Short communication

DOI: 10.1111/j.1471-0528.2011.02965.x
www.bjog.org

Uterine adherence to anterior abdominal wall

after caesarean section
SA El-Shawarby,a R Salim,a S Lavery,b E Saridogana
a
Reproductive Medicine Unit, Elizabeth Garrett Anderson Wing, UCL Institute for Womens Health, University College Hospital, London,
UK b Department of Reproductive Medicine, Hammersmith Hospital, Imperial College London, London, UK
Correspondence: Dr E Saridogan, Institute for Womens Health, University College London Hospitals, Second Floor North, 250 Euston Road,
London NW1 2PG, UK. Email ertan.saridogan@uclh.nhs.uk

Accepted 24 February 2011. Published Online 12 April 2011.

Uterine adherence to the anterior abdominal wall is not a

recognised long-term complication after caesarean section. Here
we report on 13 women with history of caesarean section who
were found to have uterine adherence during investigations for
pain or infertility. The majority of the women were diagnosed
at laparoscopy. In three women the initial diagnosis was made
by ultrasound scan and two of these were later confirmed at
laparoscopy. Apart from an association with infertility and pain,

uterine adherence to the abdominal wall may increase

morbidity at future caesarean section and the need for
hysterectomy. Long-term follow-up studies of women undergoing
caesarean section are required to investigate these findings
further.
Keywords Caesarean section, laparoscopy, long-term effects,

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.

This was a retrospective study of 13 women who were

found to have uterine adherence to the anterior abdominal wall during investigations for pain or secondary infertility over a 5-year period. They all had a history of at
least one caesarean section. Data were collected from individuals case-notes from two inner London University
teaching hospitals into a specifically designed database and
are presented here as median and range. The records of
the caesarean sections were also reviewed or, if they had
taken place at another hospital, information related to caesarean sections was requested from these hospitals.

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

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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-

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Figure 1. Pelvic ultrasound showing uterine adherence to the anterior

abdominal wall. The uterus (A) appears protruding into the abdominal
wall through a gap (B) between the rectus muscles. The rectus sheath
is seen intact as an echogenic layer above the divaricated rectus
muscles (C).

ity and/or pain. In one woman it was an incidental finding

during ovarian cystectomy, so it is possible that a number
of women go undiagnosed. In three women associated with
secondary infertility in this series, there was evidence of
tubo-ovarian involvement in addition to the uterine adhesions, and two of these achieved spontaneous pregnancies
after surgical correction (salpingo-ovariolysis).
We have the impression that we are observing an
increasing number of women with this finding in our clinical practice over recent years, although we have no comparative data to support this. This may be a reflection of
the rising caesarean section rate, the practice of not closing
the peritoneum, or increased diagnosis because of more
widespread use of laparoscopy and high-resolution ultrasound to investigate secondary infertility and pelvic pain.
The practice of not closing the peritoneum at caesarean
section is an issue under constant and considerable debate
over recent years. The finding of the uterus protruding
through a defect in the abdominal wall in some of the
women in this report supports the theory that uterine
adherence may be related to peritoneal nonclosure. The
Royal College of Obstetricians and Gynaecologists suggested that the practice of not closing the peritoneum is
associated with fewer postsurgical complications.7 In a
Cochrane review, there was an improved short-term postoperative outcome (less febrile morbidity and shorter hospital stay) if the peritoneum was not closed. It was also
concluded that long-term studies following caesarean section are still limited, although data from other surgical
procedures are reassuring, and therefore there was no evidence to justify the time taken and cost of peritoneal
closure.8 The recently published CAESAR trial9 did not
show any difference in maternal infectious morbidity rates

2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG

Postcaesarean section uterine adherence to abdominal wall

between the peritoneal nonclosure and closure groups, but

this study reported only the short-term complications.
However, a review of 33 studies showed that closure of the
peritoneum resulted in less adhesion formation.5 We were
not able to establish whether the peritoneal layers were
closed in the 13 women included in this report. However,
in the two hospitals from which these reports originate it is
routine not to close the peritoneum. This is consistent with
the findings of a previous publication related to the surgical techniques used during caesarean sections in the UK,
which showed that 71 and 66% of the obstetricians did not
close the pelvic and parietal peritoneum, respectively.10
This study is unable to ascertain whether the causative
factor is related to a particular surgical technique but it
seems plausible that the practice of not closing the peritoneum at caesarean section may be a contributing factor.
To determine if the uterine adherence is associated with a
particular surgical technique, a prospective observation or
intervention study or long-term outcomes may provide
more robust evidence.
The type of adherence we describe in this report is likely
to be significant for future operations such as caesarean
sections or hysterectomies and may increase morbidity
associated with these procedures. This would again require
a prospective observation study to confirm.

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.

Details of ethics approval

None.

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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