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(ISSN
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2771-2273)
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03
ISSUE
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P
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:
99-108
SJIF
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FACTOR
(2022:
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(2023:
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OCLC
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1121105677
Publisher:
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Servi
ABSTRACT
The purpose of the study was development of optimal delivery tactics for women with a uterine scar. 103 pregnant
women and the outcomes of their births were studied. Research and scientific work were carried out for 2020-2022.
on the basis of the obstetric department of the multidisciplinary clinic of SamSMU. The optimal delivery tactics directly
depend on the presence of somatic pathology, the timing of pregnancy, clinical signs of correction of the
postoperative scar, ultrasound data, the level of type XXVI collagen and rehabilitation measures after cesarean
section.
KEYWORDS
Viability criteria, uterine scar, cesarean section (CS), type XXVI collagen, child birth.
INTRODUCTION
CS often has a certain impact on the subsequent
reproductive activity of women: infertility, miscarriage,
spontaneous abortion, menstrual irregularities. In
addition, a CS cannot always ensure the birth of a
healthy child. Thus, in late pregnancy, infectious
diseases of the mother, severe hypoxia, and especially
in cases of very early premature birth, the health of the
unborn child depends on many factors. Although CS for
preterm birth reduces perinatal mortality, it does not
affect the incidence of perinatal morbidity, especially in
Research Article
OPTIMAL METHODS OF DELIVERY IN PREGNANT WOMEN WITH ONE
UTERINE SCAR
Submission Date:
October 20, 2023,
Accepted Date:
October 25, 2023,
Published Date:
October 30, 2023
Crossref doi:
https://doi.org/10.37547/ajps/Volume03Issue10-13
Kurbaniyazova Venera Enverovna
Samarkand State Medical University, Samarkand, Uzbekistan
Kurbaniyazova Feruza Zafarjanovna
Samarkand State Medical University, Samarkand, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ajps
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
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SJIF
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(2023:
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)
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Publisher:
Oscar Publishing Services
Servi
children born with low and very low birth weight. The
health of children born before the 32nd week of
pregnancy is often associated with underlying
maternal diseases (extragenital, infectious diseases,
etc.), as well as pregnancy complications (severe
gestosis, premature separation of a normally located
placenta).
The scar on the uterus, in turn, determines the
characteristics of the subsequent period of pregnancy,
which is often expressed in the risk of miscarriage,
placental insufficiency, and malposition of the fetus. In
addition, in women with uterine scars, there was a
delay in intrauterine growth and fetal development
due to placental insufficiency (O. V. Gorbunova, 2004;
E. V. Bolvacheva, 2007). In this regard, the issues of
pregnancy and childbirth in women with uterine scars
are very relevant.
According to the literature, from 13.0 to 50.0% of
women can be individually recommended to give birth
through the birth canal after cesarean section (L.S.
Logutova, 2006; Oden M., 2006). The frequency of
favorable outcomes of vaginal birth after CS is much
higher, although the data is variable and ranges from
80.0 to 90.0% of women with a uterine scar (L. S.
Logutova, 2006; M. Oden, 2009). At the same time, the
issue of natural delivery of women with a uterine scar
has not yet been fully studied. Risk factors and
management tactics for women with uterine scars are
not well developed. Therefore, it is necessary to
develop methods for studying the condition of women
with a uterine scar, tactics for managing pregnancy and
childbirth, as well as improving the prevention of
complications and their prediction.
Purpose of work.
Development of optimal delivery
tactics for women with a uterine scar.
Materials and methods. The study is based on a clinical
and laboratory examination of 103 women of
reproductive age with a history of one uterine scar,
who were under observation in the department of
obstetrics and gynecology of the multidisciplinary
clinic of Samarkand State Medical University for the
period from 2020 to 2022.
During clinical and laboratory examination, pregnant
women were divided into 2 groups: Group I - with a
stable scar (n=66), Group II with an incompetent scar
(n=37). Each of these groups was divided into
subgroups according to birth outcomes: “A”
- with
natural birth, “B”
- birth by cesarean section. Also, 68
postpartum women were included in the main group
for rehabilitation, and the remaining 35 were included
in the comparison group for clinical assessment of the
condition of the scar in the postoperative period and
rehabilitation.
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Figure 1. Distribution of postpartum women by rehabilitation method
The work used general clinical research methods
(general blood and urine analysis, vaginal smear,
assessment of hemostasis), as well as special research
methods, including: laboratory research methods
(determining the amount of type XXVI collagen by
ELISA, morphological examination of the scar area),
instrumental methods (ultrasound, Dopplerometry of
uterine vessels).
Variation-statistical processing of the study results was
carried out using the Statistica 6.0 program,
determining the main indicators of variation: mean
value (M), mean errors (m), standard deviation (p). The
reliability of the results obtained was determined using
the Student's test. The difference between two means
is considered significant if the p-parameter is less than
0.05. The confidence level was at least 95%.
Results. Information about the indications for the first
CS operation, important when assessing the possibility
of vaginal delivery, among which two main ones
predominated: anomalies of labor that are not
amenable to drug correction (42.64% in the main group
and 42.85% in the comparison group) and progressive
intrauterine fetal hypoxia (29.41% and 25.71%,
respectively).
At the same time, in the postoperative period, a high
frequency of various complications was noted (Table 1)
- they were detected in 17 (25%) women in the main
group and in 4 (11.42%) women in the comparison
group. Violation of uterine contractility was noted in
7.35% of cases in the main group and in 5.7% of cases in
the comparison group. Wound infection was detected
in 10.29% and postoperative endometritis in 10.29% of
cases in the main group. In the comparison group,
endometritis was not detected, but in the main group
this complication was detected in 10.6% of cases. Our
data indicate a significant percentage of purulent-
septic postpartum complications (13.59% of all
examined women of both groups).
103 women
in labor
Main (n=68)
IA group
(n=7)
II (IIA n=13,
IIB n=24)
Comparison
group (n=35)
IA (n=35)
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Based on a comparative analysis of the two groups, it
can be said that the aggravation of the postoperative
period contributes to poor healing of the scar area and,
with an intergravid period of less than two years, leads
to uterine incompetence in the scar area.
1- table
Information about the postoperative period (abs., %)
Complications after
surgery
Main group
(n=68)
Comparison
group (n=35)
P
abs
%
abs
%
Wound surface
infection
5
7.35
2
5.70
<0,01
Endometritis
7
10.29
-
-
=0,00..
Violation of uterine
contractility
(hypotonia, atony)
5
7.35
2
5.70
<0,02
Our observations confirm the literature data that
among
postpartum
complications,
purulent-
inflammatory ones take first place; when compared,
complications after surgical delivery predominate,
which once again emphasizes the importance of
natural childbirth.
When assessing long-term complications of a cesarean
section, the main clinical signs were analyzed: pain,
menstrual
irregularities,
dyspareunia,
sexual
dysfunction, changes in the microbiocenosis of the
reproductive tract (Fig. 2).
0
2
4
6
8
10
12
11
12
7
10
12
0
2
1
3
2
Main group
Compression group
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Figure 2. Analysis of long-term complications after the first cesarean section in the examined women (abs.)
As can be seen from Figure 2, chronic pelvic pain
syndrome was observed in 16.17% of women in the main
group. The intensity of the pain syndrome was
predominantly associated with the phases of the
menstrual cycle - the pain intensified on the eve of
menstruation and then subsided. Also, 17.64% of
women in the main group and 5.71% of women in the
comparison
group
complained
of
menstrual
irregularities within a year after cesarean section. As
mentioned above, the main clinical symptoms, sexual
dysfunction in the form of painful sexual intercourse
and decreased libido, were found in 14.7% of pregnant
women in the main group and in 8.57% of the
comparison group.
When analyzing the level of somatic pathology in both
groups, we did not find significant differences in all
forms and types of pathologies. Noteworthy is the
significant incidence of diseases of the urinary system
(17.64% in the main group and 17.14% in the comparison
group) and gastrointestinal tract (16.17% and 20%,
respectively). In some cases, chronic diseases of the
upper respiratory tract and varicose veins of the legs
were noted (7.35% and 8.57%, respectively).
At the same time, the presence of somatic pathology,
including inflammatory origin, significantly affects the
clinical picture of pregnancy, childbirth and the
postpartum period.
In the main group, 20.5% of pregnant women showed a
decrease in blood hemoglobin levels from normal
(91.1±1.24 g/l on average for the group). A low level of
leukocytes was detected in 8.82% of pregnant women
in the main group (group average 5.89±1.31x103/mm3).
This phenomenon is associated with their poor
nutrition and complications during pregnancy in the
form of vomiting of pregnancy, observed at the
beginning of pregnancy, since the div did not receive
enough nutrients, trace elements and vitamins.
After the first CS, the average levels of collagen type
XXVI did not differ in both groups during the second
pregnancy, but after delivery its indicator showed
significant changes in the two groups. Thus, in the
comparison group, the average concentration of type
XXVI collagen was 322.28±34.5 ng/ml; upon re-
examination 3 months after birth, a significant
decrease in the average concentration of type XXVI
collagen was noted, which amounted to 164.12±6.25
ng/ml .
The average concentration of type XXVI collagen in the
main group during pregnancy was 328.22±17.5 ng/ml,
and 3 months after birth - 363.1±48.4 ng/ml. This
indicates
the
effectiveness
of
rehabilitation
procedures. The data obtained show that collagen
type XXVI can be taken as a predictor of the choice of
method of delivery.
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In women in labor with a uterine scar, childbirth is
often complicated by DRPO (81.81%), secondary
weakness of labor (9.09%), and PONRP (10.6%). In the
main group, 35.29% (24) of postpartum women with a
uterine scar were operated on due to uterine
incompetence, 1.47% (1) due to placenta previa, 10.29%
(7) due to PONRP, 24. 24% based on the sum of relative
readings. Among postpartum women of the main
group with a risk of uterine rupture (II B subgroup
n=24), it was noted that in 7 (10.29% of the total
number) during CS there was an incomplete uterine
rupture along the scar and in 25% (17) cases there was
thinning of the scar. 20 women gave birth naturally (7
from IA and 13 from IIA); it should be noted that
postpartum complications more often occurred in
women from subgroup IIA, who were initially (36-38
weeks) diagnosed with scar failure and surgical
delivery was recommended. Bleeding both during
childbirth and in the early postpartum period was
observed in 34.7% of women.
In subgroups IB and IIB, the uterine scar during CS was
excised and subjected to histological examination.
During a morphological study of the uterine scar,
changes were observed both in the myometrial tissue
and in the vessels. When staining the prepared
preparations with hematoxylin and eosin dyes, areas of
hyperkeratosis were observed in the SSKE (stratified
squamous keratinizing epithelium), disruption of the
integrity of the SSKE layer, separation of the surface
cells, proliferation of randomly located and basal cells
in the lamina propria - acanthosis (Fig. 3).
Figure 3. Hyperkeratosis and acanthosis (hemotoxylin-eosin dye, x600), (Patient N.A., 34 years old, No. 1941)
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The lamina propria of the uterine scar under SSKE was
swollen, there was delamination of fibers, their
compression and the formation of large foci of
sclerosis consisting of fibrocytes, myocytes and
collagen fibers (muscular fibrous scars) (Fig. 4).
Figure 4. Foci of greater sclerosis (Patient N.A., 34 years old, No. 1941)
Failure of the surgical scar on the uterus was confirmed
histologically in 35.29% of the main group (subgroup
IIB). Whereas in patients of subgroup IB, the
consistency of the scar was histologically confirmed.
This fact allows us to judge the effectiveness of using
our proposed evaluation criteria to determine the
viability of the scar.
Postoperative pain in the wound area bothered the
majority (30 out of 48 - 62.5%) of postpartum women.
Women who gave birth naturally also noted pain after
ruptures (8.82% - 6 main groups and 8.57% - 3
comparison groups) and episiotomy (1.47% - 1 main
group and 5.7% - comparison groups) .
In puerperas of subgroup IIA, in 15.38% (2) of cases, a
low-grade rise in temperature was observed up to 3
days; normalization of temperature was observed in
one (8.3%) of them by the 5th day, the second by the
7th day. Subinvolution of the uterus was noted in 5.88%
of women in the main group and in 12.31% of women in
the comparison group. In a detailed analysis of patients
with uterine subinvolution, these complications were
characterized by the presence of hematometra and
lochiometra. In group II, only one woman (2.7%) had a
postpartum period complicated by endometritis.
Thus, the data obtained showed that after repeated
abdominal birth, complications of the postpartum
period were significantly higher (p<0.05) than after
natural birth. It is also necessary to note the
effectiveness and high sensitivity of the optimized
tactics for diagnosing consistency after a surgical scar,
which was confirmed by morphological analysis. Data
on the results of childbirth show a high frequency of
complications in women with a scar on the uterus,
which requires the rehabilitation of these women to
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improve their health and restore the reproductive
system.
CONCLUSION
The optimal delivery tactics directly depend on the
presence of somatic pathology, the timing of
pregnancy, clinical signs of correction of the
postoperative scar, ultrasound data, the level of type
XXVI collagen and rehabilitation measures after
cesarean section.
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)
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