https://doi.org/10.5272/jimab.2019251.

2433
Journal of IMAB
Journal of IMAB - Annual Proceeding (Scientific Papers). 2019 Jan-Mar;25(1)
ISSN: 1312-773X
https://www.journal-imab-bg.org
Original article

CLINICAL-MORPHOLOGICAL EVALUATION OF
THE QUALITY OF THE UTERINE SCAR TISSUE
AFTER CAESAREAN SECTION
Elitsa Gyokova1, Yordan Popov1, Yoana Ivanova-Yoncheva1, Anton Georgiev1,
Miroslava Dimitrova1, Tatyana Betova2, Krasimir Petrov2, Savelina Popovska2,
1) Department of Obstetrics and Gynecology, Medical University - Pleven,
Bulgaria
2) Department of Pathoanatomy, Medical University - Pleven, Bulgaria.

ABSTRACT between them.

Purpose: Caesarean section (C.S.) is the most
commonly performed operative procedure of the uterus in
women of reproductive age. Each of these women increases
their likelihood of complications in subsequent
pregnancies. There is an obsolete law in obstetrics: once a
cesarean, always a cesarean, due to the danger of failure of
the uterine scar tissue and the greatly increased possibility
of uterine rupture. This necessitates the application of
various methods of assessing the sufficiency of the scar
tissue before planning further deliveries. The most accurate
methods for determining the structure of a tissue are
histological, which by their nature can not be used during
the pregnancy but they can correlate to clinical ones.
Materials/ Methods: Prospective study of 40
pregnant women with previous C.S., divided into groups
according to the interval between the operations. Another
subsequent division of subgroups to the number of
Caesarean sections was made. The morphological
indicators were compared to a control group of dermal scar
from the same patients. The results of the clinical methods
were to be compared with the results of the same patients
from the morphological studies. We used clinical methods
such as the history of the previous pregnancies and
puerperal period, history of previous operations and the
recovery after them, ultrasound examination and evaluation
of the anterior uterine wall preoperatively. The
morphological methods used are: Hematoxylin & eosin
staining (H&E), followed by Masson Trichrome for
collagen; Weigert-Van Gieson staining for elasticity;
staining of immunohistochemistry MIB-1 (Ki-67) for cell
proliferation.
Results: The study group was presented by patients
with one or more previous C.S. that were divided in
subgroups. The shortest inter-delivery interval was 14
months, the longest – 19 years. The shorter the period
between the C.S.s was, the thinner the myometrium. Cases
of abnormal healing have been observed, including:
myometrial hyperplasia, adenomyosis, myofiber disarray,
elastosis, inflammation, fibroids, keloids. These results can
be compared to clinical data from patients but mainly with
the number of previous C.S. or those with a brief period
Conclusions: The results from our research proved
that multiple C.S. is risk factors for larger defects of the
uterine scar but not mandatory. The likelihood of
prolonged healing time was higher in cases of more than
one C.S. The dimensions of the surgical incision are
associated with clinical symptoms such as postmenstrual
smears, dysmenorrhoea and chronic pelvic pain.
Keywords: uterine rupture, caesarean section scar
tissue, vaginal birth after previous caesarean section,
uterine dehiscence
INTRODUCTION
Caesarean section (C.S.) is the most commonly
performed operative procedure of the uterus in women of
reproductive age. Each of these women increases their
likelihood of complications in subsequent pregnancies.
There is a continuous discussion about the optimal
caesarean delivery rate and what is the most appropriate
one for both maternal and fetal outcome. The increased
range of C.S. in the last decades is widening new
perspectives for complications, and further steps are
needed to reach the optimal percentages. However, in 1916,
Edwin Cragin placed an obsolete law in obstetrics that has
been executed for a long time: “Once a caesarean, always
a caesarean”, due to the danger of failure of the uterine scar
tissue and the greatly increased possibility of uterine
rupture. In the literature is reported that the chance of
uterine rupture in nulliparas during the delivery is 2 per
10 000 while it can highly increase with the multiparity
and it can reach up to 20-50 per 10 000 in vaginal
deliveries after previous caesarean section [1, 2, 3]. This
necessitates the application of various methods of assessing
the sufficiency of the scar tissue before planning further
deliveries. The most accurate methods for determining the
structure of tissue are histological, which by their nature
cannot be used during the pregnancy. These methods
correlate with some clinical ones that we tried to prove.
Several big obstetrical organizations agreed on
vaginal birth after prior caesarean section to be first choice
option as clinically safe for women with one previous C.S.

J of IMAB. 2019 Jan-Mar;25(1) https://www.journal-imab-bg.org 2433

– not only for the clinical benefits and the decreased RESULTS
possible complications but also for the economic and social The study group was presented by patients with one
factors caused by the earlier recovery [4, 5, 6, 7, 8, 9] or more previous C.S. They were divided as following:
It is known and confirmed by many researchers that Group A – 23 (57.5 %) patients with one C.S. and subgroup
factors such as short interval less than 12 months between A1 – less than 2 years ago (6 patients – 15 %), subgroup
the deliveries, macrosomia of the baby, oligohydramnion, A2 – more than 2 years (17 patients – 42.5 %); Group B –
post-term pregnancies, low pelvic score and thin with more than one C.S. (17 patients – 42.5 %). The women
myometrial thickness on ultrasound examination are were at the age between 16 and 40 years, mean age
increasing the rate of uterine rupture during VBAC [10, 11, 28.04±sd 10.958. Twenty-three (57.5%) of the women live
12, 13, 14, 15, 16]. Another retrospective study [17] in villages, and the other seventeen (42.5%) live in cities.
examined specifically patients with short inter-delivery According to ethnic group, the study population included:
interval and concluded that it is not increasing significantly Bulgarians – 19 (47.5%) and minority – 21 (45%). Marital
the incidence of uterine rupture. status showed that only 5 (12.50%) were married. There was
Lower uterine segment (LUS) thickness measurement no statistically significant difference between ethnicity and
in prenatal women with a history of past caesarian sections the healing processes in the examined group. Also, there is
could be used as a tool to predict the occurrence of a no statistically significant difference between marital
uterine defect (dehiscence or rupture of the uterine scar) in status, living location and the uterine scar recovery.
women undergoing VBAC. This was suggested in a meta-
analytical study [18], and it further added, that the Group A Group B
minimum thickness lying above the amniotic cavity at the One previous More than one
level of the uterine dehiscence cut-off range of between C.S. C.S.
2.1-4.0 mm gives a strong negative predictive value for a Total number
uterine defect to occur during VBAC, whereas a myometrial of patients 23 17
thickness cut-off range of between 06-2.0 mm provides a in the group
positive predictive value for uterine defects to occur. Bulgarians 13 6
However, according to the study, it wasn’t possible to
define a realistic cut-off thickness which could be Minority 4 17
implemented in clinical practice. Married 4 1

MATERIAL/METHODS The shortest inter-delivery interval was 14 months,

Cross sectional study was designed to examine the longest – 19 years. The ultrasound measurement results
women with prior Caesarean sections. For eight months, of the front uterine wall were between 1,73 mm and 3,79
samples of 40 women hospitalized in Clinic of Obstetrics mm. The shorter the period between the C.S.s was, the
and Gynecology at the University Hospital – Pleven, thinner the myometrium.
Bulgaria were examined. Patients’ demographic data were Cases of abnormal healing have been observed,
collected by a questionnaire after informed consent. The including: myometrial hyperplasia, myometrial
study was a part of a scientific project funded by the hypertrophy (fig. 1), adenomyosis (fig. 2), myofiber disarray
Medical University – Pleven, Bulgaria. The study protocol (fig. 3), fibrosis (fig. 4), inflammation (fig. 5), fibroids,
was approved by the Ethics Committee of Medical keloids. These results can be compared to clinical data from
University – Pleven. The data were statistically analyzed patients but mainly with the number of previous C.S. or
using the X2 test and P < 0.05 was accepted as the level of those with less than 2 years between them.
significance.
Clinical methods were used such as the history of Fig. 1. Scar with myometrial hypertrophy and fibrosis
the previous pregnancies and puerperal period, history of
previous operations and the recovery after them, ultrasound
examination and evaluation of the anterior uterine wall
preoperatively. All the patients had been examined with
ultrasound antenatally to measure the thickness of the lower
uterine segment (scar dehiscence or scar rupture). During
the operation for delivering the baby, a biopsy material
from the uterine scar was collected to be evaluated
histopathologically. The morphological methods used are:
Hematoxylin & eosin staining (H&E); Masson Trichrome
for evaluating the amount of collagen; Weigert-Van Gieson
staining for elasticity; staining of immunohistochemistry
MIB-1 (Ki-67) for cell proliferation. The morphological
indicators were compared to a control group of dermal scars
from the same patients.

2434 https://www.journal-imab-bg.org J of IMAB. 2019 Jan-Mar;25(1)

 Fig. 2. Adenomyosis with haemorrhages Fig. 5. Scar tissue with signs of inflammation

Fig. 3. Myofiber disarray with Masson Trichrome DISCUSSION

staining Our results indicate that there is a high frequency
(60%) of low healing in patients with prior C.S. less than
two years from women who experienced longer interval.
Routine screening of pregnant women for the dimension
of the uterine scar is currently not practiced in our region.
However, the dimensions of the surgical incision are
associated with clinical symptoms such as postmenstrual
smears, dysmenorrhoea and chronic pelvic pain. The
incidence of tearing in the evaluated group was higher in
patients with a short interval between births (below 24
months), a caesarean infection, two or more caesarean
sections.
In our study women from group, A1 was associated
to be more commonly with insufficiency of the uterine scar
with histologically “young” cells proliferation (fig. 6).
Infections were found regardless the ethnicity, but
significantly predominantly observed in the group of low
social status patients.
Fig. 4. Weigert-Van Gieson staining for elasticity
Fig. 6. Uterine scar with histologically “young” cells
proliferation

J of IMAB. 2019 Jan-Mar;25(1) https://www.journal-imab-bg.org 2435

 Patients who experienced a smooth puerperal period
with the prior deliveries and had long (two years at least)
inter-delivery interval, were evaluated as clinically
qualitative scar tissues (fig. 7). Their results of the
ultrasound measurements were between 2,3 and 3,79 mm.
Those patients are concluded to be safe for VBAC.
Fig. 7. Qualitative scar tissues with Weigert-Van
Gieson staining
disarray and inflammation signs.
Women with haemoglobin levels less than 110 g/l
during the re-elective C.S. were diagnosed with pregnancy-
related anaemia. The ultrasound measurements of the
patients with anaemia showed thickness of the uterine scar
less than 2.5 mm. Histologically the tissue material from
these patients showed low cells proliferation.
CONCLUSION
The results from our research proved that multiple
C.S. is risk factors for larger defects of the uterine scar but
not mandatory. The likelihood of prolonged healing time
was higher in cases of more than one C.S. Ultrasound
measurement of prior uterine scar is a useful method for
investigating the possible complications of spontaneous
vaginal birth and for detecting the patients for Re-C.S., but
we recommend its wider use at the time a pregnancy is in
the third trimester to enable individual risk assessment and
prevention. Not only the clinical history but also the live
quality standards such as well-balanced diet, clean home
and regular daily activities are decreasing the rate of
unwanted complications and healing abnormalities.
However, further researches are needed to recognize all the
risk factors and the precise incidence of complications.

ACKNOWLEDGEMENTS
There were two cases of patients with a history of This research was funded by Medical University –
fever during the puerperal period after the previous C.S. – Pleven through research project No.6/2017.
the scars of these patients were found to be with myofiber

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Please cite this article as: Gyokova E, PopovY, Ivanova-Yoncheva Y, Georgiev A, Dimitrova M, Betova T, Petrov K,
Popovska S. Clinical-morphological evaluation of the quality of the uterine scar tissue after caesarean section. J of
IMAB. 2019 Jan-Mar;25(1):2433-2437. DOI: https://doi.org/10.5272/jimab.2019251.2433

Received: 27/10/2018; Published online: 21/03/2019

Address for correspondence:

Elitsa Gyokova
Department of Obstetrics and Gynecology, Faculty of Medicine, Medical Uni-
versity - Pleven
1, Kliment Ohridski Str., 5800 Pleven, Bulgaria.
E-mail: egyokova@yahoo.com
J of IMAB. 2019 Jan-Mar;25(1) https://www.journal-imab-bg.org 2437