What does a scar on the uterus mean. A scar on the uterus - everything would be fine, but how to give birth? Can he break up? Childbirth through the natural birth canal

A scar on the uterus appears, as a rule, due to surgical intervention, which can be carried out for medical reasons.

many women childbearing age having a scar on the uterus, several questions are of interest:

1. How can this circumstance affect the course of pregnancy?
2. Is natural childbirth possible if there is a scar on the uterus, or is a caesarean section inevitable?
3. What is the outcome of childbirth in the presence of a scar on the uterus?

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

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

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

1. Wealthy (or full-fledged) scar is the one in which it happened full recovery muscle fibers after surgery. Such a scar is elastic, able to stretch with an increase in the duration of pregnancy and the growth of the uterus, it is capable of contractions during contractions.
2. Insolvent (or defective) scar- this is one in which connective tissue predominates, and it is unable to stretch and contract like muscle tissue.

What operation caused a scar on the uterus?

Another aspect to consider is the type surgical intervention, as a result of which operation a scar appeared on the uterus:

1. Scar after caesarean section can be of 2 types:

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

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

Most often, small fibroids are located on the outside of the genital organ and are removed without opening the uterus, so the scar after such an operation will form more prosperous than when opening the organ cavity, when intermuscular nodes located between the fibers of the myometrium or intermuscularly are removed.

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

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

How the process of uterine tissue recovery after surgery will take place will be influenced by the course of the postoperative period, the presence of possible postoperative complications.

So, for example, after a caesarean section, you may experience:

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

Complications after conservative myomectomy may include:

• bleeding;
• hematoma formation (accumulation of blood);
• endometritis.

Abortions and curettage of the uterine cavity, performed after the operation, injure the uterine cavity and do not contribute to the normal formation of the scar. Moreover, they increase the risk of forming an inferior scar.

All these complications will complicate the healing process of the scar.

Pregnancy period after surgery

Any tissue, including the wall of the uterus, after undergoing surgery, needs time to recover. The degree of healing of the scar depends on this. For the uterus, to restore the full functioning of the muscle layer, it takes 1-2 years, therefore optimal timing pregnancy after surgery - not earlier than 1.5 years, but not later than 4 years later. This is due to the fact that the more time passes between births, the more connective tissue in the area of ​​the scar, and this reduces its elasticity.

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

Examination of the scar on the uterus

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

1. Ultrasound research. With the onset of pregnancy, this is the only possible view research. Signs indicating the inferiority of the scar - its unevenness, discontinuity of the outer contour, the thickness of the scar is less than 3-3.5 mm.
2. Hysterosalpingography- X-ray examination of the uterus and fallopian tubes after the introduction of a contrast agent into the uterine cavity. For this procedure, a special substance is injected into the uterine cavity, and then a series of x-rays, allowing to judge the state of the inner surface postoperative scar, its position, the shape of the body of the uterus and its deviation (to the side) from the midline. Using this method, it is possible to detect the inferiority of the scar, which manifests itself in a sharp displacement of the uterus, its deformation, fixation to the anterior wall, as well as irregularities in the contours and niche of the scar. However this study does not provide enough information, and therefore is rarely used today and more often as a method of additional examination.
3. Hysteroscopy- carried out with the help of ultra-thin optical instrument a hysteroscope, which is inserted into the uterine cavity through the vagina (the procedure is performed on an outpatient basis under local anesthesia). This is the most informative method study of the condition of the scar on the uterus, which is carried out 8-12 months after the operation, on day 4-5 menstrual cycle. The usefulness of the scar is evidenced by its pink color indicating muscle tissue. Deformations and whitish inclusions in the scar area indicate its inferiority.

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

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

• the threat of abortion at different times;
• placental insufficiency (lack of supply of oxygen and nutrients to the fetus), it occurs when the placenta in the scar area is not fully muscle tissue, but to the scar.

But the main danger - uterine rupture along the scar - threatens a woman during childbirth. The problem is that uterine rupture in the presence of a scar often occurs without severe symptoms, and therefore, during childbirth, constant monitoring of the condition of the scar is necessary. This is determined by palpation (palpation) of the scar area through the anterior abdominal wall. Even during contractions, it should remain even, with clear boundaries and almost painless. At the same time, they turn Special attention on the bloody issues during childbirth (there should be few of them) and the woman in labor complains of pain.

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

Childbirth in women with a scar on the uterus

Even some 10 years ago, all women who once gave birth by caesarean section were automatically sent to caesarean sections in subsequent births. This is a serious surgical procedure, after which severe complications can occur, and the recovery of a woman after surgery is much slower than after natural (vaginal) childbirth.

Complications after caesarean section could arise both because of the surgical intervention itself, and be a consequence of the chosen method of anesthesia. Among them:

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

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

The survey includes:

• collection of obstetric anamnesis: the number and outcomes of pregnancies that preceded the current one;
• identification of concomitant diseases (special attention is paid to the cardiovascular, bronchopulmonary system);
• Ultrasound examination with evaluation of the postoperative scar;
• assessment of the condition of the fetus - a study of its blood flow (doppler), cardiac activity (cardiotocography).

Childbirth through the natural birth canal

Natural childbirth is possible if the following conditions are met:

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

2. The first operation was performed according to relative indications (indications that may not occur in these births), which are required to be reported upon discharge from the maternity hospital:

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

If the indications for caesarean section were associated solely with the features of the previous pregnancy (for example, a clinically narrow pelvis, abruption or placenta previa), then the current pregnancy can (and should) end in a vaginal delivery.

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

4. The first child is healthy.

5. This pregnancy proceeded without complications.

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

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

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

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

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

After completion of natural childbirth, the walls are examined manually (under intravenous anesthesia). postpartum uterus, in order to exclude incomplete break uterus on the scar. In this case, the doctor inserts a hand in a sterile glove into the uterine cavity and carefully feels the walls of the organ (especially the area of ​​​​the postoperative scar).

If during the examination a defect is found in the area of ​​​​the scar (it could partially or completely disperse), then in order to avoid intra-abdominal bleeding, which threatens the life of the mother, an urgent operation is performed - the area of ​​\u200b\u200bthe gap is sutured.

Indications for surgery

Childbirth should be carried out by an operative method if studies of the scar on the uterus indicate its failure:

• longitudinal scar after caesarean section or uterine surgery;
• scar after 2 or more operations;
• the location of the placenta in the area of ​​​​the scar on the uterus (this increases the risk of rupture of the uterus when it is stretched and contracted).

In this case, it remains only to determine the duration of the operation, which depends on the condition of the fetus and mother.

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

Planning and managing a pregnancy with uterine scars is somewhat different from monitoring a mother-to-be without deviations from the norm. A scar is a strong seal formed by the connective tissue and fibers of the myometric layer of the uterus. Such a formation appears at the site of rupture and regeneration of the uterine wall after surgical operation. A scar on the uterus during pregnancy - is there a chance to give birth to a baby on your own or prepare for artificial delivery?

The successful development of the fetus depends primarily on the state of the mother's body. If the surface of the uterus is marked by a dissection in the past, this, of course, will immediately affect the development of a new life.

Where do pregnancy scars come from?

A rough strip of tissue on the uterus appears not only after a planned or emergency caesarean section. The need to violate the integrity of the genital muscular organ can be dictated by such factors:

• gynecological operations (excision of adenomyosis foci, fibroid nodes);
• termination of pregnancy located in the tube or cervix;
• negative consequences of artificial termination of pregnancy or intrauterine examination;
• regenerative plastic surgery of uterine anomalies (removal of the uterine horn, intrauterine septum).

What is a scar during pregnancy

Scarring is a natural process of regeneration of living tissues, the integrity of which has been broken. The cut shell can be restored by complete or incomplete regeneration. In the first case, the wound heals with a predominance of smooth muscle cells of myocytes, in the second case, strong fibrous connective tissue becomes the material for scarring.

Accordingly, a dense trace from a previous surgical incision, depending on the quality of healing, is classified based on the degree of its consistency.

Consistent (full-fledged) cicatricial formation

The scar is filled mainly with muscle tissue, the structure of which in many respects resembles the “native” tissue of the uterine wall. Wealthy scar is different a high degree elasticity, stretches well, contracts and has sufficient potential to take on the strong pressure that the entire uterus experiences during fetal enlargement and during the birth of a child.

Insolvent (inferior) cicatricial formation

The tissue of such a scar has nothing to do with the muscle. It does not have the ability to stretch and therefore will not contract during contractions. Moreover, dense tissue can simply crack, because it consists mainly of connective tissue threads, while the muscles and vessels around it are underdeveloped. During pregnancy, the uterine scar gradually becomes thinner as it increases, and this process can be affected in modern medicine there is no possibility.

If the inferiority of the scar compaction is strongly manifested (thickness does not exceed 1 mm, many inelastic fibers, there are niches and seals in the scar), this can become a significant obstacle to planning motherhood. Normally, a scar on the uterus during pregnancy is not less than 3.6 - 3.7 mm in thickness after 32 weeks of an “interesting” position, and not less than 2 mm for a period of 37 weeks.

Specificity of postoperative incision regeneration

The quality of fusion of the dissected membranes of the uterus is largely affected by the influence of the following circumstances:

Type of operation

So, the state of the scar is affected by the method of incision of the uterus during caesarean section. At planned operation and full-term pregnancy lower part uterus is cut across. The advantages of a transverse scar over a longitudinal one are obvious: the fibers of the cut muscle tissue are located transversely on the uterus, so they recover quickly and efficiently. With a longitudinal incision, the fibers cut across the muscle course heal much more slowly. Indications for longitudinal section are emergency delivery in case of severe bleeding and severe fetal hypoxia, as well as delivery for a period of less than 28 weeks.

When cutting benign neoplasm of the uterus by conservative myomectomy, during which the tumor nodes are removed, the localization of the excised nodes, the access of surgical intervention, and the very fact of dissection of the integral membrane are of great importance for the successful regeneration of damaged tissue. Small fibroids that have formed outside the uterus are removed without surgical opening of the uterine cavity. After such an operation, a completely wealthy scar is formed, which is several times stronger than the scars that remain after intracavitary surgery, when intermuscular fibroids are removed.

The scar resulting from accidental damage to the uterus after an artificial termination of pregnancy has a more elastic structure if the perforation was only sutured during the operation, without additionally dissecting the wall of the uterus.

Terms of conception after surgery

The length of time after surgery is of paramount importance for the degree of scar regeneration. A full-fledged structure of muscle tissue is restored in 1-2 years after dissection. That is why doctors recommend that women plan a second pregnancy with a uterine scar on average 1.5 to 2 years after surgery. However, a long period of time between the first and second pregnancies (more than 4 years) is also undesirable, since the scar loses its elasticity due to an increase in the percentage of connective tissue in its structure.

Forecast for the recovery period and possible difficulties

How fewer complications after the operation, the richer the scar will be. Its normal formation can be prevented by such deviations from the norm after cesarean section, such as:

• endometritis - inflammation of the inner walls of the uterus;
• partial contraction of the uterus;
• partial rejection of the placenta from the uterus, which entails the need for curettage of the uterine cavity.

Diagnostic study of the scar on the uterus

When planning a second pregnancy with a caesarean scar, it is important to full examination to make sure that the scar formation on the uterus is consistent. To do this, experts use several methods.

1. Ultrasound procedure. During the procedure, the doctor can assess the condition of the muscle tissue and suggest what the thickness of the scar on the uterus will be during pregnancy, study the degree of healing at the site of the last dissection by the presence of niches (areas in the structure of the scar that have not grown together).
2. X-ray of the uterus. With the help of the procedure, you can study the internal structure of the scar.
3. Hysteroscopy. Using special equipment, the doctor evaluates the condition of the blood vessels located in the scar tissue, its color and shape.
4. MRI. This is the only method by which the volume of connective tissue and muscle fibers in the scar structure is determined.

Unfortunately, even such a large set of diagnostic methods will not give the doctor a detailed idea of ​​the viability or failure of the cicatricial formation. You can check this only in a practical way, that is, pregnancy and childbirth.

Features of pregnancy with a scar on the uterus

A pregnancy with a scar on the uterus is in many ways more difficult than a normal one. The scar often becomes the cause of the pathological formation of the placenta - low, marginal or complete presentation. In addition, in some cases, there are different degrees of its incorrect ingrowth into the basal, muscle layer or complete germination to the outer layer. Pregnancy is unlikely to be saved if the embryo attaches to the scar area - the forecasts in this case are unpromising.

After the onset of pregnancy, the state of scar formation is carefully monitored using ultrasound. As soon as the slightest concern for the safety of the fetus appears, the expectant mother is hospitalized and, most likely, will be left under observation in the hospital until the very birth.

Most of all, you should be wary of uterine rupture along the scar during pregnancy. This happens if the scar has become too thin over time and stretched excessively during pregnancy. It is possible to predict a dangerous condition in the form of a scar divergence, focusing on the following specific signs:

1. Feeling of intense tension in the uterine region.
2. Intense pain on palpation of the abdomen.
3. Violent irregular uterine contractions.
4. Discharge of blood from the vagina.
5. Violation or absence of the heartbeat in the fetus.

When the uterus ruptures along the scar, clinical picture is replenished with the following alarming symptoms:

1. Excruciating pain in the lower abdomen.
2. The rapid development of hypotension.
3. Nausea, vomiting.
4. The fading of contractions to a complete cessation.

As a result of what happened, the fetus in the womb is deprived of vital oxygen, and in most cases the woman experiences hemorrhagic shock due to massive internal bleeding. Unfortunately, this situation can be resolved very badly: the child dies, and the uterus has to be removed. There is a chance to save the situation by spending emergency operation caesarean section, but this requires timely diagnosis of pathology.

Medical supervision of expectant mothers in the presence of complications

In the first months of pregnancy, a woman passes general examination and, if necessary, consults with doctors of related specialties. A pregnant woman will certainly be prescribed an ultrasound examination. The procedure will help to reliably establish where the embryo is attached to the uterus. If this happened near the isthmus in the anterior part of the uterine cavity (that is, next to the scar), the pregnancy will most likely be terminated by vacuum aspiration. The need for artificial elimination of the fetal egg is due to the fact that the development of the chorion in the immediate vicinity of the previous place of rupture can provoke thinning of a well-founded scar formation and, as a result, rupture of the uterus itself. If you do not intervene in the situation, the child can be born exclusively through a caesarean section. However, there are no strict prohibitions on pregnancy even in this case, so the pregnant woman herself decides on the preservation of the baby.

The next scheduled screening in combination with ultrasound and analysis of the hormonal status of the FPC is carried out at 20-22 weeks of pregnancy. At this time, it is possible to diagnose abnormalities in the development of the child, to establish whether its size corresponds to the gestational age, to detect placental insufficiency, if any. Placental insufficiency is an indication for immediate hospitalization future mother and observation of it in stationary conditions.

If the pregnancy is proceeding satisfactorily, and the scar on the woman's uterus is wealthy, the next scheduled examination awaits the pregnant woman at 37-38 weeks of pregnancy. As a rule, all procedures are carried out where the woman plans to give birth. The “scenario” of delivery is also planned in advance, thinking through the combination medicines to be applied during childbirth. In such cases, as a rule, antispasmodics, sedatives and antihypoxic agents are used to stimulate blood flow in the uterus and placenta.

Scar on the uterus and natural childbirth

A woman who has undergone uterine surgery can give birth to a child on her own, doctors say. Delivery is likely to take place without complications if the condition of the expectant mother meets the following requirements:

• only one caesarean section in the past;
• the caesarean section was performed by a transverse incision;
• high probability of viability of the scar;
• attachment of the placenta away from the scar;
• the absence of serious chronic diseases in the mother;
• no obstetric disorders;
• the position of the baby head down in the uterus;
• the absence of a reason why a cesarean was performed at the first birth.

Physicians also give great attention prenatal development of the baby, and try to foresee the availability of suitable conditions in order to carry out an emergency caesarean section if a force majeure situation arises.

It is not always possible to realize in practice the desire of a pregnant woman to give birth on her own. A completely understandable stumbling block for natural childbirth with a scar on the uterus are:

• longitudinal dissection of the uterus during the first caesarean section;
• narrow pelvis of the woman in labor;
• the location of the placenta close to the cicatricial formation;
• low placentation;
• several scars on the uterus.

Natural delivery with a scar on the uterus. Video

Caesarean section is the most frequently performed abdominal operation, exceeding the frequency of appendectomy and hernia repair combined. Increasing the caesarean section rate creates new problem, as the number of women with an operated uterus increases, and a scar on the uterus in the future is often the only indication for a second operation. The issues of the optimal caesarean section rate are at the center of discussions among obstetricians and gynecologists, a significant increase in the frequency of operative delivery both abroad and in Russia has become an "alarming problem", since the desire to solve all obstetric problems with the help of an operation turned out to be untenable. The frequency of caesarean section in MORIAH, which also includes patients with an operated uterus, was 23.7% in 2008 and 24.9% in 2009; in the Moscow region, this figure varies from 17.7 to 20.6% , while there is a tendency to increase the number of surgical deliveries in the Moscow region as a whole, which accordingly entails an increase in the number of postoperative complications.

It is known that the risk of complications in the mother during abdominal delivery increases by 10-26 times. With urgent operations, the frequency of these complications reaches 18.9%, with planned ones - 4.2%. So far, the most common endometritis (from 17 to 40% of cases). If earlier endometritis after a planned caesarean section developed in 5-6% of cases, and after an emergency - in 22-85%, then the use of antibiotic prophylaxis made it possible to reduce these figures by 50-60%. Postpartum endomyometritis is the main cause of the formation of an inferior scar on the uterus. An important problem in the formation of a wealthy scar is the activity of tissue repair in the area of ​​the wound on the uterus. The course of healing processes is determined by a large number of factors, which include: the state of the macroorganism, the technique of surgical intervention, the suture material used, the duration of the operation and blood loss, and the course of the postoperative period. endometritis and more severe complications often hidden behind the following masking diagnoses: bleeding in the postpartum period, subinvolution of the uterus, lochio- and hematometra, etc. In recent years, doctors are increasingly faced with the problem of failure of the uterine scar in the late postoperative period and at the stage of planning the next pregnancy.

The purpose of the study was to predict pregnancy complications in women with a uterine scar after caesarean section.

Material and methods

35 patients with uterine scar failure, 4 patients in the first trimester of pregnancy, 31 at the stage of preconception preparation were examined. Average age postpartum patients was 29 years. The reason for going to the doctor was chronic pelvic pain; exacerbation of "chronic inflammation of the appendages"; dysuric disorders; secondary infertility; pregnancy planning; confirmation of the previously diagnosed incompetent scar.

A caesarean section in the lower uterine segment was performed within 1 to 5 years prior to the study, both routinely and for emergency reasons. Six examined patients underwent a second caesarean section, 2 with excision of the first scar, 4 without excision of the area of ​​the former scar. Information about previous operations was obtained only from the words of the patients; statements about the indications for surgery, the features of the operation and the postoperative period were absent in most cases. Only with careful history taking and careful questioning could it be possible to identify the features of the course of the previous pregnancy and the postoperative period. The development of complications was facilitated by an "inflammatory" obstetric and gynecological history: 34.2% of patients had endometritis after childbirth; mastitis - 8.5%; wound infection - 23.5%; endometritis after abortion - 18.2%; erosion of the cervix - 22.8%; acute salpingo-oophoritis - 11.4%, chronic - 22.8% of patients; previous infertility in history occurred in 25.7% of puerperas; wearing an IUD, previous real pregnancy, - 5,7%.

An analysis of the history of childbirth, which is not available in all cases, made it possible to determine the presence of technical errors during the operation: the use of gross manual tricks removing the head (11.2%), using a continuous suture for suturing the uterus (34.2%), using a reactogenic material (11.2%), performing inadequate hemostasis (8.5%); the duration of the operation is more than 2 hours (5.7%), the presence of pathological blood loss (8.5%).

The features of the course and management of the postpartum period in patients were: a long period of subfebrile condition (85.7%); bowel dysfunction (14.2%); presence of urinary syndrome - episodes of frequent and/or painful urination (31.4%); presence of wound infection (17.1%); application various methods local sanitation of the uterus in 74.3% of puerperas (hysteroscopy, vacuum aspiration, curettage of the cavity, lavage); appointment in the postoperative period of massive infusion therapy and long-term or repeated courses of antibiotic therapy (85.7%).

All patients underwent transvaginal and transabdominal ultrasound, three-dimensional reconstruction. In some cases, hydrosonography and hysteroscopy were used to confirm the diagnosis.

Results and discussion

As criteria for the consistency of the scar on the uterus in the late postoperative period, we considered the following signs:

• typical position of the scar (Fig. 1);
• the absence of deformations, "niches", areas of retraction from the side of the serous membrane and the uterine cavity;
• the thickness of the myometrium in the region of the lower uterine segment;
• absence of hematomas in the structure of the scar, connective tissue inclusions, liquid structures;
• visualization of ligatures in the myometrium, depending on the duration of the operation and the suture material used;
• adequate blood flow;
• condition of the vesicouterine fold, Douglas space, parametria.

Rice. one. Atypical position of the scar, heterogeneity of the structure.

In 4 observations in the first trimester of pregnancy, an inconsistent scar was detected. One patient had a corporal caesarean section and a Stark caesarean section. Failure was defined as a rupture of the corporal scar with prolapse of the fetal egg under the serous membrane of the uterus (2.8%). In 3 (8.6%) cases, a sharp thinning of the scar was detected with the preservation of the myometrium no more than 2 mm, retraction of the outer contour, retraction from the uterine cavity. In connection with high risk Obstetric complications in all cases, abortion and plasty of the lower uterine segment were performed (Fig. 2, 3).

Rice. 2. The perfect scar.

Rice. 3. Pregnancy 7 weeks. Two scars on the uterus, uterine rupture along the scar.

1 - an independent scar after a cesarean section according to Stark; 2 - rupture of the uterus, the fetal egg prolapses through the corporal scar.

Signs of insolvency of the scar outside of pregnancy were manifested in the form of deformation of the outer contour of the uterus in the lower segment and at the level of the isthmus (Fig. 4), retraction of the serous membrane (Fig. 5), a sharp thinning of the myometrium (Fig. 6), the presence of a "niche" from the side of the cavity uterus or destructive changes in the scar zone with the formation of multiple cavities in the myometrium (Fig. 7, 8).

Rice. 5. Invalid scar. Cross section. Retraction of the vesicouterine fold.

Rice. 6. Partial failure of the scar. Thinning of the myometrium, connective tissue inclusions in the area of ​​the scar.

Rice. 7. Retrodeviation of the uterus. Tissue defect in the area of ​​the scar (1).

Rice. eight. Incompetent scar after three caesarean sections. Liquid inclusions in the lower segment. Myometrium is not defined.

In 3 (8.57%) cases, the reason for visiting a doctor was dysuric manifestations, the patients were observed and treated by a urologist for several years after the previous operation. Echography revealed inconsistency of the scar on the uterus, pronounced adhesive process between uterus and bladder, endometriosis Bladder. Produced surgical treatment: in 2 cases - laparoscopic access, in 1 case - laparotomy with excision of the endometrioid infiltrate, plasty of the lower uterine segment (Fig. 9, 10).

Rice. nine. Incompetent scar, myometrium in the area of ​​the scar is not defined, endometriosis of the bladder.

1 - cervix; 2 - scar defect, endometriosis.

Rice. ten. Two scars on the uterus, endometriosis of the vesicouterine fold. Arrows indicate a myometrial defect replaced by an endometrial infiltrate.

Diagnosis of an inconsistent scar on the uterus is always difficult, especially at the stage of pregnancy planning or in the early stages of a pregnancy that has already begun. Typically, neither patients nor clinicians are prepared to accept a diagnosis based on a single ultrasound examination. Verification of the diagnosis is carried out in all cases during a consultative examination, planning of surgical treatment - using hydrosonography and hysteroscopy.

The presence of a "niche" from the side of the cavity in all cases was confirmed by hysteroscopy. In 16 cases, the insolvency of the scar was confirmed and surgical treatment was performed - excision of the scar and plasty of the lower segment during laparotomy or laparoscopic access. seam failure, reoperation, generalization of the process were not noted in any case. Menstrual function was restored in all patients. Pregnancy later occurred in 7 patients, all of them reported pregnancy and were promptly delivered live children. The remaining 22 patients refused pregnancy planning at this stage due to the high risk.

Considering the young age of the majority of patients, paraphrasing somewhat, we can unconditionally agree with the opinion of Ya.P. Solsky that "... in terms of its socio-demographic consequences, an unfavorable or disabling outcome obstetric complications much more significant than the outcome of a complication of another etiology."

It must be admitted that in the short term we should not expect a decrease in the number of postoperative complications. This is due not only to an increase in the number of patients with immunopathology and extragenital pathology (obesity, diabetes), but also with a significant increase in operational activity in . It's about in particular, a significant increase in the number of abdominal births.

We believe that the identification of the main causes of the formation of an incompetent suture on the uterus after cesarean section and the early implementation of modern diagnostic and surgical measures will improve the reproductive prognosis in patients with severe postpartum complications and implement childbearing function even in the most difficult clinical situations.

Literature

1. Kovganko P.A. Caesarean section operation - past and present (http://www.noviyegrani.com/archives/title/343).

A scar on the uterus is a special formation, consisting of myometrial fibers and connective tissue, and located where the violation and further restoration of the integrity of the uterine wall during surgical intervention was performed. The planning and course of pregnancy with a scar on the uterus is somewhat different from a normal pregnancy.

The causes of a scar on the uterus are not limited to caesarean section. The integrity of the walls of the uterus can be broken during other operations: removal of fibroids, perforation of the uterine wall during curettage, rupture of the uterus during labor hyperstimulation, various plastic reconstructive surgeries (removal of the uterine horn, removal of a tubal or cervical pregnancy along with a section of the uterine cavity).

Varieties of the scar

The scar can be wealthy and insolvent.

A wealthy scar is characterized by the predominance of muscle tissue, similar to the natural tissue of the uterine wall. A wealthy scar is elastic, can stretch, shrink 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 a network of blood vessels. The gradual growth of the uterus during pregnancy leads to a thinning of such a scar. The thinning of the scar on the uterus, in turn, is an uncontrolled process, not subject to any treatment.

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

Of considerable importance is how the incision was made during caesarean section. A longitudinal incision, which is usually made for an emergency caesarean section, is more prone to leakage than a transverse incision in the lower uterus.

Planning a pregnancy with a scar on the uterus

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

Scar assessment

You can assess the condition of the scar 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 the 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 circulatory network of the scar tissue.

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

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

Pregnancy with a scar on the uterus

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

Possibly abnormal placental accreta varying degrees: to the basal layer, muscle, ingrowth into the muscle layer or complete germination up to the outer layer.

In the event that the embryo is attached to the scar area, doctors make unfavorable prognoses - the likelihood of abortion is greatly increased.

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

Most dangerous complication there may be a rupture of the uterus at the site of the scar as a result of its thinning and overstretching. precede it most dangerous condition may characteristic symptoms, indicating the beginning of the divergence of the scar:

Tension of the uterus.

Sharp pain from touching the abdomen.

Strong arrhythmic uterine contractions.

Bloody vaginal discharge.

Violation of the fetal heartbeat.

After the gap is completed, the following are added:

Very severe pain in the abdomen.

A sharp drop in blood pressure.

Nausea and vomiting.

Termination of fights.

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

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

Many people are worried about whether natural childbirth with a scar on the uterus is real. If certain requirements are met, such births may be allowed: a single caesarean section in the past with a transverse incision, presumably a wealthy scar, the normal location of the placenta behind the scar area, the absence of any concomitant diseases or obstetric pathology, the head position of the fetus, the absence of a factor that caused the previous caesarean section. It is also important to monitor the condition of the fetus and the availability of all conditions for an emergency caesarean section in the event of critical situation in close proximity to the delivery room.

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

Many women, with a scar on the uterus, are afraid of becoming pregnant. Is such fear justified?

Scar on the uterus, what is it

Damage to the uterus during childbirth, abortion and other interventions is eliminated by surgery - sutures are applied. After healing, a scar is formed - an outgrowth of connective tissue, which over time is replaced by muscle. His condition is important for the course of subsequent pregnancy and labor activity.

Diagnosis of the condition of the scar during pregnancy

If a woman's labor activity ended by caesarean section, then it is recommended to become pregnant no earlier than after 2-3 years.
A healed scar is examined by a gynecologist when planning a subsequent pregnancy or after conception. There are 2 states of it - complete and defective. Wealthy or full-fledged is the one that does not cause pain during palpation and practically does not stand out. Defective or insolvent - it is still strongly felt and causes discomfort when examined by a gynecologist.
If conception has occurred, and during the examination, the insolvency of the scar was found - this threatens with some complications, so it is better to undergo an examination before the next pregnancy.

Risk factors in the presence of a scar and possible complications

A scar on the uterus, if it has healed completely and the tissue has managed to recover, does not threaten either the mother or the child.
A failed scar can cause:

• Miscarriage at any time.
• Pathology of the formation and functions of the placenta.
• Rupture along the old seam.

In order for pregnancy and childbirth to be successful, it is important to wait for the complete healing of the scar, as well as to choose a good medical center for childbirth.

Features of pregnancy with a scar on the uterus

Regardless of whether the scar is rich or not, throughout the pregnancy, the future mother is strictly monitored. At every scheduled inspection, the gynecologist palpates the scar and conducts an ultrasound examination.
At week 35, the condition of the pregnant woman is fully analyzed, the estimated size and weight of the baby, the location of the fetus and placenta. A decision is made about how the birth will take place. It is also suggested hospitalization a few weeks before delivery.

Features of conducting childbirth with a scar on the uterus

In most cases, a caesarean section is recommended for pregnant women with a uterine scar. At the present stage, when there are drugs that enhance cell regeneration and plastic sutures, possible variant natural childbirth.
Indications for natural delivery:

• The presence of one wealthy scar.
• The scar is located in the lower part of the uterus.
• The pregnancy is proceeding normally.
• The previous child is completely healthy.
• Ultrasound confirmation of the normal state of the uterus.
• Small fruit.

Indications for labor activity through surgery for a scar on the uterus:

• Longitudinal seam.
• Third or fourth birth in a row.
• Large child.
• Wrong presentation.
• Ultrasound examination shows the failure of the scar.
• The placenta is located on the scar or very low.

In one and the second case, childbirth takes place under the supervision of specialists, after obstetricians carefully examine the condition of the uterus under anesthesia.

Rupture of the uterus along the old scar

If the pregnancy was normal, then the likelihood of complications during childbirth is reduced to zero. However, there remains a danger of tissue divergence along the old seam both during gestation and childbirth. It all depends on the type of scar and its condition at the time of pregnancy.
A rupture along the old seam occurs more often with a vertical scar. This was done in the past with a caesarean section, now it is used only in emergency cases. At the present stage, caesarean section mainly uses a horizontal incision, which rarely diverges after healing during a subsequent pregnancy.
If the rupture still occurs during gestation, then it is urgent to apply for medical care, exist real threat life of mother and child. You can identify it by the following symptoms:

• Severe pain at the site of the old suture.
• Formation above the pubis under the skin of a hard roundness (the head of the fetus can crawl into the resulting gap).
• Pain in the abdominal cavity.

During childbirth, the following signs are also connected:

• The child began to go out and abruptly came back.
• The contractions disappeared or became weaker.
• When the fights subside strong pain continues.
• Indicators are changing heart rate fetus.

Sometimes a rupture during labor can occur imperceptibly. Therefore, monitoring is carried out during and a thorough examination after childbirth.
A scar on the uterus does not deprive a woman of the opportunity to endure and give birth healthy child. It is important to plan subsequent pregnancies and undergo thorough research before conception.