The Management of Various Complications in Pregnant Women: Scar Tissue Following a Cesarean Section assisted childbirth

Arina Grand^*

Department of Surgery, University of Stockholm, Sweden

Abstract

The localization of the Gestational Sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous Cesarean Section (CS), is what constitutes a Cesarean Scar Pregnancy (CSP). CSP is becoming more common all over the world at an alarming rate. However, there are no general recommendations regarding the prevention and treatment of abnormalities of the anterior wall of the uterus found in a neither nonpregnant myometrium, nor are there any recommendations regarding the management of CSP cases that are already present. Based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy at the Medical University of Lublin, Poland, we present the most recent information and a comprehensive approach to the biology, histology, imaging, and management of post-CS scars. We present ultrasound and MRI images of CSP, as well as tissue samples from uterine regions with a cicatrix. The treatment of various CSP complications, such as the rupture of the gravid uterus or the dehiscence of the myometrium, as well as advancements in the biology of post-CS scar tissue and the preventative measures taken to repair the scar defect (niche) prior to pregnancy are the subjects of our discussion.

The localization of the Gestational Sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous Cesarean Section (CS), is what constitutes a Cesarean Scar Pregnancy (CSP). CSP is becoming more common all over the world at an alarming rate. However, there are no general recommendations regarding the prevention and treatment of abnormalities of the anterior wall of the uterus found in a neither nonpregnant myometrium, nor are there any recommendations regarding the management of CSP cases that are already present. Based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy at the Medical University of Lublin, Poland, we present the most recent information and a comprehensive approach to the biology, histology, imaging, and management of post-CS scars. We present ultrasound and MRI images of CSP, as well as tissue samples from uterine regions with a cicatrix. The treatment of various CSP complications, such as the rupture of the gravid uterus or the dehiscence of the myometrium, as well as advancements in the biology of post-CS scar tissue and the preventative measures taken to repair the scar defect (niche) prior to pregnancy are the subjects of our discussion.

Keywords

Gestational sac • Cesarean section • Cesarean scar pregnancy • Non pregnant myometrium • Histology

Introduction

The number of cesarean sections that are performed is always increasing. In 2007, there were over 30% of CSs performed in the United States on average. In 2010, it was as high as 60% in China, and it was close to 80% in Brazil’s private sector. The prevalence of CS in Poland is approximately 30%, but it is rapidly rising [1].

A planned, repeat cesarean (an indication of the uterus’s imminent rupture) is primarily to blame for the rise in CS procedures. as a benchmark, electronic fetal monitoring; and the rising number of breech births that occur naturally in the vagina. However, women who have had a cesarean section in the past have a chance of having a vaginal birth in 60–80 percent of cases. Modern obstetrics now includes Vaginal Births After Cesarean Sections (VBACs). Pathological placentation is more likely if there has been a previous CS. Therefore, all obstetricians should be interested in developments in obstetrics and the biology of the wound following a hysterectomy. A hypo- or hyper-echoic line in the anterior lower wall of the uterus caused by a previous cesarean delivery is known as a hysterectomy cicatrix. As a result, there are two parts to a CS scar: an obvious imperfection and the scar tissue got together with the myometrium [2].

The healing of a wound is a complicated process that occurs in three stages: the damaged blood vessels’ serum inflammation (in the first few days—homeostasis and immune system reactivity), proliferation (for up to four weeks—granulation and neovascularization), and maturation or remodeling (for up to one to two years—collagen formation, deposition, and remodeling). Because the final result is the reconstruction of the incision area, these processes need to take place in the right order and within the right amount of time for the wound to be restored properly. It is suggested that the same procedures and timelines apply to the repair of an incision made during a cesarean hysterectomy. The involvement of Transforming Growth Factor beta (TGF-b), Connective Tissue Growth Factor (CTGF), Basic Fibroblast Growth Factor (bFGF), Platelet-Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF), and Tumor Necrosis Factor Alpha (TNF-a) in the process of scarring has been demonstrated by the most recent advancements in the study of cesarean scars. However, there are still insufficient studies on the physiological and pathological conditions of CS scar pathologies. The thinning of the muscle layer, which occurs in up to 60% of cases, is one of the potential long-term effects of the inadequate healing of the uterus following a cesarean section. Complications in gynecology and obstetrics are linked to this defect, including: uterine rupture, intracycle spotting, dysmenorrhea, pelvic pain, and infertility are all examples of ectopic scar pregnancies [3, 4].

Evidence

A 35-year-old Gravida 2, Para 1 patient was admitted to our department 21 weeks after experiencing a lower abdominal ache for two days. The previous CS was carried out at a different hospital, and since the fetus was in danger of asphyxiation at 40 weeks in 2010, we had no idea what procedure was used. She missed her period on her first scan following the CS. A hypo echogenic irregular area was discovered in the CS mark during this scan. Since an intrauterine pregnancy couldn’t be confirmed at that time, the patient was told about a “niche” and how to fix the scar tissue through laparoscopy. Sadly, the subsequent scan revealed a 6-week pregnancy. The term “niche” was not used. A Fetal Medicine Foundationlicensed obstetrician performed a First Trimester Screening Program for chromosomal abnormalities on the patient at 12 weeks. A scheduled cesarean section was performed on the patient at 36 weeks of pregnancy, seven years after the previous procedure. With a complete dehiscence of the myometrium, only a thin layer of peritonea covered the 2.6-millimeter-wide scar. The placenta was attached to the corpus uteri’s posterior wall. The uterus was typically sutured (double-layer continuous), and the patient did well after the procedure [5, 6].

Discussion

Today, there are more CSP diagnoses, possibly as a result of more CSs being performed. An improvement in prompt and effective management can be seen in the progression in the visualization of an early pregnancy through US. The US scan is demonstrated to be the most useful, repeatable, and cost-effective method. With new specific geometrical and anatomical considerations, a combined integrated 2D and 3D US scan can be used to evaluate the scar niche [7].

The diagnosis was correct in our first patient because the scan at six weeks revealed most of the aforementioned inclusion criteria for CSP. Many authors believe that cases of CSP are nearly identical to those of an ingrown placenta in the second or third trimester of pregnancy. As a result, performing the initial scan with particular discernment is essential. In order for the woman to make an informed decision regarding her medical treatment, she should be provided with all relevant information regarding the kind of pathology that is present in the uterine scar. One more technique for imaging cesarean scar anomalies is attractive reverberation. The use of MRI was used to assess the depth of the placenta protrusion into the bladder because all of the criteria for the diagnosis of CSP were met in our case. In the second instance, the same strategy was utilized with the same result [8].

However, the CSP patient was not advised of any treatment at the time of diagnosis. A similar case was presented in our most recent publication on the subject in 2014. At six weeks, a diagnosis of CSP was made, but the pregnant woman refused invasive treatment for personal reasons. However, we carried out an embolization and hysterectomy at 13 weeks following the confirmation of the fetal abnormalities that were fatal. Other cases were treated with expectancy, developed into placenta accreta/increta, and uterine rupture necessitated a hysterectomy and severe maternal morbidity. It might appear that a CSP is a forerunner of the accreta or percreta of the placenta. As a result, most cases that are detected early are treated surgically or pharmacologically. In this instance, severe complications occurred during the second trimester of the pregnancy as a result of the expectant management [9].

Although it has been reported that the CS niche may lead to infertility or spontaneous miscarriages if the implantation is close to or in the niche, it is believed that CS does not increase the risk of miscarriage in future pregnancies. Additionally, there have been several reports of CSP misdiagnosed as bleeding miscarriages. It is impossible to rule out the possibility that the two previous spontaneous abortions were caused by CSP. Since CSP is not a normal part of implantation, miscarriage is probably “a natural” solution. After laparoscopic repair of the cicatrix tissue, pathological findings such as the prevalence of fibrotic tissue were found in 78.9% of cases, according to the most recent literature. Endometriosis is characterized by the presence of endometrial glands inside the scar that are not connected to the endometrial surface on serial sections in the remaining 21.1% of cases [10].

Conclusion

The CS scar must be evaluated using a standardized method to identify any potential risk factors that may affect its healing, the development of the niche, and severe obstetric complications like CSP, PAS, or uterus rupture, taking into account the growing advances in scar biology.

References

1. Harb HM, Knight M, Bottomley C et al. Caesarean scar pregnancy in the UK: A national cohort study. BJOG. 125, 1663-1670.

Google Scholar, Crossref, Indexed at

2. Uharček P, Brešťanský A, Ravinger J et al. Sonographic assessment of lower uterine segment thickness at term in women with previous cesarean delivery. Arch Gynecol Obstet. 292, 609-612 (2015).

Google Scholar, Crossref, Indexed at

3. Varner, M. Cesarean Scar Imaging and Prediction of Subsequent Obstetric Complications. Clin Obstet Gynecol. 55, 988–996 (2012).

 Google Scholar, Crossref, Indexed at

4. Pomorski M, Fuchs T, Rosner Tenerowicz A et al. Standardized ultrasonographic approach for the assessment of risk factors of incomplete healing of the cesarean section scar in the uterus. Euro J Obstet Gynecol Reprod Biol. 205, 141-145(2016).

Google Scholar, Crossref, Indexed at

5. Vachon Marceau C, Demers S, Bujold E et al. Single versus double-layer uterine closure at cesarean: Impact on lower uterine segment thickness at next pregnancy. Am J Obstet Gynecol. 217, 65.e1-65.e5 (2017).

Google Scholar, Crossref, Indexed at

6. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: Etiology, diagnosis, and management. Obstet Gynecol. 107, 1373-1381 (2006).

Google Scholar, Crossref, Indexed at

7. Osborn DA, Williams TR, Craig BM. Cesarean scar pregnancy: Sonographic and magnetic resonance imaging findings, complications, and treatment. JUltrasound Med. 31, 1449-1456 (2012).

 Google Scholar, Crossref, Indexed at

8. Malik MF, Hoyos LR,  Rodriguez Kovacs J et al. Placenta Increta Complicating Persistent Cesarean Scar Ectopic Pregnancy following Failed Excision with Subsequent Preterm Cesarean Hysterectomy. Case Rep Obstet Gynecol. 2016, 4071840 (2016).

 Google Scholar, Crossref, Indexed at

9. Cignini P, Giorlandino M, Caserta L et al. The importance of early diagnosis in cesarean scar pregnancy. J Prenat Med. 1, 29–31(2007).

 Google Scholar, Indexed at

10. Sinha P, Mishra M. Caesarean scar pregnancy: A precursor of placenta percreta/accrete. J Obstet Gynaecol.  32, 621-623 (2012).

 Google Scholar, Crossref, Indexed at