wall in this area), to see the existing niches (the presence of unfused areas in the thickness of the scar), and its shape.

X-ray of the uterus (hysterography) allows you to evaluate the internal relief of the scar.

As a result of hysteroscopy, it is possible to determine the color and shape of the scar, the vascular network of the scar tissue.

MRI is considered the only method by which it is possible to determine the ratio of connective and muscle tissue in the composition of the scar.

Despite so many methods used to assess the condition of the scar, none of them will allow us to make an absolutely accurate conclusion about the consistency or failure of the scar. This can only be verified in practice, that is, during pregnancy and childbirth itself.

Pregnancy with a scar on the uterus

You need to know that a scar on the uterus during pregnancy can cause an incorrect location of the placenta: low, marginal or complete presentation.

Pathological accretion of the placenta of varying degrees is possible: to the basal layer, muscle, growth into the muscle layer or complete germination up to the outer layer.

If the embryo attaches to the scar area, doctors make unfavorable prognoses - the likelihood of termination of pregnancy is greatly increased.

During pregnancy, changes in the scar are most often monitored using ultrasound. If there is the slightest doubt, doctors recommend hospitalization and observation in a hospital until delivery.

The most dangerous complication may be uterine rupture at the site of the scar as a result of its thinning and overstretching. This most dangerous condition may be preceded by characteristic symptoms indicating the beginning of scar dehiscence:

Uterine tension.

Sharp pain from touching the stomach.

Strong arrhythmic uterine contractions.

Bloody vaginal discharge.

Fetal heartbeat disturbance.

After the break is completed, the following are added:

Very severe abdominal pain.

A sharp decrease in blood pressure.

Nausea and vomiting.

Stopping contractions.

The consequence of scar rupture can be acute oxygen starvation of the fetus, hemorrhagic shock in the mother due to internal bleeding, fetal death, or removal of the uterus.

When a uterine rupture is diagnosed along the scar, an emergency caesarean section is required to save the life of the mother and child.

Many people are concerned about whether natural childbirth with a uterine scar is real. If certain requirements are met, such births may be permitted: a single previous cesarean section with a transverse incision, a presumably healthy scar, a normal location of the placenta behind the scar area, the absence of any concomitant diseases or obstetric pathology, the cephalic position of the fetus, the absence of a factor that caused the previous caesarean section. Monitoring the condition of the fetus and the availability of all conditions for an emergency caesarean section in the event of a critical situation in the immediate vicinity of the delivery room are also important.

Contraindications to natural childbirth with a scar on the uterus are: cesarean section with a history of a longitudinal incision on the uterus, narrow pelvis, placenta at the site of the scar, placenta previa, several scars on the uterus

I decided to tell you, my dear readers, a few stories from my life, or rather, from my medical practice.

A couple of months ago, a patient came to see me, who had specially flown in from Petropavlovsk-Kamchatsky to personally meet and consult. She had two caesarean sections. Now the thickness of the myometrium in the scar area is 5 mm, and there is a niche in the uterine cavity. She really wants to have a third baby. She made me laugh to tears by talking about how she brought to her antenatal clinic the answer to her question from the website of our clinic, where I write that 5 mm is the norm, the pregnancy is carried successfully. At the hospital, the patient was told that she was crazy, that the cleaning lady there answered her, and she believed it. So the patient came to meet me. She actually has a beautiful scar, 5mm thick. To be sure, I showed her ultrasound photographs of exactly the same scar in another patient of mine, who not only carried the pregnancy to term, but also gave birth safely through the vaginal birth canal.

Even with an initial scar thickness of 1 - 2 mm, pregnancy progresses safely. This is not just my personal opinion. The same tactics are followed by all doctors in those large medical centers where I worked for many years (Family Planning and Reproduction Center and Perinatal Medical Center in Moscow).

After the story about the “cleaning lady,” I realized that my optimistic answers to questions about scars, that everything is fine, you can safely carry the pregnancy and not terminate it, are not always taken seriously, so I’ll back them up with two stories of pregnancy and childbirth.

I have been working as an obstetrician-gynecologist for 20 years and have extensive personal experience in performing cesarean sections and managing vaginal births in patients with a uterine scar, and I have the highest medical qualification category.

You see, the easiest way is to prohibit the patient from becoming pregnant or, even worse, to force her to terminate the pregnancy due to an allegedly thin scar - no one will even know whether this child could have been born. We should not forget about the possibility of severe complications after such an intervention. But, fortunately, there is a completely different level of medical experience and medical responsibility when such pregnancies continue. The outcomes are always favorable.

Some time ago, a patient called the clinic and asked me to answer the phone. I thank God that she called when I was at work. The patient's name is Olga. She told me that she was in the Perinatal Center of her region, she was examined by the chief doctor of the regional Perinatal Center, the chief obstetrician-gynecologist of the region, the leading ultrasound specialist, and she was being taken to the operating room right now. She has a scar on her uterus after two cesarean sections, now 25 - 26 weeks. And they decided to operate because the ultrasound showed that the scar had thinned down to 1 mm over a length of 9 mm. Now we need direct speech:

How much, how much? - I ask again - 9 cm?

No, 9 mm.

Does anything hurt you?

Does not hurt.

How much does the child weigh?

750 grams.

Write a refusal from the operation. With such a scar in Moscow, you would generally be at home. Do you understand that the child will be born alive, but in the future will be severely disabled due to extreme prematurity, or will not be able to withstand nursing and will die? Discharge home and come to us, we will look at the scar ourselves. It is necessary to operate only when persistent, increasing pain occurs.

Everyone is twirling their finger at my temple, saying that I am not transportable, that if I reach 28 weeks, I’m lucky, otherwise I can go to the toilet and die there, and the children will remain orphans.

Do not worry! This definitely won't happen. You carry your pregnancy to 39 - 40 weeks.

Olga wrote a refusal. I gave her my mobile phone number. We constantly kept in touch before the birth. For the first 2 weeks she was still very intimidated, then they stopped frightening her. There, at 32 weeks, no thinning was found. And they sent me home. And at 39 weeks they had a planned caesarean section, and Olga gave birth to a wonderful, healthy boy weighing 3200 g. Such Happiness! The doctor who operated said that with such a scar, you are welcome again. Here's a thin scar for you!

When making a decision on early delivery due to a thin scar, one should take an extremely balanced approach, based on real complaints and clinical manifestations, and not on theoretically possible problems.

Here is another story of pregnancy and childbirth. This has already happened in Moscow.

Patient Lena came to see me after an examination at a well-known research institute, where the ultrasound report indicated that the body of the uterus was deformed by a niche on the side of the outer contour in the area of the scar after a cesarean section, the thickness of the myometrium in some areas was 1 mm, partially the myometrium was not determined. The institute issued the following conclusion. Diagnosis: Pregnancy 10 weeks. Failure of the uterine scar after a cesarean section in 2010. Recommendations: Taking into account the ultrasound data about the failure of the scar on the uterus after a cesarean section in 2010, I consulted with Professor N, the patient was recommended to undergo surgical treatment in an institute (plasty of an incompetent scar), after termination of pregnancy at the place of residence. The patient was reported to the district obstetrician-gynecologist.

We looked at the scar on an ultrasound. It is thin (according to our data 2 mm), low-lying. However, in my experience, all patients with such scars successfully carried their pregnancies to term. This was the case in this case as well. The patient never even had a threat of miscarriage, which could have been a reason for hospitalization. At first, the frightened Lena was still afraid of rupture, I convinced her of the reliability of the uterus as best I could. Only as the pregnancy progressed did Lena calm down. By the end of the pregnancy, she and I were already joking that we would give birth through the birth canal with such a scar. Of course, we didn’t give birth ourselves, because... the scar is still thin. But the operation was performed as planned at the 40th week; on June 6, 2014, a wonderful healthy girl weighing 3100 g was born. And here it is, another, boundless Happiness!

I could continue to describe such stories, since they are not isolated at all.

This story of mine is an answer to those who want to know what happened next after I wrote in response to a question on the site that everything will be fine! By the way, about answering questions on the Internet. I answer only on my clinic website www.zyablikova.ru and on. All other sites simply repost my answers without my permission. Unfortunately, it is difficult for me to answer questions quickly and regularly due to lack of free time. I answer only sometimes, especially if the question is a cry from the soul, when you realize that with your answer you may save someone’s life and destiny. I view this as my civic duty - just to help people. I really hope that my work and this story will help many families become large families!

I invite everyone who is interested in this problem to discuss it on the site’s forum, where, if possible, I will try to participate in the discussion myself. The text of the article will be posted on the forum.