What causes a scar on the uterus. Reasons for the formation of an incompetent scar on the uterus after cesarean section. Symptoms of rupture during active labor

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Modern women experience problems with conception, pregnancy and childbirth more and more often every year. There are many reasons for this: age, inflammatory diseases of the reproductive system, poor health. As a result, pregnancy is often difficult, and childbirth is scheduled by emergency or planned caesarean section, which leaves a scar on the uterus or its cervix.

What is a uterine scar?

An area of ​​dense connective tissue in the uterus that has been damaged in the past during surgery is called a scar. This is a special formation that consists of myometrial fibers that regenerate after damage. The human body is poorly adapted to recovery, so the tears are closed not by the original tissue, but by connective tissue. It does not completely replace the muscle layer, but only restores the integrity of the uterus after the incision.

Symptoms

A postoperative scar has no characteristic symptoms. It does not bother the patient until the uterus ruptures along the scar. This is a very serious pathology, manifested by the following symptoms:

• pain in the lower and middle abdominal cavity;
• irregular and strong contractions of the uterus;
• decreased blood pressure;
• rare pulse;
• pale skin;
• nausea, vomiting.

Causes

More often, a scar appears on the cervix after childbirth. Today, the frequency of cesarean sections in maternity hospitals reaches 25%. In addition, scar defects on the female organ occur as a result of:

• perforation of the uterus during intrauterine examination or artificial termination of pregnancy;
• gynecological surgery to treat adenomyosis or remove fibroids;
• ectopic pregnancy;
• plastic surgery to remove the intrauterine septum or correct a bicornuate or saddle-shaped uterus.

Diagnostics

A woman with a suture on the uterus when planning a child should be examined before conception. Outside of pregnancy, it is necessary to evaluate the consistency of the scar in patients who have undergone operations with opening of the uterine cavity: cesarean section, suturing of the perforation, myomectomy and others. First, the doctor palpates the contours of the walls of the uterus, evaluates the suture, and determines its size.

Further examination is carried out using hysterography (examination using an ultra-precise optical device), hysterosalpingography (X-ray with a contrast agent) and ultrasound. Laboratory tests are also carried out:

• general urine and blood tests;
• blood chemistry;
• hemostasiogram, coagulogram;
• hormonal status of FPC.

Ultrasound of the scar

If a woman is pregnant, then the uterine cavity is examined for the consistency of the scar only using ultrasound. Ultrasound helps to find out the exact dimensions of the suture, the thickness of the uterine wall in this area, the presence of niches, ligatures, unfused areas and the shape of the lower uterine segment. The results will help doctors predict the likelihood of complications during pregnancy. If an ultrasound scan of the uterine scar is performed after a cesarean section or at the planning stage of conception, then days 10-14 of the menstrual cycle are more suitable for this.

Normal myometrial thickness in the scar area

The failure of the suture on the uterus after cesarean can be determined by comparing the indicators with the norm. According to the rules, the thickness of the scar after artificial delivery should be from 5 mm. If there is thinning up to 1 mm, then this indicates its failure. During pregnancy the norms are different. Since the scar becomes thinner due to the enlargement of the uterus, at the end of the term even a thickness of 3 mm will be considered normal.

Pregnancy and scar

It takes about two years for a strong suture to form in the uterine cavity. During this time, doctors advise women to wait and not plan a pregnancy. However, a break that is too long is not the best option, because four years after the scar has healed, it begins to lose elasticity. For this reason, planning and the course of pregnancy with a suture on the cervix or other part of the female organ should take place under the special supervision of a doctor.

Possible complications of pregnancy

Thinning of the uterine scar during pregnancy is normal. However, its presence can affect the condition of the fetus. Due to the atrophied area, partial, marginal or complete presentation sometimes occurs. Placenta accreta may also appear at any level of the uterine wall. If implantation of the fertilized egg occurs in the area 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 uterine rupture due to severe thinning of atrophied tissue. This is preceded by certain symptoms:

• hypertonicity of the uterus;
• pain when touching the abdomen;
• arrhythmia in the fetus;
• bleeding from the vagina;
• arrhythmic spasms of the uterus.

After uterine rupture, more serious symptoms are observed: sharp pain in the abdominal cavity, nausea and vomiting, a drop in hemodynamics, and cessation of labor. For the woman and the fetus, these consequences are disastrous. As a rule, the child experiences hypoxia, which leads to his death. A woman suffers from hemorrhagic shock. If measures are not taken in time, there is a high probability of death for the woman in labor. To save a woman, emergency hospitalization, surgical opening of the cavity with a transverse incision and curettage of the uterus are required.

Childbirth with a scar on the uterus

The uterine cavity is opened in two ways: a transverse one, which is made in the lower segment during a full-term pregnancy in a planned manner, and a corporal incision, performed in case of bleeding, during emergency surgery, hypoxia, or in case of premature delivery (up to 28 weeks). When pregnant with a scar in the uterine cavity, a woman usually undergoes a repeat cesarean section. However, medicine does not stand still, and in recent years, more and more women with a scar on the female organ after planned prenatal hospitalization are sent to give birth through natural means.

When is vaginal delivery allowed in the presence of a scar?

In the absence of contraindications, after a comprehensive examination and prenatal hospitalization at 37-38 weeks of pregnancy, a woman is allowed to have a natural birth with a suture on the uterus. However, for this to happen the following conditions must be met:

• the presence of one wealthy scar;
• the first operation was performed solely for relative indications (fetus weighing more than 4 kg, weak labor, intrauterine hypoxia, transverse or breech presentation, infectious diseases that worsened shortly before birth);
• the first operation was performed through a transverse incision and was without complications;
• the first child has no pathologies;
• this pregnancy proceeded well;
• there are no signs of an incompetent scar according to ultrasound results;
• the estimated fetal weight does not exceed 3.8 kg;
• no pathologies are observed in the fetus.

Scar after cesarean section

The scar after artificial delivery surgery heals in several stages. In the first week, the primary suture is formed, bright red in color with clear edges. Movement causes severe pain. The second stage is characterized by thickening of the scar. It changes color to a less bright one, it still hurts, but less than in the first week. This stage lasts a month after the operation, by the end of which pain when moving stops. The last phase lasts about a year. The scar changes color to pale pink, looks almost invisible, and becomes elastic. Healing occurs through the production of collagen.

Inconsistency of the uterine scar after cesarean section

The scar after opening the uterine cavity does not always heal well. A complication is an incompetent scar, which is improperly formed tissue at the incision site. The pathology is characterized by unfused 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. The pathology is a threat to the full bearing of a child, since there is a strong displacement and change in the shape of the uterus, and a violation of its contractile activity.

Treatment

If pregnancy and childbirth proceed normally, then the uterine scar does not require treatment. In the case of an incompetent scar, the woman is advised not to plan subsequent pregnancies in order to avoid obstetric complications. The only effective treatment for this pathology is laparoscopic metroplasty. Medication or any other schemes for eliminating a failed scar in the uterine cavity are ineffective. Due to the fact that the uterus is located in the abdominal cavity behind the internal organs, it is impossible to resort to a more gentle technique.

Metroplasty after caesarean section

The indication for this operation is thinning of the myometrial walls up to 3 mm and deformation of the suture in the area of ​​the postoperative scar. Its formation is mainly a complication of cesarean section. The essence of laparotomy metroplasty is the excision of a thin scar followed by the application of new sutures. Open surgery is determined by the need to provide access to the defect, which is located under the bladder in an area of ​​strong blood supply. This is associated with the risk of severe bleeding during surgery.

Metroplasty is accompanied by the isolation of large vessels and the application (temporary) of soft clamps to them in order to stop blood flow. After excision of the failed scar, plastic surgery is performed, then the clamps are removed. The advantage of the laparoscopic method is the low degree of invasiveness of surgical intervention and the low risk of formation of adhesions in the abdominal cavity. The method provides short rehabilitation times and a good cosmetic effect.

Prevention

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 condition of the scar at the stage of pregnancy planning;
• determining the location of the placenta during pregnancy;
• formation of normal conditions for scar healing after cesarean section;
• timely treatment and prevention of pathological complications;
• fetal monitoring during labor;
• CTG and ultrasound control during pregnancy;
• a balanced approach to making a decision about natural childbirth with a scar in the uterine cavity.

Video

The information presented in the article is for informational purposes only. The materials in the article do not encourage self-treatment. Only a qualified doctor can make a diagnosis and give treatment recommendations based on the individual characteristics of a particular patient.

Planning and managing a pregnancy with uterine scars is somewhat different from monitoring an expectant mother without any abnormalities. A scar is a durable seal formed by the connective tissue and fibers of the myometrial layer of the uterus. This formation appears at the site of rupture and regeneration of the uterine wall after surgery. A scar on the uterus during pregnancy - is there a chance to give birth to a baby on your own or to prepare for an artificial birth?

The successful development of the fetus depends, first of all, on the condition of the mother’s body. If the surface of the uterus is marked by a mark from a dissection in the past, this, of course, will immediately affect the development of a new life.

Where do pregnancy scars come from?

A rough strip of tissue on the uterus appears not only after a planned or emergency cesarean section. The need to violate the integrity of the sexual muscular organ may be dictated by the following factors:

• gynecological operations (excision of foci of adenomyosis, fibroid nodes);
• termination of pregnancy located in the tube or cervix;
• negative consequences of artificial termination of pregnancy or intrauterine examination;
• regenerative plastic surgery of uterine anomalies (removal of the uterine horn, intrauterine septum).

What is a scar like during pregnancy?

Scarring is a natural process of regeneration of living tissues whose integrity has been compromised. The cut shell can be restored through complete or incomplete regeneration. In the first case, the wound heals with a predominance of smooth muscle cells of myocytes, in the second case, strong fibrous connective tissue becomes the material for scarring.

Accordingly, the dense mark from the previous surgical incision is classified, depending on the quality of healing, based on the degree of its consistency.

Consistent (full) scar formation

The scar is filled mainly with muscle tissue, the structure of which in many ways resembles the “native” tissue of the uterine wall. A healthy scar has a high degree of elasticity, stretches and contracts well and has sufficient potential to take on the strong pressure that the entire uterus experiences during the enlargement of the fetus and during the birth of the child.

Incompetent (incomplete) scar formation

The tissue of such a scar has nothing to do with muscle. It is deprived of the ability to stretch and, therefore, will not contract during contractions. Moreover, dense tissue can simply crack, because it consists mainly of threads of connective tissue, while the muscles and blood vessels around it are underdeveloped. During pregnancy, the uterine scar gradually becomes thinner as it enlarges, and modern medicine has no way to influence this process.

If the inferiority of the scar seal is severe (thickness does not exceed 1 mm, there are many inelastic fibers, there are niches and seals in the scar), this can become a significant obstacle to planning motherhood. Normally, the scar on the uterus during pregnancy is no less than 3.6 - 3.7 mm in thickness after 32 weeks of the “interesting” position, and no less than 2 mm at 37 weeks.

Specifics of postoperative incision regeneration

The quality of fusion of dissected uterine membranes is largely influenced by the following circumstances:

Type of operation

Thus, the condition of the scar is influenced by the method of incision of the uterus during cesarean section. For elective surgery and full-term pregnancy, the lower part of the uterus is cut transversely. The advantages of a transverse scar over a longitudinal one are obvious: the fibers of the cut muscle tissue are located transversely on the uterus, so they are restored quickly and efficiently. With a longitudinal incision, fibers cut across the muscle tract heal much more slowly. Indications for longitudinal section are emergency delivery in case of severe bleeding and severe fetal hypoxia, as well as delivery at less than 28 weeks.

When excision of a benign uterine tumor by conservative myomectomy, during which tumor nodes are removed, the localization of the excised nodes, surgical access, and the very fact of dissection of the entire membrane are of great importance for the successful regeneration of damaged tissue. Small fibroids that have formed outside the uterus are removed without surgically opening the uterine cavity. After such an operation, a completely wealthy scar is formed, which is many times stronger in strength than the scars that remain after intracavitary surgery when intermuscular fibroids are removed.

The scar that occurs due to accidental damage to the uterus after an artificial termination of pregnancy has a more elastic structure if during the operation the perforation hole was only sutured, without additionally cutting the wall of the uterus.

Terms of conception after surgery

The length of time after surgery is of paramount importance to the extent of scar regeneration. The full structure of muscle tissue is restored 1 to 2 years after the dissection. This is why doctors recommend that women plan a second pregnancy with a uterine scar on average 1.5 to 2 years after surgery. However, a long period of time between the first and second pregnancies (more than 4 years) is also undesirable, since the scar loses its elasticity due to an increase in the percentage of connective tissue in its structure.

Forecast for the recovery period and possible difficulties

The fewer complications after surgery, the better the scar will be. Its normal formation can be hampered by such deviations from the norm after cesarean section as:

• endometritis – inflammation of the inner walls of the uterus;
• partial contraction of the uterus;
• partial rejection of the placenta from the uterus, which entails the need for curettage of the uterine cavity.

Diagnostic study of a scar on the uterus

When planning a second pregnancy with a scar after a cesarean section, it is important to undergo a full examination to make sure that the scar formation on the uterus is valid. To do this, experts use several methods.

1. Ultrasonography. During the procedure, the doctor can assess the condition of the muscle tissue and guess what the thickness of the scar on the uterus will be during pregnancy, study the degree of healing at the site of the previous dissection by the presence of niches (areas in the structure of the scar that have not grown together).
2. X-ray of the uterus. Using the procedure, you can study the internal structure of the scar.
3. Hysteroscopy. Using special equipment, the doctor assesses the condition of the blood vessels located in the scar tissue, its color and shape.
4. MRI. This is the only method by which the volume of connective tissue and muscle fibers in the structure of the scar is determined.

Unfortunately, even such a large set of diagnostic methods will not give the doctor a detailed idea of ​​the consistency or failure of scar formation. This can only be verified by practical means, that is, pregnancy and childbirth.

Features of pregnancy with a uterine scar

Pregnancy with a uterine scar is in many ways more difficult than a normal one. The scar often becomes the cause of pathological formation of the placenta - low, marginal or complete presentation. In addition, in some cases, there are varying degrees of its improper growth into the basal, muscular layer or complete growth to the outer layer. Pregnancy is unlikely to be maintained if the embryo attaches to the scar area - the prognosis in this case is unpromising.

After pregnancy, the condition of the scar formation is carefully monitored using ultrasound. As soon as there is the slightest concern for the safety of the fetus, the expectant mother will be hospitalized and, most likely, will remain under observation in the hospital until the very birth.

What you should be most concerned about is uterine rupture along the scar during pregnancy. This happens if the scar has become too thin over time and has stretched excessively during pregnancy. You can predict a dangerous condition in the form of scar divergence based on the following specific signs:

1. Feeling of strong tension in the uterine area.
2. Intense pain on palpation of the abdomen.
3. Strong irregular contractions of the uterus.
4. Discharge of blood from the vagina.
5. Abnormal or absent heartbeat in the fetus.

When the uterus ruptures along the scar, the clinical picture is supplemented with the following alarming symptoms:

1. Excruciating pain in the lower abdomen.
2. Rapid development of hypotension.
3. Nausea, vomiting.
4. Fading of contractions until complete cessation.

As a result of the incident, the fetus in the womb is deprived of vital oxygen, and the woman in most cases experiences hemorrhagic shock due to massive internal bleeding. Unfortunately, this situation can resolve very badly: the child dies and the uterus has to be removed. There is a chance to save the situation by performing an emergency caesarean section, but this requires timely diagnosis of the pathology.

Medical monitoring of expectant mothers in the presence of complications

In the first months of pregnancy, a woman undergoes a general examination and, if necessary, consults with doctors of related specialties. A pregnant woman will certainly undergo an ultrasound examination. The procedure will help to reliably determine where the embryo has attached to the uterus. If this occurs near the isthmus at the front of the uterine cavity (that is, near the scar), the pregnancy will most likely be terminated by vacuum aspiration. The need for artificial removal of the fertilized egg is due to the fact that the development of the chorion in the immediate vicinity of the previous site of rupture can provoke thinning of a wealthy scar formation and, as a consequence, rupture of the uterus itself. If you do not intervene in the situation, the child can be born exclusively through cesarean section. However, there are no strict prohibitions against pregnancy even in this case, so the question of preserving the baby is decided by the pregnant woman herself.

The next scheduled screening in combination with ultrasound and analysis of the hormonal status of the FPC is carried out at 20–22 weeks of pregnancy. At this time, it is possible to diagnose abnormalities in the development of the child, determine whether its size corresponds to the gestational age, and detect placental insufficiency, if any. Placental insufficiency is an indication for immediate hospitalization of the expectant mother and monitoring her in a hospital setting.

If the pregnancy is proceeding satisfactorily, and the woman’s uterine scar is strong, the next scheduled examination awaits the pregnant woman at 37–38 weeks of pregnancy. As a rule, all procedures are carried out where the woman plans to give birth. The “scenario” of delivery is also planned in advance, thinking through the combination of medications that will be used during childbirth. In such cases, as a rule, antispasmodics, sedatives and antihypoxic agents are used to stimulate blood flow in the uterus and placenta.

Uterine scar and natural childbirth

A woman who has undergone uterine surgery can give birth to a child on her own, doctors say. Delivery is likely to take place without complications if the condition of the expectant mother meets the following requirements:

• only one caesarean section in the past;
• the caesarean section was performed by a transverse incision;
• high probability of scar consistency;
• attachment of the placenta away from the scar;
• absence of serious chronic diseases in the mother;
• absence of obstetric disorders;
• position of the baby head down in the uterus;
• absence of a reason why a caesarean section was performed during the first birth.

Doctors also pay great attention to the baby’s intrauterine development, and try to foresee in advance the availability of suitable conditions to carry out an emergency caesarean section if a force majeure situation arises.

It is not always possible to realize in practice a pregnant woman’s desire to give birth on her own. An understandable stumbling block for natural childbirth with a uterine scar is:

• longitudinal dissection of the uterus during the first cesarean section;
• narrow pelvis of a woman in labor;
• location of the placenta close to the scar formation;
• low placentation;
• several scars on the uterus.

Natural delivery with a uterine scar. Video

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

A scar on the uterus usually appears as a result of surgical intervention, which can be performed for medical reasons.

Many women of childbearing age who have a scar on the uterus are interested in several questions:

1. How can this circumstance affect the course of pregnancy?
2. Is a natural birth possible if there is a scar on the uterus or is a cesarean section inevitable?
3. What is the outcome of childbirth with a uterine scar?

We will try to talk about all the features of childbirth for women who have such a defect.

The influence of the scar on the course of pregnancy and the upcoming birth

The degree of scar healing is of great importance, and depending on this circumstance, certain predictions can be made:

1. A healthy (or complete) scar- this is the one in which complete restoration of muscle fibers has occurred after surgery. Such a scar is elastic, capable of stretching as the gestation period increases and the uterus grows, and it is capable of contractions during contractions.
2. Incompetent (or defective) scar- this is one in which connective tissue predominates, and it is unable to stretch and contract like muscle tissue.

What operation caused the scar on the uterus?

Another aspect that should be taken into account is the type of surgical intervention, as a result of which operation the scar on the uterus appeared:

1. A scar after a cesarean section can be of 2 types:

• a transverse one is done in the lower uterine segment, as planned during a full-term pregnancy, and it is able to withstand both pregnancy and childbirth, since the muscle fibers are located transversely, and therefore fuse and heal better after surgery;
• longitudinal - performed during emergency surgery, bleeding, hypoxia (lack of oxygen) of the fetus, or up to 28 weeks of pregnancy.

2. If the scar appears as a result of conservative myomectomy(removal of nodes of a benign tumor - fibroids with preservation of the uterus), then the degree of its restoration depends on the nature of the location of the removed nodes, the access of surgical intervention (scar size), and the very 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 durable than when opening the organ cavity, when intermuscular nodes located between the myometrial fibers or intermuscularly are removed.

3. Scar as a result of perforation of the uterus after an induced abortion is also considered taking into account whether the operation was limited to only suturing the perforation hole (puncture), or whether there was also a dissection of the uterus.

The course of the postoperative period and the occurrence of possible complications

The process of restoration of uterine tissue after surgery will be influenced by the course of the postoperative period and the presence of possible postoperative complications.

For example, after a caesarean section the following may occur:

• subinvaluation of the uterus - insufficient contraction of the organ after childbirth;
• retention of parts of the placenta in the uterine cavity, which will require curettage;
• postpartum endometritis - inflammation of the inner lining of the uterus.

Complications after conservative myomectomy may include:

• bleeding;
• hematoma formation (collection of blood);
• endometritis.

Abortions and curettage of the uterine cavity performed after surgery traumatize the uterine cavity and do not contribute to normal scar formation. Moreover, they increase the risk of developing a defective scar.

All these complications will complicate the scar healing process.

Pregnancy period after surgery

Any tissue, including the wall of the uterus, needs time to recover after surgery. The degree of scar healing depends on this. For the uterus to restore the full functioning of the muscle layer, it takes 1-2 years, so the optimal time for pregnancy after surgery is no earlier than 1.5 years, but no later than 4 years. This is due to the fact that the more time passes between births, the more connective tissue grows in the scar area, and this reduces its elasticity.

That is why women who have undergone surgery on the uterus (whether myomectomy or cesarean section) are recommended to be protected from pregnancy for 1-2 years. And even before the planned conception, it is necessary to be examined for the consistency of the scar: based on the results, it will already be possible to predict the course of pregnancy and the birth itself.

Examination of the uterine scar

It is possible to examine the scar on the uterus after operations using:

1. Ultrasound examinations. If pregnancy occurs, this is the only possible type of research. Signs indicating scar inferiority are its unevenness, discontinuity of the outer contour, scar thickness less than 3-3.5 mm.
2. Hysterosalpingography- X-ray examination of the uterus and fallopian tubes after injection of a contrast agent into the uterine cavity. For this procedure, a special substance is injected into the uterine cavity, and then a series of x-rays are taken to judge the condition of the internal surface of the postoperative scar, its position, the shape of the uterine body and its deviation (to the side) 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 anterior wall, as well as uneven contours and niches of the scar. However, this study does not provide enough information, and therefore is rarely used these days and is more often used as a method of additional examination.
3. Hysteroscopy- carried out using an ultra-thin optical device, a hysteroscope, which is inserted into the uterine cavity through the vagina (the procedure is performed on an outpatient basis under local anesthesia). This is the most informative method of studying the condition of the uterine scar, which is carried out 8-12 months after surgery, on the 4-5th day of the menstrual cycle. The fullness of the scar is indicated by its pink color, indicating muscle tissue. Deformations and whitish inclusions in the area of ​​the scar indicate its inferiority.

How can the presence of a scar on the uterus affect the course of pregnancy and affect childbirth?

The presence of a scar on the uterus can affect the course of pregnancy, causing some complications:

• threat of termination of pregnancy at different stages;
• placental insufficiency (lack of supply of oxygen and nutrients to the fetus), it occurs when the placenta in the scar area is attached not to full muscle tissue, but to scar tissue.

But the main danger—uterine rupture along the scar—faces a woman during childbirth. The problem is that uterine rupture in the presence of a scar quite often occurs without pronounced symptoms, and therefore during childbirth constant monitoring of the condition of the scar is necessary. This is determined by palpation (palpation) of the scar area through the anterior abdominal wall. Even during contractions, it should remain smooth, with clear boundaries and almost painless. At the same time, special attention is paid to spotting during childbirth (there should be little of it) and the mother’s complaints of pain.

Weakening contractions, pain in the navel, nausea and vomiting - this may be a sign of the beginning of a rupture of the scar. Ultrasound will help to objectively assess the condition of the scar during childbirth. If signs of its inferiority arise (and first of all this is weak labor, then any complications during childbirth), delivery is carried out by cesarean section.

Childbirth in women with a uterine scar

Just 10 years ago, all women who once gave birth by Caesarean section were automatically sent to a Caesarean section in subsequent births. This is a serious surgical procedure, after which serious complications can arise, and a woman’s recovery after surgery is much slower than after a natural (vaginal) birth.

Complications after a cesarean section could arise either due to the surgical intervention itself or be a consequence of the chosen method of anesthesia. Among them:

• thromboembolism - the formation of blood clots that can cause blockage of blood vessels;
• heavy bleeding;
• damage to neighboring organs;
• infectious complications.

However, medicine does not stand still, and in recent years, women with a scar on the uterus, after a planned prenatal hospitalization at 37-38 weeks of pregnancy and a full comprehensive examination (in the absence of contraindications), are trying to be sent to childbirth through natural means.

The examination includes:

• collection of obstetric history: number and outcomes of pregnancies preceding the current one;
• identification of concomitant diseases (particular attention is paid to the cardiovascular and bronchopulmonary systems);
• Ultrasound examination with assessment of the postoperative scar;
• assessment of the condition of the fetus - study of its blood flow (Doppler) and cardiac activity (cardiotocography).

Vaginal birth

Natural childbirth is possible if the following conditions are met:

1. The presence of only one strong scar on the uterus.

2. The first operation was performed according to relative indications (indications that may not arise during the given birth), which the following are required to report upon discharge from the hospital:

• chronic intrauterine fetal hypoxia;
• weak labor activity;
• pelvic or transverse position of the fetus;
• large fruit (more than 4 kg);
• premature birth (previously 36-37 weeks of pregnancy);
• infectious diseases in a previous pregnancy that appeared or worsened shortly before childbirth (for example, genital herpes).

If the indications for a cesarean section were related solely to the characteristics of the previous pregnancy (for example, a clinically narrow pelvis, abruption or placenta previa), then the current pregnancy can (and should) end in a natural birth.

3. The first operation was performed in the lower uterine segment with a transverse incision, with a postoperative period without complications.

4. The first child is healthy.

5. This pregnancy proceeded without complications.

6. According to the results of an ultrasound examination performed during full-term pregnancy, there are no signs of scar failure.

7. The fetus is healthy with an estimated weight not exceeding 3.8. kg

In pregnant women with a scar on the uterus, spontaneous childbirth should take place in the maternity hospital, since round-the-clock surgical care is possible there; constant cardiac monitoring is carried out (special devices with sensors are connected to the pregnant woman that monitor the contractile activity of the uterus, the frequency of contractions, the fetal heart rate), which allows you to monitor the strength of contractions and the condition of the child during childbirth; There is an anesthesia service and a neonatologist.

In a word, natural childbirth of women with a scar on the uterus should take place in such conditions that in the event of a rupture along the scar or a threat of uterine rupture, surgical assistance is provided within the next 15 minutes.

If scar immaturity is suspected, the patient is hospitalized at 34-35 weeks of pregnancy.

After natural childbirth is completed, the walls of the postpartum uterus must be examined manually (under intravenous anesthesia) to exclude incomplete uterine rupture along the scar. In this case, the doctor inserts a hand wearing a sterile glove into the uterine cavity and carefully feels the walls of the organ (especially the area of ​​the postoperative scar).

If during the examination a defect is discovered in the area of ​​the scar (it could be partially or completely ruptured), then in order to avoid intra-abdominal bleeding, which threatens the life of the mother, an urgent operation is performed - the area of ​​the rupture is sutured.

Indications for surgery

Childbirth should be carried out surgically if studies of the uterine scar indicate its failure:

• longitudinal scar after cesarean section or uterine surgery;
• scar after 2 or more operations;
• location of the placenta in the area of ​​the uterine scar (this increases the risk of uterine rupture when it stretches and contracts).

In this case, all that remains is to determine the timing of the operation, which depends on the condition of the fetus and mother.

Thus, in a woman with a scar on the uterus, childbirth through the birth canal is permissible only if the scar is intact and the condition of the mother and fetus is normal. Childbirth should take place in specialized centers, where the mother in labor can be provided with highly qualified assistance at any time.

According to testing, a woman can give birth again naturally in 80% of cases if the first was a cesarean section. In most situations, it is safer to give birth vaginally than through surgery after a cesarean section. But when women prepare for standard labor, they are met with indignation from doctors. Obstetricians are convinced that if there is a suture on the organ, then it is unacceptable to give birth on your own in the future. There is a rupture of the uterus along the scar during pregnancy.

A uterine scar is a formation created from connective tissue. It is located in the place where the organ walls were damaged and restored during surgery. Pregnancy with the presence of adhesions is different from an ordinary one. The stitch will remain not only after a caesarean section. The walls of the organ are damaged after other surgical interventions.

There are insolvent and wealthy scars on the uterus. A strong suture stretches, contracts, withstands a certain pressure during gestation and childbirth, and is elastic. Here, muscle tissue predominates, which is similar to the natural tissue of the organ.

Which uterine scar is considered healthy? The optimal thickness is 3 mm, but 2.5 mm is allowed. Spike becomes wealthy after three years.

An incompetent scar is inelastic, incapable of contraction, and ruptures, since the muscle tissue and blood vessels are underdeveloped. The organ grows while expecting a child, and the commissure becomes thin. The thinness of the suture cannot be controlled or treated. If the failure of the scar is clearly visible and the thickness is less than 1 mm, then there are prohibitions on planning children. You can understand what a uterine scar is using ultrasound, MRI, X-ray, and hysteroscopy.

Diagnostics:

1. Ultrasound shows the size, unfused areas, and shape of the organ;
2. the internal appearance is assessed by x-ray;
3. hysteroscopy allows you to determine the shape and color;
4. MRI determines the relationship between tissues.

These methods help diagnose the problem, but not a single method allows one to draw correct conclusions about the seam. This is checked during the process of awaiting childbirth.

Causes

Suture failure poses a serious threat to both the woman and the fetus. Adhesions on the organ cause the placenta to be incorrectly positioned. In case of abnormal placenta accreta, when the embryo is attached to the uterine scar, the pregnancy is terminated at any time.

Quite often it is not possible to carry the child to term. When expecting a baby, changes in the suture are monitored using ultrasound. If there is the slightest doubt, the doctor advises the woman to receive hospital treatment before delivery.

What causes the scar on the uterus to become thinner:

1. complications after cesarean section: suture rotting, inflammation;
2. use of low-quality materials during the operation;
3. development of infectious diseases;
4. performing several operations on the organ.

Where to check a uterine scar? To monitor the symptoms of thinning of the uterine scar during pregnancy, you should be systematically examined after pregnancy and surgery. Monthly examinations with a gynecologist and ultrasound are important. Thanks to this, timely treatment is carried out.

Signs of a failed scar:

• pain in the area of ​​the uterine scar;
• stabbing pain during sexual intercourse;
• difficulty urinating;
• nausea and vomiting.

If you suddenly discover signs of incompetent scar on the uterus, you need to urgently consult a doctor. Often the postoperative suture comes apart during menstruation. The organ becomes filled with blood clots, and when there is an inflammatory process, thin areas diverge.

Signs

If the suture rips apart during a second delivery, this is a dangerous phenomenon for mother and child. This requires urgent surgical intervention. With horizontal dissection, the suture rarely diverges. Many operations are performed at the bottom of the uterus; the scar is least susceptible to rupture in subsequent births.

Ruptures occur from a previously performed cesarean section, as there is an incompetent scar on the uterus during pregnancy. The possibility of suture rupture is influenced by the type of incision during surgery. If this is a standard vertical incision - between the pubis and the navel, then it will disperse faster.

The vertical incision is rarely used, except in emergency situations. It is used when there is a threat to the baby’s life, if the child is lying across, or it is necessary to react quickly to save the mother and fetus. Such a seam breaks in 5-8% of cases. If you have multiple children, the risk of ruptures is increased. It is dangerous when the scar becomes thinner and overstretched.

Signs of the onset of a rupture:

1. the uterus is tense;
2. sharp pain when touching the abdomen;
3. irregular contractions;
4. profuse bleeding;
5. The child's heartbeat is abnormal.

When a rupture occurs, more symptoms are added:

• severe abdominal pain;
• blood pressure decreases;
• vomiting, nausea;
• the contractions end.

As a result, the fetus lacks oxygen, the mother goes into hemorrhagic shock, the child dies, and the organ is removed. The consequences of rupture of the posterior commissure during childbirth are the most unpredictable. If tissue ruptures, a cesarean section is performed, as it is urgent to save the life of the woman and the fetus.

Symptoms of discrepancy during pregnancy

Childbirth with a scar on the uterus during the second pregnancy is carried out without complications, but a certain percentage of suture dehiscence is present. An important point during the second pregnancy is the age of the woman giving birth and the short interval between conceptions. Mothers who gave birth with an incompetent uterine scar undergo repeat surgery.

During repeated pregnancy, some women undergo cesarean section, even with a standard incision on the organ. Statistics on uterine ruptures by scar say that the vertical and horizontal lower incisions rupture in 5-7% of cases. The risk of ruptures is influenced by its shape. The sutures on the organ resemble the letters J and T, and can even be shaped like an inverted T. In 5-8% of cases, T-like scars diverge.

When a rupture occurs during pregnancy, a complex condition occurs that contributes to the death of both. The main cause of complications is the failure of the uterine scar after childbirth. The main difficulty is the impossibility of predicting suture dehiscence. After all, the organ ruptures, both during childbirth and during pregnancy, even after childbirth a few days later. The obstetrician immediately detects the discrepancy during contractions.

Can a uterine scar hurt? Yes, there is discomfort when stretching. A failed suture always hurts a lot, and separation is accompanied by nausea and vomiting.

1. beginning;
2. threatening uterine rupture along the scar;
3. accomplished.

Factors influencing the onset or already occurred suture rupture are noted. The woman in labor feels unwell, has severe pain, and is bleeding.

Symptoms:

• Between contractions there is severe pain;
• contractions are weak and not intense;
• the scar on the uterus hurts during pregnancy;
• the baby moves in a different direction;
• the fetal head has gone beyond the boundaries of the rupture.

When a child’s heartbeat is abnormal, the heart rate slows down, and the pulse decreases, these are symptoms of a discrepancy. There are cases that after a rupture, labor continues and contractions also remain intense. The suture has ruptured, and signs of uterine scar rupture during pregnancy are not even observed.

Threat of rupture

Situations of discrepancy are systematically studied. If you monitor this type of birth, diagnose a suture rupture in time and perform urgent surgery, you can avoid serious complications or reduce them to a minimum. When organizing an unplanned cesarean section, the risk of death of the child due to rupture of the adhesions during childbirth is reduced. There is a rupture of the posterior commissure after childbirth, damage to the walls of the vagina, perineal skin and muscles, as well as disorders of the rectum and its wall.

When a woman is observed throughout the entire period of pregnancy, experienced obstetricians at the maternity hospital with the necessary equipment are involved in the birth. Under control, the birth takes place without complications for the mother and the child.

There are women who want to give birth at home. They should be aware that suture dehiscence may occur, so it is not recommended to perform the birth at home. If a woman gives birth naturally in a non-governmental institution, then it is necessary to clarify whether this hospital has equipment for carrying out an emergency operation.

There are signs that increase the risk of scar rupture:

• during childbirth, oxytocin and medications are used that stimulate uterine contractions;
• in the previous operation, a single-layer suture was applied, instead of a reliable double one;
• repeat pregnancy occurred earlier than 24 months after the previous one;
• a woman over 30 years old;
• presence of vertical dissection;
• the woman has experienced two or more caesarean sections.

There are techniques that diagnose suture rupture. An electronic device monitors the child's condition. There are obstetricians who use a fetoscope or Doppler, but these methods have not been proven to be effective. Institutions advise using electronic devices to monitor the condition of the fetus.

Treatment and prevention

Treatment for uterine scars involves repeated surgery, but there are also minimally invasive methods for eliminating the anomaly. Under no circumstances should you refuse therapy.

If you refuse treatment, complications arise:

• rupture during pregnancy or childbirth;
• increased organ tone;
• the scar on the uterus is bleeding;
• severe pain, it is impossible to even lie on your stomach;
• the risk of placenta accreta increases;
• lack of oxygen for the fetus.

It is not difficult to diagnose the complication. When an organ ruptures, the stomach changes shape, the uterus looks like an hourglass. Mom is worried, faints, the pulse is almost not palpable, bleeding begins, and the vagina swells. It is impossible to listen to the fetal heartbeat, as hypoxia occurs and, as a consequence, the death of the child.

The woman is admitted to the hospital, examined and undergoes surgery. First, blood loss in the patient is excluded. During the operation, the uterus is removed and blood loss is restored. After the procedure, the occurrence of blood clots and low hemoglobin is prevented. If the newborn survives, he is sent to intensive care and nursed under machines.

How to treat a scar on the uterus:

1. operation;
2. laparoscopy – excision of the existing incompetent suture and suturing of the walls of the organ;
3. metroplasty – destruction of the septum inside an organ in the presence of many niches.

To prevent uterine ruptures, conception should be planned in advance and examined. If a woman has previously had an abortion or surgery, then the body must recover. If conception occurs with a uterine scar, it is recommended to immediately register with a doctor.

When the patient is responsible for the long-awaited labor, chooses the right doctor, and carefully monitors her health during the second pregnancy, then the birth of the child will be truly joyful. There are mothers who have two scars on the uterus and a third pregnancy is a common occurrence for them. Women are ready to take such a responsible step. You can discuss the stitch and how the birth will proceed with your obstetrician in advance.