Assessment of uterine scar competence
A uterine scar forms after a cesarean section, myomectomy, perforation during curettage, or excision of the uterine horn in tubal pregnancy. The main prognostic factor is its adequacy.
Histological characteristics:
- Competent scar: muscular tissue is almost completely restored, minor foci of connective tissue are located around the vessels.
- Incompetent scar: layers of fibrous hyalinized tissue predominate, dystrophic changes are determined in the myometrium.
Diagnostic criteria:
- Before pregnancy: ultrasound, hysteroscopy, and hysterography are used. Wall deformations, niches, and splitting of muscle fibers indicate incompetence.
- During pregnancy: ultrasound of the lower uterine segment is performed. With a competent scar, the structure is homogeneous, the thickness is 3–5 mm. With incompetence, the thickness decreases to less than 3 mm, the structure becomes heterogeneous, and a niche is visualized.
Indirect signs of scar inadequacy include postoperative endometritis, secondary intention wound healing, weakness of labor activity in the past, and cervical immaturity before childbirth.
Tactics for threatening and completed uterine rupture
An impending uterine rupture along the scar is differentiated from premature detachment of a normally positioned placenta. Both conditions are characterized by hypertonus, abdominal pain, fetal hypoxia, and bloody discharge. Clarification is carried out using ultrasound, but both conditions serve as an indication for urgent laparotomy.
Action algorithm for threatening rupture:
- Immediately terminate labor activity.
- Perform a cesarean section under endotracheal anesthesia or spinal anesthesia.
- Cesarean section is performed regardless of the fetal condition. Destructive fetal operations (craniotomy) are prohibited due to the risk of violent uterine rupture. Fetal version, obstetric forceps, and breech extraction are also contraindicated.
In the case of a completed rupture, emergency laparotomy and infusion-transfusion therapy are performed. If possible, the defect is sutured to preserve the organ, but with extensive tissue crushing, subtotal hysterectomy or total hysterectomy is performed. In case of hematoma, blood vessels are sutured or the internal iliac artery is ligated. If the bladder or intestine is damaged, related specialists are involved.
Risk factors and prevention of ruptures
Prevention is based on the timely identification of high-risk pregnant women and their hospitalization in level II–III hospitals.
Main risk factors:
- Presence of scarring changes on the uterus.
- Multiparas.
- Burdened history: numerous abortions complicated by endometritis or repeated curettages.
- Anatomically narrow pelvis, large fetus, transverse fetal lie.
During labor in women at risk, continuous monitoring of labor activity, fetal condition, and head descent is necessary.
Conservative and surgical treatment of urinary incontinence
Therapy is selected depending on the form of urination disorder.
| Direction | Applied methods and drugs |
|---|---|
| Pharmacotherapy | Trospium chloride, solifenacin, tricyclic antidepressants (imipramine) |
| Behavioral therapy | Bladder training |
| Hormone replacement therapy (HRT) | Topical — estriol suppositories; systemic drugs in postmenopause |
Surgical intervention is indicated when conservative measures are ineffective for eliminating the stress component. In combined forms (a combination of stress incontinence and detrusor instability), treatment is difficult, as detrusor overactivity may occur de novo after anti-stress operations.
Briefly: answers to topical questions
What is the emergency care algorithm for acute uterine inversion?
The emergency care algorithm for uterine inversion includes immediate manual replacement followed by medical support.
- Replacement of uterine inversion — performed immediately after diagnosis under general anesthesia.
- Use of muscle relaxants — recommended if replacement is difficult.
- Tone control — after replacement, the doctor's hand is not removed from the uterine cavity until the tone of the walls is restored (but for no more than 15 minutes).
- Medical support — administration of uterotonics is mandatory after replacement.
- Antibiotic prophylaxis — recommended for patients in the postpartum period.
What surgical treatment methods are used for stress urinary incontinence?
Minimally invasive sling procedures, periurethral injections, and retropubic colpopexy are used for the surgical treatment of stress urinary incontinence.
- Sling operations — placement of a free synthetic loop around the bladder neck or under the mid-urethra. TVT (Tension-free Vaginal Tape), TVT-O (Transobturator vaginal tape), TOT (Transobturator Tape), and TVT SECUR loops are used.
- Burch procedure (Burch) — retropubic colpopexy performed when incontinence is combined with pelvic organ prolapse.
- Periurethral injections — injection of collagen, autologous fat, or Teflon into tissues to facilitate urethral closure.
Ultrasound criteria for scar incompetence are remembered by the "3-H" rule: less than 3 mm, Heterogeneity of tissue, and the presence of a "Niche" (Nisha) — a direct indication for hospitalization in a level II–III hospital.
Class and exam questions
How does a competent scar histologically differ from an incompetent one?
A competent scar consists of unchanged myometrium with small foci of connective tissue around the vessels. An incompetent scar contains fibrous hyalinized tissue and pronounced dystrophic changes in the myometrium.
Why is craniotomy not performed in threatened uterine rupture even with a dead fetus?
Destructive fetal operations have been abandoned due to their high invasiveness: manipulations on the overstretched lower uterine segment create a high risk of violent rupture.
What are the ultrasound signs of scar competence during pregnancy?
A competent scar is characterized by a homogeneous tissue structure and a lower uterine segment thickness within 3–5 mm.
What is done in case of incomplete uterine rupture if it is impossible to ligate the bleeding vessel?
The peritoneum is dissected, blood clots are removed, and if the source of bleeding cannot be found, ligation of the internal iliac artery is performed.
What else to study on this topic
- Classification of pelvic organ prolapse
- Physiology of urination in women
- Differential diagnosis of stress incontinence and overactive bladder
- Management tactics for labor in anatomically narrow pelvis and fetal macrosomia
- Technique of internal iliac artery ligation in obstetric hemorrhage
Master the entire topic in the "Obstetrics and Gynecology" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Uterine inversion" and another 973 pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 21 video lessons on the subject
Other topics in the "Gynecology" section
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.