{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T12:40:50Z","timestamp":1776429650291,"version":"3.51.2"},"reference-count":52,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2025,6,26]],"date-time":"2025-06-26T00:00:00Z","timestamp":1750896000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"University of Medicine and Pharmacy Carol Davila"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Cesarean deliveries have increased in recent years worldwide. This increase translates into an escalation of obstetrical complications that could lead to permanent injuries. Comprehensive knowledge of the risk factors for uterine scar defects and their probability factor could guide gynecologists towards decreasing the percentage of scar defects and reducing the morbidity produced by a scarred uterus. Methods: A review of the literature published in the last 10 years produced a number of 80,085 articles, from which we screened 147 articles and selected 11 recently published papers, attempting to rank the most frequently described risk factors in terms of probability. A total number of 11,349 patients who underwent CS were included from the 11 studies. Results: Cesarean scar defects developed in 19.42% of cases; our results showed that the highest probability was given by single-layer suture, with gestational diabetes being the main patient-related risk factor for scar defects. A definitive ranking of the risks is difficult to assess, because different studies focus on certain risks and most of the relevant data are missing or are omitted. Conclusions: In this study, we investigate the most common risk factors that give rise to the development of cesarian scar defects, conducting a ranking of these risks from the most probable to the least important, in order to facilitate informed decision making for providers.<\/jats:p>","DOI":"10.3390\/jcm14134551","type":"journal-article","created":{"date-parts":[[2025,6,27]],"date-time":"2025-06-27T03:33:25Z","timestamp":1750995205000},"page":"4551","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Ranking of Risk Factors Leading to Uterine Scar Defect\u2014Systematic Online Review"],"prefix":"10.3390","volume":"14","author":[{"given":"Ionita","family":"Ducu","sequence":"first","affiliation":[{"name":"Doctoral School, \u201cCarol Davila\u201d University of Medicine and Pharmacy, Dionisie Lupu Str., Nr 37, Sector 2, 020021 Bucharest, Romania"},{"name":"Life Memorial Hospital, Calea Grivi\u021bei Str., Nr 365, Sector 1, 010719 Bucharest, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8957-737X","authenticated-orcid":false,"given":"Bianca-Margareta","family":"Salmen","sequence":"additional","affiliation":[{"name":"Doctoral School, \u201cCarol Davila\u201d University of Medicine and Pharmacy, Dionisie Lupu Str., Nr 37, Sector 2, 020021 Bucharest, Romania"},{"name":"Filantropia Clinical Hospital of Obstetrics and Gynecology, Ion Mihalache Blv., Nr 11\u201313, Sector 1, 011171 Bucure\u0219ti, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4705-0606","authenticated-orcid":false,"given":"Ana-Maria","family":"Iordache","sequence":"additional","affiliation":[{"name":"Optospintronics Department, National Institute for Optoelectronics-INOE 2000, Atomistilor Str., Nr 409, 077125 Magurele, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cristiana-Elena","family":"Durdu","sequence":"additional","affiliation":[{"name":"Doctoral School, \u201cCarol Davila\u201d University of Medicine and Pharmacy, Dionisie Lupu Str., Nr 37, Sector 2, 020021 Bucharest, Romania"},{"name":"Filantropia Clinical Hospital of Obstetrics and Gynecology, Ion Mihalache Blv., Nr 11\u201313, Sector 1, 011171 Bucure\u0219ti, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roxana Elena","family":"Bohiltea","sequence":"additional","affiliation":[{"name":"Filantropia Clinical Hospital of Obstetrics and Gynecology, Ion Mihalache Blv., Nr 11\u201313, Sector 1, 011171 Bucure\u0219ti, Romania"},{"name":"Department of Obstetrics and Gynecology, University of Medicine and Pharmacy \u201cCarol Davila\u201d, Eroii Sanitari Bvd., No. 8, Sector 5, 020021 Bucharest, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/S0029-7844(97)84257-3","article-title":"One- versus two-layer closure of a low transverse cesarean: The next pregnancy","volume":"89","author":"Chapman","year":"1997","journal-title":"Obstet. Gynecol."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Bogdan, R., Bohiltea, R., and Toma, A. (2022). Respiratory Follow Up of the Premature Neonates\u2014Rationale and Practical Issues. J. Clin. Med., 11.","DOI":"10.3390\/jcm11061746"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Nemes, A., Toma, A., Dima, V., Serboiu, S., Necula, A., Stoiciu, R., Ulmeanu, A., Marinescu, A., and Ulmeanu, C. (2024). Use of Lung Ultrasound in Reducing Radiation Exposure in Neonates with Respiratory Distress: A Quality Management Project. Medicina, 60.","DOI":"10.3390\/medicina60020308"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"80","DOI":"10.3892\/etm.2020.9513","article-title":"Umbilical cord lactate compared with pH as predictors of intrapartum asphyxia","volume":"21","author":"Neacsu","year":"2020","journal-title":"Exp. Ther. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"458.e1","DOI":"10.1016\/j.ajog.2018.09.004","article-title":"Cesarean scar defect: A prospective study on risk factors","volume":"219","author":"Huhtala","year":"2018","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Toma, A., Dima, V., Alexe, A., Rusu, L., Neme\u0219, A., Gon\u021b, B., Arghirescu, A., Necula, A., Fieraru, A., and Stoiciu, R. (2024). Correlations between Head Ultrasounds Performed at Term-Equivalent Age in Premature Neonates and General Movements Neurologic Examination Patterns. Life, 14.","DOI":"10.3390\/life14010046"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1016\/j.ejogrb.2024.02.045","article-title":"Uterine wound healing after caesarean section: A systematic review","volume":"296","author":"Debras","year":"2024","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"102758","DOI":"10.1016\/j.jogoh.2024.102758","article-title":"Effects of endometrial versus non-endometrial suturing on isthmocele development; a randomized controlled trial","volume":"53","author":"Gezer","year":"2024","journal-title":"J. Gynecol. Obstet. Hum. Reprod."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Khamvongsa, P., Gotluru, C., Stavros, S., Borges, J., and Bonnice, S. (2023). Horizontal mattress uterine closure compared to single layered lock suture in cesarean section\u2014A retrospective cohort study. Eur. J. Obstet. Gynecol. Reprod. Biol. X, 20.","DOI":"10.1016\/j.eurox.2023.100234"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1080\/08941939.2019.1610530","article-title":"An Optimal Uterine Closure Technique for Better Scar Healing and Avoiding Isthmocele in Cesarean Section: A Randomized Controlled Study","volume":"34","author":"Kalem","year":"2021","journal-title":"J. Investig. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"102282","DOI":"10.1016\/j.jogoh.2021.102282","article-title":"Double-layered purse string uterine suture compared with single-layer continuous uterine suture: A randomized Controlled trial","volume":"51","author":"Dimassi","year":"2022","journal-title":"J. Gynecol. Obstet. Hum. Reprod."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"3085","DOI":"10.21608\/ijma.2023.179242.1566","article-title":"Comparative Study between Purse String Double-Layer and Classical Closure for Repairing the Uterine Incision During Cesarean Section","volume":"5","author":"Shenishan","year":"2023","journal-title":"Int. J. Med. Arts"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/j.ajog.2015.10.916","article-title":"Impact of uterine closure on residual myometrial thickness after cesarean: A randomized controlled trial","volume":"214","author":"Roberge","year":"2016","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"5","DOI":"10.61186\/sjrm.8.1.5","article-title":"Different Uterine Suturing Techniques Following Cesarean Delivery: A Systematic Review","volume":"8","author":"Abbasi","year":"2023","journal-title":"Sarem J. Med. Res."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e235321","DOI":"10.1001\/jamanetworkopen.2023.5321","article-title":"CSDi Study Group; Definition and Criteria for Diagnosing Cesarean Scar Disorder","volume":"6","author":"Murji","year":"2023","journal-title":"JAMA Netw. Open"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1002\/uog.19049","article-title":"Sonographic examination of uterine niche in non-pregnant women: A modified Delphi procedure","volume":"53","author":"Jordans","year":"2019","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1351","DOI":"10.1111\/aogs.13623","article-title":"Niche definition and guidance for detailed niche evaluation","volume":"98","author":"Jordans","year":"2019","journal-title":"Acta Obstet. Et Gynecol. Scand."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1002\/uog.6395","article-title":"High prevalence of defects in Cesarean section scars at transvaginal ultrasound examination","volume":"34","author":"Osser","year":"2009","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"102363","DOI":"10.1016\/j.bpobgyn.2023.102363","article-title":"Aetiology, risk factors and preventive strategies for niche development: A review","volume":"90","author":"Verberkt","year":"2023","journal-title":"Best. Pract. Res. Clin. Obstet. Gynaecol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"100299","DOI":"10.1016\/j.xagr.2023.100299","article-title":"Investigating the risk factors for isthmocele development after cesarean delivery","volume":"4","author":"Fakhr","year":"2024","journal-title":"AJOG Glob. Rep."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"858","DOI":"10.1016\/j.gofs.2021.06.003","article-title":"Isthmoc\u00e8le: D\u00e9finition, diagnostic, facteurs de risque, pr\u00e9vention, sympt\u00f4mes, complications, et traitements","volume":"49","author":"Torre","year":"2021","journal-title":"Gyn\u00e9col. Obs. Fertil. S\u00e9nol."},{"key":"ref_22","unstructured":"Reif, F. (1965). Statistical Physics\u2014Berkeley Physics Courses, Mc. Graw-Hill."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.ejogrb.2019.09.001","article-title":"Caesarean scar defect: Risk factors and comparison of evaluation efficacy between transvaginal sonography and magnetic resonance imaging","volume":"242","author":"Tang","year":"2019","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"101933","DOI":"10.1016\/j.jogoh.2020.101933","article-title":"A comparison of the effects of Two suture materials on isthmocele formation: A cohort study","volume":"50","author":"Hosseini","year":"2021","journal-title":"J. Gynecol. Obstet. Hum. Reprod."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1217","DOI":"10.15562\/bmj.v12i2.4241","article-title":"Ultrasound evaluation of post-cesarean uterine wound healing based on a figure of eight suturing technique","volume":"12","author":"Sitepu","year":"2023","journal-title":"Bali Med. J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"80","DOI":"10.21608\/ebwhj.2023.185215.1226","article-title":"Ultrasound Evaluation of Cesarean Uterine Scar Following Single Compared to Double Layer Closure","volume":"13","author":"Kandil","year":"2023","journal-title":"Evid. Based Women\u2019s Health J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"6523","DOI":"10.21608\/ejhm.2022.270487","article-title":"Assessment of Cesarean Section Uterine Scar by Transvaginal Ultrasound after Single Versus Double Layer Closure Techniques","volume":"89","year":"2022","journal-title":"Egypt. J. Hosp. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1111\/aogs.13714","article-title":"Ultrasound cesarean scar assessment one year postpartum in relation to one- or two-layer uterine suture closure","volume":"99","author":"Hanacek","year":"2020","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"322","DOI":"10.4274\/tjod.galenos.2021.71173","article-title":"Effect of single- and double-layer cesarean section closure on residual myometrial thickness and isthmocele\u2014A systematic review and meta-analysis","volume":"18","author":"Marchand","year":"2021","journal-title":"Turk. J. Obstet. Gynecol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"578","DOI":"10.1002\/uog.17401","article-title":"Risk of Cesarean scar defect following single- vs double-layer uterine closure: Systematic review and meta-analysis of randomized controlled trials","volume":"50","author":"Saccone","year":"2017","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1016\/j.ajog.2014.06.014","article-title":"Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: A systematic review and meta-analysis","volume":"211","author":"Roberge","year":"2014","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"893","DOI":"10.1016\/j.jmig.2016.06.020","article-title":"Emerging manifestations of cesarean scar defect in reproductive-aged women","volume":"23","author":"Tulandi","year":"2016","journal-title":"J. Minim. Invasive Gynecol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1016\/j.ijgo.2013.11.013","article-title":"Hydrosonographic assessment of the effects of 2 different suturing techniques on healing of the uterine scar after cesarean delivery","volume":"125","author":"Sevket","year":"2014","journal-title":"Int. J. Gynaecol. Obstet."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1111\/aogs.14018","article-title":"Single- or double-layer uterine closure techniques following cesarean: A randomized trial","volume":"100","author":"Baran","year":"2020","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_35","first-page":"171","article-title":"Prospective comparative study of single-layer versus double-layer closure of leg wounds after long saphenous vein harvest in coronary artery bypass graft operations","volume":"3","author":"Siddiqi","year":"2011","journal-title":"J. Thorac. Dis."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"866","DOI":"10.1111\/1471-0528.16472","article-title":"Effect of single- versus double-layer uterine closure during caesarean section on postmenstrual spotting (2Close): Multicentre, double-blind, randomised controlled superiority trial","volume":"128","author":"Stegwee","year":"2021","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"81","DOI":"10.3892\/etm.2020.9512","article-title":"Gestational diabetes modern management and therapeutic approach (Review)","volume":"21","author":"Sandu","year":"2021","journal-title":"Exp. Ther. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"478","DOI":"10.37358\/RC.18.2.6131","article-title":"Hormonal Contraception in Postpartum Patients with Gestational Diabetes Mellitus","volume":"69","author":"Ionescu","year":"2018","journal-title":"Rev. Chim."},{"key":"ref_39","unstructured":"Berceanu, C., C\u00eerstoiu, M., Mehedin\u0163u, C., Br\u0103til\u0103, P., Berceanu, S., Vl\u0103d\u0103reanu, S., Boh\u00eel\u0163ea, R., and Br\u0103til\u0103, E. (October, January 29). Hormone deficiency and its impact on the lower urinary tract. Proceedings of the 13th National Congress of Urogynecology\u2014Proceedings of the UROGYN 2016, Brasov, Romania."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1007\/s13224-021-01433-w","article-title":"Comparative study of USG and MRI in evaluation of isthmocele","volume":"71","author":"Gupta","year":"2021","journal-title":"J. Obstet. Gynecol. India"},{"key":"ref_41","first-page":"72e7","article-title":"Deficient lower-segment Cesarean section scars: Prevalence and risk factors","volume":"31","author":"Sawyer","year":"2008","journal-title":"Ultrasound Obs. Gynecol. Off. J. Int. Soc. Ultrasound Obstet. Gynecol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"3584572","DOI":"10.1155\/2022\/3584572","article-title":"Prediction of scar myometrium thickness and previous cesarean scar defect using the three-dimensional vaginal ultrasound","volume":"2022","author":"Shi","year":"2022","journal-title":"Contrast Media Mol. Imaging"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Park, I., Kim, M., Lee, H., Gen, Y., and Kim, M. (2018). Risk factors for Korean women to develop an isthmocele after a cesarean section. BMC Pregnancy Childbirth, 18.","DOI":"10.1186\/s12884-018-1821-2"},{"key":"ref_44","unstructured":"(2024, September 26). The Wound Pros. Available online: https:\/\/www.thewoundpros.com\/post\/the-role-of-antibiotics-in-treating-wound-infections."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Alto\u00e9, L., Alves, R., Sarandy, M., Morais-Santos, M., Novaes, R., and Gon\u00e7alves, R. (2019). Does antibiotic use accelerate or retard cutaneous repair? A systematic review in animal models. PLoS ONE, 14.","DOI":"10.1371\/journal.pone.0223511"},{"key":"ref_46","first-page":"CD011712","article-title":"Antibiotics and antiseptics for surgical wounds healing by secondary intention","volume":"3","author":"Norman","year":"2016","journal-title":"Cochrane Database Syst Rev."},{"key":"ref_47","first-page":"2423","article-title":"Impact of obesity on the prognosis of hypertensive disorders in pregnancy","volume":"20","author":"Bohiltea","year":"2020","journal-title":"Exp. Ther. Med."},{"key":"ref_48","first-page":"106449","article-title":"The Spiral Trial: A multicenter, randomized, controlled trial of Spiral thread sutures versus conventional thread sutures to prevent thinning of uterine scars following elective cesarean section, Contemp","volume":"107","author":"Maki","year":"2021","journal-title":"Clin. Trials"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1137","DOI":"10.1007\/s00404-018-4702-z","article-title":"Evaluation of cesarean scar after single and double layer hysterotomy closure: A prospective cross sectional study","volume":"297","author":"Tekiner","year":"2018","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"718","DOI":"10.1016\/j.tjog.2015.07.006","article-title":"Can the final sonographic assessment of the cesarean section scar be predicted 6 weeks after the operation?","volume":"55","author":"Dosedla","year":"2016","journal-title":"Taiwan J. Obstet. Gynecol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1573","DOI":"10.3109\/14767058.2015.1054276","article-title":"A comparison of two techniques of uterine closure in caesarean section","volume":"29","author":"Ercan","year":"2016","journal-title":"J. Matern. Fetal Neonatal Med."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1352","DOI":"10.1111\/aogs.13015","article-title":"Comparison of the primary cesarean hysterotomy scars after single- and double-layer interrupted closure","volume":"95","author":"Kataoka","year":"2016","journal-title":"Acta Obstet. Gynecol. Scand."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4551\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:59:30Z","timestamp":1760032770000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4551"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,26]]},"references-count":52,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["jcm14134551"],"URL":"https:\/\/doi.org\/10.3390\/jcm14134551","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,26]]}}}