Reducing the long-term impact of cesarean scar defects: a focus on prevention

As cesarean delivery rates continue to rise worldwide, the long-term obstetric and gynecological complications associated with cesarean scar defects are becoming increasingly prevalent. These include cesarean scar ectopic pregnancies, placenta previa accreta, secondary subfertility, chronic pelvic pain, and intermenstrual bleeding. The objective of this review is to evaluate how the optimization of the hysterotomy location in relation to myometrial thickness and uterine vascularity, together with an appropriate uterine closure technique, could reduce the long-term impact of cesarean scar defects. A wide range of closure techniques has been described, with substantial heterogeneity in study design, outcome measures, and follow-up intervals, limiting definitive conclusions. Emerging evidence suggests that unlocked, interrupted, purse-string, and endometrium-free sutures, along with the use of monofilament or barbed sutures, may reduce cesarean scar formation and thus the risks of scar placentation in subsequent pregnancies. These approaches may promote better healing by reducing tissue compression and ischemia, unlike continuous, locked, endometrium-inclusive sutures, which may impair perfusion. Increasing attention to endometrium-free closure and precise anatomical realignment highlights the importance of meticulous surgical technique in contemporary obstetrics. Surgical repair of cesarean scar defects improves outcomes in patients with chronic gynecological symptoms and subfertility. However, evidence supporting its role in preventing obstetric complications in subsequent pregnancies remains limited, in part because such complications are rare. Moreover, cesarean scar defect repair requires removing the scar tissue and reconstruction using healthy myometrium, which may theoretically increase the risk of dehiscence or uterine rupture in subsequent pregnancies. A key knowledge gap in much of the existing literature is its focus on imaging-defined cesarean scar defects rather than on patient-centered long-term gynecological symptoms. Well-designed, multiarm studies that incorporate standardized postpartum imaging to characterize uterine remodeling over time are essential for identifying best practices. While resource-intensive, advancing this field could improve long-term patient outcomes and reduce healthcare costs.