Clinico-morphological features of the postoperative period and healing process of the uterine scar tissue after re-cesarean section
A high number of repeat cesarean sections increases a risk of excessive bleeding, uterine atony, hysterectomy. The aim of study was to evaluate the efficacy of medical and technical methods (argon plasma coagulation, tranexamic acid, carbetocin) to prevent complications following repeat cesarean section and to improve the myometrial wound healing, to establish morphological features of uterine scar tissue in case of using argon plasma coagulation of myometrium in the area of the suture during the previous operation. Prospective cohort study of 77 patients who had undergone repeat cesarean section. I group included 37 women who had repeat cesarean section using argon plasma coagulation. Ten minutes before the operation, 15 mg/kg of tranexamic acid was injected intravenously. 100 mcg carbetocin was administered intravenously after cutting the umbilical cord. ІІ group comprised 40 women who had traditional cesarean section using Stark's technique and Joel-Cohen incision. Pathomorphological study of scarred lower uterine segment myometrium was performed. Immunohistochemical staining against CD3, CD34, CD68, vimentin, α-SMA was performed. Results are presented as Mean±SD. Total operative time was significantly shorter in the І group (37,0±2,1 minutes) compared to ІІ (46,1±1,8 minutes) (р<0,05). Volume of blood loss in the І group was 465,7±37,5 ml, and in the ІІ — 547, 7±34,6 ml (p<0.05). Patients of the І group needed analgesic for 18-24 hours, the ІІ group — 36-48 hours after operation. The width of the uterine cavity in group І was 9,8±0,37 mm, in group ІІ — 14,6±0,54 mm (р<0,05). One patient of group І and 9 patients of group ІІ had signs of uterine subinvolution. Length of hospital stay after surgery in group I was 4,7±0,12 days, in ІІ — 6,6±0,28 days. The ultrasound thickness of myometrium in group I and group II is an average of 9,32±0,64 mm and 6,24±0,59 mm, respectively. Pathomorphological data of scarred lower uterine segment myometrium showed that in group I regenerative processes have more favorable course, a tendency to restore the structure of myometrium, while in group II there were processes of disturbed regeneration with the replacement of smooth muscle tissue varying maturity of connective tissue, moderate inflammatory process. So, the use of tranexamic acid, carbetocin and argon plasma coagulation is effective in reducing perioperative blood loss, total operative time, dosage of uterotonic and analgesic medications and postoperative hospital stay in patients giving birth by repeat cesarean section. According to the pathomorphological study, argon plasma coagulation of myometrium in the area of suture increases the value of the reparative processes and promotes the formation of a morphologically complete scar, with the predominance of smooth muscle cells over connective tissue.
2. Holianovskyi, O. V. (Red.) (2013). Krovotechi v praktytsi akushera-hinekoloha: navchalnyi posibnyk. [Haemorrhage in the practice of an Obstetrician-Gynaecologist: tutorial]. Natsionalna medychna akademiia pisliadyplomnoi osvity imeni P. L. Shupyka. Kyiv : [b. v.]. – Kiev: [w.p.h].
3. Markovskyi, V. D. & Tumanskyi, V. O. (Red.). (2015). Patomorfolohiia: natsionalnyi pidruchnyk. [Pathomorphology: national textbook]. Kyiv: VSV “Medytsyna”. – Kyiv: VSV “Medicine”.
4. Ahnfeldt-Mollerup, P., Petersen, L. K., Kragstrup, J., Christensen, R. D., & Sorensen, B. (2012). Postpartum infections: occurrence, healthcare contacts and association with breastfeeding. Acta Obstet. Gynecol. Scand., 91 (12), 1440–1444. doi.org/10.1111/aogs.12008.
5. Behery, M. M., Sayed, G. A., Hameed, A. A., Soliman, B. S., Abdelsalam, W. A., & Bahaa, A. (2016). Carbetocin versus oxytocin for prevention of postpartum hemorrhage in obese nulliparous women undergoing emergency cesarean delivery. J. Matern. Fetal Neonatal Med., 29 (8), 1257–1260. doi: 10.3109/14767058.2015.1043882.
6. Conroy, K., Koenig, A. F., Yu, Y. H., Courtney, A., Lee, H. J., & Norwitz, E. R. (2012). Infectious morbidity after cesarean delivery: 10 strategies to reduce risk. Rev. Obstet. Gynecol., 5(2), 69–77. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410505/
7. Cordovani, D., Balki, M., Farine, D., Seaward, G., & Carvalho, J. C. (2012). Carbetocin at elective Cesarean delivery: a randomized controlled trial to determine the effective dose. Can. J. Anesth, 59(8), 751–757. doi: 10.1007/s12630-012-9728-2.
8. Dodd, J. M., Anderson, E. R., Gates, S., & Grivell, R. M. (2014). Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database of Systematic Reviews, Issue 7, CD004732. doi: 10.1002/14651858.CD004732.pub3.
9. Holleboom, A., Eyck, J., Koenen, S. V., Kreuwel, I. A., Bergwerff, F., Creutzberg, E. C., & Bruinse, H. W. (2013). Carbetocin in comparison with oxytocin in several dosing regimens for the prevention of uterine atony after elective caesarean section in the Netherlands. Arch. Gynecol. Obstet., 287 (6), 1111–1117. doi: 10.1007/s00404-012-2693-8.
10. Hung, H. W., Yang, P. Y., Yan, Y. H., Jou, H. J., Lu, M. C., & Wu, S. C. (2016). Increased postpartum maternal complications after cesarean section compared with vaginal delivery in 225 304 Taiwanese women. J. Matern. Fetal Neonatal Med., 29 (10), 1665–1672. doi: 10.3109/14767058.2015.1059806.
11. Khan, M., Balki, M., Ahmed, I., Farine, D., Seaward G., & Carvalho, J. C. A. (2014). Carbetocin at elective Cesarean delivery: a sequential allocation trial to determine the minimum effective dose. Canadian Journal of Anesthesia, 61 (3), 242–248. doi: 10.1097/01.aoa.0000469484.82256.52.
12. Lavoie, A., McCarthy, R. J., & Wong, C. A. (2015). The ED90 of prophylactic oxytocin infusion after delivery of the placenta during cesarean delivery in laboring compared with nonlaboring women: an up-down sequential allocation dose-response study. Anesth. Analg., 121 (1), 159–164. doi: 10.1213/ANE.0000000000000781.
13. Litwicka, K., & Greco, E. (2013). Caesarean scar pregnancy: a review of management options. Curr. Opin. Obstet. Gynecol., 25 (6), 456–461. doi: 10.1097/GCO.0000000000000023.
14. Nguyen-Lu, N., Carvalho, J. C., Farine, D., Seaward, G., Ye, X. Y., & Balki, M. (2015). Carbetocin at Cesarean delivery for labour arrest: a sequential allocation trial to determine the effective dose. Canadian Journal of Anesthesia, 62 (8), 866–874. https://doi.org/10.1007/s12630-015-0375-2.
15. Pizzagalli, F., Agasse, J., & Marpeau, L. (2015). Carbetocin versus Oxytocin during caesarean section for preventing postpartum haemorrhage. Gynecol. Obstet. Fertil., 43 (5), 356–360. Doi: 10.1016/j.gyobfe.2015.03.004.
16. Rosai, J. (Ed.). (2011). Rosai and Ackerman’s Surgical Pathology (7th ed.). (p. 25–95). Elsevier Inc.
17. Silver, R. M., Landon, M. B., & Rouse, D. J. (2006). Maternal morbidity associated with multiple repeat cesarean deliveries. Int. J. Gynecol. Obst., 107 (6), 1226–32. doi: 10.1097/01.AOG.0000219750.79480.84.
18. Sofiene, B. M., Zied, H., Laidi, B. N., Yahya, M., & Hayen, M. (2015). A comparison of two doses of tranexamic acid to reduce blood loss during cesarean delivery. Glob. Anesth. Perioper. Med., 1 (4), 93–95. doi: 10.15761/GAPM.1000123.
19. Yehia, A. H., Koleib, M. H., Abdelazim, I. A., & Atik A. (2014). Tranexamic acid reduces blood loss during and after cesarean section: A double blinded, randomized, controlled trial. Asian Pacific Journal of Reproduction, 3 (1), 53–56. doi: 10.1016/s2305-0500(14)60002-6.
This work is licensed under a Creative Commons Attribution 4.0 International License.