- Email: [email protected]
Prognosis of the cesarean section scar
Prognosis of the cesarean section scar VICTOR RUIZ-VELASCO, M.D. RAUL GAMIZ, M.D. Mexico City, Mexico
V A R IOU S E F FOR T S have been made to find a means of determining whether the uterine scar after cesarean section is normal and whether vaginal delivery in the next pregnancy is permissible. Baker1 believed that hysterography would be able to indicate the integrity of a post-cesarean section scar and since his work, a number of other reports have appeared on this subject. 2 - 14 ;-.revertheless, the real prognostic value of the x-ray findings are not well established. 14 It is our belief that the only way by which the reliability of the radiologic image can be checked is to study the scar at the time of a subsequent delivery and to correlate the clinical observations with previous x-ray plates. 5 • 14 We have endeavored to make a study of this type.
Forty-five of the patients that became pregnant and whose pregnancy reached term were cared for at the Hospital de Gineco-Obstetricia del Centro Medico Nacional and in the Hospital de Gineco-Obstetricia del Centro Medico La Raza of Mexico City. The uterine scar was carefully observed by its appearance and its consistency if another abdominal operation was done or by manual palpation in the case of a vaginal delivery. Results
Radiologic study. In 6 cases the hysterograms were unsatisfactory, so that 144 remained for the study. These have been divided into 3 groups: Group 1. These were patients whose postcesarean section radiologic studies revealed a normal hysterography, 65 cases (45 per cent) . Group II. These were patients whose radiologic studies revealed a defect in the isthmus, 57 cases (40 per cent). Group III. These were patients whose studies revealed some abnormalities in the uterine cavity, such as extravasation, irregularities of the edges, or filling defects, 22 cases (15 per cent) (Table I). Clinical study. Among the 45 patients in whom a clinical study of the scar was possible, there were 2 in which the examination was not conclusive. The remaining 43 cases were assigned to one of the three groups described, according to the previous hysterogram. Group 1. This group was made up of 26 patients whose previous radiologic studies showed a normal hysterogram. Among these
Material and methods
Radiologic study. One hundred and fifty unselected patients, who had had cesarean sections at the Hospital de Gineco-Obstetricia del Centro Medico Nacional of Mexico City, underwent hysterosalpingogram under fluoroscopic control 8 to 10 weeks after cesarean section. Fluid Lipiodol, 40 per cent, was used. When a large isthmic defect or an abnormal uterine cavity was found the radiologic study was repeated 4 to 6 months later. Clinical study. Clinical follow-up of these patients was continued for 3 to 4 years, while fertility was controlled. '5 When a new pregnancy did occur, the patient was closely observed and the scar examined after delivery. From the Departments of Obstetrics and Gynecology, Hospital de GinecoObstetricia, Centro Medico La Raza.
1119
1120 Ruiz-Velasco and Gamiz
Am.
sarean section, the scar in appearance and by palpation before it is resected appears normal. Only one patient in Groups I and II was found to have a defective scar, but she already had had four sections and a prior dehiscence. On the other hand, 2 of the .) patients with a tmly abnormal hysterogram showed a defective scar. The summary of the cases with defective scars is given in Table
it was found that 25 had a clinically normal scar and only one an imperfect one. Group II. This group included 12 patients who had had previous radiologic studies that showed a characteristic isthmic defect, classified as "common post surgical defect." In all of these a clinically normal scar was found. Group III. This group consisted of 5 patients whose previolls radiological study showed abnormalities in the uterine cavity. Three of them, having vaginal deliveries, were found to have a clinically normal scar while the other 2 suffered a dehiscence of the previous scar (Table II). To arrive at these classifications, we regarded the scar as sound under the following circllmstances: (a) When a patient has been subject to labor and a vaginal delivery, if an intrauterine palpation of the scar finds it intact. (b) When, during a subsequent ce-
III. The type of delivery was vaginal in 16 of the cases (37 per cent) and was by repeat cesarean section in 37 cases (63 per cent) (Table IV). Comment
The first part of this stud y 14 showed that, contrary to what had been suggested by other authors/· 13 the shape of the x-ray image alone cannot predict the condition of the scar nor the size of it. The persistence of the defect in a later re-examination is more valuable. A defective scar is initially present in any uterus after section, but it will gradually vanish as the cicatrization is completed. The finding of a defect by x-ray depends, therefore, upon the time when the hysterography is performed. In cases with a functionally weak scar, the defect will persist. The present study disclosed a number of interesting points. The scars which were
Table I. Radiologic study Group-' ..,---.-I -No,- - r . % I Normal hysterogram II
III
A Isthmic defects alone B Associated with cavity defects A Extravasation B Abnormality of cavity
65
45.13
57
39.58
1~ } 22
15.27
46 ) 11
Augu" 15, 1966 & Gl'nec.
J. Onst.
Table II. Clinical classification of scar in 46 patients
·1- - -..'-----.. ·..-·- - -· .-.----;----------- " ....- ".' ,
Croup
Cases
I
26 12 5
11 III
I
Normal scar
No.
Defective .>ear
% 96
25 12 3
100 60
No. 1
o 2
4 (j
!()
Table III. Cases with defective scar
Cases
2 3
History Three previous cesareans ; previous dehiscence One previous cesarean ; previous dehiscence None
Type of cesarean section
I
Hysterography
Longitudinal
Normal
Longitudinal
Large extravasation Abnormal cavity; large defect
Longitudinal
Actual clinical findings Total dehiscence. Predominance of fibrous tissue Total dehiscence. Very thin lower segment Placental implantation on scar, and destruction of it
Volume 95 Number 8
Cesarean section scar
1121
Table IV. Type of delivery in 43 patients in which scar was examined at delivery Group
Cases
Vaginal delivery I
I
III
II
26 12 5
7 6 3
% 27 50 60
Total
43
16
37
found abnormal in our clinical study were those in which vertical corporal incisions had been performed in the presence of Band's ring. This observation is in agreement with the radiologic impression that this type of incision presents the greater number of hysterographic defects. All the cases, except one with a normal radiological study or with only x-ray evidence of a "common isthmic postsurgical defect" were found on clinical examinations to have a normal scar. This corroborates our earlier conclusion that the isthmic defect which we find so commonly cannot be regarded as indicating a dangerous scar. From our studies we have established the following procedure in a case of a previous cesarean section: When two or more previous cesarean sections exist or one which has been by longitudinal incision, or one requiring a prolongation of the wound or accompanied by profuse bleeding, or there was postoperative infection or anemia, hysterosalpingography is performed between the third and fourth months after delivery. If this examination shows an abnormal isthmic defect, an abnormal uterine cavity or the presence of extravasation, we recommend that a new pregnancy be avoided and another x-ray study be done after a further 6 months. If the defects have disappeared, a trial of labor may be permitted. We do repeat cesarean sections again when
I Repeat
~esarean I
sectIOn
%
19 6 2
73 50 40
27
63
there is a probability of a defective scar and a possibility of dehiscence. This probability exists under the following circumstances: (a) if the abnormality persists in the radiologic study; (b) in those cases in which a dehiscence of a still earlier scar existed at the time of the last cesarean section, even though the repair was corrected; (c) in cases in which the placenta appears to be Implanted precisely on the uterine scar. Summary
Report is made of a series of 144 patients in whom hysterography was performed after a cesarean section. Forty-five of these were examined at the time of a later delivery, so that the original x-ray characteristics could be correlated with subsequent actual observation. Of 25 with a normal hysterogram, 24 were found to have a clin:cally normal scar. Of 12 in whom early x-ray had revealed only a characteristic isthmic defect, "the common postsurgical defect," all were found to have a clinically normal scar. Of 5 where x-ray studies had shown abnormalities of the uterine cavity, at examination after delivery 3 appeared to have normal scars, but 2 suffered uterine ruptures. It is concluded that the common postsurgical isthmic defect is of little significance and may be transitory. The finding, however, of x-ray evidence of an abnormality of the uterine cavity is of serious import.
REFERENCES
1. Baker, K.: Surg. Gynec. & Obst. 100: 690, 1955. 2. Benzi, G., and Uggeri, B.: Gynaecologia 153: 43, 1962.
3. Bockner, V. Y.: J. Obst. & Gynaec. Brit. Emp. 67: 838, 1960. 4. Durkan, J. P.: Obst. & Gynec. 24: 836, 1964.
1122 Ruiz-Velasco and Gamiz
5. I.e Cannelier, R., Bourgoin, P. C., BaIlon, C., Breton, P., and Benoit, D.: Gyncc. et obst. 62: 669, 1963. 6. Le Cannelier, R., and Bourgoin, P. C.: Presse med. 71: 2035, 1963. 7. Lapage, F., Noel, B., Lemerre, L., and Sehramm, B.: Gynec. et obst. 58: 506, 1959. 8. Lindahl, J., and Helander, C. G.: Geburtsh. u. Frauenh. 19: 959, 1959. 9. Lindahl, J., and Helander, C. G.: Gynaecologia 150: 133, 1960. 10. Sadek, M., Foda, A., Youssef, F., Shaffek, M. A., and Kassen, K. A.: Brit. J. Radiol. 35: 797, 1962.
Am.
J.
15. 1966 01>,1 . & Gynec.
Au~uS[
11. Poidevin, L. O. S.: Brit. M. J 2: 1058, 1959. 1') Poidevin, L. O. S.: AM. J. OBST. & GYXEC. 81: 67, 1961. 13. Poidevin, L. O. S., and Bockner, V. Y.: J. Obst. & Gynaee. Brit. Emp. 65: 278, 1958. 14. Ruiz-Velasco, V., Guerrero, R., Morales, A.. and Gamiz, R.: A:\1. J. OBST. & GV:-IEC. 90: 222, 1964. 15. Ruiz-Velasco, V.: Internat. J. Fertil. 10: 229, 1965. Av. Horacia 1016 Mexico 5, D. F.
V A R IOU S E F FOR T S have been made to find a means of determining whether the uterine scar after cesarean section is normal and whether vaginal delivery in the next pregnancy is permissible. Baker1 believed that hysterography would be able to indicate the integrity of a post-cesarean section scar and since his work, a number of other reports have appeared on this subject. 2 - 14 ;-.revertheless, the real prognostic value of the x-ray findings are not well established. 14 It is our belief that the only way by which the reliability of the radiologic image can be checked is to study the scar at the time of a subsequent delivery and to correlate the clinical observations with previous x-ray plates. 5 • 14 We have endeavored to make a study of this type.
Forty-five of the patients that became pregnant and whose pregnancy reached term were cared for at the Hospital de Gineco-Obstetricia del Centro Medico Nacional and in the Hospital de Gineco-Obstetricia del Centro Medico La Raza of Mexico City. The uterine scar was carefully observed by its appearance and its consistency if another abdominal operation was done or by manual palpation in the case of a vaginal delivery. Results
Radiologic study. In 6 cases the hysterograms were unsatisfactory, so that 144 remained for the study. These have been divided into 3 groups: Group 1. These were patients whose postcesarean section radiologic studies revealed a normal hysterography, 65 cases (45 per cent) . Group II. These were patients whose radiologic studies revealed a defect in the isthmus, 57 cases (40 per cent). Group III. These were patients whose studies revealed some abnormalities in the uterine cavity, such as extravasation, irregularities of the edges, or filling defects, 22 cases (15 per cent) (Table I). Clinical study. Among the 45 patients in whom a clinical study of the scar was possible, there were 2 in which the examination was not conclusive. The remaining 43 cases were assigned to one of the three groups described, according to the previous hysterogram. Group 1. This group was made up of 26 patients whose previous radiologic studies showed a normal hysterogram. Among these
Material and methods
Radiologic study. One hundred and fifty unselected patients, who had had cesarean sections at the Hospital de Gineco-Obstetricia del Centro Medico Nacional of Mexico City, underwent hysterosalpingogram under fluoroscopic control 8 to 10 weeks after cesarean section. Fluid Lipiodol, 40 per cent, was used. When a large isthmic defect or an abnormal uterine cavity was found the radiologic study was repeated 4 to 6 months later. Clinical study. Clinical follow-up of these patients was continued for 3 to 4 years, while fertility was controlled. '5 When a new pregnancy did occur, the patient was closely observed and the scar examined after delivery. From the Departments of Obstetrics and Gynecology, Hospital de GinecoObstetricia, Centro Medico La Raza.
1119
1120 Ruiz-Velasco and Gamiz
Am.
sarean section, the scar in appearance and by palpation before it is resected appears normal. Only one patient in Groups I and II was found to have a defective scar, but she already had had four sections and a prior dehiscence. On the other hand, 2 of the .) patients with a tmly abnormal hysterogram showed a defective scar. The summary of the cases with defective scars is given in Table
it was found that 25 had a clinically normal scar and only one an imperfect one. Group II. This group included 12 patients who had had previous radiologic studies that showed a characteristic isthmic defect, classified as "common post surgical defect." In all of these a clinically normal scar was found. Group III. This group consisted of 5 patients whose previolls radiological study showed abnormalities in the uterine cavity. Three of them, having vaginal deliveries, were found to have a clinically normal scar while the other 2 suffered a dehiscence of the previous scar (Table II). To arrive at these classifications, we regarded the scar as sound under the following circllmstances: (a) When a patient has been subject to labor and a vaginal delivery, if an intrauterine palpation of the scar finds it intact. (b) When, during a subsequent ce-
III. The type of delivery was vaginal in 16 of the cases (37 per cent) and was by repeat cesarean section in 37 cases (63 per cent) (Table IV). Comment
The first part of this stud y 14 showed that, contrary to what had been suggested by other authors/· 13 the shape of the x-ray image alone cannot predict the condition of the scar nor the size of it. The persistence of the defect in a later re-examination is more valuable. A defective scar is initially present in any uterus after section, but it will gradually vanish as the cicatrization is completed. The finding of a defect by x-ray depends, therefore, upon the time when the hysterography is performed. In cases with a functionally weak scar, the defect will persist. The present study disclosed a number of interesting points. The scars which were
Table I. Radiologic study Group-' ..,---.-I -No,- - r . % I Normal hysterogram II
III
A Isthmic defects alone B Associated with cavity defects A Extravasation B Abnormality of cavity
65
45.13
57
39.58
1~ } 22
15.27
46 ) 11
Augu" 15, 1966 & Gl'nec.
J. Onst.
Table II. Clinical classification of scar in 46 patients
·1- - -..'-----.. ·..-·- - -· .-.----;----------- " ....- ".' ,
Croup
Cases
I
26 12 5
11 III
I
Normal scar
No.
Defective .>ear
% 96
25 12 3
100 60
No. 1
o 2
4 (j
!()
Table III. Cases with defective scar
Cases
2 3
History Three previous cesareans ; previous dehiscence One previous cesarean ; previous dehiscence None
Type of cesarean section
I
Hysterography
Longitudinal
Normal
Longitudinal
Large extravasation Abnormal cavity; large defect
Longitudinal
Actual clinical findings Total dehiscence. Predominance of fibrous tissue Total dehiscence. Very thin lower segment Placental implantation on scar, and destruction of it
Volume 95 Number 8
Cesarean section scar
1121
Table IV. Type of delivery in 43 patients in which scar was examined at delivery Group
Cases
Vaginal delivery I
I
III
II
26 12 5
7 6 3
% 27 50 60
Total
43
16
37
found abnormal in our clinical study were those in which vertical corporal incisions had been performed in the presence of Band's ring. This observation is in agreement with the radiologic impression that this type of incision presents the greater number of hysterographic defects. All the cases, except one with a normal radiological study or with only x-ray evidence of a "common isthmic postsurgical defect" were found on clinical examinations to have a normal scar. This corroborates our earlier conclusion that the isthmic defect which we find so commonly cannot be regarded as indicating a dangerous scar. From our studies we have established the following procedure in a case of a previous cesarean section: When two or more previous cesarean sections exist or one which has been by longitudinal incision, or one requiring a prolongation of the wound or accompanied by profuse bleeding, or there was postoperative infection or anemia, hysterosalpingography is performed between the third and fourth months after delivery. If this examination shows an abnormal isthmic defect, an abnormal uterine cavity or the presence of extravasation, we recommend that a new pregnancy be avoided and another x-ray study be done after a further 6 months. If the defects have disappeared, a trial of labor may be permitted. We do repeat cesarean sections again when
I Repeat
~esarean I
sectIOn
%
19 6 2
73 50 40
27
63
there is a probability of a defective scar and a possibility of dehiscence. This probability exists under the following circumstances: (a) if the abnormality persists in the radiologic study; (b) in those cases in which a dehiscence of a still earlier scar existed at the time of the last cesarean section, even though the repair was corrected; (c) in cases in which the placenta appears to be Implanted precisely on the uterine scar. Summary
Report is made of a series of 144 patients in whom hysterography was performed after a cesarean section. Forty-five of these were examined at the time of a later delivery, so that the original x-ray characteristics could be correlated with subsequent actual observation. Of 25 with a normal hysterogram, 24 were found to have a clin:cally normal scar. Of 12 in whom early x-ray had revealed only a characteristic isthmic defect, "the common postsurgical defect," all were found to have a clinically normal scar. Of 5 where x-ray studies had shown abnormalities of the uterine cavity, at examination after delivery 3 appeared to have normal scars, but 2 suffered uterine ruptures. It is concluded that the common postsurgical isthmic defect is of little significance and may be transitory. The finding, however, of x-ray evidence of an abnormality of the uterine cavity is of serious import.
REFERENCES
1. Baker, K.: Surg. Gynec. & Obst. 100: 690, 1955. 2. Benzi, G., and Uggeri, B.: Gynaecologia 153: 43, 1962.
3. Bockner, V. Y.: J. Obst. & Gynaec. Brit. Emp. 67: 838, 1960. 4. Durkan, J. P.: Obst. & Gynec. 24: 836, 1964.
1122 Ruiz-Velasco and Gamiz
5. I.e Cannelier, R., Bourgoin, P. C., BaIlon, C., Breton, P., and Benoit, D.: Gyncc. et obst. 62: 669, 1963. 6. Le Cannelier, R., and Bourgoin, P. C.: Presse med. 71: 2035, 1963. 7. Lapage, F., Noel, B., Lemerre, L., and Sehramm, B.: Gynec. et obst. 58: 506, 1959. 8. Lindahl, J., and Helander, C. G.: Geburtsh. u. Frauenh. 19: 959, 1959. 9. Lindahl, J., and Helander, C. G.: Gynaecologia 150: 133, 1960. 10. Sadek, M., Foda, A., Youssef, F., Shaffek, M. A., and Kassen, K. A.: Brit. J. Radiol. 35: 797, 1962.
Am.
J.
15. 1966 01>,1 . & Gynec.
Au~uS[
11. Poidevin, L. O. S.: Brit. M. J 2: 1058, 1959. 1') Poidevin, L. O. S.: AM. J. OBST. & GYXEC. 81: 67, 1961. 13. Poidevin, L. O. S., and Bockner, V. Y.: J. Obst. & Gynaee. Brit. Emp. 65: 278, 1958. 14. Ruiz-Velasco, V., Guerrero, R., Morales, A.. and Gamiz, R.: A:\1. J. OBST. & GV:-IEC. 90: 222, 1964. 15. Ruiz-Velasco, V.: Internat. J. Fertil. 10: 229, 1965. Av. Horacia 1016 Mexico 5, D. F.