The increasing rate of elective and indicated caesarean sections worldwide has led to new pathologies and management challenges. The number of patients undergoing trial of labor after caesarean section (TOLAC) is also increasing. Three professional societies provide detailed guidelines based on scientific evidence for the management of patients attempting vaginal birth after caesarean section (VBAC). However, they do not provide any recommendations for the actual surgical steps to be followed to minimize the risks of uterine rupture (UR) during TOLAC. Uterine scar condition, intrapartum management and maternal health status correlate to uterine scar rupture risk and provide guidance for parturient TOLAC eligibility. TOLAC and vaginal delivery success rate as reported by the largest studies is between 60% and 77%. Uterine rupture is more prevalent in VBAC-2 patients (1.59%) in contrast to VBAC-1 (0.72%). Additionally, VBAC-2 patients have higher incidence of caesarean hysterectomy 0.56% vs. 0.19% for VBAC-1. The chances of successful VBAC increase when the interpregnancy/interdelivery interval is less than 6.3 years and less than 24 months, respectively. No difference was detected between the techniques of uterine incision closure of the previous CS and TOLAC results, although closure of the CS uterine incision in 2 layers seems to be practiced more widely. Niche or isthmocele presents another complication of CS. Secondary infertility due to niche, will eventually direct to hysteroscopic or laparoscopic repair, depending on the residual myometrial thickness (RMT) as measured by US scan. When RMT is below 3 mm or 2.5 mm surgery can be performed, to prevent any spontaneous UR in case of pregnancy. Monitoring by US scanning of hysterotomy scar after myomectomy can detect hematoma. In patients with severe postoperative pain but hemodynamically stable follow up by US scan examination can direct the management decision. In those patients with active bleeding and deterioration of hysterotomy scar edema will be an indication to surgery. There is no firm evidence regarding which type of thread, knotting or sequence of suturing is more favorable to reduce the risk of UR after VBAC or hysterotomy after myomectomy.
PMID 30837118 30837118 DOI 10.1016/j.bpobgyn.2019.01.009 10.1016/j.bpobgyn.2019.01.009 Tanos et al. 2019, Tanos 2019
Cite this article
Tanos, V., & Toney, Z. A. (2019). Uterine scar rupture - Prediction, prevention, diagnosis, and management. Best practice & research. Clinical obstetrics & gynaecology, 59, 115-131. https://doi.org/10.1016/j.bpobgyn.2019.01.009
Tanos V, Toney ZA. Uterine scar rupture - Prediction, prevention, diagnosis, and management. Best Pract Res Clin Obstet Gynaecol. 2019;59:115-131. doi:10.1016/j.bpobgyn.2019.01.009
Tanos, Vasilios, and Zara Abigail Toney. "Uterine scar rupture - Prediction, prevention, diagnosis, and management." Best practice & research. Clinical obstetrics & gynaecology, vol. 59, 2019, pp. 115-131.
Kremer TG et al., 2019·Rev Assoc Med Bras (1992)·
Open Access
An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.
Bujold E et al., 2026·American Journal of Obstetrics and Gynecology·
Open Access
Normal uterine function depends on cyclical regeneration and the capacity to sustain pregnancy. A cesarean incision represents an injury to this remarkable organ. Although the uterus possesses exceptional healing potential, cesarean delivery increases the risk of secondary infertility, pelvic pain, uterine rupture, and abnormal placentation in subsequent pregnancies. The two most important determinants of successful hysterotomy healing after cesarean delivery are the location of the incision and the surgical technique used for closure. The anatomic site of entry-whether the corpus, lower uterine segment, or cervix-defines the tissue composition, vascularity, and contractility at the wound margins, which in turn influence how the scar remodels and withstands subsequent pregnancies. Surgical technique is also important. A robust body of experimental and clinical evidence demonstrates that restoring anatomic integrity by reapproximating uterine layers while excluding the endometrium produces stronger scars and reduces late complications. The rationale for excluding the endometrium is to prevent displacement of endometrial tissue into the myometrium and to avoid mucosal tearing against a foreign body (i.e. suture material), both of which predispose to defective healing. When the endometrium is incorporated, healing is often impaired, leading to niches or isthmoceles, adenomyosis, and endometriosis at the scar site. Over time, these defects have been recognized as contributors to abnormal bleeding, pelvic pain, infertility, uterine rupture, and placenta accreta spectrum disorders. Despite this evidence, single-layer closures that incorporate endometrium became widely adopted because of their speed and simplicity, while their long-term sequels were initially underappreciated. This has prompted renewed scrutiny of closure techniques, including comparisons of single-layer vs double-layer closure, locking vs nonlocking sutures, type of sutures, and the direction of suture. Collectively, the data show that optimal closure respects uterine anatomy, restores the natural alignment of tissues, and achieves hemostasis without compromising perfusion or strangulating tissues. Building on these principles, we herein describe a refined 3-layer closure. The first layer approximates decidua and junctional myometrium while excluding surface endometrium to prevent tissue entrapment and bacterial contamination. The second layer restores anatomic wall integrity by reapproximating the bulk of the myometrium, thereby reinforcing strength and distributing tension across the scar. The third layer reapproximates superficial myometrium and serosa, smoothing the uterine surface and reducing adhesions. This technique is not simply a return to traditional double-layer methods or an extension of single-layer practice, but rather a refinement that integrates lessons from visceral surgery and contemporary obstetric data. Its rationale is to restore anatomy, secure hemostasis without ischemia, and preserve long-term uterine function. While short-term safety appears comparable across closure methods, evidence increasingly indicates that long-term reproductive outcomes depend on how closure respects tissue biology. We argue that appropriate repair is more important than a fast repair: meticulous restoration of uterine anatomy should take precedence over operative speed. The enduring success of a hysterotomy repair depends on the surgical technique employed, as it directly affects women's future reproductive health.
Pregnancy Complications · Premature Rupture of Membranes
Hsu JZ et al., 2025·Eur J Obstet Gynecol Reprod Biol·
Endometriosis is a chronic gynaecological condition affecting reproductive-aged women. It has been associated with infertility and potential risks for adverse pregnancy outcomes, although population-level evidence remains limited. This retrospective cohort study, including 147,950 pregnant women aged 20-45 years, used nationwide population-based data to compare the outcomes between women with (n = 11,400) and without (n = 136,550) endometriosis between 2000 and 2021. Baseline characteristics, comorbidities and pregnancy outcomes were compared between the groups. Multivariable regression analyses were performed to calculate adjusted relative risks (aRR) and 95 % confidence intervals (CI) for various pregnancy outcomes, and subgroup analyses were conducted by maternal age and infertility status. Among 147,950 pregnancies, women with endometriosis [mean ± standard deviation (SD) age 32.38 ± 4.51 years] had higher socio-economic status, more comorbidities, and more surgical history compared with women without endometriosis (mean ± SD age 30.06 ± 4.96 years). Women with endometriosis had increased risk of miscarriage (aRR 1.13, 95 % CI 1.03-1.24), preterm birth (aRR 1.31, 95 % CI 1.26-1.37), premature rupture of membranes (aRR 1.11, 95 % CI 1.06-1.16), placenta previa (aRR 1.63, 95 % CI 1.45-1.84), urinary tract infection (aRR 1.44, 95 % CI 1.31-1.59), and caesarean section (aRR 1.13, 95 % CI 1.11-1.16). Subgroup analysis revealed that risk of miscarriage was only higher in women aged 35-45 years and women without infertility. Risks of preterm birth, placenta previa and caesarean section were elevated across all subgroups, suggesting that endometriosis contributes independently to adverse pregnancy outcomes. Endometriosis is an independent risk factor for several pregnancy complications, supporting the need for tailored prenatal care and closer monitoring of affected women to improve maternal outcomes.
Slaoui A et al., 2025·International Journal of Surgery Case Reports·
Open Access
This case underscores the effectiveness of a combined laparoscopic and hysteroscopic approach in managing isthmocele, achieving symptom resolution and uterine integrity restoration. Individualized management and long-term follow-up are essential for optimizing outcomes.