Uterine rupture along the scar: a serious and dangerous complication during pregnancy. All about the scar on the uterus after cesarean section How do the scar on the uterus look

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

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

A scar on the uterus may be the result of:

previous caesarean section;
conservative myomectomy. uterus - a benign tumor of the muscular layer of the uterus, which is removed while preserving the organ, such an operation is called "conservative myomectomy". This surgery usually restores the ability of patients to conceive, however, after the operation, there is always a scar on the uterus;
perforation of the uterus (piercing the wall) during instrumental removal of the ovum or uterine mucosa during abortion;
removal of the tube during tubal pregnancy, especially if the tube is removed with a small area of \u200b\u200bthe uterus from which it comes - the uterine angle.

Consistency of the scar on the uterus

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

A scar is considered to be healthy, in which there was a complete restoration of muscle fibers after surgery. Such a scar is able to stretch with an increase in the duration of pregnancy and the growth of the uterus, it is elastic and capable of contracting during contractions. If the amount of connective tissue predominates in the scar, then such a scar will be considered inferior, since the connective tissue is not able to stretch and contract in the way that muscle tissue can.

So, the following factors influence the degree of recovery of the scar on the uterus:

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

Diagnosis of the condition of the scar on the uterus

A woman with a scar on the uterus needs to be examined for the viability of the scar even before the onset of pregnancy in order to have complete information about the prognosis of the course of pregnancy and childbirth. Outside of pregnancy, it is necessary to assess the viability of the scar on the uterus in patients who have undergone operations associated with the risk of forming an inferior scar. These operations include conservative myomectomy with opening of the uterine cavity, caesarean section performed by a longitudinal incision on the uterus, surgery to suture a perforation on the uterus after an abortion with opening of the uterine cavity. Examination of the scar on the uterus is possible with the help of hysterosalpingography, hysterography and ultrasound. If pregnancy has already occurred, then the diagnosis of the scar condition is possible only with the help of a dynamic ultrasound study.

Features of childbirth

A few years ago, many obstetrician-gynecologists were guided by the slogan: "Caesarean section once - always caesarean section" to determine the tactics of childbirth.

However, now the opinion of experts has changed. After all, caesarean section was and remains a serious surgical procedure, after which serious complications can occur. Despite the well-established methods of operative delivery, it should be recognized that the risk of postoperative complications is significantly higher compared with patients who gave birth through the natural birth canal. And the process of recovery of the body after vaginal delivery is much faster.

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

Given this, in the past 10 years, doctors have been trying to deliver women with a scar on the uterus through the natural birth canal.

To resolve the issue of the method of delivery, all pregnant women with a scar on the uterus are shown scheduled antenatal hospitalization at 37-38 weeks of pregnancy for a complete comprehensive examination. The hospital analyzes the obstetric history (number and outcomes of pregnancies), identifies concomitant diseases (for example, from the cardiovascular, broncho-pulmonary system, etc.), an ultrasound examination is performed, including an assessment of the postoperative scar, the condition of the fetus is assessed (Doppler - a study of blood flow, cardiotocography - a study of the cardiac activity of the fetus).

Indications for childbirth through the natural birth canal

Carrying out childbirth in a natural way is possible under the following conditions:

The pregnant woman has only one wealthy scar on the uterus.
The first operation was carried out according to "transient" indications; this is the name of the indications for surgery that first arose during previous births and may not necessarily appear in subsequent ones. These include:
- chronic intrauterine fetal hypoxia - insufficient oxygen supply to the fetus during pregnancy. This condition can occur for various reasons, but does not recur in the next pregnancy;
- weakness of labor activity - insufficiently effective contractions that do not lead to the opening of the cervix;
- - the fetus is located with the pelvic end to the exit from the uterus. This position of the fetus is not in itself an indication for surgery, but is a reason for caesarean section only in conjunction with other indications and is not necessarily repeated during the next pregnancy. Other abnormal positions of the fetus, such as the transverse position (in this case, the child cannot be born spontaneously) may also not recur during the next pregnancy;
- large fruit (more than 4000 g);
- premature birth (premature births are considered to occur before the 36-37th week of pregnancy);
- infectious diseases detected in a previous pregnancy, in particular an exacerbation of a herpes infection of the genitals shortly before childbirth, which was the reason for a caesarean section, will not necessarily occur before the next birth.
When a puerperal is discharged from the maternity hospital, the doctor is obliged to explain to the woman exactly what indications the caesarean section was performed for. If they were associated only with the features of the first pregnancy (detachment or clinically narrow pelvis, etc.), then the second pregnancy may well (and ideally should) end in natural childbirth.
The first operation must be performed in the lower uterine segment with a transverse incision. The postoperative period should proceed without complications.
The first child must be healthy.
This pregnancy should proceed without complications.
An ultrasound examination performed at full-term pregnancy showed no signs of scar failure.
There must be a healthy fetus. The estimated weight of the fetus should not exceed 3800 g.

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

If a scar defect during pregnancy is suspected, the patient should be hospitalized long before delivery, at 34-35 weeks of gestation.

Indications for surgery

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

Indications for repeated caesarean section are:

A scar on the uterus after a corporal caesarean section, or an operation performed by a longitudinal incision on the uterus (in this case it has a very high risk of failing).
Scar after two or more operations.
Insolvency of the scar, determined by the symptoms and ultrasound data.
The location of the placenta in the area of the scar on the uterus. If the placenta is located in the area of the postoperative scar, then its elements are deeply embedded in the muscular layer of the uterus, which increases the risk of rupture of the uterus during its contraction and stretching.

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

Possible Complications

A scar on the uterus can cause some complications during pregnancy. Most often, there is a threat of termination of pregnancy at different times (occurs in every third pregnant woman with a scar on the uterus) and placental insufficiency (that is, the supply of insufficient oxygen and nutrients through the placenta). Often such a pathology occurs when the placenta is attached in the area of the postoperative scar and appears due to the attachment of the placenta not in the area of \u200b\u200bfull-fledged muscle tissue, but in the area of \u200b\u200bitaltered scar tissue.

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

Therefore, during childbirth, the state of the scar is constantly monitored. Experts determine it by palpation through the anterior abdominal wall, that is, by probing the scar area. Despite the contractions, it should remain even, with clear boundaries and almost painless. Of great importance is the nature of bloody discharge during childbirth (there should be few of them) and the woman in labor complains of pain. Nausea, vomiting, pain in the navel, weakening of contractions may be signs of the onset of a scar rupture. For an objective assessment of the state of the scar in childbirth, an ultrasound study is used. And with the emerging signs of his inferiority, which in the first place is the weakness of labor activity or any other complications during childbirth, they proceed to delivery by caesarean section.

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

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Pathogenesis

A scar on the uterus is an altered area of tissue that was formed due to 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 last stages, diagnostic methods are used to assess the structure of tissues, which help prevent possible complications. Pathology is not treated, but is the main factor in choosing the method of delivery.

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

In the first case, the site of damage is replaced by 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 to fully mature. The functional state of 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 the fibers of the myometrium, elastic areas. They have the ability to contract at the moment of tension of the uterus, they can withstand stress. The norm of scar thickness is from 5 mm.
Insolvent. They are formed by connective tissue, have low elasticity, are not able to contract during contractions, and have low tear resistance. Diagnosed at a thickness of 1 mm.

When the examination plan and obstetric management of pregnancy is determined, it is important to take into account the localization of the scar. It can be located in the body of the uterus, in its lower part or in the neck 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 implications. A woman complains of pain in the lower abdomen, spotting, periodic irregular contractions. The condition worsens, systolic pressure falls, 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	The scar appears at the site of the incision of the uterine wall to extract the child, mainly the lower third
Myomectomy	Removal of fibroids - a 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
Recovery operation	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 place where the embryo was attached may include part of the uterus if implantation occurred in its neck and the area of the fallopian tube, which is located near the uterus itself

Features of a failed scar

The main reason for the formation of such a scar is the reduction of areas of the myometrium, 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 such a pathology, there is a high probability of developing hemorrhage into the peritoneum or into the uterine cavity, the attachment of an infection with the development of sepsis. In the last stages, the scar can lead to ruptures (during childbirth), the development of a focus of inflammation.

Reasons for education:

emergency cesarean;
inflammation of the seams;
curettage during abortion;
postoperative complications;
conception in the early stages after caesarean.

If there is a suspicion of scar failure, urgent hospitalization is required. This is due to a high chance of abortion and the appearance of other pathologies.

In the presence of an insolvent scar (assessed by ultrasound diagnostics) and the woman’s desire to give birth again, it is recommended to perform a laparoscopic operation to excise the tissue and apply a full-fledged suture that will not interfere with a normal pregnancy.

The appearance of a scar in any organs means a violation of their normal functioning. This is due to the deterioration of blood supply and tissue innervation. With repeated pregnancies, a 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 of the uterine mucosa. A particularly unpleasant situation is observed if the foci of the disease appear on the scar. In this case, surgery is most often required.
Endometritis. Inflammatory process in the endometrium. The disease in a chronic form can lead to infertility and even the need to remove the uterus.
Myometritis (inflammation of the muscle membrane).
Parametritis (pathology of the connective tissue).
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 viability of the scar. Informative methods in this case are:

Hysterography. The procedure involves the introduction of a contrast agent into the uterus and an x-ray examination.
Hysteroscopy. It consists in introducing a thin tube with a video camera at the end into the uterine cavity. The hysteroscope is used to examine the inner lining, curettage and, if necessary, remove the formations.
Gynecologicalultrasound. An examination of the uterine cavity is performed, which shows an intermittent and uneven contour in the area of the scar with endometrium exuded.

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

With symptoms of impending rupture during childbirth, an obstetric examination is performed and the risk is assessed by assessing the shape of the uterus and its contractile activity. Ultrasound is used to look at the state of the tissue, highlight defects in the myometrium and areas of its thinning.

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

Pregnancy and scar

It takes about two years for a well-formed suture on the uterus to fully form. This time is recommended to the patient to wait until the next attempt to become pregnant. Not the best option is a long break, after four years the scar begins to gradually lose elasticity.

Pregnancy with a suture on the uterus is necessarily under the supervision of an obstetrician-gynecologist.

Complications

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

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

childbirth

There are two types of opening the uterine cavity:

cross section. It is done during a planned operation.
Corporal. It is performed with the necessary urgent delivery, delivery before the 28th week, hypoxia or bleeding.

Re-pregnancy most often leads to a caesarean section. However, more and more patients with a scar are sent for 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 so that a woman can give birth on her own:

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

Indication	Description
Longitudinal scar	The probability of an unfavorable outcome in this case is much higher
Two or more scars	Pregnancy after two or more cesareans is resolved surgically
Some interventions in the reproductive system	Myomectomy of the posterior wall of the uterus, plastic surgery for organ developmental disorders, surgery for ectopic pregnancy in the cervical region
Gap in history	Natural childbirth is contraindicated if the previous pregnancy was accompanied by a rupture
Scar failure	Signs of a significant amount of scar tissue have a poor prognosis
Pathology of the placenta	The operation is performed with placenta previa or its localization in the area of scar formation
narrow pelvis	The loads that the fetus provokes when passing through the birth canal aggravate the condition and provoke a rupture

If during natural childbirth a woman in labor with a scar has a threat of rupture, the operation is performed on an emergency basis. After caesarean section, the defect of the wall of the organ is sutured. With severe bleeding with the impossibility of suturing or a massive hematoma, the uterus is extirpated.

Therapy

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

Surgery is considered the only effective method of therapy. Medical 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.

metroplastic

An indication for plasty 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 to remove scar tissue with suturing. It can be performed laparoscopically and laparotomically.

An open operation is caused by the need to access an organ site that is located in a zone 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 the isolation of large veins and arteries and the imposition of clamps on 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 time.

Scar prevention

When planning pregnancy and preparing for it, it is necessary to identify and treat all chronic diseases. It is recommended to 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. Carefully monitor the scar with ultrasound. When comparing all the factors and research data, the issue of a planned caesarean section is decided.

Due to the increase in the number of obstetric operations, such as caesarean section, experts note an increase in subsequent complications. One of the most common pathologies after caesarean section is the failure of the scar on the uterus. What are the reasons for the development of this pathology and whether it is possible to prevent it, we will ask the experts.

Reasons for development

According to gynecologists, an inconsistent scar on the uterus is a complex pathology that requires surgical treatment. The risk of developing pathology after cesarean section is associated with many factors, including the individual characteristics of the organism.

An incompetent scar is an abnormally formed scar tissue at the site of the uterine incision. Pathology is characterized by the presence of non-fused areas, cavities, insufficient thickness of scar tissue and the presence of a large amount of connective tissue, which will not allow the uterus to fully stretch during a subsequent pregnancy.

Experts note that the development of complications often occurs after a second operation. Pathology often leads to the impossibility of bearing a child.

The most common causes of the development of this pathology are:

Performing an emergency caesarean section.
Development of postoperative endometritis.
Early re-pregnancy after surgery.
Inflammatory processes and infection of the suture.
Termination of pregnancy by curettage after caesarean section.

What causes the development of pathology

The formation of an insolvent scar threatens to rupture the uterine wall when carrying a child. This, in turn, can lead to severe bleeding and death of the mother and child. Today, thanks to the development of a diagnostic gynecological base, it is possible to determine the state of the scar even before the conception of a child, which significantly reduces the percentage of unfavorable outcomes of repeated bearing of a baby after a cesarean section.

When re-planning pregnancy after surgical delivery, women are advised to conduct regular ultrasound of the uterus in order to timely detect changes in the scar. At the slightest suspicion of a scar tissue defect in pregnant women, patients are recommended to be hospitalized until delivery.

A little about stitches after childbirth and how to quickly heal the stitches on the perineum

Dangerous signs during pregnancy are:

Muscle tension in the uterus
Pain when touching the abdomen
Uncontrolled uterine contractions
Vaginal discharge with blood
Malfunctions in the heartbeat of the child

The following signs speak of deterioration and rupture of the uterine wall:

Sharp severe pain in the abdomen
Low blood pressure
Vomit
Termination of labor activity

In the presence of these symptoms, the patient is shown an urgent caesarean section.

Diagnostic methods

The main methods for diagnosing the condition of the scar on the uterus are ultrasound, hydrosonography and hysteroscopy.

According to the results of pelvic ultrasound, specialists evaluate the condition of the scar according to the following criteria:

Myometrial changes
Scar condition
The presence of visible ligatures
The presence of scar niches
Scar tissue thickness

Ultrasound can reveal the complete and partial failure of the scar on the uterus. Complete failure implies immediate surgical treatment, the purpose of which is the complete excision of scar tissue, followed by new sutures. The operation is performed to enable the formation of a full-fledged scar on the uterus.

When making a diagnosis of “Partial failure”, doctors may prescribe additional studies.

After MRI, echohysteroscopy and hysteroscopy, specialists determine the need for surgical treatment.

Thus, with the help of an initial ultrasound examination, it is possible to fully assess the condition of the scar on the uterus and take timely measures for effective treatment. This examination should be completed by every woman who has had an operative childbirth, especially before planning the next pregnancy.

Surgical treatment

According to the results of ultrasound, the doctor decides on the need for surgical treatment of an incompetent scar. The operation is performed by an open method. This need arises due to the inconvenient location of the uterus behind the internal organs. Also, an open operation allows you to adequately assess the degree of possible bleeding, which often occurs during surgery.

Conventional laparoscopy in this surgical treatment cannot provide control over the amount of blood lost, complicates the stitching of the uterine wall and often turns into emergency open surgery.

How long can discharge last after caesarean section

Heavy bleeding can occur due to good blood circulation in this organ. It is not uncommon for a patient to require a transfusion of blood products during surgery.

However, according to Konstantin Puchkov, MD, professor and director of the Center for Clinical and Experimental Surgery in Moscow, he managed to develop an effective method of laparoscopic surgical treatment of an incompetent uterine scar.

Operative author's method allows to exclude blood loss and provide strong stitching of tissues, as well as exclude the possibility of adhesions. The advantages of the method are minimal tissue damage, quick rehabilitation and the absence of extensive scars on the patient's skin.
The method is of particular importance for women who plan to have a child in the future. Also for women with certain comorbidities such as uterine fibroids that can be removed in a single operation.

After operation

Therapy after the intervention consists in taking antibacterial and hormonal drugs. In the recovery period, the presence of discharge mixed with blood from the vagina for 6 to 12 days is considered the norm. In the early days, there may be an increase in body temperature and pain in the uterus.

You can wash only after the doctors remove the stitches. Up to this point, it is not recommended to wet the seam. During the entire time of hospitalization, the patient is treated with a seam with special antiseptic solutions.

Before discharge from the hospital, a woman undergoes an ultrasound scan to monitor the healing of the scar on the uterus. Also, ultrasound must be carried out at certain intervals, which are determined by the attending physician.
Pregnancy planning is possible only after the approval of the attending doctor based on the positive dynamics of scar healing.

natural childbirth

Many are sure that if there is a scar on the uterus, natural childbirth is not possible. However, this opinion is erroneous. Today, specialists can allow natural childbirth if the condition of the mother and child does not require surgical intervention.

What is the difference between children born by caesarean section from other babies

Natural childbirth is permitted in the following cases:

The caesarean section was performed by transverse incision.
Long period between births.
The operation was performed once.
Wealthy scar.
No change in the position of the placenta.
Absence of pathologies and concomitant diseases.
Correct position of the fetus.
No reason for a caesarean.

During labor, women who decide to give birth on their own after a caesarean section are closely monitored. An important condition for such childbirth is the complete readiness of the operating room, in the immediate vicinity of the birth unit. This condition must be observed in case of possible complications of labor activity, which may require urgent surgical intervention.

Collapse

After a caesarean section, a connective tissue scar remains on the uterus. With the next birth, it can lead to a very dangerous complication - uterine rupture. This phenomenon causes severe bleeding, severe traumatic and hemorrhagic shock. It is difficult to save a woman in labor and her fetus in such conditions. Further on why the uterus ruptures along the scar during pregnancy, what are the symptoms of this dangerous phenomenon, and how to prevent it.

Causes of uterine rupture along the scar

Although uterine ruptures are relatively uncommon, they are one of the leading causes of death in women during or shortly after childbirth. The main factors that cause the most dangerous complication are:

Pathological atrophic processes in the muscular uterine membrane (myometrium) that occur after miscarriages, unsuccessful abortions, and various inflammations.
Not very high-quality operations to remove tumors from the muscular uterine tissue (myomas) using laparoscopy.
Poor suture material, due to which the muscle and connective fibers of the uterus do not normally grow together.
Sewing of the uterine walls with an unreliable single-layer, and not a two-layer, suture.
The woman in labor has already had more than two cesarean deliveries.
Doctors used oxytocin, misoprostol, and other drugs that help the body produce hormone-like substances, prostaglandins, that stimulate uterine contractions during childbirth.
Medical negligence and the use of outdated methods during childbirth, leading to discoordination (impaired contractions of the uterine walls). For example, to remove the fetus from the mother's womb, obstetricians may press too hard on the abdomen or use various "ancient" auxiliary tools, such as forceps. And at the same time, completely disregard the atrophic processes in the uterine muscles.
Stimulation of labor due to the fact that hypertonicity is observed in the muscular uterine membrane, and labor pains are not intense enough due to pathologies in the structure of the uterine walls.
In some cases obstetricians are still trying to change the location of the fetus. This very often ends not only with rupture of the uterus, but also with death.
Abnormally large size of the baby's head relative to the pelvic floor. Recently, this problem has become very relevant, as the number of women with too narrow a pelvis has increased. Gigantism of the fetal head is especially dangerous for ladies of small stature.
Not the last role is played by the age of women in labor: the older the woman, the more often breaks.
The risk also increases if a new pregnancy occurs only a few years after the caesarean section.
The place where the incision was made is another important factor. Tearing is rare if the baby is removed from the mother's womb using a vertical (rather than horizontal) incision made between the pubic bone and the umbilicus in the lower uterine segment.

Symptoms

When the uterus ruptures during childbirth, a woman:

blood may begin to flow from the vagina;
when touching the stomach, a woman experiences severe pain;
intense colic is felt in the area of \u200b\u200bthe peritoneum;
the baby's head stops moving towards the exit from the birth canal and, as it were, goes back;
there is severe pain in the area of the scar. Between individual fights, it is especially intense;
a bulge may appear in the region of the pubic bone, due to the fact that the head of the fetus “breaks through” the uterine suture;
the fetus begins anomalies with cardiac activity (very low pulse, a decrease in heart rate);
the uterus unnaturally often contracts. And it does it irregularly.

To prevent a serious complication, specialists use ultrasound to determine the size of the scar, and at the time of childbirth, they carefully monitor the strength of contractions. Such measures do not always help fix the uterine rupture in time. It happens that contractions do not disappear even after the scar has ruptured.

Uterine rupture occurs not only during childbirth, but also before and after them.

How often does this happen?

There is an erroneous opinion that women with a healed "post-caesarean" education can no longer give birth at all. This is not true. Numerous studies have shown that scarring problems in parturient women who have had a caesarean section occur relatively infrequently - approximately in one case in 100-150. True, the quality of medical care plays an important role here. If it is low, the probability of uterine rupture increases by 5-7 times.

How often uterine rupture occurs during pregnancy depends to a large extent on the location where the suture is located and what type it is:

The most popular horizontal incision in the lower region today is relatively safe - because of it, tears occur only in 1-5% of cases.
If the incision was made vertically, the risks of scar rupture are approximately the same - 1-5%.
The latest overseas studies have shown that the most dangerous is the "classic" caesarean incision in the lower segment. With it, a gap occurs in about 5-7% of cases. Today, a lower segment incision is resorted to only in extreme circumstances, when the life of the fetus and mother is in mortal danger.

The probability of a dangerous phenomenon also depends on the shape of the scar. Cuts made in the shape of a J or T are considered safer than those that look like an inverted T.

An important role is played by the number of caesarean sections. Recent studies conducted in the United States show that the scar diverges during the following births:

in 0.5-0.7% after one cesarean. This is less than the risk of rupture with other major birth complications - fetal distress, a prolapsed umbilical cord, or a placenta detached before birth;
in 1.8 - 2.0% after several births, which were accompanied by an incision of the uterus and abdominal wall;
in 1.2-1.5% after three cesarean births.

The results of a study conducted by specialists from the British Royal College do not differ much from the data of their American colleagues: 0.3-0.4% of cases of rupture.

However, according to the same data, a repeat caesarean is still more reliable. With it, the risk of ruptures drops to 0.2%.

What to do?

If a uterine rupture occurs, the main thing is to provide qualified assistance as quickly as possible. According to one well-known American clinic, a woman can be saved if she is given no later than 15-20 minutes after the suture divergence.

If it is not known for sure whether there is a gap, doctors will conduct the following studies:

ultrasound. With its help, the doctor will check what happens to the muscle fibers in the area of the scar, whether they are intact.
Magnetic resonance imaging. This diagnostic method will allow you to carefully examine the area of artificial tissue fusion.
X-ray of the uterus.

Why is a seam divergence dangerous for mother and child?

The divergence of the seam can destroy both the mother and the baby. To prevent this from happening, a woman expecting a baby should carefully listen to her feelings, be close to a medical institution and not be alone.

How to prevent a break?

A woman who is preparing to give birth after a caesarean cannot do without regular visits to the antenatal clinic. It is there that she will be helped to determine how high the risk of an unsuccessful outcome of the operation is.

It is especially important to regularly check:

whether the fetus has macrosomia (oversized), as this increases the risk of ruptures. To avoid macrosomia, you should not eat foods that are high in sugar;
whether the expectant mother has a narrowing of the bone pelvis and flattening in the area of the sacrum;
whether premature discharge of amniotic fluid has begun.

Women with a uterine scar are highly discouraged from giving birth outside the clinic. Recent studies by American and British experts have shown that "home" childbirth dramatically increases the likelihood of suture divergence. It is better for women with a scar to go to the hospital a week and a half before the possible onset of childbirth.

In order to prevent such a dangerous situation as a divergence of a scar on the uterus, a pregnant woman needs constant medical supervision, examinations and diagnostics using modern methods and equipment.

Scar on the uterus- this is a fragment of the connective tissue layer in combination with muscles, which was formed after the violation of the integrity of the organ.

Currently, a lot of women are forced to carry out surgical interventions on the pelvic organs, and in particular, on the uterus, even before childbirth or in the young reproductive period.

Consequently, there is a process of violation of the integrity of the original tissues. If this is an operative intervention taking place under aseptic conditions, then there is a process of scar formation by the type of an inflammatory non-bacterial process.

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At the initial stage, the process of primary tension occurs, i.e. tissue bonding at the site of integrity violations. Subsequently, granulation tissue begins to form as a result of the development of elastin fibers with a small content of collagen. After this process, the scar will form immature, loose and prone to stretching.

Therefore, when exposed to heavy physical exertion, the process of seam divergence may occur. This process takes about one month. And after three months, growths of bundles of collagen and elastin fibers are formed.

Finally, the scar is formed only after a year or more, since the vessels in it are gradually dying off, and there is a tension in the fibers.

As a result of the intervention, full-fledged muscle tissue is no longer formed, it will be mixed with connective tissue. Therefore, women who undergo interventions must first be aware of all the possible risks that arise after surgical interventions, because. a scar on the uterus can subsequently lead to complications in the course of pregnancies and possible delivery.

Symptoms

In the normal state, when a woman does not have a pregnancy, and also if the process proceeded according to all the rules of asepsis and antisepsis, the scar will not show symptoms. Therefore, the early recovery period is so important, because it is on the process of scar formation that further life and possible pregnancy will largely depend.

Basically, the scar on the uterus begins to manifest itself only during the development of pregnancy, when there is active growth and an increase in the size of the uterus. Since new muscle fibers are not restored, the existing ones are stretched, as well as the tension of the connective tissue in the scar area.

It can manifest itself in different ways, it all depends on its initial correct forcing, as well as the presence of signs of consistency:

Gap stages

Currently, there are 3 main clinical stages in the development of uterine rupture along the postoperative scar:

Causes of scars on the uterus

There can be quite a few reasons leading to the development of a scar on the uterus. This is due to the increased diagnosis of gynecological pathologies, an increase in the number of infertility, promiscuous sex life with a lack of protective equipment, as well as the unwillingness of women to have many children.

The main cause in terms of pathogenesis is traumatic injury, with the development of loss of integrity of muscle tissue in the uterus.

The most common causes include the following::

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Varieties of a scar on the uterus

First of all, scars are divided according to their functionality.

It can be:

In addition, scars differ in location. It depends on the type of surgery. a:

Inferomedian or incision in the lower segment. Similar types are typical for caesarean section.
Corporal cut would be typical for uterine body reconstruction surgery.
Diffuse location of the scar on the uterus It is not possible with the removal of fibroids or traumatic effects.

Diagnostics

At present, with the development of medical technologies, diagnosis is not difficult. But it poses a greater danger if a woman comes to an appointment already pregnant. Those. no preliminary assessment of the quality of the condition of the scar on the uterus is carried out, and the doctor is forced to choose expectant tactics until the second and third screenings.

This is due to the fact that outside the state of pregnancy, even on old scars, it is difficult to determine the consistency, since there is no process of uterine distension.

Unfortunately, it is possible to assess the condition of the scar on the uterus only when conducting various instrumental studies. At the appointment and during an external examination, the doctor can only suspect the presence of cicatricial elements on the uterus of a woman by the presence of scars on the anterior abdominal wall, or by clarifying the anamnesis data from which it can be concluded that the procedures have occurred.

Of the methods of instrumental diagnostics, there are:

Since diagnosis is of great importance precisely at the time of pregnancy, a non-invasive and safe method for the fetus should be chosen. Currently, this is ultrasound diagnostics. It is prescribed by a doctor starting from the 30th week of pregnancy, if there are any violations in the structure, then the multiplicity increases for 7 or 10 days. In addition, a Doppler study and assessment of the vital activity of the fetus using cardiotocography is carried out.

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Planning a pregnancy with a scar on the uterus

This is a rather important stage for a woman, since it is from him that her further course will occur, as well as the development of complications.

It is necessary to assume a possible conception no earlier than two years after the previous ones have passed, it is during this time that the process of developing a full-fledged scar on the uterus takes place, but also this interval should not be too long, it should reach no more than 5-6 years, since subsequently, even a full-fledged timid is subjected to sclerosis.

A similar process subsequently also leads to the development of insolvency and a possible rupture of the scar on the uterus. It is necessary to consult a specialist with diagnostic measures, if even before the onset of pregnancy there is a question about preliminary metroplasty.

Pregnancy with a scar on the uterus

A few years ago, a woman with a scar on the uterus was sent for prenatal hospitalization without fail and she underwent an operation.

Is natural childbirth possible?

Currently, more and more doctors are inclined to the possibility that a woman can give birth in a natural way, even if there is a scar, but with the condition of its solvency.

In many cases, they proceed without complications.

The group that can give birth on their own includes women with a history of a single caesarean section in history, the condition of a transverse incision during this operation, the presence of signs of consistency of scars, the absence of attachments of placental tissue to the scar, the absence of maternal diseases or complications during pregnancy, as well as the correct position of the fetus .

Indications for caesarean section

The operation of caesarean section prescribes a second one if:

The consequences of the scar

Consequences:

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It can be a variety of options for the course of the postoperative period.
In most cases, the most serious complication is the formation of adhesions in the pelvic organs.
It can also be inflammatory processes.
The development of endometriosis of the uterine body and its spread outside the organ.

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Complications

There may be the following complications:

Treatment

Unfortunately, at present, medicine has not developed methods of therapeutic measures aimed at treating scars on the uterus.

In the absence of pregnancy, no treatment of the scar on the uterus, provided that there are no complications and everything is normal, is not required.
If pregnancy has occurred, then tactics are chosen after determining the viability of the scar and the place of attachment of the fetal egg. During a normal pregnancy, no specific measures are required to treat the scar. It can only be used to prescribe drugs aimed at improving blood circulation in the mother-placenta-fetus system, since there is a possibility that the pregnancy will not develop fully enough.
In the event that in the early stages of pregnancy a pronounced insolvency of the scar is revealed or attachment of a fetal egg to this area, a woman is offered an abortion in order to avoid possible complications.

In the absence of pregnancy and the presence of signs of a defect in the scar tissue, especially if inflammatory processes occurred in this area after surgery, subsequent metroplasty may be required with excision of the old scar tissue and new sutures.

Forecast

This concept is rather ambiguous in relation to the scar on the uterus:

If a woman does not plan pregnancy in the future, and also if the postoperative period was uneventful, then the prognosis will be favorable.
If a woman subsequently plans to have children, then the prognosis will be based primarily on the assessment of the viability of the scar.
If there were no complications in the postoperative period, and enough time has passed for its full formation.

In addition, it will be formed from the concepts of the state of dynamic development of a real pregnancy.

If a woman passes all the examinations on time, the child has a small or average weight for a given period, in addition, there is no infection and polyhydramnios, then the prognosis will be favorable.

If there are such factors, then there is a possibility that it can become relatively unfavorable. When therapeutic tactics are taken in time and delivery is carried out in a hospital of the appropriate level with the possible assistance to the child, even if he is born prematurely. An unfavorable prognosis is possible if the insolvency is not diagnosed in time, and therapeutic tactics are not taken.