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DOI: 10.1111/j.1471-0528.2011.02965.x
www.bjog.org
uterine adhesions.
Please cite this paper as: El-Shawarby S, Salim R, Lavery S, Saridogan E. Uterine adherence to anterior abdominal wall after caesarean section. BJOG
2011;118:11331135.
Introduction
Methods
For the last 30 years there has been a global public concern about increasing caesarean section rates.1 The United
Kingdom National Sentinel Audit reported that the three
most frequently mentioned complications of caesarean
section were increased risk of thromboembolism, severe
haemorrhage and risks for subsequent pregnancies.2
An additional potential risk after caesarean section is
adhesion formation. Adhesion bands are reported to be
among the most common complications of such procedures and are found in nearly half of the women at the
time of their repeat caesarean section.3 Postoperative
intra-abdominal and pelvic adhesions can cause infertility,
chronic pelvic pain and intestinal obstruction. One- or
two-layer closure of the uterus4 and closure of peritoneum5 at caesarean section have been debated as important factors that influence the development and extent of
postoperative adhesions. Uterine adherence to the anterior
abdominal wall is not a recognised long-term complication after caesarean section. Here we report on 13 such
women, most of whom presented with pain or secondary
infertility.
Results
All 13 women had undergone a caesarean section through a
low transverse skin incision and the uterine incision had
been low transverse in all of them. We were unable to find
any record of whether the visceral or parietal peritoneum
had been closed. Polyglactin sutures had been used for uterine closure, and two-layer closure had been carried out in all
but one of the women. No adhesion barriers had been used.
2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
1133
El-Shawarby et al.
The majority of the women were diagnosed at laparoscopy (10/13), and in three women the initial diagnosis was
made by ultrasound scan, two of which were later confirmed at laparoscopy. The presenting symptom was secondary infertility in eight women, pelvic pain in two
women, and both infertility and pelvic pain in two women.
One woman was found to have an adherent uterus as an
incidental finding during a laparoscopic ovarian cystectomy
procedure. The median age of the study population was
34 years (2939 years). The median number of pregnancies
before diagnosis was one (range 14), and the median
number of previous caesarean sections was one (range
12). None of the women had had any laparotomies other
than caesarean section(s), and in only one, caesarean
section had been complicated by postoperative febrile morbidity and wound infection. In one of the two women who
had had two caesarean sections, uterine adherence was
noted at the time of second caesarean section.
In 12 women who had a laparoscopy, the uterus was
found to be densely adherent to the anterior abdominal
wall (Figure S1). In three women (3/12), laparoscopic separation of the adherent uterus revealed a defect in the
abdominal wall parietal peritoneum and the uterine wall
was partially protruding through this defect, into a gap
between the rectus muscles. Only one woman had evidence
of pelvic inflammatory disease at laparoscopy and there
was minimal endometriosis in two women.
Preoperative pelvic ultrasound scan was completely normal in eight women, revealed intramural fibroids in two
women, and a suspected adherent uterus in three women.
On transvaginal ultrasound scan, an adherent uterus was
diagnosed when the caesarean section scar (at the level of
the reflection of the urinary bladder) was adherent to the
anterior abdominal wall and was fixed and immobile at this
point, when the uterus was pushed gently with the examining probe. An example of ultrasound showing uterine
adherence to the anterior abdominal wall is shown in Figure 1. Table S1 demonstrates the clinical features of the
women in the study.
Discussion
In this report we describe laparoscopic and ultrasound
detection of uterine adherence to the anterior abdominal
wall following caesarean section. Obstetricians occasionally
experience this finding at subsequent caesarean section, and
a recent article reported three such cases encountered during repeat caesarean section.6 On physical examination, the
uterus may be found to be adherent to the abdominal wall
and the cervix may be difficult or impossible to see because
it has been pulled upwards. In the current series, these
adhesions were found during laparoscopic or ultrasound
examinations in women presenting with secondary infertil-
1134
2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
Conclusion
To the best of our knowledge, the present study, although
limited by its small sample size and its retrospective nature,
represents the largest available case-series in the literature
describing this long-term complication of caesarean section.
It is also the first report on its laparoscopic and ultrasound
detection. Multicentre long-term follow-up studies for
women undergoing caesarean section are needed to investigate this finding further.
Disclosure of interest
None.
Contribution to authorship
SE and ES wrote the article and were involved in the management of the women. The co-authors were also involved
in the management of the women, and in revising the final
manuscript.
Funding
None.
Acknowledgements
None.
Supporting information
The following supplementary material is available for this
article.
Figure S1. Laparoscopy showing uterine adherence to
the anterior abdominal wall.
Table S1. Clinical features of the women in the study.
Additional Supporting Information may be found in the
online version of this article.
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting information
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding
author. j
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