What causes a scar on the uterus. Uterine rupture along the scar: a serious and dangerous complication during pregnancy. Rupture of the uterus along the scar

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.

At the present stage, a transverse incision in the lower part of the uterus is most often practiced.

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

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).
Hardening of the scar: it turns pale and hurts less (next three weeks).
The color of the scar becomes pale pink, it is practically invisible, and gains 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:

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

Any intrauterine manipulation in the first year after cesarean section has a detrimental effect on the condition and quality of the scar

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.

You need to get pregnant as planned, especially if the woman has a scar on her uterus after a caesarean section

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:

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).
Spontaneous early miscarriage, threatened miscarriage, premature birth.
Incorrect location of the placenta: low, marginal or complete presentation.
Major blood loss during childbirth.
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:

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

The following signs directly indicate organ rupture:

Sharp and severe pain in the uterine area.
Decreased blood pressure in a pregnant woman.
Vomit.
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):

The woman had only had one caesarean section in the past.
The placenta is well located - outside the scar area.
There are no concomitant diseases - indications for cesarean section.
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 stimulant 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:

Lengthwise cut. The probability of divergence in this case is quite high.
The woman has had two or more caesarean sections in the past.
During my previous birth there was a uterine rupture.
The scar is incompetent with a predominance of connective tissue.
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:

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.
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.
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.

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

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

Varieties of tripe

The scar can be solvent or insolvent.

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

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

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

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

Planning a pregnancy with a uterine scar

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

Scar assessment

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

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

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

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

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

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

Pregnancy with a scar on the uterus

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

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

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

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

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

Uterine tension.

Sharp pain from touching the stomach.

Strong arrhythmic uterine contractions.

Bloody vaginal discharge.

Fetal heartbeat disturbance.

After the break is completed, the following are added:

Very severe abdominal pain.

A sharp decrease in blood pressure.

Nausea and vomiting.

Stopping contractions.

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

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

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

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

A scar on the uterus occurs due to healing after surgery. There are two types: wealthy and insolvent. The latter has a high risk of rupture, therefore, if such a scar is diagnosed, it is not recommended to become pregnant without plastic surgery. When carrying a child with an area of fibrous tissue on the uterus, a woman is constantly under the supervision of a doctor. Regular ultrasound examinations are recommended in the third trimester.

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Pathogenesis

A uterine scar is a changed area of tissue that is formed as a result of damage to the myometrium. The cause is trauma and surgery. Outside of pregnancy there are no clinical symptoms. During gestation and childbirth, it can lead to uterine rupture. Therefore, in the final stages, diagnostic methods are used to assess the structure of tissues, which help prevent possible complications. The pathology cannot be treated, but is the main factor in choosing the method of delivery.

Scar formation is a natural healing process after injury. Depending on the level of reactivity of the body and the length of the incision or punctures, regeneration occurs in several ways: complete restoration (restitution) or defective (substitution).

In the first case, the damaged area is replaced by the myometrium, in the second - by large bundles of fibrous tissue (looks like a scar). The risk of a scar increases in the presence of an inflammatory process. It takes at least two years for the tissue to fully mature. The functional state of the organs depends on the nature of healing.

Classification

In medical practice, scars are classified according to the type of tissue that replaces the area of damage. There are two types of scars:

Wealthy. Formed from myometrial fibers, elastic areas. They have the ability to contract when the uterus is tense and can withstand stress. The norm for scar thickness is 5 mm.
Insolvent. They are formed by connective tissue, have low elasticity, are not able to contract during contractions, and have low resistance to tearing. Diagnosed with a thickness of 1 mm.

When determining the examination plan and obstetric management of pregnancy, it is important to take into account the location of the scar. It can be located in the body of the uterus, in its lower part, or in the cervix with the area adjacent to the internal pharynx.

Signs of the disease

The scar itself does not appear. Clinical symptoms appear when the uterus ruptures. The latter has serious consequences. A woman complains of pain in the lower abdomen, spotting, and periodic irregular contractions. The condition worsens, systolic pressure drops, tachycardia, nausea and vomiting appear.

Manifestations depend on the location of the scar and the clinical stage:

Causes

The main reasons for the appearance of a scar are:

Cause	Description
C-section	A scar appears at the site of the incision of the uterine wall to remove the child, mainly in the lower third
Myomectomy	Removal of fibroids - benign growth of the muscle layer. In the area of its localization, it becomes significantly thinner and can be replaced by scar tissue
Perforation	The walls of the uterus are pierced during curettage or abortion
Reconstructive surgery	Such interventions are carried out after uterine rupture or due to the removal of a rudimentary horn. The latter means a malformation in which the uterus has two separate parts
Ectopic pregnancy	Removal of the site where the embryo was attached may include part of the uterus if implantation occurred in the cervix and the area of the fallopian tube, which is located near the uterus itself

Features of an incompetent scar

The main reason for the formation of such a scar is the reduction of areas of the myometrium and the presence of a large amount of fibrous tissue. This pathology is most dangerous in the first 14 days after the intervention, since there is an increased risk of inflammation. With this pathology, there is a high probability of developing hemorrhage into the peritoneum or into the uterine cavity, and the addition of infection with the development of sepsis. In the final stages, the scar can lead to ruptures (during childbirth) and the development of a focus of inflammation.

Reasons for education:

emergency caesarean section;
inflammation of sutures;
curettage during abortion;
postoperative complications;
early conception after cesarean section.

If scar failure is suspected, urgent hospitalization is required. This is associated with a high chance of miscarriage and the appearance of other pathologies.

If there is an incompetent scar (assessed by ultrasound) and the woman wants to give birth again, it is recommended to perform laparoscopic surgery to excise the tissue and apply a full suture that will not interfere with a normal pregnancy.

The appearance of a scar in any organ means a disruption in their normal functioning. This is due to deterioration of blood supply and tissue innervation. In case of repeated pregnancies, the woman must be observed by a gynecologist.

Consequences

A scar on the uterus can lead to the formation of pathologies such as:

Endometriosis. It is a proliferation of cells in the lining of the uterus. A particularly unpleasant situation occurs if foci of the disease appear on the scar. In this case, surgical intervention is most often required.
Endometritis. Inflammatory process in the endometrial area. The disease in its chronic form can lead to infertility and even the need to remove the uterus.
Myometritis (inflammation of the muscle membrane).
Parametritis (connective tissue pathology).
Dysmenorrhea (painful periods).
Spontaneous abortion.
Placenta previa.
Painful childbirth.
Cervical erosion.
Fetal hypoxia.

Diagnostics

The main task of assessing the functionality of the uterus is to study the consistency of the scar. In this case, informative methods are:

Hysterography. The procedure involves injecting a contrast agent into the uterus and conducting an X-ray examination.
Hysteroscopy. It involves inserting a thin tube with a video camera at the end into the uterine cavity. The hysteroscope is used to examine the inner membrane, curettage and, if necessary, remove formations.
GynecologicalUltrasound. An examination of the uterine cavity is carried out, which shows an intermittent and uneven contour in the area of the scar with worn-out endometrium.

The data obtained is taken into account during the second pregnancy. From the end of the second trimester, an ultrasound is performed once every 7-10 days.

If there are symptoms of impending rupture during labor, an obstetric examination is performed and the risk is assessed by assessing the shape of the uterus and its contractile activity. An ultrasound scan looks at the condition of the tissue, identifying myometrial defects and areas of thinning.

The fetus is monitored using cardiotocography or Doppler ultrasound. In case of rupture, differential diagnosis is carried out with inflammation of the appendix, renal colic, or beginning labor. Additionally, an examination by a surgeon may be necessary.

Pregnancy and scar

It takes about two years for a strong suture on the uterus to fully form. The patient is advised to wait this time until the next time she tries to get pregnant. A long break is not the best option; after four years, the scar begins to gradually lose its elasticity.

Pregnancy with a suture on the uterus must be under the supervision of an obstetrician-gynecologist.

Complications

Thinning of the scar is normal, but may affect the condition of the embryo. Due to the atrophied area, placenta previa or its accretion can develop on any part of the organ wall. If embryo implantation occurs in the scar area, this is a bad sign. There is a high risk of early labor or spontaneous abortion.

The most serious complication is rupture. As a result of the rupture, the woman experiences hemorrhagic shock, which can be fatal. To save the patient, hospitalization, opening the organ with a transverse incision and curettage are performed. The resulting hypoxia can most likely lead to the death of the child.

Childbirth

There are two types of opening of the uterine cavity:

Cross section. Done during a planned operation.
Corporate. Performed when there is a need for urgent delivery, delivery before the 28th week, hypoxia or bleeding.

Repeated pregnancy most often leads to cesarean section. However, more and more patients with a scar are undergoing natural childbirth. This is possible in the absence of contraindications, examination and hospitalization before the onset of labor at 37-38 weeks.

There are conditions that must be met for a woman to give birth on her own:

relative indications for the first operation (large fetus, weakness of labor, hypoxia, exacerbation of chronic infections, malpresentation of the fetus);
absence of pathology in the first child;
successful pregnancy;
the presence of a wealthy scar in a single quantity;
performing the first operation through a transverse incision, provided that healing proceeded without complications;
the estimated weight of the fetus is less than 3.5-4 kg and the absence of pathologies;
no signs of scar failure on ultrasound examination.

Indication	Description
Longitudinal scar	The likelihood of an unfavorable outcome in this case is much higher
Presence of two or more scars	Pregnancy after two or more caesarean sections can be resolved surgically
Some interventions in the reproductive system	Myomectomy of the posterior wall of the uterus, plastic surgery for organ development disorders, surgery for ectopic pregnancy in the cervix
Gap in history	Natural childbirth is contraindicated if the previous pregnancy was accompanied by a rupture
Scar failure	Signs of significant amounts of scar tissue have a poor prognosis
Pathology of the placenta	The operation is performed when placenta previa or its localization in the area of scar formation
Narrow pelvis	The stresses that the fetus provokes when passing through the birth canal aggravate the condition and provoke rupture

If, during a natural birth, a woman in labor with a scar is in danger of rupture, the operation is performed on an emergency basis. After cesarean section, the organ wall defect is sutured. In case of severe bleeding with impossibility of suturing or massive hematoma, hysterectomy is performed.

Therapy

During normal pregnancy and childbirth, no treatment is required. In the case of an incompetent scar, the woman is not advised to plan a pregnancy in the future. This can cause serious complications.

Surgery is considered the only effective treatment method. Drug or other methods of scar treatment are ineffective. Due to the location of the organ, it is not possible to resort to more gentle methods.

Metroplasty

The indication for plastic surgery is thinning of the walls of the muscular layer of the uterus up to 3 mm or deformation of the suture. The essence of metroplasty is the removal of scar tissue with suturing. It can be performed laparoscopically and laparotomically.

Open surgery is caused by the need to access an area of the organ that is located in an area of strong blood circulation. The choice of surgical intervention is associated with a high risk of hemorrhage during the intervention. The intervention is accompanied by isolating large veins and arteries and applying clamps to them to prevent bleeding. After excision of the scar, plastic surgery is performed. The advantages of the technique are low invasiveness and low risk. It has a short recovery period.

Prevention of scar formation

When planning and preparing for pregnancy, it is necessary to identify and treat all chronic diseases. It is recommended that you try to conceive at least 24 months after uterine surgery. It is important to register before 12 weeks. During pregnancy, regular visits to the obstetrician-gynecologist are made. In the first trimester- once a month, once every 14 days - in the second trimester, once a week - in the third.

Risk factors for uterine rupture are determined in advance. The scar is carefully monitored using ultrasound. By comparing all factors and research data, the issue of a planned caesarean section is decided.

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

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

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

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

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

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

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

What operation caused the scar on the uterus?

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

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

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

2. If the scar appears as a result of conservative myomectomy(removal of nodes of a benign tumor - fibroids with preservation of the uterus), then the degree of its restoration depends on the nature of the location of the removed nodes, the access of surgical intervention (scar size), and the very fact of opening the uterus.

Most often, small fibroids are located on the outer side of the reproductive organ and are removed without opening the uterus, so the scar after such an operation will be more durable than when opening the organ cavity, when intermuscular nodes located between the myometrial fibers or intermuscularly are removed.

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

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

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

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

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

Complications after conservative myomectomy may include:

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

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

All these complications will complicate the scar healing process.

Pregnancy period after surgery

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

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

Examination of the uterine scar

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

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

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

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

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

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

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

Childbirth in women with a uterine scar

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

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

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

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

The examination includes:

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

Vaginal birth

Natural childbirth is possible if the following conditions are met:

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

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

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

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

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

4. The first child is healthy.

5. This pregnancy proceeded without complications.

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

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

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

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

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

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

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

Indications for surgery

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

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

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

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

A scar on the uterus is a serious problem in modern obstetrics, especially considering that the frequency of delivery by cesarean section is constantly increasing.

A uterine scar is spoken of when surgery was performed on the uterus. A scar can never have a muscular structure like the myometrium. It is always associated with the formation of connective tissue. If there is a lot of it, then it has a significant effect on the contractile activity of the uterus, dramatically disrupting it. This is due to the fact that connective tissue is not capable of contraction.

A scar on the uterus during pregnancy in a woman can be a consequence of such surgical interventions in the past as:

— conservative myomectomy (removal of the myomatous node followed by suturing of the uterine wall);

- suturing the uterine wall after perforation performed during a medical abortion.

The course of reparative processes in a postoperative wound is influenced by a number of factors, which include the type of suture material, the characteristics of the body in relation to the formation of a certain type of collagen that makes up the connective tissue, the presence or absence of infection in the postoperative wound, surgical technique (the better it is, the better the wound healing occurs).

What is an incompetent uterine scar?

To predict the course of pregnancy, it is very important to evaluate the scar on the uterus after cesarean section. One of the reliable ways to assess its quality is ultrasound in the first weeks of pregnancy. Using this method, the thickness of the postoperative scar on the uterus is measured, as well as the identification of possible niches, that is, defects along the scar.

Normally, the scar should have a thickness of 5 centimeters or more by the end of full-term pregnancy. As a rule, to obtain reliable results, either a vaginal sensor is used, or, if an abdominal sensor is used, the bladder must be well filled. The consistency of the uterine scar can be assessed both during pregnancy and at the planning stage. In the latter case, this will make it possible to identify an incompetent scar (complete failure), when pregnancy is contraindicated without certain therapeutic measures.

It is also possible to indirectly assess the consistency of the scar by identifying the characteristics of the course of the postoperative period. Certain circumstances may indicate an increased risk of having an incompetent scar.

Thus, thinning of the scar on the uterus indicates its failure.

How does pregnancy proceed if there is a scar on the uterus?

A scar on the uterus leaves a serious imprint on the course of pregnancy. Every obstetrician-gynecologist knows these features, and therefore takes them into account at the stage of pregnancy management. These should include the following:

- increased frequency of threatened miscarriage;

- development of placental insufficiency in a higher percentage of cases than in the general population of pregnant women;

- abnormalities of placenta attachment (tight attachment, true rotation, placenta previa).

Abnormalities of placental attachment are the most serious problem. They may cause spotting during pregnancy with placenta previa or may cause abnormal separation of the placenta. These, in turn, lead to an increased incidence of manual separations, as well as cases of hysterectomy due to true rotation.

Which scar is insolvent and the reasons for its formation

A scar is considered defective in two cases:

- if its thickness is less than 5 millimeters;

— there are defects (so-called niches).

Usually, a scar becomes insolvent if an inflammatory process develops or poor surgical technique (tissues are restored in layers). Certain signs allow one to suspect an incompetent scar on the mammary tract during pregnancy.

— there was an increase in body temperature in the postoperative period;

- presence of pathological discharge from the wound, etc.

The suture material also has a direct impact on the consistency of the scar. Thus, catgut most often leads to the development of an incompetent scar. Vicryl is the best suture material in this regard, as the tissue heals well.

Grigory Rubtsov - Last Year's Eyes

How to give birth with a uterine scar?

If there is a scar, childbirth with a scar on the uterus can be twofold:

— through the natural birth canal (under constant ultrasound monitoring);

- by caesarean section.

It should be understood that vaginal birth is possible only if the following conditions are met:

- absence of indications for cesarean section, which were in the first birth;

— possibility of continuous ultrasound monitoring;

Failure of the scar during childbirth can lead to death for both mother and child. Therefore, in case of any deviation from the normal course, such childbirth should be completed by caesarean section as a matter of urgency.

The effect of caesarean section on the condition of the uterus

Every surgical intervention on the uterus does not pass without leaving a trace. Therefore, at present, in gynecology, such a concept as disease of the operated uterus has been formed. It lies in the fact that the operation leads to various neurohumoral abnormalities. As a result, this is accompanied by menstrual irregularities, pain and other unpleasant symptoms.

Thus, the number of surgical interventions on the uterus in women of reproductive age should be reduced as much as possible. This will avoid certain problems in the future. Obstetrician-gynecologist Marina Slavina

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Uterine scar and its effect on pregnancy

If there is a scar on the cervix during pregnancy, many women are concerned about its effect on repeated childbirth and the possibility of it occurring naturally.

Reasons for appearance

C-section

A type of operation that resulted in a scar on the uterus. If the injury is a consequence of a cesarean section, the woman should have an idea of what kind of incision was made. If there is a planned caesarean section, a transverse incision is made in the lower part of the uterus. In this case, there is a high probability of the formation of a full-fledged scar that will withstand repeated pregnancy and childbirth. Placenta accreta, emergency delivery, or a short pregnancy requiring a cesarean section lead to a longitudinal incision being made in the uterus. This condition is unfavorable for the fusion of muscle fibers.

Other reasons

The cause of the scar may be a previous conservative myomectomy, suturing of a perforation on the cervix, or removal of the fallopian tube. The damage formed during myomectomy is characterized based on the presence of an opening of the uterine cavity. If the fibroid is small, it is often located outside the uterus and opening its cavity is not required. In this case, a wealthy scar is formed and its thickness is sufficient for bearing a child in the future. Perforation of the uterus during an abortion leads to positive results if it was carried out only by suturing the hole itself, without cutting the uterine walls.

Scar condition

In order to predict pregnancy and further childbirth in the presence of a scar on the uterus, it is necessary to know the degree of its healing, based on which it can be solvent (full) or insolvent. A uterine scar is healthy if the muscle fibers have fully recovered after surgery and its normal size is 2.5 mm or more in the narrowest area. This damage has an elastic structure, capable of both contraction and stretching, so pregnancy with such a scar passes without complications. If the scar consists mainly of connective tissue, it is classified as inferior, since it is not able to stretch or contract. Several factors influence how the uterine scar will recover:

Postoperative pregnancy

The time interval between the operation and the onset of pregnancy plays an important role in scar healing. For optimal formation, at least 12 months are required. However, if you are planning a pregnancy, you should not wait more than 4 years after a cesarean section, as the scar will become covered with connective tissue and become less elastic.

Postoperative period

The course of the period following the operation, as well as possible complications, affect the viability of the scar. Complications include intrauterine inflammation, weak contraction after childbirth, delayed placenta followed by cleansing.

Diagnosis of the condition

If you have a scar on the uterus, you need to undergo an examination to determine its consistency even before pregnancy occurs. This is necessary for a more accurate prognosis of the course of pregnancy with a scar and subsequent births. If there is a risk of scar failure, this should be identified outside of pregnancy. Several methods are used to examine damage:

Hysterosalpingography

A reagent is injected into the uterine cavity, after which the uterus and fallopian tubes are examined using X-ray equipment. The pictures will show the condition of the scar from the inside, its location, as well as the internal shape of the uterus, its cervix and the degree of deviation from the middle. Unfortunately, this study provides an incomplete picture, so it is used as an additional way to obtain information after cesarean section.

Hysteroscopy

The most informative diagnostic method is to examine the inside of the uterus using a very thin optical instrument inserted through the vagina. The study can be carried out only 8 months after cesarean section on the 4th day of the menstrual cycle. A full-fledged scar should have a uniform pink color without white inclusions.

This method is used after pregnancy has occurred, since other methods are unacceptable.

Indications for independent childbirth

In most cases, doctors try to play it safe, and a pregnancy with a scar ends in a cesarean section. However, today the patient can be given the opportunity to give birth to a baby naturally. The following conditions must be met:

Pregnancy occurred no earlier than 24 months later. after surgery. In this case, we can talk about the consistency of the scar and the ability of the surrounding tissues to withstand the load during contractions;
The ultrasound examination shows the consistency of the scar;
The weight of the unborn child should be small. The norm does not exceed 3.5 kg. Otherwise, the scar on the uterus will not withstand the load, thinning of the tissues and placental abruption will occur;
Natural birth is allowed only if the baby is in cephalic presentation;
The placenta must be located along the posterior uterine wall. Otherwise, uterine rupture may occur, which will lead to fetal asphyxia and death;
Correspondence between the size of the pelvis and the head of the unborn baby. Otherwise, high pressure will be exerted on the lower part of the uterus, which will lead to its overstretching;
Pregnancy occurs when there is no more than one scar on the uterus;
The fetus develops without pathological changes and without placenta previa;
The first caesarean section occurred unplanned or the pregnancy is accompanied by complications.

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Indications for caesarean section

In addition to the above indications during pregnancy with a scar, there may be factors that indicate a mandatory cesarean section.

Failed scar

This factor is detected both by ultrasound and in the presence of certain symptoms: scar pain, pain in the lower uterine segment and discomfort indicate that additional research is necessary.

Pregnancy time

If pregnancy occurs earlier than 18 months. after cesarean. The chance of an incompetent scar is quite high, so complications may arise during natural childbirth.

Fetal weight

If the maximum weight of the child is exceeded and the weight is more than 3.5 kg, the anterior uterine wall experiences excessive stress and stretching, so natural childbirth can be dangerous, since the scar on the uterus can separate.

Fetal presentation

Childbirth with a breech or leg presentation is accompanied by a high risk, both for the child himself and for the mother in labor. If the child lies obliquely and transversely, this is an undeniable factor for cesarean section, regardless of the fact that the pregnancy occurs with a scar.

Location of the placenta

With placenta previa, there is a high risk of placenta abruption, which will result in severe bleeding. If the placenta is located low on the anterior uterine wall, there is a high probability of its attachment to scar tissue, and this threatens chronic fetal hypoxia. Moreover, pregnancy with a scar can be dangerous because placenta accreta occurs, and this also threatens fetal hypoxia.

Pelvic width

If a woman in labor has a very narrow pelvis, this can lead to rupture of the uterus along the scar due to excessive tension of the tissue in its area.

Number of scars

If there is more than one scar on the uterus that appeared during a cesarean section or other surgical procedures, then natural labor is impossible.

Fetal pathology

If the fetus develops with pathological abnormalities, delivery without surgery can be dangerous both for it and for the woman in labor.

Indications for the first cesarean section

If the first cesarean section was performed according to absolute indications, based on the state of health and clinical characteristics, then the second birth cannot be natural.

Management of natural childbirth

Most doctors try to give preference to natural labor, but a scar on the uterus puts such women in labor at risk, since placenta accreta and scar divergence can occur. In this case, the natural birth process can only take place if certain equipment and conditions are available in the maternity hospital. Required conditions include:

Ultrasound and fetal monitoring

As soon as a patient with a scar enters the hospital with contractions, an ultrasound examination should be immediately performed. Based on the results, the doctor will evaluate the position of the baby, the placenta, the condition of the scar, as well as a number of other points that affect natural labor. If the norm for all indicators is not exceeded, then there is no reason for concern. In order to have constant control over the condition of the fetus and listen to its heartbeat, the woman is connected to a CHT machine.

Anesthesia and resuscitation

To smoothly dilate the cervix and relax the muscles, the woman in labor needs to receive epidural anesthesia. In addition, there must be a prepared operating room and intensive care unit for the woman and the unborn baby.

Contraindications for natural childbirth

When having a natural birth with a scar on the uterus, it is strictly prohibited:

Stimulate labor with oxytocin, since rapid labor with a scar can lead to the uterus breaking down and rupturing;
Use forceps or turn the fetus for malpresentation;
Wait more than 15 hours if labor is weak, water breaks and the cervix is not dilated;
The slightest manifestation of alarming symptoms requires immediate medical intervention.

Caesarean section during labor

If during natural labor there are difficulties on the part of the woman in labor or the fetus, an emergency cesarean section is performed. Complications include acute fetal hypoxia, premature rupture of amniotic fluid and lack of opening of the cervix, placental abruption, rupture of the uterine muscles, bleeding, threatened uterine rupture, placenta accreta, etc.

Even if there is a scar in the uterine area, there is a possibility of natural childbirth. If all conditions are met, the probability of a scar rupture is 1 in 100 cases. The main thing is to consult a doctor in time. Successful birth, health to you and your unborn baby!

Is natural childbirth possible?

Where it's thin, that's where it breaks! Do you know this expression? What is the consistency of a uterine scar? What is a scar? In what cases does it occur? How long does it take for it to fully form? Scar thickness and consistency - are these concepts the same? Is it possible for a scar to diverge during pregnancy? What are the conditions for a natural birth for a woman with a uterine scar? Is it worth connecting the emotional component? Or is it simply necessary to soberly and competently assess the situation? Let's look at these questions in order.

Surgical interventions on a woman’s body and possible consequences

A wonderful idea of nature - the creation of the female body in order to fulfill a holy and noble mission, to bear and give birth to full-fledged offspring! The norm of a full-fledged family is the creation of conditions for fertilization, gestation and birth of healthy offspring. However, not every representative of the fair half of humanity can boast of complete women's health during pregnancy. On the path to healthy motherhood, various obstacles may arise, which, with a competent, correct, timely, qualified approach, can be overcome and resolved. We are talking about forced surgical interventions in a woman’s body, necessary to correct her health.

For example, an operation such as a conservative myomectomy can restore a patient's ability to conceive. The fibroid is removed, but the organ is preserved. However, after surgery, as a rule, a scar always forms. A scar can also occur during various necessary plastic reconstructive surgeries (when the uterine horn is removed, a tubal or cervical pregnancy is operated on simultaneously with the uterine angle). The wall of the uterus is perforated during surgery to forcefully remove the fertilized egg; if labor is overstimulated, rupture may occur. For some women during pregnancy, doctors prescribe a planned caesarean section if they are unable to deliver on their own. As a result, the integrity of the uterus is compromised. After suturing the incisions, punctures or ruptures made, a scar is formed on the uterus. All of this can have consequences during pregnancy.

Restoration of sutures after surgery

A uterine scar is a special type of formation that consists of myofibrils and connective tissue. It is located in the place where surgical intervention was performed and a violation occurred, and then the integrity of the uterine wall was restored. Analysis of scar formation and recognition of its consistency is very important for the further prognosis of a woman’s condition, the possibility of bearing a child and spontaneous childbirth. For this, there are a number of criteria by which the norm of a formed, wealthy scar on the uterus is determined.

What signs characterize a wealthy (full) scar? It is elastic and stretches well during pregnancy. It contains full-fledged muscle fibers. When forming a scar, it is especially important how the dissection was performed. If the cut was made across the muscle fibers, then the chances that they will heal well and recover are greater than if they were cut lengthwise. The timing of scar formation plays a role. Doctors believe that the best period that should pass after surgery is approximately 1-2 years. But no more than 4 years, because the scar becomes overgrown with connective tissue, and this, in turn, reduces its elasticity.

Signs that indicate inferiority (failure) of the scar are its unevenness, the outer contour is intermittent, it is thinned by less than 3-3.5 mm. If more than 3-4 years have passed after the operation, then a lot of connective tissue forms in it, it becomes inelastic and can separate during pregnancy.

Types of diagnostics

If the family has decided to conceive a child and the woman’s uterus has already been subjected to surgical intervention at this point, it is necessary to diagnose the formed scar to predict the course of the planned pregnancy. If the operation took place not long ago, diagnostics will help determine the rate of healing, answer the question of how the scar is formed, and evaluate it (the thickness of the scar and its viability are different concepts!).