Ultrasound diagnosis of an incompetent scar on the uterus in the long-term postoperative period. Thin scar on the uterus after cesarean section

Due to the increase in the number of obstetric operations, such as cesarean sections, experts note an increase in subsequent complications. One of the most common pathologies after cesarean section is the failure of the uterine scar. What are the reasons for the development of this pathology and is it possible to prevent it, let’s ask specialists.

Reasons for development

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

An incompetent scar is abnormally formed scar tissue at the site of the uterine incision. The pathology is characterized by the presence of unfused 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 subsequent pregnancy.

Experts note that the development of complications often occurs after repeated surgery. Pathology often leads to the inability to bear a child.

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

• Carrying out an emergency caesarean section.
• Development of postoperative endometritis.
• Early recurrent pregnancy after surgery.
• Inflammatory processes and infection of the suture.
• Termination of pregnancy by curettage after cesarean section.

What does the development of pathology lead to?

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

When re-planning pregnancy after surgical delivery, women are recommended to undergo regular ultrasounds 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.

What to do when the internal or external seam breaks after childbirth

Dangerous signs during pregnancy are:

1. Uterine muscle tension
2. Pain when touching the abdominal area
3. Uncontrolled uterine contractions
4. Vaginal discharge mixed with blood
5. Irregularities in the baby's heartbeat

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

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

If these symptoms are present, the patient is indicated for an emergency cesarean section.

Diagnostic methods

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

Based on the results of a pelvic ultrasound, specialists evaluate the condition of the scar according to the following criteria:

• Myometrial changes
• Scar condition
• Presence of visible ligatures
• Presence of scar niches
• Scar tissue thickness

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

When diagnosing “Partial failure,” doctors may prescribe additional tests.

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 uterine scar and take timely measures for effective treatment. Every woman who has undergone surgical childbirth should undergo this examination, especially before planning her next pregnancy.

Surgical treatment

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

Conventional laparoscopy for this surgical treatment cannot provide control over the amount of lost blood, complicates the suturing of the uterine wall and often leads to emergency open surgery.

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Heavy bleeding may occur due to good blood circulation in this organ. Often, during surgery, the patient requires a transfusion of blood products.

However, according to the statement of Konstantin Puchkov, Doctor of Medical Sciences, 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.

The author's surgical method eliminates blood loss and ensures strong tissue suturing, as well as eliminating the possibility of adhesions. The advantages of the method are minimal tissue damage, quick recovery 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 concomitant diseases, such as uterine fibroids, which can be removed during one operation.

After operation

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

You can wash only after the doctors remove the stitches. It is not recommended to wet the seam until this point. During the entire hospitalization, the patient’s suture is treated with special antiseptic solutions.

Before being discharged from the hospital, a woman undergoes an ultrasound to monitor the healing of the uterine scar. Also, ultrasound must be performed at certain intervals, which are determined by the attending physician.
Planning a pregnancy is possible only after the approval of the attending doctor based on the positive dynamics of scar healing.

Natural birth

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

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Natural childbirth is permitted in the following cases:

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

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

After a cesarean section, different scars may remain on the uterus - stable, in which there are usually no problems in the process of carrying the next pregnancy, and insolvent - which can disperse at any time and lead, in the absence of emergency medical care, to the death of the mother and child.

The scar on the uterus after cesarean section can be vertical or horizontal. The latter is performed as low as possible - this maximally guarantees its successful healing. A vertical incision is usually a consequence of an emergency operation, when the goal of doctors is to perform the operation very quickly to save the life of the child, and sometimes his mother. The scar after a cesarean section heals completely faster if the suture material was good, and after the birth of the child, postpartum problems did not arise, such as acute endometritis, and uterine curettage was not required. For the same reason, women who have a suture on the uterus after a cesarean section are advised to take very good precautions against unplanned conception of a child for at least 6-12 months, because surgical abortion can have a very negative effect on the scar.

It is believed that a scar after a cesarean section on the uterus takes about 2 years to heal. Doctors always advise women who have a vertical scar to endure this period of time. But at the same time, it is undesirable to leave a long gap between pregnancies; optimally 2-4 years. But before conception, you should at least undergo an ultrasound scan of the uterine scar after a cesarean section. It is performed with a vaginal sensor and with a full bladder (including during pregnancy).

The doctor pays attention to the structure and thickness of the uterine wall where the scar passes. If there is thinning up to 1 mm, then this indicates failure of the uterine scar after cesarean section, which is very bad. In addition, attention is paid to the unevenness of the scar, depressions in it and the predominance of connective tissue, whereas it should be muscle. If the scar is incompetent, you cannot become pregnant. The thickness of the scar on the uterus after cesarean section is normally 5 mm. During pregnancy it will become thinner. And at the end of it, even 3 mm will be considered a good thickness. Although doctors say that even with 1 mm at the end of the third trimester, discrepancies occur extremely rarely.

Another problem that can be identified by ultrasound and MRI is endometriosis of the cesarean scar. With this pathology, it is necessary to excise the affected tissue. That is, it is impossible to do without intervention in the uterus. And after this, hormonal drugs are usually prescribed to help avoid relapse of endometriosis. At least while the woman is taking the drug. Treatment of scars after cesarean section for endometriosis (correct diagnosis is important to avoid unnecessary surgical operations!) is carried out in the presence of lesions in the muscle wall. In this case, abdominal surgery is performed.

In addition to ultrasound, doctors advise that before planning the next pregnancy, hysteroscopy is performed - a procedure in which the doctor can visually, using a special optical device inserted through the vagina into the uterine cavity, assess the consistency of the postoperative scar. This study is more informative than ultrasound.

If all is well, you can plan pregnancy and childbirth after a cesarean section with a uterine scar without fear. Many women undergo two or three operations. And they give birth to healthy, full-term children. It is important to register early with an antenatal clinic or a paid medical center and be very attentive to the doctor’s recommendations and listen to your feelings. Especially if the scar on the uterus hurts during pregnancy, because this may be a sign of its imminent rupture. A very difficult situation. To avoid this, you need to undergo an ultrasound on time and measure the thickness of the scar. If necessary, doctors will perform emergency surgery to save the lives of mother and child. Other possible symptoms include occasional vomiting, tingling and sharp pain. Women compare this pain to what happens when you pour salt into a wound. The fetus shows signs of oxygen deficiency - hypoxia.

Other possible complications during pregnancy are the threat of miscarriage, transverse or pelvic position of the fetus, placenta previa. Pregnancies often have an unfavorable prognosis if the placenta is located along the anterior wall and extends onto the scar. If the doctor notices that a woman’s uterine scar thickness during pregnancy is far from normal, she undergoes surgical delivery. Often this is an operation at 37-38 weeks. If the scar is normal, then delivery is performed as close as possible to the expected date of birth. This situation is most favorable for the fetus. In some cases, natural childbirth is possible after a cesarean section. But only with almost ideal health of the woman and the fetus, a favorable course of the postpartum period, and good condition of the uterine scar.

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

Currently, many women are forced, even before giving birth or during the young reproductive period, to undergo surgical interventions on the pelvic organs, and in particular on the uterus.

Consequently, the process of violating the integrity of the original tissues occurs. If this surgical intervention takes place under aseptic conditions, then the process of scar formation occurs according to the type of inflammatory non-bacterial process.

At the initial stage, the process of primary tension occurs, i.e. bonding tissues at the site of disruption. Subsequently, granulation tissue begins to form due to the development of elastin fibers with a small collagen content. After this process, the scar will form immature, loose and susceptible 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 form.

The scar is finally formed only after a year or more, since the vessels located in it gradually undergo death, and the fibers are stretched.

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 during pregnancy and possible delivery.

Symptoms

In a normal state, when a woman is not pregnant, and also if the process proceeded according to all the rules of asepsis and antisepsis, the scar will not show symptoms. This is why the early recovery period is so important, because it is the process of scar formation that will largely determine future life activity and possible pregnancy.

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

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

Stages of rupture

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

Causes of scars on the uterus

There can be many 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 incidence of infertility, promiscuity with a lack of protective equipment, as well as the reluctance of women to have many children.

The main cause from the point of view of pathogenesis is traumatic injury, with the development of loss of integrity of muscle tissue in the uterine area.

Among the most common reasons are the following::

Types of scar on the uterus

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

It can be:

In addition, scars vary in location. It depends on the type of surgical intervention A:

• Inferomedian or incision in the lower segment. Similar types are typical for a caesarean section.
• Corporal section will be typical for surgery to reconstruct the body of the uterus.
• Diffuse location of the scar on the uterus This is not possible with the removal of fibroids or traumatic effects.

Diagnostics

Nowadays, with the development of medical technologies, diagnosis is not difficult. But it poses a greater danger if a woman comes to the appointment already pregnant. Those. There is no preliminary assessment of the quality of the uterine scar, and the doctor is forced to choose a wait-and-see approach until the second and third screenings.

This is due to the fact that outside of pregnancy, even on old scars, it is difficult to determine the consistency, since the process of stretching the uterus does not occur.

Unfortunately, the condition of the uterine scar can only be assessed by conducting various instrumental studies. At the appointment and during an external examination, the doctor can only suspect the presence of scar elements on the woman’s uterus by the presence of scars on the anterior abdominal wall, or by clarifying the anamnesis data from which it is possible to draw a conclusion about the procedures that occurred.

Instrumental diagnostic methods include:

Since diagnosis is of great importance precisely at the time of pregnancy, a method that is non-invasive and safe for the fetus should be chosen. Currently, this is ultrasound diagnostics. It is prescribed by a doctor starting from 30 weeks of pregnancy; if there are any abnormalities in the structure, then the frequency increases to 7 or 10 days. In addition, Doppler examination and assessment of fetal vital activity using cardiotocography are performed.

Planning a pregnancy with a uterine scar

This is quite an important stage for a woman, since it is from this stage that her further progress will be determined, 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 development of a full-fledged scar on the uterus occurs, but also this period should not be too long, it should reach no more than 5-6 years, since subsequently, even a full-fledged robe is subjected to sclerosis.

A similar process subsequently also leads to the development of incompetence and possible rupture of the uterine scar. A specialist consultation with diagnostic measures is required if the question of preliminary metroplasty arises even before pregnancy.

Pregnancy with a scar on the uterus

Just a few years ago, a woman with a scar on the uterus was required to go to prenatal hospitalization and undergo surgery.

Is natural childbirth possible?

Currently, more and more doctors are inclined to the possibility that a woman can give birth naturally, even with the presence of a scar, but with the condition of its viability.

In many cases they occur without complications.

The group that can give birth on their own includes women with one history of cesarean section, the condition of a transverse incision during this operation, the presence of signs of scar consistency, 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

A repeat caesarean section is prescribed if:

Consequences of a scar

Consequences:

• These 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 beyond the organ.

Complications

The following complications may occur:

Treatment

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

1. In the absence of pregnancy, no treatment for the scar on the uterus, provided that there are no complications and everything is normal, is not required.
2. If pregnancy has occurred, then the tactics are chosen after determining the viability of the scar and the site of attachment of the fertilized egg. During a normal pregnancy, no specific measures aimed at treating the scar are required. Only the prescription of medications aimed at improving blood circulation in the mother-placenta-fetus system can be used, since there is a possibility that the pregnancy will not develop fully enough.
3. If severe scar incompetence is detected in the early stages of pregnancy or the attachment of the fertilized egg to this area, the woman is offered termination of pregnancy to avoid possible complications.

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

Forecast

This concept is quite ambiguous in relation to a uterine scar:

1. If a woman does not plan to become pregnant in the future, and also if her postoperative period proceeded without complications, then the prognosis will be favorable.
2. If a woman plans to have children in the future, the prognosis will be based primarily on an assessment of the condition of the scar.
3. If no complications arose in the postoperative period, and enough time has passed for its full formation.

In addition, it will consist of concepts of the state of dynamic development of a real pregnancy.

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

If there are such factors, then there is a possibility that it may become relatively unfavorable. When treatment tactics are taken on time and delivery is carried out in a hospital of the appropriate level with the possibility of providing assistance to the child, even if he is born premature. An unfavorable prognosis is possible if the failure is not diagnosed in time and treatment tactics are not undertaken.

Prevention

First of all, it comes down to the correct medical tactics:

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

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

Varieties of tripe

The scar can be solvent or insolvent.

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

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

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

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

Planning a pregnancy with a uterine scar

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

Scar assessment

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

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

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

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

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

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

Pregnancy with a scar on the uterus

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

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

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

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

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

Uterine tension.

Sharp pain from touching the stomach.

Strong arrhythmic uterine contractions.

Bloody vaginal discharge.

Fetal heartbeat disturbance.

After the break is completed, the following are added:

Very severe abdominal pain.

A sharp decrease in blood pressure.

Nausea and vomiting.

Stopping contractions.

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

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

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

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

The value and significance of a caesarean section is difficult to overestimate: it has already saved hundreds of thousands of lives. On the other hand, the technique, brought to perfection, provokes doctors and pregnant women to unreasonably frequently use surgical delivery.

Nowadays, more and more women prefer not to give birth through the natural birth canal, but resort to the services of surgical gynecology. The problem is that after such an operation, as a rule, a scar remains on the uterus.

Normal healing option

The human body is poorly adapted to regeneration. In response to any tissue damage, fibroblast cells are the first to react. Their high activity at the site of damage leads to the fact that the defect is closed not by the original tissue, but by connective tissue.

Connective tissue cannot fully replace muscle tissue: it can only restore the integrity of the uterus by closing the surgical incision.

As for the uterus, its body consists of several layers of smooth muscle fibers (myometrium). Smooth muscle cells are also capable of reproducing, but they divide at a much lower rate than fibroblasts. If the myometrium is incised and then sutured, a scar will form where the edges of the incision meet.

Connective tissue is significantly inferior to muscle tissue in a number of key properties:

1. Weak elasticity. A large number of collagen fibers allows the scar to be strong, but its elasticity tends to zero.
2. Lack of contractility. When needed (during childbirth), this part of the uterus will not be able to help the uterus push out the baby.
3. The inner lining (endometrium) on such a surface is very thin or does not form at all. If the embryo attaches in this place, one should be wary of the ingrowth of chorionic villi into the scar, which leads to placenta accreta.
4. At the junction of smooth muscle and scar tissue, muscle fibers lose orientation, intertwine randomly, and also cannot perform their functions.

Immediately after birth, a rapid contraction of the uterus should occur: this allows the bleeding to stop. A scar on the uterus after a previous cesarean section (CS) may interfere with the contraction process.

Reasons for development

Any more or less significant damage to the myometrium, which can occur in different situations, leads to the development of a scar. For example, these:

• Surgical delivery (CS).
• Penetrating injuries of the abdominal cavity and pelvic organs.
• Surgeries on the uterus (most often to remove fibroids).
• The use of invasive techniques for diagnostic purposes.

If myometrial defects arise, nature tries to close them quickly. The most suitable material for this is connective tissue. Everything would be fine, but when another pregnancy occurs, the uterus must withstand significant loads both during gestation and childbirth.

The scar remaining from the previous intervention may turn out to be a “weak spot” of the uterus.

This condition must be taken into account by gynecologists during monitoring of a pregnant woman. According to the International Classification of Diseases, X Revision (ICD 10), in the category “Medical care for the mother with an established or suspected anomaly of the pelvic organs (O 34),” there is a subindex O 34.2: postoperative scar of the uterus, requiring the provision of medical care to the mother.

Varieties

Women who have previously undergone uterine surgery require close attention from the antenatal clinic staff. Obstetricians-gynecologists divide scars into two large groups:

1. Wealthy. That is, those that should not affect the course of the current pregnancy and natural childbirth.
2. Insolvent. Scars that can cause problems with pregnancy and childbirth.

Evaluation criteria have been developed for them that allow them to be classified into one group or another. Current pregnancy management tactics are developed depending on the conclusion about the viability of the scar. Ultrasound, direct hysteroscopy (examination of the uterine cavity using an endoscope) and biopsy are used as diagnostic methods.

Research methods

Assessment of the health of the scar should be carried out at the stage of pregnancy planning. This recommendation is due to the fact that it is better to conduct the study twice:

1. The first is on days 4–5 of the menstrual cycle, when the endometrial layer is very thin and you can access the underlying surface. Then the scar can be easily examined during hysteroscopy, and it is easy to take a tissue sample (biopsy).
2. For the second study, 10-14 days are more suitable. A special contrast is injected into the uterine cavity and an ultrasound is performed using a vaginal probe.

The results obtained allow us to predict the likelihood of complications if a woman decides to become pregnant in the near future.

Criteria for usefulness

A healthy scar on the uterus during pregnancy is not dangerous. It is strong, dense and mature. When carrying out instrumental diagnostics, the following is revealed:

• Uniformity throughout.
• The layer of connective tissue is narrow.
• It is surrounded by smooth muscle.
• White color.
• A biopsy reveals very few fibroblast cells.
• Single vessels, large and medium caliber.

With these characteristics, pregnancy and childbirth with a uterine scar usually proceed normally. However, additional attention from obstetricians and gynecologists is still required.

To achieve a similar degree of maturity, an average of 2 to 4 years must pass after suturing the incision.

It is very rare, but cases of complete remusculization have been described. This is when even a scar on the uterus is not found. Naturally, such an outcome will be the most favorable in terms of the upcoming pregnancy and childbirth.

Criteria for immaturity

If less than two years have passed since the operation, scar failure should be expected. The degree of immaturity is judged by the following signs:

• Connective tissue appears as a heterogeneous, focal structure.
• The thickness of the seam itself is more than 1 cm or less than 3 mm.
• Swelling of the scar is noted.
• A biopsy reveals fibroblasts in large numbers.
• There are many small vessels that are woven into a disordered network.

With such characteristics of the postoperative scar, pregnancy will proceed with great difficulties and risks. The most dangerous complication is uterine rupture along the scar.

Risk factors

The best way to avoid problems with an incompetent uterine scar after a cesarean section is to immediately give birth naturally. Fortunately, modern anesthesia allows you to do this painlessly. If you cannot do without surgery (situations may be different), then you can at least reduce the likelihood of “poor” healing.

More often, incompetent scars are caused by:

• Inadequate adherence to the rules of asepsis and antisepsis during surgery: infectious complications (endomyometritis) have a very bad effect on the healing of the incision.
• The occurrence of significant blood loss.
• Surgical technique with significant trauma to the uterus.
• Suture material not removed.
• Any intrauterine manipulation within a year after surgery.
• Transition of a cut into a gap. Then the resulting defect can spread to the cervix, which leads to the appearance of scars on it.

Scars on the cervix after a classic CS should not remain. If they are the result of a rupture, then healing occurs poorly due to the poor blood supply to this section.

During subsequent pregnancies, they need to be looked after very carefully. During childbirth, they can separate, so they often serve as an indication for CS surgery.

Obstetric and gynecological tactics

Despite its apparent simplicity, cesarean section is always associated with the likelihood of postoperative complications. Therefore, even with an existing scar, the option of delivering the baby through the natural birth canal is being considered.

Routine management of pregnancy and childbirth

If the scar is well established, the woman is subject to routine observation at the antenatal clinic. However, ultrasound monitoring is recommended to be carried out more often than usual.

This is due to the fact that elastic muscle fibers stretch well, and scar tissue becomes thinner and loses strength. Therefore, it is necessary to monitor the degree of stretching of the uterus and, if the scar has become excessively thin or has lost its uniformity, take the necessary measures.

In modern obstetric practice, it is considered absolutely normal to give birth through natural means, even with several scars on the uterus.

The correctness of this trend is confirmed by the lower number of complications in the postpartum period that are associated with the operation.

Risk of pathology of pregnancy and childbirth

The failure of the uterine scar always causes many problems for both gynecologists and their patients. For such women, the likelihood of a pathological pregnancy and childbirth is very high. Possible complications:

• The growth of chorionic villi into the connective tissue of the scar, which entails placenta accreta.
• Spontaneous termination of pregnancy in the early stages.
• Anemia in pregnancy.
• Threat of miscarriage and premature birth.
• Placenta previa.
• Excessive blood loss during childbirth.
• Uterine rupture.

According to statistics, women with a history of cesarean section are more likely to suffer from pregnancy complications.

The health status of such pregnant women requires increased monitoring. Some of the possible complications can be seen at the first planned ultrasound, and appropriate pregnancy management tactics can be developed.

The last four problems on the list are very serious. The threat of miscarriage, placenta previa, and significant predicted blood loss may make vaginal birth too risky. Then all that remains is to hope for a CS operation.

The last point is extremely dangerous. Both for the life of the fetus and the mother.

Uterine rupture

As the fetus grows, the uterus increases in size due to the elasticity of its muscles. At the same time, connective tissue is not so elastic. It can stretch, but at the same time it becomes thinner and loses its strength.

In medical practice, cases are described when a rupture occurs even in a non-pregnant uterus, on which a scar remains. This occurs when using drugs that cause severe spasm of smooth muscles.

Clinical picture

A uterine rupture along a scar that occurs during pregnancy is a dangerous complication. Harbingers of danger (threatening rupture) are:

1. Gradually increasing pain in the lower abdomen, growing over several days.
2. The appearance of scanty bleeding from the vagina.
3. Increased pain when palpated in the area of ​​the postoperative scar on the skin.

It can be difficult to catch the moment when a threatened break turns into an accomplished one. The most common signs are:

1. Sharp pain in the abdomen or pelvis.
2. Signs of internal bleeding: paleness, moist skin, drop in blood pressure, weak pulse.
3. On the child's part - bradycardia.

It also happens that the breakup occurs unnoticed by the woman. So, if labor has already begun by this point, the symptom may be disguised as pushing or even absent due to anesthesia.

Then the fate of her and the child directly depends on the attention of others, the size of the defect that appears and the time spent on transportation to the hospital.

Completed uterine rupture is a resuscitation condition. If doctors suspect it, operative delivery should be performed within 10–37 minutes from the onset of persistent fetal bradycardia.

Moreover, divergence of the connective tissue itself and separation of muscle fibers from it (actually, rupture) can occur. There is a difference between them.

1. In the case of a true rupture, the muscle layers, the outer lining of the uterus and the peritoneum are damaged. If the placenta was located in the defect area, it exfoliates. This course poses a very great threat to the mother due to intense blood loss, and to the fetus due to acute placental insufficiency. Unfortunately, it is extremely rare to save a child.
2. Divergence along the scar is less dangerous, since in this case the integrity of the myometrium, the outer membranes of the uterus, is preserved. The fetus and umbilical cord remain in its cavity. The blood loss is not so massive and the woman is often able to be taken to the hospital, where an urgent surgical delivery is performed.

Stimulation of labor can also provoke a rupture. Thus, in the USA, the use of prostaglandins in women with a uterine scar is contraindicated.

Consequences

With such a serious complication, saving the child and mother is the first priority. They decide what to do next at the operating table.

It all depends on the size of the defect and the patient’s desire to give birth in the future. If the defect is small, it can be sutured. Large and longitudinal - may require unconditional removal of the uterus.

Prevention measures

To avoid such significant threats, you should always try to give birth on your own, if there are no direct indications for CS surgery.

Nowadays, an incompetent scar is not an insurmountable obstacle to a normal pregnancy and childbirth. If its strength can interfere with normal pregnancy, plastic surgery is prescribed.

During its course, all unreliable connective tissue is excised, the muscles are stitched together in layers, and then you just need to wait about 2-4 years. Until the scar, created according to all the rules, matures and it is safe to carry and give birth to a child.