Cesarean Section Complications

Cesarean Section Complications
Karen Y. Oh, MD
DIFFERENTIAL DIAGNOSIS
Common
  • During Pregnancy
    • Placenta Accreta Spectrum
    • Dehiscence
    • Uterine Rupture
  • Postpartum
    • Bladder Flap Hematoma
    • Endometritis
    • Normal Cesarean Section Scar (Mimic)
Less Common
  • Uterine Rupture, Delayed
  • Cesarean Section Scar Ectopic
  • Endometrioma in Cesarean Section Scar
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
  • During pregnancy
    • Determine history of prior cesarean section (C-section)
    • Visualize lower uterine segment
      • Confirm hypoechoic myometrial layer present
      • Risk of rupture/dehiscence increases as lower uterine thickness decreases
      • Myometrium absent if uterine rupture/dehiscence has occurred
    • Document placental location
      • Placenta previa associated with accreta spectrum in 5% of cases
      • Take care to show preservation of subplacental hypoechoic zone if implantation on the C-section scar
      • Use Doppler liberally to assess for abnormal vascularity
  • Postpartum
    • Immediate postoperative complications often difficult to differentiate due to gas and edema in soft tissues from delivery
    • Healed C-section scar normally associated with focal mild thinning of myometrium
Helpful Clues for Common Diagnoses
  • Placenta Accreta Spectrum
    • Abnormal penetration of placental tissue beyond endometrial lining of uterus
      • Accreta: Attached to myometrium without muscular invasion
      • Increta: Chorionic villi invading myometrium
      • Percreta: Penetration of chorionic villi through uterine wall
    • Loss of subplacental hypoechoic zone
      • Should normally be present over entire placental surface
      • Hypoechoic zone may be difficult to see when placenta is anterior
      • Switch to high resolution transducer
    • Placenta previa present in almost all cases
    • Thinning of underlying myometrium ≤ 2 mm can be a sign of placental invasion
    • “Swiss cheese” placenta
      • Multiple hypoechoic placental vascular lacunae (“tornado-shaped” vessels)
      • Better positive predictive value than loss of subplacental hypoechoic zone
    • Interruption of bladder wall-uterine interface
      • Normal bladder mucosa is echogenic
      • Large vessels, or nodularity, extending through bladder wall can be seen with percreta
  • Dehiscence
    • Incomplete rupture: Disrupted myometrium but intact serosa
      • Loss of hypoechoic myometrial layer
      • Usually at site of prior C-section
    • In pregnancy, patient may be followed carefully to allow fetus to mature
      • Delivery indicated for any sudden pain
      • Reports of successful repair and continuation of pregnancy
    • MR may be helpful to assess for location and size of dehiscence
  • Uterine Rupture
    • Full thickness tear of uterine wall
      • May occur during pregnancy, labor, or puerperium
      • Highest risk in patients with history of C-section
    • Focal discontinuity of the myometrium at rupture site
      • Usually anterior lower uterine segment or site of prior myomectomy
      • Fetal parts and fluid in peritoneal cavity
    • During labor, imaging rarely performed as patient is emergently delivered operatively
      • Simultaneous maternal-fetal distress
      • Risk of rupture during spontaneous labor with prior C-section ≈ 5/1,000
    • In setting of trauma, CT useful → look for maternal solid organ injury also
  • Bladder Flap Hematoma
    • Hypoechoic clot at site of C-section on serosal surface
      • Between lower uterine segment and bladder wall
  • Endometritis
    • Most commonly occurs after delivery or termination
      • Associated with postpartum fever and pelvic pain
    • Endometrium may appear normal or have nonspecific findings
      • Thickened, heterogeneous endometrium
      • Echogenic foci of gas in endometrial cavity can be seen but also commonly related to delivery
      • Large amount of echogenic fluid concerning for pyometra
    • Retained products of conception (RPOC) is a risk factor
      • Sonographic appearance of RPOC overlaps with endometritis
      • Use Doppler to check for vascularity within endometrial contents
  • Normal Cesarean Section Scar (Mimic)
    • Focal triangular or wedge-shaped defect in myometrium
      • Anterior lower uterine segment
    • Small amount of fluid in scar is normal
      • Cystic-appearing C-section scar
      • May be confused with ectopic gestational sac in early pregnancy
      • Doppler ultrasound shows an avascular collection of fluid
Helpful Clues for Less Common Diagnoses
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Aug 10, 2016 | Posted by in OBSTETRICS | Comments Off on Cesarean Section Complications

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