Defining cesarean scar disorder

Cesarean scar disorder is a term for the constellation of symptoms secondary to a uterine niche, as defined by a panel of 31 international experts in a recent Delphi study.

Cesarean delivery (CD) is the most common worldwide surgery, with an unhealed defect in the uterine myometrium known to be a long-term complication. This defect is often referred to as a cesarean scar defect or a uterine niche. Sixty percent of women present with a niche after CD, and 25% present with a large defect with a residual myometrium under 3 mm.

Symptoms such as dysmenorrhea, infertility chronic pelvic pain, and postmenstrual spotting are experienced by 30% to 40% of women with a CD niche, impacting their quality of life. Literature describes a wide variety of symptoms, therapies, and conditions for CD niche, as it is a newly observed condition. This leads to difficulty providing treatments and counseling.

To define the clinical condition presenting as a symptomatic niche in the uterine CD scar, investigators conducted an eDelphi study from November 22, 2021, to May 16, 2022. Delphi studies are widely used in healthcare research, involving anonymous consultation, feedback, and qualitive analysis through an iterative process.

Symptoms associated with a niche were evaluated through a systematic literature search. Full-text English language studies reporting on symptoms associated with CD niche were evaluated by 2 independent researchers.

Items were categorized into 6 themes: nomenclature, gynecological symptoms, fertility-related symptoms, social relationships and participation, obstetrical symptoms, and conditions to exclude and diagnostic criteria.

A niche expert was defined as, “an obstetrician or gynecologist who consults on more than 30 niche-related issues annually and has participated or is actively participating in niche or CD-related research.” Experts who met inclusion criteria were invited to participate in the analysis.

In the first Delphi round, questions focused on discussion among a focus group of patients to include patient perspective. After the questionnaire was completed, the results were discussed in a focus interview with experienced representatives. An invitation to participate in an online meeting discussing the proposed definition was given to women with a large symptomatic niche.

There were 29 symptoms associated with a niche through literature search and suggestions from the focus group, along with 5 potential diagnostic criteria, 5 potential conditions needing exclusion, and 2 questions about niche nomenclature. In the first 2 rounds, participation was seen from all 31 experts, 29 of which participated in the third round.

After discussing terms such as niche disease, niche disorder, cesarean scar syndrome, and cesarean scar disease,Cesarean scar disorder was the term given to a niche that caused relevant symptoms. This term was chosen because it, “implied the origin of the symptoms and emphasized that as an abnormal condition.”

Cesarean scar disorder was defined as a condition requiring at least 1 primary or 2 secondary symptoms alongside a sonographic finding of a niche. Experts also agreed related obstetric issues should be classified as complications of cesarean scar disorder.

The minimum criteria before diagnosis of cesarean scar disorder includes a minimum of 3 regular menstrual cycles following CD and before diagnosis, needing to be premenopausal, and complaining of symptomatic niche beginning or worsening significantly after CD.

Input from 4 patient representatives led to an agreement on the proposed definition, with no additional items suggested.

Reference

Klein Meuleman SJM, Murji A, van den Bosch T, et al. Definition and criteria for diagnosing cesarean scar disorder. JAMA Netw Open. 2023;6(3):e235321. doi:10.1001/jamanetworkopen.2023.5321