Women with a scar on the uterus. Reasons for the formation of an incompetent scar on the uterus after cesarean section. Attachment of the fertilized egg and its growth

Recovery after childbirth is often difficult, even if it was natural. After a cesarean section, postoperative problems are added to various postpartum problems, the main one of which is a scar on the uterus. During the operation, the abdominal cavity and the muscular organ itself are dissected. The tissue healing process does not always proceed normally. The condition of the scar is of particular importance for women planning to become pregnant again after a cesarean section.

What is a scar on the uterus after cesarean section?

A uterine scar is a formation that consists of myometrial fibers (the upper muscle layer) and connective tissue. It occurs in the process of dissecting an organ with the subsequent restoration of its integrity by suturing.

Today, during a caesarean section, a transverse incision in the lower part of the uterus is most often practiced. This segment has a minimum of blood vessels, which promotes rapid healing. Due to the use of modern synthetic absorbable threads, the edges of the wound are fixed for a long time, which is also important for the formation of a proper scar.

The healing of a scar on the uterus after a cesarean section goes through a number of stages:

1. The formation of the primary seam is bright red in color and has clear edges. It is very painful for a woman to move (first week).
2. Hardening of the scar: it turns pale and hurts less (next three weeks).
3. The color of the scar becomes pale pink, it is practically invisible, and acquires elasticity due to the production of collagen (within a year after the operation).

This is a normal course of regeneration - a scar is formed, which is called wealthy. It can contract and stretch well (which is very important during subsequent pregnancy and childbirth), since it consists of smooth muscles and a narrow layer of connective tissue. This scar contains large and medium-sized vessels.

In medical practice, there are rare cases of complete remusculization of the uterine scar, when it cannot even be detected. Of course, this is an ideal option for upcoming pregnancy and childbirth.

If the healing outcome is unfavorable, an incompetent scar is formed (this often happens with a longitudinal incision). It is inelastic, unable to contract, since it consists mostly of connective tissue (muscle tissue is underdeveloped). The scar may have thickenings and depressions (niches), swelling, and the blood vessels in it are intertwined into a chaotic mesh. As the uterus grows during pregnancy, such a scar will inevitably become thinner and may even tear. Moreover, it is impossible to stop this process. An incompetent scar has certain thickness parameters - more than 1 cm or less than 3 mm.

In general, the human body is not very well adapted to regeneration. In response to any damage, fibroblasts are the first to react - cells that cover the defect with connective tissue instead of the original one. However, this tissue is not able to fully replace muscle tissue, for example, in the uterus. Myometrial cells (the upper muscular layer of the uterus) divide at a slower rate than fibroblasts, so when a cut is made, a scar inevitably forms at the site where the edges are fixed.

Factors leading to scar failure

The following factors increase the risk of pathological suture formation after cesarean section:

1. Emergency surgery.
2. Insufficient compliance with aseptic and antiseptic rules during the process of cutting and suturing. Infections negatively affect the healing process.
3. Serious blood loss during surgery.
4. Significant trauma to the uterus, transition of the incision into a rupture (then the scar can also affect the cervix).
5. Intrauterine manipulations after cesarean section for a year (especially scraping of blood clots or abortion using this method).

Video: professor (obstetrician-gynecologist) talks about the scar after cesarean section and the factors influencing its healing

Features of pregnancy and childbirth

First of all, a woman should always try to give birth on her own: after all, today many expectant mothers choose surgical delivery, even if there are no direct indications for it.

After surgery, the next pregnancy can be planned only after two years. You shouldn’t delay it too long - more than four years, since the scar on the uterus will lose its elasticity even more over the years.

At the planning stage, a woman needs a comprehensive examination in order to fully diagnose the condition of the scar. After all, its failure can lead to various complications - pathologies of pregnancy:

1. Ingrowth of chorionic villi into the connective tissue and subsequent placenta accreta. If the embryo attaches directly to the scar area, then gynecologists often recommend that the woman terminate the pregnancy (usually using a vacuum method).
2. Spontaneous early miscarriage, threatened miscarriage, premature birth.
3. Incorrect location of the placenta: low, marginal or complete presentation.
4. Major blood loss during childbirth.
5. Uterine rupture.

Photo gallery: complications during pregnancy and childbirth associated with a uterine scar

A scar on the uterus often leads to abnormal attachment of the placenta. A scar on the uterus can lead to large blood loss during childbirth. Due to the rupture, the fetus can be fully or partially released into the woman’s abdominal cavity

Uterine rupture is the most severe complication of pregnancy, which can be caused by a scar. This dangerous condition is preceded by the following alarming symptoms:

1. Tension of the uterine muscles.
2. Arrhythmic contraction of the uterus.
3. Pain when touching the stomach.
4. Failures in the fetal heart rate (due to oxygen starvation).

The following signs directly indicate organ rupture:

1. Sharp and severe pain in the uterine area.
2. Decreased blood pressure in a pregnant woman.
3. Vomit.
4. Stopping labor (if rupture occurs during childbirth).

If the uterus ruptures, a woman needs an urgent caesarean section.

Of course, many women are interested in whether natural childbirth is possible after a cesarean section if there is a scar on the uterus. This is quite possible under several favorable circumstances (simultaneously):

1. The woman had only had one caesarean section in the past.
2. The placenta is well located - outside the scar area.
3. There are no concomitant diseases - indications for cesarean section.
4. Correct cephalic position of the fetus.

At the beginning of such a natural birth, a woman is advised to take antispasmodics, sedatives, as well as drugs against hypoxia in the fetus, which improve fetoplacental blood flow. Delivery, as a rule, takes a long time, since it should be carried out very carefully, without any stimulating drugs. If the cervix dilates slowly, without external intervention, then the risk of rupture of the makti will be minimal. The condition of the fetus is also constantly monitored and conditions are created for an emergency caesarean section if necessary.
Under certain circumstances, natural birth after cesarean is quite possible

There are a number of contraindications when natural childbirth is impossible in the presence of a scar on the uterus:

1. Lengthwise cut. The probability of divergence in this case is quite high.
2. The woman has had two or more caesarean sections in the past.
3. During my previous birth there was a uterine rupture.
4. The scar is incompetent with a predominance of connective tissue.
5. The woman in labor has a narrow pelvis: loads during the passage of the fetus can cause rupture (especially if the fetus is large).

Video: uterine scar after cesarean section during subsequent pregnancy

Diagnostic methods

Today, there are a number of diagnostic methods that can determine the condition of the uterine scar even at the stage of pregnancy planning, which, of course, helps reduce the percentage of unfavorable pregnancy outcomes:

1. Ultrasonography. Determines the thickness of the scar, the ratio of muscle and connective tissue in it, the existing niches and thickenings. It is optimal to do an ultrasound twice. The first is immediately after the end of menstruation (4–5 days of the cycle). The endometrium at this time is still very thin, and the tissue underneath can be clearly assessed. The second study is carried out on days 10–14. If an ultrasound diagnosis is made of “scar failure,” then additional procedures are prescribed - hysterography and MRI.
2. X-ray hysterography makes it possible to examine the relief of the scar. A special agent is injected into the uterus that absorbs X-rays. The result is a contour drawing of the organ cavity.
3. MRI allows you to assess the consistency and elasticity of a scar, and identify the percentage of connective tissue in it.

Surgical treatment of incompetent scar in the uterus

If a woman planning a pregnancy is diagnosed with an “incompetent scar,” this is not yet an obstacle to bearing a child. A surgical operation (plastic) is possible, the purpose of which is to excise scar tissue and apply new sutures.

There are no medications or any other schemes for eliminating an incompetent scar on the uterus.

The operation is performed using the open method, since the uterus is located behind other internal organs. In addition, this allows you to assess the degree of bleeding, which is inevitable during surgery, especially since the uterus has very good blood circulation. During the operation, the surgeon excises all the connective tissue and then stitches the muscles together layer by layer.

As for the laparoscopy method, it is difficult to control the amount of lost blood and it is difficult to stitch the walls of the uterus. However, such operations are practiced at the Moscow Center for Clinical and Experimental Surgery (their developer is Konstantin Puchkov, Doctor of Medical Sciences, Professor, Director of this center). Moreover, during one operation it is possible not only to correct the scar, but also, for example, to remove uterine fibroids. The advantage of the method is minimal tissue damage, the absence of a scar on the woman’s skin and quick recovery.
The laparoscopic method causes minimal damage to tissue

Therapy after surgery includes taking antibacterial and hormonal medications. In the first days after surgery, the body temperature may rise, and the woman often feels pain in the uterine area. Light bleeding from the genital tract lasting 6–12 days is normal.

If the operation was open, then the patient can wash only after removing the external sutures. While in the hospital, the seam is treated with an antiseptic solution.

Before discharge from the hospital, an ultrasound is mandatory: it allows you to evaluate the healing process. The procedure will continue to be carried out at certain time intervals.

Within two years after plastic surgery, a new, rich scar should form, and the woman will be able to safely carry and give birth to a baby. It is better to coordinate pregnancy planning with your doctor, who will confirm the good quality of the scar.

Women who have had a caesarean section may well carry and give birth to one, two, three or more children. True, bearing a fetus, its well-being, the ability to give birth in the future independently, without the help of surgeons, and forecasts for planning a subsequent pregnancy directly depend on such a thing as a scar on the uterus. The scar remains, this is inevitable. In this article we will tell you how a scar is formed, what determines its viability or failure, how to be examined and what are the norms for scar thickness.

How is it formed?

During a caesarean section, the fetus and placenta are removed through an incision in the uterus. The incision can be vertical if the child needs to be removed as quickly as possible (in some cases during an emergency CS) or horizontal in the lower segment of the uterus during a planned operation. After the incision, the edges in the incision area are tightened and sutured with special self-absorbable surgical sutures. From this moment on and for about 2 years, a scar forms at the site of the incision.

Already one day after a cesarean section, collagen bundles and fibrin threads lead to sticking of the cut edges. At the site of adhesion, new myocytes begin to form - cells of the uterine tissue, and small blood vessels are formed. After a week, elastic fibers appear and collagen is produced. The process of formation of new uterine cells is completed approximately three weeks after surgery. This is an ideal scenario, but in practice things may be slightly different.

When exposed to negative factors, areas of growth of hyalinized tissue are found among new myocytes. The proportion of coarse connective tissue predominates. Sometimes sclerotic processes are observed around the formed blood vessels and in neighboring tissues. This often leads to the formation of a pathological keloid scar.

In this case, it does not matter whether it is longitudinal or transverse. Such a scar not only looks unsightly (this is visible to diagnostic doctors), but is also undesirable for planning a pregnancy. The reasons why scar formation occurs with a predominance of rough connective tissue, or the production of myocytes is insufficient, are numerous and not fully understood. It is generally accepted that this process can be influenced by:

• complications in the postoperative period, infections, inflammatory process;
• the state of the microflora of the genital tract of the postpartum woman;
• the general health of the woman even before childbirth;
• the location of the incision and the technique of applying internal sutures, the skill of the surgeon.

There is also an increased risk of developing an incompetent scar in women whose reasons for undergoing surgery are premature placental abruption, complete placental previa, a long anhydrous period, as well as severe gestosis, obesity and prolonged anemia. All these nuances after surgery lead to a state of temporary severe immunodeficiency crisis, which leads to improper healing of the incision site on the uterus.

Consistency and insolvency - norms

When cesarean sections were a relative rarity, there was almost no question about the consistency or failure of the scar. Now the proportion of surgical births has increased, so the number of multiparous women with a scar on the uterus is also approximately 15-20%. Despite these impressive figures, there is no single standard in Russia by which a tripe could be considered good or bad. For now, this question is left to the discretion of the doctor, and doctors’ opinions can be very different.

They are similar only in that a scar that is homogeneous throughout its entire length and does not contain thinning or areas of pathological growth of connective tissue should be considered wealthy. In all other respects, the best medical minds on the planet today have not yet come to a consensus.

Russian scientists and practicing surgeons Lebedev and Strizhakov devoted several years to the clinical and morphological study of excised scar tissue, which was obtained during repeated CS operations. The result of their work was the following data on the normal permissible scar thickness:

Scar failure

The World Health Organization (WHO), based on the results of European studies, states that the minimum permissible thickness of a wealthy scar, in which even repeated natural childbirth is quite possible (if only one caesarean section was previously performed), is 3.5 mm (for a period from 36 to 38 weeks). It is not recommended to consider a formation of less thickness as untenable, but independent childbirth is undesirable.

In Canada, for example, the generally accepted practice of measuring the scar is only for pregnant women who are going to give birth in a completely physiological way - through the birth canal. At 38 weeks, a thickness of 2 mm is considered acceptable. And in Switzerland, the acceptable thickness before childbirth is 2.5 mm. For non-pregnant women who are just thinking about having another baby, in Russia, by default, a thickness of more than 2.5 mm is considered normal. Anything less significantly increases the risk of uterine rupture not only during contractions, but also long before them - during pregnancy.

Some diagnosticians are fully confident that thickness itself has little effect on the likelihood of rupture of the reproductive organ; it is the uniformity along the entire length that is important. This is indirectly confirmed by practice: sometimes women with a 2 mm scar carry a child well, who is born at term through a repeat CS, but with a 5 mm but heterogeneous scar, serious problems arise.

It should be noted that any scar on the uterus increases the likelihood of a pathological pregnancy. Common pathologies due to scars are:

• miscarriage;
• infertility;
• delayed fetal development;
• placenta previa;
• risk of early detachment of the “children’s place”;
• fetoplacental insufficiency;
• total accretion of the placenta into the scarred area may require removal of the “baby place” along with the uterus.

The most dangerous is considered to be uterine rupture. The reproductive organ grows with the baby, the uterine tissue stretches, there is less collagen and myocytes in the area of ​​the scar, and therefore the scar itself stretches very, very poorly. Uterine rupture during pregnancy leads to severe internal bleeding, often to the death of the mother and fetus. If a rupture occurs during childbirth, there is a chance of salvation.

Diagnostics

With the diagnosis of scar conditions both in Russia and in the world, things are not going well. Overdiagnosis prevails when the doctor tells a woman with a good, rich scar of 6 mm about the likelihood of rupture and persuades her to have an abortion so as not to risk it. This is an understandable consequence of the lack of uniform standardization in determining the viability of scars.

Nevertheless, his condition needs to be examined. And it is advisable to start this already 8-9 months after the operation. It is believed that it is at this time that the scar “reveals” all its “surprises” to the diagnostician. In any case, before planning a pregnancy, it is advisable to visit a doctor and insist on examining the internal suture on the uterus.

What diagnostic methods exist?

Ultrasound

This method is one of the most common, although its effectiveness for these purposes raises many questions in the professional community. Nevertheless, examination of the scar for consistency and the ability to withstand another pregnancy should begin with ultrasound diagnostics. The examination is carried out with both a transabdominal and transvaginal sensor. Intravaginal examination indicators are considered more reliable.

The doctor will determine the extent of the scar, be able to measure the thickness of the residual muscle layer, and also determine the niche space under the scar. The doctor will declare an incompetent scar if the niche is 50% or more in depth correlated with the residual muscle layer.

Full scar on the uterus

Defective scar on the uterus

But it is clearly not worth prohibiting a woman from giving birth or insisting on termination of pregnancy because of a thin scar based on ultrasound results. More detailed information on ultrasound about the condition of the scar after cesarean can be obtained before pregnancy and in the first trimester. At the end of pregnancy, adequate assessment is difficult.

Hysterography

A fairly effective method for assessing a scar, but with its own nuances. It is carried out only for non-pregnant people, since it involves contact with x-ray radiation. Essentially, the method is an x-ray of the uterus and its tubes using a contrast agent.

The procedure, with an accuracy of up to 97%, makes it possible to see signs of pathological scarring, but the method does not allow determining the true cause of what is happening and making predictions. For example, it will not be possible to make a diagnosis of “endometriosis of a postoperative scar” based on the obtained x-ray; it is possible that an MRI of the uterus will be needed. An incompetent scar may be indicated by a slight forward displacement of the uterus according to the results of hysterography, uneven and jagged contours, and defects in the filling of the uterus with a contrast solution.

Hysteroscopy

This method also assumes that you are not pregnant at the time of the examination. An optical device (part of a hysteroscope) is inserted into the uterus, and on the screen the doctor sees everything that happens inside the reproductive organ. This method is considered one of the most accurate today. An incompetent scar on the uterus looks like a whitish stripe (if connective tissue predominates), retractions may be noticeable (if the scar is thin).

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

At all times uterine ruptures are among the most severe complications in obstetrics, as they are always accompanied by bleeding, severe combined shock (traumatic and hemorrhagic), often the death of the fetus, and sometimes the woman. Among the causes of maternal mortality, uterine ruptures occupy 7-8th place, but their frequency does not decrease significantly, accounting for 0.1-0.5% of all births.

The lack of reduction in the incidence of uterine rupture is due to a number of reasons.

• Uterine rupture is based on pathological changes in the myometrium, which are the result of previous abortions, spontaneous miscarriages, inflammatory diseases and cicatricial changes. Healthy uterine tissue practically does not tear during childbirth, but if there are morphological changes in the uterine wall, the damaged tissue structure may “spread” or rupture.
• The frequency of cesarean sections has increased to 20-25% (and in some obstetric hospitals - up to 30% and higher), reconstructive plastic surgeries, removal of deep-lying myomatous nodes (a conglomerate of nodes) using the laparoscopic method, which increases the number of women of reproductive age with the presence of a scar on the uterus . At the same time, it is not always possible to correctly assess the consistency of the scar.
• In recent years, there has been a tendency towards forced management of labor and shortening its duration. For this purpose, labor stimulation is often used without taking into account the possibility of pathological changes in the muscular wall of the uterus. Artificial intensification of labor is often accompanied by discoordinated hyperdynamic labor, which in turn can be a direct cause of uterine rupture.
• The frequency of abnormal forms of the bony pelvis has increased, which are essentially “erased” forms of narrow pelvises, which are difficult to diagnose and sometimes not recognized at all.
• Unfortunately, to this day, violent uterine ruptures occur as a result of actions to move the fetus (from breech presentation to cephalic presentation) or during its extraction (high or atypical obstetric forceps, pressure on the fundus of the uterus).

Uterine ruptures are observed mainly in multiparous women, multigravidas with a burdened obstetric history, and very rarely in primigravida women. In the latter case, we may be talking about a rupture of the rudimentary uterine horn (in case of anomalies of its development: bicornuate, double). Such ruptures occur during pregnancy (20-26 weeks).

Uterine rupture always indicates shortcomings in the organization of obstetric care at all stages of monitoring a pregnant woman:

• lack of prevention of fetal macrosomia in women of short stature, stocky build, with a narrowing of the size of the bony pelvis;
• timely undiagnosed low-lying large myomatous nodes;
• forced management of labor in women with a complicated obstetric history;
• incorrect assessment of the consistency or failure of the uterine scar;
• labor stimulation during discoordinated labor, accompanied by hypertonicity of the myometrium, a rapid abrupt increase in intrauterine pressure; with weakness of labor contractions and pushing, which are a consequence of the structural inferiority of the uterine wall;
• gross forced extraction of the fetus during caesarean section, the presence of obstacles from the bony pelvis, birth canal, as well as an overstretched lower segment;
• timely undiagnosed varying degrees of disproportion between the fetal head and maternal pelvis.

What provokes / Causes of uterine rupture during pregnancy:

The main components contributing to the development of such a serious complication as uterine rupture are the combination of pathomorphological changes in the myometrium with the presence of difficulties in the advancement of the fetus, the use of birth stimulants, which often lead to discoordinated labor, as well as in some cases with violent actions to remove the fetus.

The main causes of uterine rupture are as follows.

• Morphological structural inferiority of the walls of the uterus as a result of cicatricial, inflammatory and degenerative changes, as well as micro-tears, which can occur with severe overdistension of the uterine cavity or with a complicated course of previous births and abortions.
• Mechanical and functional obstacles (difficulties) during the opening of the cervix (uterine pharynx) or the movement of the fetus through the birth canal.
• Hyperdynamic, discoordinated nature of labor, including when attempting forced delivery (labor stimulation).
• Uterine rupture as a result of violent acts during childbirth.
• Rupture of the rudimentary uterine horn.

Most often there is a combination of the above reasons.

Let us dwell in some detail on the main causes and risk factors of uterine rupture.

Pathogenesis (what happens?) during Uterine Ruptures during Pregnancy:

Morphological structural inferiority of the myometrium. Healthy uterine tissue, as a rule, cannot rupture during childbirth. Labor in a young primigravida woman will most likely stop, but the uterus will not rupture. Uterine ruptures in the vast majority of cases are the result of pathomorphological structural changes that develop after abortions, spontaneous miscarriages, curettage of the uterine walls with sharp surgical instruments, as well as a consequence of previous inflammatory diseases and microtraumas.

The main cause of uterine rupture is the scar after cesarean section, myomectomy, or uterine perforation.

The processes of damage to the myometrium consist of the simultaneous development of inflammatory and cicatricial changes. Moreover, they are often asymptomatic and are accompanied by long-term persistence of infection and destruction of connective tissue (fibrosis, scarring). First of all, the vessels are damaged, their permeability increases, perivascular edema, microthrombosis and hemorrhages are formed.

Under the influence of inflammatory mediators, the myocyte cytoskeleton is reorganized and intercellular contacts are weakened. The muscle tissue of the uterus is characterized by an extremely developed vascular network. Around each muscle fiber in the middle lining of the uterus there are up to 3-4 capillaries. With excessive intensification of labor, the arterial inflow and venous outflow of blood is disrupted. There is a sharp plethora, impaired microcirculation, microthrombosis, and desquamation of the endothelium. Thus, damaging factors primarily affect the vascular system of the uterus, disrupt blood supply, microcirculation, and over time, changes in the extracellular matrix and dystrophic changes in muscle tissue occur. During the inflammatory process in the uterus, macrophages and inflammatory cytokines accumulate, which makes the inflammatory process sustainable.

The processes of morphological changes in uterine tissue can occur as an acute inflammation (endomyometritis) or asymptomatic. The uterus retains the ability to stretch and contract, but additional stress during childbirth in the form of artificially intensifying contractions and pushing, or during violent labor that occurs to overcome an obstacle, can cause rupture of the defective part of the uterus.

The main morphological damaging factors are hypoxia, decreased blood supply to the myometrium (ischemia), inflammation, and mechanical stress. All these damages cause metabolic disorders: decreased oxidative phosphorylation and ATP formation, decreased synthesis of contractile proteins, increased anaerobic glycolysis, increased consumption of energy reserves. Therefore, with an inferior structure of the uterus, primary and/or secondary weakness of labor often develops.

After an incision in the uterine wall (caesarean section, myomectomy, removal of the tubal angle of the uterus), a limited number of muscle and connective tissue cells die, and the myometrial structure is not fully restored. At the junction of the edges of the incision, the accumulation of collagen remains, the connective tissue retains its cellular structure, and in certain areas where there was an inflammatory reaction, microvascularization is reduced. Thus, the excessive load that occurs during violent, discoordinated labor on defective areas of the myometrium can cause them to spread or rupture.

Any regeneration of parenchymal cells cannot fully restore the original architecture of the myometrium. Therefore, naturally, childbirth in women with a uterine scar is possible and safe only if it is absolutely physiological, when no additional interventions are required (labor stimulation, anesthesia, artificial extraction of the fetus).

When trying to increase the strength of contractions (pushing) or increase the basal tone of the uterus in the presence of scarring or degenerative changes in the myometrium, rupture of defective muscle tissue is possible.

Of course, uterine rupture in women with a burdened obstetric and gynecological history, the presence of a scar after surgical interventions, or dystrophic changes in the uterus after endomyometritis occurs quite rarely, even with suboptimal management of labor, but, most importantly, it is possible. In this regard, it is very important to take into account the obstetric situation (large fetus, post-term pregnancy, “immature” cervix at the due date), which can greatly increase the risk of developing this complication or, on the contrary, reduce it to a minimum.

Weakness of labor with a defective myometrial structure most often indicates the impossibility of developing stronger contractions to overcome obstacles in childbirth with a narrow pelvis and a large fetus. Attempts to intensify labor with the help of oxytotic drugs in women with a burdened obstetric and gynecological history and defective myometrial structure often lead to uterine rupture.

Artificial intensification of labor may be accompanied by discoordinated contractions, a sharp increase in intrauterine pressure, and uterine hypertonicity. There is a rupture of connections between smooth muscle fibers in places of least resistance (foci of inflammation, dystrophy, sclerosis and atrophy).

Morphological studies of specimens of removed uteruses due to their ruptures reveal extensive fields of scar tissue, foci of cellular large-fiber connective tissue, diffuse intermuscular and perivascular sclerosis in combination with edema and inflammatory infiltration.

Often, ingrowth of chorionic villi into the uterine scar is detected if the placenta is localized in the area of ​​the previous uterine incision.

Mechanical obstacles during childbirth. The second group of reasons, which are an important component in the sum of aggravating factors for the risk of uterine rupture during childbirth, includes mechanical and functional obstacles to the opening of the cervix (uterine pharynx) or the advancement of the fetus along the birth canal:

• anatomical, or functional, rigidity of the cervix (dystocia) - cicatricial changes after diathermocoagulation, old ruptures, the presence of an unrecognized myomatous node in the lower segment of the uterus, its centripetal growth, large size;
• narrow pelvis;
• a high degree of disproportion between the fetal head and the mother's pelvis (large fetus, posterior parietal asynclitic insertion, extension presentation, lack of configuration of the fetal head in post-term pregnancy, hydrocephalus).

In the presence of a significant obstacle to the advancement of the fetus and increased contractile activity of the uterus, a gradual shift of the main mass of the uterine muscles occurs upward, towards its bottom (the process of contraction and retraction), and the lower segment of the uterus becomes thinner and overstretched (distraction). The cervix is ​​pinched between the fetal head and the walls of the pelvis, and swelling of its tissue occurs. Finally, the degree of overextension and thinning of the lower segment exceeds the possible limit and rupture of blood vessels (hematoma, bleeding), fissure, incomplete or complete rupture of the uterus occurs.

Changes in the uterine wall should be considered as a factor predisposing to rupture, and a mechanical obstacle should be considered as a factor directly causing overstretching of the lower segment of the uterus and its rupture.

In this regard, a correct assessment of anamnestic data, the obstetric situation, the course of labor, the nature of labor and other risk factors for uterine overdistension make it possible to correctly select the method of delivery (planned or emergency caesarean section) and avoid uterine rupture.

Hyperdynamic uncoordinated nature of labor. Hyperdynamic discoordinated labor occurs when labor stimulation is not indicated, when autonomic balance is disturbed with a predominance of parasympathetic (cholinergic) influences. Against the background of increased basal tone of the uterus, contractions become frequent (more than 5 in 10 minutes), uneven in strength and duration, painful and unproductive. The mechanism of opening of the uterine pharynx changes. Instead of a gradual stretching of smooth muscle and connective tissue fibers, which are arranged circularly and spirally, they rupture, reaching the internal pharynx and spreading to the lower segment of the uterus. In this case, the rupture of the lower segment of the uterus may be incomplete. A hematoma forms, which gradually permeates the myometrium and periuterine tissue. In the absence of timely diagnosis, the contractile activity of the uterus is disrupted, and hypotonic bleeding begins.

Discoordinated and hyperdynamic (intensified) labor is accompanied by a sharp abrupt increase in intra-amniotic pressure, untimely (prenatal and early) rupture of amniotic fluid, and high energy consumption, which also contributes to the rupture of the pathologically altered myometrium.

Violent uterine rupture (uterine rupture as a result of violent acts during childbirth). TO Violent factors of uterine rupture during childbirth include excessively strong pressure on the fundus of the uterus (Kristeller maneuver), which changes the degree of elasticity of the myometrium and the propagation of the contractile wave, which causes separation between smooth muscle fibers at the place of their least resistance.

Violent uterine ruptures most often occur as a result of additional impact on the overstretched lower segment due to outside intervention, i.e., the additional factor is a direct cause that aggravates an already existing critical situation.

This situation is observed when trying to turn the fetus in a transverse position and rupture of amniotic fluid (advanced transverse position of the fetus), when applying high obstetric forceps when there is some discrepancy between the fetal head and the size of the pelvis.

Forced uterine rupture should include the inept use of birth-stimulating drugs, exceeding generally accepted dosages, and birth stimulation with hypertonicity, causing violent contractions and pushing.

It should be taken into account that with a rough mechanical impact on the uterus (a blow to the abdomen, forcible extraction of the fetus by the leg with a narrow pelvis, collision of twins), violent rupture is possible even with a normal structure of the myometrium, but such cases are practically not observed at present.

Rupture of the rudimentary uterine horn. Rupture of the rudimentary uterine horn is possible during pregnancy if the fertilized egg penetrates through the fallopian tube into the uterine cavity. With excessive stretching of the thin tissue of the rudimentary uterine horn at 16-22 weeks, a rupture occurs like a rupture of the fallopian tube (severe pain, intra-abdominal bleeding, hemorrhagic and traumatic shock).

Classification of uterine ruptures

There are many classifications of uterine ruptures, each of which has advantages and disadvantages. In our country, the classification proposed by L. S. Persianinov (1964) has become widespread, in which uterine ruptures are divided according to a number of characteristics.

• By time of origin:
  • ruptures during pregnancy;
  • ruptures during childbirth.
• According to pathogenetic characteristics.
• Spontaneous uterine ruptures (occurring without any external intervention):
  • mechanical (in the presence of a mechanical obstacle to the birth of the fetus);
  • histopathic (with pathological changes in the uterine wall);
  • mechanohistopathic (with a combination of a mechanical obstacle to delivery and pathological changes in the uterine wall).
• Violent uterine ruptures:
  • traumatic (from rough intervention during childbirth or during pregnancy and childbirth from accidental injury);
  • mixed (from external influence in the presence of hyperextension of the lower segment).
• According to the clinical course:
• threatening rupture;
• the beginning of the rupture;
• accomplished break.
• According to the nature of the damage:
  • crack (tear);
  • incomplete rupture (not penetrating into the abdominal cavity, involving only the mucous and muscular membranes) occurs in those places of the uterus where the peritoneum is loosely connected to the muscular membrane, usually in the lateral sections of the lower segment of the uterus, along its rib. Such a rupture is accompanied by the formation of a hematoma in the loose tissue of the pelvis, most often between the leaves of the broad ligament of the uterus or under its peritoneal cover. The hematoma may reach the hepatic region;
  • complete rupture - penetrating into the abdominal cavity, involving all muscle layers. Complete ruptures occur 9-10 times more often than incomplete ones.
• By localization:
  • rupture in the fundus of the uterus;
  • rupture in the body of the uterus;
  • gap in the lower segment;
  • separation of the uterus from the vaginal vaults.

Classification of uterine ruptures according to ICD-10 (1998):

• Uterine rupture before labor begins
• Uterine rupture during childbirth

Rupture of the anterior wall of the lower segment of the uterus most often occurs along the scar after a cesarean section and can be complete or incomplete.

With early recognition and prompt surgical intervention, uterine rupture along the scar is accompanied by slight blood loss.

Sometimes crushing of the edges of the wound, extensive hemorrhages in the lower segment, in the vesico-uterine fold, and swelling of the peri-vesical tissue are observed.

These ruptures can complement cervical ruptures of the third degree, extensive damage to the vagina, which indicates the influence of discoordinated labor, as well as mechanical and violent factors, on the origin of the rupture.

Rupture of the anterior wall of the lower segment of the uterus with transition to the lateral sections or uterine ruptures along the lateral surface also have a mixed origin. Mechanical, violent, and morphopathic factors participate in their development. As a rule, they are accompanied by thinning of the lower segment, damage to large vessels (the upper part of the uterine artery and the vaginal artery), extensive damage to the cervix and vagina, and uterine atony. Often an interligamentous hematoma is formed with its significant spread (periovesical tissue, retroperitoneal space). The length of lateral ruptures of the lower segment of the uterus is 5-10-15 cm, usually longer for ruptures along the left edge and shorter for ruptures along the right edge. These breaks are usually incomplete, rarely complete.

Ruptures in the area of ​​the lateral sections of the lower segment of the uterus have an unfavorable course, accompanied by massive blood loss and high maternal mortality. Ruptures of the anterior wall of the uterine body occur in the presence of scars after suturing uterine perforation during abortion, corporal cesarean section and other surgical interventions. Almost always, these ruptures are histopathic, always complete, often located in the longitudinal direction, have a length from 3-4 to 15 cm or more, i.e., they can continue from the fundus to the border of the body and lower segment, crossing the entire anterior wall of the uterus. Less commonly, the ruptures have an oblique direction from the tubular angle to the border of the body and the lower segment on the opposite side, and in these cases the ruptures have a greater extent (10-16 cm).

Ruptures of the anterior wall of the uterine body, more often than ruptures in other localizations, are accompanied by the birth of parts of the fetus or the entire fetus into the abdominal cavity. In this case, there is significant blood loss, which is associated with uterine atony and bleeding from damaged myometrial tissue.

Lacerations of the posterior wall of the uterine body are usually complete; the localization of the ruptures depends on their genesis: with morphopathological changes in the myometrium due to past operations, complications of abortion (conservative myomectomy, uterine perforation, etc.), they are usually located in the area of ​​the uterine body, closer to the bottom, their length is relatively small (3-6 cm).

With mechanical forced genesis, rupture of the myometrium occurs in the lower part of the uterus, often has a transverse direction, a large extent, up to the separation of the uterus from the posterior and lateral vaginal fornix with transition to the lateral parts of the uterus (usually to its left edge), to the cervix, i.e. e. has a complex course. In these cases, the edges of the rupture are crushed, the formation of extensive interligamentous hematomas and massive external bleeding are possible. The prognosis for these ruptures is extremely unfavorable.

A rupture in the fundus of the uterus, in the area of ​​the tubal angles, has only a morphopathological genesis (surgery for tubal pregnancy with excision of the uterine angle, perforation of the uterus during abortion, conservative myomectomy, etc.). All ruptures of this localization are complete, their length rarely exceeds 4-6 cm, and are accompanied by the development of hemorrhagic and traumatic shock.

Symptoms of uterine rupture during pregnancy:

The clinical picture of threatening uterine rupture has undergone certain changes, becoming more blurred and devoid of many striking, previously described signs. Therefore, when managing pregnant women and women in labor, it is necessary to take into account all data that can help in assessing the risk and threat of uterine rupture.

Clinic of threatening uterine rupture due to disproportion in the size of the fetus and maternal pelvis

The classic clinical descriptions of threatening uterine rupture in cases of mechanical obstruction to fetal birth are well known:

• rapid labor activity;
• change in the shape of the uterus due to hyperextension of the lower segment;
• round ligament tension;
• increased uterine tone;
• sharp pain on palpation of the uterus;
• high standing contraction ring, which also has an oblique direction;
• lack of advancement of the fetal head;
• large birth tumor;
• pinching of the anterior lip of the cervix and its swelling;
• swelling of the vagina, external genitalia;
• restless behavior of the woman in labor;
• constant leakage of amniotic fluid.

This classic picture of impending uterine rupture takes time to develop. Meanwhile, expectant tactics for 1.5-2 hours for functional assessment of the pelvis are currently outdated, and the issue of disproportion between the fetus and the mother’s pelvis should be resolved already in the first stage of labor. From the point of view of modern obstetrics, the development of the entire classical clinic of threatening uterine rupture is possible only with long-term observation and improper management of labor. Currently, the symptoms of impending uterine rupture are more subdued, which depends on the widespread use of painkillers.

Not a single case of uterine rupture is asymptomatic. The doctor sees and describes the clinical picture of a threatening uterine rupture, but does not evaluate it properly, “does not recognize” the threat of uterine rupture. The diagnosis should be based not only on clinical signs of disproportion between the fetus and the mother’s pelvis, but also on the presence of risk factors indicating incompetence of the uterine walls, in particular a burdened obstetric and gynecological history, a complicated course of this pregnancy and a pathological course of childbirth.

Uterine rupture clinic in the presence of a scar or pathomorphological changes in the myometrium

A typical complication of pregnancy with defective myometrial structure is threatening premature birth at 30-35 weeks, when the uterus is maximally distended. Most often noted:

• pain in the lower abdomen and lower back, sometimes without clear localization;
• deterioration of the fetus;
• arterial hypotension;
• slight bleeding from the genital tract;
• hypertonicity of the uterus.

In the presence of a defective (incompetent) scar on the uterus, local pain may appear if the scar is located on the anterior wall of the uterus, or vague diffuse pain in the lower back and sacrum may occur if the defective area of ​​the uterus is localized on the posterior wall of the uterus.

The onset of labor with histopathic changes in the uterus is most often pathological in nature: untimely rupture of amniotic fluid in combination with an “immature” or “insufficiently mature” cervix; pathological preliminary period; discoordinated painful labor or decreased tone, inexcitability of the uterus, turning into persistent weakness of labor. A common complication is labor anomalies.

Excessively strong labor may develop in response to inadequate labor-stimulating therapy. Initial weakness, and then violent labor, and vice versa, are typical variants of the pathology of contractile activity of the uterus, leading to uterine rupture.

Symptoms of threatened rupture of the pathologically altered myometrium and incoordination of labor are very similar (unevenness of contractions in strength, duration and frequency; hypertonicity and pain of contractions, difficulty and cessation of spontaneous urination, even if there is no disproportion between the fetal head and maternal pelvis, etc.).

Uterine rupture can occur in both the first and second stages of labor. If a uterine rupture occurs during the period of expulsion of the fetus, then it may be born alive. Immediately after uterine rupture, the general condition of the woman in labor worsens: severe weakness, pale skin appears, the pulse becomes soft, easily compressible, thread-like, and blood pressure decreases (shock).

Uterine rupture clinic differs in diversity, and at the same time several obligatory symptoms can be identified.

An inevitable accompaniment of uterine rupture is sharp pain in the abdomen. The pain can be of a very diverse nature. There may be cramping pain in the lower abdomen and lower back, which is mistaken for labor, while it reflects the onset and progressive rupture of the uterus.

In some cases, when the uterus ruptures, there is a sharp, sudden pain that occurs at the height of the contraction. The woman in labor feels that something inside has “burst.” Labor activity stops. The shape of the uterus changes, and small parts of the fetus are felt under the skin of the abdomen. There is no fetal heartbeat (the fetus dies quickly). There are signs of bleeding in the abdominal cavity. Bloody discharge appears from the genital tract. Urine mixed with blood.

A characteristic symptom is bloating, which may appear in the early postpartum period. With complete ruptures of the uterus with accumulation of blood in the abdominal cavity, there are symptoms of peritoneal irritation. The main symptom of a completed uterine rupture is a decrease in blood pressure.

At the birth of the fetus, parts of the fetus are easily identified in the abdominal cavity, located as if directly under the anterior abdominal wall. The patient's condition with uterine rupture is very serious, a forced position is noted, and when this changes, there is an increase in pain and a deterioration in the general condition.

When palpating a ruptured uterus, the following symptoms are observed: increasing pain, tension and poor relaxation of the uterus. Soreness can be over the entire surface of the uterus or local - in the lower segment. There are no clear contours of the “postpartum” uterus, or the uterus takes on an irregular shape and rises up into the hypochondrium. When a rupture occurs along the scar, a bulge or protrusion appears on the anterior wall of the uterus. With incomplete uterine rupture and the formation of an interligamentous hematoma, a sharply painful formation is palpated, closely adjacent to the lateral surface of the uterus. The latter is usually deflected in the opposite direction.

Bleeding is a mandatory symptom of uterine rupture. It can be external, internal and combined.

Complete uterine rupture during pregnancy. When a uterine rupture occurs during pregnancy, diagnostic difficulties sometimes arise. Characteristic symptoms are signs of internal bleeding and irritation of the peritoneum, forced positioning, bloating, and a positive phrenicus symptom. The fetus dies. Hypovolemia progresses (dizziness, weakness, arterial hypotension, thirst, dry mouth, dry coated tongue), etc. Uterine rupture during pregnancy occurs along the scar, most often during the maximum period of distension of the uterine cavity (30-35 weeks). Hemorrhagic shock develops quickly.

Diagnosis of uterine ruptures during pregnancy:

Treatment of uterine ruptures during pregnancy:

Doctor's tactics for threatening uterine rupture

Impending uterine rupture is a condition that precedes spontaneous uterine rupture, but uterine rupture has not yet occurred. In this regard, it is necessary to immediately stop labor by putting the patient under anesthesia and perform an emergency delivery. In the presence of a living fetus in any obstetric situation - lower median laparotomy, cesarean section, revision of the uterus and abdominal cavity. In case of a dead fetus and the presence of conditions (full opening and location of the fetal head in the pelvic cavity), a fetal destruction operation is performed, followed by a control examination of the uterine walls.

If there is a threat of uterine rupture, delivery through the natural birth canal is contraindicated: application of obstetric forceps, vacuum extraction of the fetus, extraction by the pedicle and inguinal fold.

Often, after a diagnosis of impending uterine rupture is made, uterine rupture occurs during preparation for surgery. Therefore, as soon as a diagnosis of an impending disaster is made, anesthesia should be started immediately before the woman in labor is transferred to the operating room. It is possible to prevent the transition of a threatening rupture into a completed uterine rupture only by stopping labor and immediate delivery.

Attempts to extract the fetus through the natural birth canal should not be attempted, even if the head is in the pelvic cavity, since a threatened rupture will immediately turn into an accomplished one.

After a cesarean section and revision of the uterus and abdominal cavity, before suturing the rupture, 1.0 ml of prostin E2 or F2 is injected into the thickness of the uterus (so that the uterus contracts well and bleeding decreases). A vitamin-energy complex is administered intravenously in a stream or frequent drops (60 drops/min) to increase the contractility of the uterus and restore energy costs. The complex contains 150 ml of 40% glucose solution (15 IU insulin subcutaneously), 15 ml of 5% ascorbic acid solution, 10 ml of 10% calcium gluconate solution, 150 ml of cocarboxylase, 2 ml of ATP, 2 ml of vitamin B6.

Doctor's tactics in case of uterine rupture

Treatment for a complete uterine rupture includes: emergency surgery (transsection), anesthesia with mechanical ventilation, as well as anti-shock measures (transfusion and infusion therapy, elimination of hemocoagulation disorders).

Surgical treatment of uterine rupture. The following operations are performed: suturing the rupture, supravaginal amputation and hysterectomy.

If there is a small linear rupture, no bleeding, chorioamnionitis, or metroendometritis, suturing the rupture is acceptable, which, if necessary, can be supplemented with sterilization.

However, it should be taken into account that pathologically altered tissue may not heal well. Currently, strong synthetic and semi-synthetic threads are used that do not dissolve within a month. During operations for uterine rupture, drainage of the abdominal cavity is necessary.

In case of extensive trauma, incomplete uterine rupture, the presence of retroperitoneal hematoma, rupture with damage to vascular bundles, severe infectious process in the uterus, etc., it is necessary to expand the scope of the operation (extirpation, supravaginal amputation of the uterus, ligation of the internal iliac arteries).

The time at which the operation begins is essential: since the life expectancy of patients with uterine rupture on average does not exceed 3 hours, which depends on the rapid development of severe shock.

Laparotomy must be performed urgently within minutes of diagnosis. Transportation of patients is unacceptable.

If the uterus has ruptured, attempts at delivery through the natural birth canal should not be made. In all obstetric situations, only laparotomy is indicated without attempting to extract the fetus (even if the presenting part is in the pelvic cavity).

Combined anesthesia is indicated, including anesthesia, prolonged mechanical ventilation, and sometimes the introduction of a novocaine solution under the parietal peritoneum, omentum and other reflexogenic zones.

It should be considered a mistake if, after a control manual examination of the “postpartum” uterus and a diagnosis of uterine rupture, the patient is allowed to awaken from anesthesia. Even a short-term absence of anesthesia aggravates the degree of shock.

The extent of surgical intervention is determined by the following factors: the extent of the uterine rupture (degree of tissue damage) and the condition of the patient.

The more severe the patient’s condition, the faster it is necessary to complete the operation. Extensive ruptures of uterine tissue should generally be an indication for hysterectomy. In case of linear ruptures and in cases where excision of damaged tissue is possible, it is necessary to preserve the uterus.

The beginning and completion of uterine rupture requires transection, regardless of the condition of the fetus. Simultaneously with the operation, it is necessary to carry out a set of anti-shock and anti-anemic measures.

In case of incomplete uterine rupture, if there is an extensive subperitoneal hematoma, it is necessary to first dissect the peritoneum, remove clots and liquid blood, and apply ligatures to the damaged vessels. After reliable hemostasis, sutures are placed on the wound. If it is difficult to stop bleeding, ligation of the internal iliac arteries is recommended, since the uterine arteries are difficult to find due to parametrium hematomas. Surgery for uterine rupture should be performed by an experienced surgeon.

Infusion and transfusion therapy program

The most severe consequence of uterine rupture is pain shock and intra-abdominal bleeding, which often leads to the development of hemorrhagic shock. Therefore, timely and adequate infusion-transfusion therapy in combination with surgery is the most effective and reliable means of saving the patient. Fluid therapy should be started immediately and continued during and after surgery. This task cannot be simplified as just restoring the bcc. It is necessary to take into account the entire complex of protective and adaptive reactions that occur in response to injury, blood loss and surgical aggression.

If a uterine rupture occurred in a hospital, the diagnosis was made in a timely manner and the doctor immediately began surgery, the patient’s blood pressure may be slightly reduced (90/60 mm Hg), but not critical.

Compensation for the pain reaction and blood loss within 1 liter is carried out due to the centralization of blood circulation, which stimulates the sympathetic-adrenal system, vasoconstriction, increased stroke volume, and an increase in cardiac output. Vasoconstriction for a certain time (short-term) ensures the adaptation of the vascular bed to the reduced BCC. General vascular resistance increases. As a protective reaction, the transition of fluid from the interstitial space to the vascular bed (hemodilution) develops. This occurs due to a decrease in peripheral venous pressure and a change in the flow of fluid from the venous vessels into the interstitial tissues. Autohemodilution not only restores the volume of the vascular bed to a certain extent, but also flushes out stagnant red blood cells from the depot; all this partially restores microcirculation and oxygen exchange, but for a short time (in the first 20-30 minutes after uterine rupture).

Centralization of blood circulation provides primarily blood supply to vital organs - the brain, heart, liver. In other organs and tissues (kidneys, adrenal glands, muscular system, skin), blood perfusion decreases, capillary blood flow is partially switched off, redox processes for some time are ensured by a transition to anaerobic wasteful glycolysis, which depletes glycogen reserves in the liver. If the patient has previous hypoproteinemia, impaired microcirculation and the hemostatic system, adaptation may be short-term.

When the uterus ruptures, blood loss, hypovolemia, impaired microcirculation, tissue hypoxia, metabolic acidosis occur, initiating changes in the blood coagulation system, which are the basis for the development of DIC syndrome, secondary fibrinolysis and hypocoagulation.

It should be taken into account that when the uterus ruptures, bleeding cannot be stopped; it continues. In this regard, all activities are carried out in parallel to each other: a team of surgeons begins an emergency operation, another (anesthesiologists-resuscitators) - intensive infusion-transfusion therapy.

The action scheme is as follows.

• Assess the most important indicators - pulse rate, blood pressure, respiratory rate, level of consciousness, and on their basis - the severity of blood loss and its approximate volume. Provide oxygen (intranasal catheter, mask spontaneous or artificial ventilation). Bladder catheterization.
• Simultaneously puncture and catheterize the vein, start with the ulnar vein, and catheterize the central vein. Take blood for a study of group affiliation, a general analysis (hemoglobin, hematocrit number, red blood cells, platelets), a biochemical study (creatinine, potassium, sodium, chlorides, CBS, total protein) and to determine blood coagulation parameters (prothrombin, aPTT, thrombin time, fibrinogen, clotting time).
• Pour 1 liter of FFP, as well as colloidal solutions (polyglucin, hydroxyethyl starch preparations) over 30-60 minutes. Most often, transfusions of colloidal solutions are started, but as soon as the plasma is thawed, it is necessary to administer it.

If manifestations of hypocoagulable bleeding persist, continue the administration of FFP, increasing the volume of its transfusion to 2 liters.

With a total blood loss of more than 2 liters or blood loss of up to 30% of the total volume, unstable hemodynamic parameters, and increasing pallor, red blood cell transfusion is necessary. All solutions are poured warm.

Despite the negative aspects of blood transfusions, it is necessary to emphasize that canned donor (and in very severe cases, warm donor) blood is practically the only means of restoring the transport of oxygen and carbonic acid (carbonic acid) in the recipient’s body.

The criterion for the adequacy of replenishing the BCC deficit is CVP and hourly diuresis. Until the central venous pressure reaches 10-12 cm of water. Art. and hourly diuresis does not exceed 30 ml/h, the patient needs to continue infusion therapy.

The ratio of transfusion volumes of FFP and red blood cells is usually 3:1. Hemoglobin content is 80 g/l with adequate oxygen delivery and systolic blood pressure of 90 mmHg. Art. in conditions of normovolemia and bleeding control, it allows to reduce the intensity of transfusion therapy.

Transfusion of platelet concentrate is indicated when their level decreases below 50.0. 109/l, the appearance of hemorrhage and petechial bleeding on the skin (the therapeutic dose is the transfusion of 4-6 doses of platelet concentrate).

Constant monitoring of hemodynamics, oxygenation, coagulogram data, platelet counts, blood concentration parameters, ECG, CBS, which is necessary for correcting transfusion therapy, should be carried out.

When transfusing more than 4 doses of red blood cells or FFP (at a rate of more than 1 dose in 15-20 minutes), administration of 10 ml of a 10% calcium chloride solution is indicated to prevent citrate intoxication and hypocalcemia.

Often, a single transfusion of 1-2 liters of FFP is not enough, since the transfused coagulation factors are quickly consumed and bleeding can resume, requiring repeated transfusion of FFP (usually after a few hours). The volume of FFP depends on the dynamics of coagulogram parameters and the stability of hemostasis parameters. The criteria for the success of therapy are the level of prothrombin, fibrinogen, aPTT, and platelet count. All these indicators, with sufficient and effective therapy, should have a clear tendency towards normalization.

It is dangerous to overload the right side of the heart. Too intensive volume transfusion therapy, the desire to “stabilize blood pressure at normal levels” can lead to circulatory overloads, disruption of the primary platelet plug, increased blood loss, and decreased levels of platelets and plasma coagulation factors.

Moderate arterial hypotension (blood pressure in the range of 90/60-110/70 mm Hg), volumetric infusion therapy providing sufficient organ perfusion (criterion - hourly diuresis and blood saturation) are physiologically justified, necessary and sufficient.

The severity of acute massive blood loss is determined mainly by the resulting deficiency of plasma coagulation factors in the circulation and loss of bcc.

Adequate and rapid restoration of consumed plasma coagulation factors and replenishment of circulating fluid volume is the most important goal of transfusion tactics. The administration of colloidal solutions and crystalloids most often ensures the achievement of normovolemia and adequate tissue oxygenation, provided that the hemoglobin level is not lower than 80 g/l.

Transfusion of FFP should not be standard; it is aimed at replenishing plasma, primarily labile (V and VIII) coagulation factors. Erythrocyte transfusion is prescribed in the presence of circulatory hypoxia, which is characterized by severe pallor of the skin and conjunctiva, tachycardia, shortness of breath and the participation of the scalene muscles and nasal wings in the act of inspiration, provided that adequate oxygen delivery is ensured and normovolemia is achieved (but not massive hemodilution).

If there is a pronounced increase in central venous pressure, limiting the volume of FFP transfusion, plasmapheresis in a volume of 800-1000 ml is indicated. With the removed plasma, PDP, circulating endotoxins, and proteolytic enzymes are removed from circulation.

The volume of infusion at the first stage is determined ex juvanticus and should approximately be 30 ml/kg for stage I shock, 50 ml/kg for stage II, and 60 ml/kg of weight for stage III. So, with a patient’s body weight of 70 kg, the volume of infusion therapy is 2100, 3500 and 4200 ml, respectively, on the 1st day of intensive care.

It should be noted that the decisive criterion for the effectiveness of infusion-transfusion therapy is not so much its volume as the infusion rate, which determines the hemodynamic response to therapy.

Solutions are administered at a volumetric rate that allows for the fastest possible normalization of systolic blood pressure, and it should not be lower than 70 mmHg. Art., which allows you to maintain adequate blood flow in the life support organs. The most typical reactions of victims with shock to infusion-transfusion therapy are the following.

1. OptionI. Systolic blood pressure and central venous pressure in response to forced fluid administration quickly reach normal values, which, as a rule, occurs in mild shock and is a prognostically favorable sign.
2. OptionII. Systolic blood pressure, against the background of active infusion support, including the use of colloidal plasma substitutes and glucocorticosteroids, begins to gradually recover and is stably maintained above critical values, while central venous pressure remains below normal.
3. OptionIII. Systolic blood pressure and central venous pressure remain critical, despite the jet infusion of plasma replacement drugs, glucocorticosteroids, and natural colloids. A similar reaction of the cardiovascular system occurs in extremely severe shock and forces the use of drugs that have a positive inotropic and vasoconstrictor effect. To carry out infusion-transfusion therapy in this category of victims, two and sometimes three veins are used.

Lack of hemodynamic stabilization is an indication for intravenous infusion of adrenomimetic drugs (dopamine, mesaton, norepinephrine), the dose and rate of administration of which are determined individually.

Forecast Even with the modern state of obstetric care, uterine rupture remains unfavorable for the fetus. The outcome for the mother is determined by the amount of blood loss and the severity of the shock. Due to the increasing frequency of cesarean sections and the increasing number of pregnant women with a scar on the uterus, the management of pregnancy and childbirth has special specifics.

Prevention of uterine rupture during pregnancy:

Prenatal consultation plays a major role in the prevention of uterine rupture. When registering a pregnant woman, it is necessary to evaluate her medical history, the number of pregnancies and births, their outcomes, the body weight of the children born, previous operations on the uterus and their nature. Women with a scar on the uterus after a cesarean section, myomectomy, or surgery for an ectopic pregnancy deserve special attention. You should read the extract from the hospital, which indicates the extent of the operation, the course of the postoperative period, and the data of the morphological study.

It is important to identify risk factors for morphological failure of the myometrium: complicated abortions, repeated uterine curettage, chronic and acute inflammatory diseases of the pelvic organs, the presence of an additional uterine horn and other anomalies of its development.

It is necessary to prevent fetal macrosomia. For this purpose, proper nutrition is recommended: reduced consumption of foods containing sugar.

It is very important to identify narrowing of the bony pelvis and its abnormal shapes. Most often they are present in short women or with an android body type.

Vaginal examination reveals flattening of the sacrum, narrowing of the transverse dimensions, the so-called long pelvis. If the distance from the upper border of the pubic symphysis to the ischial tuberosity exceeds 10.5 cm, labor may be complicated by difficult advancement of the head, which will require the use of labor stimulation. The combination of structural inferiority of the uterine wall with a narrow pelvis, difficult advancement of the head and forced delivery is the main component of uterine rupture.

Hospitalization of women with risk factors in a hospital should be no later than 7-10 days before the expected date of birth.

In the prenatal department of the maternity hospital, an in-depth study of the condition of the pregnant woman and her fetus is carried out. All existing risk factors are re-evaluated to decide on the timing and method of delivery. The following issues should be resolved in advance.

• Is vaginal delivery possible and with what risk for the mother and fetus?
• If the risk is high, should a caesarean section be planned before the onset of labor, but close to the expected due date?
• With an average risk in terms of labor management, they indicate the need to conduct labor without the use of corrective therapy (meaning labor stimulation, anesthesia), i.e., childbirth is carried out through the natural birth canal with its physiological development and course. Deviation from the normal course of labor (untimely rupture of amniotic fluid, an “immature” cervix, weakness or incoordination of labor) are indications for cesarean section.
• In case of low risk (but risk!), the possibility of corrective therapy is emphasized, but without repeated labor stimulation, increasing the dosage of labor stimulants, and it is also necessary to promptly identify additional complicating factors (formation of a posterior view with a large fetus in a woman in labor with a burdened obstetric-gynecological history or an extensor presentation of the head fetus). In all these cases, they indicate the advisability of revising the tactics of labor management from conservative to cesarean section.
• If there is a scar on the uterus, childbirth is carried out through the natural birth canal only if it is absolutely normal, with cephalic presentation, with full proportionality between the fetal head and the mother’s pelvis, when no additional anesthesia is required (except for epidural anesthesia).

The use of narcotic analgesics can neutralize the clinical picture of the threat of uterine rupture, and labor stimulation can cause rupture of the incompetent area of ​​the uterus. Until now, there are no absolutely reliable criteria for the usefulness of a uterine scar. Particular attention should be paid to preventing uterine rupture during childbirth in women with risk factors (complicated obstetric history, narrow pelvis, uterine scar).

• It is necessary to monitor the synchronicity of the opening of the uterine pharynx and the advancement of the fetal head. So, during normal childbirth and the opening of the uterine pharynx by 6 cm, the head should be located as a small segment in the inlet of the small pelvis, with an opening of 8 cm - as a large segment, and with full opening - in the pelvic cavity.
• The second stage of labor (from the moment of complete opening of the cervix) should not exceed 2-3 hours for primiparous women, 1-2 hours for multiparous women. If during this time the fetus is not born, then in most cases a cesarean section or vaginal surgery is indicated, depending on the specific conditions.
• Prevention of violent uterine ruptures involves avoiding turning the fetus from a breech presentation to a cephalic presentation and vice versa, or attempting to remove the fetus when the uterine os is not fully open. The risk of damage to the lower segment of the uterus during delivery operations with a high-standing head should be taken into account.
• Prevention of deep ruptures of the cervix, which can continue to the lower segment of the uterus, consists of prescribing antispasmodics for cervical rigidity and dystocia, proper management of labor, and careful surgical delivery, which can only be performed with the full opening of the uterine pharynx.

Which doctors should you contact if you have uterine ruptures during pregnancy:

Is something bothering you? Do you want to know more detailed information about uterine rupture during pregnancy, its causes, symptoms, methods of treatment and prevention, the course of the disease and diet after it? Or do you need an inspection? You can make an appointment with a doctor– clinic Eurolab always at your service! The best doctors will examine you, study external signs and help you identify the disease by symptoms, advise you and provide the necessary assistance and make a diagnosis. you also can call a doctor at home. Clinic Eurolab open for you around the clock.

How to contact the clinic:
Phone number of our clinic in Kyiv: (+38 044) 206-20-00 (multi-channel). The clinic secretary will select a convenient day and time for you to visit the doctor. Our coordinates and directions are indicated. Look in more detail about all the clinic’s services on it.

(+38 044) 206-20-00

If you have previously performed any research, Be sure to take their results to a doctor for consultation. If the studies have not been performed, we will do everything necessary in our clinic or with our colleagues in other clinics.

I am posting the article not so that they will write “a lot of letters”, but because it is important for me, and therefore in full. Those who are too lazy to read don’t need to comment about it at all. For anyone who needs it, please read for your health :)

"Aggravating circumstance." Childbirth with a scar on the uterus.

Currently, a scar on the uterus is increasingly becoming a companion to pregnancy. How can this circumstance affect the course of pregnancy and the outcome of childbirth? Is it possible for a woman with a uterine scar to give birth naturally or is a caesarean section inevitable?

A scar on the uterus may be the result of:

• previous caesarean section;
• conservative myomectomy. Uterine fibroids are a benign tumor of the muscular layer of the uterus, which is removed while preserving the organ; this operation is called “conservative myomectomy.” This surgical intervention usually restores the ability of patients to conceive, but after the operation there is always a scar on the uterus;
• perforation of the uterus (piercing the wall) during instrumental removal of the fertilized egg or uterine mucosa during abortion;
• removal of a tube during tubal pregnancy, especially if the tube is removed along with a small part of the uterus from which it originates - the uterine angle.

The consistency of the uterine scar

For the course of pregnancy and the prognosis of the upcoming birth with a uterine scar, the nature of scar healing is important. Depending on the degree of healing, the scar can be considered complete, or wealthy, and inferior, or insolvent.

A scar in which complete restoration of muscle fibers has occurred after surgery is considered healthy. Such a scar can stretch with increasing gestational age and growth of the uterus; it is elastic and capable of contraction during contractions. If the amount of connective tissue in the scar predominates, then such a scar will be considered inferior, since the connective tissue is not able to stretch and contract the way muscle tissue can.

So, the degree of restoration of the uterine scar is influenced by the following factors:

1. The type of surgical intervention after which this scar was formed. If the scar is formed after a cesarean section, then the pregnant woman needs to know which incision was used to perform the operation. Usually, with full term and planned surgery, the incision is made in the transverse direction in the lower uterine segment. In this case, the conditions for the formation of a full-fledged scar that can “withstand pregnancy and childbirth” are more favorable than if the uterus was dissected longitudinally. This is due to the fact that the muscle fibers at the site of the incision are located transversely and after dissection they grow together and heal better than if the incision was not made along the muscle layer. A longitudinal incision in the uterus is mainly performed when emergency delivery is necessary (in case of bleeding, acute fetal hypoxia (hypoxia - lack of oxygen), as well as for caesarean section performed up to 28 weeks.
   A scar on the uterus can result not only from a cesarean section, but also from conservative myomectomy, suturing of uterine perforation, and removal of the fallopian tube.
   If a woman had uterine fibroids before pregnancy and she underwent a conservative myomectomy (removal of nodes of a benign tumor - fibroids while preserving the uterus), then the nature of the location of the removed nodes, surgical access, and the fact of opening the uterine cavity are important. Typically, small fibroids located on the outside of the uterus are removed without opening the cavity of the latter. The scar after such an operation will be more consistent than when opening the uterine cavity to remove intermuscular myomatous nodes located intermuscularly or between the fibers of the myometrium. If the scar on the uterus is formed due to perforation of the uterus after an artificial abortion, then the obstetric prognosis is more favorable if the operation was limited only to suturing the perforation without additional dissection of the uterine wall.
2. Duration of pregnancy after surgery. The degree of healing of the uterine scar also depends on the amount of time that has passed since the operation. After all, any tissue needs time to recover. The same goes for the wall of the uterus. It has been established that restoration of the functional usefulness of the muscle layer after surgery occurs within 1-2 years after surgery. Therefore, the most optimal is the onset of pregnancy in the interval from 1-2 years after surgery, but not later than 4 years, since a long interval between births leads to an increase in connective tissue in the scar area, which reduces its elasticity. Therefore, for women who have undergone surgery on the uterus, be it a cesarean section or a conservative myomectomy, obstetricians-gynecologists recommend contraception in the next 1-2 years.
3. The course of the postoperative period and possible complications. The process of restoration of uterine tissue after surgery also depends on the characteristics of the postoperative period and possible complications. Thus, complications of a cesarean section can include postpartum endometritis - inflammation of the inner lining of the uterus, subinvolution of the uterus (insufficient contraction of the uterus after childbirth), retention of parts of the placenta in the uterine cavity with subsequent curettage complicating the formation of a full-fledged scar.

Diagnosis of the condition of the uterine scar

A woman with a uterine scar needs to be examined for the consistency of the scar even before pregnancy in order to have complete information about the prognosis of pregnancy and childbirth. Outside of pregnancy, it is necessary to assess the consistency of the uterine scar in patients who have undergone operations associated with the risk of developing a defective scar. Such operations include conservative myomectomy with opening of the uterine cavity, cesarean section performed with a longitudinal incision on the uterus, surgery to suturing a perforation in the uterus after an abortion with opening of the uterine cavity. Examination of the uterine scar is possible using hysterosalpingography, hysterography and ultrasound. If pregnancy has already occurred, then diagnosing the condition of the scar is possible only with the help of dynamic ultrasound examination.

Hysterosalpingography is an X-ray examination of the uterus and fallopian tubes after the injection of a contrast agent into the uterine cavity. In this case, a contrast agent (visible on an x-ray) is injected into the uterine cavity, then a series of x-rays are taken. Based on their results, it is possible to judge the condition of the internal surface of the postoperative scar, determine the position, shape of the uterine cavity and its deviation away from the midline. With this method, the inferiority of the scar will be indicated by a pronounced displacement of the uterus, its fixation to the anterior wall, deformations, niches and uneven contours of the scar. Due to insufficient information content, this study is currently used quite rarely or as an additional research method.

The most informative instrumental method for studying the condition of a uterine scar is hysteroscopy - examination of the uterine cavity using an ultra-thin optical device, a hysteroscope, which is inserted into the uterine cavity through the vagina.

After surgery, hysteroscopy is performed after 8-12 months and on the 4-5th day of the menstrual cycle. Currently, there are small-diameter hysteroscopes that allow this procedure to be performed on an outpatient basis and under local anesthesia. The pink color of the scar during hysteroscopy indicates its usefulness and consistency, it indicates muscle tissue, and whitish inclusions and deformations in the area of ​​the scar indicate its inferiority.

Complications after conservative myomectomy may include bleeding, hematoma formation (collection of blood), and endometritis.

Also, unfavorable factors for the formation of a postoperative scar include abortions and curettage of the uterine cavity, performed after a previous operation, which injure the uterine cavity. They significantly worsen the prognosis of the upcoming birth and increase the risk of developing a defective scar.

The condition of the uterine scar is usually assessed during pregnancy using ultrasound.

Signs indicating the inferiority of the scar are, for example, its unevenness, discontinuity of the outer contour, thinning of the scar to less than 3-3.5 mm.

Features of labor management

Just a few years ago, many obstetrician-gynecologists were guided by the slogan: “Once a caesarean section, always a caesarean section” when determining delivery tactics.

However, at present, the opinion of experts has changed. After all, a caesarean section was and remains a serious surgical procedure, after which serious complications can arise. Despite the proven methods of surgical delivery, it should be recognized that the risk of postoperative complications is significantly higher compared to patients who gave birth through the vagina. And the process of recovery of the body after vaginal birth is much faster.

Complications after surgery can be associated both with the surgical procedure itself and with the method of anesthesia. The highest risk is thromboembolic complications (during any operation there is a risk of blood clots that can cause blockage of blood vessels), severe bleeding, damage to neighboring organs and infectious complications.

Taking this into account, over the past 10 years, doctors have been attempting to deliver women with a uterine scar through the natural birth canal.

To resolve the issue of the method of delivery, all pregnant women with a uterine scar are advised to undergo planned prenatal hospitalization at 37-38 weeks of pregnancy for a full comprehensive examination. In the hospital, an obstetric history is analyzed (number and outcomes of pregnancies), concomitant diseases are identified (for example, from the cardiovascular, bronchopulmonary system, etc.), an ultrasound examination is performed, including an assessment of the postoperative scar, and the condition of the fetus is assessed (Doppler - study of blood flow, cardiotocography - study of fetal cardiac activity).

Indications for vaginal delivery

Natural childbirth is possible if the following conditions are met:

1. The pregnant woman has only one strong scar on the uterus.
2. The first operation was performed for “transient” indications; this is the name for indications for surgery that first arose during a previous birth and may not necessarily appear in subsequent ones. These include:
   • chronic intrauterine fetal hypoxia - insufficient oxygen supply to the fetus during pregnancy. This condition can occur for various reasons, but will not recur in the next pregnancy;
   • weakness of labor - insufficiently effective contractions that do not lead to dilatation of the cervix;
   • breech presentation - the fetus is located with the pelvic end towards the exit of the uterus. This position of the fetus in itself is not an indication for surgery, but serves as a reason for cesarean section only in conjunction with other indications and does not necessarily repeat during the next pregnancy. Other malpositions of the fetus, such as transverse position (in which the baby cannot be born spontaneously), may also not be repeated during the next pregnancy;
   • large fruit (more than 4000 g);
   • premature birth (births occurring before the 36th-37th week of pregnancy are considered premature);
   • infectious diseases identified in a previous pregnancy, in particular an exacerbation of a herpetic infection of the genitals shortly before childbirth, which was the reason for a cesarean section, do not necessarily occur before the next birth.
   When a postpartum woman is discharged from the maternity hospital, the doctor is obliged to explain to the woman exactly what indications the cesarean section was performed for. If the indications for a cesarean section were related only to the characteristics of the first pregnancy (abruption or placenta previa, clinically narrow pelvis, etc.), then the second pregnancy may well (and ideally should) end in natural birth.
3. The first operation should be performed in the lower uterine segment with a transverse incision. The postoperative period should proceed without complications.
4. The first child must be healthy.
5. This pregnancy should proceed without complications.
6. An ultrasound examination performed during full-term pregnancy shows no signs of scar failure.
7. There must be a healthy fetus. The estimated weight of the fetus should not exceed 3800 g.

Spontaneous births in pregnant women with a uterine scar should take place in an obstetric hospital, where round-the-clock highly qualified surgical care is available, and there are anesthesiological and neonatal services. Childbirth is carried out with constant cardiac monitoring. This means that special sensors are connected to the pregnant woman directly during childbirth. One of them records the contractile activity of the uterus, contractions, and the other records the fetal heart rate. Such monitoring makes it possible to determine the condition of the child during childbirth, as well as the strength of contractions. Natural childbirth in a woman with a uterine scar should be carried out in such conditions that in the event of a threat of uterine rupture or if the uterus ruptures along the scar, it is possible to provide surgical assistance in a timely manner, within the next few minutes.

If scar deficiency is suspected during pregnancy, the patient should be hospitalized long before birth, at 34-35 weeks of pregnancy.

Indications for surgery

If any signs indicate an inferior scar on the uterus, childbirth should be operative - it is only necessary to determine the timing of delivery depending on the condition of the fetus and mother.

Indications for repeat caesarean section are:

1. A scar on the uterus after a corporal cesarean section, or an operation performed with a longitudinal incision in the uterus (in this case it has a very high risk of failure).
2. Scar after two or more operations.
3. Scar failure, determined by symptoms and ultrasound data.
4. Location of the placenta in the area of ​​the uterine scar. If the placenta is located in the area of ​​a postoperative scar, then its elements are deeply embedded in the muscular layer of the uterus, which increases the risk of uterine rupture when it contracts and stretches.

If a woman with a uterine scar gave birth through the vaginal birth canal, a mandatory postpartum event is a manual examination of the walls of the postpartum uterus to exclude incomplete uterine rupture along the scar. This operation is performed under intravenous anesthesia. In this case, the doctor inserts a hand in a sterile glove into the uterine cavity, carefully feels the walls of the uterus and, of course, the area of ​​the postoperative scar on the uterus. If a defect is detected in the area of ​​the scar, if it has partially or completely ruptured, in order to avoid intra-abdominal bleeding, urgent surgery is required to suture the area of ​​the rupture, which threatens the life of the mother.

Possible complications

A scar on the uterus can cause some complications during pregnancy. Most often, there is a threat of termination of pregnancy at different times (found in every third pregnant woman with a scar on the uterus) and placental insufficiency (i.e., the supply of insufficient oxygen and nutrients through the placenta). Often this pathology occurs when the placenta is attached to the area of ​​a postoperative scar and appears due to the placenta being attached not in the area of ​​full muscle tissue, but in the area of ​​altered scar tissue.

However, the main danger a woman faces during childbirth is uterine rupture along the scar. The problem is that uterine ruptures in the presence of a scar often occur without significant symptoms.

Therefore, during childbirth, the condition of the scar is constantly monitored. Experts determine it by palpation through the anterior abdominal wall, that is, by palpating the scar area. Despite the contractions, it should remain smooth, with clear boundaries and practically painless. The nature of bloody discharge during childbirth (there should be little of it) and the mother’s complaints of pain are important. Nausea, vomiting, pain in the navel, weakening contractions may be signs of the beginning of a scar rupture. To objectively assess the condition of the scar during childbirth, an ultrasound examination is used. And if signs of its inferiority arise, which primarily include weakness of labor or any other complications during childbirth, they proceed to delivery by cesarean section.

Thus, in a woman with a uterine scar, spontaneous childbirth is permissible only if the scar is intact and the mother and fetus are in normal condition; they should be carried out in large specialized centers, where the woman in labor can be provided with highly qualified assistance at any time.