Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2025 Oct;104(10):1972-1979.
doi: 10.1111/aogs.70005. Epub 2025 Aug 21.

Prevalence of cesarean scar disorder in patients 3 years after a first cesarean section

Saskia J M Klein Meuleman  1   2 , Carry Verberkt  1   2 , Pere N Barri  3 , Ally Murji  4 , Oliver Donnez  5 , Grigoris Grimbizis  6 , Ertan Saridogan  7 , Tom Bourne  8   9 , Jian Zhang  10 , Michal Pomorski  11 , Shunichiro Tsuji  12 , Thierry van den Bosch  9   13 , Sanne I Stegwee  14 , Judith A F Huirne  1   2 , Robert A de Leeuw  1   2 ; 2Close study group, CSDi study group
Affiliations
Randomized Controlled Trial

Prevalence of cesarean scar disorder in patients 3 years after a first cesarean section

Saskia J M Klein Meuleman et al. Acta Obstet Gynecol Scand. 2025 Oct.

Abstract

Introduction: A symptomatic uterine niche is a long-term complication after a cesarean section (CS). A group of international niche experts reached consensus on a standardized definition of a disorder caused by a symptomatic niche, named cesarean scar disorder (CSDi). However, the prevalence of this disorder is unclear. The aim of this study was to assess the prevalence of CSDi in patients 3 years after a first CS.

Material and methods: A secondary analysis was performed on the 3-year follow-up results of the 2Close study. The 2Close study was a multicenter randomized controlled trial that evaluated single- versus double-layer uterine closure at CS in 32 hospitals in the Netherlands and included 2292 patients (registered in Dutch trial register: [NTR5480]). Patients, aged ≥18 years, undergoing a first CS were included. Three months after their CS, transvaginal ultrasonography was performed to evaluate the uterine scar for the presence of a niche. Three years after their CS, a digital questionnaire was sent to evaluate the primary and secondary symptoms of CSDi. For this secondary analysis, patients were excluded if they were pregnant, breastfeeding, or using hormonal contraception. The primary outcome of the study was the prevalence of CSDi.

Results: Of the 1648 participants who completed the 3-year questionnaire, patients were excluded due to pregnancy or breastfeeding (n = 305), use of hormonal contraception (n = 509), missing ultrasound evaluations (n = 76), and incomplete responses (n = 88). Of the 670 patients included in this analysis, 543 (81.0%) had a uterine niche visible on ultrasound and 127 (19.0%) were without a niche. The prevalence of CSDi at 3 years following a first CS was 42.5% (285/670). Most reported symptoms were chronic pelvic pain (35.0%), postmenstrual spotting (32.8%), and abnormal vaginal discharge (23.2%).

Conclusions: Our study found a high prevalence of CSDi 3 years following their first CS. Symptoms were self-reported and the exclusion criteria of pregnancy, breastfeeding, or hormonal contraception use could have introduced selection bias. Therefore, this percentage could be an overestimation of the actual prevalence. However, this high prevalence should be included in counseling patients with a scheduled CS.

Keywords: abnormal uterine bleeding; cesarean scar defect; cesarean section; chronic pelvic pain; infertility; postmenstrual spotting; uterine niche.

PubMed Disclaimer

Conflict of interest statement

Judith A. F. Huirne received grants from ZonMw for the conduct of the study, and additionally received grants from Samsung, NWO‐TTW, and PlantTec Medical GmbH, and a fee from Olympus, all outside the submitted work. An institutional grant was received from Olympus, Hologic, Benetec, and Medical Dynamics, outside the submitted work. All other authors declare no competing interests.

Figures

FIGURE 1
FIGURE 1
(A) An uterus 3 months post section without a uterine niche. (B) An uterus 3 months post section with a uterine niche.
FIGURE 2
FIGURE 2
Flowchart summarizing selection of included population.
See this image and copyright information in PMC

References

    1. World Health Organization . Caesarean section rates continue to rise, amid growing inequalities in access 2021. https://www.who.int/news/item/16‐06‐2021‐caesarean‐section‐rates‐continu...
    1. Tang X, Wang J, Zhang X, Hua K. 1711 cesarean scar defect: risk factors and comparison of evaluation efficacy between transvaginal sonography and magnetic resonance imaging. J Miny Invas Gynecol. 2019;26:S157‐S158. - PubMed
    1. Jordans IPM, Verberkt C, De Leeuw RA, et al. Definition and sonographic reporting system for cesarean scar pregnancy in early gestation: modified Delphi method. Ultrasound Obstet Gynecol. 2022;59:437‐449. - PMC - PubMed
    1. Colmorn LB, Petersen KB, Jakobsson M, et al. The Nordic Obstetric Surveillance Study: a study of complete uterine rupture, abnormally invasive placenta, peripartum hysterectomy, and severe blood loss at delivery. Acta Obstet Gynecol Scand. 2015;94:734‐744. - PubMed
    1. Stegwee SI, van der Voet LF, Ben AJ, et al. Effect of single‐ versus double‐layer uterine closure during caesarean section on postmenstrual spotting (2Close): multicentre, double‐blind, randomised controlled superiority trial. BJOG. 2021;128:866‐878. - PMC - PubMed

Publication types