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THE ROLE OF ULTRASONIC STUDY IN THE DIAGNOSIS OF
UTERINE SCAR FAILURE IN PREGNANT WOMEN AFTER CESAREAN
SECTION
Olimjonova Saodatxon Maxammadjon qizi
Master's student of the Department of Obstetrics and Gynecology of the
Tashkent Medical Academy
An Andrey Vladimirovich
Associate Professor, Department of Obstetrics and Gynecology, Doctor of
Medical Sciences, Tashkent Medical Academy
https://doi.org/10.5281/zenodo.14557783
Abstract.
The significant frequency of cesarean sections, which has been 15-
30% or more in recent years, leads to a pressing problem — an increase in the
number of women of reproductive age with a uterine scar. The postulate "once a
cesarean section — always a cesarean section", which is dominant in the
management of this contingent of women, should become a thing of the past.
According to the authors, the frequency of conservative delivery of women with
a uterine scar after a cesarean section ranges from 30 to 70%. The choice of
tactics for managing labor in such women mainly depends on the condition of
the uterine scar. Difficulties in assessing the condition of the uterine scar during
pregnancy are due to the lack of expression of clinical symptoms and limitations
in the use of objective research methods. According to the authors, such a
clinically significant symptom as local pain during palpation in the lower
abdomen with scar failure is detected only in 18.3% of cases. Methods for
examining the condition of the uterine scar during pregnancy are very limited,
and practically the only one is ultrasound scanning (ultrasound).
Keywords:
uterine scar, niche, isthmocele, ultrasound.
In a normal pregnancy, ultrasound examination of women with a uterine
scar should be performed at least three times (upon registration, at 20-24 weeks
of pregnancy, and at 30-32 weeks). It is advisable to perform echography of the
uterine scar at 34-36 weeks of pregnancy with a formed lower uterine segment,
which is when ultrasound examination is most informative and has the greatest
practical significance.
Indications for the first cesarean section were distributed as follows:
abnormal labor activity that could not be corrected with medication — 15
women (38.5%), clinically contracted pelvis — 8 (20.5%), breech presentation
of the fetus — 8 (20.5%), increasing severity of chronic fetal hypoxia — 3
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(7.7%), premature placental abruption — 2 (5.1%), large fetus — 2 (5.1%),
severe gestosis — 1 woman (2.6%). Clinical signs of scar failure in the form of
discomfort, pain in the lower uterine segment, local tenderness in the lower
abdomen were determined in 6 pregnant women (15.3%). In these cases, the
clinical data coincided with the echographic picture of scar failure.
During ultrasound examination of the myometrium in the lower uterine
segment, the scar was carefully assessed based on the following features:
measurement of the overall thickness, uniformity of the scar, presence of
thinning areas, scar structure, presence of acoustically dense areas indicating
connective tissue degeneration of the scar area, scar contours and its
echogenicity. A uniform scar 4-5 mm thick, uniform in thickness throughout,
with clear even contours, without thinned areas, acoustic compactions, with
normal echogenicity of the lower segment, similar to that in other parts of the
uterus, was considered viable during ultrasound examination.
A healthy scar was diagnosed in 25 pregnant women (64.2%). Of this group,
3 pregnant women (12%) were delivered vaginally, 22 pregnant women were
re-operated on a planned basis for various obstetric indications. Of these, 9
women (40.9%) had a clinically narrow pelvis, 3 (13.6%) had breech
presentation of the fetus, 5 (22.7%) had a large fetus, 4 (18.2%) had a severe
form of gestosis, 1 pregnant woman (4.6%) had the placenta located in the scar
area.
An insolvent scar was diagnosed by ultrasound in 10 pregnant women
(25.6%), of whom 9 women were operated on urgently and one on a planned
basis. During a repeated planned cesarean section, the uterine scar was
insolvent in 7 pregnant women, false-positive results were observed in 3
women, and scar insolvability was not confirmed during the operation.
Thus, as a result of the study of the scar area during surgery in 14 women
with a questionable or incompetent scar during ultrasound, it was found that the
coincidence of the echographic assessment and the actual state of the uterine
scar was confirmed during surgery in 9 of 14 pregnant women (64.3%). In 4
cases out of 25 (16%) there was a false-negative result. A false-positive result
was determined in 5 cases out of 14 (35.7%). The coincidence of the
echographic and intraoperative results, according to our data, was 64.3% (false
positive result - 35.7%, false-negative - 16%). The table shows the results of
comparing the echographic picture and the actual state of the uterine scar
during surgery. The authors assess the informativeness of the ultrasound
method of examining the uterine scar differently. Authors using transvaginal
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probes and a combination of B-mode ultrasound with color Doppler mapping
(CDM) to assess the state of the uterine scar have a higher percentage of
matches (from 57.5% to 76%) and a lower percentage of false positive results
(from 21.3% to 7%).
"Scar failure", "incomplete uterine scar", "niche", "isthmocele",
"uteroperitoneal fistula", "post-caesarean section scar defect", "post-operative
scar thinning" - these are the most common definitions of this condition found in
the literature. There is currently no single generally accepted term describing
this pathological condition outside of pregnancy. In our opinion, the most
accurate description of the essence of changes in the scar area outside of
pregnancy is the terms "defect" or "thinning" of the uterine scar, which in some
cases can be supplemented by a morphological characteristic of the scar type -
with or without niche formation. A niche is a hypoechoic zone along the inner
surface of the uterus in the post-caesarean section scar area, which is an
asymmetric myometrial defect.
The incidence of uterine scar defects after CS varies significantly and is within
24-70% [5-7]. At the same time, according to O. Osser et al., the true prevalence
of this condition can reach 61% after the first CS and 100% after three CS. The
vast majority of cases of scar thinning after CS, even with niche formation, are
asymptomatic and are detected by chance during ultrasound examination (US).
The clinical picture with significant uterine scar defects is most often
characterized by postmenstrual bleeding from the genital tract (15.2-82.0%),
menorrhagia (12-38%), pelvic pain, the onset of which is associated with the CS
operation (4.5-11.0%), dyspareunia (3.4-9.6%). Most patients are characterized
by a combination of symptoms. According to literature data, the risk of
developing secondary infertility after a CS can be 4-19%, while a negative factor
is considered to be the accumulation of mucus or blood in the area of the defect
or niche, which leads to the accumulation of fluid in the uterine cavity and
disruption of sperm function and the implantation process.
References:
1.
Robson SJ, de Costa CM. Thirty years of the World Health Organization's
target caesarean section rate: time to move on. Med J Aust 2017; 206:181-5.
2.
[Krasnopol'skii VI, Buianova SN, Shchukina NA, Logutova LS Insufficiency
of the suture (scar) on the uterus after CS: problems and solutions (editorial
article). Ross. vestn. akushera-ginekologa. 2015; 3:4-8.
3.
Arakelian A.S., Martynov S.A., Khoroshun N.D. et al. Diagnostics and
surgical correction of uterine scar failure after CS using laparoscopy and
hysteroscopy. In: Sukhikh G.T., Adamyan L.V. (eds.). Proceedings of the XXIX
MODELS AND METHODS IN MODERN SCIENCE
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Congress "New Technologies in Diagnostics and Treatment of Gynecological
Diseases", Moscow, June 7-10, 2016. M, 2016; pp. 179-80.
