A scar on the uterus appears, as a rule, as a result of surgical intervention, which can be carried out 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 natural childbirth possible if there is a scar on the uterus, or is a caesarean section inevitable?
- What is the outcome of childbirth in the presence of a scar on the uterus?
We will try to talk about all the features of the birth of women who have such a defect.
The impact 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:
- Wealthy (or full-fledged) scar- this is the one in which there was a complete restoration of muscle fibers after surgery. Such a scar is elastic, able to stretch with an increase in the duration of pregnancy and the growth of the uterus, it is capable of contractions during contractions.
- Insolvent (or defective) scar- this is one in which connective tissue predominates, and it is unable to stretch and contract like muscle tissue.
What operation caused a scar on the uterus?
Another aspect to consider is the type of surgery, as a result of which operation a scar appeared on the uterus:
1. A scar after a caesarean section can be of 2 types:
- the transverse one is done in the lower uterine segment, in a planned manner during full-term pregnancy, and it is able to withstand both pregnancy and childbirth, since the muscle fibers are located transversely, and therefore grow together and heal better after surgery;
- longitudinal - performed during an emergency operation, with bleeding, hypoxia (lack of oxygen) of the fetus or for up to 28 weeks of pregnancy.
2. If the scar appeared due to conservative myomectomy(removal of nodes of a benign tumor - fibroids with preservation of the uterus), then the degree of its recovery depends on the nature of the location of the removed nodes, access to surgical intervention (the size of the scar), the very fact of opening the uterus.
Most often, small fibroids are located on the outside of the genital organ and are removed without opening the uterus, so the scar after such an operation will form more prosperous than when opening the organ cavity, when intermuscular nodes located between the fibers of the myometrium or intermuscularly are removed.
3. Scar due to uterine perforation after induced abortion is also considered taking into account whether the operation was limited only to suturing the perforation (puncture), or if there was also a dissection of the uterus.
The course of the postoperative period and the occurrence of possible complications
How the process of restoring uterine tissue after surgery will take place will be influenced by the course of the postoperative period, the presence of possible postoperative complications.
So, for example, after a caesarean section, you may experience:
- 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 is an inflammation of the lining of the uterus.
Complications after conservative myomectomy may include:
- bleeding;
- hematoma formation (accumulation of blood);
- endometritis.
Abortions and curettage of the uterine cavity, performed after the operation, injure the uterine cavity and do not contribute to the normal formation of the scar. Moreover, they increase the risk of forming an inferior scar.
All these complications will complicate the healing process of the scar.
Pregnancy period after surgery
Any tissue, including the wall of the uterus, after undergoing surgery, needs time to recover. The degree of healing of the scar 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 not earlier than 1.5 years, but not later than 4 years later. This is due to the fact that the more time passes between childbirth, 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 it be myomectomy or caesarean section) are recommended to protect themselves from pregnancy for 1-2 years. And even before the planned conception, it is necessary to be examined for the viability 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 scar on the uterus
It is possible to examine the scar on the uterus after surgery using:
- Ultrasound research. With the onset of pregnancy, this is the only possible type of study. Signs indicating the inferiority of the scar - its unevenness, discontinuity of the outer contour, the thickness of the scar is less than 3-3.5 mm.
- Hysterosalpingography- X-ray examination of the uterus and fallopian tubes after the introduction of a contrast agent into the uterine cavity. For this procedure, a special substance is introduced into the uterine cavity, and then a series of x-rays are taken to judge the condition of the inner surface of the postoperative scar, its position, the shape of the body of the uterus and its deviation (to the side) from the midline. Using this method, it is possible to detect the inferiority of the scar, which manifests itself in a sharp displacement of the uterus, its deformation, fixation to the anterior wall, as well as irregularities in the contours and niche of the scar. However, this study does not provide enough information, and therefore is rarely used today and more often as a method of additional examination.
- Hysteroscopy- carried out using an ultra-thin optical device of 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 for studying the state of the scar on the uterus, which is carried out 8-12 months after the operation, on the 4th-5th day of the menstrual cycle. The usefulness of the scar is evidenced by its pink color, indicating muscle tissue. Deformations and whitish inclusions in the scar area 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:
- the threat of abortion at different times;
- 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-fledged muscle tissue, but to scar tissue.
But the main danger - uterine rupture along the scar - threatens a woman during childbirth. The problem is that uterine rupture in the presence of a scar often occurs without severe 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 even, with clear boundaries and almost painless. At the same time, special attention is paid to spotting during childbirth (there should be few of them) and the woman in labor complains of pain.
Weakening of contractions, pain in the navel, nausea and vomiting - this may be a sign of the beginning of a scar rupture. Ultrasound will help to objectively assess the condition of the scar during childbirth. If there are signs of his inferiority (and first of all it is a weak labor activity, then any complications during childbirth), delivery is carried out by caesarean section.
Childbirth in women with a scar on the uterus
Even some 10 years ago, all women who once gave birth by caesarean section were automatically sent to caesarean sections in subsequent births. This is a serious surgical procedure, after which severe complications can occur, and the recovery of a woman after surgery is much slower than after natural (vaginal) childbirth.
Complications after caesarean section could arise both because of the surgical intervention itself, and 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 birth through natural routes.
The survey includes:
- collection of obstetric anamnesis: the number and outcomes of pregnancies that preceded the current one;
- identification of concomitant diseases (special attention is paid to the cardiovascular, bronchopulmonary system);
- Ultrasound examination with evaluation of the postoperative scar;
- assessment of the condition of the fetus - a study of its blood flow (doppler), cardiac activity (cardiotocography).
Childbirth through the natural birth canal
Natural childbirth is possible if the following conditions are met:
1. The presence of only one wealthy scar on the uterus.
2. The first operation was performed according to relative indications (indications that may not occur in these births), which are required to be reported upon discharge from the maternity hospital:
- chronic intrauterine fetal hypoxia;
- weak generic activity;
- pelvic or transverse position of the fetus;
- large fruit (more than 4 kg);
- premature birth (before 36-37 weeks of pregnancy);
- infectious diseases in a previous pregnancy that came to light or worsened shortly before childbirth (for example, genital herpes).
If the indications for caesarean section were associated solely with the features of the previous pregnancy (for example, a clinically narrow pelvis, abruption or placenta previa), then the current pregnancy can (and should) end in a vaginal delivery.
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 conducted 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 cardio monitoring is carried out (special devices with sensors are connected to the pregnant woman that control the contractile activity of the uterus, the frequency of contractions, the heart rate of the fetus), 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 the immaturity of the scar is suspected, the patient is hospitalized at 34-35 weeks of pregnancy.
After the completion of natural childbirth, the walls of the postpartum uterus are examined manually (under intravenous anesthesia) to exclude incomplete rupture of the uterus along the scar. In this case, the doctor inserts a hand in 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 found in the area of the scar (it could partially or completely disperse), then in order to avoid intra-abdominal bleeding, which threatens the life of the mother, an urgent operation is performed - the area of \u200b\u200bthe gap is sutured.
Indications for surgery
Childbirth should be carried out by an operative method if studies of the scar on the uterus indicate its failure:
- longitudinal scar after caesarean section or uterine surgery;
- scar after 2 or more operations;
- the location of the placenta in the area of the scar on the uterus (this increases the risk of rupture of the uterus when it is stretched and contracted).
In this case, it remains only to determine the duration 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 viable, the mother and fetus are in a normal state. Childbirth should be carried out in specialized centers, where at any time a woman in labor can be provided with highly qualified assistance.
Scar on the uterus is a dense connective tissue in a place where the integrity of the walls of the organ was violated due to surgical intervention. For women who give birth again, the presence of such a defect poses a certain risk, as it is associated with a repeated rupture. For this reason, such patients should be more closely monitored by physicians.
Symptoms
Scars on the cervix and its walls during rupture are characterized by the following symptoms:
- Pain in the abdomen;
- Bloody discharge from the genital tract;
- Irhythmic, but strong muscle contractions (contractions);
- Decreased blood pressure;
- Pulse is frequent, but hardly perceptible;
- The skin becomes pale;
- There is nausea and vomiting.
In some cases, the rupture is not accompanied by the above symptoms.
The scar can be wealthy or insolvent. In the first case, it is characterized by the fact that there was a complete restoration of the wall and muscle fibers. A wealthy scar on the uterus has a thickness of at least 3 mm.
The fabrics are elastic, stretch well and withstand impressive pressure, and also contract during contractions. In the second case, connective tissues predominate in this area, and muscle fibers remain underdeveloped. It is slightly elastic, unstable to tearing and does not shrink during contractions.
Clinical stages of rupture
This phenomenon can be threatening, begun and completed.
The threatening stage is accompanied by pain in the lower back and abdomen, nausea and vomiting.
The scar that has begun (or spreading) is characterized by an increase in the tension of the uterus, a sharp pain on palpation, increased non-rhythmic frequent contractions, bloody discharge, and a slowing of the fetal pulse.
The completed gap manifests itself as very severe pain, discharge with blood, cessation of contractions or attempts, increased heart rate, and a drop in blood pressure.
Causes
Scars are normal after caesarean section. They are formed at the site of an incision in the wall of the uterus to extract the baby. They also remain after myomelectomy - a procedure for removing a benign formation.
Diagnostic curettage and abortion also leave traces. This also applies to reconstructive operations, for example, after a rupture or removal of a rudimentary horn. They also remain with a scar after an ectopic pregnancy, which ended with the removal of the tube or cervix.
Diagnostics
First of all, the doctor analyzes the obstetric and gynecological history. It takes into account past diseases of the genital area, surgical interventions, features and outcome of previous pregnancies. The outcomes of childbirth are also taken into account (natural, through caesarean, with complications, etc.).
Then an ultrasound is scheduled. The study allows you to assess the state of the defect, its contours, the amount of muscle and connective tissue, to identify cavities, if any. In addition, the norm of the thickness of the scar located on the uterus is analyzed, since this indicator will be taken into account when choosing the method of delivery.
A hysterogram may be ordered. Such an analysis is carried out on the 7-7th day of the cycle. First of all, the state of the inner surface of the defect is determined.
Hysteroscopy is a method consisting in the use of special optical instruments to examine the uterine cavity through the cervix. The procedure is carried out on the 4-5th day of the cycle. Determine the number of vessels, the shape and color of the defect.
During pregnancy in the third trimester, ultrasound is performed every 7-10 days.
Scar tear diagnosis
Pregnancy with a complication - a scar on the uterus - is subject to more careful control. First, the doctor collects an anamnesis. Asks about the time of onset of pain, discharge. Determines if these moments are related to childbirth or medical intervention.
After that, the woman is examined, blood pressure, pulse are measured, and the abdomen is palpated. External obstetric examination consists in determining the shape of the uterus, its muscle tension, as well as the position of the fetus. The doctor works only with his hands.
After that, an ultrasound is prescribed, which allows you to find out how thick the muscle layer is and whether there are other defects, to assess the condition of the defect after the operation. It may be necessary to undergo a fetal ultrasound with dopplerography. Thus, doctors will receive information about the state of the blood vessels of the fetus, umbilical cord and placenta.
For the same purpose, they are sent for cardiotocography. The degree of motor activity of the child, the frequency and rhythm of heart contractions, the activity of the muscles of the uterus are assessed.
Treatment and indications for caesarean section
During pregnancy, this phenomenon does not require any specific treatment. Childbirth in this case can proceed both naturally and by caesarean section.
A woman can give birth to a child on her own in such cases: a cesarean in the past with a transverse scar, there are no chronic ailments and complications of the course of pregnancy (preeclampsia, placental insufficiency), the placenta is located outside the dangerous area, fetal presentation is head, the mother's pelvis and the size of the child. For successful independent childbirth, it is necessary that the scar be wealthy, its optimal thickness is 3 mm, but sometimes 2.5 mm is also allowed.
A caesarean section is necessary in the following situations: a history of caesarean section with a longitudinal scar, two or more defects, failure (connective tissues predominate), the placenta is located near the dangerous area, a clinically narrow pelvis, a trace on the posterior wall after myomectomy, suturing of tears, and also during cervical pregnancy.
If there is a rupture of the uterus along the scar, then an urgent caesarean section is performed in order to get the fetus as soon as possible and save the life of the mother and child. After the baby was taken out, the defect is sutured. In rare cases, it is necessary to remove the organ completely. This happens when the walls are severely damaged, which cannot be repaired by suturing.
Complications and consequences
A scar on the uterus can threaten the fetus and the pregnant woman with the following complications:
- Fetal hypoxia is a severe pathology caused by insufficient blood supply;
- placental insufficiency;
- Anomalies in the location and attachment of the placenta: presentation, dense, increment, ingrowth, germination, low;
- The threat of miscarriage or premature birth;
- uterine rupture;
- Violation of blood clotting with subsequent formation of blood clots;
- Hemorrhagic shock is a violation of breathing, circulation, and functions of the nervous system against the background of significant blood loss.
Prevention measures
To protect herself and her child, a woman must perform a number of activities. For example, it is recommended to plan a subsequent pregnancy no earlier than 2 years after the first one.
As a result of a caesarean section, a seam remains on the body of the uterus, which eventually transforms into a scar. It can cause complications during repeated pregnancy and childbirth, so it should be examined by a doctor in a timely manner. After assessing the structure and type of the scar, the gynecologist decides on the possibility of natural childbirth after the operation.
What is a scar and what causes it
The uterine scar is a structural formation, which includes fibers of the myometrium (the muscle tissue of the uterus) and connective tissue. It turns out as a result of a violation of the integrity of the uterine wall and its subsequent plastic surgery with a medical suture.
As a rule, the incision in the uterus is sutured with a special continuous suture (double-row or single-row). In the process, self-absorbable suture threads are used: Kaproag, Vicryl, Monocryl, Dexon and others. The sutures heal and completely dissolve in a few weeks or months, depending on the individual's ability to regenerate tissues. After childbirth, the gynecologist must monitor the healing process of the suture using ultrasound to prevent internal inflammation.
After about 6-12 months, a scar forms at the site of the suture. The process of its formation is long, since during a caesarean section, not only the mucous surface is damaged, but also the nerve endings. That is why it is recommended to take systemic painkillers for several days after the operation, which do not affect the lactation process.
In addition to the cesarean operation, there are other factors for the appearance of a scar on the uterus.
- Abortion. After scraping, perforation of the walls and fibrosis may appear in the cavity of a hollow organ, as a result of which small scars remain in the tissue.
- Removal of formations: benign (cysts, polyps, fibroids) or malignant (uterine cancer). Such operations are always accompanied by a violation of the integrity of the uterine walls.
- Rupture of the uterus. Damage to a hollow organ can occur with hyperstimulation of labor, rapid pathological labor, multiple pregnancy, etc.
- Ruptures of the perineum, birth canal, uterine cervix. With a rupture of the neck of the 3rd degree, obtained in the process of natural childbirth, the uterine walls are damaged, which requires suturing.
- erosion treatment. Any pathology therapy (including surgical or laser removal, medication) leads to the formation of a scar at the site of erosion.
- Ectopic pregnancy. To remove the fetus from the fallopian tube or cervix, surgical excision is used, as a result of which scars remain on the wall of the hollow organ.
- Plastic restoration procedures. The seam also appears after uterine plasty, for example, as a result of amputation of the horn.
Within a year after a cesarean section, it is highly undesirable to terminate a new pregnancy by curettage, since in the process the doctor can damage a fresh scar.
Types of scars on the uterus
Uterine scars after caesarean section differ in structure and method of formation. The possibility of subsequent natural childbirth, the risk of pregnancy pathologies, ruptures, etc. depends on their shape and type.
According to the structure, the scar can be wealthy and insolvent. And depending on the method of making the incision, a transverse or longitudinal seam is formed.
Wealthy and insolvent scar
A healthy postoperative scar is natural and normal with a sufficient level of elasticity. Muscle rather than connective cells predominate in its composition, which makes the scar closest to the natural tissue of the uterine wall. Such a scar can withstand the pressure of the fetus during repeated pregnancy and its passage through the birth canal. The thickness of the formation should be normal from 5 millimeters. During subsequent pregnancy, it will gradually thin out, and 3 mm will be considered a good indicator of thickness. Many doctors claim that even with 1 mm at the end of the 3rd trimester, the risk of suture divergence is negligible.
What does a full-fledged scar on the uterus look like after a cesarean section
If the formed scar after caesarean section has a thickness of up to 1 mm, then they speak of its failure. Such a formation is heterogeneous in structure, has various recesses or thickenings along the perimeter, threads. It is dominated by connective inelastic tissue where there should be muscle along with an active vascular plexus. An inferior thinned scar is a contraindication for re-pregnancy, since as the uterus enlarges, its tissue will not stretch, but will tear. As a result, intrauterine bleeding and dangerous health consequences can develop. Unfortunately, the thinning of the scar on the uterus is not controlled and is not amenable to therapy.
There are risk factors that provoke the formation of an insolvent scar:
- corporal CS (the incision is made along the uterus, as well as LME with dissection of its tissues);
- inflammation of the suture during postoperative rehabilitation;
- new pregnancy in the first two years after CS;
- abortion with curettage during the rehabilitation period (about a year).
In order for the scar to fully form, you should wait for the recommended period before re-pregnancy or abortion - at least 2 years. During this time, it is desirable to protect yourself with hormonal or barrier contraception (except for the intrauterine device).
The thickness of the incompetent scar after caesarean section - the danger of planning a subsequent pregnancy
Transverse and longitudinal
During a planned CS, a transverse incision is made in the lower uterus. At the same time, neat and even edges of the incision are obtained, which are then easy to match and grow together with the help of suture material.
A longitudinal incision is used in case of urgent delivery by CS (internal bleeding, acute fetal hypoxia, cord entanglement, etc.). In this case, the edges of the incision are difficult to match, and the wound may heal unevenly.
Management of pregnancy and childbirth if a scar is present
Gynecologists have called the optimal period between caesarean section and planning a new pregnancy - 2 years. During this time, a good wealthy scar is formed, which retains elasticity. It is also not recommended to take a break for more than 4 years, since the ability of the seam to stretch decreases over time (muscle fibers gradually weaken and atrophy). It should be borne in mind that the longitudinal scar is more susceptible to degenerative changes.
What risks should be expected for pregnant women with a postoperative scar on the uterus.
- Irregular placenta previa (marginal, low, complete).
- Pathological fusion of the placenta with the myometrium, the basal or outer layer of the uterus.
- Attachment of the fetal egg in the scar area, which greatly increases the risk of miscarriage or premature birth.
If a woman becomes pregnant, but the scar has thinned and become defective, then she is placed in a hospital for preservation from the 34th week. With a full-fledged scar, observation is necessary a couple of weeks before the due date. The attending physician assesses the condition of the walls of the uterus and decides on the possibility and expediency of natural childbirth, the tactics of their management, etc.
Repeated caesarean section
It is known that with an inconsistent scar on the uterus, in most cases, a planned CS is performed. As a rule, after the previous operation, all the same relative indications for surgical delivery remain, for example:
- anatomically or clinically (large child) narrow pelvis;
- damage to the birth canal;
- isthmic-cervical insufficiency of the neck;
- polyhydramnios;
- multiple pregnancy;
- placenta previa;
- breech presentation of the child.
In these cases, a planned cesarean is prescribed, and the viability of the scar does not matter.
Also absolute indications for each subsequent CS are:
- scar after longitudinal CS;
- postoperative scars on the uterus in an amount of more than one;
- scar failure confirmed by ultrasound;
- placement of the placenta or baby in the postoperative scar area, which increases the likelihood of uterine tissue rupture during natural contractions;
- weak or absent labor activity in patients with a wealthy scar.
Many patients worry that after each caesarean section, the risk of miscarriage and spontaneous abortion increases. In practice, after the second CS on the scar, the question arises of the possible sterilization of a woman by tubal ligation to ensure the prevention of pregnancy. With each new operation, the risk of scar deficiency increases, which threatens with dangerous consequences for the life and health of a woman. And as you know, most women ignore regular visits to the uzist in the postpartum period and become pregnant with an inferior scar.
natural childbirth
After CS, natural labor activity is allowed subject to the following requirements:
- no more than one abdominal operation on the uterus in the entire history of the disease;
- transverse wealthy scar, which is confirmed by ultrasound and gynecological examination;
- the location of the placenta and the attachment of the fetus outside the scar zone;
- correct presentation of the fetus;
- singleton pregnancy;
- lack of indications for planned CS, complications and pathologies of pregnancy.
According to medical statistics, only 30% of patients have a wealthy scar after surgery and the possibility of subsequent natural childbirth. The latter are carried out in a specialized maternity hospital, where there is not only a delivery room, but also an obstetric hospital with surgical, neonatal and anesthetic services. In the event of a uterine rupture, a woman in labor must be provided with emergency surgical care within 10 minutes - this is an important condition for natural childbirth. The process is necessarily accompanied by cardiac monitoring, which allows you to record the cardiac activity of the fetus for the prompt detection of hypoxia.
After natural childbirth, the doctor must palpate the uterine walls to exclude cracks and incomplete ruptures in the scar area. During the examination, temporary intravenous anesthesia is used. If during the examination a complete or partial divergence of the walls of the suture was found, then an urgent operation is prescribed to suture the gap, which will prevent intra-abdominal bleeding.
Rupture of the uterus along the old scar
It is the most common cause of damage to the integrity of the uterus during childbirth. Unfortunately, it often occurs without specific symptoms, so the risk of postpartum complications increases.
What factors can indicate the divergence of the old scar:
- thinning (thickness less than 1 mm) and overstretching of the scar;
- uterine hypertonicity;
- severe pain in the lower abdomen;
- arrhythmic contractions;
- vaginal bleeding;
- fluctuations in the fetal heart rate.
Already after the rupture of the scar, the following symptoms join:
- acute unbearable pain in the abdomen;
- fever;
- a sharp drop in pressure;
- vomit;
- weakening or complete cessation of labor activity.
In medicine, 3 stages of rupture of the uterine walls along the scar have been identified.
- Threatening. The integrity of the walls of the hollow organ is not yet broken, but a crack in the scar is observed. A pregnant woman may feel pain in the lower abdomen on the right, especially on palpation of the suture zone. These symptoms are indications for a planned CS. If the pathology is detected during childbirth, then painful and weak contractions are noted, which practically do not contribute to the opening of the cervix. Doctors stop labor and perform an emergency CS.
- Started. In a pregnant woman, a hematoma (a cavity with blood) is formed in the area of rupture of the uterine scar, which can come out of the vagina in the form of bloody clots. The pregnant woman notes uterine tone, pain in the scar area. Uzist can diagnose weak cardiac activity, fetal hypoxia. During the birth period, the uterus is constantly in tension and does not relax, there may be severe pain in the abdomen and lumbosacral region, vaginal bleeding. Attempts are also weak and painful.
- Accomplished. Internal bleeding and classic symptoms develop: pallor of the skin, dilated pupils and sunken eyes, tachycardia or arrhythmia, shallow breathing, vomiting, confusion or loss of consciousness. A complete rupture of the uterus often leads to the fact that the child, along with the placenta, is in the abdominal cavity.
The second and third stages of the rupture involve a caesarean section, as a result of which the child and placenta are removed, and a reliable suture material is applied to the rupture site. Sometimes damage to the uterine walls occupy a large area and threaten the health of a woman, which is an indication for emergency amputation of a hollow organ. After CS, the patient is transferred to the intensive care unit.
If the scar ruptured during pregnancy and natural childbirth, what consequences can be expected:
- premature birth;
- acute hypoxia of the child, a violation of his respiratory function;
- hemorrhagic shock in the mother (a condition caused by internal bleeding);
- intrauterine fetal death;
- miscarriages in the early stages;
- uterus removal.
Monitoring of the condition of the uterine scar
The first year after CS, the patient should visit specialists to monitor the resorption of sutures and scar formation. This is necessary to identify possible risks and pathologies in a new pregnancy and childbirth.
The following methods are used to assess the structure of the scar.
- ultrasound. The main study that allows you to reliably determine the dimensions of the scar (thickness and length), shape, location, structure (presence of niches or bulges). It is thanks to ultrasound that the viability of the scar is determined, and a crack or threatening rupture can also be detected.
- Hysterography. X-ray examination of a hollow organ is accurate, but not completely safe. It is used when it is necessary to examine the internal structure of the scar and assess the risks of ruptures.
- Hysteroscopy. A minimally invasive examination of the organ cavity, for which a hysteroscope is used. Allows you to more accurately determine the shape of the scar, its color, the quality of the circulatory network in the tissues.
- MRI of the uterus. This method is used to additionally assess the proportions of muscle and connective tissue in the scar structure.
Scars after CS: quantity, can it be removed
Medical statistics show that if the first birth was carried out with the help of an operation, then the subsequent ones are likely to have indications for it. At the same time, many patients worry about how many scars on the uterus will remain after each caesarean section.
Normally, during a subsequent operation, the doctor performs excision of the old scar, removes adhesions and forms a new one. Thus, it reduces the area of possible damage during each surgical intervention. But there are situations when you have to make a new second, third, etc. suture on the uterus. For example, if a woman has a multiple pregnancy or a large fetus, which led to overstretching of the uterus and a change in its position. Or the next caesarean section may not be planned, but emergency, which will require the doctor to apply not a transverse, but a second longitudinal suture. Also, this situation is possible with a breech presentation of the fetus.
It is difficult to predict how many scars on the uterus and abdomen will remain after a series of CS. Each case is individual, and often the doctor makes a decision already during the operation.
Also, patients are interested in whether it is possible to remove all these scars in order to get pregnant normally and bear a child. First of all, the possibility of removal will depend on the viability of the scar.
Formed in 3 stages. On the first, a primary scar appears - reddish-pink, uneven. On the second, it thickens and acquires a purple hue. On the third, the scar becomes overgrown with connective tissue and turns white (the process takes about a year). After the specified period, the doctor assesses the consistency of the scar using ultrasound or MRI.
If the scar turns out to be insolvent, and a new pregnancy poses a danger to the life of a woman, then the doctor may suggest hysteroscopic metroplasty - an operation to excise an old scar on the uterus. Under anesthesia with the help of special devices, the doctor cuts the scar and forms a new one with the help of reliable suture material. In the absence of the rush associated with a caesarean section, the surgeon can make smooth suture edges that are easily aligned, leaving a high probability of forming a thick thick scar. That is, you can remove the scar on the uterus, but only strictly for medical reasons.
A scar on the uterus is a mandatory consequence of a caesarean section. It is not considered a contraindication for a new pregnancy, but the formation should take place under the supervision of a physician. With an inconsistent or thinned scar, special tactics for managing pregnancy and childbirth are required, which will prevent uterine rupture.
The scar on the uterus is a serious problem of modern obstetrics, especially considering that the frequency of delivery by caesarean section is constantly increasing.
A scar on the uterus is said in the case when surgery was performed on the uterus. The 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, sharply disrupting it. This is due to the fact that the connective tissue is not capable of contraction.
A scar on the uterus during pregnancy in a woman may be the result of such surgical interventions in the past as:
- conservative myomectomy (removal of the myomatous node with subsequent suturing of the uterine wall);
- suturing of the uterine wall after perforation made 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, and the surgical technique (which is better, the better the wound heals).
What is an inconsistent scar on the uterus?
To predict the course of pregnancy, it is very important to evaluate the scar on the uterus after cesarean. 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, either a vaginal probe is used to obtain reliable results, or, if an abdominal probe is used, the bladder must be well filled. It is possible to assess the consistency of the scar on the uterus both during pregnancy and at the stage of its planning. In the latter case, this will reveal an inconsistent scar (complete failure), when pregnancy is contraindicated without certain therapeutic measures.
It is also possible to indirectly assess the viability of the scar by elucidating the features of the course of the postoperative period. Some circumstances may indicate an increased risk of having an incompetent scar.
Thus, the thinning of the scar on the uterus indicates its failure.
How does pregnancy proceed with 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, therefore, he takes them into account at the stage of pregnancy. These should include the following:
- increased frequency of threatened abortion;
- the development of placental insufficiency in a larger percentage of cases than in the general population of pregnant women;
- anomalies of placental attachment (tight attachment, true rotation, placenta previa).
Anomalies of attachment of the placenta are the most serious problem. They can lead to spotting during pregnancy with placenta previa, or they can cause placental separation abnormalities. These, in turn, lead to an increased frequency of manual separations, as well as cases of removal of the uterus for true rotation.
What 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, the scar becomes insolvent in the event of the development of an inflammatory process or poor surgical technique (tissues are not restored in layers). Certain signs make it possible to suspect an inconsistent scar on the pact during pregnancy.
- there was an increase in body temperature in the postoperative period;
- the presence of pathological discharge from the wound, etc.
The suture material also has a direct impact on the viability of the scar. So, catgut most often leads to the development of an inconsistent scar. Vicryl is the best suture material in this regard, as the tissues heal well.
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How to give birth with a scar on the uterus?
In the presence of 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 delivery is possible only if the following conditions are met:
- lack of indications for caesarean section, which were in the first birth;
— the possibility of continuous ultrasonic monitoring;
Insolvency of the scar in childbirth can be fatal for both the mother and the child. Therefore, with any deviation from the normal course, such childbirth should be completed by a caesarean section as a matter of urgency.
The effect of caesarean section on the condition of the uterus
Each surgical intervention on the uterus does not pass without a trace. Therefore, at present, in gynecology, such a concept as the 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 a violation of the menstrual cycle, 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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Scar on the uterus and its effect on pregnancy
In the presence of a scar on the cervix during pregnancy, many women are concerned about the question of its effect on repeated births and the possibility of passing them naturally.
Reasons for the appearance
- C-section
A type of operation that resulted in a scar on the uterus. If the injury is a consequence of a caesarean, the woman should be aware of which incision was made. In the presence of 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 ingrowth, an emergency delivery, or a short gestation requiring a caesarean section result in a longitudinal incision being made in the uterus. This condition is unfavorable for the fusion of muscle fibers.
- Other reasons
The reason for the appearance of the scar can be a conservative myomectomy, suturing of a perforation on the cervix, or removal of the fallopian tube. Damage formed during myomectomy is characterized based on the presence of an opening of the uterine cavity. With a small size of fibroids, it is often located outside the uterus and opening its cavity is not required. In this case, a wealthy scar is formed and the norm of its thickness is sufficient for bearing a child in the future. Perforation of the uterus during abortion leads to positive results if it was carried out only with suturing of the hole itself, without incision of the uterine walls.
Consistency of the scar
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 wealthy (full-fledged) or insolvent. A scar on the uterus is consistent if the muscle fibers have fully recovered after the operation and its norm is from 2.5 mm 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 mainly consists of connective tissue, it belongs to the category of defective ones, since it is not able to stretch or contract. How the scar on the uterus will be restored is influenced by several factors:
postoperative pregnancy
The time interval between the operation and the onset of pregnancy plays an important role in the healing of the scar. For optimal formation, at least 12 months are needed. However, if pregnancy is planned, then you should not wait more than 4 years after cesarean, as the scar will be 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, retention of the placenta with subsequent cleaning.
Condition Diagnostics
If you have a scar on the uterus, you need to be examined for its viability even before pregnancy occurs. This is necessary for a more accurate prediction 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 on 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 neck 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 caesarean.
- Hysteroscopy
The most informative diagnostic method is to examine the inside of the uterus using a very thin optical device inserted through the vagina. The study can be carried out only 8 months after cesarean on the 4th day of the menstrual cycle. A full-fledged scar should have a uniform pink color without white patches.
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. However, today the patient can be given the opportunity to give birth to a baby in a natural way. The following conditions must be met:
- Pregnancy occurred no earlier than 24 months later. after surgery. In this case, we can talk about the viability of the scar and the ability of the surrounding tissues to withstand the load during contractions;
- The conducted ultrasound study shows the viability of the scar;
- The mass 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, tissue thinning and placental abruption will occur;
- Childbirth in a natural way is allowed only if there is a head presentation of the child;
- It must be the location of the placenta on the back of the uterine wall. Otherwise, uterine rupture may occur, which will lead to asphyxia of the fetus and its death;
- Matching the size of the pelvis and head of the future baby. Otherwise, high pressure will be applied to the lower part of the uterus, which will lead to its overstretching;
- Pregnancy passes when there is no more than one scar on the uterus;
- The fetus develops without pathological changes and without placenta previa;
- The first caesarean was unplanned or the pregnancy proceeds with 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.
- Insolvent scar
This factor is detected both with the help of ultrasound and in the presence of certain symptoms: soreness of the scar, pain in the lower uterine segment and discomfort indicate that additional research is needed.
- Pregnancy time
If pregnancy occurs earlier than 18 months after caesarean. The chance of an inconsistent 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 stretch, so natural childbirth can be dangerous, because the scar on the uterus can disperse.
- Fetal presentation
Childbirth with a breech or foot presentation is accompanied by a high risk, both for the child and for the woman in labor. If the child lies obliquely and transversely, this is an indisputable factor for a caesarean, regardless of the fact that the pregnancy passes with a scar.
- Location of the placenta
With placenta previa, there is a high risk of placental 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 the scar tissue, and this threatens with chronic fetal hypoxia. Moreover, pregnancy with a scar can be dangerous because placenta ingrowth occurs, and this also threatens fetal hypoxia.
- Pelvis Width
If the woman in labor has a very narrow pelvis, this can lead to uterine rupture along the scar due to excessive tissue tension in its area.
- Number of scars
If there is more than one scar on the uterus that appeared during a cesarean or other operational actions, then natural labor is impossible.
- Fetal pathology
If the fetus develops with pathological abnormalities, delivery without surgery can be dangerous both for him and for the woman in labor.
- Indications for the first caesarean
If the first caesarean was performed according to absolute indications, based on the state of health and clinical features, 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 at risk, since placenta ingrowth and scar divergence can occur. In this case, the natural birth process can take place only if certain equipment and conditions are available in the maternity hospital. The prerequisites include:
- Ultrasound and fetal monitoring
As soon as a patient with a scar enters the hospital with contractions, an ultrasound examination should be performed immediately. Based on the results, the doctor will assess the position of the baby, the placenta, the condition of the scar, as well as a number of other points that affect the natural labor activity. If the norm of all indicators is not exceeded, then there is no reason for concern. To have constant control over the condition of the fetus and listen to its heartbeat, a woman is connected to the KGT apparatus.
- Anesthesia and resuscitation
For smooth opening of the cervix and relaxation of the muscles, the woman in labor must be given epidural anesthesia. In addition, there should be a prepared operating room and resuscitation for the woman and the unborn baby.
Contraindications for natural childbirth
Taking natural childbirth with a scar on the uterus is strictly prohibited:
- Stimulate labor with oxytocin, as rapid labor with a scar can cause the uterus to fail and rupture;
- Use forceps or fetal rotation for incorrect presentation;
- Wait more than 15 hours with weak labor activity, discharge of water and lack of cervical dilatation;
- The slightest manifestation of alarming symptoms requires the immediate intervention of doctors.
Caesarean section during childbirth
If during natural labor there are difficulties on the part of the woman in labor or the fetus, an emergency cesarean is performed. Complications include acute fetal hypoxia, premature rupture of amniotic fluid and lack of opening of the cervix, placental abruption, uterine muscle rupture, bleeding, threat of uterine rupture, placenta ingrowth, etc.
Even if there is a scar in the uterine area, there is a chance of natural childbirth. Under all conditions, the probability of a rupture along the scar is 1 out of 100 cases. The main thing is to consult a doctor in time. Successful delivery, health to you and your unborn baby!
- Is natural childbirth possible?
Where it is thin, it breaks there! Do you know such an expression? What is the consistency of the scar on the uterus? What is a scar? In what cases does it occur? How long does it take for it to fully develop? Scar thickness and consistency - are these concepts the same? Is it possible for a scar to diverge during pregnancy? What are the conditions for natural childbirth for a woman with a scar on the uterus? Should I include an emotional component? Or is it just necessary to soberly and competently assess the situation? Let's take these questions in order.
Surgical interventions in the body of a woman and possible consequences
A wonderful idea of nature is the creation of a female body in order to fulfill a holy and noble mission, to endure and give birth to full-fledged offspring! The norm of a full-fledged family is the creation of conditions for fertilization, bearing and birth of healthy offspring. However, not every representative of the beautiful half of humanity can boast of full-fledged women's health during pregnancy. On the way 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 the body of a woman, necessary to correct her health.
For example, surgery such as a conservative myomectomy can restore women's ability to conceive. Fibroids are removed, but the organ is preserved. However, after the surgical intervention, as a rule, a scar is always formed. A scar can also occur during various necessary plastic reconstructive surgeries (when the uterine horn is removed, a tubal or cervical pregnancy is operated simultaneously with the uterine angle). The wall of the uterus is perforated during an operation to force the removal of the fetal egg, with hyperstimulation of labor, a rupture may occur. For some women during pregnancy, according to indications, if self-delivery is impossible, doctors prescribe a planned caesarean section. As a result, the integrity of the uterus is violated. After suturing the incisions, punctures or tears, a scar is formed on the uterus. All of these can have implications during pregnancy.
Restoration of sutures after surgery
A scar on the uterus is a special type of formation, which consists of myofibrils and connective tissue. It is located in the place where the surgical intervention was performed and there was a violation, and then the restoration of the integrity of the uterine wall. It is very important for the further prognosis of the woman's condition, the possibility of bearing a child and independent childbirth, the analysis of the formation of the scar and the recognition of its viability. For this, there are a number of criteria by which the norm of a well-formed scar on the uterus is determined.
What signs characterize a wealthy (full-fledged) scar? It is elastic, 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 incision was made across the muscle fibers, then the chances that they will fuse well and recover are greater than if they were cut along. The time of scar formation plays a role. Doctors believe that the best time to pass after the operation is approximately 1-2 years. But not more than 4 years, because. the scar is overgrown with connective tissue, and this, in turn, reduces its elasticity.
The signs that indicate the inferiority (failure) of the scar are its unevenness, the outer contour is discontinuous, 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 is formed in it, it becomes inelastic and may disperse 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 that moment, it is necessary to diagnose the formed scar in order to predict the course of the planned pregnancy. If the operation took place not so long ago, diagnostics will help determine the healing rate, answer the question of how the scar is formed, and evaluate it (the thickness of the scar and its viability are different concepts!).
Many women, with a scar on the uterus, are afraid of becoming pregnant. Is such fear justified?
Scar on the uterus, what is it
Damage to the uterus during childbirth, abortion and other interventions is eliminated by surgery - sutures are applied. After healing, a scar is formed - an outgrowth of connective tissue, which over time is replaced by muscle. His condition is important for the course of subsequent pregnancy and labor.Diagnosis of the condition of the scar during pregnancy
If a woman's labor activity ended by caesarean section, then it is recommended to become pregnant no earlier than after 2-3 years.A healed scar is examined by a gynecologist when planning a subsequent pregnancy or after conception. There are 2 states of it - complete and defective. Wealthy or full-fledged is the one that does not cause pain during palpation and practically does not stand out. Defective or insolvent - it is still strongly felt and causes discomfort when examined by a gynecologist.
If conception has occurred, and during the examination, the insolvency of the scar was found - this threatens with some complications, so it is better to undergo an examination before the next pregnancy.
Risk factors in the presence of a scar and possible complications
A scar on the uterus, if it has healed completely and the tissue has managed to recover, does not threaten either the mother or the child.A failed scar can cause:
- Miscarriage at any time.
- Pathology of the formation and functions of the placenta.
- Rupture along the old seam.
Features of pregnancy with a scar on the uterus
Regardless of whether the scar is rich or not, throughout the pregnancy, the future mother is strictly monitored. At each scheduled examination, the gynecologist feels the scar and conducts an ultrasound examination.At week 35, the condition of the pregnant woman, the estimated size and weight of the baby, the location of the fetus and placenta are fully analyzed. A decision is made about how the birth will take place. It is also suggested hospitalization a few weeks before delivery.
Features of conducting childbirth with a scar on the uterus
In most cases, a caesarean section is recommended for pregnant women with a uterine scar. At the present stage, when there are drugs that enhance cell regeneration and plastic sutures, a possible variant of natural childbirth.Indications for natural delivery:
- The presence of one wealthy scar.
- The scar is located in the lower part of the uterus.
- The pregnancy is proceeding normally.
- The previous child is completely healthy.
- Ultrasound confirmation of the normal state of the uterus.
- Small fruit.
- Longitudinal seam.
- Third or fourth birth in a row.
- Large child.
- Wrong presentation.
- Ultrasound examination shows the failure of the scar.
- The placenta is located on the scar or very low.
Rupture of the uterus along the old scar
If the pregnancy was normal, then the likelihood of complications during childbirth is reduced to zero. However, there remains a danger of tissue divergence along the old seam both during gestation and childbirth. It all depends on the type of scar and its condition at the time of pregnancy.A rupture along the old seam occurs more often with a vertical scar. This was done in the past with a caesarean section, now it is used only in emergency cases. At the present stage, caesarean section mainly uses a horizontal incision, which rarely diverges after healing during a subsequent pregnancy.
If the rupture still occurs during gestation, then it is necessary to urgently seek medical help, there is a real threat to the life of the mother and child. You can identify it by the following symptoms:
- Severe pain at the site of the old suture.
- Formation above the pubis under the skin of a hard roundness (the head of the fetus can crawl into the resulting gap).
- Pain in the abdominal cavity.
- The child began to go out and abruptly came back.
- The contractions disappeared or became weaker.
- When the contractions subside, the intense pain continues.
- The fetal heart rate changes.
A scar on the uterus does not deprive a woman of the opportunity to endure and give birth to a healthy child. It is important to plan subsequent pregnancies and undergo thorough research before conception.
