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How are c section adhesions diagnosed. C-Section Adhesions: Diagnosis, Causes, Treatment & Post-Surgery Pain Management

How are C-section adhesions diagnosed. What causes adhesions after cesarean delivery. What treatment options are available for C-section scar tissue. How to manage pain from adhesions following a C-section.

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Understanding C-Section Adhesions: Formation and Impact

C-section adhesions are bands of scar tissue that form inside the abdomen after cesarean delivery. These adhesions can develop between organs, tissues, and the abdominal wall, potentially causing complications and discomfort. Understanding the formation and impact of these adhesions is crucial for both patients and healthcare providers.

Adhesions typically develop as part of the body’s natural healing process following surgery. During a C-section, the body responds to the incision and tissue manipulation by producing fibrous scar tissue. While this is a normal response, excessive scar tissue formation can lead to adhesions that may cause various issues.

Common locations for C-section adhesions

  • Between the uterus and bladder
  • Between the uterus and abdominal wall
  • Around the ovaries and fallopian tubes
  • Between the uterus and intestines

Can adhesions form after a single C-section? Yes, adhesions can develop even after a single cesarean delivery. However, the risk of adhesion formation increases with multiple C-sections or other abdominal surgeries.

Diagnosing C-Section Adhesions: Challenges and Methods

Diagnosing C-section adhesions can be challenging, as they are not always easily detectable through standard imaging techniques. In many cases, adhesions are discovered during subsequent surgeries or when they cause symptoms that prompt further investigation.

Diagnostic methods for C-section adhesions

  • Physical examination
  • Ultrasound imaging
  • MRI (Magnetic Resonance Imaging)
  • Laparoscopy
  • CT scan (in some cases)

Is MRI effective in diagnosing C-section adhesions? While MRI can provide detailed images of abdominal structures, it may not always accurately predict the presence or extent of adhesions. As demonstrated in the case report, severe adhesions between the bladder and uterus were not detected on pre-surgery MRI.

Are there any definitive methods to predict intra-abdominal adhesions before surgery? Currently, there are no methods in the literature that can predict adhesions with true certainty. This limitation highlights the importance of being prepared for potential complications during subsequent surgeries.

Causes and Risk Factors for C-Section Adhesions

Understanding the causes and risk factors associated with C-section adhesions can help healthcare providers and patients take preventive measures and manage expectations. While some factors are unavoidable, others can be mitigated through proper surgical techniques and post-operative care.

Primary causes of C-section adhesions

  1. Surgical trauma to tissues
  2. Inflammation and infection
  3. Blood or clots left in the surgical area
  4. Foreign materials (such as sutures or mesh)
  5. Genetic predisposition to excessive scar formation

Risk factors that may increase the likelihood of adhesion formation

  • Multiple C-sections or abdominal surgeries
  • Endometriosis
  • Pelvic inflammatory disease
  • Prolonged surgery time
  • Postoperative complications (e.g., infection)

Does endometriosis increase the risk of C-section adhesions? Yes, endometriosis can significantly increase the risk of adhesion formation. As seen in the case report, a patient with a history of endometriosis developed severe adhesions between the bladder and uterus, necessitating an atypical incision during the cesarean section.

Treatment Options for C-Section Adhesions

Managing C-section adhesions often depends on the severity of symptoms and the impact on a patient’s quality of life. Treatment options range from conservative approaches to surgical interventions.

Non-surgical treatment options

  • Physical therapy and exercises
  • Massage therapy
  • Pain management techniques
  • Anti-inflammatory medications

Surgical interventions for adhesions

  1. Laparoscopic adhesiolysis
  2. Open surgery for adhesion removal
  3. Hysteroscopy (for intrauterine adhesions)

What is adhesiolysis? Adhesiolysis is a surgical procedure to remove or separate adhesions. It can be performed laparoscopically or through open surgery, depending on the extent and location of the adhesions.

Are there risks associated with adhesion removal surgery? Yes, there are potential risks, including the formation of new adhesions, organ injury, and bleeding. The decision to undergo adhesion removal surgery should be carefully considered and discussed with a healthcare provider.

Managing Scar Tissue Pain After C-Section

Scar tissue pain following a C-section can be a significant concern for many women. Understanding the nature of this pain and exploring various management strategies can help improve quality of life and reduce discomfort.

Common symptoms of scar tissue pain

  • Pulling or tugging sensations
  • Sharp or burning pain
  • Numbness or tingling
  • Restricted movement or flexibility

Pain management techniques

  1. Scar massage and desensitization
  2. Heat or cold therapy
  3. Transcutaneous electrical nerve stimulation (TENS)
  4. Gentle stretching exercises
  5. Over-the-counter pain medications
  6. Prescription pain relievers (in severe cases)

How long does scar tissue pain typically last after a C-section? The duration of scar tissue pain can vary significantly among individuals. While some women may experience relief within a few months, others may have persistent pain for a year or more. Seeking early intervention and proper management can help reduce the duration and intensity of pain.

Preventing C-Section Adhesions: Surgical Techniques and Innovations

While it may not be possible to completely prevent adhesion formation, certain surgical techniques and innovations aim to reduce their occurrence and severity. Surgeons and healthcare providers are continually exploring new methods to minimize adhesion-related complications.

Adhesion prevention strategies during surgery

  • Minimally invasive surgical techniques
  • Careful tissue handling
  • Thorough irrigation of the surgical site
  • Use of anti-adhesion barriers or gels
  • Proper closure techniques

Innovative approaches to adhesion prevention

  1. Biodegradable adhesion barriers
  2. Pharmacological agents to reduce inflammation
  3. Gene therapy targeting adhesion-related proteins
  4. Stem cell-based treatments

Are anti-adhesion agents effective in preventing C-section adhesions? Anti-adhesion agents, such as barriers and gels, have shown promise in reducing adhesion formation. However, their effectiveness can vary, and they may not completely prevent adhesions in all cases. Continued research is needed to develop more effective prevention strategies.

Long-Term Implications of C-Section Adhesions

Understanding the potential long-term implications of C-section adhesions is crucial for patients and healthcare providers. These adhesions can have various effects on a woman’s health and future pregnancies.

Potential long-term effects of adhesions

  • Chronic pelvic pain
  • Infertility or difficulty conceiving
  • Increased risk of ectopic pregnancy
  • Bowel obstruction
  • Complications during future surgeries

Impact on future pregnancies and deliveries

  1. Increased risk of placenta previa or accreta
  2. Potential need for alternative incision types in future C-sections
  3. Longer surgery times due to adhesion-related complications
  4. Increased risk of bladder or bowel injury during subsequent surgeries

Can C-section adhesions affect natural childbirth in future pregnancies? While many women with a history of C-section adhesions can still have successful vaginal births after cesarean (VBAC), adhesions may increase the risk of uterine rupture or other complications. Each case should be carefully evaluated by a healthcare provider to determine the safest delivery method.

Patient Education and Support for C-Section Adhesion Management

Educating patients about C-section adhesions and providing ongoing support is essential for effective management and improved outcomes. Healthcare providers play a crucial role in empowering patients with knowledge and resources to navigate potential adhesion-related challenges.

Key components of patient education

  • Understanding the nature of adhesions and their potential impacts
  • Recognizing signs and symptoms that may indicate adhesion-related issues
  • Learning about prevention strategies and postoperative care
  • Exploring available treatment options and their pros and cons
  • Understanding the importance of follow-up care and communication with healthcare providers

Support resources for patients

  1. Support groups for women with C-section adhesions
  2. Online forums and communities
  3. Educational materials and workshops
  4. Physical therapy and rehabilitation services
  5. Psychological support and counseling

How can patients effectively communicate their concerns about C-section adhesions to their healthcare providers? Open and honest communication is key. Patients should keep a detailed record of their symptoms, including when they occur and what triggers or alleviates them. They should also prepare a list of questions and concerns to discuss during appointments, ensuring that all aspects of their condition are addressed.

By fostering a collaborative approach between patients and healthcare providers, the management of C-section adhesions can be optimized, leading to improved quality of life and better outcomes for women who have undergone cesarean deliveries.

Difficulty in predicting intra‐abdominal adhesion before cesarean section: A case report

Clin Case Rep. 2022 Mar; 10(3): e05643.

Published online 2022 Mar 27. doi: 10.1002/ccr3.5643

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Author information Article notes Copyright and License information Disclaimer

Data Availability Statement

Severe adhesions between the bladder and uterus necessitated an atypical incision in the cesarean section of a woman with endometriosis. This could not be predicted with pre‐surgery MRI. No methods in the literature are able to predict adhesions with true certainty; it is therefore still difficult to diagnose intra‐abdominal adhesions.

Keywords: adhesion, cesarean section, endometriosis, MRI

It is difficult to diagnose all conditions in the abdominal cavity by present medical procedure. We should consider the possibility of an unusual uterine incision in women with a history of endometriosis, adenomyosis, or severe dysmenorrhea.

The lower transverse incision is a basic surgical technique for cesarean sections, but other uterine incisions may be selected in certain cases, such as placenta previa and accreta. We present a case of fundal uterine incision delivery due to severe adhesions between the bladder and uterus caused by endometriosis. There is no description of such adhesion caused by endometriosis in the recent literature review regarding difficult cesarean sections by Visconti et al.
1 Moreover, we could not find a report that clarifies the provided solutions to the difficulties of performing cesarean surgery in women with endometriosis; hence, we could not predict abdominal adhesions or uterine displacement by magnetic resonance imaging (MRI) before delivery. As a consequence, we searched for methods predicting intra‐abdominal adhesions preoperatively.

A 41‐year‐old nulliparous woman diagnosed with endometriosis during treatment for infertility was referred to our hospital at 13 weeks of gestation after in vitro fertilization (IVF) and frozen embryo transfer (FET). She was prescribed low‐dose estrogen progestin pills before the IVF‐FET. We suspected placenta previa based on transvaginal ultrasound findings at 24 weeks of gestation and diagnosed the patient with total placenta previa at 30 weeks of gestation by MRI (Figure ). Massive genital bleeding and uterine contractions appeared at 31 weeks of gestation. The patient was hospitalized and prescribed magnesium sulfate intravenously (1.0 g per hour) and antenatal corticosteroids (betamethasone 12 mg twice every 24 h) intramuscularly. The symptoms recurred 4 days later, and intravenously, ritodrine hydrochloride was administered. Since tocolysis was infeasible due to the side effects of the beta‐mimetic agent, including parotid gland swelling and elevated serum amylase (3074 U/L), we performed a cesarean section under spinal anesthesia.

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(A) MRI image performed at 30 weeks of gestational age. (B) Position of the uterine walls during the operation. The bladder (shaded), anterior (crosses), fundus (horizontal stripes), and posterior (solid yellow) uterine walls are located at the front of the body

After a lower vertical abdominal incision, the right round ligament and oviduct were located in the center of the surgical field, and there were firm adhesions between the bladder and the anterior uterine wall. We made a midline vertical (classical) incision to avoid bladder injury, and a male infant weighing 1884 g was delivered in the cephalic position, with Apgar scores of 3 and 8. The infant was admitted to the Neonatal Intensive Care Unit (NICU) due to prematurity and low birth weight. The placenta was placed on the internal ostium of the uterus and was separated smoothly without massive bleeding. After the uterine suture, the incision was found to cross through the uterine fundus toward the posterior wall (Figure ). Consequently, the incision was similar to a transverse fundal uterine incision. We also found lesions of endometriosis, and adhesions between the posterior wall of the uterus and the sigmoid colon (Figure ). Anti‐adhesion agents were placed on the fundal uterine incision, and the abdominal wall was sutured. The estimated blood loss, including amniotic fluid during surgery, was 1605 ml, and the operation time was 56 min.

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(A) Bladder is still firmly adhered to the anterior wall of the uterus after suturing of the uterine wound. A uterine incision extends toward the posterior wall of the uterus. (B) After the uterine suture, the incision (dotted line) crosses through the uterine fundus (solid line) toward the posterior wall. The round ligament (vertical stripe line) and oviduct (horizontal stripe lines) are located at the center, and the bladder (dotted pattern) is firmly adhered to the anterior uterine wall

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Posterior wall of the uterus adheres to the sigmoid colon, and lesions of endometriosis are apparent (white triangle)

One day post‐surgery, the patient’s hemoglobin level was 9.2 g/dl; blood transfusion was therefore avoided. The mother was discharged 6 days after surgery. At 41 days postpartum, we found a hyperechoic lesion, representing the wound, located in the uterine fundus (Figure ). The baby was discharged from the NICU 60 days after birth, without any major complications.

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Forty‐one days after surgery, transvaginal ultrasound shows the wound (white triangle) located around the fundal of the uterus (solid white line)

Since the placenta covered the internal uterine ostium in the MRI image at 30 weeks gestation, we diagnosed the patient with placenta previa (Figure ). The bladder, anterior, fundus, and posterior uterine walls were located toward the front of the body (Figure ). This situation was not predicted upon preoperative MRI. Intraoperative findings revealed that the uterus was displaced, and the bilateral round ligaments and oviducts were located in toward the front (Figure ). The adhesions between the bladder and uterus may have resulted from endometriosis. The patient demonstrated foci at the closed Douglas pouch during the operation (Figures  and ). Endometriosis was observed only by inspection and was not confirmed by pathological examination. However, the diagnosis was assumed to be correct because there was no history of pelvic inflammatory disease or abdominal surgery. The obstetricians and radiologists of the team retrospectively discussed the prenatal MRI during the postpartum period; however, they could not detect the round ligament or oviduct in the image because of the resolving limit. We investigated whether there were other methods available to diagnose unusual uterine positions.

3.1. Difficult cesarean sections

Visconti et al
1. reviewed difficult cesarean sections. The article discussed “difficult” cesarean sections divided into four categories: difficult access to the lower uterine segment, complicated fetal extraction, laceration or organ damage, and abnormal placentation. The “difficult access” category included leiomyomas, obesity, and previous abdominal surgery, but not endometriosis. The article stated that the degree of adhesions created after abdominal surgery varies widely among individuals, making it impossible to predict. Therefore, if we are unable to distinguish between endometriosis and postoperative adhesions, adhesions caused by endometriosis are also considered difficult to predict. Previous studies have reported several methods that may predict intra‐abdominal adhesions.

3.2. Abdominal scar characteristics

There are several reports on whether differences in the color and shape of skin markers and striae gravidarum can predict intra‐abdominal adhesions in pregnant women who have had at least one prior surgery. Prospective comparative studies have reported that factors related to skin markers, such as scar color and length, are associated with intra‐abdominal adhesions.
2,
3,
4 In contrast, Taylan et al
5. denied the accuracy of predictions using these methods, and Jaafer et al
6. demonstrated that these markers are not clinically reliable.

3.3. Sliding sign

Reid et al. presented the “sliding sign” technique to predict a closed pouch of Douglas preoperatively.
7,
8 The technique using transvaginal ultrasonography is well known as a non‐invasive and effective approach for detecting endometriotic adhesions in the pouch of Douglas and deep infiltrating endometriosis. A negative “sliding sign” was noted when the anterior rectosigmoid colon or the anterior rectum was fixed to the posterior uterine fundus or retrocervix. Hudelist et al
9. also concurred with these findings and deemed them useful. Ichikawa et al
10. proposed a scoring system that allowed for an accurate prediction of pelvic adhesion status and may potentially be an indicator of postoperative adhesion and infertility.

However, all these examinations were performed in a non‐pregnant state; hence, it is doubtful whether they are useful for predicting adhesions of the anterior wall of the uterus in pregnant women, as in this case.

Baron et al
11. examined the “sliding sign” of the uterus under the inner part of the fascia of the abdominal muscles during deep breathing in the third trimester. They reported that it was useful for predicting the presence or absence of intra‐abdominal adhesions. This method may be useful for this case; however, a report of 112 pregnant women in 2021 revealed low reproducibility of these results.
12

3.4. MRI

Some articles suggested that MRI cannot be used for definitive diagnosis or endometriosis staging.
13,
14 Therefore, laparoscopy remains the procedure of choice. MRI has a high sensitivity for the diagnosis of ovarian endometriosis, but it has poor results in the detection of other types of endometrioses, including intra‐abdominal adhesions. Randall et al. reported that the “sheargram,” cine‐MRI technique depicts the amount of sliding between the abdominal contents and the wall of the abdominal cavity during respiratory cycles,
15,
16 but the results have yet to be generalized.

In this case, MRI performed during pregnancy showed a raised bladder, but no intra‐abdominal adhesions. Therefore, we concluded that adhesions are difficult to predict using MRI alone. Since our patient also had adhesions in the pouch of Douglas, it may be possible that the “sliding sign” of the posterior fornix and adhesions between the abdominal wall and uterus could be detected. However, a large clinical study of the “sliding sign” technique does not exist and therefore should be a topic for future research.

3.5. Fundal uterine incision

Kotsuji et al. reported a case of transverse fundal uterine incision in 2004,
17 and a case series in 2014,
18 which showed that this procedure has the potential to avoid transection of the placenta, preventing heavy bleeding and catastrophic fetal blood loss. However, such a case is rare, and the actual risk of uterine rupture and placenta accreta in subsequent pregnancies is unknown. In our case, the anterior uterine wall adhered to the vesicouterine pouch. We cut open the uterine corpus to create a classical incision, while avoiding bladder damage; however, a transverse fundal uterine incision was made, which may result in an increased risk of uterine rupture and placenta accreta in subsequent pregnancies.

3.6. Endometriosis and pregnancy outcome

It has been demonstrated that women with a history of endometriosis have an increased risk of obstetric complications, such as placenta previa, preterm delivery, preterm premature rupture of membranes, and stillbirth and the severity of endometriosis may have an adverse impact on pregnancy outcomes.
19,
20,
21 This case could be evaluated as stage IV in the revised American Society for Reproductive Medicine scoring system; the case has a high‐risk for obstetrical complications
20 that may develop into placenta previa and preterm delivery. Firm adhesion caused an atypical uterine incision. Several methods for predicting intra‐abdominal adhesions before surgery have been reported, and it is necessary to use such procedures. However, it is difficult to diagnose all conditions in the abdominal cavity. Physicians should consider the possibility of an unusual uterine incision in women with a history of endometriosis, adenomyosis, or severe dysmenorrhea. It is also necessary to share information with the surgical team in charge and prepare for possible damage to the surrounding organs. Advances in and increased utilization of assisted reproductive technology has resulted in an increased rate of pregnancies with severe endometriosis, which means that unexpected complications can occur during prenatal and delivery periods.

We encountered a case where the anterior wall of the uterus adhered to the vesicouterine pouch, making it difficult to perform the usual lower uterine approach for a cesarean section; the baby had to be delivered through a fundal incision. It is difficult to diagnose all conditions in the abdominal cavity by present medical procedure; so, physicians should consider the possibility of an unusual uterine incision in women with a history of endometriosis, adenomyosis, or severe dysmenorrhea.

The authors have no potential conflict of interest to declare.

Yu Wakaki involved in the clinical care of the patient and contributed to the conception, drafting, review, and revision of the manuscript. Kaori Watanabe and Yukiko Kumasaka involved in the clinical care of the patient and contributed to the conception and drafting. Rika Suzuki involved in the clinical care of the patient and contributed to the conception, drafting, review, and revision of the manusucript.

Written informed consent was obtained from the patient for the publication of this work.

We would like to thank Editage (www.editage.com) for English language editing.

Suzuki N, Wakaki Y, Watanabe K, Kumasaka Y, Suzuki R. Difficulty in predicting intra‐abdominal adhesion before cesarean section: A case report. Clin Case Rep. 2022;10:e05643. doi: 10.1002/ccr3.5643
[CrossRef] [Google Scholar]

Funding information

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

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C-Section Scar Endometriosis – Seckin Endometriosis Center

Home » C-Section Scar Endometriosis

In this Article

    • C-section scar endometriosis prevalence
    • C-section scar endometriosis causes
    • C-section scar endometriosis symptoms
    • Diagnosis
    • Treatment
    • Patient story 

C-Section Scar Endometriosis

Endometriosis lesions most commonly appear in the peritoneum, and in the ovaries, bladder, and bowels. More rarely, endometriosis can also develop in the incision site of a Cesarean section (C-section). This is called C-section scar endometriosis.

C-section scar endometriosis prevalence

Due to its varying clinical presentation and overall rareness, there are currently no concrete data on the prevalence of this type of endometriosis. The literature reports an incidence of 0.03% to 0.8%. 

The increasing number of C-section procedures means that there is also an increase in the prevalence of C-section scar endometriosis.

C-section scar endometriosis causes

The exact way in which a C-section can cause endometriosis is not clear. Factors, such as hormones or wound environment may contribute to the development of this type of endometriosis. 

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