Adhesions After C Section: Symptoms, Treatment & Prevention

Some women opt for a C-section while others may have to undergo this surgery because of some health complications they might be facing while pregnant. Whatever may be the reason for a woman to undergo a C-section, complications such as adhesions may arise after a few months or even after a few years of the delivery. Browse through this post and learn about the symptoms of this condition. Also, find out how you can prevent it.

What Are Adhesions?

Abdominal adhesions are a common complication of surgery. When your body undergoes the surgery, tough tissue bands may form between your abdominal tissues and organs, which are known as adhesions. It is difficult to prevent or stop them from forming. They may appear like spider webs or nylon strands that surround the organs of your body. These strands are powerful and may cause an obstruction in the blood flow or cause disruption in the functions of various internal organs.

How Do Adhesions Form After a C-Section?

Abdominal adhesions are very common, especially after abdominal surgeries such as a C-section. There is a very less likelihood of its occurrence during a laparoscopic surgery because the incision is comparatively small. However, during a c-section, a bigger incision is made. Therefore, there are more chances of trauma or injury to the peritoneum.

The peritoneum is a clear membrane that covers the abdominal organs. But when this protective and slippery lining gets damaged during a c-section, the body’s immune system gets rolling and starts healing itself. This leads to the formation of sticky scar tissue, which is also known as fibrin matrix and inflammation.

In most cases, these scar tissues or bands dissolve with the help of a biochemical process, which is also known as fibrinolysis. But during a surgical procedure, fibrinolysis may not happen that effectively because of low levels of blood chemicals that are required for the process. This means the tissues or bands do not dissolve but instead they develop into adhesions. This may occur a few weeks, few months or even years after you may have undergone a C-section. Most abdominal surgeries can cause the risk of abdominal adhesions. However, C-sections pose a much higher risk.

What Are the Symptoms of C-section Adhesions?

Here are some symptoms of adhesion pain after C-section adhesion:

• If you experience trouble in standing erect or straight.
• If you have unexplained pain in your abdomen years after undergoing a C-section.
• If you have a bloated or swollen tummy.
• If you experience pain during sexual intercourse.
• If you experience pain or tenderness in your scar.
• If you experience intense menstrual pain, especially after undergoing a C-section.
• If you experience severe pelvic pain.
• If you face secondary infertility.

What Are the Visual Characteristics of Adhesions After a C-section?

You can establish whether or not you have adhesions following a c-section by observing some simple signs. If you have an indented c-section scar, which is thick and raised, then you may have adhesions. Also, if your scar is darker than the rest of your skin colour, chances are you may have dense adhesions, which may be irrespective of the fact that the scar protrudes out, lays flat, or is indented.

What Are the Possible Complications?

Here are some complications of adhesions that can arise after a c-section:

• Adhesions can cause dyspareunia or pain during sexual intercourse.
• Adhesions may result in infertility too.
• Some women may experience pelvic pain because of adhesions.
• Adhesions may cause complications and difficulties in further abdominal surgeries.

How to Treat C-section Adhesions

The complications that occur because of adhesions can be treated. A procedure called adhesiolysis can be performed to cure infertility or pain associated with adhesions. If you experience trouble in passing stools, surgery may be conducted to reopen your intestine. In most cases, the treatments are successful, but there is always a risk of further complication, which may occur because of new adhesions. However, laparoscopic adhesiolysis may be a better option because it reduces the formation of adhesions.

How to Prevent the Formation of C-section Adhesions

It is important to learn that all surgeons are aware of the fact that adhesions may result in complications. Therefore, a number of measures adopted by the surgeons aim at minimising the risk of C-section scar adhesions:

• The use of certain medication may reduce the chances of adhesions.
• By closing the peritoneum post, a caesarean section will less likely cause adhesions.
• By creating a barrier between the damaged tissues to prevent them from sticking may minimise the occurrence of adhesions.
• One of the most effective and best ways to reduce or prevent the risk of bowel adhesions after a C-section or other kinds of complications is by opting for a vaginal delivery if possible.

Reducing the risk of adhesions is one of the best ways of saving yourself from this condition rather than having them surgically removed in the later stages of your life. For more information on this topic, it is suggested that you speak with your doctor and learn about the possible risks and options you can have.

Also Read:

Reasons of Leg Pain After C-section Delivery
How to Recover after C-section Delivery
Back Pain After C-Section

How To Tell If You Have Adhesions After C-Section

C-sections are one of the most common surgeries in the U.S. For many women a c-section isn’t a choice — it is the only safe way to deliver the baby. Most c-section are routine and go as planned. However, many women are unaware of the post-surgical complications that can occur months or even years after a C-section. When the body heals from the procedure, it forms bands of internal scar tissue called adhesions. Adhesions can cause a host of problems if left untreated, including chronic pain, female infertility and life-threatening bowel obstructions. Unfortunately, they are often misdiagnosed because adhesions and pelvic adhesions do not appear on diagnostic tests such as x-rays.

Many of us know about the scar that is left after c-section, but you may be surprised to learn that the way your scar looks can be an indication of your internal healing. Research now suggests that there is a strong correlation between the physical characteristics of an external c-section scar and the adhesions underneath it. Women can use researchers’ findings to help determine whether they have adhesions after a c-section.

What are adhesions?

Adhesions are strands of collagen that form in the body after a surgery, trauma, infection or inflammation. Unfortunately, they are rarely discussed and many patients have never heard the term ‘adhesions.’ Because they are part of the body’s natural healing process, there is no way to prevent adhesions from forming and the surgeries designed to remove them cause more to form.

Adhesions can look like spider webs covering the organs or like filmy, white strands of nylon rope constricting structures inside the body. These powerful strands of collagen wrap around structures at the healing site and can restrict blood flow or reduce the function of internal organs. They can bind tissues and organs, resulting in mild to excruciating pain.

Symptoms of Post C-Section Adhesions

When we talk to patients, they often have an ‘aha moment.’ We begin describing what someone with post-surgical adhesions typically experiences and thecommon response is “Wow, you’re describing me!” Women who have had c-section often know something is wrong – they can feel it, whether is a specific pain or a tightness that they have trouble describing. Unfortunately, many physicians will tell them that pain after c-section is common and that there is nothing to be done about it.

The following are common symptoms of adhesions after a c-section. If these describe you, you may have adhesions.

• Non-diagnosable abdominal pain (sometimes years after your c-section)
• Trouble standing up straight
• Swollen/bloated abdomen
• Pain during intercourse
• Painful bowel movements
• Secondary infertility
• Chronic pelvic pain
• Increased menstrual pain (since c-section)
• Pain/tenderness at the location of your scar

Now that you are familiar with the symptoms of post c-section adhesions, we will look at the different visual characteristics of a c-section scar and what it can tell you about the presence of adhesions.

How to Tell if You Have C-Section Adhesions

Lay flat on your back and examine your c-section scar. Women with flat, small scars without significant pigment changes (changes in skin color) are less likely to have adhesions in their pelvis. However, a scar that pulls towards the back (indented) or one that is raised and thick — with or without changes in the color of the skin in that area — suggests the presence of dense adhesions. Additionally, women with scars that are darker in color than the rest of their skin are are much more likely to have adhesions, regardless of whether the scar indents, lays flat or protrudes out.

If your scar looks like the example above — indented without any changes to the pigment — there is a high probability that you have adhesions. Because the skin is indented, women with this type of scar are more likely to have dense adhesions than those whose scar looks similar but is flat, without indentation.

If you scar looks similar to this second image above (raised with pigment change), you also likely have adhesions. Women with this type of scar are most likely to have dense adhesions, which cause pain and dysfunction, because the scar exhibits characteristics from both risk categories — raised and different pigmentation than the surrounding skin.

What to Do if You Think You Have Adhesions

If your symptoms match those described in this article and your scar resembles the examples provided, there is a high probability that you have adhesions. Few options exist for women with abdominal adhesions after a c-section. Surgeons can cut or burn (lyse) adhesions, but the invasive procedure leads to the formation of new adhesions. Some women are able to live without treatment, while others experience recurring, debilitating pain and dysfunction.

If you or a woman you know is suffering from adhesions after a c-section, we encourage you to fill out a contact form or call us at 1-352-336-1433. You will be able to schedule a phone consultation with one of our certified therapists, at no cost, and learn whether our non-surgical treatment is appropriate for you.

References:

http://www.ncbi.nlm.nih.gov/pubmed/25304098

http://www.ncbi.nlm.nih.gov/pubmed/18178195

http://www.ncbi.nlm.nih.gov/pubmed/21306338

“Oh Baby – Now That’s a Scar!” Scar Release & C-sections

By Marjorie Brook, LMT

According to the World Health Organization, cesarean (c-section), rates continue to rise around the world. The rate in the United States of America it is 32.2% and in New Zealand is 25.9%, which works out to 1-in-3 women. But no matter how well-trained the surgeon may be, there will be scar tissue formation after a C- Section. Scar tissue needs to form to help the wound heal, but there is a tiny problem: adhesions.  Adhesions occur internally when the body undergoes severe trauma such as a surgery, inflammation or infection.   Unfortunately, most doctors either fail to disclose or show concern in regard to adhesion formation and a protocol to minimize it and the issues that can arise from them has never be established.    

The most common incision for a C- Section is made horizontally (often called a bikini cut), which is just above the pubic bone. The incision is cut through the lower abdomen at the top of the pubic hair just over the hairline. The muscles of the stomach are not cut but they are pulled apart so that the doctor can gain access to the uterus. In an emergency cesarean the incision will most likely be a vertical incision (from the navel to the pubic area) which will allow a faster deliver. The surgeon also pulls the bladder down to protect it during surgery. Scarring from the incision builds up underneath the incision as well as in the uterus. As the c-section scar starts to heal and the uterus reduces back adhesions form.

Scar tissue after a C Section is not preventable. Scar tissue is fibrous tissue that replaces normal tissue after an injury. While it contains the same materials as normal tissue, the quality of the scar tissue is inferior to that of the tissue it replaces. It is very important to understand that the scar that you can see is actually only the tip of the iceberg. All surgeries involve multiple layers of sutures and go much deeper than just the visible scar on the surface.

Another significant factor to be considered is the effect of adhesion formation on the internal organs.  The organs are supposed to slip and slide around each other. Organs need this movement in order to function properly. When adhesions are present, the sliding surfaces stick to each other and drag across one another causing tensional pulls. The resulting restrictions can cause limited range of motion and pain in other areas of the body.

It can take up to two years after a surgery or trauma to fully heal.  Pain and issues may not even surface until well after the Mom has “recovered” from the surgery. Years can pass and by then, the symptoms may not be associated with the scar.

Common complaints after a c-section can include sensitivity of the scar itself and nerves being caught up in the scar tissue causing itching, hyper or hypo sensitivity.   This will make pants irritating or leave the Mom unable to feel anything from the scar to the pubic bone.  Leaning over to pick up baby can be painful. The tensional pull from the scar may cause postural changes, that along with a decrease in the support of the back from the abdominal muscles could result in back pain. The scarring can cause the adjacent muscles to develop trigger points that refer pain to areas like the clitoris or urethra.

There can be issues with lower digestion such as irritable bowel syndrome or constipation and bloating.  Adhesions around the uterus, bladder and fallopian tubes can lead to painful intercourse, frequent urination and fertility challenges. 

Let’s not forget the emotional issues that can arise as a direct result of the scar.  There is the self–consciousness about the appearance of the scar. Some women will not touch the scar and surrounding area.  A simple pull or pressure on the scar can cause a continual minor or a sudden major PTSD reaction.   Lack of sleep and mental stress from chronic pain that doctors do not acknowledge and family members do not understand can be detrimental.

Scar tissue can have an adverse effect on every one of the bodies systems.  They are interconnected and encased by the fascia and the smallest of restrictions can cause problems.  The good news is that there is much that can be done to minimize and correct the issues.

C-section scarring can be improved or corrected altogether by releasing the tissue and proper therapeutic rehab (every expecting mother needs to be trained in pelvic floor exercises for both pre & post pregnancy).  As the scar tissue is released layer by layer, and fibers encouraged to lay down in the proper alignment, the tissue will become softer and function can be restored to the tissue surround the area. This reduces tensional pulls and reduces the adhesions. The tissue needs to be released in all directions, proper circulation (lymph included) restored, range of motion and body mechanics re-established.

The body needs time to heal, so for the best results light therapy such as myofasical release and lymphatic massage can start right after the surgery.  Gentle range of motion stretching and proper body mechanics (how to feed, pick up and carry the baby etc) should be done in accordance with the mother’s ability and healing. After 12 weeks the tissue can be released via the STRAIT (Scar Tissue Release And Integrated Therapies) Method  a three-dimensional, fascial-release system that works to minimize scar-tissue development and the subsequent physiological restrictions. As tissue is forever remodeling there in no time limit to working on scars.  A difference can be made and balance restored no matter how old the scar is.

1. William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 25.
2.  Centers for Disease Control and Prevention  www.cdc.gov
3. World Health Organization http://www. who.int/

Symptoms, Causes, Diagnosis & Treatments

Overview

What is Asherman’s syndrome?

Asherman’s syndrome is an acquired condition (one you are not born with) that refers to having scar tissue in the uterus or in the cervix (the opening to the uterus). This scar tissue makes the walls of these organs stick together and reduces the size of the uterus. Asherman’s syndrome is also known as intrauterine synechiae or uterine synechiae. Synechiae means adhesions. Asherman’s syndrome is also called intrauterine adhesions (IUA).

How common is Asherman’s syndrome?

Asherman’s syndrome is considered a rare disease. It is hard to say how often it actually occurs because it is not always diagnosed. Some research estimates that IUA happen in nearly 20% of women who have had dilation and curettage (D&C) after pregnancy complications.

Symptoms and Causes

What are the symptoms of Asherman’s syndrome?

• Having very light periods (hypomenorrhea).
• Having no periods (amenorrhea).
• Having severe cramping or pain.
• Being unable to get or stay pregnant.

Some women have no symptoms, and some women have normal periods.

What causes Asherman’s syndrome?

• Scar tissue from uterine surgery like dilation and curettage (D&C). (This is the cause of more than 90% of IUA.)
• Scar tissue after a Cesarean section or from sutures used to stop hemorrhages.
• Endometriosis.
• Infections of the reproductive organs.
• Radiation treatment.

Diagnosis and Tests

What tests are used to diagnose Asherman’s syndrome?

Your doctor will take a medical history and will do a physical examination. Adhesions will not be found by physical examination. A cervical blockage might be indicated if an instrument is not able to enter the cervix.

Your doctor might order hormone tests to rule out endocrine problems, or he or she might use hormones to try to induce bleeding.

Another option is saline infusion sonography (SIS), also called sonohysterosonography or ultrasound of the uterus. SIS uses saline solution that flows into the uterus to make imaging clearer.

Hysterosalpingography uses an X-ray to look inside your uterus. This procedure allows your healthcare provider the ability to see if there are any growths or blockages in your uterus or fallopian tubes.

The best way to diagnose Asherman’s syndrome is hysteroscopy. This procedure allows the doctor to put a telescope and camera into the uterus to see the whole uterine cavity.

Management and Treatment

How is Asherman’s syndrome treated?

The goal of treatment is to make the uterus regain its normal size and shape. In addition to diagnosis, hysteroscopy can also be used to treat IUA by cutting the adhesions with very small scissors, lasers, or other types of instruments that use hooks or electrodes. You might have to have more than one procedure. In addition, after the procedures, your doctor might prescribe hormones to let your uterine lining grow back correctly. This will allow you to have normal periods again.

Prevention

Can Asherman’s syndrome be prevented?

Some researchers think that women who have any type of uterine surgery or injuries to the uterus should also have hormone therapy or mechanical separation of uterine walls after their procedures to prevent IUA. This means that a stent is left in the uterus for a period of time in order to stop IUA. Before trying to get pregnant, women who have had uterine surgeries may be advised to have imaging done to see if they have any type of adhesions.

In addition, research has shown that the timing of D&Cs can have some influence on adhesion formation. For instance, adhesions are more likely to happen if a postpartum D&C is done two to four weeks after delivery.

Outlook / Prognosis

What is the outlook for Asherman’s syndrome?

After treatment, when the uterus goes back to its correct shape and size, problems with menstruation should be resolved. This should help a woman to become pregnant if that is what she wants.

Repeat C-sections: Is there a limit?

How many C-sections can women safely have?

Answer From Yvonne Butler Tobah, M.D.

Each repeat C-section is generally more complicated than the last. However, research hasn’t established the exact number of repeat C-sections considered safe.

Women who have multiple repeat cesarean deliveries are at increased risk of:

• Problems with the placenta. The more C-sections you’ve had, the greater is your risk of developing problems with the placenta — such as the placenta implanting too deeply into the uterine wall (placenta accreta) or the placenta partially or completely covering the opening of the cervix (placenta previa). Both conditions increase the risk of premature birth, excessive bleeding, and the need for blood transfusion and the surgical removal of the uterus (hysterectomy).
• Complications related to adhesions. Bands of scar-like tissue (adhesions) develop during each C-section. Dense adhesions can make a C-section more difficult and increase the risk of a bladder or bowel injury and excessive bleeding.
• Incision-related complications. The risk of incision-related problems, such as a hernia, increases as the number of previous abdominal incisions grows. Surgical repair might be needed.

The number of C-sections you’ve had can also affect your future delivery options. A trial of labor isn’t recommended after three or more prior C-sections.

Deciding how you will deliver your next baby after a previous C-section can be a complex decision. Talk to your health care provider. He or she can help you weigh the risks of a repeat C-section against your desire for future pregnancies.

With

Yvonne Butler Tobah, M.D.

June 25, 2020

Show references

1. Berghella V. Repeat cesarean delivery. https://www.uptodate.com/contents/search. Accessed Feb. 17, 2020.
2. American College of Obstetricians and Gynecologists. Committee Opinion No. 761: Cesarean delivery on maternal request. Obstetrics & Gynecology. 2019; doi:10.1097/AOG.0000000000003006.

See more Expert Answers

.

Can We Predict the Presence and Severity of Intra-Abdominal Adhesions before Cesarean Delivery – FullText – Gynecologic and Obstetric Investigation 2017, Vol.

82, No. 6

Abstract

Aims: The study aimed to investigate whether we can predict the presence and severity of intra-abdominal adhesions before cesarean delivery using patient history, symptoms, and abdominal skin scar characteristics. Methods: In this prospective study, 143 pregnant women with history of previous abdominal surgery were included and they delivered by cesarean. Preoperative abdominal scar characteristics and symptoms as well as intraoperative abdominal adhesions were evaluated using the Manchester Scar Scale, a symptomatology questionnaire and the More Comprehensive Adhesion Scoring Method, respectively. Results: Patients with adhesions (n = 98) and without adhesions (n = 45) had similar baseline characteristics. In the adhesion group, abdominal scar scoring parameters were significantly increased. However, there was no significant correlation among total scar score, adhesion score, and symptom score. Conclusion: Despite the availability of many proposed methods, accurate prediction of the severity of surgery-related adhesions is beyond our current abilities. Therefore, as healthcare providers, obstetricians should avoid unnecessary use of the cesarean approach. This approach is more effective, beneficial, realizable, and reasonable than the prediction of surgery-related adhesions.

© 2016 S. Karger AG, Basel

Introduction

Cesarean delivery (CD) is the most widely performed obstetric surgery, and the rate at which CD is performed is increasing rapidly. In the United States, 1 in 3 women gave birth by CD in 2011; higher rates of CD are reported in developing countries, with an incidence of 40% in 2008 [1,2]. Although CD is frequently performed as per fetal indications, it can also result in various severe maternal and fetal complications in comparison to vaginal delivery, including severe hemorrhage, shock, cardiac arrest, fetal loss, major infections, venous thromboembolism, uterine rupture, and hysterectomy [3]. Additionally, one of the most important complications of CD is intra-abdominal adhesions.

Adhesions, which are abnormal bonds between the surfaces of anatomical structures, can present with varying severity after repeated intra-abdominal or pelvic surgeries. The consequences of these pathological bonds include bowel obstruction, chronic abdominal and pelvic pain, the need for re-intervention, ectopic pregnancy, infertility, and inadvertent organ injury or loss during surgery [4].

Despite the absence of a reliable noninvasive method for identifying intra-abdominal adhesions preoperatively, several authors have proposed abdominal scar features as a possible predictor for the presence and severity of adhesions [5,6,7].

As a consequence of the potentially severe complications of CD and the associated morbidity, we aimed to investigate whether the presence and severity of intra-abdominal adhesions can be predicted preoperatively using a 4-step evaluation process based on abdominal scar characteristics and associated symptoms.

Materials and Methods

This prospective cohort study was conducted at a tertiary referral center at the Ege University Hospital during the period from January 2015 to June 2015. A total of 143 patients who had undergone at least one previous abdominal surgery including laparoscopy, laparotomy, or CD were scheduled for elective CD and included in the study. Patients with systemic inflammatory and vascular diseases such as infections, including wound infections (which may alter scar formation), diabetes, endometriosis, systemic lupus erythematosus, and other types of vasculitis that can affect the nature of wound healing were excluded. Following a detailed explanation of the aims of the study, informed consent was obtained from all participants. The Ethics Committee of Ege University Hospital approved the study (reference number 14-4/4).

All patients were evaluated with a 4-step algorithm. Each step was performed by different researchers who were not informed about other assessment scores, in order to avoid bias.

The first step consisted of patient history; age, parity, body mass index, smoking, and history of previous surgeries (number and type of operations, and time since the last operation) were evaluated. As all patients were Caucasian, ethnicity was excluded from the study parameters. Additionally, full blood count results of all patients were recorded. The second step was performed by another member of the research team questioning the symptoms, which could be related with abdominal adhesions. All patients were asked about the frequency of chronic or intermittent pelvic pain, urogenital symptoms (dyspareunia, pollakiuria, urinary retention, recurrent vaginal infection, and pelvic inflammatory disease [PID]), and gastrointestinal symptoms (constipation and bloating) since the last surgery. Symptoms were rated numerically from 0 to 3 according to severity.

As the third step of the process, abdominal scar assessment was performed in the operating room while the patient was anesthetized, lying in the supine position under a standard operating light source that was focused on the abdomen. Another member of the team evaluated the abdominal scars of all subjects using the Manchester External Scar Scale and recorded photographic evidence of all scars. This scoring system was successfully applied for a wide scale of scars and consists of significant descriptors, which were correlated to histological score [8]. If there were multiple abdominal scars, the researcher included the scar with highest score for statistical analysis.

At the final step, the operating surgeon, who was not informed about the previous steps, evaluated all patients for intra-abdominal adhesions using the More Comprehensive Adhesion Scoring Method (min-max scores: 0-138) [9]. Twenty-three anatomical sites inside the abdominopelvic cavity were examined and assessed for the presence, severity (0 = none, 1 = filmy/avascular, 2 = some vascularity and/or dense, and 3 = cohesive), and extent (0 = none, 1 = coverage <26%, 2 = coverage 26-50%, and 3 = coverage >50%) of the adhesions. Based on their intraoperative total adhesion scores, patients were categorized in to 2 groups as with or without adhesion, that is, 0 or ≤1, respectively.

Ultimately, all collected data were analyzed using SPSS statistical software package version 17.0 (Chicago, IL, USA). The normality assumption for the continuous responses was checked using the Shapiro-Wilk test, and the homogeneity of variances was controlled with Levene test. Student t test and Mann-Whitney U test were used as parametric and non-parametric tests, respectively, for comparing the differences between 2 groups. Fisher exact test and chi-square test were used to assess the differences of categorical parameters. Bivariate correlations were analyzed by Pearson correlation coefficient test or Spearman’s rank correlation test. Monte Carlo Simulation Method was used when expected frequencies were lower than 20%. We assumed an aberrant pattern of scarring in 60% of women with adhesions according to the study published after assessment of scars after cesarean deliveries by Salim et al. [5]. Our power analysis was done with beta and alpha errors of 0.2 and 0.05, respectively. The assumed rate of adhesions was 35% in low scar score, compared with 65% in those with a higher scar score. Based on these parameters, we calculated that at least 100 patients would be included in the study. Significance was set at p < 0.05 and data were represented as mean ± SD.

Results

The preoperative patient characteristics and blood count results are shown in Table 1. Smoking rate, number of previous operations, and neutrophil fraction were significantly higher in patients with intra-abdominal adhesions.

Table 1

Preoperative patient characteristics and laboratory findings

Comparison of preoperative symptom assessment of patients with and without intra-abdominal adhesions is demonstrated in Table 2. The most common symptoms were recurrent vaginal infection (26.5 vs. 20%) and pelvic pain (22.4 vs. 15.5%). However, there was significant difference between the 2 groups in their expression of pelvic pain and PID, which was more predominant in patients with adhesions.

Table 2

Preoperative symptom severity scores of patients

Abdominal scar characteristics were preoperatively assessed for all patients using the Manchester Scar Scale. The records are presented in Table 3. Total scar scores with parameters of color, appearance, contour, and distortion were significantly increased in patients with abdominal adhesions. In addition, color was the most significantly increased scar parameter in patients with abdominal adhesions (p < 0.01).

Table 3

Preoperative skin scar characteristics of patients

In patients with intra-abdominal adhesions, mean adhesion score was 20.3 ± 13.1 (range 4-55). The most common locations for adhesions were observed to involve bladder (76.5%), anterior uterine surface (74.4%), omentum (66.3%), and caudal part of anterior abdominal wall (65.3%). Total adhesion score was found to increase with number of previous operations; however, severity of adhesions did not show similar correlation.

Analysis of correlations between preoperative symptom score, abdominal scar score, and abdominal adhesion score showed no statistically significant correlation either between symptoms and adhesion score or between scar score and adhesion score (Table 4). However, there was a statistically significant correlation between symptom score and scar score with a low importance rate of 18.4% (p < 0.05).

Table 4

Correlation analysis between scores of preoperative symptoms, skin scar, and adhesion

Discussion

Increasing rates of CD, without concomitant improvement in maternal and fetal mortality and morbidity, is a global concern [1,2,3]. Repeated CDs have been reported to progressively increase serious maternal complications including higher rates of hemorrhage, uterine rupture, surgical injury, adhesions, and hysterectomy [4,5,6]. Maternal morbidity is markedly raised from 15 to 83% due to the presence of placenta previa and placenta accreta, which increased significantly with repeated CDs compared to vaginal delivery [10]. Multiple CDs are also associated with an increased risk of cystotomy, ureteral injury, bowel injury, ileus, and intensive care unit admission [11]. Increasing numbers of CD are not only associated with maternal morbidity but also with perinatal complications such as stillbirth, preterm birth, and fetuses of small size for gestational age [11,12]. In addition, spontaneous abortion and cesarean scar ectopic pregnancies are important concerns that should be noted [13].

Several studies have demonstrated that CD is associated with a high risk of adhesion development mostly between the uterus and surrounding organs [14]. The presence and severity of adhesions have been reported to increase with increasing number of CD. After the first cesarean section and a third cesarean section, the incidences of adhesions were reported as 46 and 75%, respectively [15]. Although the incidence of adhesions is lower at primary CD in comparison to gynecological surgeries, the percentage of women with adhesions increases with each subsequent CD [16]. Besides many severe complications caused by adhesions, treatment procedures of adhesiolysis accounted for $1.3 billion of healthcare costs in 1994 in the United States [17].

Abdominal adhesions are pathological band-like structures that form between organ surfaces as an inflammatory response after surgery, infection, or chemical irritation. After surgical trauma, the wound healing process of peritoneal tissue involves a very complex mechanism consisting of inflammatory cells, cytokines, coagulation molecules, and fibrin deposition [18]. An imbalance in this complex molecular and cellular process results in adhesion formation starting immediately after the surgery. Infection, tissue ischemia, tissue desiccation, intraperitoneal blood, and reactive foreign bodies (such as talc powder from gloves and sutures) have been reported as being common risk factors [19]. Surgical technique, genetic factors, white blood cells, and fibroblast activities are also proposed as risk factors in adhesion development [20,21].

As a consequence of many concerns associated with adhesions, researchers are probing underlying reasons and trying to find proper and available methods to predict and decrease adhesion-related complications. In this study, we aimed to reveal whether we could predict the presence and severity of abdominal adhesions before CD by using simple and practical assessment methods that can be easily performed by every obstetrician rather than hard-to-reach and elusive techniques.

Recently, some authors suggested abdominal scar characteristics as a possible predictor for severity of intra-abdominal adhesions proposing the similarities in healing of skin and peritoneum. In 2 similar studies published by Salim et al. [5] and Kahyaoglu et al. [6], depressed abdominal scars were reported as being associated with intra-abdominal adhesions. Stocker et al. [7], using more detailed scoring methods, suggested that patients with a palpable scar were most likely to have pelvic adhesions.

However, an important point to ponder is that peritoneal wound healing occurs over the whole surface unlike skin and other tissues, which heals from the edges of disrupted epithelium [22,23]. This fundamental difference of healing behavior breaks the estimated similarity in response to injury. We have found higher abdominal scar scores in patients with abdominal adhesions but there was no statistically significant correlation between abdominal scar score and abdominal adhesion score. Even so, further trials with larger numbers are needed to investigate this issue.

Preoperative fraction of blood neutrophils, which are crucial cellular players in adhesion formation, was significantly increased in patients with adhesions [24,25]. However, the same difference was not detected for other cellular components.

According to assessment of adhesion-related symptoms, pelvic pain is the most commonly reported complaint [26]. In addition to pelvic pain, considering adhesions can disrupt the functions of pelvic organs, we also investigated other suspected symptoms such as constipation, bloating, dyspareunia, recurrent vaginal infection, PID, pollakiuria, and urinary retention. However, there was no correlation between preoperative symptom score and adhesion score.

In conclusion, this study showed that despite many proposed methods, accurately predicting the severity of surgery-related adhesions remains beyond our current abilities. Although certain imaging methods such as transabdominal and transvaginal ultrasonography, visceral slide, and cine MRI are suggested as feasible methods for identifying intra-abdominal adhesions (with accuracy of 76-92%), all reported studies were non-blinded, and none of them included pregnant patients. This is important because pregnant women have altered abdominal anatomy due to the growing uterus [27]. These methods are also commonly applied for imaging the upper abdominal segment and abdominal wall, which are far from the essential spaces of the pelvic cavity and lower abdominal segment typically operated upon during obstetric surgery. Therefore, as healthcare providers, obstetricians should aim to prevent unnecessary CD surgery. This approach is more effective, beneficial, realizable, and reasonable than the prediction of surgery-related adhesions.

Funding

No special funding.

Disclosure Statement

All authors declare that there is no conflict of interest.

Acknowledgments

The authors want to thank Dr. L.J. Stocker from University of Southampton in United Kingdom, for providing scale of adhesion scoring method which was used in our study.

References

1. 
   Hamilton BE, Hoyert DL, Martin JA, Strobino DM, Guyer B: Annual summary of vital statistics: 2010-2011. Pediatrics 2013;131:548-558.
   




2. 
   Hacettepe University Institute of Population Studies (HUIPS): Turkey Demographic and Health Survey, 2008. Ankara, Hacettepe University Institute of Population Studies, Ministry of Health General Directorate of Mother and Child Health and Family Planning, T.R. Prime Minister Undersecretary of State Planning Organization and TÜBITAK, 2009.
   




3. 
   Gregory KD, Jackson S, Korst L, Fridman M: Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol 2012;29:7-18.
   




4. 
   Marshall NE, Fu R, Guise JM: Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol 2011;205:262.e1-e8.
   




5. 
   Salim R, Kadan Y, Nachum Z, Edelstein S, Shalev E: Abdominal scar characteristics as a predictor of intra-abdominal adhesions at repeat cesarean delivery. Fertil Steril 2008;90:2324-2327.
   




6. 
   Kahyaoglu I, Kayikcioglu F, Kinay T, Mollamahmutoglu L: Abdominal scar characteristics: do they predict intra-abdominal adhesions with repeat cesarean deliveries? J Obstet Gynaecol Res 2014;40:1643-1648.
   




7. 
   Stocker LJ, Glazebrook JE, Cheong YC: Are skin scar characteristics associated with the degree of pelvic adhesions at laparoscopy? Fertil Steril 2014;101:501-505.
   




8. 
   Beausang E, Floyd H, Dunn KW, Orton CI, Ferguson MW: A new quantitative scale for clinical scar assessment. Plast Reconstr Surg 1998;102:1954-1961.
   




9. 
   Improvement of interobserver reproducibility of adhesion scoring systems. Adhesion Scoring Group. Fertil Steril 1994;62:984-988.
   




10. 
    Clark EA, Silver RM: Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol 2011;205(6 suppl):S2-S10.
    




11. 
    Nisenblat V, Barak S, Griness OB, Degani S, Ohel G, Gonen R: Maternal complications associated with multiple cesarean deliveries. Obstet Gynecol 2006;108:21-26.
    




12. 
    Smith G, Pell JP, Dobbie R: Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003;362:1779-1784.
    




13. 
    Rotas MA, Haberman S, Levgur M: Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006;107:1373-1381.
    




14. 
    Morales KJ, Gordon MC, Bates GW Jr: Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007;196:461.e1-e6.
    




15. 
    Tulandi T, Agdi M, Zarei A, Miner L, Sikirica V: Adhesion development and morbidity after repeat cesarean delivery. Am J Obstet Gynecol 2009;201:56.e1-e6.
    




16. 
    Lyell DJ: Adhesions and perioperative complications of repeat cesarean delivery. Am J Obstet Gynecol 2011;205(6 suppl):S11-S18.
    




17. 
    Ray NF, Denton WG, Thamer M, Henderson SC, Perry S: Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994. J Am Coll Surg 1998;186:1-9.
    




18. 
    Boland GM, Weigel RJ: Formation and prevention of postoperative abdominal adhesions. J Surg Res 2006;132:3-12.
    




19. 
    El-Mowafi DM, Diamond MP: Are pelvic adhesions preventable? Surg Technol Int 2003;11:222-235.
    




20. 
    Alpay Z, Saed GM, Diamond MP: Postoperative adhesions: from formation to prevention. Semin Reprod Med 2008;26:313-321.
    




21. 
    Blumenfeld YJ, Caughey AB, El-Sayed YY, Daniels K, Lyell DJ: Single- versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions. BJOG 2010;117:690-694.
    




22. 
    Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeons: Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery. Fertil Steril 2008;90(5 suppl):S144-S149.
    




23. 
    Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL: Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management. Dig Surg 2001;18:260-273.
    




24. 
    Tamagawa-Mineoka R: Important roles of platelets as immune cells in the skin. J Dermatol Sci 2015;77:93-101.
    




25. 
    Glazener CM, Abdalla M, Stroud P, Naji S, Templeton A, Russell IT: Postnatal maternal morbidity: extent, causes, prevention and treatment. Br J Obstet Gynaecol 1995;102:282-287.
    




26. 
    Latthe P, Mignini L, Gray R, Hills R, Khan K: Factors predisposing women to chronic pelvic pain: systematic review. BMJ 2006;332:749-755.
    




27. 
    Zinther NB, Fedder J, Friis-Andersen H: Noninvasive detection and mapping of intraabdominal adhesions: a review of the current literature. Surg Endosc 2010;24:2681-2686.
    

Author Contacts

Enes Taylan, MD

Department of Obstetrics and Gynecology

Ege University School of Medicine

Bornova TR-35100 Izmir (Turkey)

E-Mail [email protected]

Department of Obstetrics and Gynecology

New York Medical College

Valhalla, NY 10595 (USA)

E-Mail [email protected]

Article / Publication Details

First-Page Preview

Received: June 06, 2016
Accepted: November 26, 2016
Published online: December 20, 2016

Issue release date: November 2017

Number of Print Pages: 6

Number of Figures: 0

Number of Tables: 4

ISSN: 0378-7346 (Print)
eISSN: 1423-002X (Online)

For additional information: https://www.karger.com/GOI

Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.

Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.

Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Magnetic resonance imaging of the female pelvis after Cesarean section: a pictorial review | Insights into Imaging

Scar/niche/other terms

The cut of the uterus, like in any other surgical procedure, leads to scarring. If the patient requires imaging in the early post-Cesarean section period for some reason, we can observe the formation of the scar. If CT is performed for acute maternal indications, the healing uterine incision is seen as a hypodense part of the lower uterine segment, less enhancing than the remaining myometrium on post-contrast phases (Fig. 2). If MRI is performed for any reason, one can appreciate the signal changes in the myometrium of the lower uterine segment that depend on the time since C-section, reflecting the evolution of the blood in the incision site and forming scar which may present T2-hypointesity due to fibrous tissue (Fig. 3). If the uterine scar is incompletely healed, thinning and retraction of the uterine wall are observed with only residual myometrium adjacent to the scar. This forms a triangular or semicircular defect at the site of the scar which is T2-hyperintense and is called Cesarean scar niche. It has been defined as the indentation of the myometrium of at least 2 mm [8]. It has been reported that approximately 50% of women with a history of C-section have a uterine niche on hysterography, sonohysterography, or transvaginal ultrasonography (TVUS) [16]. The severity of complications has been related to niche size, and large niches are defined as having a depth of at least 50 or 80% of the anterior myometrium, or the remaining myometrial thickness ≤ 2.2 mm when evaluated by TVUS and ≤ 2.5 mm when evaluated by sonohysterography [17].

Fig. 2

A 34-year-old primigravida primipara 12 days after C-section complicated by dissection of the posterior wall of the uterus. CT in a venous phase shows the normal postoperative appearance of a recent cesarean delivery incision which is hypodense as compared to the intact myometrium (thin arrow)

Fig. 3

MRI of the lumbar-sacral part of the vertebral column in the sagittal plane. a FSE/T2WI. b FSE/T1WI. c STIR image. The study performed for neurological indications 2 weeks after C-section shows the forming scar in the anterior uterine wall, best appreciated as a thick hypointense band on STIR (c arrow). Blood (hyperintense on T1WI and T2WI, suppressed on STIR) and clot (T1- and T2-hypointense, slightly hyperintense on STIR) in a still distended uterine cavity

The post-C-section niche belongs to the most frequent incidental findings on MRI of the lumbar-sacral part of the vertebral column which is much more frequently performed than pelvic MRI in women. The field of view (FOV) of this study quite often covers the uterus in part or even as a whole [18]. Extension of FOV of lumbar spine MRI in women generally seems to be a good idea, because in a significant percentage of cases, low back pain may have a gynecological cause as a consequence of the C-section for instance, but also of other pathologies of the female reproductive organs. The post-C-section niche presents as thinning of the myometrium in the anterior uterine wall above the cervix (Fig. 4a, b). After repeated C-sections, there may be two or more such defects. The abnormal outline of the uterine wall may be seen on both the internal and external sides of the scar (Fig. 5).

Fig. 4

MRI of the lumbar-sacral part of the vertebral column in the sagittal plane. a FSE/T2WI. b STIR image. Post-C-section niche, hyperintense against the background of the hypointense myometrium, is shown by the arrows

Fig. 5

Pelvic MRI, FSE/T2WI in sagittal plane: two hyperintense niches after two C-sections (arrows)

It is worth mentioning at this point that there is no general consensus in the literature as far as naming of changes in the uterus after C-section is concerned, with interchangeably used terms: scar, scar defect, deficient cesarean scar, dehiscence, niche, isthmocele, pouch, diverticulum [10, 11, 19, 20].

The niche may be a reservoir of fluid or blood (hematoma soon after C-section or blood product accumulation in case of adenomyosis with T1-hyperintensity) (Fig. 6). Prolonged menstruation and abnormal postmenstrual bleeding are potential consequences. The niche may be a place of intrauterine device (IUD) malposition as well when the lower end of IUD is located in it, with—at least theoretical—risk of perforation [19].

Fig. 6

Pelvic MRI, SE/T1WI in the sagittal plane. Hyperintense blood reservoir in the C-section scar defect with intact serosa (arrow), which is isointense to the myometrium

Dehiscence/rupture

If the endometrium and full thickness of the myometrium are ruptured, we face the incomplete rupture of the uterine wall that is called uterine dehiscence: only the serosal layer is intact in such cases and visible as a thin T2-hypointense line. It can lead to complete uterine rupture (or self-amputation of the uterine body) if the serosal layer is also torn. On MRI, there is no line on the periphery of the lesion that would separate the uterus from the surrounding tissues (Fig. 7). If it happens during pregnancy, uterine rupture requires immediate surgical intervention [11] and hysterectomy may be necessary although, if possible, a uterus-saving procedure is preferred.

Fig. 7

Pelvic MRI. A 42-year-old woman with a history of three C-sections. a GRE/T2*WI in the coronal plane (skin scar is shown by a thick arrow). b FSE/T1WI and c FSE/T2WI, both in the sagittal plane, depict a huge blood reservoir (T1-hyperintense, of mixed signal intensity on T2WI) with no serosal layer (no hypointense line) on the outer surface (thin white arrows). In pathology report: adenomyosis with autoamputation of the uterine body

Adhesions

As every surgical intervention, C-section may result in adhesions—both inside (synechiae) and outside the uterus. Similar to cases of endometriosis which implies the formation of adhesions, they can be directly visualized on MRI [21]. They present as T2-hypointense bands and after C-section and are most often and best seen between the anterior uterine wall and the bladder (Fig. 8) and between the uterus and the anterior abdominal wall (Fig. 9). The abnormal uterine position and flexion resulting from the adhesions (Fig. 10) may cause chronic pain and decreased fertility. Pelvic adhesions are also associated with other complications, including bowel obstruction and tubal obstruction. The latter, as well as uterine synechiae, may be another cause of infertility [11]. It is not infrequent that in a female patient with a history of C-section referred to lumbar spine MRI due to “low back pain,” the spine is normal and post-C-section niche and adhesions and/or endometriosis are detected.

Fig. 8

The same patient as in Fig. 5. The arrow points at T2-hypointense adhesion between the uterus and the bladder

Fig. 9

Pelvic MRI in the sagittal plane. FSE/T2WI (a). CUBE/3D/T2WI (b). Thick hypointense adhesions between the abnormally flexed uterus and an anterior abdominal wall

Fig. 10

A 20-year-old woman with a history of synovial sarcoma of the right inguinal region, followed up routinely for oncological indications, 2 months (a FSE/T2WI) and 5 months (b CUBE/3D/T2WI) after C-section. The post-C-section scar is not visible; however, adhesions between the uterus and the bladder wall can be suspected (a) and are confirmed 3 months later, not only by the loss of the fat plane in between but also by the retroflexion of the uterus

Endometrial implants

Endometrial implants may be seeded on the way of surgical approach during C-section. MRI is a method of choice of their non-invasive detection [21]. Apart from adenomyosis that was mentioned before in the uterine wall itself, endometrial implants after C-section are most frequently seen in the anterior abdominal wall and in the bladder wall (Fig. 11). The foci of heterotopic endometrium in deep infiltrating endometriosis (DIE) are surrounded by hypertrophied fibrous-muscular tissue which results in the formation of solid nodules of low signal intensity on T2-weighted images. This is not always reflected in high signal intensity on T1-weighted images, or the lesions show only slightly increased signal intensity. The fat-saturated T1-weighted sequences are very important as they allow better visualization of small hyperintense endometriotic implants against a background without other hyperintense elements (fat) [21]. Even though the rates of scar endometriosis in the abdominal wall after C-section are reported as being up to 1.73% among women with endometriosis, Adriaanse et al., the authors of a large study of over 3000 women, suggest that the complication is underestimated (e.g., their study only described the incidence in women who underwent surgery, and not women with scar endometriosis who did not undergo surgery) and that with increasing rates of C-sections, the incidence will be higher [22]. Within the urinary system, the bladder is mentioned as a site most commonly affected by deep pelvic endometriosis (85% of cases). Up to 50% of patients with bladder endometriosis have a history of pelvic surgery with C-section in the first place [23]. Endometriosis is another cause of adhesions, pain, and infertility.

Fig. 11

Pelvic MRI consulted for Sports Medicine Centre, Warsaw (images published with permission). FSE/T2WI in the sagittal (a) and axial (c) planes, FSE, T1 fat-saturated image, and the sagittal plane (b). Endometriotic implants on the way of C-section: in the bladder wall (thin arrows) and in the abdominal wall (thick arrows). The lesions are mostly T2-hypointense and T1-isointense, with very tiny foci of hyperintensity

C-section scar pregnancy

C-section scar may be a place of ectopic pregnancy. This ectopy is reported among the rarest forms of ectopic pregnancies, but up to 72% of C-section scar pregnancies occur in women with a history of 2 or more Cesarean deliveries [24]. After spontaneous abortion or termination of such pregnancy, the residual tissues of the placenta and decidua (retained products of conception (RPOC)) may be difficult to remove and require treatment with methotrexate. MRI may be necessary to assess the full extent of RPOC and in treatment monitoring. The signal intensity of RPOC may be variable on both T2- and T1-weighted images depending on the presence and degree of evolution of hemorrhage and on tissue necrosis. A heterogenous mass with contrast enhancement in the uterine wall and endometrial cavity in this clinical setting represents RPOC (Fig. 12) [25].

Fig. 12

Pelvic MRI in the sagittal plane, FSE/T2WI (a). Dynamic contrast-enhanced fat-saturated T1 sequence before (b) and after (c) gadolinium administration. Retained products of conception (RPOC) of mixed signal intensity in the C-section niche after treatment with potassium chloride and methotrexate (arrows)

Abnormal placentation

Abnormal placentation may also result from previous C-section which is the independent risk factor for placenta previa in the subsequent pregnancy (Fig. 13). Prior C-section and placenta previa are the two most important risk factors for placental adhesion disorder (PAD), also called morbidly adherent placenta (MAP), which includes placenta accreta, increta, and percreta [26, 27]. MAP can lead to placental retention, uncontrollable postpartum bleeding, postpartum infection, and hysterectomy although less definitive surgical intervention and/or uterine artery embolization is preferred, if possible [11]. MRI is recommended between 24 and 30 gestational weeks (GW), with a lower degree of diagnostic success before and after these gestational ages [28], although sometimes even an early MRI may show clearly the abnormality (Fig. 14). Gradient echo sequences enable delineation of the placental-myometrial interface while spin echo sequences depict T2-hypointense bands within the placenta that suggest invasive placentation (fortunately, there is no need to distinguish placenta accreta from placenta increta due to similar treatment). The study protocol should include single-shot fast spin echo T2-weighted sequences (vendor acronyms: HASTE, SSFSE, SSTSE, FASE) and balanced gradient echo sequences (TrueFISP, FIESTA, Balanced FFE, True SSFP, respectively) in the axial, sagittal, and coronal planes with respect to the uterus. The purpose is to visualize the entire placental-myometrial interface. T1-weighted images should be used to assess for retroplacental hemorrhage and DWI sequence—for invasion, in the best projection, most often sagittal [27, 28]. The cardinal imaging findings of placenta accreta are T2-hypointense intraplacental bands, heterogeneity of the placenta, and abnormal disorganized placental vascularity (Fig. 15) [29]. Diagnosis of placenta percreta is based on the lack of the myometrium and of the fat plane between the placenta and surrounding tissues with placental signal disrupting the T2-hypointense line of the bladder and/or bowel wall, or abdominal wall muscles [28]. However, both in the literature and in the author’s own experience, there are a number of pitfalls that must be taken into account while using MRI as an adjunct to US in the diagnostic process of abnormal placentation. Possible pitfalls include the following:

• Thinning or even loss of retroplacental T2 dark zone which may be a normal finding in the growing pregnancy or may be encountered in case of uterine dehiscence after previous C-section

• Blood clots mimicking dark intraplacental bands

• Bulges indenting the bladder that suggest invasion while they may represent bladder varices (Fig. 16) or focal bulge in the region of the maternal umbilicus which is a physiological finding caused by the separation of the rectus muscles in growing pregnancy [26, 27]

Fig. 13

A 37-year-old woman, 4th pregnancy, 34 GW, history of 2 C-sections. FSE/T2WI (a) and FIESTA/2D image (b), both in sagittal projection, show placenta previa overlying completely the internal cervical os (a, thin arrow). The thick arrow points at the hypointense C-section scar in the abdominal wall (b)

Fig. 14

A 34-year-old woman, 4th pregnancy, dichorionic, diamniotic, 11 GW, history of 2 C-sections. FIESTA/2D image (a) and dynamic contrast-enhanced fat-saturated T1 sequence after gadolinium administration (b), both in sagittal projection, show placenta increta in the post-C-section scar. The urinary bladder did not show abnormalities on cystoscopy

Fig. 15

A 32-year-old woman, 3rd pregnancy, 24 GW, history of a classical C-section 2 years ago and ectopic scar pregnancy 1 year ago. FIESTA/2D image (a), SSFSE/T2WI (b), and FGR/T1WI (c), all in sagittal projection, show elevated vascularity at the placental-myometrial interface—placenta accreta in the post-C-section scar

Fig. 16

The same woman as in Fig. 13. The lack of visibility of the fragment of the bladder wall (thin arrow, a) and blurred placenta, uterus, and abdominal wall interface (thin arrow, b) are highly suggestive of placenta percreta while the bulge indenting the bladder with preserved bladder wall most likely represents the varix (thick arrow, c)

All the authors in the literature stress the necessity of complementary use of both US and MRI in these clinical situations [26,27,28,29].

90,000 Signs of adhesions in the abdominal cavity. Causes of development, treatment

Signs of abdominal adhesion, development, treatment

Adhesion often occurs after surgical interventions on the abdominal organs. It can proceed without any manifestations, but it can also cause quite pronounced discomfort. In some cases, the adhesive process occurs outside of surgical interventions and not only in the abdominal cavity.The idea of ​​this pathology, including what is the adhesion process in the small pelvis in women, will help to seek medical help in time.

Dynamics of the development of adhesive disease in the abdominal cavity

All organs of the abdominal cavity are surrounded by the peritoneum, which serves as their protection from damage. If some pathological process (often inflammatory) occurs in an organ, fibrin fibers fall out in this place, which form adhesions that limit this location from healthy organs.This process starts with a perforated stomach ulcer, destructive appendicitis, and so on. Also, adhesions can occur in the abdominal cavity as a result of surgical intervention as a reaction to the touch of surgical instruments, talcum powder that is used to treat surgical gloves, and so on.

Due to the presence of adhesions, the abdominal organs stick together. The result of such bonding will be a violation of the blood supply to the organ and its functions.So, if adhesions are formed between the loops of the intestine, intestinal obstruction is formed – there is a violation of the stool, pain in the abdomen, which are signs of an adhesions in the abdominal cavity.

In the international classification of diseases, the adhesive process in the abdominal cavity and small pelvis is considered separately.

Causes of the adhesions in the abdominal cavity

This pathological condition can develop for a variety of reasons. There are three main groups of factors that can provoke the formation of adhesions:

1. Mechanical injuries.These are abdominal injuries from a fall from a height, a bullet or knife wound, as a result of surgery.
2. Diseases of the abdominal cavity organs of an inflammatory nature. So, adhesive disease can develop as a result of the current or after the transferred cholecystitis (inflammation of the gallbladder), enteritis (inflammation of the small intestine), adnexitis (inflammation of the ovaries), and so on.
3. Chemical damage to the abdominal organs. Most often observed with the outpouring of bile or stomach contents (for example, when a perforated stomach ulcer occurs).

Adhesion often occurs in the small pelvis. It can develop rapidly, with characteristic symptoms, or be asymptomatic. So, adhesions after a cesarean section often do not appear in any way. They can be diagnosed when a woman turns to a doctor about the impossibility of getting pregnant again, since the adhesion process in the small pelvis can provoke female infertility.

Pain with intestinal adhesions and other signs

There are several signs that may indicate the development of the pathological process under consideration:

• intermittent vomiting that occurs regardless of food intake;
• pain in the abdomen or chest cavity;
• chronic constipation;
• violation of gas discharge.

These are characteristic features of the adhesion process. Pain with adhesions in the intestines may not depend on food intake and increases over time. Symptoms of diaphragmatic adhesions are manifested by pain at the border between the thoracic and abdominal cavity, impaired excursion (movement) of the diaphragm, and difficulty breathing. Clinical symptoms of adhesions in the small pelvis may be absent.

Adhesive disease is long-term: abdominal pain occurs frequently, then becomes constant, its intensity increases.

Treatment of adhesions

Treatment of postoperative adhesions is carried out using conservative and surgical methods. They are in no hurry to resort to surgical treatment, since re-introduction into the abdominal cavity can provoke an even greater development of the adhesive process. The operation is performed without fail if critical changes occur in the abdominal cavity. The severity of adhesions can only be determined during an operation – for example, performed for intestinal obstruction.The most effective method for removing adhesions that have formed around the fallopian tubes is laparoscopic surgery. The recovery process after such treatment proceeds quickly and with minimal risk of complications. At the heart of the conservative treatment of adhesive disease are diet (restriction of coarse fiber food) and physiotherapy methods.

How to treat adhesions after appendectomy, the doctor decides – it can be surgery or conservative methods of treatment (diet, physiotherapy).In the early stages of the development of the adhesive process, it can be influenced by conservative methods. Drug treatment of adhesions can also be prescribed in gynecology – for adhesions that have arisen in the area of ​​the appendages, vaginal suppositories are used, but such therapy is not very effective.

In the event of adhesions after removal of the uterus, treatment is extremely rare, since they do not cause a feeling of discomfort, and the reproductive function is in any case lost forever. The doctor determines the feasibility of treating the adhesions in this case, based on the complaints of the patients.

More detailed information on pathology, including the causes of adhesions in the chest cavity, can be obtained on our website https://www.dobrobut.com/.

Related services:

Physiotherapy
Family doctor consultation

Laparotomy metroplasty (with inconsistency of the uterine scar after Caesarean section)

Laparotomy metroplasty (with inconsistency of the uterine scar after Cesarean section)

Laparotomy metroplasty (with inconsistency of the uterine scar after Caesarean section)

At the preoperative appointment, the Gynecologist will select the most appropriate method of performing the operation, taking into account all the factors individually for each patient.

Currently, an increasing number of pregnancies end in operative delivery of the Caesarean section. In this regard, the incidence of such a pathology as inconsistency of the uterine scar has increased. It is almost impossible to avoid this complication by performing certain actions – it all depends on the woman’s body, her reaction to suture material, the location of the uterus and the previous situation that led to the use of surgical delivery.

A scar on the uterus after a cesarean section can be wealthy or inconsistent.A solid scar is of sufficient thickness and does not contain any cavities (niches). Such a scar is quite elastic and can stretch and withstand stress during pregnancy and childbirth. An insolvent scar is characterized by a small thickness, the formation of depressions (niches). Need to treat an inconsistent uterine scar? The answer depends on the patient’s further plans for childbirth, on the symptoms that bother her. The decision is made individually in each case!

Pregnancy with an inconsistent scar on the uterus is associated with the risk of rupture of the uterus during pregnancy and childbirth, rotation of the placenta in the area of ​​the scar.

All of these conditions threaten the life of the patient and the fetus. Also described is the perforation of the uterus in the niche area when an intrauterine device is inserted into the uterine cavity. Diagnosis of inconsistency of the uterine scar is difficult and requires the use of a complex of instrumental studies. All types of examinations for the establishment of this diagnosis can be carried out in our Paracelsus MC on the day you visit a gynecologist!

Ultrasound examination is an important method for assessing the course of reparative processes and assessing the viability of the scar of the operated uterus.Ultrasound criteria for a complete inconsistent scar on the uterus: complete or partial (thinning of the myometrium up to 2 mm) myometrium defect in the form of a niche (depression) in the projection of the scar on the uterus. It is also characterized by scar heterogeneity and decreased blood flow (vascularization) in the area of ​​the scar, which indicates the presence of rough scar tissue. Magnetic resonance imaging (MRI) of the pelvis is a fairly accurate method for assessing the condition of the uterine scar after cesarean section. MRI allows you to determine the size of the niche and the thickness of the uterine wall in the area of ​​the scar, to assess the state of peri-uterine tissue and the severity of the scar process in the vesicouterine space.

If an inconsistency of a scar on the uterus is found or suspected of it, according to the above studies, diagnostic hysteroscopy is indicated. In case of scar failure, the presence of a niche, retraction in the area of ​​the scar is noted. The scarcity of the vascular pattern and the whitish color of the scar tissues are often noted, which indicates the predominance of the connective tissue component. Occasionally, suture remnants and endometrioid cysts can be found in the scar area.This pathology is treated only by surgery. The most effective method of scar plasty is through the laparotomic approach. Laparotomy is an operation in which all manipulations are carried out through an incision in the anterior abdominal wall of a woman. Laparotomy access, can be longitudinal or transverse, type decision

laparotomy is accepted by the surgeon and depends on many factors, such as concomitant diseases, previous surgical interventions and the presence of a postoperative scar in the patient.

In most cases, a transverse suprapubic approach (according to Pfannenstiel) is used to perform the repair of the uterine scar. After entering the abdominal cavity, the gynecologist examines and evaluates the internal organs, isolates the uterus, and evaluates the scar.

Complete or partial excision of an inconsistent scar on the uterus within healthy tissues is performed, if necessary, separation of adhesions, after which the wall of the uterus is restored with several rows of sutures. An absorbable material is used to close the wall of the uterus.

All removed tissues must be sent for histological examination.

After examination and cleansing (sanitation) of the abdominal cavity, control of the absence of bleeding, the instruments are removed. The anterior abdominal wall is sutured. The skin is sutured with an intradermal cosmetic suture. Today there are a number of special gels that the surgeon inserts into the abdominal cavity to prevent adhesion

Readings:

1. Partial or complete inconsistency of the postoperative scar on the uterus in women planning pregnancy.
2. Complete inconsistency of the postoperative scar on the uterus with severe clinical manifestations.
3. Severe endometriosis of the uterus in the area of ​​the incompetent scar.

You can undergo the entire preoperative examination at the Paracelsus Multidisciplinary Clinic in one day! Surgery examination and validity of examination results:

• colposcopy-12 months
• Ultrasound of the pelvic organs
• Ultrasound of the kidneys, bladder, retroperitoneal space.
• Ultrasound of the veins of the lower extremities – 3 months
• Swab for flora, bacteriological culture from the cervical canal -10 days
• Oncocytology from the cervix – 6 months
• General urine analysis-10 days,
• Complete blood count and reticulocytes -10 days,
• Electrocardiogram with decoding -14 days,
• Blood for HIV, Hepatitis B, Hepatitis C, Syphilis 3 months.
• Biochemical blood test: general, direct, indirect Bilir., Total protein, albumin, urea, glucose, creatinine, uric acid, AST, ALT, alkaline phosphatase, blood sodium and potassium, cholesterol, blood pH -10dn
• Coagulogram – 10 days
• Blood group and Rh factor
• Fluorography – 6 months.
• Mammography -24 months (after 36 years)
• Ultrasound of mammary glands (up to 36 years old) -12 months
• Consultation of a therapist, anesthesiologist and other specialists according to indications.

Other examinations can be added according to indications. Anesthesia: These operations are performed under spinal anesthesia or under endotracheal anesthesia. The method of pain relief is chosen jointly by the anesthesiologist and the surgeon, of course, taking into account the wishes of the patient.

Contraindications:

Planned intervention is not performed for clinically significant blood clotting disorders, acute infections, decompensated somatic diseases (hypertension, unstable angina pectoris, severe diabetes mellitus, severe anemia).After the surgical treatment in Our MC Paracelsus, from the 1st postoperative day, the patients begin physiotherapy, which has a beneficial effect on the postoperative course and prevents the formation of adhesions, leads to full healing of the scar on the uterus.

90,000 Closure versus non-closure of the peritoneum by caesarean section: short and long-term outcome

Non-suturing of the peritoneum after caesarean section takes less operating time and therefore is less expensive, but information on possible long-term disadvantages is limited.

There are many ways to perform a caesarean section, the methods used depend on a number of factors, including the clinical situation and the preference of the operating surgeon. The peritoneum is a thin membrane of cells supported by a thin layer of connective tissue. During a caesarean section, these peritoneal surfaces must be cut in order to reach the uterus and for the baby to be born. After a caesarean section, it is standard practice to close the peritoneum by stitching (suturing) two layers of tissue that cover the abdominal cavity and cover the internal organs to restore the anatomy.However, it has been suggested that peritoneal adhesions are more likely than less likely to form if the peritoneum is sutured, possibly as a result of a tissue reaction to suture material. This review of trials considered whether or not these thin layers of tissue should be routinely sutured after delivery by caesarean section. Twenty-nine randomized controlled clinical trials were identified with differences in methodological quality; 21 trials with over 17,000 women provided data for the review.For most women, having no sutures in the peritoneum saved a few minutes [operating time] and also had shorter hospital stays. Postoperative adhesion formation was assessed in only four trials involving 282 women. They did not show any difference in leaving the two layers of the peritoneum free [uncovered] compared to closing both. Long-term outcomes have not been adequately assessed, in particular adhesion formation, reproductive failure, and ease of other operations later in life.Although the methodological quality of the studies varied, overall, the results were consistent between the best and worst quality trials. Further research is needed to further evaluate all of these outcomes.

Postoperative scar endometriosis – LOTOS MC

Pivovarov Artem Georgievich

Head of the surgical department, surgeon

Endometriosis is a chronic, progressive, recurrent and hormone-dependent disease in which benign proliferation of tissue occurs outside the uterine cavity, similar in morphological and functional properties to the endometrium.In other words, the cells that should be and function inside the uterus migrate to other organs and tissues, while continuing to perform their functions.

Symptoms and causes of the disease

We will consider one of the types of disease – postoperative scar endometriosis. Already from the name it is clear that this type of endometriosis develops after an operation, namely a cesarean section. During the operation, the endometrial cells enter the surgical wound and, under certain conditions, continue to function there.Symptoms of the disease usually appear no earlier than 6-12 months after surgery, after the restoration of the menstrual cycle. Sometimes this period lasts long enough and women go to the doctor even after a few years.

The symptomatology of the disease is cyclical. During or before menstruation, local pain appears in the area of ​​the postoperative scar, which becomes more intense with each cycle. After a while, patients find a seal in the scar area, which also becomes larger with each cycle.This usually becomes the reason for going to the doctor.

Diagnostics

Diagnosis of scar endometriosis is usually straightforward. Postponed caesarean section, the presence of an enlarging formation in the postoperative scar, which causes pain during menstruation – a combination of these three facts is enough to establish a diagnosis even without additional examination. However, patients are often referred to purulent surgeons, suspecting suppuration of the scar, and even to oncologists, suspecting a malignant process.To clarify the diagnosis, ultrasound of the abdominal wall is used, less often an MRI is required.

Treatment

Treatment of postoperative scar endometriosis is only surgical. Complete excision of the lesion within healthy tissues is required. But even this cannot 100% guarantee the absence of a relapse of the disease. In some cases, hormone therapy is prescribed before and after surgery, which is necessary to reduce the lesion and reduce the risk of recurrence.

For small superficial lesions, the operation can be performed under local anesthesia on an outpatient basis and includes only excision of endometriosis.With large and multiple foci located in the thickness of the muscles, it is necessary to perform a more voluminous intervention, which includes not only excision of the foci of endometriosis, but also plastic surgery of the abdominal wall (mini-abdominoplasty, abdominoplasty).

Such interventions are performed already under anesthesia and require hospitalization for 1-2 days.

The length of the rehabilitation period also depends on the volume of the operation.

– Pivovarov Artem Georgievich

Method of preventing bladder damage during repeated caesarean section

The invention relates to medicine, namely to the specialty of obstetrics and gynecology, and can be used to prevent damage to the bladder during repeated caesarean section, when the anatomical landmarks are violated and the wall of the bladder is “soldered” to the uterus.

Analogs of the invention:

There is a known method of retrograde isolation of the posterior wall of the bladder from adhesions after a previously transferred cesarean section with laparoscopic subtotal and total hysterectomy (Patent No. 2572448 dated 01.12.2014), which consists in separating the posterior wall of the bladder from the anterior vaginal wall and uterus from adhesions. Sequential adhesions are dissected in the medial direction from the lateral sections to the midline of the uterus. In this case, the round ligaments of the uterus, the uterine ends of the fallopian tubes, the ovarian branches of the uterine arteries, the anterior and posterior leaves of the wide ligaments of the uterus are first coagulated and dissected.The paravesicular spaces are separated from both sides to the level of the anterior vaginal fornix, the uterine vessels are coagulated, crossed from both sides, after which the posterior wall of the bladder is retrogradely “blunt” separated from the anterior vaginal fornix and the anterior surface of the cervix in the adhesion-free area. The method allows to avoid the risk of perforation of the bladder wall, to reduce intraoperative blood loss.

The disadvantage of this method (Patent No. 2572448 from 01.12.2014) is the impossibility of its use to isolate the bladder from adhesions during a cesarean section. The present invention relates to gynecology and endosurgery.

There is a known method of improving visualization of the border of the bladder wall and the uterine wall during their fusion after a previously transferred caesarean section with laparoscopic subtotal and total hysterectomy by introducing methylene blue solution into the bladder to moderate filling and sequential dissection of adhesions in the direction from the body of the uterus to its cervix [E.O. Sazonova. Laparoscopic hysterectomy: modern approaches. – Author’s abstract. dis. Cand. honey. sciences. – M., 2002. – 22 p.].

The disadvantages of this method are increased bleeding of the uterine wall and, as a result, blurred visualization of the dissection border, as well as the danger of damage to the bladder wall during its intimate fusion with the uterine wall.

Invention prototype.

The closest in purpose and set of essential features is the classic method of acute separation of the bladder.(National guidelines. Obstetrics. Ed. By E.K. Ailamazyan, V.I. Kulakov, V.E. Radzinsky, G.M.Savelyeva. 2014).

According to the known method of cesarean section with a cross section of the lower segment, the vesicouterine fold of the peritoneum is opened at the place of its greatest mobility with cutting tools, which then make a move under the peritoneum in each direction, and the fold is dissected in the transverse direction. The bladder is separated from the lower segment of the uterus with a swab.

Criticism of the prototype.

In the case of a repeated cesarean section according to the prototype, a woman in many cases has a dense fusion of the bladder with the lower segment of the uterus, and when the bladder and uterus are exposed by an “acute” or “blunt” way from the fusion of the bladder and uterus, ulceration of the urinary tract often occurs bladder and increased bleeding.

Purpose of the invention.

An object of the invention is to reduce the number of complications such as bladder injury during a second cesarean section.

The essence of the invention.

The essence of the proposed method is illustrated in Fig. 1, where the bladder – pos. 1, vesicouterine fold – pos. 2, “hydraulic cushion” – pos. 3, the wall of the uterus – pos. 4.

In case of repeated caesarean section after delimiting the abdominal cavity with napkins, a solution of sodium chloride in the amount of 40-50 ml is injected under the vesicouterine fold (Fig. 1, item 2), while under the pressure of the injected solution in the space between the bladder and the lower segment of the uterus (Fig.1 item 4) a “hydraulic” cushion is formed (Fig. 1, pos. 3). Due to the pressure of the liquid, the “soldered” vesicouterine fold (Fig. 1, item 2) is separated. Separated from the lower uterine segment, the vesicouterine fold together with the bladder (Fig. 1 pos. 1) is displaced downward.

Then the operation is performed according to the generally accepted technique: hysterotomy, fetal extraction, hysterorrhaphy, peritonization, restoration of the anterior abdominal wall.

Comparative characteristics of the essential features of the prototype and the invention.

Distinctive features of the invention and prototype.

1. Using the method when the bladder is soldered to the lower segment of the uterus.

2. Separation of the vesicouterine fold with the urinary bladder hydraulically, when a solution of sodium chloride in the amount of 40-50 ml is injected under the vesicouterine fold.

Clinical use.

The developed method of hydraulic separation of the urinary bladder from the anterior wall of the uterus was used in 110 puerperas with repeated cesarean section, who had a pronounced adhesions intraoperatively and the bladder was “soldered” to the lower segment of the uterus.

Characteristics of medical and economic efficiency.

1. It is expected to reduce the number of intraoperative complications during caesarean section, such as trauma to the bladder.

2. A decrease in postoperative complications (formation of vesicouterine fistulas) is expected.

3. Relatively low consumption of dressings and medicines.

Clinical example 1

Postpartum woman M., 37 years old.

Was admitted to the RCH maternity hospital No. 3 with a diagnosis of pregnancy 37 weeks, AAA (scar after 2 cesarean section operations).

3rd pregnancy, 3rd abdominal labor is coming. The real pregnancy was going smoothly. Examined and prepared for surgery.

Operation Caesarean section in the lower segment of the uterus.

Incision on the anterior abdominal wall according to Pfannenstiel with excision of the old scar, the anterior abdominal wall was opened in layers. An autopsy revealed a pregnant uterus, the size corresponding to the gestational age. There is a pronounced adhesive process, the bladder is “soldered” to the anterior wall of the uterus in the scar zone.A solution of sodium chloride in the amount of 40 ml was introduced under the vesicouterine fold, a “hydraulic cushion” was created, an incision was made in a place free from the bladder, and the vesicouterine fold, together with the bladder, was lowered down. Hysterotomy according to Gusakov, a male fetus weighing 3360 g, 51 cm in height was removed by the head, according to Apgar it was estimated 7-8 points. Hysterorrhaphy, peretonization, sanitation of the abdominal cavity, restoration of the anterior abdominal wall. Aseptic sticker.

The postoperative period was uneventful.

Discharged in satisfactory condition.

At the control examination in a month: no complaints, no dysuric phenomena. Ultrasound examination revealed no pathology.

Clinical example 2

Postpartum woman M., 24 years old. Was admitted to the RCH maternity hospital No. 3 with a diagnosis of 37 weeks pregnancy, breech presentation, AAA (scar after 2 cesarean section operations).

Third pregnancy, third abdominal labor is coming. The real pregnancy was going smoothly.

Examined and prepared for surgery. Operation Caesarean section in the lower segment of the uterus.

Incision on the anterior abdominal wall according to Pfannenstiel with excision of the old scar, the anterior abdominal wall was opened in layers. An autopsy revealed a pregnant uterus of the size corresponding to the gestational age. There is a pronounced adhesive process, the bladder is “soldered” to the anterior wall, in the middle third of the uterus above the scar zone. A solution of sodium chloride in the amount of 40 ml was introduced under the vesicouterine fold, a “hydraulic cushion” was created, an incision was made in a place free from the bladder, and the vesicouterine fold, together with the bladder, was lowered down.Hysterotomy according to Gusakov, a female fetus weighing 3100 g, 50 cm in height was extracted by the leg, according to Apgar it was estimated 7-8 points. Hysterorrhaphy, peretonization, sanitation of the abdominal cavity, restoration of the anterior abdominal wall. Aseptic sticker.

The postoperative period was uneventful.

Discharged in satisfactory condition.

At the control examination after 24 days: no complaints, no dysuric phenomena. Vaginal examination revealed no pathology. The ultrasound picture was normal.

Information taken into account

1. Zaripov T.Sh., Zemlyanskov P.A., Gainullina L.S. Poberezhnaya, Movergoz S.V .: Method of retrograde isolation of the posterior wall of the bladder from adhesions after a previously underwent cesarean section with laparoscopic subtotal and total hysterectomy. Patent No. 2572448 dated 01.12.2014

2. National guidance. Obstetrics. Ed. E.K. Ailamazyan, V.I. Kulakova, V.E. Radzinsky, G.M. Savelyeva 2014 – prototype.

3.E.O. Sazonov. Laparoscopic hysterectomy: modern approaches. – Author’s abstract. dis. Cand. honey. sciences. – M., 2002. – 22 p .: A way to improve visualization of the border of the bladder wall and the wall of the uterus during their fusion after a previously transferred cesarean section with laparoscopic subtotal and total hysterectomy by introducing methylene blue solution into the bladder until moderate filling and sequential dissection of adhesions in the direction from the body of the uterus to its cervix.

A method for preventing damage to the bladder during a repeated caesarean section, which consists in separating the bladder from the lower segment of the uterus, characterized in that after delimiting the abdominal cavity with napkins under the vesicouterine fold, a sodium chloride solution is injected in an amount of 40-50 ml, forming a “hydraulic cushion “, along the upper edge of the” hydraulic cushion “an incision of the vesicouterine fold is made and, together with the hydraulically separated urinary bladder, the vesicouterine fold is pushed downward, after which a hysterotomy is performed.90 057 90 000 Caesarean section interferes with the conception of the next child

A very painful process of childbirth is an inevitability that women have to face when having a baby. However, in some cases, doctors prescribe a caesarean section. Then the baby is removed during surgery through an incision in the abdomen, and the expectant mother does not have to experience severe pain caused by the opening of the birth canal and the passage of the baby through them.

Usually, such an operation is carried out for medical reasons and the purpose is to preserve the health of the mother or fetus, and not the desire to reduce the sometimes very prolonged pain of the woman in labor.

Scientists have been studying for many years how a cesarean section affects a child born in this way. There are studies that have shown that this leads to problems with immunity and overweight in children (however, some groups dispute such conclusions of colleagues).

Now scientists decided to find out how the operation affects and whether the operation affects possible sisters and brothers “Caesar.”That is, on a woman’s ability to conceive another child after such an operation.

A team of researchers from the Penn State College of Medicine looked at stories of women who gave birth by vaginal delivery and caesarean section to find the answer to this question. The data are published in the scientific journal JAMA Network Open.

Previously, scientists reported that women whose baby was born through surgery are less likely to give birth to another child. But was this due to their personal decision or is it still the consequences of the surgical intervention?

Researchers analyzed the stories of 2021 women between the ages of 18 and 35, who provided data on unprotected sex and emerging conceptions within three years after the birth of their first child.

About 600 of these women gave birth to their first child by caesarean section. It turned out that these women were more likely to be older and shorter than other women in labor, were overweight or obese. They were also more likely to seek medical help with conception, and were more likely to receive fertility testing or fertility treatments.

Approximately 69% of women who gave birth by caesarean section became pregnant after unprotected intercourse.In the case of women who gave birth to a child in the classical way, this figure was 78%.

Caesarean section should be chosen if there are serious medical indications for this. In other cases, scientists advise you to weigh the pros and cons well and, perhaps, choose another doctor who will control the birth process.

Photo Wikimedia Commons.

Importantly, women who have undergone a caesarean section are also less likely to give birth to a live child. This unenviable relationship persisted even after the researchers took into account the mother’s age, the woman’s body mass index before pregnancy, time to conception of the first child, weight gain during pregnancy, previous induced abortions, diabetes, hypertension, hospitalization during pregnancy, and other factors.

Study co-author Dr. Richard Legro notes that the advantage of the new work is that he and his colleagues examined whether factors such as trauma or pain after caesarean section interfere with the observed picture.

Legros believes that it is the accounting for unprotected intercourse (and not just the time that has passed since the first child was conceived) that has become the strength of this study. And, although the work did not establish why conceptions after surgery occurred less often, the obstetrician-gynecologist suggests that it is a matter of physiological reasons.

It is possible that bacteria from the air could enter the pelvic organs and fallopian tubes during the operation, which could affect subsequent attempts to become pregnant, says Legros. He also believes that scarring after uterine incision can have a negative impact on the subsequent embryo implantation process (although incisions are made in a different part of the uterus where implantation usually takes place).

These results of the study led scientists to create recommendations for women under 35 years old who, after a caesarean section, could not become pregnant after a year of unprotected intercourse.They advise such women to seek medical help to conceive other children.

Legros also notes that data from this study may be useful for clinicians advising women who deliberately choose between vaginal delivery and caesarean section.

It is possible that the identified differences will persuade some couples who want to have multiple children to more difficult, but still natural childbirth. Even if a caesarean section is proposed for medical reasons, it is always worth remembering that such an operation is convenient for doctors because of its predictability and the ability to plan surgical intervention in advance (as opposed to the unpredictable natural process of childbirth).Therefore, perhaps in some cases it would be more correct not to agree immediately to a cesarean section, but simply to look for another doctor.

However, it is hardly worth risking the health of the mother and child and abandoning the operation if there are serious indications for this, only because of the possible difficulties with conceiving a second child. However, new scientific evidence raises important new questions that could lead to better care for women in the postpartum period in the future.

Previously Vesti.Ru reported that caesarean section has already changed human evolution.

90,000 Caesarean section in dogs | Veterinary clinic Ark. Animal Reproduction and Health Center

Caesarean section is an operation to remove puppies from the female’s uterus.

Caesarean section can be a planned or emergency operation.

Indications for Caesarean section in dogs:

An indication for urgent surgery is the pathological course of the labor process, that is, when the dog cannot give birth to puppies even with the help of obstetric manipulations.Pathologies can be from the mother, fetuses, or a combination of these two reasons.

On the mother’s side, primary or secondary birth weakness is more common.

With primary birth weakness, labor did not start on time. In this case, the uterus does not respond to impulses from the fetus. Causes can be “single puppy syndrome”, or excessive stretching of the myometrium (muscles of the uterus), for example, due to many puppies, excess amniotic fluid, large fetuses.

Secondary birth weakness develops due to the depletion of the myometrium, as a result of obstruction of the birth canal (torsion, damage to the uterus, the discrepancy between the size of puppies and the birth canal, the presence of several puppies in the birth canal at the same time).

On the part of the fetus, the consequence that causes the pathology of labor are: atypical position, deformities, large fetuses, intrauterine death of the fetus.

Emergency Caesarean section is used when other methods of obstetrics have proved ineffective.

Bitches of some breeds are subjected to planned Caesarean section due to the anatomical features of the structure of the pelvic bones and skull: bulldog, chihuahua, corgi. Also, if a female of a breed prone to multiple births has a singleton pregnancy (single puppy syndrome).

What difficulties do doctors and breeders face during the planned operation:

It is very important to correctly determine the timing of the operation, since if it is carried out early, when the puppies are not yet ready for extrauterine life, then they are more likely to die. Also, if the female is “walking over” the pregnancy, there is a danger that the puppies will die in utero.

Therefore, to determine the time of the operation, the doctor may prescribe additional studies: an ultrasound scan to assess the viability of the fetus, a progesterone test to confirm that the hormonal background corresponds to the end of pregnancy.

It is also recommended that dog owners measure females’ temperature in the last week of gestation twice a day to track temperature drops indicating the end of fruiting.

What can you ask the surgeon who will perform the Caesarean section:

If the time and condition of the dog permits, make an intradermal (cosmetic) suture so that the puppies do not lick the sutures and do not need to be removed.

Leave one placenta. If the female rejects her cubs (there is no maternal instinct), it is recommended to anoint the backs of the babies with the placenta so that the dog, smelling and licking the puppies, understands that these are her own children.To show the maternal instinct, you can also anoint the puppies with the urine of the female.
It should be noted about some stereotypes among the owners: that after the Caesarean section in the next pregnancy, they will have to perform the operation again, that after the operation the female will not have milk.

Every pregnancy and childbirth is unique, so it is difficult to predict these physiological processes in advance. If you have any questions, it is better to discuss your options with your doctor in advance when you need to go to the clinic.

Situations when you need to contact the clinic:

The rectal temperature has decreased, and again increased to normal, but labor does not begin.
The dog has a greenish-brown discharge from the loop, but the puppy is not born after 2 hours.
Red outflows from the loop.
Contractions are not observed, although the amniotic fluid came out more than 2 to 3 hours ago.
Weak, intermittent pushing for 2 – 3 hours.
Strong pushing lasts 20 – 30 minutes, but the puppy does not come out.
More than 2 – 3 hours have passed since the fetus emerged, but another puppy does not come out.
In case you are not sure that the dog has given birth to all the puppies.