Skin scar characteristics in prediction of severe intraperitoneal adhesions in women undergoing repeat caesarean section
DOI:
https://doi.org/10.7196/SAMJ.2026.v116i6.3175Keywords:
Caesarean section, adhesions, prediction, skin scar characteristicsAbstract
Background. Caesarean section (CS) is the most performed abdominal procedure and is known to be associated with the development of intraperitoneal adhesions. These adhesions may lead to difficult repeat surgery and complications such as haemorrhage, and bladder and bowel injury. Determining which women are at risk for adhesions could help with triaging those who may be at risk for a complicated repeat surgery. Scar characteristics have been proposed as preoperative prediction tools for adhesions.
Objectives. To assess whether abdominal scar characteristics correctly predict intraperitoneal adhesions in women undergoing repeat CS.
Methods. In this prospective blinded observational study at Nelson Mandela Academic Hospital, in Eastern Cape Province of South Africa, 419 women were enrolled. We assessed whether we could use skin scar characteristics to predict the presence of intraperitoneal adhesions at repeat CS. Women who met the inclusion criteria were approached in the third trimester, and the previous CS scar was examined. The characteristic features of the scar were described and documented, while the findings were blinded to the surgeon who was carrying out the CS. The surgeon was instructed to describe the types of intraperitoneal adhesions and their characteristics in theatre, documenting them on the questionnaire.
Results. Adhesions were present in 53.5% of the 419 women enrolled. Women with dense adhesions were older, and had more previous CSs, longer incision-to-delivery time and more blood loss. The type of incision did not predict adhesions. Depressed scars were more likely to be associated with dense adhesions (p<0.0001). Using a depressed scar as a predictor had a sensitivity of 21.4% (95% confidence interval (CI) 17.5 - 25.36), and a specificity of 96.4% (CI 94.63 - 98.19), meaning it missed most participants with adhesions but had an excellent ability to identify those without adhesions. It had a positive predictive value of 87.3% (CI 84.08 - 90.46) and negative predictive value of 50.2% (CI 46.68 - 58.24).
Conclusion. Although abdominal scar characteristics have low sensitivity in predicting dense intraperitoneal adhesions, they have excellent specificity. The abdominal scar can therefore be used by surgeons to identify patients who are unlikely to have dense intraperitoneal adhesions. This would be particularly useful in district hospitals for triaging patients with previous CS who can be operated on safely, while referring others to level 2 or 3 hospitals.
References
1. Awonuga AO, Fletcher NM, Saed GM, Diamond MP. Postoperative adhesion development following caesarean section and open intra-abdominal gynaecological operations: A review. Reprod Sci 2011;18(2):1166-1185. https://doi.org/10.1177/1933719111414206
2. Shi Z, Ma L, Yang Y, et al. Adhesion formation after previous caesarean section - a meta-analysis and systematic review. BJOG 2011;118(4):410-422. https://doi.org/10.1111/j.1471-0528.2010.02808.x
3. Hesselman S, Hogberg U, Rassjo E-B, et al. Abdominal adhesions in gynaecologic surgery after caesarean section: A longitudinal population-based register study. BJOG 2018;125(5):597-603. https:// doi.org/10.1111/1471-0528.14708
4. Poole JH. Adhesions following caesarean delivery: Review of their occurrence, consequences and preventative management using adhesion barriers. Women’s Health 2013;9(5):467-477. https://doi. org/10.2217/WHE.13.45
5. Salim R, Kadan Y, Nachum Z, et al. Abdominal scar characteristics as a predictor of intra-abdominal adhesions at repeat caesarean delivery. Fertil Steril 2008;90(6):2324-2327. https://doi.org/10.1016/j. fertnstert.2007.10.037
6. Stocker LJ, Glazebrook JE, Cheong YC. Are skin scar characteristics associated with the degree of pelvic adhesions at laparoscopy? Fertil Steril 2008;101(2):501-505. https://doi.org/10.1016/j. fertnstert.2013.10.026
7. Taylan E, Akdemir A, Ergenoglu AM, et al. Can we predict the presence and severity of intra- abdominal adhesions before caesarean delivery? Gynecol Obstet Invest 2017;82(6):521-526. https:// doi.org/10.1159/000454767
8. Pergialoitis V, Frountzas M, Siotos C, et al. Cesarean wound scar characteristics for the prediction of pelvic adhesions: A meta-analysis of observational studies. J Matern Fetal Neonatal Med 2017;30(4):486-491. https://doi.org/10.1080/14767058.2016.1176135
9. Kahyaoglu I, Kayikcioglu F, Kinay T, Mollamahmutoglu L. Abdominal scar characetristics: Do they predict intra-abdominal adhesions with repeat caesarean deliveries. J Obstet Gynaecol Res 2014;40(6):1643-1648. https://doi.org/10.11111/jog.12429
10. Khalaf M, Abdel-Reheem F, El-Nashar I, et al. Cesarean skin scar characteristics for preoperative predicition of intra-abdominal adhesions at repeat caesarean delivery; a prospective cohort study. Ann Gynecol Obstet 2020;4(1):72-76. https://doi.org/10.36959/468/469
11. Mayibenye M, Buga GAB, Mdaka ML, Nanjoh MK. Transabdominal sonographic sliding signs for preoperative prediction of dense intra-abdominal adhesions in women undergoing repeat Cesarean delivery. Ultrasound Obstetr Gynecol 2024;64(6):792-798. https://doi.org/10.1002/uog.29133
12. Kantor J. Reliability and photographic equivalency of the scar cosmesis assessment and rating (SCAR) scale, an outcome measure of postoperative scars. JAMA Dermatol 2017;153(1):55-60. https://doi. org/10.1001/jamadermatol.2016.3757
13. Tulandi T, Lyell DJ. Classification of intra-abdominal adhesions after caesarean delivery. Gynecol Surg 2013;10(1):25-29.https://doi.org/10.1007/s10397-012-0765-1
14. Nuamah MA, Browne JL, Ory AV, et al. Prevalence of adhesions and associated postoperative complications after caesarean section in Ghana: A prospective cohort study. Reproductive Health 2017;14(1):143. https://doi.org/10.1186/s12978-017-0388-0
15. Moro F, Mavrelos D, Pateman K, Holland T, Hoo WL, Jurkovic D. Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section. Ultrasound Obstetr Gynecol 2015;45(2):223-228. https://doi.org/10.1002/uog.14628
16. Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench 2013;6(1):14-17. https://doi.org/10.22037/ghfbb.v6i1.332
17. Awonuga AO, Belotte J, Abuanzeh S, et al. Advances in the pathogenesis of adhesion development: the role of oxidative stress. Reproduct Sci 2014;21(7):823-836. https://doi.org/10.1177/1933719114522550 18. Okabayashi K, AshrafianH, Zacharakis E, et al. Adhesions after abdominal surgery: A systematic review of the incidence, distribution and severity. Surg Today 2014;44(3):405-420. http://www.ohri.ca/
programs/clinical_epidemiology/oxford.asp
19. Mooij R, Mwampagatwa IH, van Dillen J, Stekelenburg J. Association between surgical technique, adhesions and morbidity in women with repeat caesarean section: A retrospective study in a rural hospital in Western Tanzania. BMC Pregnancy Childbirth 2020;20(1):582. https://doi.org/10.1186/ s12884-020-03229-8
20. Morales KJ, Gordon MC, Bates GW Jr. Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol 2007;196(5):461.e1-e6. https://doi.org/10.1016/j.ajog.2006.12.017
21. Kinay T, Ucok BS, Ramoglu S, Tapisiz O, Erkaya S, Koc S. Maternal obesity and intra-abdominal
adhesion formation at caesarean delivery. J Matern Fetal Neonat Med 2022;35(12):2241-2246. https://
doi.org/10.1080/14767058.2020.1783231
22. Çim N, Elci E, Elci GG, et al. Are the skin scar characteristics and closure of the parietal peritoneum associated with pelvic adhesions? Turk J Obstet Gynecol 2018;15(1):28-32. https://doi.org/10.4274/ tjod.55491
23. El-Agwany AS. Pfannenstiel incision scar characteristics: Relation to pelvic adhesion after caesarean section. Gynecol Surg 2016;13(4):525-527. https://doi.org/10.1007/s10397-016-0979-8
24. Tulandi T, Al-Sannan B, Akbar G, et al. Prospective study of intraabdominal adhesions among women of different races with or without keloids. Am J Obstet Gynecol 2011;204(2):132.e1-e4. https://doi. org/10.1016/j.ajog.2010.09.005
Additional Files
Published
Issue
Section
License
Copyright (c) 2026 M Mayibenye, G A B Buga, M Mdaka, N Nanjoh
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Licensing Information
The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
Publishing Rights
Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.
