Bleeding from the lower body dripping and dripping after cesarean section may be due to the formation of a defect in the scar area of the uterine incision.
Some women have intermittent bleeding from the vagina during the non-menstrual period after cesarean section. Although it is not necessarily a lot, it is still quite disturbing to normal life and affects mood, sometimes accompanied by increased bleeding after sexual intercourse and menstrual pain. Don’t take it lightly, it may be because the uterine incision site has not grown well, forming a “small pit” with the uterine cavity at the incision, which we call the incision (scar) defect, defect or diverticulum after cesarean section.
So, what are the common causes of scar defects? What are the clinical manifestations of the defect after its formation? How is it diagnosed? What are the risks of scar defects? What treatments are available? How to avoid or reduce the formation of scar defects? This article will clear the fog and unravel the mystery for you!
I. Definition
Previous Cesarean Scar Defect (PCSD) refers to the formation of a depression or diverticulum in the uterine cavity at the uterine incision after cesarean section in the lower part of the uterus, which hinders the drainage of menstrual blood and accumulates in the diverticulum due to the living flap of the depression or diverticulum, resulting in prolonged menstruation, dripping, intermenstrual vaginal bleeding, post-coital bleeding, and even infertility and dysmenorrhea. The endometrial tissue in the diverticulum appears to be out of sync with the endometrium of the official cavity, which may also lead to abnormal vaginal bleeding.
Etiology
Any factors that interfere with the healing of the uterine incision.
1.Posterior position of uterus: it can increase the tension of the uterine incision and cause mechanical pulling between the upper and lower edges of the incision in the healing process, resulting in poor healing of the incision and formation of incision scar defect;
2, contractions lasting more than 5 h before cesarean section, dilatation of the uterine orifice ≥ 5 cm, and use of uterine constrictors;
3, incision position: too high position may cause both uterine body and cervical tissue to appear in the incision, resulting in short and thick upper edge, thin and long lower edge, and different tensions on the upper and lower edges of the incision; too low position may lead to reduced blood supply to the surrounding tissues, resulting in tissue ischemia and necrosis, and poor healing of the incision;
4, suture technique: single-layer suture is more likely to be weak than double-layer suture, leading to the formation of defects at the incision; too close suture can also lead to a reduction in blood supply to the incision site, resulting in ischemic necrosis and the formation of potential cavities;
5, endometriosis at the incision: the endometrial exfoliation and bleeding increase the tension at the site, resulting in the formation of a defect;
6, cough, constipation, vomiting and obstructed discharge of foreign body in the uterine cavity: all can lead to increased pressure in the uterine cavity and outward expansion of the incision;
7, various factors that cause or induce incisional infection: inflammation of the reproductive tract, long operation time, poor application of postoperative antibiotics, long operation time, high intraoperative blood loss, premature rupture of fetal membranes, delayed labor;
8.Return cesarean section less than 2-3 years after the last one: the original scar has not healed well, the blood supply is poor and dead space is easily formed;
9. Systemic factors: hypoproteinemia, edema, and other underlying pathologies.
Clinical manifestations
1.Incomplete menstruation: lasting more than 1~2 weeks;
2.Vaginal bleeding after sexual intercourse or increase of existing bleeding;
3.Dysmenorrhea;
4, chronic pelvic pain;
5, scar site pregnancy.
IV. Hazards
1.Continuous vaginal bleeding leads to infection in the reproductive tract and affects the quality of life of women;
2, dysmenorrhea and chronic pelvic pain affect normal life and work;
3, scar site pregnancy can lead to uterine rupture, increase the risk of postpartum bleeding, and increase maternal mortality;
4. Secondary infertility: the residual menstrual blood affects the penetration of sperm into the cervical mucus and the fertilization of the egg in the defective area, resulting in developmental failure.
Secondary infertility – abnormal bleeding from scar defect / diverticulum leading to failure of fertilized egg implantation
V. Diagnosis
1. History: post-cesarean section, risk factors for poor incisional healing;
2. Clinical manifestations: persistent vaginal bleeding, post-coital bleeding, dysmenorrhea;
3. Differential diagnosis: irregular menstrual cycle; intrauterine device; known abnormal vaginal bleeding not related to cesarean section, including endometrial polyp, submucosal fibroid, endometrial hyperplasia, endometrial cancer, etc.
4.Auxiliary examinations.
(1) Vaginal ultrasound: the sagittal plane of the uterus shows the mucosal layer at the lower uterine incision is uneven, the myometrial layer is partially or completely defective in echogenicity, and irregular liquid dark areas are connected with the uterine cavity and close to the plasma membrane layer;
The scar defect is seen under the negative ultrasound
(2) Hysteroscopy: incisional defect/diverticulum formation, dark brown mucus or blood retention in the defect; more capillary distribution on the local endometrial surface, microscopic fibrous tissue forming a “live flap” at the lower edge of the incision on the anterior wall of the lower uterine segment; in most cases, the diagnosis can be confirmed by the presence of old blood collection in the indentation;
Hysteroscopy shows old foci of blood accumulation
(3) MRI: discontinuity of the endometrium and myometrium at the defect site, partial or complete loss of the myometrium;
MRI: scar defect foci (indicated by red arrows)
(4) Hysterosalpingogram (HSG): The contrast between the contrast agent and the uterine wall is used to observe whether the contrast agent has penetrated into the myometrium and the depth and shape of the penetration, which can be observed on film;
HSG with scar defect foci (red arrow)
(5) Hysterosalpingography (SHG): sterile saline is injected into the uterine cavity, and vaginal ultrasonography is performed after adequate separation of the endometrium, and the defect pattern can be observed.
VI. Treatment
1, conservative treatment: mainly for patients with mild symptoms to perform symptomatic treatment with drugs, commonly used drugs are anti-inflammatory, pain relief, hormone therapy drugs. Commonly used artificial cycle or oral contraceptive treatment for 3-6 cycles. It can reduce the volume of menstruation, prevent reproductive tract infection, contraception and delay the role of re-pregnancy.
2.Surgical treatment: Applicable to those who have poor conservative treatment or aggravated lesions. Different options are available according to the severity of the disease.
(1) Hysteroscopy: It is suitable for mild patients with poor conservative treatment. By removing or cauterizing the lining of the diverticulum and the cystic wall of the local depression, the endocrine glands with secretion function are destroyed; at the same time, the tissue of the lower edge of the depression is removed and trimmed, and the microtubules are removed so that menstrual blood cannot accumulate, achieving the purpose of “diagnosis and treatment in one”.
Diagnosis and treatment of hysteroscopic scar defect: a. hysteroscopic distribution of blood vessels at the bleeding site of the scar defect; b. old bleeding spots at the site of the scar defect; c. hysteroscopic excision of the scar defect; d. after excision of the scar defect
(2) Negative surgery: for poor hysteroscopic excision of the scar. Enter the bladder-cervical space through the anterior vaginal vault, open the anterior peritoneum, enter the abdominal cavity, incise the scar to the uterine cavity under probe guidance, excise the scar tissue at the weak spot, remove blood and clots by suction tube, and intermittently suture the incision under probe guidance.
Excision of scar tissue at the weak point, cut and suture myotomy, continuous suturing of the vaginal incision
(3) Laparoscopic surgery: It is suitable for scar defects in various cases, and the anterior wall of the uterine incision can be re-sutured by laparoscopic excision of the incisional scar, which reduces the stimulation of the pelvic and abdominal cavities and reduces pelvic and abdominal adhesions, and has the advantages of fast postoperative recovery compared with open surgery. However, this method has high operator requirements and is not suitable to be performed at the primary level.
Laparoscopic resection of diverticula at the scar site after the whole procedure and resection
(4) Open surgery: It is mostly used for more serious scar defects, severe patients who cannot be treated by the above three procedures, or those who are limited by medical conditions and technology. The uterine incision is re-sutured by removing the scarred diverticular tissue. This method is rarely used as a last resort because of the greater risk and trauma, and the poorer results.
VII. Prevention
Strictly grasp the indications for cesarean section, for unavoidable cesarean section, do intraoperative suturing, actively prevent infection, and actively treat underlying diseases in the perioperative period for patients with comorbidities.