Definition and Criteria for Diagnosing Cesarean Scar Disorder

Saskia J M Klein Meuleman; Ally Murji; Thierry van den Bosch; Oliver Donnez; Grigoris Grimbizis; Ertan Saridogan; Frederick Chantraine; Tom Bourne; Dirk Timmerman; Judith A F Huirne; Robert A de Leeuw; CSDi Study Group

doi:10.1001/jamanetworkopen.2023.5321

Uterine and Pelvic Conditions · Acquired Uterine Conditions

Definition and Criteria for Diagnosing Cesarean Scar Disorder

Klein Meuleman SJM, Murji A, van den Bosch T, Donnez O, Grimbizis G, Saridogan E, Chantraine F, Bourne T, Timmerman D, Huirne JAF, de Leeuw RA, CSDi Study Group

Published March 2023 JAMA Network Open, 6(3), e235321

DOI 10.1001/jamanetworkopen.2023.5321 PMID 36988956 PMC PMC10061236

RRM Academy Synopsis

Experts define cesarean scar disorder as a symptomatic uterine niche

A modified Delphi study of 31 international experts agreed on a name for the symptoms linked to a cesarean scar niche. The panel chose cesarean scar disorder as the name for a symptomatic uterine niche. The definition needs a niche on ultrasound plus at least 1 primary or 2 secondary symptoms. All four patient representatives agreed with the proposed definition.

Key Findings

The definition pairs an ultrasound niche, an indentation at the scar at least 2 mm deep, with at least 1 primary symptom or 2 secondary symptoms (RoA 77.8%).
Cesarean scar disorder won the vote on naming, with a rate of agreement (RoA) of 96.2%. Four other names, among them cesarean scar syndrome, were also discussed.
Experts agreed diagnosis needs at least 3 regular menstrual cycles after cesarean delivery (RoA 93.5%), a premenopausal patient (RoA 100%), and symptoms that began or significantly worsened afterward (RoA 80.6%).
Experts also agreed to exclude cycles without ovulation (RoA 100%), other intracavitary pathology (RoA 93.5%), postmenstrual spotting with another cause (RoA 80.6%), cervical dysplasia, and vaginal or uterine infections (each RoA 74.2%).
Cesarean scar pregnancy, uterine dehiscence or rupture, and placenta accreta spectrum count as complications (RoA 70.4%). Experts agreed the literature is insufficient to classify miscarriage as a symptom (RoA 96.7%).

Interpretation

This modified Delphi consensus study brought together 31 international experts over three rounds, with consensus set at a rate of agreement of at least 70%. All four patient representatives on the panel endorsed the final definition. The authors note that the symptom-count criteria have not yet been clinically tested and that the weight of individual symptoms needs further study. The definition applies to premenopausal women, and the authors propose revisiting it after 1 year. The findings support further validation studies of this definition in clinical practice.

RRM Context

Restorative reproductive medicine looks for the cause of a health problem before treating it. This includes both partners. Clear criteria for a symptomatic uterine niche give doctors a shared starting point: a scan finding paired with specific symptoms. A niche in a cesarean scar can be linked to secondary infertility. Clear criteria help doctors look for that root cause.

Our editorial summary of this paper, not the article's abstract.

Abstract

Importance

Approximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms.

Objective

To achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition.

Design, Setting, and Participants

A consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022.

Main Outcomes and Measures

Definition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche.

Results

In total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis.

Conclusions and Relevance

In this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.

Topics

Uterine and Pelvic Conditions › Acquired Uterine Conditions › Cesarean Scar Defect · Clinical Guidelines and Standards › Diagnostic Criteria and Classification › Diagnostic Criteria

Saskia J M Klein Meuleman, Ally Murji, Thierry van den Bosch, Oliver Donnez, Grigoris Grimbizis, Ertan Saridogan, Frederick Chantraine, Tom Bourne, Dirk Timmerman, Judith A F Huirne, Robert A de Leeuw

S Meuleman, A Murji, T Bosch, O Donnez, G Grimbizis, E Saridogan, Fred Chantraine, F Chantraine, Thomas Bourne, T Bourne, D Timmerman, J Huirne, Bob Leeuw, Rob Leeuw, Bobby Leeuw, R Leeuw

PMID 36988956 36988956 DOI 10.1001/jamanetworkopen.2023.5321 10.1001/jamanetworkopen.2023.5321 Klein Meuleman et al. 2023, Klein Meuleman 2023

Definition and Criteria for Diagnosing Cesarean Scar Disorder

Experts define cesarean scar disorder as a symptomatic uterine niche

Key Findings

Interpretation

RRM Context

Abstract

Topics

By this author

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