Position and integrity of the uterine scar is determined by cervical dilation at the time of Caesarean section

[en] OBJECTIVE: Abnormal invasion of the placenta is more common after an elective Caesarean birth suggesting that pre-labour Caesarean section increases the likelihood of a scar above the internal cervical os - predisposing to a scar pregnancy in the future. The aim of this study was to assess the location and integrity of the uterine scar in postpartum women who delivered by Caesarean section at various stages of labour. METHODS: This was a prospective cohort study where women undergoing a first Caesarean section at term had a transvaginal ultrasound examination three months postpartum. The location of the Caesarean scar in relation to the internal cervical os was assessed as well as the presence of a scar niche. RESULTS: A total of 407 pregnant women were recruited into the study: 103 with cervical dilatation <2cm, 261 with cervical dilatation 3-7cm and 43 with cervical dilatation >8cm. There was a statistically significant correlation between cervical dilatation at the time of the section and the position of the uterine scar. The scar was positioned in the uterus above the internal cervical os in 97.1% (100/103) of women delivered at 0-2cm cervical dilatation, whereas the scar was located at or below the internal cervical os in 97.7% (42/43) of cases delivered at 8-10cm cervical dilatation (p<0.001). Uterine scar defects (niches) were observed in 38.1% (64/168) of women with the scar above compared to 17.9% (43/239) with the scar at or below the internal cervical os (p<0.001). CONCLUSION: Pre-labour and early labour Caesarean birth is associated with an increased prevalence of a scar in the uterine cavity as well as a scar niche. Caesarean birth in late labour resulted in positioning of the uterine scar in the endocervical canal and fewer scar niches. Positioning and integrity of the uterine scar after pre-labour and early labour Caesarean birth explains the predisposition to abnormal placental invasion in subsequent pregnancy. This article is protected by copyright. All rights reserved.

Disciplines :

Reproductive medicine (gynecology, andrology, obstetrics)

Author, co-author :

Kamel, R.

Kaelin Agten, A.

NOEL, Laure ; Centre Hospitalier Universitaire de Liège - CHU > Département de gynécologie-obstétrique > Service de gynécologie-obstétrique (CHR)

Eissa, T.

Sharaf, M.

Negm, S.

Thilaganathan, Basky

Language :

English

Title :

Position and integrity of the uterine scar is determined by cervical dilation at the time of Caesarean section

Publication date :

2020

Journal title :

Ultrasound in Obstetrics and Gynecology

ISSN :

0960-7692

eISSN :

1469-0705

Publisher :

John Wiley & Sons, Hoboken, United States - New Jersey

Peer reviewed :

Peer Reviewed verified by ORBi

Available on ORBi :

since 07 February 2021

Statistics

Number of views

72 (9 by ULiège)

Number of downloads

3 (3 by ULiège)

More statistics

Scopus citations^®

Scopus citations^®
without self-citations

OpenCitations

Bibliography

Silver RM. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet Gynecol 2015; 126: 654–668.
Calí G, Timor-Tritsch IE, Palacios-Jaraquemada J, Monteaugudo A, Buca D, Forlani F, Familiari A, Scambia G, Acharya G, D'Antonio F. Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 51: 169–175.
Agten AK, Monteagudo A, Timor-Tritsch IE, Thilaganathan B. Cesarean Scar Pregnancy Registry: an international research platform. Ultrasound Obstet Gynecol 2020; 55: 438–440.
Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005; 192: 1458–1461.
Higgins MF, Monteith C, Foley M, O'Herlihy C. Real increasing incidence of hysterectomy for placenta accreta following previous caesarean section. Eur J Obstet Gynecol Reprod Biol 2013; 171: 54–56.
van der Voet LF, Bij de Vaate AM, Veersema S, Brolmann HA, Huirne JA. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG 2014; 121: 236–244.
Naji O, Daemen A, Smith A, Abdallah Y, Saso S, Stalder C, Sayasneh A, McIndoe A, Ghaem-Maghami S, Timmerman D, Bourne T. Visibility and measurement of cesarean section scars in pregnancy: a reproducibility study. Ultrasound Obstet Gynecol 2012; 40: 549–556.
Jordans IPM, de Leeuw RA, Stegwee SI, Amso NN, Barri-Soldevila PN, van den Bosch T, Bourne T, Brölmann HAM, Donnez O, Dueholm M, Hehenkamp WJK, Jastrow N, Jurkovic D, Mashiach R, Naji O, Streuli I, Timmerman D, van der Voet LF, Huirne JAF. Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure. Ultrasound Obstet Gynecol 2019; 53: 107–115.
Fabres C, Aviles G, De La Jara C, Escalona J, Muñoz JF, Mackenna A, Fernández C, Zegers-Hochschild F, Fernández E. The cesarean delivery scar pouch: clinical implications and diagnostic correlation between transvaginal sonography and hysteroscopy. J Ultrasound Med 2003; 22: 695–700; quiz, 701–702.
Ludwin A, Martins WP, Ludwin I. Evaluation of uterine niche by three-dimensional sonohysterography and volumetric quantification: techniques and scoring classification system. Ultrasound Obstet Gynecol 2019; 53: 139–143.
Agten AK, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-Tritsch I. The clinical outcome of cesarean scar pregnancies implanted “on the scar” versus “in the niche”. Am J Obstet Gynecol 2017; 216: 510.e1–510.e6.
Zimmer EZ, Bardin R, Tamir A, Bronshtein M. Sonographic imaging of cervical scars after Cesarean section. Ultrasound Obstet Gynecol 2004; 23: 594–598.
Shi XM, Wang Y, Zhang Y, Wei Y, Chen L, Zhao YY. Effect of Primary Elective Cesarean Delivery on Placenta Accreta: A Case–Control Study. Chin Med J (Engl) 2018; 131: 672–676.
Colmorn LB, Krebs L, Klungsoyr K, Jakobsson M, Tapper AM, Gissler M, Lindqvist PG, Källen K, Gottvall K, Bordahl PE, Bjarnadóttir R, Langhoff-Roos J. Mode of first delivery and severe maternal complications in the subsequent pregnancy. Acta Obstet Gynecol Scand 2017; 96: 1053–1062.
Kamara M, Henderson JJ, Doherty DA, Dickinson JE, Pennell CE. The risk of placenta accreta following primary elective caesarean delivery: a case–control study. BJOG 2013; 120: 879–886.
Kagan KO, Sonek J. How to measure cervical length. Ultrasound Obstet Gynecol 2015; 45: 358–362.
Antila-Långsjö RM, Mäenpää JU, Huhtala HS, Tomás EI, Staff SM. Cesarean scar defect: a prospective study on risk factors. Am J Obstet Gynecol 2018; 219: 458.e1–458.e8.
Regnard C, Nosbusch M, Fellemans C, Benali N, van Rysselberghe M, Barlow P, Rozenberg S. Cesarean section scar evaluation by saline contrast sonohysterography. Ultrasound Obstet Gynecol 2004; 23: 289–292.
Vikhareva O, Rickle GS, Lavesson T, Nedopekina E, Brandell K, Salvesen KÅ. Hysterotomy level at Cesarean section and occurrence of large scar defects: a randomized single-blind trial. Ultrasound Obstet Gynecol 2019; 53: 438–442.
Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH. Detection of cesarean scars by transvaginal ultrasound. Obstet Gynecol 2003; 101: 61–65.
Vikhareva Osser O, Valentin L. Risk factors for incomplete healing of the uterine incision after caesarean section. BJOG 2010; 117: 1119–1126.
van der Voet LLF, Bij de Vaate AM, Heymans MW, Brölmann HAM, Veersema S, Huirne JAF. Prognostic Factors for Niche Development in the Uterine Caesarean Section Scar. Eur J Obstet Gynecol Reprod Biol 2017; 213: 31–32.
Stegwee SI, Jordans I, van der Voet LF, van de Ven PM, Ket J, Lambalk CB, de Groot C, Hehenkamp W, Huirne J. Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta-analysis. BJOG 2018; 125: 1097–1108.
Di Spiezio Sardo A, Saccone G, McCurdy R, Bujold E, Bifulco G, Berghella V. Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials. Ultrasound Obstet Gynecol 2017; 50: 578–583.
Timor-Tritsch IE, Monteagudo A, Cali G, Vintzileos A, Viscarello R, Al-Khan A, Zamudio S, Mayberry P, Cordoba MM, Dar P. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol 2014; 44: 346–353.
Timor-Tritsch IE, Monteagudo A, Cali G, Palacios-Jaraquemada JM, Maymon R, Arslan AA, Patil N, Popiolek D, Mittal KR. Cesarean scar pregnancy and early placenta accreta share common histology. Ultrasound Obstet Gynecol 2014; 43: 383–395.
Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006; 107: 1373–1381.
Iacovelli A, Liberati M, Khalil A, Timor-Tritsch I, Leombroni M, Buca D, Milani M, Flacco ME, Manzoli L, Fanfani F, Calì G, Familiari A, Scambia G, D'Antonio F. Risk factors for abnormally invasive placenta: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2020; 33: 471–481.